Monday, September 16, 2013

Lit Bits: Sept 16, 2013

From the recent medical literature...

1. Severe Sepsis and Septic Shock: A Review in NEJM  

Angus DC, van der Poll T. N Engl J Med 2013; 369:840-851.  

Sepsis is one of the oldest and most elusive syndromes in medicine… 

Incidence and Causes
…Severe sepsis occurs as a result of both community-acquired and health care–associated infections. Pneumonia is the most common cause, accounting for about half of all cases, followed by intraabdominal and urinary tract infections. 7,8,11,12 Blood cultures are typically positive in only one third of cases, and in up to a third of cases, cultures from all sites are negative. 7,11,13,14 Staphylococcus aureus and Streptococcus pneumoniae are the most common gram-positive isolates, whereas Escherichia coli, klebsiella species, and Pseudomonas aeruginosa predominate among gram-negative isolates.11,14 An epidemiologic study of sepsis showed that during the period from 1979 to 2000, gram-positive infections overtook gram-negative infections.15 However, in a more recent study involving 14,000 ICU patients in 75 countries, gram-negative bacteria were isolated in 62% of patients with severe sepsis who had positive cultures, gram-positive bacteria in 47%, and fungi in 19%.12 … 

Clinical Features
The clinical manifestations of sepsis are highly variable, depending on the initial site of infection, the causative organism, the pattern of acute organ dysfunction, the underlying health status of the patient, and the interval before initiation of treatment. The signs of both infection and organ dysfunction may be subtle, and thus the most recent international consensus guidelines provide a long list of warning signs of incipient sepsis (Table 1Table 1Diagnostic Criteria for Sepsis, Severe Sepsis, and Septic Shock.).5 Acute organ dysfunction most commonly affects the respiratory and cardiovascular systems. Respiratory compromise is classically manifested as the acute respiratory distress syndrome (ARDS), which is defined as hypoxemia with bilateral infiltrates of noncardiac origin.22 Cardiovascular compromise is manifested primarily as hypotension or an elevated serum lactate level. After adequate volume expansion, hypotension frequently persists, requiring the use of vasopressors, and myocardial dysfunction may occur.23 
The brain and kidneys are also often affected. Central nervous system dysfunction is typically manifested as obtundation or delirium. Imaging studies generally show no focal lesions, and findings on electroencephalography are usually consistent with nonfocal encephalopathy. Critical illness polyneuropathy and myopathy are also common, especially in patients with a prolonged ICU stay.24 Acute kidney injury is manifested as decreasing urine output and an increasing serum creatinine level and frequently requires treatment with renal-replacement therapy. Paralytic ileus, elevated aminotransferase levels, altered glycemic control, thrombocytopenia and disseminated intravascular coagulation, adrenal dysfunction, and the euthyroid sick syndrome are all common in patients with severe sepsis.5 … 

The Surviving Sepsis Campaign, an international consortium of professional societies involved in critical care, treatment of infectious diseases, and emergency medicine, recently issued the third iteration of clinical guidelines for the management of severe sepsis and septic shock (Table 2 Guidelines for the Treatment of Severe Sepsis and Septic Shock from the Surviving Sepsis Campaign.).23 The most important elements of the guidelines are organized into two “bundles” of care: an initial management bundle to be accomplished within 6 hours after the patient's presentation and a management bundle to be accomplished in the ICU.23 Implementation of the bundles is associated with an improved outcome.46,47 

The principles of the initial management bundle are to provide cardiorespiratory resuscitation and mitigate the immediate threats of uncontrolled infection. Resuscitation requires the use of intravenous fluids and vasopressors, with oxygen therapy and mechanical ventilation provided as necessary. The exact components required to optimize resuscitation, such as the choice and amount of fluids, appropriate type and intensity of hemodynamic monitoring, and role of adjunctive vasoactive agents, all remain the subject of ongoing debate and clinical trials; many of these issues will be covered in this series.23 Nonetheless, some form of resuscitation is considered essential, and a standardized approach has been advocated to ensure prompt, effective management.23 The initial management of infection requires forming a probable diagnosis, obtaining cultures, and initiating appropriate and timely empirical antimicrobial therapy and source control (i.e., draining pus, if appropriate). 

The choice of empirical therapy depends on the suspected site of infection, the setting in which the infection developed (i.e., home, nursing home, or hospital), medical history, and local microbial-susceptibility patterns. Inappropriate or delayed antibiotic treatment is associated with increased mortality.48,49 Thus, intravenous antibiotic therapy should be started as early as possible and should cover all likely pathogens. It has not been determined whether combination antimicrobial therapy produces better outcomes than adequate single-agent antibiotic therapy in patients with severe sepsis.50-53 Current guidelines recommend combination antimicrobial therapy only for neutropenic sepsis and sepsis caused by pseudomonas species. Empirical antifungal therapy should be used only in patients at high risk for invasive candidiasis.50  

The patient should also be moved to an appropriate setting, such as an ICU, for ongoing care. After the first 6 hours, attention focuses on monitoring and support of organ function, avoidance of complications, and de-escalation of care when possible. De-escalation of initial broad-spectrum therapy may prevent the emergence of resistant organisms, minimize the risk of drug toxicity, and reduce costs, and evidence from observational studies indicates that such an approach is safe.54 The only immunomodulatory therapy that is currently advocated is a short course of hydrocortisone (200 to 300 mg per day for up to 7 days or until vasopressor support is no longer required) for patients with refractory septic shock.23 This recommendation is supported by a meta-analysis,55 but the two largest studies had conflicting results,56,57 and other clinical trials are ongoing. 58,59 … 

For the rest of the review (full-text free):  

2. Door-to-Balloon Time and Mortality among Patients Undergoing Primary PCI 

Daniel S. Menees, et al. N Engl J Med 2013; 369:901-909

Background: Current guidelines for the treatment of ST-segment elevation myocardial infarction recommend a door-to-balloon time of 90 minutes or less for patients undergoing primary percutaneous coronary intervention (PCI). Door-to-balloon time has become a performance measure and is the focus of regional and national quality-improvement initiatives. However, it is not known whether national improvements in door-to-balloon times have been accompanied by a decline in mortality. 

Methods: We analyzed annual trends in door-to-balloon times and in-hospital mortality using data from 96,738 admissions for patients undergoing primary PCI for ST-segment elevation myocardial infarction from July 2005 through June 2009 at 515 hospitals participating in the CathPCI Registry. In a subgroup analysis using a linked Medicare data set, we assessed 30-day mortality. 

