1. Overuse of CT Pulmonary Angiography in the Evaluation of Patients with
Suspected PE in the ED
Crichlow A, et al. Acad Emerg Med. 2012;19:1219-1226.
Background: Clinical decision rules have been developed and
validated for the evaluation of patients presenting with suspected pulmonary
embolism (PE) to the emergency department (ED).
Objectives: The objective was to assess the percentage of
computed tomographic pulmonary angiography (CT-PA) procedures that could have
been avoided by use of the Wells score coupled with D-dimer testing
(Wells/D-dimer) or pulmonary embolism rule-out criteria (PERC) in ED patients
with suspected PE.
Methods: The authors conducted a prospective cohort study of
adult ED patients undergoing CT-PA for suspected PE. Wells score and PERC were
calculated. A research blood sample was obtained for D-dimer testing for
subjects who did not undergo testing as part of their ED evaluation. The
primary outcome was PE by CT-PA or 90-day follow-up. Secondary outcomes were ED
length of stay (LOS) and CT-PA time as defined by time from order to initial
radiologist interpretation.
Results: Of 152 suspected PE subjects available for analysis
(mean ± SD age = 46.3 ± 15.6 years, 74% female, 59% black or African American,
11.8% diagnosed with PE), 14 (9.2%) met PERC, none of whom were diagnosed with
PE. A low-risk Wells score (≤4) was assigned to 110 (72%) subjects, of whom
only 38 (35%) underwent clinical D-dimer testing (elevated in 33/38). Of the 72
subjects with low-risk Wells scores who did not have D-dimers performed in the
ED, archived research samples were negative in 16 (22%). All 21 subjects with
low-risk Wells scores and negative D-dimers were PE-negative. CT-PA time
(median = 160 minutes) accounted for more than half of total ED LOS (median =
295 minutes).
Conclusions: In total, 9.2 and 13.8% of CT-PA procedures
could have been avoided by use of PERC and Wells/D-dimer, respectively.
2. Safe exclusion of PE using the Wells rule and qualitative D-dimer
testing in primary care: prospective cohort study
Geersing G, et al. BMJ 2012; 345:e6564
Introduction
For many doctors, patients with unexplained shortness of
breath or pleuritic chest pain pose a diagnostic dilemma. In particular doctors
in primary care, who in many countries are the first to be consulted when
patients have these symptoms, have to differentiate between common self
limiting diseases, such as myalgia or respiratory tract infections, and the
rarer life threatening diseases such as pulmonary embolism. As the symptoms of
pulmonary embolism may be relatively mild, it can be easily missed,1 2 and
because pulmonary embolism has a high mortality doctors do not always get another
chance if it is misdiagnosed.3 As a result, most doctors in primary care have a
low threshold for referring patients with suspected pulmonary embolism and only
10-15% of referred patients are actually diagnosed as having the condition.4
To stratify patients with suspected pulmonary embolism
between a high probability (need for referral) of having the condition compared
with a low probability, clinical decision rules (combining the different
characteristics of patients and the disease into a score) have been developed.
The clinical decision rule developed by Wells and colleagues is the most widely
known, validated, and implemented tool for the detection of pulmonary embolism
in secondary care. The Wells clinical decision rule combines seven items into a
score ranging from 0 to 12.5. Based on many studies in secondary care, a
threshold of below 2 or 4 or more was introduced into the rule.5 Below these
levels patients are classified, respectively, as being at very low risk or low
risk of having pulmonary embolism. A large diagnostic management study in
secondary care concluded that a negative laboratory based quantitative D-dimer
(degradation product of fibrin) test result in patients with a Wells score of
≤4 safely excluded pulmonary embolism without the need for additional
investigations by imaging.6
Such a diagnostic strategy seems ideal in primary care to
facilitate decisions on referral to secondary care, in particular since easy to
use point of care D-dimer tests providing results within minutes are available
for use at the doctor’s practice or in the patient’s home.7 Before such a
diagnostic strategy can be implemented, however, it needs to be validated in
the proper setting of primary care.8 9 Owing to differences in the spectrum of
disease, symptoms, and doctors’ experience, encouraging results from referral
centres may not be readily applicable in primary care.10 11
We carried out a formal external validation of the Wells
pulmonary embolism rule combined with a point of care qualitative D-Dimer test
to evaluate the safety and efficiency of using this clinical decision rule in
primary care.
Abstract
Objective To validate the use of the Wells clinical decision
rule combined with a point of care D-dimer test to safely exclude pulmonary
embolism in primary care.
Design Prospective cohort study.
Setting Primary care across three different regions of the
Netherlands (Amsterdam, Maastricht, and Utrecht).
Participants 598 adults with suspected pulmonary embolism in
primary care.
Interventions Doctors scored patients according to the seven
variables of the Wells rule and carried out a qualitative point of care D-dimer
test. All patients were referred to secondary care and diagnosed according to
local protocols. Pulmonary embolism was confirmed or refuted on the basis of a
composite reference standard, including spiral computed tomography and three
months’ follow-up.
Main outcome measures Diagnostic accuracy (sensitivity and
specificity), proportion of patients at low risk (efficiency), number of missed
patients with pulmonary embolism in low risk category (false negative rate),
and the presence of symptomatic venous thromboembolism, based on the composite
reference standard, including events during the follow-up period of three
months.
Results Pulmonary embolism was present in 73 patients
(prevalence 12.2%). On the basis of a threshold Wells score of ≤4 and a
negative qualitative D-dimer test result, 272 of 598 patients were classified
as low risk (efficiency 45.5%). Four cases of pulmonary embolism were observed in
these 272 patients (false negative rate 1.5%, 95% confidence interval 0.4% to
3.7%). The sensitivity and specificity of this combined diagnostic approach was
94.5% (86.6% to 98.5%) and 51.0% (46.7% to 55.4%), respectively.
Conclusion A Wells score of ≤4 combined with a negative
qualitative D-dimer test result can safely and efficiently exclude pulmonary
embolism in primary care.
Full-text (free): http://www.bmj.com/content/345/bmj.e6564
3. Temporal and Safety Outcomes of Skipping Oral Contrast for Non-traumatic
Abd CTs
A. IV contrast alone
vs IV and oral contrast CT for the diagnosis of appendicitis in adult ED
patients
Kepner AM, et al. Amer J Emerg Med. 2012;30:1765-1773.
Objective: When the diagnosis of appendicitis is uncertain,
computerized tomography (CT) scans are frequently ordered. Oral contrast is
often used but is time consuming and of questionable benefit. This study
compared CT with intravenous contrast alone (IV) to CT with IV and oral
contrast (IVO) in adult patients with suspected appendicitis.
Methods: This is a prospective, randomized study conducted
in a community teaching emergency department (ED). Patients with suspected
appendicitis were randomized to IV or IVO CT. Scans were read independently by
2 designated study radiologists blinded to the clinical outcome. Surgical
pathology was used to confirm appendicitis in patients who went to the
operating room (OR). Discharged patients were followed up via telephone. The primary
outcome measure was the diagnosis of appendicitis. Secondary measures included
time from triage to ED disposition and triage to OR.
Results: Both IV (n = 114) and IVO (n = 113) scans had 100%
sensitivity (95% confidence interval [CI], 89.3-100 and 87.4-100, respectively)
and negative predictive value (95% CI, 93.7-100 and 93.9-100, respectively) for
appendicitis. Specificity of IV and IVO scans was 98.6 and 94.9 (95% CI,
91.6-99.9 and 86.9-98.4, respectively), respectively, with positive predictive values
of 97.6 and 89.5 (95% CI, 85.9-99.9 and 74.2-96.6). Median times to ED
disposition and OR were 1 hour and 31 minutes (P less than .0001) and 1 hour
and 10 minutes (P = .089) faster for the IV group, respectively. Patients with
negative IV scans were discharged nearly 2 hours faster (P = .001).
Conclusions: Computerized tomography scans with intravenous
contrast alone have comparable diagnostic performance to IVO scans for
appendicitis in adults. Patients receiving IV scans are discharged from the ED
faster than those receiving IVO scans.
