1. New US STEMI Guidelines Are More User Friendly
Lisa Nainggolan, Heartwire. Dec 18, 2012
BOSTON — Newly issued US guidelines for the treatment of
ST-elevation MI (STEMI) are "much more user friendly for practicing
cardiologists and get quickly to the bottom line," says one member of the
writing committee, Dr James Fang (University Hospitals Case Medical Center,
Cleveland, OH) [1,2].
Fang told heart wire that prior US STEMI recommendations
have been "much more encyclopedic," but this time the writing committee
tried to focus on what people were going to use. "It can be as
authoritative as any document, but if nobody is going to bother picking it up,
then we really haven't succeeded in our purpose. We wanted more synthesis of
available evidence in our conclusions."
The new 2013 ACCF/AHA guidelines for the management of STEMI
are published simultaneously in Circulation and the Journal of the American
College of Cardiology, by Dr Patrick O'Gara (Brigham and Women's Hospital,
Boston, MA) and colleagues; they were developed in collaboration with the
American College of Emergency Physicians (ACEP) and Society for Cardiovascular
Angiography and Interventions (SCAI).
Improving Symptom Recognition and Big Emphasis on Cardiac
Rehab
Fang says there are a number of key points in the new
recommendations: improving recognition of the symptoms of heart attack;
advising that ECGs are done in the field by ambulance personnel to facilitate
more rapid triage and quicker treatment; stronger endorsement of the use of
hypothermia for cardiac-arrest victims; and a bigger push for better cardiac
rehabilitation and postprocedural care.
"We have focused on the concept of 'total ischemic
time'--not only the technical aspects in terms of the procedure itself and
adjuvant therapies, but really concentrating on things like care of the patient
prior to arrival and the need to try to get the patient assessed quickly. We
can't open a vessel until the patient is identified, and one of the greatest
delays in the management of this particular condition is time to recognition,
because once it's recognized, we can move quickly.
"We've also addressed the issues of patients who have a
cardiac arrest, who become unconscious, with the idea of hypothermia--which has
become reasonably well-established, and the guidelines also speak to
that," adds Fang. This is the first time the STEMI guidelines have
endorsed hypothermia "to this degree," he says, but he cautions that
there are many more details that remain to be ironed out (eg, the degree of
hypothermia).
Finally, the document puts an overriding emphasis on better
cardiac rehabilitation, improving the care of the patient after the procedure.
"We wanted to focus on the transition from postprocedure to home, from
having a heart attack to the care afterward. This needs to be carefully
orchestrated," Fang stresses.
This includes ensuring referral for cardiac rehabilitation,
with a table in the new guidelines itemizing considerations such as smoking
cessation, cholesterol management, social needs, depression, and cultural and
gender-related factors that may contribute to outcomes.
O'Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA
guideline for the management of st-elevation myocardial infarction. A report of
the American College of Cardiology Foundation/American Heart Association Task
Force on Practice Guidelines. Circulation 2012 [Epub ahead of print]
Full-text (free): http://circ.ahajournals.org/content/early/2012/12/17/CIR.0b013e3182742cf6.full.pdf+html
2. IV Lidocaine Beats IV Morphine for Patients with
Renal Colic in the ED
Soleimanpour H, et al. BMC Urol. 2012;12(13)
Intro
Affecting 1–5 % of the population in industrialized
countries, renal colic is considered as a major concern in medicine. Renal
colic has been reported to be experienced by 20 % of white males and 5-10 % of
white females. [1] The classic presentation of acute renal colic includes
sudden pain onset radiating from the flank to the lower extremities which is
usually accompanied by microscopic hematuria (85 % of cases), nausea and
vomiting. Costovertebral angle tenderness is a common finding as well. [2]
To relieve the pain until being discharged or undergoing the
required operation is mostly performed in emergency departments. [1] To achieve
this, numerous medications including antiemetics, narcotics, non-steroidal
anti-inflammatory drugs, antispasmodics, anti-diuretics, ketorolac, nifedipine,
prednisone, acetaminophen and prochlorperazine have been introduces. [2]
Lidocaine, being an appropriate choice in treating visceral
and central pain, might also be useful wherever narcotics are inefficient or
lead to undesirable side effects. Intravenous lidocaine is effective in controlling
neuropathic pains such as: diabetic neuropathy, post-operative pain,
post-herpetic pain, headaches and neurological malignancies. [3,4] Therefore we
aimed at investigating and reviewing the analgesic effects of intravenous
lidocaine compared with intravenous morphine in patients with renal colic.
Abstract
Background: Despite the fact that numerous medications have
been introduced to treat renal colic, none has been proven to relieve the pain
rapidly and thoroughly. In this study, we aimed at comparing the effects of
intravenous lidocaine versus intravenous morphine in patients suffering from
renal colic.
Methods: In a prospective randomized double-blind clinical
trial performed in the emergency department of Imam Reza educational hospital
of Tabriz, Iran, we studied 240 patients, 18–65 years old, who were referred
due to renal colic. Patients were divided into two groups. In group I (120
people) single-dose intravenous lidocaine (1.5 mg/kg) was administered and in
group II (120 people) single-dose intravenous morphine (0.1 mg/kg) was
administered slowly. Visual Analogue Pain Scale (VAS) was recorded while admission,
5, 10, 15 and 30 minutes after injection. Statistical data and results were
studied using descriptive statistics as percentage and Mean ± SD. To compare
the response to treatment, Mann–Whitney U-test was used in two groups.
Consequently, the data were analyzed using the SPSS16 software.
Results Pain score measured in two groups five minutes after
the injection of lidocaine and morphine were 65 % and 53 % respectively (95% CI
0.60 - 0.69, CI 0.48 – 0.57, p = 0.0002).108 (90 %) patients (95 % CI 0.84 –
0.95) from group I and 84 (70%) patients (95 % CI 0.62 - 0.78) from group II
responded appropriately at the end of the complete treatment. The difference
was statistically significant (p = 0.0001).
Conclusions Changing the smooth muscle tone and reducing the
transmission of afferent sensory pathways, lidocaine causes a significant
reduction in pain.
Full-text (free): http://www.biomedcentral.com/1471-2490/12/13
3. Emerging concepts in the diagnosis and treatment
of patients with undifferentiated angioedema
Bernstein JA, et al. Internat J Emerg Med 2012, 5:39
Angioedema is a sudden, transient swelling of
well-demarcated areas of the dermis, subcutaneous tissue, mucosa, and
submucosal tissues that can occur with or without urticaria. Up to 25% of
people in the US will experience an episode of urticaria or angioedema during
their lifetime, and many will present to the emergency department with an acute
attack. Most cases of angioedema are attributable to the vasoactive mediators
histamine and bradykinin.
Histamine-mediated (allergic) angioedema occurs through a
type I hypersensitivity reaction, whereas bradykinin-mediated (non-allergic)
angioedema is iatrogenic or hereditary in origin.
Although their clinical presentations bear similarities, the
treatment algorithm for histamine-mediated angioedema differs significantly
from that for bradykinin-mediated angioedema.
Corticosteroids, and epinephrine are effective in the
management of histamine-mediated angioedema but are ineffective in the
management of bradykinin-mediated angioedema. Recent advancements in the
understanding of angioedema have yielded pharmacologic treatment options for
hereditary angioedema, a rare hereditary form of bradykinin-mediated
angioedema. These novel therapies include a kallikrein inhibitor (ecallantide)
and a bradykinin β2 receptor antagonist (icatibant).
The physician’s ability to distinguish between these types
of angioedema is critical in optimizing outcomes in the acute care setting with
appropriate treatment. This article reviews the
pathophysiologic mechanisms, clinical presentations, and diagnostic
laboratory evaluation of angioedema, along with acute management strategies for
attacks.
