Tuesday, March 18, 2014

Lit Bits: March 18, 2014

From the recent medical literature...

1. Sepsis study comparing 3 treatment methods shows same survival rate

NIH-funded clinical trial tested specific protocols against usual high-level care

Survival of patients with septic shock was the same regardless of whether they received treatment based on specific protocols or the usual high-level standard of care, according to a five-year clinical study. The large-scale randomized trial, named ProCESS for Protocolized Care for Early Septic Shock, was done in 31 academic hospital emergency departments across the country and was funded by the National Institute of General Medical Sciences (NIGMS), a component of the National Institutes of Health.

The results of the trial, led by Derek C. Angus, M.D., M.P.H., and Donald M. Yealy, M.D., of the University of Pittsburgh, appear online on March 18, 2014, in the New England Journal of Medicine.

"ProCESS set out to determine whether a specific protocol would increase the survival rates of people with septic shock. What it showed is that regardless of the method used, patient survival was essentially the same in all three treatment groups, indicating that sepsis patients in these clinical settings were receiving effective care," said Sarah Dunsmore, Ph.D., who managed the ProCESS trial for NIGMS.

The ProCESS Investigators. A Randomized Trial of Protocol-Based Care for Early Septic Shock. 2014 March 18 [Epub ahead of print]

Background: In a single-center study published more than a decade ago involving patients presenting to the emergency department with severe sepsis and septic shock, mortality was markedly lower among those who were treated according to a 6-hour protocol of early goal-directed therapy (EGDT), in which intravenous fluids, vasopressors, inotropes, and blood transfusions were adjusted to reach central hemodynamic targets, than among those receiving usual care. We conducted a trial to determine whether these findings were generalizable and whether all aspects of the protocol were necessary.

Methods: In 31 emergency departments in the United States, we randomly assigned patients with septic shock to one of three groups for 6 hours of resuscitation: protocol-based EGDT; protocol-based standard therapy that did not require the placement of a central venous catheter, administration of inotropes, or blood transfusions; or usual care. The primary end point was 60-day in-hospital mortality. We tested sequentially whether protocol-based care (EGDT and standard-therapy groups combined) was superior to usual care and whether protocol-based EGDT was superior to protocol-based standard therapy. Secondary outcomes included longer-term mortality and the need for organ support.

Results: We enrolled 1341 patients, of whom 439 were randomly assigned to protocol-based EGDT, 446 to protocol-based standard therapy, and 456 to usual care. Resuscitation strategies differed significantly with respect to the monitoring of central venous pressure and oxygen and the use of intravenous fluids, vasopressors, inotropes, and blood transfusions. By 60 days, there were 92 deaths in the protocol-based EGDT group (21.0%), 81 in the protocol-based standard-therapy group (18.2%), and 86 in the usual-care group (18.9%) (relative risk with protocol-based therapy vs. usual care, 1.04; 95% confidence interval [CI], 0.82 to 1.31; P=0.83; relative risk with protocol-based EGDT vs. protocol-based standard therapy, 1.15; 95% CI, 0.88 to 1.51; P=0.31). There were no significant differences in 90-day mortality, 1-year mortality, or the need for organ support.

Conclusions: In a multicenter trial conducted in the tertiary care setting, protocol-based resuscitation of patients in whom septic shock was diagnosed in the emergency department did not improve outcomes.

Who was included?
We recruited patients in the emergency department in whom sepsis was suspected according to the treating physician, who were at least 18 years of age, who met two or more criteria for systemic inflammatory response syndrome11 (see the Methods section in the Supplementary Appendix), and who had refractory hypotension or a serum lactate level of 4 mmol per liter or higher. We defined refractory hypotension as a systolic blood pressure that either was less than 90 mm Hg or required vasopressor therapy to maintain 90 mm Hg even after an intravenous fluid challenge. We initially required the fluid challenge to be 20 ml or more per kilogram of body weight, administered over the course of 30 minutes, but in April 2010, we simplified the requirement to a challenge of 1000 ml or more administered over the course of 30 minutes. Patients did not have to be in shock on arrival in the emergency department but had to be enrolled in the study in the emergency department within 2 hours after the earliest detection of shock and within 12 hours after arrival.

What was the alternative protocol?
Protocol-based standard therapy also used a team approach with a set of 6-hour resuscitation instructions, but the components were less aggressive than those used for protocol-based EGDT (Figure S2 in the Supplementary Appendix). ProCESS investigators designed the protocol-based standard-therapy approach on the basis of a review of the literature, two independent surveys of emergency physician and intensivist practice worldwide,5,12 and consensus feedback from investigators. Protocol-based standard therapy required adequate peripheral venous access (with placement of a central venous catheter only if peripheral access was insufficient) and administration of fluids and vasoactive agents to reach goals for systolic blood pressure and shock index (the ratio of heart rate to systolic blood pressure) and to address fluid status and hypoperfusion, which were assessed clinically at least once an hour. In contrast to the triggers in the EGDT protocol, protocol-based standard therapy recommended packed red-cell transfusion only if the hemoglobin level was less than 7.5 g per deciliter. The protocol for standard therapy mandated administration of fluids until the team leader decided that the patient's fluids were replete. The standard-therapy protocol, like the EGDT protocol, did not specify the type of fluid or vasopressor and did not specify nonresuscitation aspects of care, which were provided by the treating physician.

Figure S2: Protocol for Standard Therapy

Full-text (free at time of publication): http://www.nejm.org/doi/full/10.1056/NEJMoa1401602 Select article 

Accompanying editorial. Full-text (free at time of publication): http://www.nejm.org/doi/full/10.1056/NEJMe1402564

2. Ultrasonography/MRI Versus CT for Diagnosing Appendicitis

Aspelund G, et al. Pediatrics. 2014 Mar 3. [Epub ahead of print]

BACKGROUND: Cross-sectional imaging increases accuracy in diagnosing appendicitis. We hypothesized that a radiation-free imaging pathway of ultrasonography selectively followed by MRI would not change clinical end points compared with computed tomography (CT) for diagnosis of acute appendicitis in children.

METHODS: We retrospectively reviewed children (less than 18 years old) who had diagnostic imaging for suspected acute appendicitis between November 2008 and October 2012. Before November 2010 CT was used as the primary imaging modality (group A); subsequently, ultrasonography was the primary imaging modality followed by MRI for equivocal findings (group B). Data collected included time from triage to imaging and treatment and results of imaging and pathology.