B. Does Limiting Oral
Contrast Decrease ED Length of Stay?
You betcha!
Hopkins CL, et al. West J Emerg Med. 2012 [Epub ahead of
print]
Introduction: The purpose of this study was to examine the
impact on Emergency department (ED) length of stay (LOS) of a new protocol for
intravenous (IV)-contrast only abdominal/pelvic computed tomography (ABCT)
compared to historical controls.
Methods: This was a retrospective case-controlled study
performed at a single academic medical center. Patients ≥ 18 undergoing ABCT
imaging for non-traumatic abdominal pain were included in the study. We
compared ED LOS between historical controls undergoing ABCT imaging with PO/IV
contrast and study patients undergoing an IV-contrast-only protocol. Imaging
indications were the same for both groups and included patients with clinical
suspicion for appendicitis, diverticulitis, small bowel obstruction, or
perforation. We identified all patients from the hospital’s electronic
storehouse (imaging code, ordering department, imaging times), and we
abstracted ED LOS and disposition from electronic medical records.
Results: Two hundred and eleven patients who underwent PO/IV
ABCT prep were compared to 184 patients undergoing IV-contrast only ABCT prep.
ED LOS was shorter for patients imaged with the IVcontrast only protocol (4:35
hrs vs. 6:39 hrs, p less than 0.0001).
Conclusion: Implementation of an IV-contrast only ABCT prep
for select ED patients presenting for evaluation of acute abdominal pain
significantly decreased ED LOS.
Full-text (free): http://escholarship.org/uc/item/5bk7k82r
4. Make the ED Ouchless, Says AAP
By Nancy Walsh, Staff Writer, MedPage Today. Published:
October 29, 2012
The systematic and comprehensive management of pain and
anxiety is a crucial component of emergency department (ED) care for all
children, a clinical report from the American Academy of Pediatrics (AAP)
stated.
"Encouragingly, improvements in the recognition and
treatment of pain in children have led to changes in the approach to pain
management for acutely ill and injured pediatric patients," Joel A. Fein,
MD, of the University of Pennsylvania in Philadelphia, and colleagues wrote in
the November Pediatrics.
Many potential barriers exist in the treatment of pain in
children in emergency situations, including the complexity of assessment,
difficulties in communication, lack of staff, and medication concerns, such as
adverse effects. To address these concerns and to provide up-to-date
information on the use of analgesic and sedative drugs in the pediatric
emergency setting, the AAP assembled evidence-based guidance on implementing
and maintaining optimal care for use by hospital and transport staff. "Recent
advances in the approach and support for pediatric analgesia and sedation, as
well as new products and devices, have improved the overall climate of the ED
for patients and families in search of the 'ouchless' ED," the report
authors observed.
A first principle was that the initial evaluation of the
child in the ED should include an assessment of pain, which can be done, depending
on the child's age and developmental level, using numerical scales; the FACES
pain scale, in which the child identifies which facial expression most
resembles his or her degree of discomfort; or a neonatal pain scoring tool. Protocols
should be in place to guide the administration of medications, such as
ibuprofen, acetaminophen, or oral oxycodone, as well as for the use of topical
anesthetics for any likely painful procedure, such as placement of an
intravenous line, lumbar puncture, or suturing lacerations.
Provision should also be made for the safe administration of
analgesics before the child reaches the hospital, the report noted. Even the
administration of analgesia should be done in as painless a manner as possible.
One useful approach is to use warmed lidocaine buffered with bicarbonate and
administered slowly, according to the AAP report.
For neonates, pain can be alleviated with topical
anesthetics, and also by having the infant suck sucrose solution from a
pacifier immediately before a procedure. Having family members present can be
another potentially comforting strategy, along with providing a child-friendly
room or area with toys and potential distractions available.
Various methods of drug administration, such as transmucosal
or inhaled, can further ease delivery of analgesia during evaluation and
treatment, as well as using agents such as nitrous oxide that not only have
analgesic properties but which are also anxiolytic. Many ED clinicians today
are using short-acting agents such as propofol to provide sedation, which not
only helps alleviate pain but can improve the likelihood that the child will
remain still during procedures.
"The most important part of providing safe sedation for
children is the establishment of appropriate sedation systems and sedation
training programs with credentialing guidelines for sedation providers that
specifically address the core competencies required for the care of pediatric
patients," Fein and colleagues stated.
In addition, the AAP along with other medical societies has
recommended that ED caregivers perform a structured risk stratification for
each individual child before sedation is begun, including examination of the
airway and consideration of any pre-existing conditions.
Specific discharge criteria also should be in place, so that
children who have been sedated are not sent home at a time when adverse events
could still occur. Written follow-up instructions should always be given to
parents.
A particular concern in the clinical report was in
evaluating and treating children with disabilities, who may have particular
difficulties in communicating their feelings of pain, anxiety, and fear, and
may exhibit poorly regulated behaviors and a lack of cooperation. So-called
"child life specialists," who are trained in dealing with stressful
situations in children, can be particularly helpful for children with these
developmental or behavioral problems. And of utmost concern for these children,
the report states, "Myths of pain insensitivity or indifference must be
actively avoided."
Finally, the report emphasized, a regular quality
improvement program that involves transport teams and all ED staff must
continually review processes and outcomes associated with pediatric pain
management.
"Multiple modalities are now available that allow pain
and anxiety control for all age groups. Future research should concentrate on
pharmacologic, nonpharmacologic, and device-related technology that can assist
in reducing the pain and distress associated with medical procedures," the
report concluded.
All authors have reported no conflicts of interest, and the
AAP has not accepted any commercial involvement in the development of this
clinical report.
Fein J, et al "Relief of pain and anxiety in pediatric
patients in emergency medical systems" Pediatrics 2012; 130: e1391-e1405.
5. Gerontologists outline how doctors can bridge communication gap with
older patients
By Carolyne Krupa, amednews staff. Posted Oct. 29, 2012.
With the elderly population expected to increase
substantially in the next two decades, physicians need to be prepared for the
unique challenges they will face treating these patients, says a new report
from the Gerontological Society of America.
Nearly one in five Americans will be 65 or older by 2030,
according to the U.S. Administration on Aging. People in this age group make
nearly twice as many physician office visits per year than adults 45 to 65. Yet
the Centers for Disease Control and Prevention estimates that two-thirds of
older people are unable to understand the information given to them about their
prescription medications.
The society’s report offers recommendations for physicians
and other health professionals on how best to communicate with this growing
patient population. It is intended to help dispel some of the myths and
stereotypes physicians may have about older patients and give concrete
suggestions for good communication strategies, said Jake Harwood, a professor
in the Dept. of Communication at the University of Arizona in Tucson, who
chaired the advisory board that oversaw the report’s development.
Assuming that all elderly patients are frail, dependent,
hard of hearing or cognitively impaired can lead to a patronizing communication
style that many older people find disrespectful, he said.
“The consequence would be medical encounters in which the
patient is annoyed or dissatisfied,” Harwood said. “That is not an optimal
environment for the patient to gather the information he or she needs, or for
the patient to trust the physician and follow through on his or her
recommendations.”
The report offers 29 recommendations for avoiding poor
communication, such as recognizing one’s stereotypes, minimizing background
noise, and monitoring and controlling arm movements and other nonverbal
behavior when talking with patients. Clear physician-patient communication is
essential, yet many health professionals don’t get enough training on
interacting with elderly patients, Harwood said.
Other experts in patient communication say physicians need
to be aware if a patient has any cognitive impairments, poor health literacy or
sensory limitations such as poor hearing and eyesight.
Poor communication can be detrimental to a patients’ health,
said Cynthia Boyd, MD, MPH, associate professor of medicine with the Dept. of
Medicine Division of Geriatric Medicine and Gerontology at Johns Hopkins
University School of Medicine in Baltimore. If there is bad communication,
patients are more likely to miss appointments or fail to follow medical advice,
such as properly taking medications, said Pam Mason, director of Audiology
Professional Practices with the American Speech-Language-Hearing Assn.