Full-text (free): http://link.springer.com/content/pdf/10.1186%2F1865-1380-5-39
4. What is the incidence of major adverse cardiac
events in ED CP patients with a normal ECG, TIMI score of zero and initial
troponin ≤99th centile? An observational study
Kelly AM. Emerg Med J 2013;30:15-18
Objective To determine the rate of major adverse cardiac
events (MACE) in patients assessed in an emergency department (ED) for chest
pain with a non-ischaemic ECG, Thrombolysis in Myocardial Infarction (TIMI)
score of 0 and initial troponin I (TnI) ≤99th centile.
Methods This was a sub-study of a prospective observational
study of adult patients with potentially cardiac chest pain who underwent
evaluation for acute coronary syndrome in an urban teaching hospital. Adult
patients with non-traumatic chest pain were eligible for inclusion. Those with
ECG evidence of acute ischaemia or an alternative diagnosis were excluded. Data
collected included demographic, clinical, ECG, biomarker and outcome data. Low
risk was defined as a TIMI risk score of 0 and initial TnI ≤99th centile.
Primary outcome of interest was defined as MACE within 7 days. MACE included
death, cardiac arrest, revascularisation, cardiogenic shock, arrhythmia, and
prevalent (cause of presentation) and incident (occurring within the follow-up
period) myocardial infarction (MI). Analysis was by descriptive and clinical
performance analyses.
Results 651 patients were studied of whom 215 met the low risk
criteria. There was one MACE in this group (0.47%, 95% CI 0.08% to 2.6%)—a
revascularisation within 7 days without prevalent MI. Negative predictive value
of low risk classification was 99.5% (95% CI 97% to 100%) at both 7 and
30 days. Negative likelihood ratio, weighted by prevalence, was 0.005 at both
intervals.
Conclusion Risk stratification for early discharge based on
ECG, TIMI score of 0 and presentation TnI ≤99th centile appears to identify a
group at very low risk of MACE. Research to prospectively validate this is
warranted.
5. Adherence to PIOPED II Investigators'
Recommendations for CT Pulmonary Angiography
Adams DM, et al. Amer J Med 2013;126:36-42.
Background
Computed tomography (CT) pulmonary angiography use has
increased dramatically, raising concerns for patient safety. Adherence to
recommendations and guidelines may protect patients. We measured adherence to
the recommendations of Prospective Investigation of Pulmonary Embolism
Diagnosis (PIOPED II) investigators for evaluation of suspected pulmonary
embolism and the rate of potential false-positive pulmonary embolism diagnoses
when recommendations of PIOPED II investigators were not followed.
Methods
We used a structured record review to identify 3500
consecutive CT pulmonary angiograms performed to investigate suspected
pulmonary embolism in 2 urban emergency departments, calculating the revised
Geneva score (RGS) to classify patients as “pulmonary embolism unlikely”
(RGS≤10) or “pulmonary embolism likely” (RGS over10). CT pulmonary angiograms
were concordant with PIOPED II investigator recommendations if pulmonary
embolism was likely or pulmonary embolism was unlikely and a highly sensitive
D-dimer test result was positive. We independently reviewed 482 CT pulmonary
angiograms to measure the rate of potential false-positive pulmonary embolism
diagnoses.
Results
A total of 1592 of 3500 CT pulmonary angiograms (45.5%)
followed the recommendations of PIOPED II investigators. The remaining 1908 CT
pulmonary angiograms were performed on patients with an RGS≤10 without a
D-dimer test (n=1588) or after a negative D-dimer test result (n=320). The
overall rate of pulmonary embolism was 9.7%. Potential false-positive diagnoses
of pulmonary embolism occurred in 2 of 3 patients with an RGS≤10 and a negative
D-dimer test result.
Conclusions
Nonadherence to recommendations for CT pulmonary angiography
is common and exposes patients to increased risks, including potential
false-positive diagnoses of pulmonary embolism.
Full-text (free): http://www.amjmed.com/article/S0002-9343(12)00557-8/fulltext
6. Repeat CT Scans in Transferred Trauma Patients
Nearly 40% of patients transferred to a trauma center had
repeat computed tomography scans for various reasons.
Trauma patients transferred from one hospital to another
often undergo repeat computed tomography (CT) scans, some of which are
clinically important (e.g., to assess progression of an intracranial
hemorrhage) and some of which have no clear indication. To determine the
frequency of repeat CT scanning, investigators reviewed charts from a
consecutive convenience sample of 211 trauma patients transferred to the
emergency department at a level 1 trauma center in Virginia.
Overall, 39% of patients underwent at least one repeat scan.
Cervical spine scans were the most frequently repeated (39%), followed by chest
(37%), pelvic (32%), abdominal (30%), maxillofacial (20%), and head (16%) CT
scans. Additional charges averaged $1762 per patient with at least one repeat
scan. The average additional radiation dose for repeat-scan patients was 21.5
mSv — almost half the 50 mSv level found to predict an elevated cancer risk
among atomic bomb survivors.
Comment: More than a third of trauma transfers in this study
had repeat scans. Given that cervical spine scans were the most frequently
repeated type of scan, we can't chalk this up to clinically indicated repeat
scans. Community hospitals and trauma centers should work together to send
images with patients. Not being able to load an imaging disk or unwillingness
to interpret images from another institution are not valid excuses. Another
elephant in the room is billing: radiologists may not get paid for two
interpretations of the same scan. Insurers need to ensure fair compensation for
specialists who provide expert image interpretation at the receiving center in
order to guide clinical decision making.
— Daniel J. Pallin, MD, MPH. Published in Journal Watch
Emergency Medicine January 11, 2013. Citation(s): Jones AC et al. Repeated
computed tomographic scans in transferred trauma patients: Indications, costs,
and radiation exposure. J Trauma Acute Care Surg 2012 Dec; 73:1564.
7. Continued rise in the use of mid-level providers in
US EDs, 1993–2009
Brown DFM, et al. Interna J Emerg Med. 2012;5:21.
Background: Emergency department (ED) visits in the US have
risen dramatically over the past 2 decades. In order to meet the growing
demand, mid-level providers (MLPs) – both physician assistants (PAs) and nurse
practitioners (NPs) – were introduced into emergency care. Our objective was to
test the hypothesis that MLP usage in US EDs continues to rise.
Findings: We analyzed ED data from the National Hospital
Ambulatory Medical Care Survey to identify trends in ED visits seen by MLPs. We
also compared MLP-only visits (defined as visits where the patient was seen by
a MLP without being seen by a physician) with those seen by physicians only.
During 1993 to 2009, 8.4% (95%CI, 7.6–9.2%) of all US ED visits were seen by
MLPs. These summary data include marked changes in MLP utilization: PA visits
rose from 2.9% to 9.9%, while NP visits rose from 1.1% to 4.7% (both Ptrend less
than 0.001). Together, MLP visits accounted for almost 15% of 2009 ED visits
and 40% of these were seen without involvement of a physician. Compared to
physician only visits, those seen by MLPs only were less likely to arrive by
ambulance (16% vs 6%) and be admitted (14% vs 3%).
Conclusions: Mid-level provider use is rising in US EDs. By
2009, approximately one in seven visits involved MLPs, with PAs managing twice
as many visits as NPs. Although patients seen by MLPs only are generally of
lower acuity, these nationally representative data confirm that MLP care
extends beyond minor presentations.
Full-text (free): http://link.springer.com/article/10.1186/1865-1380-5-21
8. ECG Electrode Misplacement, Misconnection, and
Artifact
Harrigan RA, et al. J Emerg Med. 2012;43(6):1038-1044.
Background: Electrocardiograms (ECGs) are performed by
humans, and thus are subject to human error. An underappreciated source of
electrocardiographic abnormality is electrode misconnection, both limb and precordial,
and improper placement, which is principally an issue with the precordial
electrodes due to anatomic variation. Patterns of abnormality exist;
recognition allows the emergency physician to avoid mistaking the resulting
electrocardiographic findings for true pathology.