RESULTS: Six hundred sixty-two patients had imaging for suspected appendicitis (group A = 265; group B = 397, of which 136 [51%] and 161 [41%], respectively, had positive imaging for appendicitis). Negative appendectomy rate was 2.5% for group A and 1.4% for group B. Perforation rate was similar for both groups. Time from triage to antibiotic administration and operation did not differ between groups A and B. There was higher proportion of positive imaging and appendectomies in group A and thus more negative imaging tests in group B (ultrasonography and MRI), but diagnostic accuracy of the 2 imaging pathways was similar.

CONCLUSIONS: In children with suspected acute appendicitis, a radiation-free diagnostic imaging of ultrasonography selectively followed by MRI is feasible and comparable to CT, with no difference in time to antibiotic administration, time to appendectomy, negative appendectomy rate, perforation rate, or length of stay.

3. Patient preferences for testing for PE in the ED using a shared decision-making model

Geyer BC, et al. Amer J Emerg Med 2014;32:233-236.

Introduction: Shared decision making (SDM) is a process whereby patients and clinicians work together to make informed medical decisions that incorporate patient values. Recent data suggest that, for patients with low pretest probability of pulmonary embolism (PE), doubling the standard d-dimer cutoff may reduce the need for imaging with minimal increase in missed PE diagnoses. We used an SDM approach to determine patient preferences regarding this diagnostic approach.

Methods: We prospectively enrolled a consecutive sample of emergency department (ED) patients presenting with chest pain or dyspnea. We provided patients with a standardized description of the diagnostic workup for PE. We also provided image arrays describing the risks of computed tomography in low pretest probability patients and the risks of deferring imaging assuming a d-dimer was less than twice the value normally considered positive. We surveyed patients for their preference to undergo or defer imaging in this scenario.

Results: We enrolled 203 ED patients. Mean age was 55 ± 17 years, and 61% were male. Seventy-four patients (37%) elected to defer computed tomography of the pulmonary arteries testing. Patients with a previous PE diagnosis were less likely to defer computed tomography of the pulmonary arteries testing (P = .007). There was no association between the decision to defer testing and age, sex, family history of PE, or self-assessed risk-taking tendency.

Conclusions: When presented with a hypothetical scenario, more than one-third of patients deferred imaging for PE based on low clinical probability and a d-dimer less than twice the normal threshold. An SDM approach is acceptable to patients and may decrease imaging for PE.

4. Risk of TBI in Children less than 24 Months with Isolated Scalp Hematomas

Dayan PS, et al. Ann Emerg Med. 2014 March 13 [Epub ahead of print]

Study objective: We aimed to determine the association between scalp hematoma characteristics and traumatic brain injuries in young children with blunt head trauma who have no other symptoms or signs suggestive of traumatic brain injuries (defined as “isolated scalp hematomas”).

Methods: This was a secondary analysis of children younger than 24 months with minor blunt head trauma from a prospective cohort study in 25 Pediatric Emergency Care Applied Research Network emergency departments. Treating clinicians completed a structured data form. For children with isolated scalp hematomas, we determined the prevalence of and association between scalp hematoma characteristics and (1) clinically important traumatic brain injury (death, neurosurgery for traumatic brain injury, intubation greater than 24 hours for traumatic brain injury, or positive computed tomography (CT) scan in association with hospitalization ≥2 nights for traumatic brain injury); and (2) traumatic brain injury on CT.

Results: Of 10,659 patients younger than 24 months were enrolled, 2,998 of 10,463 (28.7%) with complete data had isolated scalp hematomas. Clinically important traumatic brain injuries occurred in 12 patients (0.4%; 95% confidence interval [CI] 0.2% to 0.7%); none underwent neurosurgery (95% CI 0% to 0.1%). Of 570 patients (19.0%) for whom CTs were obtained, 50 (8.8%; 95% CI 6.6% to 11.4%) had traumatic brain injuries on CT. Younger age, non-frontal scalp hematoma location, increased scalp hematoma size, and severe injury mechanism were independently associated with traumatic brain injury on CT.

Conclusion: In patients younger than 24 months with isolated scalp hematomas, a minority received CTs. Despite the occasional presence of traumatic brain injuries on CT, the prevalence of clinically important traumatic brain injuries was very low, with no patient requiring neurosurgery. Clinicians should use patient age, scalp hematoma location and size, and injury mechanism to help determine which otherwise asymptomatic children should undergo neuroimaging after minor head trauma.

5. Factors Associated With the Disposition of Severely Injured Patients Initially Seen at Non–Trauma Center EDs: Disparities by Insurance Status

Delgado MK, et al. JAMA Surg. 2014 Feb 19 [Epub ahead of print]

Importance  Trauma is the leading cause of potential years of life lost before age 65 years in the United States. Timely care in a designated trauma center has been shown to reduce mortality by 25%. However, many severely injured patients are not transferred to trauma centers after initially being seen at non–trauma center emergency departments (EDs).

Objectives  To determine patient-level and hospital-level factors associated with the decision to admit rather than transfer severely injured patients who are initially seen at non–trauma center EDs and to ascertain whether insured patients are more likely to be admitted than transferred compared with uninsured patients.

Design, Setting, and Participants  Retrospective analysis of the 2009 Nationwide Emergency Department Sample. We included all ED encounters for major trauma (Injury Severity Score, above 15) seen at non–trauma centers in patients aged 18 to 64 years. We excluded ED discharges and ED deaths. We quantified the absolute risk difference between admission vs transfer by insurance status, while adjusting for age, sex, mechanism of injury, Injury Severity Score, weekend admission and month of visit, and urban vs rural status and median household income of the home zip code, as well as annual ED visit volume and teaching status and US region.

Main Outcomes and Measures  Inpatient admission vs transfer to another acute care facility.

Results  In 2009, a total of 4513 observations from 636 non–trauma center EDs were available for analysis, representing a nationally weighted population of 19 312 non–trauma center ED encounters for major trauma. Overall, 54.5% in 2009 were admitted to the non–trauma center. Compared with patients without insurance, the adjusted absolute risk of admission vs transfer was 14.3% (95% CI, 9.2%-19.4%) higher for patients with Medicaid and 11.2% (95% CI, 6.9%-15.4%) higher for patients with private insurance. Other factors associated with admission vs transfer included severe abdominal injuries (risk difference, 15.9%; 95% CI, 9.4%-22.3%), urban teaching hospital vs non–teaching hospital (risk difference, 26.2%; 95% CI, 15.2%-37.2%), and annual ED visit volume (risk difference, 3.4%; 95% CI, 1.6%-5.3% higher for every additional 10 000 annual ED visits).

Conclusions and Relevance  Patients with severe injuries initially evaluated at non–trauma center EDs were less likely to be transferred if insured and were at risk of receiving suboptimal trauma care. Efforts in monitoring and optimizing trauma interhospital transfers and outcomes at the population level are warranted.