The remainder of the article (full text free): http://www.ama-assn.org/amednews/2012/10/29/hlsa1029.htm
6. Screened & Examined: The Out-of-Control Patient Safety Pendulum (on
verbal orders)
Ballard DW. Emerg Med News. 2012;34(11B).
Wait. What's that you
say? You need an electronic order for that? OK, wait a second, let me find a
computer … logging on … could I just get started without an official order? Not
possible, eh? OK, here we go. It's in!
That's a typical communication in the ED. Latinphiles may
recognize that the word “communication” has its origins in the Latin
“communicare,” meaning to impart, share, or make common. A major component of
ED communication is sharing and imparting treatment orders, and as we all know,
we can do this in multiple ways — by pen, keystroke, and larynx. It is the
latter on which I'd like to focus.
The spoken order, often sterilely called the “verbal order,”
or VO, has become somewhat of an anathema at some U.S. hospitals. A recent
systematic review described broad differences in verbal order policies across
40 acute care hospitals with many restricting the use of verbal orders and in
some instances even simple face-to-face orders such as requesting a single dose
of acetaminophen. (Jt Comm J Qual Patient Saf 2012;38[1]:24.) As best as I can
tell, the rationale for such restrictive policies is threefold: the
availability of emerging technology (computerized order entry), a litany of
anecdotal evidence on patient safety risk, and a strong suggestion from the
Joint Commission as part of their national patient safety goals. What I'd like
to know is, where is the evidence?
Wait, what's that? You
need another order. Why? Because I am changing the nature of this discussion?
Really? OK, let me log in. Here we go. Just a moment to jump into intergalactic
hyperspace. Typing it in now. Order up!
Where was I? As it turns out, the evidence for restrictive
verbal order policies is almost purely anecdotal. I'm certain you've heard some
variation of this anecdote before. It proceeds along the lines of the broken
telephone game where kids whisper a phrase to each other around a circle and
see what comes out the other side. “I took my dog for a walk today, and then I
gave him some food” morphs into “I took Michael for a walk today, and then I
shaved him something good.” Or like an iPhone autocorrect embarrassment, you
text about your “neighbor's child prodigy,” but your iPhone turns it into a
text about your “neighbor's child prostitute.” Broken communication anecdotes
in the healthcare arena go like this (examples courtesy of the Institute of
Safe Medication Practices):
“An emergency room physician verbally ordered 'morphine 2 mg
IV,' but the nurse heard 'morphine 10 mg IV,' and the patient received a 10 mg
injection and developed respiratory arrest.”
“[A] physician called in an order for 15 mg of hydralazine
to be given IV every TWO hours. The nurse, thinking that he had said '50 mg,'
administered an overdose to the patient who developed tachycardia and had a
significant drop in blood pressure.” (Dynamics 2006;17[1]:20.)
Anecdotes can be powerful (as can Narcan), and we all have
experienced moments of misdirected communication in the workplace. The danger
of the spoken order seems to make intuitive sense. But is there actual evidence
in the literature supporting a patient safety benefit for restrictive verbal
order policies?
Huh? Another order?
Are you sure? This should definitely be covered by the previous order. Yes, OK,
I know you want to protect patient safety, and your license, too. Yes, I know
management is tracking this closely. No, you don't want to take a verbal on it?
OK, then, but I have to admit that these interruptions are distracting. And
I've been reading a lot about the danger of interruptions in the ED. A
significant source of error, you know. Sorry, you don't want to hear about this
without a separate order, so we'll drop it. Logging back in. Waiting. It's in.
Now, here we go, the actual evidence. It's quite sparse. A
2009 review on the topic, by Wakefield and Wakefield, summarizes it nicely:
“The literature consists primarily of nonsystematic and anecdotal evidence of
the relationship between verbal order utilization and actual or potential
patient harm. To our knowledge, the only large-scale study of hospital verbal
order policies is a 1990 report of a survey of nursing and pharmacy leaders'
self-report of selected features of their hospitals' verbal order policies.”
(Qual Saf Health Care 2009;18[3]:165.)
The only study specifically looking at errors associated
with verbal orders compared with handwritten or computer entry actually
demonstrated a counterintuitive decrease in errors with verbal orders compared
with other types. (Qual Saf Health Care 2009;18[3]:165; Arch Pediatr Adolesc
Med 1994;148[12]:1322.)…
The remainder of the essays (full-text free): http://tinyurl.com/dx6wxfb
7. Review: Steroid shots offer limited benefit for sciatica
Steroid injection into the spine provides only small,
short-term relief for sciatica-related leg and back pain, according to a review
of 23 clinical trials involving more than 3,100 patients. "Given that the
treatment effect is likely to be small and short term, patients with sciatica
should discuss the potential risks involved in [steroid injections] with their
doctor before agreeing to the procedure," according to the study
co-author. The study appeared in the Annals of Internal Medicine.
8. Acute diverticulitis: demographic, clinical and laboratory features
associated with CT findings in 741 patients.
Longstreth GF, et al. Aliment Pharmacol Ther. 2012 Sep 11.
doi: 10.1111/apt.12047. [Epub ahead of print]
BACKGROUND: Computed tomography (CT) demonstrates
diverticulitis severity.
AIM: To assess demographic, clinical and leucocyte features
in association with severity.
METHODS: We reviewed medical records of 741 emergency
department cases and in-patients with diverticulitis. CT findings were: (i)
nondiagnostic; (ii) moderate (peri-colic inflammation); and (iii) severe
(abscess and/or extra-luminal gas and/or contrast).
RESULTS: Patients with severe vs. nondiagnostic/moderate
findings had fewer females (42.4% vs. 58.2%, P = .004), less lower abdominal
pain only (74.7% vs. 83.7%, P = .042) and more constipation (24.4% vs. 12.5%, P
= .002), fever (52.2% vs. 27.0%, P less than .0001), leucocytosis (81.5% vs.
55.2%, P less than .0001), neutrophilia (86.2% vs. 59.0%, P less than .0001),
'bandemia' (18.5% vs. 5.5%, P less than .0001) and the triad of abdominal pain,
fever and leucocytosis (46.7% vs. 19.9%, P less than .0001) respectively.
Severe vs. nondiagnostic/moderate findings occurred in 4.8% vs. 95.2% without
fever or leucocytosis, 7.0% vs. 93.0% with fever, 12.3% vs. 87.7% with
leucocytosis and 25.1% vs. 74.9% with fever and leucocytosis respectively (P less
than .0001). The former group (odds ratio [95% CI]) included females less often
(0.45 [0.26-0.76]) and had less lower abdominal pain only (0.54 [0.29-0.99])
and more constipation (2.32 [1.27-4.23]), fever (2.13 [1.27-3.57]) and
leucocytosis (2.67 [1.43-4.99]).
CONCLUSIONS: Less than 50% of severe cases have the clinical/laboratory
triad of abdominal pain, fever and leucocytosis, but only 1 of 20 with pain who
lack fever and leucocytosis have severe diverticulitis. Male gender, pain not
limited to the lower abdomen, constipation, fever and leucocytosis are
independently associated with severe diverticulitis.
9. Dilemmas in the diagnosis of acute community-acquired bacterial
meningitis
Brouwer MC, et al. The Lancet 2012;380:1684 – 1692.
Rapid diagnosis and treatment of acute community-acquired
bacterial meningitis reduces mortality and neurological sequelae, but can be
delayed by atypical presentation, assessment of lumbar puncture safety, and
poor sensitivity of standard diagnostic microbiology. Thus, diagnostic dilemmas
are common in patients with suspected acute community-acquired bacterial
meningitis. History and physical examination alone are sometimes not sufficient
to confirm or exclude the diagnosis. Lumbar puncture is an essential
investigation, but can be delayed by brain imaging. Results of cerebrospinal
fluid (CSF) examination should be interpreted carefully, because CSF
abnormalities vary according to the cause, patient's age and immune status, and
previous treatment. Diagnostic prediction models that use a combination of
clinical findings, with or without test results, can help to distinguish acute
bacterial meningitis from other causes, but these models are not infallible. We
review the dilemmas in the diagnosis of acute community-acquired bacterial
meningitis, and focus on the roles of clinical assessment and CSF examination.