Objectives: The purpose of this clinical review is to
describe the patterns of electrocardiographic electrode reversal, misplacement,
and artifact and thus make them recognizable to the Emergency Physician.
Discussion: Common limb electrode reversals feature
distinctive patterns manifesting as unexpected morphologic and frontal plane
axis changes in the QRS complexes in the limb and augmented leads. Precordial
electrode misplacement (improper positioning of the electrodes on the chest) is
common and may mimic a pseudoinfarction pattern, or ST-segment/T-wave changes,
which must be recognized as the result of the misplacement rather than true
cardiac ischemia. Precordial electrode reversal should be suspected when the
normal R/S wave amplitude transition is violated. Electrocardiographic artifact
must be distinguished from dysrhythmia to avoid a potentially hazardous
progression to unnecessary diagnostics and therapeutics.
Conclusions: The hallmarks of electrode misconnection,
misplacement, and electrocardiographic artifact can be easily mastered by the
Emergency Physician; recognition of these findings can positively impact
patient care by avoiding unnecessary intervention secondary to misattribution
of findings on the 12-lead ECG to cardiac pathology.
Full-text (free if registered): http://www.medscape.com/viewarticle/775860
9. A Model of Cost-effectiveness of tPA in Patient
Subgroups 3 to 4.5 Hours after Onset of Acute Ischemic Stroke
Boudreau DM, et al. Ann Emerg Med. 2013;61:46-55. .
Study objective
The European Cooperative Acute Stroke Study III (ECASS III)
showed that recombinant tissue plasminogen activator (rtPA) administered 3 to
4.5 hours after acute ischemic stroke led to improvement in patient disability
versus placebo. We evaluate the long-term incremental cost-effectiveness of
rtPA administered 3 to 4.5 hours after acute ischemic stroke onset versus no
treatment according to patient clinical and demographic factors.
Methods
We developed a disease-based decision analytic model to
project lifetime outcomes of patients post–acute ischemic stroke from the payer
perspective. Clinical data were derived from the ECASS III trial, longitudinal
cohort studies, and health state preference studies. Cost data were based on
Medicare reimbursement and other published sources. We performed probabilistic
sensitivity analyses to evaluate uncertainty in the analysis.
Results
rtPA in a hypothetical cohort resulted in a gain of 0.07
years of life (95% credible range 0.0005 to 0.17) and 0.24 quality-adjusted
life-years (95% credible range 0.01 to 0.60) and a difference in cost of $1,495
(95% credible range –$4,637 to $6,100) compared with placebo. The incremental
cost-effectiveness ratio for all patients was $6,255 per quality-adjusted
life-year gained; for patients younger than 65 years, cost saving; for patients
aged 65 years or older, $35,813 per quality-adjusted life-year; for patients
with baseline National Institutes of Health Stroke Scale (NIHSS) score 0 to 9,
$16,322 per quality-adjusted life-year; for patients with NIHSS score 10 to 19,
$37,462 per quality-adjusted life-year; and for patients with NIHSS score
greater than or equal to 20, $2,432 per quality-adjusted life-year. The
majority of other subgroups such as sex, history of stroke, and history of
hypertension were either cost saving or cost-effective, with the exceptions of
diabetes and atrial fibrillation.
Conclusion
The results indicate that rtPA in the 3- to 4.5-hour
therapeutic window provides improvement in long-term patient outcomes in most
patient subgroups and is a good economic value versus no treatment.
10. Restrictive transfusion strategy superior for
severe acute GI bleeding
By Mary Ann Moon, IMNG Medical News 1/2/2013
For patients with severe acute GI bleeding, outcomes are
significantly better when a restrictive transfusion strategy is used - limiting
the hemoglobin threshold to 7 g/dL - rather than a liberal transfusion strategy
allowing a 9 g/dL threshold, according to a report published online Jan. 2 in
the New England Journal of Medicine.
In a single-center randomized controlled trial involving 889
patients, the restrictive transfusion strategy resulted in significantly lower
mortality, lower rates of rebleeding, less frequent need for rescue therapy,
fewer complications, and shorter hospitalizations than did the liberal
transfusion strategy. "Our results suggest that in patients with acute GI
bleeding, a strategy of not performing transfusion until the hemoglobin
concentration falls below 7 g/dL is a safe and effective approach," said
Dr. Càndid Villanueva of Hospital de Sant Pau, Barcelona, and his associates.
"Current international guidelines recommend decreasing
the hemoglobin threshold level for transfusion ... from 10g/dL to 7 g/dL"
in such patients, but these recommendations are based on trials involving
critically ill patients with normovolemic anemia that did not include subjects
with acute bleeding. "Transfusion requirements may be different for
patients with acute hemorrhage due to factors such as hemodynamic instability
or rapid onset of anemia" resulting from extremely low hemoglobin levels.
In particular, results of animal studies suggest that
transfusion can be especially harmful in patients with bleeding from portal
hypertension sources, "since restitution of blood volume after hemorrhage
can lead to a rebound increase in portal pressure, which is associated with a
risk of rebleeding," the investigators noted.
To examine the effects of different transfusion strategies
in this setting, Dr. Villanueva and his colleagues enrolled adults who
presented with hematemesis, melena, or both, randomly assigning 444 to receive
restrictive transfusion (with a target range for the posttransfusion hemoglobin
level of 7-9 g/dL) and 445 to receive liberal transfusion (with a target range
of 9-11 g/dL).
The study protocol permitted transfusions to be administered
at the discretion of the attending physician any time symptoms or signs of
anemia developed, massive bleeding occurred, or surgical intervention was
needed, as well as when hemoglobin levels dipped below the assigned threshold.
All the study subjects underwent emergency gastroscopy
within 6 hours of presentation, with appropriate treatment when the source of
the bleeding was identified. Diagnoses included peptic ulcer, esophageal
varices, cirrhosis, portal hypertension, and nonvariceal lesions.
The primary outcome measure, mortality from any cause at 45
days, was significantly lower in the restrictive-strategy group (5%) than the
liberal-strategy group (9%). Death resulted from uncontrolled bleeding in 0.7%
vs 3.1% of the 2 groups, respectively, the researchers said (N. Engl. J. Med.
2013 Jan. 2 [doi:10.1056/NEJMoa1211801]).
The rate of rebleeding also was significantly lower with the
restrictive strategy (10% vs. 16%), and length of hospital stay was
significantly shorter. In addition, rescue therapy for esophageal varices with
balloon tamponade or a transjugular intrahepatic portosystemic shunt was
required less often in the restrictive-strategy group than in the
liberal-strategy group, as was emergency surgery to control further bleeding
from peptic ulcer.
The rate of overall complications was significantly lower
with the restrictive strategy (40%) than with the liberal strategy (48%), as
was the rate of serious adverse events. In addition, transfusion reactions and
cardiac events such as pulmonary edema were more frequent with the liberal
strategy.
"Our results are consistent with those from previous
observational studies and randomized trials performed in other settings, which
have shown that a restrictive transfusion strategy did not increase, and even
decreased, the mortality observed with a liberal transfusion strategy,"
Dr. Villanueva and his associates said.
The facts are in
Dr. Loren Laine comments: This important study
"provides long-awaited evidence to guide practice and justify current
recommendations for the management of upper GI bleeding," said Dr. Laine.
A restrictive transfusion strategy reduced the relative risk
of mortality at 45 days by 45%. Extrapolating the study findings, only 25
patients would have to be treated with a restrictive rather than a liberal
transfusion strategy to avert one additional death.