Results: Median door-to-balloon times declined significantly, from 83 minutes in the 12 months from July 2005 through June 2006 to 67 minutes in the 12 months from July 2008 through June 2009 (P less than 0.001). Similarly, the percentage of patients for whom the door-to-balloon time was 90 minutes or less increased from 59.7% in the first year to 83.1% in the last year (P less than 0.001). Despite improvements in door-to-balloon times, there was no significant overall change in unadjusted in-hospital mortality (4.8% in 2005–2006 and 4.7% in 2008–2009, P=0.43 for trend) or in risk-adjusted in-hospital mortality (5.0% in 2005–2006 and 4.7% in 2008–2009, P=0.34), nor was a significant difference observed in unadjusted 30-day mortality (P=0.64). 

Conclusions: Although national door-to-balloon times have improved significantly for patients undergoing primary PCI for ST-segment elevation myocardial infarction, in-hospital mortality has remained virtually unchanged. These data suggest that additional strategies are needed to reduce in-hospital mortality in this population. 

3. Use of the PECARN Blunt Abdominal Injury Rules in Cases of Suspected Abuse 

Letter to the editor
We congratulate the Pediatric Emergency Care Applied Research Network (PECARN) investigators for another important study, which, when validated, could be a powerful tool to decrease unnecessary radiation exposure in children. However, we caution that there is potential for harm if this rule, even when validated, is applied to children with concern for physical abuse. 

Abusive abdominal injury is the second-leading cause of death from physical abuse and occurs predominantly in children younger than 3 years,1 who made up only a small proportion of the cohort studied in this article. Subjects were excluded if their injury occurred more than 24 hours before presentation, but in cases of abuse (as distinct from peer-on-peer assaults), an accurate history is commonly lacking, presentations may be delayed, or the true time of injury may be unknown.2, 3 Although “physical assault involving the abdomen” was an inclusion criterion, subjects were recruited from the emergency department and therefore might not be enrolled if assault was recognized only after hospital admission, because of a changing history or abnormal laboratory study or imaging results. 

The goal of the proposed decision rule is to identify children with intra-abdominal injury who require acute intervention, defined by the authors as laparotomy, embolization, blood transfusion, or intravenous fluid… 

The remainder of the letter (full-text free):  

Reply from the authors
We thank Drs. Lindberg, Berger, and Lane for their comments about our article titled “Identifying Children at Very Low Risk of Clinically Important Blunt Abdominal Injuries.” They express concerns in implementing a clinical prediction rule for the evaluation of children with blunt torso trauma when the mechanism of injury is abuse. However, there are 2 main limitations to the comments from this group. First, they are misinterpreting the outcome variable of our study and are attempting to apply the clinical prediction rule to a different outcome variable. Patients with none of the variables in the prediction rule are at very low risk for intra-abdominal injury undergoing acute intervention and therefore “abdominal CT [computed tomography] is generally unwarranted.” The rule is not generated to predict an outcome of any intra-abdominal injury, rather only those undergoing acute intervention. 

If one needs to identify an injury that does not require a therapeutic intervention (as in physical abuse), then it is not appropriate to use the rule… 

The remainder of the reply (full-text free):  

4. Safety of US-guided thoracentesis in patients with abnormal preprocedural coagulation parameters. 

Hibbert RM, et al. Chest. 2013 Aug;144(2):456-63.  

BACKGROUND: Despite a low incidence of hemorrhagic complications following thoracentesis, correction or attempted correction of abnormal preprocedural coagulation parameters is still commonly performed. We aimed to assess hemorrhagic complications following ultrasound-guided thoracentesis in patients with abnormal preprocedural coagulation parameters. 

METHODS: We analyzed 1,009 ultrasound-guided thoracenteses performed between January 2005 and September 2011 on patients with international normalized ratio (INR) > 1.6, serum platelet values < 50 × 109/L, or both. Procedures were divided into two groups: those in whom abnormal preprocedural coagulation parameters were not corrected before the thoracentesis (group 1) and a second group in which patients received a transfusion of platelets or fresh frozen plasma prior to thoracentesis (group 2). All procedures were evaluated for hemorrhagic complications as defined by the National Institutes of Health Common Terminology Criteria for Adverse Events. 

RESULTS: A total of 1,009 ultrasound-guided thoracenteses were included in our study, consisting of 706 procedures in 538 patients in group 1 and 303 procedures in 235 patients in group 2. There were four hemorrhagic complications out of 1,009 procedures (0.40%; 95% CI, 0.15%-1.02%): zero in group 1 (0 of 706 or 0.0%; 95% CI, 0%-0.68%) and four in group 2 (four of 303 or 1.32%; 95% CI, 0.51%-3.36%). 

CONCLUSIONS: Hemorrhagic complications are infrequent after ultrasound-guided thoracentesis, and attempting to correct an abnormal INR or platelet level before the procedure is unlikely to confer any benefit. We consider the procedure safe in patients with abnormal preprocedural parameters when performed by expert personnel. 

5. Value of helical CT in the early diagnosis of esophageal FBs in adults 

Liu YC, et al. Amer J Emerg Med. 2013;31:1328-32. 

To investigate the relationship between early use of computed tomography (CT) and complications associated with esophageal foreign body impaction in adults.

Material and Methods
A retrospective study was performed on 120 patients (63 females, 57 males, median age 50 years) with a history of foreign bodies. All had negative findings on clinical examination. All cases underwent unenhanced helical CT, and patients with positive findings underwent esophagoscopy within 6 hours. All patients were followed up postoperatively. 

CT demonstrated 100% sensitivity, 92.6% specificity, 100% negative predictive value, and 97.9% positive predictive value. Esophageal foreign bodies were associated with a high incidence of complications in adults, and there was a significant difference in the incidence of complications between different durations of impaction (P less than .01). In total, 37 patients presented with complications: 32 patients with grade I, 3 with grade II, 2 with grade III, and 0 with grade IV. 

Esophageal foreign bodies were associated with a high incidence of complications in adults. CT could detect foreign bodies accurately in the early stages, and then FBs could be removed as early as possible, which may reduce the incidence of complications. Moreover, the great majority of complications were of lower grades. Thus, CT may be a useful first-line radiological tool for the early diagnosis of esophageal foreign bodies in adults.

6. A Risk Prediction Score for Kidney Failure or Mortality in Rhabdomyolysis  

McMahon Gm, et al. JAMA Intern Med. 2013 Sep 2. [Epub ahead of print] 

Importance  Rhabdomyolysis ranges in severity from asymptomatic elevations in creatine phosphokinase levels to a life-threatening disorder characterized by severe acute kidney injury requiring hemodialysis or continuous renal replacement therapy (RRT). 

Objective  To develop a risk prediction tool to identify patients at greatest risk of RRT or in-hospital mortality. 