Full-text (subscription only): http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)61185-4/abstract
10. Cost-(in)effectiveness of
routine coagulation testing in the evaluation of CP in the ED
Kochert E, et al. Amer J Emerg Med. 2012;30:2034-2038.
Introduction: Approximately 5% of all US emergency
department (ED) visits are for chest pain, and coagulation testing is
frequently utilized as part of the ED evaluation.
Objective: The objective was to assess the
cost-effectiveness of routine coagulation testing of patients with chest pain
in the ED.
Methods: We conducted a retrospective chart review of
patients evaluated for chest pain in a community ED between August 1, 2010, and
October 31, 2010. Charts were reviewed to determine the number and results of
coagulation studies ordered, the number of coagulation studies that were
appropriately ordered, and the number of patients requiring a therapeutic
intervention or change in clinical plan (withholding of
antiplatelet/anticoagulant, delayed procedure, or treatment with fresh frozen
plasma or vitamin K) based on an unexpected coagulopathy. We considered it
appropriate to order coagulation studies on patients with cirrhosis,
known/suspected coagulopathy, active bleeding, use of warfarin, or ST-elevation
myocardial infarction.
Results: Of the 740 patients included, 406 (55%) had
coagulation studies ordered. Of those 406, 327 (81%) patients with coagulation
studies ordered had no indications for testing. One of the 327 patients (0.31%;
95% confidence interval, 0.05%-1.7%) tested without indication had a clinically
significant coagulopathy (internationalized normalization ratio above 1.5,
partial thromboplastin time above 50 seconds), but none (0%; 95% confidence
interval, 0%-1.2%) of the patients with coagulation testing performed without
indication required a therapeutic intervention or change in clinical plan. The
cost of coagulation testing in these 327 patients was $16780.
Conclusions: Coagulation testing on chest pain patients in
the ED is not cost-effective and should not be routinely performed.
11. Low-Dose Steroids in Sepsis Are Associated with Increased In-Hospital
Mortality
This study from the Surviving Sepsis Campaign does not
support use of steroids in septic shock.
Research has provided conflicting results regarding the
benefit of steroids in septic shock. As part of the Surviving Sepsis Campaign,
investigators analyzed data from 17,847 patients who were eligible for low-dose
steroids because they required vasopressor therapy after fluid resuscitation.
Eligible patients had at least two systemic inflammatory response syndrome
criteria, at least one organ dysfunction criterion, and a suspected site of
infection.
Just over half of patients received low-dose steroids (50 mg
intravenously four times per day or 100 mg three times per day), most within 8
hours of presentation. Patients in Europe and South America were more likely to
receive steroids than those in North America (59%, 52%, and 46%, respectively).
Patients with pneumonia and those on mechanical ventilation were more likely to
receive steroids than their counterparts.
Hospital mortality was significantly higher in patients who
received low-dose steroids than in those who did not (41% vs. 35%; adjusted
odds ratio, 1.18).
Comment: Although some patients with sepsis have diminished
response to exogenous corticotropin despite normal glucocorticoid levels, this
observational study shows that administering steroids to septic patients does
not improve outcomes and is not indicated.
— Kristi L. Koenig, MD, FACEP, FIFEM. Published in Journal
Watch Emergency Medicine November 2, 2012. Citation: Casserly B et al. Low-dose
steroids in adult septic shock: Results of the Surviving Sepsis Campaign.
Intensive Care Med 2012 Oct 12; [e-pub ahead of print].
12. Panel Lays Out Blueprint for Troponin Testing
By Chris Kaiser, Cardiology Editor, MedPage Today.
Published: November 14, 2012
Action Points
- Most current assays for cardiac troponin are robust with respect to both sensitivity and analytic performance around the lower limits of detectability. These assays are able to selectively detect cardiac troponin to the exclusion of troponin from other tissues.
- It is important to recognize that elevated troponin in and of itself does not indicate myocardial infarction (MI); rather, it is a sensitive and specific determinant of myocardial necrosis that is nonspecific relative to the etiology of that necrosis, according to the authors of a consensus statement on the use of troponin assays. Because it is not specific for MI, troponin evaluation should be performed only if clinically indicated for suspected MI. An elevated troponin level must always be interpreted in the context of the clinical presentation, the statement noted.
- Highly sensitive troponin assays have made it necessary for professional societies to issue the first-ever consensus statement on troponin testing.
Abstract (and at the moment, full-text free): http://content.onlinejacc.org/article.aspx?articleid=1389700
13. (Non-)Utility of head CT in the evaluation of vertigo/dizziness in the
ED
Lawhn-Heath C, et al. Emerg Radiol. 2012 Sep 2. [Epub ahead
of print]
Acute dizziness (including vertigo) is a common reason to
visit the emergency room, and imaging with head CT is often performed initially
to exclude a central cause. In this study, consecutive patients presenting with
dizziness and undergoing head CT were retrospectively reviewed to determine
diagnostic yield.
Four hundred forty-eight consecutive head CTs in a
representative sample of dizzy emergency room (ER) patients, including patients
with other neurological symptoms, were reviewed to identify an acute or
subacute cause for acute dizziness along with the frequency and modalities used
in follow-up imaging.
The diagnostic yield for head CT ordered in the ER for acute
dizziness is low (2.2 %; 1.6 % for emergent findings), but MRI changes the
diagnosis up to 16 % of the time, acutely in 8 % of cases. Consistent with the
American College of Radiology appropriateness criteria and the literature, this
study suggests a low diagnostic yield for CT in the evaluation of acute
dizziness but an important role for MRI in appropriately selected cases.
14. Low-Dose Aspirin for Preventing Recurrent Venous Thromboembolism?
BACKGROUND: Patients who have had a first episode of
unprovoked venous thromboembolism have a high risk of recurrence after
anticoagulants are discontinued. Aspirin may be effective in preventing a
recurrence of venous thromboembolism.
METHODS: We randomly assigned 822 patients who had completed
initial anticoagulant therapy after a first episode of unprovoked venous
thromboembolism to receive aspirin, at a dose of 100 mg daily, or placebo for
up to 4 years. The primary outcome was a recurrence of venous thromboembolism.
RESULTS: During a median follow-up period of 37.2 months,
venous thromboembolism recurred in 73 of 411 patients assigned to placebo and
in 57 of 411 assigned to aspirin (a rate of 6.5% per year vs. 4.8% per year;
hazard ratio with aspirin, 0.74; 95% confidence interval [CI], 0.52 to 1.05;
P=0.09). Aspirin reduced the rate of the two prespecified secondary composite
outcomes: the rate of venous thromboembolism, myocardial infarction, stroke, or
cardiovascular death was reduced by 34% (a rate of 8.0% per year with placebo
vs. 5.2% per year with aspirin; hazard ratio with aspirin, 0.66; 95% CI, 0.48
to 0.92; P=0.01), and the rate of venous thromboembolism, myocardial
infarction, stroke, major bleeding, or death from any cause was reduced by 33%
(hazard ratio, 0.67; 95% CI, 0.49 to 0.91; P=0.01). There was no significant
between-group difference in the rates of major or clinically relevant nonmajor
bleeding episodes (rate of 0.6% per year with placebo vs. 1.1% per year with
aspirin, P=0.22) or serious adverse events.
CONCLUSIONS: In this study, aspirin, as compared with
placebo, did not significantly reduce the rate of recurrence of venous
thromboembolism but resulted in a significant reduction in the rate of major
vascular events, with improved net clinical benefit. These results substantiate
earlier evidence of a therapeutic benefit of aspirin when it is given to
patients after initial anticoagulant therapy for a first episode of unprovoked
venous thromboembolism.