Dr. Laine is at Yale University, New Haven, Conn., and the
Veterans Affairs Connecticut Healthcare System, West Haven. He reported no
financial conflicts of interest. These remarks were taken from his editorial
accompanying Dr. Villanueva's report (N. Engl. J. Med. 2013 Jan. 2
[doi:10.1056/NEJMe1212009]).
11. Less Is Better for Treating Whiplash
By Charles Bankhead, Staff Writer, MedPage Today. December
21, 2012
Active clinical management that included physical therapy
showed a small advantage over usual care after 4 months, as assessed by the
Neck Disability Index (NDI). The advantage had disappeared by 8 months, and
outcomes in the treatment groups remained similar at 12 months.
An economic analysis showed that active management cost more
and provided less quantitative benefit compared with usual care, as reported
online in The Lancet. "Our findings show that no additional benefit exists
to providing active management consultations in the emergency department,"
said Sarah E. Lamb, DPhil, of the University of Warwick in Coventry, England. A
package of physiotherapy has a modest effect on early recovery of persisting
symptoms but is not cost effective from a U.K. National Health Services
perspective." Extensive reviews of interventions for whiplash injury have
found little or no data to support many of the treatments employed.
Following its review of the evidence, the Quebec Task Force
on Whiplash Injury suggested a stepped-care approach, beginning with advice and
positive reinforcement and moving on to other interventions, including physical
therapy, if symptoms persist (Spine 1995; 20(8 suppl): 1S-73S). A similar
approach has been used successfully in the management of back pain, the authors
noted. Some clinical guidelines recommend physical therapy, which lacks
supporting evidence, they added.
Borrowing elements from several different clinical
strategies, Lamb and colleagues conducted a two-phase randomized study involving
emergency departments at 12 hospitals that treated patients with grade I-III
acute whiplash-associated disorder.
In the first phase, investigators randomized the hospitals
to usual care or active management, which included distribution of a patient education
booklet to augment active-management consultations that focused on changing
beliefs and negative health behaviors. Investigators trained
emergency-department personnel in active management, which was applied during
clinical visits with patients who came to the hospitals randomized to active
management. Staff members were instructed to limit treatments to those that
would be appropriate for soft-tissue injury. The first phase lasted 12 months.
During the second phase of the study, investigators randomized
patients from the first phase to six sessions of physical therapy or a single
advice session. The sessions included reinforcement of advice provided during
the emergency-department visit. The primary outcome was the change in Neck
Disability Index (NDI) at the end of each phase of the study. The NDI assesses
pain-related activity restriction across 10 domains. A secondary outcome was
the change in score on the Short Form-12 and in other instruments that
addressed neck-specific symptoms, work restriction and lost compensation, and
healthcare resource use.
The investigators randomized 3,851 patients, of whom 2,704
provided follow-up data to 12 months. The results showed a 0.5-point difference
between groups on the mean NDI score, which did not reach statistical
significance.
During the second phase of the study, investigators
randomized 599 volunteers from the first phase to usual-care consultations and
a single physical therapy advice session or to six sessions of physical therapy
that included reinforcement of clinical advice as well as hands-on therapy
targeted to soft tissue injury. The NDI was completed after 4, 8, and 12
months.Blinding of patients and clinicians to treatment group assignments at
all phases of the study was not possible.
After 4 months, the patients assigned to the more intensive
treatment arm showed a net treatment effect of 3.7 points on the NDI compared
with the usual-care group (P=0.0029). By 8 months, the difference had dwindled
to 1 point and then increased to 2 points at 12 months, neither of which was
statistically significant.
A 4-day (adjusted) difference in lost work days favored
active intervention at all time points. Patients' self-rated benefit was
significantly higher at 4 months with active intervention (P less than 0.0001)
but not at the other assessments. Other secondary endpoints did not differ
significantly between groups at any assessment.
The economic analysis produced a higher cost for active
intervention during both phases of the study. The estimated cost of active
intervention averaged about $500 per patient during the first phase and $675
during the second phase. Corresponding costs for usual care were $450 and $580.
Comparison of quality-adjusted life years showed a lower average gain for
active treatment during phase I (0.755 versus 0.758) and during the second
phase (0.691 versus 0.702).
The author of an accompanying commentary suggested that
meaningful improvement in whiplash management will occur only when expectations
and behaviors change. "Part of the issue might be that people with
whiplash should not be attending an emergency department," Robert Ferrari,
MD, of the University of Alberta in Edmonton, wrote. "It is unlikely that
most whiplash victims have any need for radiological studies, and what the
emergency physician otherwise has to offer these patients is not clear."
Expectations and beliefs could be the key to better outcomes
after whiplash, he continued. A Canadian study showed that whiplash patients
who expected to "get better soon" recovered three times as quickly
compared with patients who thought they would never get better. "Those who
hold expectations of a poor outcome might be having those expectations
reinforced by the experience of a presentation to an accident and emergency
department," Ferrari wrote.
Legislative action could effect changes in expectations
surrounding whiplash by reducing "the extent to which expectations can be
met -- i.e., less contact with lawyers, insurers, and the treatment industry
could reduce the encouragement of these expectations and the behavior that
follows."
The study was supported by the National Institute for Health
Research. The authors and Ferrari had no relevant disclosures.
Abstract: Lamb SE, et al Lancet 2012; http://www.ncbi.nlm.nih.gov/pubmed/23260167
See also: 12-minute educational video reduces pain and
recidivism for ED patients with whiplash:
12. Images in Clinical Medicine
Large Right Inguinal Hernia
Clonus after a Stroke
Superior mesenteric artery syndrome
13. Pediatric Corner
A. (In)Efficacy of
Intravenous Lidocaine to Reduce Pain and Distress associated with Propofol
Infusion in Pediatric Patients During Procedural Sedation
Depue K, et al. Pediatr Emerg Care. 2013;29:13-16
Background: Research suggests that young children experience
an increased incidence and severity of discomfort during propofol infusion.
Evaluations of varied interventions to reduce or eliminate this discomfort with
adult subjects suggest that premedication with intravenously administered
lidocaine (0.5 mg/kg) offers the best overall effectiveness.
Objective: Because this regimen’s efficacy in a pediatric
population is undocumented, we conducted a randomized, double-blind,
placebo-controlled study to determine the effectiveness of intravenous
lidocaine pretreatment to alleviate pain in pediatric subjects before propofol
infusion.
Methods: Subjects (aged 2–7 years) scheduled for painless
diagnostic procedures received either a saline placebo or 1 of 2 lidocaine
doses before administering propofol. To capture the patient’s baseline
behavioral state, a trained observer administered the validated Face, Legs,
Activity, Cry, Consolability Pain Assessment Scale before propofol infusion.
During deep sedation induction, the sedating physician, a trained research
assistant, and the patient’s parent documented maximum distress using a 100-mm
visual analog scale (VAS).
Results: Ninety-one subjects participated. We found no
difference in VAS pain scores between groups pretreated with lidocaine 0.25
mg/kg, lidocaine 0.5 mg/kg, and placebo. Statistical analysis also found no
interrater differences between parents, physician, or observer VAS scores.
Conclusions: Our data do not support using lidocaine
pretreatment to alleviate pain/discomfort in pediatric patients during propofol
infusion.
B. Appendicitis: CT
Scan vs Ultrasound Depends on Hospital Type
Yael Waknine. Medscape Medical News. Dec 24, 2012
Community hospitals are more than 4 times more likely than
pediatric institutions to use radiation-exposing computed tomography (CT) scans
and 80% less likely to use ultrasound for pre-appendectomy evaluations in
children, study results suggest.
Jacqueline M. Saito, MD, MSCI, and colleagues from
Washington University School of Medicine in St. Louis, Missouri, also found
that both diagnostic tools were less sensitive for appendicitis in the
community hospital setting.
As previously reported by Medscape Medical News, CT
screening of children with abdominal pain has skyrocketed while appendicitis
rates remain unchanged, adding to growing concerns regarding the link between
excessive radiation exposure and cancer risk later in life.