6. Reduction of admit wait times: the effect of a leadership-based program

Patel PB, et al. Acad Emerg Med. 2014;21(3):266–273.

Objectives: Prolonged admit wait times in the emergency department (ED) for patients who require hospitalization lead to increased boarding time in the ED, a significant cause of ED congestion. This is associated with decreased quality of care, higher morbidity and mortality, decreased patient satisfaction, increased costs for care, ambulance diversion, higher numbers of patients who leave without being seen (LWBS), and delayed care with longer lengths of stay (LOS) for other ED patients. The objective was to assess the effect of a leadership-based program to expedite hospital admissions from the ED.

Methods: This before-and-after observational study was undertaken from 2006 through 2011 at one community hospital ED. A team of ED and hospital leaders implemented a program to reduce admit wait times, using a computerized hospital-wide tracking system to monitor inpatient and ED bed status. The team collaboratively and consistently moved ED patients to their inpatient beds within an established goal of 60 minutes after an admission decision was reached. Top leadership actively intervened in real time by contacting staff whenever delays occurred to expedite immediate solutions to achieve the 60-minute goal. The primary outcome measures were the percentage of ED patients who were admitted to inpatient beds within 60 minutes from the time the beds were requested and ED boarding time. LOS, patient satisfaction, LWBS rate, and ambulance diversion hours were also measured.

Results: After ED census, hospital admission rates, and ED bed capacity were controlled for using a multivariable linear regression analysis, the admit wait time reduction program contributed to an increase in patients being admitted to the hospital within 60 minutes by 16 percentage points (95% confidence intervals [CI] = 10 to 22 points; p less than 0.0001) and a decrease in boarding time per admission of 46 minutes (95% CI = 63 to 82 minutes; p less than 0.0001). LOS decreased for admitted patients by 79 minutes (95% CI = 55 to 104 minutes; p less than 0.0001), for discharged patients by 17 minutes (95% CI = 12 to 23 minutes; p less than 0.0001), and for all patients by 34 minutes (95% CI = 25 to 43 minutes; p less than 0.0001). Patient satisfaction increased 4.9 percentage points (95% CI = 3.8 to 6.0 points; p less than 0.0001). LWBS patients decreased 0.9 percentage points (95% CI = 0.6 to 1.2 points; p less than 0.0001) and monthly ambulance diversion decreased 8.2 hours (95% CI = 4.6 to 11.8 hours; p less than 0.0001).

Conclusions: A leadership-based program to reduce admit wait times and boarding times was associated with a significant increase in the percentage of patients admitted to the hospital within 60 minutes and a significant decrease in boarding time. Also associated with the program were decreased ED LOS, LWBS rate, and ambulance diversion, as well as increased patient satisfaction.

7. ED Variation in Utilization and Diagnostic Yield of Advanced Radiography in Diagnosis of PE

Kindermann DR, et al. J Emerg Med. 2014 Mar 14 [Epub ahead of print] 

Background: There is growing pressure to measure and reduce unnecessary imaging in the emergency department.

Objective: We study provider and hospital variation in utilization and diagnostic yield for advanced radiography in diagnosis of pulmonary embolism (PE) and to assess patient- and provider-level factors associated with diagnostic yield.

Methods: Retrospective chart review of all adult patients presenting to four hospitals from January 2006 through December 2009 who had a computed tomography or VQ scan to evaluate for PE. Demographic data on the providers ordering the scans were collected. Diagnostic yield (positive scans/total scans ordered) was calculated at the hospital and provider level. The study was not designed to assess appropriateness of imaging.

Results: There was significant variation in utilization and diagnostic yield at the hospital level (chi-squared, p less than 0.05). Diagnostic yield ranged from 4.2% to 8.2%; after adjusting for patient- and provider-level factors; the two hospitals with an emergency medicine residency training program had higher diagnostic yields (odds ratio [OR] 2.0, 95% confidence interval [CI] 1.6–2.5 and OR 1.9, 95% CI 1.5–2.4). There was no significant variation in diagnostic yield among the 90 providers after adjusting for patient, hospital, and provider characteristics. Providers with less than 10 years of experience had lower odds of diagnosing a PE than more experienced graduates (OR 0.8, 95% CI 0.6–0.9).

Conclusions: Although we found significant variation in utilization of advanced radiography for PE and diagnostic yield at the hospital level, there was no significant variation at the provider level after adjusting for patient-, hospital-, and provider-level factors.

8. CSF/blood glucose ratio as an indicator for bacterial meningitis

Tamune H, et al. Amer J Emerg Med 2014;32:263-266.

Background: Bacterial meningitis is an emergent disease requiring prompt diagnosis and treatment with appropriate antimicrobials. Although the lumbar puncture is widely used as a diagnostic tool for bacterial meningitis, it remains unclear which value in cerebrospinal fluid (CSF) analysis in emergency laboratory tests precisely predicts the presence of bacterial meningitis.

Methods: This is a single-center, retrospective review of medical records to determine which emergency laboratory CSF test results are useful for predicting bacterial meningitis. The diagnosis of meningitis is made when the white blood cell count in CSF exceeds 5 cells/μL, while the diagnosis of bacterial meningitis additionally requires the growth of a pathogen from a CSF culture or the identification of a pathogen in Gram staining of CSF specimen.

Results: We identified 15 patients with bacterial meningitis and 129 patients with aseptic meningitis. While neutrophil-predominant pleocytosis and a decreased glucose level in CSF can predict the presence of bacterial meningitis, the CSF/blood glucose ratio is more precise (optimal cut-off=0.36, sensitivity=92.9%, specificity=92.9%, area under the curve=.97) even after administration of antimicrobials prior to examination in the emergency department.

Conclusion: This study suggests that the CSF/blood glucose ratio may be a better single indicator for bacterial meningitis. Since the CSF glucose and blood glucose values are promptly and easily obtained from a lumbar puncture, the CSF/blood glucose ratio should be considered as a timely diagnostic indicator of bacterial meningitis. It may also help exclude the diagnosis of bacterial meningitis especially in cases in which no microorganisms can be cultured.

9. Short-course antibiotic treatment for community-acquired alveolar pneumonia in ambulatory children: a double-blind RCT

Five days as good as ten days of treatment.

Greenberg D, et al. Pediatr Infect Dis J. 2014 Feb;33(2):136-42.

BACKGROUND: Studies on short-course treatment of childhood pneumonia in the developed world are lacking. We compared clinical and laboratory outcomes of a 3-day or a 5-day to a 10-day treatment in young children with community-acquired alveolar pneumonia.