15. Cool Images in Clinical Medicine
Dermoscopy of Nits and Pseudonits
Rhinophyma
Giant Basilar-Artery Aneurysm
Thoracolumbar Fracture with Preservation of Neurologic
Function
Hemolytic Anemia after Mitral-Valve Repair
Anaphylaxis Associated with Blue Dye
Varicella pneumonia in an immunocompetent adult
Herpetic whitlow
Pituitary apoplexy masquerading as bacterial meningitis
Tongue hyperpigmentation during hepatitis C treatment
16. Inexperienced Physicians Practice More Expensive Medicine
Larry Hand Nov 05, 2012. Medscape Medical News
Less-experienced physicians practice more expensive medicine
than more-experienced physicians do, according to a study published in the
November issue of Health Affairs. The practice patters of less-experienced
physicians may be a driving factor in rising healthcare costs.
Ateev Mehrotra, MD, MPH, associate professor of medicine at
the University of Pittsburgh and a policy analyst at the RAND Corporation,
Pittsburgh, Pennsylvania, and colleagues analyzed data provided by
Massachusetts Health Quality Partners and 4 health insurance plans to compare
cost profiles of 12,116 Massachusetts physicians who treated 1.13 million
patients in 2004 and 2005.
The Affordable Health Care Act requires Medicare to develop
physician cost profiles this year, and health insurance plans are using them to
develop tiered provider networks, the researchers write. Cost profiles compare
how a physician uses resources compared with how their peers do.
Compared with the most experienced physicians (40 or more
years of practice), physicians with fewer than 10 years of experience had 13.2%
higher cost profiles, physicians with 10 to 19 years of experience had 10.0%
higher cost profiles, physicians with 20 to 29 years of experience had 6.5%
higher cost profiles, and physicians with 30 to 39 years of experience had 2.5%
higher cost profiles.
"This finding suggests that less-experienced physicians
will, on average, be negatively affected by policies that use physician cost
profiles unless they modify their practice patterns," the researchers
write. "For example, it is more likely that less-experienced physicians
will be excluded from high-value networks or will receive lower payments under
Medicare's value-based payment modifier program, which is slated to begin in
2015."
Two possible explanations may explain the differences in
cost profiles, the researchers write. First, newer physicians may practice in
more costly patterns than more-experienced physicians, and second, differences
in cost profiles "may reflect an issue with the cost-profiling
methodology." Newer physicians may be more familiar with and may use the
most expensive treatment modalities, and they also may treat sicker patients
and in general treat more aggressively, the researchers write.
It is also possible, they add, that a "cohort
effect" exists, with the less-experienced physicians as a group remaining
more costly going forward rather than lowering costs as they gain experience.
"If there is a cohort effect involved, our results suggest that
postgraduate training programs and specialty boards need to educate physicians
on their responsibility to be good stewards of health care resources," the
researchers write.
Notable Exceptions
The researchers found no associations with cost profiles in
2 notable areas: They found no association between cost profiles and
malpractice claims, which is consistent with previous study results, and they
found no significant association between cost profiles and size of physician
practices, even though recent incentives have been offered to encourage
physicians to join larger groups or accountable care organizations.
Limitations of the study include the lack of measurement for
quality of care and the fact that it was limited to Massachusetts, which has a
high density of physicians and academic medical centers and higher healthcare
costs than the national average. Also, the comparisons are across all
specialties, which if taken individually would show "notable
variations," the researchers write.
The study's policy implications include "the fact that
there will be losers and winners in any cost-profiling effort," the
researchers conclude. If the differences are derived from the methodology of
cost-profile creation, they suggest development of a better methodology. If the
differences are driven by actual practice differences, they suggest further
research to understand the reasons for the practice patterns.
"Our findings cannot be considered final, but they do
underscore the need to better understand physician practice patterns and what
influences that behavior," Dr. Mehrotra said in a news release.
The study was funded by the Commonwealth Fund and the US
Department of Labor. Dr. Mehrotra was supported by a grant from the National
Center for Research Resources, National Institutes of Health. The other authors
have disclosed no relevant financial relationships.
Health Affairs. 2012:31;2453-2463
17. Complaint-specific Predictors of High Patient/Parent Satisfaction
A. Predictors of
Parent Satisfaction in Pediatric Laceration Repair.
Lowe DA, et al. Acad Emerg Med. 2012 Oct;19(10):1166-1172.
Objectives: Patient and parent satisfaction are important
measures of quality of care. Data are lacking regarding satisfaction with
emergency procedures, including laceration repair. The objective was to define
the elements of care that are important to parents during a pediatric
laceration repair and to determine the predictors of excellent parent
satisfaction.
Methods: This was a cross-sectional observational study of a
convenience sample of patients younger than 18 years of age presenting for
laceration repair to an urban tertiary care children's hospital emergency
department (ED). At the end of the ED visit, parents completed a survey
developed for this study assessing ratings of their experience and their
perception of how their child experienced the repair. Exploratory factor
analysis was used to derive the factors comprising parents' perception of the
laceration repair process. A separate factor analysis was performed for the 0-
to 4-years age subgroup. Multivariate logistic regression was used to determine
which of these factors predicted excellent parent satisfaction with the visit,
and also satisfaction with the procedure itself, adjusting for sociodemographic
factors.
Results: A total of 408 parents returned completed surveys
(response rate = 76%). Factor analysis revealed that three factors provided a
summary of the 16 survey items. They were labeled "provider
performance,""anxiety and pain," and "cosmetic
appearance," based on factor loading patterns. Provider performance was
the only predictor of satisfaction with the visit (adjusted odds ratio [OR] =
11.6; 95% confidence interval [CI] = 6.2 to 21.6). Provider performance
(adjusted OR = 4.7; 95% CI = 3.1 to 7.2) and cosmetic appearance (adjusted OR
2.7; 95% CI = 1.7 to 4.2) predicted satisfaction with the procedure. Anxiety
and pain did not predict either outcome.
Conclusions: Provider performance, which comprises the
elements of physician communication, caring attitude, confidence, and hygiene,
is the strongest predictor of excellent parent satisfaction for pediatric
patients with ED visits for laceration repair.
B. Factors Associated
With High Levels of Patient Satisfaction with Pain Management
Shill J, et al. Acad Emerg Med. 2012;19:1212-1215.
Objectives: The objective was to determine, among emergency
department (ED) patients, the factors associated with a high level of
satisfaction with pain management.
Methods: This was a prospective cohort study in a single
ED. Consecutive adult patients, with triage pain scores of ≥4 (numerical rating
scale = 0 to 10), were enrolled. Variables examined included demographics,
presenting complaint, pain scores, nurse-initiated analgesia, analgesia
administered, time to first analgesia, specific pain communication, and whether
“adequate analgesia” was provided (defined as a decrease in pain score to below
4 and a decrease from the triage pain score of ≥2). The level of patient
satisfaction with their pain management (six-point scale: very unsatisfied to
very satisfied) was determined by a blinded investigator 48 hours post
discharge. Logistic regression analyses were undertaken.
Results: Data were complete for 476 patients: mean
(±standard deviation [SD]) age was 43.6 (±17.2) years, and 237 were males
(49.8%, 95% confidence interval [CI] = 45.2% to 54.4%). A total of 190 (39.9%,
95% CI = 35.5% to 44.5%) patients were “very satisfied” with their pain
management, and 207 (43.5%, 95% CI = 39.0% to 48.1%) patients received adequate
analgesia. Three variables were associated with the patient being very
satisfied: the provision of adequate analgesia (odds ratio [OR] = 7.8, 95% CI =
4.9 to 12.4), specific pain communication (OR = 2.3, 95% CI = 1.3 to 4.1), and
oral opioid administration (OR = 2.0, 95% CI = 1.1 to 3.4). Notably, the
provision of nurse-initiated analgesia to 211 patients (44.3%, 95% CI = 39.8% to
48.9%) and the short time to analgesia (median = 11.5 minutes; interquartile
range [IQR] = 2.0 to 85.8 minutes) were not associated with being very
satisfied.