"Broadly-applicable strategies to systematically
maximize diagnostic accuracy for childhood appendicitis, while minimizing
ionizing radiation exposure, are urgently needed," the authors write,
noting that evaluations may be streamlined by using algorithms developed with
broad validity to decrease reliance on preoperative imaging and radiation
exposure while avoiding unnecessary hospital transfers, admissions, operations,
and missed diagnoses.
The retrospective study was published online December 24 in
Pediatrics.
C. Comparison of
Rectal, Axillary, Tympanic, and Temporal Artery Thermometry in the Pediatric
Emergency Room
Batra P, et al. Pediatr Emerg Care. 2013;29:63-66.
Background: Accurate measurement of temperature in the
emergency room is important for diagnosis as well as investigating a patient. Various
noninvasive methods thermometry are available today, but there is no consensus
on the most accurate method of thermometry.
Study Objective: The present study was conducted to compare
different methods of temperature measurement available in the emergency room,
that is, rectal, axillary, and temporal artery and tympanic membrane.
Design: This was a cross-sectional observational study
Patients: Fifty febrile and 50 afebrile children aged 2 to
12 years attending the pediatric emergency room of a tertiary care hospital
were included. Temperatures were measured using rectal, axillary, tympanic
(right and left), and temporal artery thermometers and were compared.
Results: All the temperatures correlated well with rectal
temperature, with temporal artery temperature showing the best correlation
(correlation coefficients, 0.99 in the febrile and 0.91 in the afebrile group).
Conclusions: Temporal artery thermometry has the potential
to replace rectal thermometry in a busy emergency room setting.
D. AAP: All Work and
No Play Bad for Kids
Recess during school offers children cognitive, social,
emotional, and physical benefits they don't get through academics alone,
according to the American Academy of Pediatrics.
Note that recess allows a space between classes outside of
concentrated classroom work, which aids cognitive processing and academic
performance, and should not be withheld for punitive or academic reasons.
Recess during school offers children cognitive, social,
emotional, and physical benefits they don't get through academics alone, the
American Academy of Pediatrics (AAP) wrote in a policy statement.
E. Pediatric UTI:
Does the Evidence Support Aggressively Pursuing the Diagnosis?
Newman DH, et al. Ann Emerg Med 2013 [Epub ahead of print]
The epidemiology of pediatric fever has changed considerably
during the past 2 decades with the development of vaccines against the most
common bacterial pathogens causing bacteremia and meningitis. The decreasing
incidence of these 2 conditions among vaccinated children has led to an
emphasis on urinary tract infection as a remaining source of potentially hidden
infections in febrile children.
Emerging literature, however, has led to questions about
both the degree and nature of the danger posed by urinary tract infection in
nonverbal children, whereas the aggressive pursuit of the diagnosis consumes
resources and leads to patient discomfort, medical risks, and potential
overdiagnosis. We review both early and emerging literature to examine the
utility and efficacy of early identification and treatment of urinary tract
infection in children younger than 24 months. We conclude that in well children
of this age, it may be reasonable to withhold or delay testing for urinary
tract infection if signs of other sources are apparent or if the fever has been
present for fewer than 4 to 5 days.
F. Prevalence of
Abusive Fractures of the Hands, Feet, Spine, or Pelvis on Skeletal Survey:
Perhaps “Uncommon” Is More Common Than Suggested
Lindberg DM, et al. Pediatr Emerg Care 2013;29:26-29.
Objective: Recently, it has been suggested that views of the
hands, feet, spine, and pelvis should be omitted from routine skeletal surveys
(SSs) because these fractures are rarely identified by SS. Our objective was to
describe the prevalence of fractures to the hands, feet, spine, or pelvis among
SSs obtained for children in a large, multicenter population who underwent
consultation for physical abuse.
Methods: This was a retrospective secondary analysis of data
from the Examining Siblings To Recognize Abuse research network, a consortium
of 20 US child abuse teams who collected data for all children younger than 10
years who underwent consultation for concerns of physical abuse. This secondary
analysis included data only from index children and excluded data from siblings
and contacts. Consulting child abuse physicians reported the number of
fractures identified and those that were detected by SS.
Results: Among 2049 initial SSs, 471 (23.0%) showed at least
1 previously unknown fracture including 49 (10.4%) that showed a fracture to
the hands, feet, spine, or pelvis. In 10 cases, the SS identified at least 1
fracture of the hands, feet, spine, or pelvis when no other fractures were
identified.
Conclusions: A significant number of occult, abusive
fractures would have been missed if SSs had omitted or deferred views of the
hands, feet, spine, and pelvis. Given the risks associated with missed abuse,
these views should be routinely included in the radiographic SS.
G. Implementation of
an evidence based guideline reduces blood tests and LOS for the limping child
in a paediatric ED
McCanny PJ, et al. Emerg Med J 2013;30:19-23
Introduction Acute non-traumatic limp is a common reason for
children to present to the emergency department (ED). There is a wide
differential diagnosis for these patients, and there are certain serious
conditions which cannot be missed. An evidence based guideline for the ‘limping
child’ was designed and the impact of guideline implementation on a number of specific,
predefined quantitative outcomes was assessed.
Methods An initial retrospective chart review over 3 months
was carried out for all patients presenting with acute non-traumatic limp.
Following guideline introduction and implementation, information was gathered
prospectively for a further 3 month period. Data outcomes between the two
patient groups were then compared.
Results 110 patients met the criteria for inclusion: 56
pre-guideline and 54 post-guideline implementation. Baseline characteristics
and diagnosis breakdown were similar in both groups. The rate of laboratory
investigations was significantly reduced following guideline implementation
(68% of patients pre-guideline, vs 48% post-guideline; (χ2), p=0.03). The
number of x-rays carried out was similar in each group (74 pre- vs 67
post-guideline, mean 1.32 vs 1.28; (χ2), p=0.53). Length of time spent in the
ED was significantly reduced following guideline implementation (median time
150 min pre- vs 82.5 min post-guideline; (χ2), p=0.04). No cases of serious
pathology were missed using the guideline.
Conclusion Implementation of an evidence based clinical
practice guideline for the limping child in a paediatric ED reduced the overall
time patients spent in the ED, reduced the need for unnecessary laboratory
investigations and ensured that appropriate investigations were carried out on
an individual patient basis.
H. Pediatric DKA: Is
Fluid Replacement Rate Associated with Cerebral Edema?
Development of subclinical cerebral edema did not differ
between children who received slower versus more rapid fluid replacement.
Glaser NS et al. Pediatrics 2013 Jan; 131:e73
OBJECTIVE: Previous studies show that vasogenic cerebral
edema (CE) occurs during diabetic ketoacidosis (DKA) treatment in children, but
the role of intravenous fluids in contributing to CE is unclear. We used
magnetic resonance diffusion weighted imaging to quantify subclinical CE in
children with DKA randomized to 2 intravenous fluid regimens.
METHODS: Children with DKA were randomized to receive fluids
at a more rapid rate (n = 8) or a slower rate (n = 10), with all other aspects
of DKA treatment kept identical. Children underwent diffusion weighted imaging
3 to 6 hours and 9 to 12 hours after beginning DKA treatment and after recovery
from DKA (≥72 hours after beginning treatment). We calculated brain apparent
diffusion coefficient (ADC) values as the average of measurements in the basal
ganglia, thalamus, frontal white matter, and hippocampus and determined the
mean brain ADC value during DKA treatment by averaging data from the 3- to
6-hour and 9- to 12-hour measurements. The difference in mean brain ADC between
DKA treatment and postrecovery was used as an index of the severity of CE
during DKA treatment.