Design, Setting, and Participants  Retrospective cohort study of 2371 patients admitted between January 1, 2000, and March 31, 2011, to 2 large teaching hospitals in Boston, Massachusetts, with creatine phosphokinase levels in excess of 5000 U/L within 3 days of admission. The derivation cohort consisted of 1397 patients from Massachusetts General Hospital, and the validation cohort comprised 974 patients from Brigham and Women’s Hospital. 

Main Outcomes and Measures  The composite of RRT or in-hospital mortality. 

Results  The causes and outcomes of rhabdomyolysis were similar between the derivation and validation cohorts. In total, the composite outcome occurred in 19.0% of patients (8.0% required RRT and 14.1% died during hospitalization). The highest rates of the composite outcome were from compartment syndrome (41.2%), sepsis (39.3%), and following cardiac arrest (58.5%). The lowest rates were from myositis (1.7%), exercise (3.2%), and seizures (6.0%). The independent predictors of the composite outcome were age, female sex, cause of rhabdomyolysis, and values of initial creatinine, creatine phosphokinase, phosphate, calcium, and bicarbonate. We developed a risk-prediction score from these variables in the derivation cohort and subsequently applied it in the validation cohort. The C statistic for the prediction model was 0.82 (95% CI, 0.80-0.85) in the derivation cohort and 0.83 (0.80-0.86) in the validation cohort. The Hosmer-Lemeshow P values were .14 and .28, respectively. In the validation cohort, among the patients with the lowest risk score (less than 5), 2.3% died or needed RRT. Among the patients with the highest risk score (above 10), 61.2% died or needed RRT. 

Conclusions and Relevance  Outcomes from rhabdomyolysis vary widely depending on the clinical context. The risk of RRT or in-hospital mortality in patients with rhabdomyolysis can be estimated using commonly available demographic, clinical, and laboratory variables on admission. 

7. A Green Light for Colchicine to Treat Acute Pericarditis  

Harlan M. Krumholz, MD, SM reviewing Imazio M et al. for the ICAP Investigators. N Engl J Med 2013 Sep 1.  

When added to anti-inflammatory agents, the drug significantly improved outcomes after a first attack.  

Although some experts have recommended the use of colchicine for acute pericarditis, the recommendation has not been based on strong clinical-trial evidence. To address this gap in knowledge, investigators conducted the randomized, double-blind, ICAP trial at five centers in Italy. They assigned 240 patients with a first episode of acute pericarditis to receive colchicine (0.5 mg twice/day for patients weighing over 70 kg and 0.5 daily for those weighing ≤70 kg) or placebo for 3 months. All patients were treated with anti-inflammatory agents, mostly aspirin or ibuprofen. 

The primary endpoint, incessant or recurrent pericarditis during 18-month follow-up, occurred significantly less frequently in the colchicine group than in the placebo group (17% vs. 38%; relative risk, 0.56; 95% confidence interval, 0.30–0.72). Also, fewer patients in the colchicine group had persistent symptoms at 72 hours (19% vs. 40%; P=0.001). The remission rate at 1 week was higher in the colchicine group than in the placebo group (85% vs. 58%; P less than 0.001). Adverse-event rates were similar in the two groups.  

Comment: This study strengthens the evidence for the use of colchicine to treat acute pericarditis. Although these results may not surprise many clinicians, having the evidence to support this practice is reassuring.  

Citation(s): Imazio M et al. for the ICAP Investigators. A randomized trial of colchicine for acute pericarditis. N Engl J Med 2013 Sep 1; [e-pub ahead of print].  

8. Oral and IV Acetylcysteine for Treatment of Acetaminophen Toxicity: A Systematic Review and Meta-analysis. 

Green JL, et al. West J Emerg Med. 2013 May;14(3):218-26. 

Introduction: There are few reports summarizing the effectiveness of oral and intravenous (IV) acetylcysteine. We determined the proportion of acetaminophen poisoned patients who develop hepatotoxicity (serum transaminase above 1000 IU/L) when treated with oral and IV acetylcysteine.  

Methods: Studies were double abstracted by trained researchers. We determined the proportions of patients who developed hepatotoxicity for each route using a random effects model. Studies were further stratified by early and late treatment.  

Results: We screened 4,416 abstracts; 16 articles, including 5,164 patients, were included in the meta-analysis. The overall rate of hepatotoxicity for the oral and IV routes were 12.6% and 13.2%, respectively. Treatment delays are associated with a higher rate of hepatotoxicity.  

Conclusion: Studies report similar rates of hepatotoxicity for oral and IV acetylcysteine, but direct comparisons are lacking. While it is difficult to disentangle the effects of dose and duration from route, our findings suggest that the rates of hepatotoxicity are similar for oral and IV administration. 

9. Overtreatment of presumed UTI in older women presenting to the ED 

Gordon LB, et al. J Am Geriatr Soc. 2013;61(5):788-92.  

OBJECTIVES: To determine how often older women presenting to an emergency department (ED) are diagnosed with a urinary tract infection (UTI) without a positive urine culture and to investigate whether collecting urine by catheterization instead of clean catch improves the accuracy of the urinalysis (UA).

DESIGN: Retrospective chart review. 

SETTING: Academic-affiliated ED in Providence, Rhode Island. 

PARTICIPANTS: One hundred fifty-three women aged 70 and older with diagnosis of UTI in the ED between December 1, 2008, and March 1, 2010. 

MEASUREMENTS: Chief complaint, review of systems, results of UA and culture, urine procurement (clean catch, straight catheter, or newly inserted Foley catheter), antibiotic administered or prescribed, and diagnosis. A confirmed UTI was defined as a positive urine culture, with microbial growth of 10,000 colony-forming units (CFU)/ mL or more for clean-catch specimens and 100 CFU/mL or more for newly inserted catheter specimens; an ED diagnosis of UTI was defined as the designation by an ED physician. 

RESULTS: Of 153 individuals with an ED-diagnosed UTI, only 87 (57%) had confirmed UTI according to culture. Of the remaining 66 with negative cultures, 63 (95%) were administered or prescribed antibiotics in the ED. The method of urine procurement affected the ability of a UA to predict the culture result (P = .02), with catheterization yielding a lower proportion of false-positive UA (31%) than clean catch (48%). 

CONCLUSION: Nearly half of older women diagnosed with a UTI in an ED setting did not have confirmatory findings on urine culture and were therefore inappropriately treated. Catheterization improved the accuracy of UA when assessing older women for possible UTI. 