Conclusions: The receipt of adequate analgesia (as defined)
is highly associated with patient satisfaction. This variable may serve as a
clinically relevant and achievable target in the pursuit of best-practice pain
management.
18. Ultrasound Updates (from ACEP News and EM News)
A. Bedside Ultrasound
Assessment of Left Ventricular Function
By Siadecki S, et al. ACEP News October 2012
Emergency physicians must often manage critically ill
patients whose hemodynamic status is unclear, especially early in the course of
their disease.
Correct and timely diagnosis of the prevailing hemodynamic
process is of utmost importance, and the physical exam and vital signs alone
are often unreliable. Moreover, congestive heart failure is extremely prevalent
in the emergency department population, andmore than half of patients with
moderate to severe systolic dysfunction have never been diagnosed with heart
failure.
Bedside echocardiography by the emergency physician offers a
rapid, noninvasive, and inexpensive method to determine the role that the
patient's systolic cardiac function may be playing in their disease process.
Besides the diagnosis of heart failure, assessment of left ventricular
(LV)function can help distinguish between cardiac and other etiologies of
undifferentiated hypotension or shock. Multiple studies have demonstrated that
emergency physicians with focused training in transthoracic echocardiography
can accurately determine left ventricular ejection fraction (LVEF) in
critically ill patients.
In combination with other common emergency department
ultrasound applications such as evaluation of the inferior vena cava (IVC) as a
marker of intravascular volumestatus, and evaluation of the lungs and pleura,
assessment of LVEFcan be a valuable tool in the management of critically ill
patients…
For the rest of the essay (free): http://www.acep.org/Education/Continuing-Medical-Education-(CME)/Focus-On/Focus-On--Bedside-Ultrasound-Assessment-of-Left-Ventricular-Function/
B. Focused Renal
Ultrasonography
By Smith TY, et al. ACEP News August 2012
Renal ultrasonography has replaced more invasive
radiographic assessments such as IVP (intravenous pyelogram) in the diagnosis
of the more common kidney complaints. In the emergency department, bedside
renal ultrasound has allowed the physician to quickly and accurately assess the
kidneys and the bladder for obstruction. Goredlik et al. found that in the
diagnosis of renal calculus, the sensitivity of renal ultrasound alone was 93%
and specificity83%.1 When combined with kidney ultrasound biopsy (KUB),the
specificity increased to 100%.
There are multiple chief complaints that can lead to the
diagnosis of renal pathology, including flank pain, abdominal pain,back pain,
urinary retention, dysuria, and/or hematuria. The emergency physician can
easily bring the ultrasound machine to the bedside for quick assessment of the
kidneys and the bladder to evaluate for renal pathology.
For the rest of the essay (free): http://www.acep.org/Content.aspx?id=88214
C. Pediatric Hip
Ultrasound
By Martin J, et al. ACEP News July 2012
Acute onset of limp or refusal to bear weight is a common
presenting complaint in the Pediatric Emergency Department (PED).1 History and
physical examination may be limited by the child's age and ability to
cooperate. With a broad differential, including infectious, traumatic,
inflammatory, intra-abdominal, hematologic, and other musculoskeletal disorders
as etiologies, it is imperative that the emergency department workup be
thorough.
Even when the pain can be localized to the hip, the
differential diagnosis remains broad (Table 1). The history and physical
examination can help guide the differential diagnosis. When there is a high
clinical suspicion for infectious or inflammatory pathology (fevers, painful
range of motion, overlying erythema),laboratory studies, including a blood
culture, complete blood cell count, C-reactive protein, and an erythrocyte
sedimentation rate, are indicated.
Plain radiographs can screen for fractures, avascular
necrosis and destructive lesions, but have limited utility for detectingjoint
effusions. Ultrasound is an excellent
modality for identifying joint effusions, and detection of an effusion focuses
the differential diagnosis toward osteomyelitis, transient synovitis, or septic
arthritis, and away from neoplasms, avascular necrosis, slipped capital femoral
epiphysis (SCFE) or Legg-Calvé-Perthes disease.
Point of care ultrasound to detect hip effusion can serve as
an adjunct to the history and physical examination in the evaluation of hip
pain in the pediatric population. It is
an ideal imaging modality in pediatric patients due to its ease of use,
portability, reproducibility, low cost and, perhaps most important, lack of
radiation exposure…
For the rest of the essay (free): http://www.acep.org/Education/Continuing-Medical-Education-(CME)/Focus-On/Focus-On--Pediatric-Hip-Ultrasound/
D. Ultrasound
Effective (and Less Radiation) for Diagnosing Appendicitis
By Butts C. Emerg Med News 2012;34:7
A 25-year-old man presents to the ED complaining of pain in
his lower abdomen for three days. He states that the pain initially began in
his periumbilical area, and has now migrated to his lower abdomen. He describes
subjective fevers, chills, and nausea.
His blood pressure is 110/80 mm Hg, heart rate is 100 bpm,
respiratory rate is 12 bpm, and his temperature is 100.8°F. His exam reveals
significant tenderness to his right lower quadrant with rebound. A bedside
ultrasound reveals acute appendicitis, a commonly suspected diagnosis in
patients with abdominal pain. Many practitioners rely on computed tomography to
make the definitive diagnosis in suspicious cases, but this approach may not be
feasible or advised. Obtaining a CT scan frequently requires intravenous and
oral contrast, which may be time-consuming, and growing concerns about the
long-term effects of routine CT scans may cause the emergency physician to
reconsider this modality.
Bedside ultrasound of the appendix is typically considered a
more advanced application, but it can be successfully performed by the
emergency physician. Visualization of the features of acute appendicitis in the
correct clinical scenario may allow the practitioner to make the diagnosis
without additional imaging.
An inflamed appendix is best visualized with a
high-frequency transducer, which allows for sufficient resolution of the area
and identification of the organ. This transducer will provide excellent
resolution but limited depth of penetration, so bedside ultrasound of the
appendix may be limited by patient habitus.
A helpful starting point for the bedside sonographer to
identify the appendix is to begin the exam at the area of maximal pain or
tenderness. Alternatively, the transducer can be placed in the approximate
location of McBurney's point. Gentle compression of the transducer should be
applied to displace overlying bowel. The initial orientation of the transducer
is less important because the orientation of the appendix is variable. The entire
right lower quadrant should be scanned in both orientations.
An inflamed appendix typically appears as a “target” in
transverse because of edema within its walls. The characteristic finger-like
shape of the appendix can be seen in the longitudinal orientation. The appendix
can be differentiated from other segments of bowel by its blind end. The total
diameter will be greater than 6 mm and the lumen will not compress with
pressure because it is fluid-filled. Anechoic (black) fluid may be seen
surrounding the area, particularly with advancing appendicitis. Application of
color Doppler may reveal increased flow, secondary to hyperemia. Finding an
appendix with these characteristics can help to confirm an appendicitis
diagnosis, but not localizing the appendix does not rule it out because patient
habitus, bowel gas, or atypical positioning may hide it from view. A normal
appendix is frequently difficult to localize to rule out acute appendicitis.
Further evaluation and management is warranted in cases where appendicitis is
clinically suspected without clear sonographic evidence.
19. ID Updates from James Roberts, MD, EM
News
Dr. Roberts is the chairman of emergency medicine and the
director of the division of toxicology at Mercy Catholic Medical Center, and a
professor of emergency medicine and toxicology at the Drexel University College
of Medicine, both in Philadelphia.
A. Neisseria
Gonorrhoeae: The New Superbug (October 2012)
The emergence of extended spectrum beta-lactamase-producing
bacteria is worrisome. ESBLs make some rather nasty bacteria like E. coli and
Klebsiella resistant to our most powerful and universally used antibiotics. So
far, carbapenems are still effective, and they should be empirically used if
ESBL organisms are suspected or prevalent, a scenario especially prominent in
urosepsis.
Resistant organisms are a way of life in modern medicine,
and primarily are the result of our own technology and clinical zeal that have
produced and overused extremely powerful antimicrobials. But Mother Nature
always wins out in the end. Bacteria are clever enough to develop resistance to
even the most powerful antibiotics produced by the highly competitive and
gargantuanly profitable pharmaceutical industry.
