1. Syncope Risk Stratification Tools Vs Clinical Judgment: An
Individual Patient Data Meta-Analysis
Costantino
G, et al. Amer J Med. 2014 May 23 [Epub ahead of print]
Background:
There have been several attempts to derive syncope prediction tools to guide clinician
decision-making. However they have not been largely adopted possibly because of
their lack of sensitivity and specificity. We sought to externally validate the
existing tools and to compare them to clinical judgment, using an individual
patient data meta-analysis approach.
Methods: Electronic
databases, bibliographies and experts in the field were screened to find all
prospective studies enrolling consecutive subjects presenting with syncope to
the emergency department. Prediction tools and clinical judgment were applied
to all patients in each dataset. Serious outcomes and death were separately
considered during emergency department stay and at 10 and 30 days after
presenting syncope. Pooled sensitivities, specificities, likelihood ratios and
diagnostic odds ratios, with 95% CIs were calculated.
Results: Thirteen
potentially relevant papers were retrieved (11 authors). Six authors agreed to
share individual patient data. In total, 3681 patients were included. Three
prediction tools (OESIL, SFSR, EGSYS) could be assessed by the available
datasets. None of the evaluated prediction tools performed better than clinical
judgment in identifying serious outcomes during emergency department stay, at
10 and 30 days after syncope.
Conclusions:
Despite the use of an individual patient data approach to reduce heterogeneity
between studies, a large variability was still present. Current prediction
tools did not show better sensitivity, specificity, or prognostic yield
compared to clinical judgment in predicting short-term serious outcome after
syncope. Our systematic review strengthens the evidence that current prediction
tools should not be strictly used in clinical practice.
2. Reflections on Sepsis Management post-Process
A. In Sepsis, a Report of No Difference
May Make a Lot of Difference
Millar WB.
Ann Emerg Med 2014;63:A21-A25.
A report
from the first of 3 major trials of contrasting approaches to sepsis treatment
suggests that a piece of embattled ground may be shifting. The Protocolized
Care for Early Septic Shock (ProCESS) trial is the American entry in a
coordinated 3-study effort that also includes the Australasian Resuscitation in
Sepsis Evaluation (ARISE) and Protocolised Management in Sepsis (ProMISe)
studies. All 3 investigations both build on and scrutinize the 2001 findings of
Emanuel P. Rivers, MD, MPH, and colleagues at Detroit's Henry Ford Hospital in
a landmark article1 that promoted early goal-directed therapy (EGDT) as a best
practice in sepsis care.
The results
of ProCESS appeared last March 18,2 finding no significant differences in
clinical outcomes among 3 approaches: EGDT; protocol-based standard care not
requiring central venous catheterization, administration of inotropes, or blood
transfusions; and “usual care.” In what University of Pittsburgh professor of
emergency medicine and ProCESS investigator Donald Yealy, MD, described as an
expansion on Dr. Rivers's work, ProCESS suggests that the key term in the
phrase early goal-directed therapy is the first one. Early recognition and
aggressive response are probably responsible for the advances the field has
made since Dr. Rivers's article appeared, an inference that will be
strengthened if the forthcoming studies are consistent with the findings of
ProCESS. Catheterization and the associated ScVO2 monitoring appear optional,
not essential.
Severe
sepsis lacks the drama of acute myocardial infarction or stroke, but it is
comparably menacing when assessed in absolute numbers—exceeding 750,000 cases a
year around the time of the report by Dr. Rivers3 and described more recently
as increasing4 —and even more lethal, with short-term mortality of 20% or more
even after the past decade's advances.
“One out of
5 people who come in with a heart attack don't die,” Dr. Yealy noted. He sees
the new findings supporting a timing-based detection and treatment paradigm
comparable to that established for myocardial infarction. Although there is no
identifiable threshold analogous to the golden hour, “what we know is the
earlier the better…. Not everybody has it when they walk in the door; they may
get sicker right in front of your eyes, so while we had people who may have
been in the emergency department for up to 10 hours, they weren't in sepsis for
10 hours. They were waiting for a bed and then became septic. That's an
important distinction.” (The implications pertaining to crowding and boarding
appear obvious.)
Dr. Yealy
saluted Dr. Rivers's 2001 report as a turning point in treatment of the
condition. “Up until that point, almost every sepsis study showed no ability to
change outcomes,” he said. “And the outcomes were awful, so not only couldn't
you change them, they were bad—and by bad I mean 30 to 50% of the people died.