METHODS: A double-blind, randomized, placebo-controlled trial was conducted in 2 stages: (1) 3 days versus 10 days and (2) 5 days versus 10 days. Amoxicillin (80 mg/kg/d; divided into 3 daily doses) was used for all arms. Case definition was: age 6-59 months; radiologically confirmed community-acquired alveolar pneumonia; temperature ≥38.5°C; peripheral white blood cell count ≥15,000/mm³; status permitting outpatient treatment. Scheduled visits were on days 4-5 and 10-14 with daily telephone interviews for 30 days. Treatment failure was defined by the need for a rescue treatment or hospitalization. Secondary outcomes were: duration of fever and symptoms and white blood cell and C-reactive protein responses.

RESULTS: During Stage 1, 4/10 (40%) and 0/12 (0%) evaluable patients failed in the 3-day and 10-day arms, respectively (P = 0.16). Therefore, the 3-day arm was replaced by a 5-day arm (Stage 2). No failures occurred in the 5-day (n = 56) and 10-day (n = 59) arms. Overall, 4/10 (0%), 0/56 and 0/42 (0%) children failed in the 3-day, 5-day and 10-day arms, respectively (P less than 0.001, 3-day versus 5-day or 10-day). Secondary outcomes were similar in the 5-day and 10-day arms.

CONCLUSION: In 6- to 59-month-old outpatients with community-acquired alveolar pneumonia, a 5-day course with high-dose oral amoxicillin was not inferior to a 10-day course. The 3-day regimen may be associated with an unacceptable failure rate

10. Images in Clinical Practice

Vanishing Lung Syndrome

Frank’s Sign

Herpes Labialis and Facial-Nerve Paralysis 

Frontal Sinusitis Causing Epidural Abscess and Puffy Tumor 

11. Prehospital Airway Management in Adults: Is Intubation the Best Strategy?

In a retrospective registry review of adults with out-of-hospital cardiac arrest, outcomes were better with no advanced airway placement.

McMullan J, et al. Airway management and out-of-hospital cardiac arrest outcome in the CARES registry. Resuscitation 2014 Feb 18. [Epub ahead of print]

BACKGROUND: Optimal out of hospital cardiac arrest (OHCA) airway management strategies remain unclear. We compared OHCA outcomes between patients receiving endotracheal intubation (ETI) versus supraglottic airway (SGA), and between patients receiving [ETI or SGA] and those receiving no advanced airway.

METHODS: We studied adult OHCA in the Cardiac Arrest Registry to Enhance Survival (CARES). Primary exposures were ETI, SGA, or no advanced prehospital airway placed. Primary outcomes were sustained ROSC, survival to hospital admission, survival to hospital discharge, and neurologically-intact survival to hospital discharge (cerebral performance category 1-2). Propensity scores characterized the probability of receiving ETI, SGA, or no advanced airway. We adjusted for Utstein confounders. Multivariable random effects regression accounted for clustering by EMS agency. We compared outcomes between (1) ETI vs. SGA, and (2) [no advanced airway] vs. [ETI or SGA].

RESULTS: Of 10,691 OHCA, 5591 received ETI, 3110 SGA, and 1929 had no advanced airway. Unadjusted neurologically-intact survival was: ETI 5.4%, SGA 5.2%, no advanced airway 18.6%. Compared with SGA, ETI achieved higher sustained ROSC (OR 1.35; 95%CI 1.19-1.54), survival to hospital admission (1.36; 1.19-1.55), hospital survival (1.41; 1.14-1.76) and hospital discharge with good neurologic outcome (1.44; 1.10-1.88). Compared with [ETI or SGA], patients receiving no advanced airway attained higher survival to hospital admission (1.31; 1.16-1.49), hospital survival (2.96; 2.50-3.51) and hospital discharge with good neurologic outcome (4.24; 3.46-5.20).

CONCLUSION: In CARES, survival was higher among OHCA receiving ETI than those receiving SGA, and for patients who received no advanced airway than those receiving ETI or SGA.

See related article: Wang HE, et al. Association of out-of-hospital advanced airway management with outcomes after traumatic brain injury and hemorrhagic shock in the ROC hypertonic saline trial. Emerg Med J. 2014 Mar;31(3):186-91. Abstract: http://www.ncbi.nlm.nih.gov/pubmed/23353663

12. SIRS rampant and non-specific in US EDs

Horeczko T, et al. Epidemiology of the SIRS. West J Emerg Med 2014 Feb 19 [Epub ahead of print]

Introduction: Consensus guidelines recommend sepsis screening for adults with systemic inflammatory response syndrome (SIRS), but the epidemiology of SIRS among adult emergency department (ED) patients is poorly understood. Recent emphasis on cost-effective, outcomes-based healthcare prompts the evaluation of the performance of large-scale efforts such as sepsis screening. We studied a nationally representative sample to clarify the epidemiology of SIRS in the ED and subsequent category of illness.

Methods: This was a retrospective analysis of ED visits by adults from 2007 to 2010 in the National Hospital Ambulatory Medical Care Survey (NHAMCS). We estimated the incidence of SIRS using initial ED vital signs and a Bayesian construct to estimate white blood cell count based on test ordering. We report estimates with Bayesian modified credible intervals (mCIs).

Results: We used 103,701 raw patient encounters in NHAMCS to estimate 372,844,465 ED visits over the 4-year period. The moderate estimate of SIRS in the ED was 17.8% (95% mCI: 9.7 to 26%). This yields a national moderate estimate of approximately 16.6 million adult ED visits with SIRS per year. Adults with and without SIRS had similar demographic characteristics, but those with SIRS were more likely to be categorized as emergent in triage (17.7% versus 9.9%, p less than 0.001), stay longer in the ED (210 minutes versus 153 minutes, p less than 0.0001), and were more likely to be admitted (31.5% versus 12.5%, P less than 0.0001). Infection accounted for only 26% of SIRS patients. Traumatic causes of SIRS comprised 10% of presentations; other traditional categories of SIRS were rare.

Conclusion: SIRS is very common in the ED. Infectious etiologies make up only a quarter of adult SIRS cases. SIRS may be more useful if modified by clinician judgment when used as a screening test in the rapid identification and assessment of patients with the potential for sepsis.

13. Effect of MicroEEG on Clinical Management and Outcomes of ED Patients c AMS: A RCT

Zehtabchi S, et al. Acad Emerg Med. 2014;21:283-291.