RESULTS: Mean brain ADC values during DKA treatment were
significantly higher than postrecovery values, consistent with vasogenic CE
(842 ± 38 vs 800 ± 41×10(-6) mm(2)/second, P = .002). We did not detect
significant differences in ADC elevation in children treated with more rapid
versus slower rehydration (β coefficient 0.11 for 1 SD change in ADC, 95%
confidence interval: -0.91 to 1.13).
CONCLUSIONS: ADC changes during DKA treatment (reflective of
vasogenic CE) do not appear to be substantially affected by the rate of
intravenous fluid administration..
14. Energy Drinks Promise Edge, but Experts Say
Proof Is Scant
By Barry Meier, New York Times, January 1, 2013
Energy drinks are the fastest-growing part of the beverage
industry, with sales in the United States reaching more than $10 billion in
2012 — more than Americans spent on iced tea or sports beverages like Gatorade.
Their rising popularity represents a generational shift in what people drink,
and reflects a successful campaign to convince consumers, particularly
teenagers, that the drinks provide a mental and physical edge.
The drinks are now under scrutiny by the Food and Drug
Administration after reports of deaths and serious injuries that may be linked
to their high caffeine levels. But however that review ends, one thing is
clear, interviews with researchers and a review of scientific studies show: the
energy drink industry is based on a brew of ingredients that, apart from
caffeine, have little, if any benefit for consumers.
“If you had a cup of coffee you are going to affect
metabolism in the same way,” said Dr. Robert W. Pettitt, an associate professor
at Minnesota State University in Mankato, who has studied the drinks.
Energy drink companies have promoted their products not as
caffeine-fueled concoctions but as specially engineered blends that provide
something more. For example, producers claim that “Red Bull gives you wings,”
that Rockstar Energy is “scientifically formulated” and Monster Energy is a
“killer energy brew.” Representative Edward J. Markey of Massachusetts, a
Democrat, has asked the government to investigate the industry’s marketing
claims.
Promoting a message beyond caffeine has enabled the beverage
makers to charge premium prices. A 16-ounce energy drink that sells for $2.99 a
can contains about the same amount of caffeine as a tablet of NoDoz that costs
30 cents. Even Starbucks coffee is cheap by comparison; a 12-ounce cup that
costs $1.85 has even more caffeine.
As with earlier elixirs, a dearth of evidence underlies such
claims. Only a few human studies of energy drinks or the ingredients in them
have been performed and they point to a similar conclusion, researchers say —
that the beverages are mainly about caffeine.
Caffeine is called the world’s most widely used drug. A
stimulant, it increases alertness, awareness and, if taken at the right time,
improves athletic performance, studies show. Energy drink users feel its kick
faster because the beverages are typically swallowed quickly or are sold as
concentrates.
“These are caffeine delivery systems,” said Dr. Roland
Griffiths, a researcher at Johns Hopkins University who has studied energy
drinks. “They don’t want to say this is equivalent to a NoDoz because that is
not a very sexy sales message.”…
The remainder of the essay (free): http://www.nytimes.com/2013/01/02/health/scant-proof-is-found-to-back-up-claims-by-energy-drinks.html
15. Post-Hospital Syndrome — An Acquired, Transient
Condition of Generalized Risk
Krumholz HM. N Engl J Med 2013; 368:100-102.
To promote successful recovery after a hospitalization,
health care professionals often focus on issues related to the acute illness
that precipitated the hospitalization. Their disproportionate attention to the
hospitalization's cause, however, may be misdirected. Patients who were
recently hospitalized are not only recovering from their acute illness; they
also experience a period of generalized risk for a range of adverse health
events. Thus, their condition may be better characterized as a post-hospital
syndrome, an acquired, transient period of vulnerability. This theory would
suggest that the risks in the critical 30-day period after discharge might
derive as much from the allostatic and physiological stress that patients
experience in the hospital as they do from the lingering effects of the
original acute illness. At the time of discharge, physiological systems are
impaired, reserves are depleted, and the body cannot effectively defend against
health threats.
Nearly one fifth of Medicare patients discharged from a
hospital — approximately 2.6 million seniors — have an acute medical problem
within the subsequent 30 days that necessitates another hospitalization. These
recently discharged patients have heightened risks of myriad conditions, many
of which appear to have little in common with the initial diagnosis. For
example…
The remainder of the essay (free) with 17-minute audio
interview: http://www.nejm.org/doi/full/10.1056/NEJMp1212324
16. Presenting
symptoms of MI predict short- and long-term mortality: The MONICA/KORA
Myocardial Infarction Registry.
Kirchberger I, et al. Am Heart J. 2012 Dec;164(6):856-61.
BACKGROUND: It is unknown whether clinical outcomes differ
with specific symptoms of an acute myocardial infarction (AMI). The objective
of this study was to investigate the association between 13 self-reported
symptoms and 28-day case fatality or long-term all-cause mortality in patients
with AMI.
METHODS: The sample consisted of 1,231 men and 415 women
aged 25 to 74 years hospitalized with a first-time AMI recruited from a
population-based AMI registry. Multivariable logistic regression modeling was
used to assess the relationship between symptom occurrence and 28-day case fatality.
Cox proportional hazards models were used to determine the effects on long-term
mortality. Analyses were adjusted for sex, age, type of AMI, diabetes,
prehospital delay time, and reperfusion therapy.
RESULTS: The median observation time was 4.1 years
(interquartile range 15 years). Twenty-eight-day case fatality was 6.1%, and
long-term mortality was 10.6%. Patients who experienced fear of death (odds
ratio [OR] 0.11, 95% confidence interval [CI] 0.03-0.47), diaphoresis (OR 0.45,
95% CI 0.25-0.82), or nausea (OR 0.45, 95% CI 0.22-0.95) had a significantly
decreased risk of dying within 28 days, whereas syncope (OR 5.36, 95% CI
2.65-10.85) was associated with a higher risk. A decreased risk for long-term
mortality was found for people with pain in the upper abdomen (hazard ratio
0.43, 95% CI 0.19-0.97), whereas dyspnea was related to an increased risk
(hazard ratio 1.50, 95% CI 1.11-2.06). The absence of chest symptoms was
associated with a 1.85-fold risk for long-term mortality (95% CI 1.13-3.03).
CONCLUSIONS: Specific symptoms are associated with
mortality. Further research is required to illuminate the reasons for this
finding.
17. Evidence-based Review by Ann Emerg Med
A. Are There
Pharmacologic Agents That Safely and Effectively Treat Post–Lumbar Puncture
Headache?
Hunter BR, et al. Ann Emerg Med. 2013;61:84-85.
Take-Home Message
Although intravenous caffeine has demonstrated efficacy for
post–lumbar puncture headache in patients who have received spinal anesthesia,
its efficacy and safety remain uncertain in patients presenting to the
emergency department (ED) after a typical diagnostic lumbar puncture.
…Commentary
The spinal dura is punctured during a diagnostic lumbar
puncture or spinal anesthesia. Penetration of the dura may also occur as an
unintended complication of epidural anesthesia. Post–lumbar puncture headache
has been reported to occur in 3% to 36% of lumbar punctures4 (with higher rates
occurring when a traumatic needle is used) and may require symptomatic therapy.
Although epidural blood patching is effective,5 it is an invasive treatment
that is typically performed by an anesthesiologist or interventional
radiologist. Because specialty consultation is not readily available in many ED
settings, a safe and effective pharmacologic intervention for post–lumbar
puncture headache would be a preferable alternative.