Perhaps unknown to other clinicians, Neisseria gonorrhoeae,
AKA the wily gonococcus, has slowly developed antibiotic resistance that has
morphed this once easy-to-treat organism into a potential superbug. This is not
yet water cooler fodder in the ED, but this phenomenon has not escaped the
watchful eye of the Centers for Disease Control and Prevention or publications
in erudite but rarely read infectious disease journals. It's time for an update
for emergency physicians who treat gonococcus regularly so they understand the
rather scary scenario that may make gonococcal infections untreatable…
For the rest of the essay (free): http://journals.lww.com/em-news/Fulltext/2012/10000/InFocus__Neisseria_Gonorrhoeae__The_New_Superbug.4.aspx
B. Treatment of
Uncomplicated Pyelonephritis in Women (September 2012)
The Infectious Diseases Society of America and the European
Society for Microbiology and Infectious Diseases recently updated its
guidelines for treating acute uncomplicated cystitis in women, recommending
only three common antibiotics and eschewing fluoroquinolones. (See FastLinks.)
The same article also pontificated on the treatment for uncomplicated acute
pyelonephritis in women.
The guidelines were limited to premenopausal non-pregnant
women with no known urological abnormalities and no significant comorbidities.
The population had so-called uncomplicated pyelonephritis, but many decidedly
complicated individuals populate the ED. The resistance and prevalence of the
local flora and the collateral damage of antimicrobial therapy were considered
important factors in making optimal empirical treatment decisions, just as they
were with the recommendations for acute cystitis…
For the rest of the essay (free): http://journals.lww.com/em-news/Fulltext/2012/09000/InFocus__Treatment_of_Uncomplicated_Pyelonephritis.6.aspx
C. Uncomplicated
Acute Cystitis: Times Have Changed (August 2012)
If you thought you knew all about the modern and up-to-date
treatment of acute cystitis in women, think again. Times have changed, as have
treatment regimens and the profile of infecting organisms. The overuse of
antibiotics has culled out resistant bacteria that used to be easily controlled
with even one or two doses of simple antibiotics, such as amoxicillin.
E. coli would readily die when the first few molecules of
antibiotics filtered into the infected urinary bladder. But if you haven't
reviewed this topic in the past few years and continue to use the same
antibiotics you did when you were an intern, you're behind the times. Updated
clinical practice guidelines for treating acute uncomplicated cystitis in women
were published in 2010 by some prestigious infectious diseases societies. This
month: garden-variety acute cystitis; next month: -pyelonephritis. Also read
last month's column on the emergence of bacteria that produce extended spectrum
-B-lactamase (ESBL), substances that inactivate once-invincible antibiotics,
making some E. coli and Klebsiella -infections impossible to cure without using
some rather exotic antimicrobials…
For the rest of the essay (free): http://journals.lww.com/em-news/Fulltext/2012/08000/InFocus__Uncomplicated_Acute_Cystitis__Times_Have.4.aspx
20. Medscape Emergency Medicine Cardiology Corner
A. Mattu’s Literature
Update 2012: 3 Articles You've Gotta Know!
Amal Mattu, MD Nov
15, 2012
His 3 favorite articles for 2012:
- Canto JG, et al for the NRMI Investigators. Association of Age and Sex With Myocardial Infarction Symptom Presentation and In-Hospital Mortality. JAMA. 2012;307:813-822.
- Than M, et al. 2-Hour Accelerated Diagnostic Protocol to Assess Patients With Chest Pain Symptoms Using Contemporary Troponins as the Only Biomarker: The ADAPT Trial. J Am Coll Cardiol. 2012;59:2091-2098.
- Nishijima DK, et al, for the KP CREST Network. Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and pre-injury warfarin or clopidogrel use. Ann Emerg Med. 2012;59(6):460-468.e7.
His discussion (full-text free): http://www.medscape.com/viewarticle/774474
B. ECGs
1. What
Life-Threatening Condition Does This Tracing Show?
Wang K. Medscape Cardiology: ECG of the Week
2. Three Questions
for 1 Tracing
Wang K. Medscape Cardiology: ECG of the Week
21. Hospitals Slash Central Line Infections with Program That Empowers
Nurses
Kuehn BM. JAMA. 2012;308(16):1617-1618.
It's been 31 months since a patient in the intensive care
unit has developed a central line–associated bloodstream infection (CLABSI) at
the Peterson Regional Medical Center in Kerrville, Tex, said nurse educator
Theresa Hickman, RN, during a press briefing in September.
Comprehensive Unit-based Safety Program (CUSP) has helped
hospital units drastically reduce or eliminate central line infections.
Hickman credits this achievement—eliminating infections that
were once considered inevitable—to the staff of the 125-bed rural hospital,
which implemented the Comprehensive Unit-based Safety Program (CUSP), an initiative
being rolled out at hospitals nationwide to curb hospital-acquired infections.
Hickman described it as the most powerful quality improvement effort she's
encountered in her 32-year career. What makes it different from many other
efforts is that it empowers nurses and other frontline caregivers to identify
and fix problems that may compromise patient safety.
“We listen to the wisdom of our frontline caregivers,” she
said.
And she's not alone in singing the praises of the program.
Over the past 4 years, CUSP has been rolled out at 1100 intensive care units
across the country, and preliminary data suggest that the effort has cut the
rate of CLABSIs nationally by 40%, reducing the rate of infections per 1000
central-line days from 1.9 to 1.1. According to Carolyn Clancy, MD, director of
the Agency for Healthcare Research and Quality (AHRQ), which sponsored the
project, the program has prevented 2000 infections, saved 500 lives, and saved
$34 million in health costs.
“This could be health care's man-on-the-moon moment,” said
Peter Pronovost, MD, senior vice president for patient safety and quality at
Johns Hopkins Medicine in Baltimore, who created the program with colleagues at
Hopkins and has been testing its effectiveness.
Pronovost explained that the program was inspired by the
death of an 18-month-old girl at Hopkins as a result of a CLABSI. Infection
rates were high at the hospital when the girl died. The hospital implemented a
series of improvements, including nurse-administered checklists to ensure
infection prevention practices were followed, hospital-wide culture about
infection prevention underwent a change, and performance measures to gauge
implementation were put in place.
“It worked,” he said. “Infections were virtually
eliminated.”
The toolkit derived from this effort became CUSP, and with
funding from the AHRQ, Pronovost has systematically tested its implementation
on an increasingly larger scale. First, a 2-year, $500 000 project to implement
the program at Michigan hospitals, led by the Michigan Health and Hospital
Association, reduced CLABSIs by 66% at 100 intensive care units across the
state within 6 months, eliminating such infections in 65% of the units. The
latest results come from a 4-year effort to roll out the program in 44 states.
The remainder of the essay (full-text free): http://jama.jamanetwork.com/article.aspx?articleid=1386607
22. Topical Ivermectin Lotion for Treatment of Head Lice
One 10-minute application was very effective and could help
avoid systemic medication.
Although head lice do not transmit disease, infestation
causes pruritus, eczematization, social stigmatization, and school absence. Use
of the first- line agents permethrin and pyrethrins is limited by emerging
resistance. Lindane is disfavored because of neurologic toxicity, and malathion
is flammable. Two recently approved agents, spinosad and benzyl alcohol lotion,
are relatively expensive. Oral ivermectin has known efficacy when other
treatments have failed. These researchers report the findings of two
manufacturer-supported studies of topical ivermectin.
In multicenter, randomized, double-blinded,
vehicle-controlled trials of a single dose of ivermectin 0.5% lotion without nit
combing, a total of 132 index patients aged 6 months and older with three or
more live lice (and more than 600 family members who had 1 or more live lice)
received ivermectin lotion or vehicle alone. The primary end point was the
number of patients who were louse-free by day 2 and remained louse-free through
days 8 and 15. Ivermectin or vehicle was applied to dry hair and rinsed out
after 10 minutes. In the intention-to-treat population, significantly more
ivermectin recipients than vehicle recipients were louse-free on day 2 (95% vs.