Objectives: Altered mental status (AMS) is a common presentation in the emergency department (ED). A previous study revealed 78% electroencephalogram (EEG) abnormalities, including nonconvulsive seizure (NCS; 5%), in ED patients with AMS. The objective of this study was to assess the impact of EEG on clinical management and outcomes of ED patients with AMS.

Methods: This was a randomized controlled trial at two urban teaching hospitals. Adult patients (≥18 years old) with AMS were included. Excluded patients had immediately correctable AMS (e.g., hypoglycemia) or were admitted before enrollment. Patients were randomized to routine care (control) or routine care plus EEG (intervention). Research assistants used a scalp electrode set with a miniature, wireless EEG device (microEEG) to record standard 30-minute EEGs at presentation, and results were reported to the ED attending physician by an off-site epileptologist within 30 minutes. Primary outcomes included changes in ED management (differential diagnosis, diagnostic work-up, and treatment plan from enrollment to disposition) as determined by surveying the treating physicians. Secondary outcomes were length of ED and hospital stay, intensive care unit (ICU) requirement, and in-hospital mortality.

Results: A total of 149 patients were enrolled (76 control and 73 intervention). Patients in the two groups were comparable at baseline. EEG in the intervention group revealed abnormal findings in 93% (95% confidence interval [CI] = 85% to 97%), including NCS in 5% (95% CI = 2% to 13%). Using microEEG was associated with change in diagnostic work-up in 49% (95% CI = 38% to 60%) of cases and therapeutic plan in 42% (95% CI = 31% to 53%) of cases immediately after the release of EEG results. Changes in probabilities of differential diagnoses and the secondary outcomes were not statistically significant between the groups.

Conclusions: An EEG can be obtained in the ED with minimal resources and can affect clinical management of AMS patients.

14. Urinalysis is an inadequate screen for rhabdomyolysis

Alhadi SA, et al. Amer J Emerg Med 2014;32:260-262.

Study Objectives: Hematuria by urine dipstick with absent red blood cells (RBCs) on microscopy is indicative of rhabdomyolysis. We determined the sensitivity of this classic urinalysis (UA) finding in the diagnosis of rhabdomyolysis.

Methods: We conducted a retrospective electronic medical record review of patients with a primary or secondary diagnosis of rhabdomyolysis with a creatine phosphokinase (CPK) greater than 1000 IU/L and a UA within the first 24 hours. Data were collected using a standardized data form, and a blinded panel of 3 emergency medicine physicians reviewed selected cases. Sensitivity and 95% confidence intervals (CIs) were calculated for detection of rhabdomyolysis by UA.

Results: During the study period, 1796 patients were diagnosed with rhabdomyolysis, of whom 228 met inclusion criteria. The mean peak CPK was 27509 IU/L. One hundred ninety-five (86%) had a urine dip-positive for blood. However, only 94 patients (41%) had a positive urine dip and negative microscopic hematuria, resulting in a sensitivity of 41% (95% CI, 35%-47%). In a subset of 66 patients (29%) with more severe rhabdomyolysis (initial CPK, ≥10000 IU/L; mean CPK, 53365 IU/L), UA had a sensitivity of 55% (95% CI, 43%-67%). Broadening the definition of negative microscopy from 0 to 3 RBCs to less than 10 RBCs only increased the sensitivity to 79% (95% CI, 73%-83%).

Conclusions: The combination of a positive urine dip for blood and negative microscopy is an insensitive test for rhabdomyolysis, and the absence of this finding should not be used to exclude the diagnosis.

15. Barriers and Facilitators to Intraosseous Access in Adult Resuscitations When Peripheral Intravenous Access Is Not Achievable

Cheung WJ, et al. Acad Emerg Med. 2014;21:250-256.

Objectives: Studies suggest that intraosseous (IO) access is underutilized in adult resuscitations, despite recommendations from advanced trauma and cardiac life support guidelines. The objective was to determine factors associated with IO access use by physicians during adult resuscitations when intravenous (IV) access is not immediately achievable.

Methods: This study was an online survey among physicians purposefully recruited from various clinical care areas at three teaching hospitals. Questions were generated from the qualitative results of 20 iterative interviews, verified for internal validity, and piloted. The interview guide was based on the constructs of the Theory of Planned Behavior (TPB), which elicits salient attitudes, social influences, and control beliefs that potentially influence intention to use IO access. Recruitment took place in September 2012 until reaching more than 100% of the required sample size (n = 200). Internal consistency was measured using Cronbach's alpha, and the effect of TPB constructs and specific beliefs were assessed with regression analyses.

Results: For the 205 respondents, the mean age was 35 years (range = 20 to 66 years), and 53.3% were male. Participants’ departmental affiliations were 50.3% emergency medicine (EM), 16.9% internal medicine, 14.9% anesthesia, 10.8% general surgery, and 7.2% critical care. Residents comprised 60.7% of the sample, and 39.3% were attending physicians. Median intention to use IO access when IV is not immediately achievable was 4.67 (interquartile range [IQR] = 4 to 5) out of 5 (5 highest) and predicted by the following TPB constructs: attitudes (AdjCoefficients = 0.504; 95% confidence interval [CI] = 0.334 to 0.673), social influences (AdjCoefficients = 0.285; 95% CI = 0.172 to 0.398), and control beliefs (AdjCoefficients 0.217; 95% CI = 0.113 to 0.320). Physicians were more likely to use IO access if they believed that it provided rapid vascular access for delivering large volumes of fluids, could prevent delays in care, and was associated with a low complication rate. Conversely, the perception that nurses are not familiar or supportive of IO access and a lack of physician confidence regarding the appropriate indications for IO access were barriers to use.

Conclusions: These data are an important step in the knowledge-to-action process, as they identify specific factors associated with physician use of IO access. Interventions addressing these actionable facilitators and barriers are likely to have a positive effect on increasing the appropriate physician use of this potentially life-saving technique in adult patients requiring emergent vascular access.

16. Statins for Healthy People: A Cocktail Party Manifesto

David Newman, MD, EP Monthly, March 10, 2014

Despite assertions by the AHA and others, the research simply does not support the use of statins in low-risk patients. Now go tell your friends.

In November the American Heart Association released its shiny new guidelines for the management of cholesterol, and in the process set off a firestorm. Talk shows talked, pundits opined, and cardiologists postured. But in the center of it all there is an evidence base that offers a clear-eyed view. Do statins for healthy people save lives?

Why should emergency physicians tune in to the statin debate? Atorvastatin is the best selling drug of all time, and statins are the best selling class. The question of whether statins work is therefore central to the legitimacy of the medical sciences. In addition there’s an excellent chance that you, or one of your first degree relatives, has been prescribed a statin. And finally, gifted cocktail party goers (read: you EPs) always take pride in knowing more than anyone about the latest medical scandal. Here’s your chance.