Unfortunately, this Cochrane review found only 1 small,
high-quality study3 reporting results indicating that intravenous caffeine is
effective for treating post–lumbar puncture headache. In this trial of 41
patients with post–lumbar puncture headache, a single intravenous dose of 500
mg of caffeine sodium benzoate resulted in an absolute risk reduction of 61% in
persistent headache at 1 to 2 hours. Although the magnitude of effect is
impressive (number needed to treat=1.6), 30% of the caffeine-treated patients
had post–lumbar puncture headache recurrence, though no timeframe was
specified, and other adverse events were not recorded. In addition, the applicability
of these results to the ED setting is limited because the majority of enrolled
patients were postpartum women who had received spinal anesthesia. Included in
this review was another randomized trial6 evaluating caffeine for post–lumbar
puncture headache in postpartum women that did not demonstrate a statistically
significant difference in visual analog scale at 4 or 24 hours between patients
treated with oral caffeine or placebo.
Individual trials reported statistically significant and
clinically meaningful reductions in visual analog scale pain scores for
gabapentin,7 theophylline,8 and hydrocortisone.9 These trials, however,
suffered from a high risk of bias and would have limited application in an ED
setting.
Intravenous caffeine appears to be the most promising
pharmacologic agent for patients with post–lumbar puncture headache. However,
to date its efficacy has been demonstrated only in a single trial of patients
receiving spinal anesthesia.
The full-text (with references and results): http://www.annemergmed.com/article/S0196-0644(12)00242-9/fulltext
B. How Accurate Are
Rapid Influenza Diagnostic Tests?
Jacobus CH, et al. Ann Emerg Med. 2013;61:89-90.
Take-Home Message
The results of rapid influenza diagnostic tests can be used
to rule in but not rule out influenza.
…Commentary
Patients with influenza-like illness commonly present to
emergency departments (EDs) during the winter, significantly increasing ED crowding
during those times.1 Seasonal influenza also carries a substantial burden of
morbidity and mortality, killing 24,000 people per year and hospitalizing
370,000; those chronically ill or at the extremes of age are at particular
risk.2, 3 The ability to rapidly diagnose influenza may help decrease further
diagnostic testing and inappropriate antibiotic use, as well as increase timely
antiviral administration to appropriate patients.
This high-quality diagnostic meta-analysis used
state-of-the-art methods to examine the accuracy of commercially available
rapid influenza diagnostic tests. Sensitivity, pooled across the different
tests examined, was moderate but specificity was high. According to the
likelihood ratio estimates, the use of rapid influenza diagnostic tests in the
ED will be highly dependent on the pretest probability of the patient
population being tested. If confirmation is needed for a patient with a high
clinical suspicion for acute influenza and a negative rapid test result, a
specimen should be sent for reverse transcriptase polymerase chain reaction or
viral culture. Head-to-head comparisons of the different brands of tests were
not performed, but no test was noted to outperform any other.
The full-text (with references and results): http://www.annemergmed.com/article/S0196-0644(12)00695-6/fulltext
18. New Strategy May
Cut HF Admissions from ED
By Charles Bankhead, Staff Writer, MedPage Today. January 08,
2013
A heart failure observation unit might reduce hospital
admissions from emergency departments (EDs) by half, authors of a viewpoint
article suggest.
An alternative approach would be a two-level targeted ED
evaluation to determine a patient's risk and eligibility for discharge,
according to Sean P. Collins, MD, of Vanderbilt University in Nashville, and
co-authors who published their viewpoint online in the Journal of the American
College of Cardiology.
The first level would comprise three broad areas
representing high risk:
·
Key precipitating factors, including ischemia,
uncontrolled arrhythmias, and infection
·
Hemodynamic status, such as hypoxia,
hypotension, and cardiogenic shock
·
Other confounders/contributors, such as renal
dysfunction, hyponatremia, COPD, and diabetes
Therapy begins concurrently with the workup, primarily
intravenous diuretics and topical or sublingual nitroglycerin. Depending on
response to treatment, most patients follow one of three clinical pathways:
·
Low-risk patients who respond to therapy --
possibly eligible for discharge after observation
·
High-risk patients -- worsening in response to
therapy (~20% of patients)
·
Intermediate-risk patients -- partial response
to therapy, no high-risk features
The investigators suggested seven interventions that could
be performed in an observation unit for heart failure:
·
Observe response to therapy
·
Identify high-risk traits
·
Conduct routine diagnostic testing
·
Educate patients and caregivers
·
Perform guideline-directed therapy
·
Arrange early follow-up
·
Optimize medical therapy
"The interventions in the observation unit are not
complex or costly and in fact conserve significant resources compared with
admission," the authors wrote.
"We estimate that up to 50% of patients with heart
failure could be safely discharged from the ED after a brief period of
observation, thus avoiding unnecessary admissions and minimizing
readmissions," they wrote.
In an accompanying editorial, Akshay S. Desai, MD, and Lynne
W. Stevenson, MD, of Brigham and Women's Hospital in Boston, wrote, "The
term 'observation' is partly strategic, as observation unit stays (less than 24
hours) are currently exempt from [payer] penalties imposed on 30-day
readmissions and might therefore provide a lower-cost alternative to
hospitalization for selected patients."
The editorialists acknowledged the need for alternate routes
of heart failure treatment that will reduce hospitalization but noted that
performing randomized trials to test the incremental value of this approach
presents challenges.
For example, there are no data about patient risk that could
inform the decision of ED personnel to admit a patient to an observation unit.
And, conversely, similar data are lacking to make informed decisions about
discharge from such an observation unit.
19. Why You Should
Sometimes Prescribe a Placebo
Arthur L. Caplan, PhD. Jan 03, 2013
Hi. I'm Art Caplan, from the NYU Langone Medical Center
Division of Medical Ethics in New York City. Today I want to talk about a tough
moral challenge that many physicians face: Should I ever prescribe a placebo to
somebody, knowing that it is a placebo? Should I ever give something to a patient
just because I want to give them something, even though I know that it is
ineffective?
There are 2 types of placebos that we will be talking about.
One is literally a sugar pill, something that is absolutely inert and is not
expected to do anything. The other is sometimes aspirin or maybe a pill that
has a mild effect, but is more or less still irrelevant as any type of
treatment that one would seriously give. Interestingly, Medscape conducted a
survey in which roughly 50% of doctors said that they would never do this;
about one quarter said that they would; and the remainder, nearly 20%, said
that it depends.
I faced this issue myself. A few years ago, we had people
coming into the hospital from different cultures who expected to get some kind
of a pill. If they went to the doctor and they didn't get something, they
thought it was a sign of disrespect, and they would absolutely go to somebody
else. Even though we thought that their anxiety was not particularly related to
any underlying disease or that they had some type of a cold and didn't need
further follow-up, our doctors were giving aspirin to these people just as a
way to make sure that they maintained a relationship with them and that they
would come back for future care, instead of turning to alternative medicine or
just not returning because they thought they were not being taken seriously.
Sometimes, culturally, the use of placebo is something that
you have to really consider. It is part of what patient expectations are. You
can certainly try to talk them out of that expectation, but in my experience
with this particular population in New York City, that wasn't going to happen.
I can at least think of some areas where a placebo is justified.
I also believe that sometimes there is such a thing as a
placebo effect. You can make people feel better sometimes just because they
took a pill. An enormous number of people actually respond to pain medication
in part due to the placebo effect, so I can imagine situations where a doctor
might say, "I don't want to give you a dangerous drug. Let's see if this
helps your chronic pain or your complaint about feeling anxious," and then
give a placebo and see if it goes away.
What becomes ethically challenging about that behavior is
whether you then debrief the patient later. And I think you have to. I think
you have to say, "I gave you a placebo. It did help and you did feel
better. Maybe that's the placebo effect, but I don't think you have an
underlying disease and there isn't something here to treat." You don't
want to leave the patient feeling that they have a pill and there is a real
disease if they are responding to the placebo. Part of placebo use, if you are
going to do it, is debriefing the patient or coming clean later about what is
going on and what was done. They might get angry and say that you deceived them
or tricked them. You may say, "No, I just wanted to see whether there was
a placebo effect. It is real, and I wanted to see if you responded to it,
because that is part of what I need to know in order to treat you better."