10. Images (and Videos) in Clinical Medicine 

Scrotal Calcinosis 

Upper Limb Clonus 

Staphylococcal Toxic Shock Syndrome

Severe Vitamin D Deficiency — Rickets

Palmoplantar pustulosis

Hair casts (pseudonits)

A Woman’s Secret

Female with Rash

11. Factors affecting pediatric isotonic fluid resuscitation efficiency: a RCT evaluating the impact of syringe size 

Harvey G, et al. BMC Emerg Med 2013, 13:14 doi:10.1186/1471-227X-13-14

Goal-directed therapy guidelines for pediatric septic shock resuscitation recommend fluid delivery at speeds in excess of that possible through use of regular fluid infusion pumps. In our experience, syringes are commonly used by health care providers (HCPs) to achieve rapid fluid resuscitation in a pediatric fluid resuscitation scenario. At present, it is unclear which syringe size health care providers should use when performing fluid resuscitation to achieve maximal fluid resuscitation efficiency. The objective of this study was therefore to determine if an optimal syringe size exists for conducting manual pediatric fluid resuscitation.  

This 48-participant parallel group randomized controlled trial included 4 study arms (10, 20, 30, 60 mL syringe size groups). Eligible participants were HCPs from McMaster Children’s Hospital, Hamilton, Canada blinded to the purpose of the trial. Consenting participants were randomized using a third party technique. Following a standardization procedure, participants administered 900 mL (60 mL/kg) of isotonic saline to a simulated 15 kg child using prefilled provided syringes of the allocated size in rapid sequence. Primary outcome was total time to administer the 900 mL and this data was collected through video review by two blinded outcome assessors. Sample size was predetermined based upon a primary outcome analysis using one-way ANOVA.  

12 participants were randomized to each group (n=48) and all completed trial protocol to analysis. Analysis was conducted according to intention to treat principles. A significant difference in fluid resuscitation time (in seconds) was found between syringe size group means: 10 mL, 563s [95% CI 521; 606]; 20 mL, 506s [95% CI 64; 548]; 30 mL, 454s [95% CI 412; 596]; 60 mL, 455s [95% CI 413; 497] (p less than 0.001).  

The syringe size used when performing manual pediatric fluid resuscitation has a significant impact on fluid resuscitation speed, in a setting where fluid filled syringes are continuously available. Greatest efficiency was achieved with 30 or 60 mL syringes. 

12. A comparison of bilevel and continuous PAP noninvasive ventilation in acute cardiogenic pulmonary edema 

Li H, et al. Amer J Emerg Med 2013;31:1322-27. 

Whether bilevel positive airway pressure (BiPAP) is advantageous compared with continuous positive airway pressure (CPAP) in acute cardiogenic pulmonary edema (ACPO) remains uncertain. The aim of the meta-analysis was to assess potential beneficial and adverse effects of CPAP compared with BiPAP in patients with ACPO. 

Randomized controlled trials comparing the treatment effects of BiPAP with CPAP were identified from electronic databases and reference lists from January 1966 to December 2012. Two reviewers independently assessed study quality. In trials that fulfilled inclusion criteria, we critically evaluate the evidence for the use of noninvasive ventilation on rates of hospital mortality, endotracheal intubation, myocardial infarction, and the length of hospital stay. Data were combined using Review Manager 4.3 (The Cochrane Collaboration, Oxford, UK). Both pooled effects and 95% confidence intervals (CIs) were calculated. 

Twelve randomized controlled trials with a total of 1433 patients with ACPO were included. The hospital mortality (relative risk [RR], 0.86; 95% CI, 0.65-1.14; P = .46; I2 = 0%) and need for requiring invasive ventilation (RR, 0.89; 95% CI, 0.57-1.38; P = .64; I2 = 0%) were not significantly different between patients treated with CPAP and those treated with BiPAP. The occurrence of new cases of myocardial infarction (RR, 0.95; 95% CI, 0.77-1.17; P = .53, I2 = 0%) and length of hospital stay (RR, 1.01; 95% CI, −0.40 to 2.41; P = .98; I2 = 0%) were also not significantly different between the 2 groups. 

There are no significant differences in clinical outcomes when comparing CPAP vs BiPAP. Based on the limited data available, our results suggest that there are no significant differences in clinical outcomes when comparing CPAP with BiPAP. 

13. Ibuprofen vs acetaminophen vs their combination in the relief of musculoskeletal pain in the ED: a RCT 

Bondarsky EE, et al. Amer J Emerg Med. 2013;31:1357-60. 

Non-opioid analgesics are often administered to emergency department (ED) patients with musculoskeletal pain but if inadequate, opioids are given with associated potential adverse events. We tested the hypothesis that the reduction in pain scores with the combination of ibuprofen and acetaminophen would be at least 15 mm greater than with either of the agents alone.  

We conducted a double-blind, randomized, controlled trial of adult ED patients with acute musculoskeletal pain. Patients were randomized to oral ibuprofen 800 mg, acetaminophen 1 g, or their combination. Pain scores across the groups were compared with repeated measures analysis of variance at 20, 40, and 60 minutes. A sample of 30 patients in each group had 80% power to detect a 15 mm difference in pain scores across the groups (α = .05).  

Thirty patients were randomized to each study group. Mean (SD) age was 36 (15), 54% were male, 73% were white, and 13% were Hispanic. Groups were well balanced in baseline characteristics including initial pain scores (59, 61, and 62 for ibuprofen, acetaminophen, and their combination). Pain decreased over the one hour study period for all groups (P less than .001) with mean (SD) scores about 20 mm lower on the Visual Analogue Scale than the mean initial score. However, there was no significant difference among treatments (P = .59). The need for rescue analgesics was similar across groups.  

We conclude that the combination of ibuprofen and acetaminophen did not reduce pain scores or the need for rescue analgesics compared with either agent alone in ED patients with pain secondary to acute musculoskeletal injuries. 

14. Managing Bleeding in Anticoagulated Patients in the Emergency Care Setting 

Pollack CV. J Emerg Med. 2013;45:467-477.  

Orally administered anticoagulants that offer alternatives to warfarin have been developed in recent years and are currently available for reduction of stroke risk in patients with non-valvular atrial fibrillation, the prophylaxis of venous thromboembolism after hip or knee replacement surgery, and the treatment and secondary risk reduction of deep vein thrombosis and pulmonary embolism. 

This article will provide a brief introduction to these new oral anticoagulants and then review the approaches that can be taken for the emergency management of hemostasis in patients bleeding or at risk for bleeding while receiving warfarin or one of two newer agents, the direct thrombin inhibitor dabigatran or the factor Xa inhibitor rivaroxaban. 

Oral anticoagulant use is widespread and likely to continue to increase. Warfarin has been the standard of care in oral anticoagulation for many years; its bleeding risks are well known and associated emergency protocols are well established. As newer oral anticoagulants become more widely used, similar procedures will need to be developed. Although there are as yet no specific reversal agents for these newer drugs, recommendations for overdose, emergency hemostasis, and preoperative management are available. Further, while the newer agents do not require routine coagulation monitoring, assays for use in non-routine situations are being explored. 