There is general consensus among the scientific community that statins lead to worthwhile benefits among those at high risk of cardiovascular events (though half of patients in surveys, when informed of the actual benefits and harms, decide against statins). There is, however, considerable controversy in the scientific community about statins for healthy people, those at a less than 20% risk of heart attack, stroke, or death in the next 10 years.

The Numbers Needed to Treat for preventing a heart attack and stroke in low risk people taking a statin  for five years are estimated at 60 and 268, respectively. The Number Needed to Harm for getting diabetes due to a statin is estimated at about 1 in 50. In other words it may be as or more likely that a statin would cause diabetes, a chronic and life-altering condition, than prevent a one-time nonfatal heart attack.

With this unattractive balance of harms and benefits, why would anyone healthy take a statin? The answer is to live longer, which is where the heart of the controversy lies. If statins do extend life in healthy people, it seems reasonable to believe that there may be a public health benefit to expanding statin use—something the new AHA guidelines recommend.

So, do statins save lives? Recent publications, including by the Cochrane Collaboration (1)  and in the Journal of the American Medical Association (by the same authors, reporting the same data) (2), conclude that indeed low risk people die less often if they take a statin. Unfortunately, however, the case is not closed. This claim, it turns out, is almost entirely dependent on one publication, the single most important analysis of this critical question, because it a) had the largest number of relevant study subjects (134000), and b) performed an individual patient-level analysis, which allowed the authors to examine low risk patients separately from the others. The paper in question was published in the Lancet in 2012 (3), and the results are remarkable. Most of the paper examines outcomes other than mortality, which are of limited interest to those sniffing out the controversy. In webfigure 9 (an online supplement at the bottom of the Lancet article’s webpage), however, is a shockingly simple answer to whether or not statins have been shown to reduce mortality in low risk patients. The answer is ‘no’.

For 5 out of the 6 lowest risk groups there is no statistical mortality benefit to statins compared to placebos (and in the 6th group the benefit is borderline). This holds true whether the subjects had a history of vascular disease or not. In other words, whether a patient has had vascular events or problems in the past doesn’t seem to matter. For the nearly 50,000 subjects at a less than 20% risk according to their risk score at study entry, mortality was not reduced by taking a statin.

Could it be this simple? Apparently. Consider the problem solved, the question answered. And healthy people being offered statins should be told this. Though, of course, most are not. How could they be when most physicians don’t know? But as a physician and prescriber, as the family’s source of medical knowledge, and as a master cocktail conversationalist, you may find this information useful.

17. Effects of a dedicated regional psychiatric emergency service on boarding of psychiatric patients in area EDs

Zeller S, et al. West J Emerg Med. 2014 Feb;15(1):1-6.

INTRODUCTION: Mental health patients boarding for long hours, even days, in United States emergency departments (EDs) awaiting transfer for psychiatric services has become a considerable and widespread problem. Past studies have shown average boarding times ranging from 6.8 hours to 34 hours. Most proposed solutions to this issue have focused solely on increasing available inpatient psychiatric hospital beds, rather than considering alternative emergency care designs that could provide prompt access to treatment and might reduce the need for many hospitalizations. One suggested option has been the "regional dedicated emergency psychiatric facility," which serves to evaluate and treat all mental health patients for a given area, and can accept direct transfers from other EDs. This study sought to assess the effects of a regional dedicated emergency psychiatric facility design known at the "Alameda Model" on boarding times and hospitalization rates for psychiatric patients in area EDs.

METHODS: Over a 30-day period beginning in January 2013, 5 community hospitals in Alameda County, California, tracked all ED patients on involuntary mental health holds to determine boarding time, defined as the difference between when they were deemed stable for psychiatric disposition and the time they were discharged from the ED for transfer to the regional psychiatric emergency service. Patients were also followed to determine the percentage admitted to inpatient psychiatric units after evaluation and treatment in the psychiatric emergency service.

RESULTS: In a total sample of 144 patients, the average boarding time was approximately 1 hour and 48 minutes. Only 24.8% were admitted for inpatient psychiatric hospitalization from the psychiatric emergency service.

CONCLUSION: The results of this study indicate that the Alameda Model of transferring patients from general hospital EDs to a regional psychiatric emergency service reduced the length of boarding times for patients awaiting psychiatric care by over 80% versus comparable state ED averages. Additionally, the psychiatric emergency service can provide assessment and treatment that may stabilize over 75% of the crisis mental health population at this level of care, thus dramatically alleviating the demand for inpatient psychiatric beds. The improved, timely access to care, along with the savings from reduced boarding times and hospitalization costs, may well justify the costs of a regional psychiatric emergency service in appropriate systems.

What is this new model of care?
“A dedicated psychiatric emergency services (PES) unit is a stand-alone ED specifically for psychiatric patients. Although many are independent or on a separate campus, most PES units in the U.S. are affiliated with an adjacent medical ED.20 Rather than merely triaging and transferring psychiatric patients as is common in a standard ED, in a PES unit, patients are evaluated, receive intensive treatment, and are allowed time for observation and healing (typically, up to 24 hours is permitted onsite in these programs, which are considered to be outpatient services).21 A common goal of PES programs is stabilization of acute symptoms and avoidance of psychiatric hospitalization when possible; the added time for onsite treatment and observation (which has led such operations to be known as “23-hour facilities”) is what typically makes these results feasible.

“The PES model is hailed as an important method of reducing boarding of psychiatric patients in the ED22 and enhancing patient care.18 In comparison to the more prevalent “consultant model” in EDs, PES is associated with more timely psychiatric emergency care and increased safety and access.23 A PES unit can effectively treat to the point of discharge, or provide alternatives to hospitalization, which can reduce demand for psychiatric inpatient beds.”

Editorial (full-text free): http://escholarship.org/uc/item/1xf4j0t9

18. Thirteen Mobile Apps Every ED Provider Should Test Drive  

Elbert Chu, Associate Producer, MedPage Today. Mar 3, 2014

Here are the best mobile apps for emergency medicine physicians gleaned from a recent EMJ paper by Michelle Lin, MD, Iltifat Husain, MD, Salim Rezaie, MD, and remixed with a talk from last month’s AAEM meeting by Graham Walker, MD.

How do you triage over 500 emergency medicine-related apps between the Apple and Android Apps universe? Call in a consult. Better yet, call four.