In general, I don't think placebo should be off-limits. What
I think is off-limits is not telling the truth in the long run to your patient.
If you are going to try placebo approaches with particular patients, I think
you should have a strategy for debriefing them and for letting them know what
was done, so that trust can still be maintained between you and your patient.
3-minute video (free with registration): http://www.medscape.com/viewarticle/776832
20. Essays from the
NEJM
A. Ensuring
Physicians' Competence — Is Maintenance of Certification the Answer?
John K. Iglehart, and Robert B. Baron, M.D.
N Engl J Med 2012; 367:2543-2549.
Pressed by their leaders, external stakeholders, and a
public troubled by lapses in the quality of care and unsustainable cost
increases, physicians are facing stiffer challenges in initiatives designed to
link more closely the goals of learning with the delivery of better care and
measures of greater accountability. The initiatives are works in progress being
implemented by national accrediting organizations, state medical licensing
boards, the federal government, and others,1-5 but the most contentious among
them (and the focus of this article) is the maintenance of certification (MOC)
program sponsored by the American Board of Medical Specialties (ABMS) and its
24 member boards, which promote continuous professional development.6 MOC
requires most certified specialists to seek recertification on a periodic basis
— typically every 10 years — by successfully completing a four-part assessment
designed to test their medical knowledge, clinical competence, and skills in
communicating with patients. The MOC program was initiated in 2000, but the
pace of recertification has accelerated since 2009. Approximately 375,000
board-certified specialists and subspecialists (about half the number that the
24 boards certified initially) meet MOC requirements, according to the ABMS.
Although the number of specialists engaged in the process
grows by about 50,000 diplomates a year, the exercise also draws strong
criticism from physicians who assert that MOC is too expensive and the process
is too time-consuming. Another concern is a requirement that a secure examination
(one of MOC's four parts) be completed without access to outside sources of
information. This condition contradicts what medical students and residents are
currently taught: they should take advantage of the best sources of information
rather than rely entirely on their memory. Younger physicians also suggest that
so-called grandfathers7 (generally specialists who were certified before 1990
and received time-unlimited credentials) should also face the rigors of
recertification (Eggen M: personal communication). Among 66,689 diplomates of
the American Board of Internal Medicine (ABIM) who hold only time-unlimited
certificates, only 1% have chosen to become recertified through MOC. The ABIM
also certifies physicians who practice in 19 subspecialties. Since 1990, all
certificates issued by the ABIM have required diplomates to complete MOC to
remain certified. Two ABIM areas of specialty actually were established before
1990 without ever having issued time-unlimited certificates — critical care
medicine in 1987 and geriatrics in 1988. Like ABIM, other specialties also
report low recertification rates among their diplomates with time-unlimited
certificates, including dermatology (8%), nuclear medicine (12%), plastic
surgery (5%), and urology (1%). One of us holds a time-unlimited certificate
and is enrolled in MOC.
More than 75 years ago, the ABMS and its predecessor
organization began to build a national system of standards for educating
medical specialists.8 As originally conceived, securing board certification was
considered a once-in-a-lifetime challenge designed to show a doctor's
competence after completion of residency training. Until 1969, all the
ABMS-member boards issued lifetime specialty certificates, but as the skills
necessary to practice medicine grew exponentially and research showed that, on
average, the clinical skills of physicians decline over time,9 time-unlimited
certification was called into question. Since its founding in 1969, the
American Board of Family Medicine (ABFM) issued only time-limited certificates.
Initially these certificates were valid for 7 years, but now they remain valid
as long as a diplomate meets MOC requirements.10,11 As of 2000, the ABMS
adopted MOC as a policy with general standards for all of its member boards.
Subsequently, the 24 boards began issuing time-limited certificates that were
usually good for 10 years, but each board was on its own schedule, and the
American Board of Pathology was the last to issue certificates, in 2006….
The remainder of the essay: http://www.nejm.org/doi/full/10.1056/NEJMhpr1211043
B. Higher-Complexity
ED Billing Codes — Sicker Patients, More Intensive Practice, or Improper
Payments?
Stephen R. Pitts, M.D., M.P.H. N Engl J Med 2012;
367:2465-2467.
A recent analysis of Medicare billing data for
evaluation-and-management services, conducted by the Office of Inspector
General (OIG) of the Department of Health and Human Services, showed that
between 2001 and 2010, the proportion of claims for lower reimbursement
categories decreased while the use of higher-paid categories increased across
all visit types.1 The largest increase reported was in level 5 emergency
department (ED) visits (Current Procedural Terminology [CPT] code 99285;
average reimbursement, $173) — from 27% to 48% of Medicare discharges…
The remainder of the essay: http://www.nejm.org/doi/full/10.1056/NEJMp1211315
21. As Nurse Lay Dying, Offering Herself as
Instruction in Caring
By Abby Goodnough, New York Times, January 11, 2013
A nurse terminally ill with cancer volunteers to be a
subject of research for students from her alma mater.
SOUTH HADLEY, Mass. — It was early November when Martha
Keochareon called the nursing school at Holyoke Community College, her alma
mater. She had a proposal, which she laid out in a voice mail message.
“I have cancer,” she said after introducing herself, “and
I’m wondering if you’ll need somebody to do a case study on, a hospice
patient.”
Perhaps some nursing students “just want to feel what a
tumor feels like,” she went on. Or they could learn something about hospice
care, which aims to help terminally ill people die comfortably at home. “Maybe
you’ll have some ambitious student that wants to do a project,” Ms. Keochareon
(pronounced CATCH-uron) said after leaving her phone number. “Thank you. Bye.”
Kelly Keane, a counselor at the college who received the
message, was instantly intrigued. Holyoke’s nursing students, like most, learn
about cancer from textbooks. They get some experience with acutely ill patients
during a rotation on the medical-surgical floor of a hospital. They practice
their skills in the college’s simulation lab on sophisticated mannequins that
can “die” of cancer, heart attacks and other ailments. But Ms. Keochareon, 59,
a 1993 graduate of Holyoke’s nursing program, was offering students something
rare: an opportunity not only to examine her, but also to ask anything they
wanted about her experience with cancer and dying.
“She is allowing us into something we wouldn’t ever be privy
to,” Ms. Keane said.
So it was that a few weeks later, two first-year nursing
students, Cindy Santiago, 26, and Michelle Elliot, 52, arrived at Ms.
Keochareon’s tiny house, a few miles from the college. She was bedbound, cared
for by a loyal band of relatives, hospice nurses and aides. Both students were
anxious.
“Sit on my bed and talk to me,” Ms. Keochareon said. The
students hesitated, saying they had been taught not to do that, to prevent
transmission of germs. What they knew of nursing in hospitals — “I’m here to
take your vitals, give you your medicine, O.K., bye,” as Ms. Santiago put it —
was different, after all.
They had come with a list of questions. Ms. Keochareon was
suffering from pancreatic cancer, and they had researched the disease ahead of
time. They were particularly curious about why she had survived for so long.
She had lived with her illness for more than six years — an extraordinary span
for pancreatic cancer, which often kills within months after diagnosis.
Why, the students asked, had she managed to keep eating and
keep on weight? What was she taking for the pain? How long had it taken for
doctors to give her a diagnosis?
“They ask good questions,” Ms. Keochareon said one morning,
her lips stained red from the liquid oxycodone she was sipping frequently
between doses of other drugs. “I forget half the stuff I learned as a nurse,
but I remember everything about pancreatic cancer. Because I’m living it.”
For Ms. Keochareon, this was a chance to teach something
about the profession she had found late and embraced — she became a nurse at
40, after raising her daughter and working for years on a factory floor…
The remainder of the essay (with video): http://www.nytimes.com/2013/01/11/us/fatally-ill-and-making-herself-the-lesson.html