The introduction of alternative oral anticoagulants will require emergency procedures that differ in some respects from those currently in place for warfarin and it will be necessary for Emergency Medicine professionals to become familiar with these procedures. Clinical stabilization of the bleeding or at-risk patient remains the emergency physician’s priority. 

15. Implementation of an Outpatient Electronic Health Record and ED Visits, Hospitalizations, and Office Visits among Patients with Diabetes. 

Reed ME, et al. JAMA. 2013;310(10):1060-1065.  

IMPORTANCE: The US federal government is spending billions of dollars in physician incentives to encourage the meaningful use of electronic health records (EHRs). Although the use of EHRs has potential to improve patient health outcomes, the existing evidence has been limited and inconsistent. 

OBJECTIVE: To examine the association between implementing a commercially available outpatient EHR and emergency department (ED) visits, hospitalizations, and office visits for patients with diabetes mellitus. 

DESIGN, SETTING, AND POPULATION: Staggered EHR implementation across outpatient clinics in an integrated delivery system (Kaiser Permanente Northern California) between 2005 and 2008 created an opportunity for studying changes associated with EHR use. Among a population-based sample of 169,711 patients with diabetes between 2004 and 2009, we analyzed 4,997,585 person-months before EHR implementation and 4,648,572 person-months after an EHR was being used by patients' physicians. 

MAIN OUTCOMES AND MEASURES: We examined the association between EHR use and unfavorable clinical events (ED visits and hospitalizations) and office visit use among patients with diabetes, using multivariable regression with patient-level fixed-effect analyses and adjustment for trends over time. 

RESULTS: In multivariable analyses, use of the EHR was associated with a statistically significantly decreased number of ED visits, 28.80 fewer visits per 1000 patients annually (95% CI, 20.28 to 37.32), from a mean of 519.12 visits per 1000 patients annually without using the EHR to 490.32 per 1000 patients when using the EHR. The EHR was also associated with 13.10 fewer hospitalizations per 1000 patients annually (95% CI, 7.37 to 18.82), from a mean of 251.60 hospitalizations per 1000 patients annually with no EHR to 238.50 per 1000 patients annually when using the EHR. There were similar statistically significant reductions in nonelective hospitalizations (10.92 fewer per 1000 patients annually) and hospitalizations for ambulatory care-sensitive conditions (7.08 fewer per 1000 patients annually). There was no statistically significant association between EHR use and office visit rates. 

CONCLUSIONS AND RELEVANCE: Among patients with diabetes, use of an outpatient EHR in an integrated delivery system was associated with modest reductions in ED visits and hospitalizations but not office visit rates. Further studies are needed to quantify the association of EHR use with changes in costs. 

16. Effect of the Low Risk Ankle Rule on the frequency of radiography in children with ankle injuries 

Boutis K, et al. CMAJ 2013 [Epub ahead of print] 

Background: The Low Risk Ankle Rule is a valid ated clinical decision rule that has the potential to safely reduce radiography in children with acute ankle injuries. We performed a phased implementation of the Low Risk Ankle Rule and evaluated its effectiveness in reducing the frequency of radiography in children with ankle injuries. 

Methods: Six Canadian emergency departments participated in the study from Jan. 1, 2009, to Aug. 31, 2011. At the 3 intervention sites, there were 3 consecutive 26-week phases. In phase 1, no interventions were implemented. In phase 2, we activated strategies to implement the ankle rule, including physician education, reminders and a computerized decision support system. In phase 3, we included only the decision support system. No interventions were introduced at the 3 pair-matched control sites. We examined the management of ankle injuries among children aged 3–16 years. The primary outcome was the proportion of children undergoing radiography. 

Results: We enrolled 2151 children with ankle injuries, 1055 at intervention and 1096 at control hospitals. During phase 1, the baseline frequency of pediatric ankle radiography at intervention and control sites was 96.5% and 90.2%, respectively. During phase 2, the frequency of ankle radiography decreased significantly at intervention sites relative to control sites (between-group difference –21.9% [95% confidence interval [CI] –28.6% to –15.2%]), without significant differences in patient or physician satisfaction. All effects were sustained in phase 3. The sensitivity of the Low Risk Ankle Rule during implementation was 100% (95% CI 85.4% to 100%), and the specificity was 53.1% (95% CI 48.1% to 58.1%).  

Interpretation: Implementation of the Low Risk Ankle Rule in several different emergency department settings reduced the rate of pediatric ankle radiography significantly and safely, without an accompanying change in physician or patient satisfaction. 

17. Are US-Guided Injections Effective for Trochanteric Bursitis?  

Allan S. Brett, MD reviewing McEvoy JR et al. AJR Am J Roentgenol 2013 Aug.  

The site of injection might determine whether a patient responds. We often assume that bursitis is the cause of pain and tenderness over the greater trochanter of the hip. Patients with greater trochanteric pain syndrome often receive corticosteroid injections, not necessarily guided by imaging.  

However, the relevant anatomy is complex: Several different bursae are present, and the anatomy varies from person to person.In this retrospective single-site study, researchers in Wisconsin reviewed records of 65 patients who received ultrasound-guided trochanteric corticosteroid injections and who returned pre- and postinjection pain questionnaires. Injections were initiated at the site of maximal tenderness in all patients, but the ultimate location of the needle tip was the greater trochanteric bursa (i.e., deep subgluteus maximus bursa) in 41 patients and into the subgluteus medius bursa in 24 patients. Location of the needle tip was at the discretion of injecting radiologists; no anatomic ultrasound findings distinguished between the two groups. Among patients who received injections into the greater trochanteric bursa, pain improved significantly at 14 days (median improvement, 3 points on a 10-point visual analog scale; P less than 0.01). In contrast, median improvement was 0 among those who received injections into the subgluteus medius bursa. 
Comment: This study's flaws include nonrandomized assignment of injection sites and exclusion of an unspecified number of patients who did not return surveys. Nevertheless, the findings might explain why response to steroid injections is so variable in clinical practice. Although these injections are easily done in primary care settings, I believe that we should consider referring selected patients for ultrasound-guided injections, if a specialist who is familiar with these landmarks is available. A nice review of greater trochanter anatomy is available online free of charge (Anesth Analg 2009; 108:1662). 

Citation(s): McEvoy JR et al. Ultrasound-guided corticosteroid injections for treatment of greater trochanteric pain syndrome: Greater trochanter bursa versus subgluteus medius bursa. AJR Am J Roentgenol 2013 Aug; 201:W313. (  

18. Which Patients Might Benefit from Endovascular Stroke Therapy? 
Hooman Kamel, MD reviewing Lemmens R et al. Neurology 2013 Aug 13. 