We start with Michelle Lin, MD, editor-in-chief of Academic Life in EM, Iltifat Husain, MD, editor-in-chief of iMedicalApps, and Salim Rezaie, MD, founder of R.e.b.e.l. EM. This trio assembled a top 10 list of mobile apps for the Emergency Medicine Journal last week. They get extra points for making sure almost all the apps work offline as well. They have a much more thorough writeup of the features, so check out the paper.

I've remixed their list with a talk about apps by Graham Walker, MD, co-founder of the NNT at last month's American Academy of Emergency Medicine meeting to come up with a baker's dozen that I like.

One takeaway from looking at the list and recommendations is that the Apple app universe offers a much richer selection of top rated EM mobile apps.

19. Mutant Adenosine Deaminase 2 in a Polyarteritis Nodosa Vasculopathy

Whooops. How did this title get in here? I must have had a fleeting flashback to my third-year medical school rotation in Internal Medicine. Sorry about that. Let’s move to something more relevant to our ED practices.

19. Azithromycin and levofloxacin use and increased risk of cardiac arrhythmia and death.

Rao GA, et al. Ann Fam Med. 2014 Mar-Apr;12(2):121-7.

PURPOSE Azithromycin use has been associated with increased risk of death among patients at high baseline risk, but not for younger and middle-aged adults. The Food and Drug Administration issued a public warning on azithromycin, including a statement that the risks were similar for levofloxacin. We conducted a retrospective cohort study among US veterans to test the hypothesis that taking azithromycin or levofloxacin would increase the risk of cardiovascular death and cardiac arrhythmia compared with persons taking amoxicillin.

METHODS We studied a cohort of US veterans (mean age, 56.8 years) who received an exclusive outpatient dispensation of either amoxicillin (n = 979,380), azithromycin (n = 594,792), or levofloxacin (n = 201,798) at the Department of Veterans Affairs between September 1999 and April 2012. Azithromycin was dispensed mostly for 5 days, whereas amoxicillin and levofloxacin were dispensed mostly for at least 10 days.

RESULTS During treatment days 1 to 5, patients receiving azithromycin had significantly increased risk of death (hazard ratio [HR] = 1.48; 95% CI, 1.05-2.09) and serious arrhythmia (HR = 1.77; 95% CI, 1.20-2.62) compared with patients receiving amoxicillin. On treatment days 6 to 10, risks were not statistically different. Compared with patients receiving amoxicillin, patients receiving levofloxacin for days 1 to 5 had a greater risk of death (HR = 2.49, 95% CI, 1.7-3.64) and serious cardiac arrhythmia (HR = 2.43, 95% CI, 1.56-3.79); this risk remained significantly different for days 6 to 10 for both death (HR = 1.95, 95% CI, 1.32-2.88) and arrhythmia (HR = 1.75; 95% CI, 1.09-2.82).

CONCLUSIONS Compared with amoxicillin, azithromycin resulted in a statistically significant increase in mortality and arrhythmia risks on days 1 to 5, but not 6 to 10. Levofloxacin, which was predominantly dispensed for a minimum of 10 days, resulted in an increased risk throughout the 10-day period.

Related Essay: Stop Using Azithromycin

Neil Canavan. Medscape. February 18, 2014

NEW YORK CITY — Treatment guidelines increasingly recommend that certain antibiotics, particularly the macrolide azithromycin, no longer be used to treat many common infections. Inappropriate use has led to widespread antibiotic resistance and is contributing to the emergence of super bugs.

At least one prominent emergency medicine expert suggests that the drug not be used at all.

"If we don't stop, we're not going to have good antibiotics in the future," warned Joseph Lex, MD, from Temple University in Philadelphia, here at the American Academy of Emergency Medicine (AAEM) 20th Annual Scientific Assembly. "Every country that has recommended the use of narrow-spectrum antibiotics instead has seen a fall in their resistance rates. We just have to get to the point where we do the same thing."

Dr. Lex is hardly a lone voice in this call to move away from the abuse of broad-spectrum antibiotics. Current guidelines present a chorus of similar opinions.

Azithromycin was developed in 1980 and has been marketed in the United States since 1991. As of 2011, it is the most commonly prescribed antibiotic. The current indications for azithromycin are acute bacterial exacerbations of chronic pulmonary disease, acute bacterial sinusitis, community-acquired pneumonia, pharyngitis, tonsillitis, uncomplicated skin and skin structure infection, urethritis and cervicitis, and genital ulcer disease.

If we don't stop, we're not going to have good antibiotics in the future.

However, just last year, the Canadian Pediatric Society strongly recommended that azithromycin not be used to treat acute pharyngitis, otitis media, or community-acquired pneumonia (Paediatr Child Health. 2013;18:311-313).

That guidance did not recommend that clinicians consider not using it — it's recommendation is "do not use," stressed Dr. Lex. The only exceptions for azithromycin use area life-threatening beta-lactam allergy and pneumonia caused by an atypical bacteria.

"The long half-life of azithromycin contributes to the development of resistance," he explained. The way the drug is being used, "you're likely to get a subinhibitory nasal pharyngeal concentration, so these kids actually become carriers of azithromycin-resistant pneumococci."

What are the better alternatives? See the remainder of the essay: http://www.medscape.com/viewarticle/820736

20. Is Fever Treated More Promptly Than Pain in the Pediatric ED?

Dvorkin R, et al. J Emerg Med. 2014;46:327-34.

Fever can be treated with a higher priority than pain in the pediatric emergency department (ED) population.

The primary objective was to assess whether patients with a fever are treated with acetaminophen or ibuprofen more promptly than they are treated for pain.

A retrospective descriptive study was performed on all patients between the ages of 3 and 19 years who received acetaminophen or ibuprofen in the pediatric ED from February 1, 2010 to January 31, 2011. The time interval from arrival to treatment with acetaminophen or ibuprofen was compared for those patients with a fever (≥100.4°F) and those without a fever and had reported pain. Other measurable points (time of vital signs, bed assignment, and medication order) on the medical record were compared to further describe any differences.

Pediatric patients with fever (n = 1097) received ibuprofen or acetaminophen a median of 54.0 min (interquartile range [IQR], 35.4−89.3 min) after arrival. The corresponding median time for afebrile patients (n = 1861) that received the same medications was 83.2 min (IQR, 52.7−136.1). The difference between medians was 24.6 min (95% confidence interval 21.3−27.9 min).

Fever is treated more promptly than pain in the pediatric ED. This difference is associated with prevailing and largely unfounded concerns about fever and the undertreatment of pain (oligoanalgesia).