31%), day 8 (85% vs. 21%), and day 15 (74% vs. 18%; P less than 0.001 for each
comparison). Adverse events, including pruritus, excoriation, and erythema,
occurred equally often with ivermectin and control (in approximately 1% of both
groups).
Comment: Results of this large, rigorous study indicate that
single-dose topical ivermectin 0.5% lotion without nit combing is
well-tolerated and very effective. The day 15 louse-free rate of 74% resembles
rates with other two-application topical agents and may reflect imperfect
application, viable eggs, or reinfestation. A second application may improve
prolonged clearance rates. Head-to-head studies, resistance data, postmarketing
data, and cost-benefit analysis are needed to determine which topical agents
should be first-line therapy, which should be reserved for certain populations,
and when oral pediculicides are appropriate. Lastly, changes in no-nit policies
are needed to prevent unnecessary school absenteeism.
— Mary Wu Chang, MD. Published in Journal Watch Dermatology
October 31, 2012.
Citation: Pariser DM et al. N Engl J Med 2012 Nov 1;
367:1687-1693.
23. Prehospital Computer Interpretation of ECGs Is Inaccurate
Nearly half of patients with STEMI were missed in this
single-site retrospective study.
Bhalla MC et al. Prehosp Emerg Care 2012 Oct 15
Background. Identifying ST-segment elevation myocardial
infarctions (STEMIs) in the field can decrease door-to-balloon times.
Paramedics may use a computer algorithm to help them interpret prehospital
electrocariograms (ECGs). It is unknown how accurately the computer can
identify STEMIs.
Objectives. To Determine the sensitivity and specificity of
prehospital ECGs in identifying patients with STEMI.
Methods. Retrospective cross-sectional study of 200
prehospital ECGs acquired using Lifepak 12 monitors and transmitted by one of
more than 20 emergency medical services (EMS) agencies to the emergency
department (ED) of a Summa Akron City Hospital, a level 1 trauma center between
January 1, 2007, and February 18, 2010. The ED sees more than 73,000 adult
patients and treats 120 STEMIs annually. The laboratory performs 3,400
catheterizations annually. The first 100 patients with a diagnosis of STEMI and
cardiac catheterization laboratory activation from the ED were analyzed. For
comparison, a control group of 100 other ECGs from patients without a STEMI
were randomly selected from our Medtronic database using a random-number
generator. For patients with STEMI, an accurate computer interpretation was
“acute MI suspected.” Other interpretations were counted as misses. Specificity
and sensitivity were calculated with confidence intervals (CIs). The sample
size was determined a priori for a 95% CI of ±10%.
Results. Zero control patients were incorrectly labeled
“acute MI suspected.” The specificity was 100% (100/100; 95% CI 0.96–1.0),
whereas the sensitivity was 58% (58/100; 95% CI 0.48–0.67). This would have
resulted in 42 missed cardiac catheterization laboratory activations, but zero
inappropriate activations. The most common incorrect interpretation of STEMI
ECGs by the computer was “data quality prohibits interpretation,” followed by
“abnormal ECG unconfirmed.”
Conclusions. Prehospital computer interpretation is not
sensitive for STEMI identification and should not be used as a single method
for prehospital activation of the cardiac catheterizing laboratory. Because of
its high specificity, it may serve as an adjunct to interpretation.
24. Nasal FBs: Efficacy and safety of the “mother’s kiss” technique: a
systematic review of case reports and case series
Cook S, et al. CMAJ 2012:184.E904-E912
Background: Foreign bodies lodged in the nasal cavity are a
common problem in children, and their removal can be challenging. The published
studies relating to the “mother’s kiss” all take the form of case reports and
case series. We sought to assess the efficacy and safety of this technique.
Methods: We performed a comprehensive search of the Cochrane
library, MEDLINE, CINAHL, Embase, AMED Complementary and Allied Medicine and
the British Nursing Index for relevant articles. We restricted the results to only
those studies involving humans. In addition, we checked the references of
relevant studies to identify further possibly relevant studies. We also checked
current controlled trials registers and the World Health Organization search
portal. Our primary outcome measures were the successful extraction of the
foreign object from the nasal cavity and any reported adverse effects. We
assessed the included studies for factors that might predict the chance of
success of the technique. We assessed the validity of each study using the
Newcastle–Ottawa scale.
Results: Eight relevant published articles met our inclusion
criteria. The overall success rate for all of the case series was 59.9%
(91/152). No adverse effects were reported.
Interpretation: Evidence from case reports and case series
suggests that the mother’s kiss technique is a useful and safe first-line
option for the removal of foreign bodies from the nasal cavities of children.
Full-text (free): http://www.cmaj.ca/content/184/17/E904.full
25. The Price of False Beliefs: Unrealistic Expectations as a Contributor
to the Health Care Crisis
Woolf SH. Ann Fam Med. 2012;10:491-494.
The alarming rise in health care costs haunts our society.
The United States now spends $2.6 trillion per year on health care,1 and the
spiraling costs are placing unsustainable burdens on employers and workers,
Medicare and Medicaid, state and local governments, and American families. A
growing proportion of Americans are now foregoing health care to pay for other
household needs or are facing bankruptcy.2 A variety of strategies have been
proposed to slow medical cost inflation, such as realigning financial
incentives to discourage costly procedures, accountable care organizations, the
patient-centered medical home, and malpractice reforms. Evidence that any of
these ideas will bend the cost curve remains limited.
A more basic but possibly neglected strategy for reducing
demand for health services is to confront unrealistic beliefs about their
benefits. Health care expenditures ultimately begin with a decision to use the
service, a decision that may rest on false expectations—among patients,
clinicians, or both. Removing the need for the service by correcting such misperceptions
is a potentially more effective way to curb costs than many current reforms can
achieve. Financial incentives are important, but they are weak when pitted
against core beliefs. If patients and clinicians widely hold that a procedure
is life-saving and harmless, any reform is unlikely to curb demand until those
misconceptions are addressed.
Studies suggest that patients, clinicians, and society often
hold unrealistic expectations about the effectiveness of tests and treatments.
Two articles in this issue add to that literature. In New Zealand, Hudson et
al3 surveyed 977 primary care patients and found that many overestimated the
benefits of cancer screening and chemopreventive medications. The minimum
benefit from screening that respondents deemed acceptable was less than their
known benefit. The survey had a modest sample size and low response rate (36%),
and its findings might not be fully applicable to other countries, but US
studies have reported a similar problem. For example, a variety of studies
document Americans' appetite for procedures of dubious effectiveness and their
overestimation of benefits.4,5 Many Americans underestimate the probability of
harms and are quite willing to receive false-positive results and unnecessary
biopsies for the chance to detect cancer.6,7 Public complacency about the
safety of health care is only occasionally shaken, as when a conspicuous
tragedy or disclosures of industry wrongdoing draw attention to specific
dangers.
Physicians are not immune to false beliefs about clinical
efficacy or complication rates.8 Correcting such misperceptions has always been
part of the impetus for the evidence-based medicine movement and its
promulgation of systematic evidence reviews, practice guidelines, and other
tools that present the facts on benefits, safety, and scientific uncertainties.
Even these tools, however, can reflect the misconceptions of those who produce
them. The specialists who serve on expert panels derive much of their clinical
case knowledge from the patients with advanced disease who fill their clinics.
Having seen the worst of the worst, they are less sympathetic to expressions of
concern about the potential harms of interventions or imperfections in efficacy
studies.9 Whereas epidemiologists consider the population denominator to put
the numerator in perspective, the world of specialists is confined to the
numerator, giving them a skewed basis for judging the population prevalence of
diseases or benefit-risk ratios. Were this not enough, the preeminent scientists
who often serve on guideline panels bring additional biases, such as being the
authors of key studies under review or having financial ties to industry.10...
The remainder of the essay (free): http://www.annfammed.org/content/10/6/491