In patients whose imaging showed brain tissue at risk for infarction, successful reperfusion was associated with better outcomes regardless of whether the internal carotid or middle cerebral artery was occluded.  

Endovascular stroke therapy continues to hold out promise, but in several recent randomized clinical trials it did not improve clinical outcomes compared with intravenous thrombolysis alone. For endovascular therapy to prove itself in this regard will probably require a combination of speedy intervention, technically sound devices, and appropriate patient selection.To advance our understanding of the patient-selection component, the DEFUSE-2 investigators now report a substudy comparing the association between reperfusion and clinical outcomes in patients with occluded internal carotid artery (ICA) and in those with occluded middle cerebral artery (MCA).  

The multicenter DEFUSE-2 study enrolled patients anticipated to undergo endovascular therapy within 12 hours after stroke onset, and performed magnetic resonance imaging 90 minutes before endovascular therapy and 12 hours and 5 days afterward. The authors examined whether perfusion-diffusion mismatch (i.e., tissue presumably at risk for infarction) and successful reperfusion correlated with favorable clinical response (improvement by ≥8 points on the NIH Stroke Scale or a modified Rankin Scale score of 0–1 at 30 days). 

Of 98 eligible patients, the 28 with ICA occlusion had more severe strokes than the 70 with MCA occlusion but had similar rates of perfusion-diffusion mismatch (79% vs. 80%) and successful reperfusion (61% vs. 59%). In patients with MCA occlusion and perfusion-diffusion mismatch, those with reperfusion more often had a favorable clinical response (70%) than those without reperfusion (43%). This effect was even more dramatic with ICA occlusion and perfusion-diffusion mismatch: 69% favorable clinical response with reperfusion versus 0% without.  

Comment: As with earlier observational studies, these findings hold out the possibility that endovascular stroke therapy can rescue certain patients, which may be useful particularly when intravenous thrombolysis fails. Such patients should be transferred to stroke centers with endovascular capability for potential treatment and enrollment in randomized clinical trials evaluating the newest generation of endovascular devices.  

Citation(s): Lemmens R et al. Comparison of the response to endovascular reperfusion in relation to site of arterial occlusion. Neurology 2013 Aug 13; 81:614  

19. An ED Patient with Syncope: Interactive Case from NEJM 

Fox MC, et al. N Engl J Med 2013; 369:e9 

A 35-year-old man presented to the ED after a sudden loss of consciousness while playing soccer with friends. He recalled the sudden onset of lightheadedness and a tingling sensation across his forehead for a few seconds before he lost consciousness. He had no history of head trauma, chest pain, palpitations, dyspnea, anxiety, nausea, lightheadedness, or loss . .. 

20. “Good” Patients and “Difficult” Patients [in the ED]— Rethinking Our Definitions 

Louise Aronson, M.D. N Engl J Med 2013; 369:796-797  

Four weeks after his quadruple bypass and valve repair, 3 weeks after the bladder infection, pharyngeal trauma, heart failure, nightly agitated confusion, and pacemaker and feeding-tube insertions, and 2 weeks after his return home, I was helping my 75-year-old father off the toilet when his blood pressure dropped out from under him. As did his legs.

I held him up. I shouted for my mother. As any doctor would, I kept a hand on my father's pulse, which was regular: no pauses, no accelerations or decelerations. 

My mother was 71 years old and, fortunately, quite fit. She had been making dinner and said she dropped the salad bowl when I yelled for her. She took the stairs two at time. Something about my tone, she said. 

Together, we lowered my father to the bathroom floor. I told her to keep him talking and to call me if he stopped, and then I dialed 911. 

In the emergency department, after some fluids, my father felt better. My mother held his hand. We compared this new hospital with the last one where we'd spent so many weeks but which had been diverting ambulances elsewhere that evening. The doctor came in and reported no ECG changes and no significant laboratory abnormalities, except that the INR was above the target range. The doctor guessed the trouble was a bit of dehydration. He would watch for a while, just to be safe. 

My mother waited with my father. The rest of us filed in and out, not wanting to crowd the tiny room. Then my father's blood pressure dropped again. I told the nurse and stayed out of the way. She silenced the alarm, upped the fluids, and rechecked the blood pressure. It was better. But less than half an hour later, we listened as the machine scanned for a reading, dropping from triple to double digits before it found its mark. The numbers flashed, but the silenced alarm remained quiet. I pressed the call button, and when the nurse arrived I asked her to call for the doctor. When no one came, I went to the nursing station and made my case to the assembled doctors and nurses. They were polite, but their unspoken message was that they were working hard, my father wasn't their only patient, and they had appropriately prioritized their tasks. I wondered how many times I had made similar assumptions and offered similar assurances to patients or families. 

After weeks of illness and caregiving, it can be a relief to be a daughter and leave the doctoring to others. But I had been holding a thought just beyond consciousness, and not just because I hoped to remain in my assigned role as patient's offspring. At least as important, I didn't want to be the sort of family member that medical teams complain about. Now that I'd apparently taken on that persona, there was no longer any point in suppressing the thought. Although the differential diagnosis for hypotension is long, my father's heart was working well, I had adhered to the carefully calculated regimen that we'd received for his tube feeds and free water intake, and he did not have new medications or signs of infection. Those facts and his overly thin blood put internal bleeding like a neon sign at the top of the differential. 

I rested my hand on my father's arm to get his attention and said, “Dad, how much would you mind if I did a rectal?” 

We doctors do many things that are otherwise unacceptable. We are trained not only in how to do such things but in how to do them almost without noticing, almost without caring, at least in the ways we might care in different circumstances or settings. A rectal exam on one's father, of course, is exactly the same as other rectal exams — and also completely different. Luckily for me, my father was a doctor too. When I asked my crazy question, he smiled. 

“Kid,” he replied, “do what you have to do.”
I found gloves and lube. I had him roll onto his side. And afterward, I took my bloody gloved finger out into the hallway to prove my point. 

I realize that walking to the nurses' station holding aloft one's bloody, gloved hand is not an optimal tactic from a professionalism standpoint — but it worked. A nurse followed me back into my father's room, saw my panicked mother holding a bedpan overflowing with blood and clots, and called for help. Within seconds, the room filled, and minutes later, when the ICU team showed up, I stood back, a daughter again. 

In retrospect, what is most interesting is how much more comfortable I felt performing an intimate procedure on my father than demanding the attention of the professionals assigned to care for him. Abiding by the unspoken rules of medical etiquette, I had quieted my internal alarms for more than 2 hours. Instead, I had considered how doctors and nurses feel about and treat so-called pushy or “difficult” families, and as a result, I had prioritized wanting us to be seen as a “good patient” and “good family” over being a good doctor-daughter. 