21. What the Digital Footprint Reveals about Public Health?

Ayers JW, et al. Could Behavioral Medicine Lead the Web Data Revolution? JAMA. 2014 Feb 27 [Epub ahead of print]

Digital footprints left on search engines, social media, and social networking sites can be aggregated and analyzed as health proxies, yielding anonymous and instantaneous insights. At present, nearly all the existing work has focused on acute diseases. This means the value added from web surveillance is reduced because the effectiveness of even high-profile systems such as Google Flu Trends are inferior to already strong traditional surveillance.1 Conversely, the future of web surveillance is promising in an area where traditional surveillance is largely incomplete: behavioral medicine, a multidisciplinary field incorporating medicine, social science, and public health and focusing on health behaviors and mental health.

The proportion of illness (or death) attributable to health behaviors or psychological well-being has steadily increased over the last half century, while surveillance of these outcomes has remained largely unchanged. Investigators simply ask people about their health on surveys. However, surveys have well-known limitations, such as respondents’ reluctance to participate, social desirability biases, difficulty in accurately reporting behaviors, long lags between data collection and availability, and provisions (sometimes legal) curtailing the inclusion of politically sensitive topics like gun violence. Most importantly, the expense of surveys means many topics are either not covered or are covered restrictively (eg, clinical depression screeners are included in the Behavioral Risk Factor Surveillance System just every other year). Given the current budget climate, survey capacity will likely worsen before it improves. To overcome these limits, behavioral medicine should now embrace web data.

First, behavioral medicine requires observing behavior or the manifestation of mental health problems. Doing so online is easier, more comprehensive, and more effective than with surveys because many outcomes are passively exhibited there. For example, one study showed how precise health concerns changed during the US recession of December 2008 through 2011 by systematically selecting Google search queries and using the content of each query to describe the concern and the change in volume to describe the prevalence of each concern. Stomach ulcer symptoms, for example, were 228% higher (95% CI, 35%-363%) than expected during the recession, with queries thematically related to arrhythmia, congestion, and pain (including many foci like head, tooth, and back) also elevated.2 This approach highlights how web data can reveal largely assumption-free insights via systematic data generation of hundreds of possible outcomes rather than arbitrary a priori selection of a few outcomes by investigators.

Second, web data reflect more than the individual because social context can also be captured online. Online networks can reveal how mechanistic drivers such as social norms spread and influence population health. For example, social patterns in obesity promotion and suppression have been described by pooling Facebook posts that encourage television watching or going outdoors, which was associated with variability in neighborhood obesity rates.3 Moreover, social support concepts are often expressed in web data, such as observing specific instances of caregiving and confidence on Twitter. As a result, behavioral medicine can move away from understanding aggregation based purely on location and toward understanding health in the context of our human interconnectedness…

22. Tid Bits

A. Stethoscopes surpassed only by fingertips for picking up bacteria

The diaphragm of the stethoscope picked up more bacteria, including methicillin-resistant Staphylococcus aureus, than any part of the providers' hand except the fingertips during a physical exam, according to a study in the journal Mayo Clinic Proceedings. The findings highlight the need to cleanse a stethoscope after every use, according to the study's lead author.

B. Reducing Blood Culture Contamination in Community Hospital EDs: A Multicenter Evaluation of a Quality Improvement Intervention

C. Coronary CT for asymptomatic diabetics

This study found about one-third of asymptomatic type 2 diabetes patients had significant coronary artery disease on coronary computed tomographic angiography with a subsequent high risk for cardiac events.

D. CT Appears Safe in Patients With Pacemakers, ICDs 

Patients with cardiac rhythm management devices showed no clinically significant major or minor events related to computed tomography imaging over a 10-year period at two large-volume care centers, researchers reported.

E. Improving patient satisfaction by adding a physician in triage (PIT)

Results: Improvement was noted in the absolute Press Ganey® scores in the Post-PIT time period across all questions analyzed with statistically significant differences noted for 8 of the 10 questions studied.

Shortcomings: “…Secondly, we compared the 6-month period before and the 6-month period after our intervention. Although the demographic information provided through the surveys was similar in both groups no perfectly matched control exists for comparison.

“Furthermore, we used an additional faculty physician to staff the triage area. It is certainly possible that an additional physician working in the main part of the ED could have reproduced the benefits demonstrated in this study. We assume that because we, like many EDs, deal with multiple patients in our waiting room during the busiest times of day, the effects would not have been the same.

“Our low response rate to the patient satisfaction survey is another limitation, with survey respondents representing 2.7% of all ED visits for the year and only 16% of those surveyed. Nevertheless, the response rate was similar across both groups…”

F. Slightly high blood pressure linked to stroke risk

In an analysis of 19 studies conducted in the U.S., Europe and Asia, Chinese researchers found that people with a prehypertensive reading of 120-139/80-89 mm Hg were 66% more likely to suffer a stroke than those with normal blood pressure level. The risk of hypertension was 44% higher among those with low-range prehypertension and 95% greater among high-range prehypertensive patients. The findings appear in the journal Neurology.

G. Compression stockings fail to prevent post-thrombotic syndrome

Compression stockings were not effective in preventing post-thrombotic syndrome in patients with a deep leg vein clot, a study in The Lancet found. Researchers tracked 806 patients with a deep leg vein clot for up to two years and found that about 14% of compression stocking users developed post-thrombotic syndrome compared with about 13% of those who wore placebo stockings.

H. Hard Time with Consultants?

Conflict Prevention, Conflict Mitigation, and Manifestations of Conflict During Emergency Department Consultations

I. Glucosamine Study: No Help for Knee Pain      

The popular dietary supplement glucosamine showed no evidence of structural benefits among patients with chronic knee pain typical of osteoarthritis, a randomized trial found.

J. Marker Detects Concussion, Predicts Its Severity     
Levels of total tau protein in blood shortly after a head injury were not only diagnostic for clinically definite concussion, but were significantly predictive of persistent symptoms, researchers said.

K. USPSTF: Drug-Free Teens? Not Yet    
There is currently no solid evidence showing that any doctor-led intervention is effective at preventing children and adolescents from using drugs other than tobacco, the U.S. Preventive Services Task Force found.

L. Codeine as Good as Hydrocodone after DC of ED Pts with Acute Extremity Pain

M. Obese Trauma Patients Have Worse Outcomes

Severely obese trauma patients were at least 30% more likely to die and approximately twice as likely to have a major complication compared with nonobese patients.

N. Management of Skin Abscesses in the Era of MRSA

Singer AJ, Talan DA. N Engl J Med 2014; 370:1039-1047.

Abstract: The incidence of abscesses is increasing, and community-acquired methicillin-resistant Staphylococcus aureus (MRSA) has become common. This review explains the role of ultrasonography and provides guidance on the management of skin abscesses and the use of antibiotics.