Although many physicians would have made different choices than I did, the impetus for my decisions lay in a trait of our medical culture. When we call patients and families “good,” or at least spare them the “difficult” label, we are noting and rewarding acquiescence. Too often, this “good” means you agree with me and you don't bother me and you let me be in charge of what happens and when. Such a definition runs counter to what we know about truly good care as a collaborative process. From the history that so often generates the diagnosis to the treatment that is the basis of care or cure, active participation of patients and families is essential to optimal outcomes. 

There will always be patients and families who are considered high maintenance, challenging, or both by health care providers. Among them are a few with evident mental illness, but most are simply trying their best to understand and manage their own or their loved ones' illness. That we sometimes feel besieged or irritated by these advocates speaks to opportunities for improvement in both medical culture and the health care system. Culturally, we could benefit from a lens shift toward seeing more-vocal patients and families as actively engaged in their health care, presenting new, potentially important information, and expressing unmet care needs. At the systems level, we need to both count (using specially designated sections of the medical record) and reward (through diagnostic and billing codes) the time that providers spend talking to patients and families. 

I'll never know whether such changes would have altered my behavior or that of the medical staff on the night of my father's massive intestinal bleed, and fortunately we all acted in time. I do know that 8 years later, the most vivid image I have of that night is not my father wobbling in the bathroom surrounded by cold, hard tile and angular metal structures, or a mustard yellow bedpan filling with bright red blood. The image is this, a worst-case might-have-been scenario had I not been there, had I not had medical training, had I not spoken up: my parents, sleepy because it was by then late at night, snuggled up together at the top of the gurney, my mother resting her head against my father's chest, their eyes closed, their faces relaxed. His systolic blood pressure, usually 130, dropping to 80 and then 70. The monitors turned off or ignored. The lights dim. A short nap and they'd feel better. A little rest and maybe it would be time to go home. 

21. Effect of the Duration of ED Observation on CT Use in Children with Minor Blunt Head Trauma 

Schonfeld D, et al. Ann Emerg Med. 2013 Jul 24 [Epub ahead of print] 

STUDY OBJECTIVE: We determine the effect of the duration of emergency department (ED) observation on computed tomography (CT) rate for children with minor blunt head trauma. 

METHODS: We performed a prospective cohort study of children with blunt head trauma and a Glasgow Coma Scale score greater than 14. We defined time from injury as the time from head injury to initial physician (emergency attending physician or fellow) assessment. For children who were observed in the ED before CT decisionmaking, we defined ED observation time as time from initial physician assessment to the decision whether to obtain a CT. After adjusting for time from injury, patient age, sex, physician type, and study month, we measured the effect of ED observation time on CT rate in each of the 3 Pediatric Emergency Care Applied Research Network Traumatic Brain Injury risk groups. 

RESULTS: Of the 1,605 eligible patients, we enrolled 1,381 (86%). Of the enrolled patients, 676 (49%) were observed in the ED and 272 (20%) had a CT performed. After adjustment, every hour of ED observation time was associated with a decrease in CT rate for children in all 3 traumatic brain injury risk groups: high risk (adjusted odds ratio [OR] 0.11; 95% confidence interval [CI] 0.05 to 0.24), intermediate risk (adjusted OR 0.28; 95% CI 0.21 to 0.36), and low risk (adjusted OR 0.47; 95% CI 0.31 to 0.73). All 8 children with a significant traumatic brain injury had an immediate CT. 

CONCLUSION: For children with minor blunt head trauma, ED observation time was associated with a time-dependent reduction in cranial CT rate, with no delay in the diagnosis of a significant traumatic brain injury. 

22. Pediatric Intussusception Best Treated at Pediatric Hospitals 

Rates of bowel resection and complications were lower when children with intussusception had surgery at pediatric hospitals.

McAteer JP, et al. J Am Coll Surg. 2013 Aug;217(2):226-232.e3 

BACKGROUND: Although previous studies have shown that radiologic intussusception reduction is more likely at children's hospitals, no study to date has compared outcomes among children advancing to surgical intervention. We hypothesized that rates of bowel resection would differ between hospitals with and without pediatric surgeons. 

STUDY DESIGN: We conducted a population-based retrospective cohort study using Washington State discharge records. All children younger than 18 years undergoing operative intussusception reduction between 1999 and 2009 were included (n = 327). Data were collected on demographics, disease severity, comorbidities, and concomitant gastrointestinal pathology. Multivariate logistic regression was used to estimate odds of intestinal resection during operative intussusception reduction.

RESULTS: Pediatric hospitals treated a smaller proportion of children older than 4 years of age (12.1% vs 44.4%), as well as a greater proportion of Medicaid patients (50.9% vs 42.6%). Patients at pediatric hospitals had a lower prevalence of underlying intestinal anomalies or identifiable mass lesions (14.3% vs 16.7%). "Severe disease" (perforation, ischemia, acidosis) was more common at pediatric hospitals (17.6% vs 9.3%). Overall, bowel resection was more commonly performed at nonpediatric hospitals (59.3% vs 33.0%). On multivariate analysis, the odds of bowel resection were significantly lower at pediatric compared with nonpediatric hospitals (odds ratio [OR] 0.20, p less than 0.001), and this association was strongest in younger patients. Adjusted odds of postoperative complications were greater for bowel resection patients (OR 2.83, p less than 0.001). 

CONCLUSIONS: Bowel resection during operative intussusception reduction is more likely at hospitals without pediatric surgeons, and is associated with increased complications. Improved outcomes may be achieved by efforts aimed at standardizing care and decreasing variability in the treatment of pediatric intussusception. 

23. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a RCT 

Zahed R, et al. Amer J Emerg Med. 2013;31:1389-92.

Epistaxis is a common problem in the emergency department (ED). Sixty percent of people experience it at least once in their life. There are different kinds of treatment for epistaxis. This study intended to evaluate the topical use of injectable form of tranexamic acid vs anterior nasal packing with pledgets coated with tetracycline ointment. 

Topical application of injectable form of tranexamic acid (500 mg in 5 mL) was compared with anterior nasal packing in 216 patients with anterior epistaxis presented to an ED in a randomized clinical trial. The time needed to arrest initial bleeding, hours needed to stay in hospital, and any rebleeding during 24 hours and 1 week later were recorded, and finally, the patient satisfaction was rated by a 0-10 scale. 

Within 10 minutes of treatment, bleedings were arrested in 71% of the patients in the tranexamic acid group, compared with 31.2% in the anterior nasal packing group (odds ratio, 2.28; 95% confidence interval, 1.68-3.09; P less than .001). In addition, 95.3% in the tranexamic acid group were discharged in 2 hours or less vs 6.4% in the anterior nasal packing group (P less than .001). Rebleeding was reported in 4.7% and 11% of patients during first 24 hours in the tranexamic acid and the anterior nasal packing groups, respectively (P = .128). Satisfaction rate was higher in the tranexamic acid compared with the anterior nasal packing group (8.5 ± 1.7 vs 4.4 ± 1.8, P less than .001).

Topical application of injectable form of tranexamic acid was better than anterior nasal packing in the initial treatment of idiopathic anterior epistaxis. 

24. Budweiser is most popular beer among injured ER patients, pilot study says 

Brian Alexander, NBC News, Aug. 15, 2013  

Many people who end their Friday or Saturday nights in a hospital emergency room have been drinking alcohol. In fact, public health experts estimate that about one-third of all injury-related ER visits involved alcohol consumption.  

But what, exactly, are people drinking? What types of alcohol and even what brands? Is there a direct link between advertising and marketing and later injury?  

Until now, those questions have been unanswerable, frustrating alcohol epidemiology researchers. But if results of a pilot study conducted by researchers from Johns Hopkins Bloomberg School of Public Health hold up, there may soon be a way to connect the dots. 

When the Hopkins researchers surveyed ER patients who’d been drinking, they found that Budweiser was the number one brand consumed, followed Steel Reserve Malt Liquor, Colt 45 malt liquor, Bud Ice (another malt liquor), Bud Light, and a discount-priced vodka called Barton’s.  

Though Budweiser has 9.1 percent of the national beer market, it represented 15 percent of the of the E.R. “market.” The disparity was even more pronounced for Steel Reserve. It has only .8 percent of the market nationally, but accounted for 14.7 percent of the E.R. market. In all, Steel Reserve, Colt 45, Bud Ice, and another malt liquor, King Cobra, account for only 2.4 percent of the U.S. beer market, but accounted for 46 percent of the beer consumed by E.R. patients. 

“Some products are marketed to certain groups of people in our society,” explained Traci Toomey, the director of the University of Minnesota’s alcohol epidemiology program, who was not involved in the study. Higher-alcohol malt liquor, for example, is heavily advertised in African-American neighborhoods. “So we might want to put some controls on certain products if we find they are tied to greater risk. But how they are marketed and priced is critical information and that has been very hard to study.” 

“The Federal Trade Commission, in reports, and in personal communication with me, said this kind of research cannot be done,” David Jernigan, a professor of public health at Johns Hopkins and the director of the study told NBC News. “The National Institute on Drug Abuse gave me similar pushback.”  

Though Jernigan was quick to point out that no conclusions could be made about beer or malt liquor advertising, pricing, or even consumption based on the study since it was too small – 105 patient interviews -- and took place in only one hospital in Baltimore in mostly black neighborhood, he proved such research was possible.  

By using a drop down menu on a small notebook computer, the survey takers managed to obtain information from patients, and to include about 400 brands, in less than five minutes. At first, Jernigan, said, many patients refused to talk. But then the survey takers, with the permission of the emergency room staff, donned white coats. After that, patients talked freely.  

Overall, malt liquor and lower alcohol beer dominated consumption but vodka, gin, brandy and cognac were overrepresented, too. 

25. Tid Bits 

A. Study ties mindfulness among docs to patient satisfaction  

Physicians who ranked in the top third of mindfulness scores had higher-quality conversations with patients and attained better patient satisfaction ratings than those who were in the bottom third, a study published in the Annals of Family Medicine found. Doctors were caring for patients with HIV, and mindfulness was defined as "purposeful and nonjudgmental attentiveness to one's own experience, thoughts and feelings." 

B. Methylprednisolone Injections for the Carpal Tunnel Syndrome: A Randomized, Placebo-Controlled Trial  

Atroshi I, et al. Ann Intern Med.  2013;159(5):309-317. 

C. A Song Makes Guidelines Work Better    

BARCELONA -- By incorporating dry, professional asthma guidelines into a music video that went -- pardon the pun -- viral, researchers say they have dramatically improved hospital-wide knowledge of procedures for ill patients.  

D. Ablation May Lower Stroke Risk in Afib   

Patients who underwent ablation for atrial fibrillation had stroke rates comparable with those who didn’t have the arrhythmia, researchers found.

E. Yelling at Teens Won’t Fix Bad Behavior  

Parents who yell, insult, or swear in an effort to correct bad behavior may perpetuate the behavior and increase a child’s risk for depression, new research suggests.  

F. Better myocardial infarction notice: More on trops 

Patients with acute chest pain, angina pectoris, or other symptoms suggestive of acute myocardial infarction account for approximately 10% of all emergency department consultations. Absolute changes seem to be the preferred metrics for both hs-cTnT and hs-cTnI in the early diagnosis of acute myocardial infarction. The combination of absolute and relative changes provides a small added value for hs-cTnT, but not for hs-cTnI. 

G. Treat All Infants less than 2 years with stringently diagnosed AOM? 

All children younger than 2 with acute otitis media diagnosed according to current American Academy of Pediatrics guidelines should receive antibiotics, researchers said.  

H. Doctors may be overconfident in their diagnoses, study says  

A Baylor College of Medicine study found physicians may be overconfident in their diagnostic decisions, which could affect patient care, and researchers said health care facilities need better ways of telling doctors their diagnoses are not correct. Study data reported in JAMA Internal Medicine found physicians expressed similar levels of confidence in diagnoses for difficult and easy cases when they were correct only about 6% of the time in tougher calls, compared with 55% of the time in easier situations. 

I. Leadless ECG monitoring 

This study found that extended monitoring with the Zio Patch for up to 14 days is feasible, with high patient compliance, high analyzable signal time and incremental diagnostic yield beyond 48 hours for all arrhythmias types. These findings may have significant implications in device selection, monitoring duration and care pathways for arrhythmia evaluation and atrial fibrillation surveillance. 

J. Children with ADHD manifest some autistic traits  

Children with attention-deficit/hyperactivity disorder had a twentyfold increased risk of showing some autism-related traits, including language delay and social and emotional problems, compared with those without the condition, a study in the journal Pediatrics showed. Of 242 6- to 18-year-olds with ADHD, 18% showed autistic-type behaviors, while fewer than than 1% of 227 typically developing peers manifested such behaviors. 

K. One Spouse’s Friends Benefit the Other’s BP    

The quality of a person’s social network influenced his or her spouse’s blood pressure, and so, potentially cardiovascular risk, researchers found.  

L. Early 'Junk Food' Exposure Risks Kids' Mental Health