What Dr. Rivers showed is that if you worked hard to identify early, in other
words not wait until it was obvious, and you worked hard to treat it as quickly
as possible, you could improve.”
That
improvement has been significant, at least among patients enrolled in clinical
studies: a review of multicenter randomized trials in 2013 found that 18-day
inhospital mortality decreased from 47% to 29% between 1991 and 1995, and 2006
and 2009.5 Mortality in ProCESS, assessed at the 60-day point, is even lower:
21.0% with the EGDT protocol, 18.2% with protocolized standard therapy, and
18.9% with usual care (with no significant differences up to 1 year), still an
alarming death toll, but improving.
Although
some early responses to ProCESS6 view its null result comparing the 3 arms as
damaging to the position that Dr. Rivers has advocated, Dr. Yealy dismissed
that interpretation, emphasizing that EGDT remains one of 3 effective
approaches. “Nowhere is anyone saying, ‘Go back to 15 years ago, where sepsis
was often ignored or underdiagnosed until it was too late and undertreated.’ That
is not where we're heading.” Instead, he contended, ProCESS sorts out variables
that contributed to both Dr. Rivers's results and the subsequent wider
progress.
“We would
not be here today with this clarity from the ProCESS trial…without his work,”
Dr. Yealy said. “Our trial refines his observations; it does not refute them.
“Dr.
Rivers's approach was very resource intensive, both in terms of equipment and
of skill and technique. It's not easy to do, and a lot of sites even with his
strong results didn't fully implement it. They would take pieces of it, or not
do it at all,” Dr. Yealy continued. “We asked the question, in today's world,
not 10 or 12 years ago, do you need all of those resuscitative actions?… The
reason why we have a concurrent control, the ‘usual care,’ is that in the
interim 10 years, people have learned that other things matter early: giving
antibiotics sooner, managing how you place people on mechanical ventilation,
watching their blood sugars when they're sick. We knew that other things had
changed in the background that could either magnify or change the impact of the
Rivers approach”….
B. Unbundling Early Sepsis
Resuscitation
Jones AE.
Ann Emerg Med. 2014;63:654-5.
In 2004,
the Surviving Sepsis Campaign released its first international guidelines for
the management of severe sepsis and septic shock, with updates published in
2008 and 2012.1, 2 and 3 These guidelines are a compilation of graded evidence
and expert consensus and are recommended as best practices for the management
of severe sepsis. As a part of the recommendations, the Surviving Sepsis
Campaign suggests the use of a sepsis care bundle, which is a set of elements
of clinical care derived from the guidelines. The rationale for the bundle is
that, when implemented as a group, the recommendations “have an effect on
outcomes beyond implementing the individual elements alone.”4 Furthermore,
using bundles is supposed to simplify the complex processes of the care of
patients with severe sepsis. But do we need bundles?
From a
logical perspective, I believe that the application of bundles in severe sepsis
can work only if 4 simple principles apply: (1) the individual components are
evidence based; (2) the collective efficacy is proven; (3) the implementation
is easy and can be practically accomplished; and (4) they are generalizable to
all patients with the target condition. When these principles are considered in
relation to the 2012 Surviving Sepsis Campaign sepsis care bundle, it appears
that perhaps the cart is before the horse.
The
Surviving Sepsis Campaign bundle is reportedly evidence based. However, how can
it be evidence based when the bundle elements have changed between 2008 and
2012, yet no new published data to change practice have emerged; several of the
bundle elements are not the same as guideline recommendations (eg, the 2012
guidelines recommend antibiotics within 1 hour of recognition of severe sepsis
or septic shock, yet the bundle recommends antibiotics within 3 hours of
emergency department triage); and many of the individual components and the aggregate
of the 2012 care bundle have no supportive efficacy evidence, such as ordering
blood cultures or simply measuring a central venous pressure or central venous
oxygen saturation (without an intervention tied to the measurement), suggesting
that expert opinion may be driving these components much more than data-driven
evidence? Finally, one must consider that outcomes for population studies
depend on the statistical means and SDs of that population. A concern that
clinicians should have with bundles focuses on the potential threats to
external validity (generalizability) of the results of these studies to the
nuances of other, potentially different populations, as well as individual
patients. When the results of these studies are forced to management of
individual patients, then the statistical divergence between the state of
population and that of the individual is amplified, and both compliance and
efficacy decrease.
Presently,
the efficacy of implementing the 2012 Surviving Sepsis Campaign sepsis care
bundle is uncertain. Although authors have reported associative (noncausal)
data suggesting mortality benefit from older Surviving Sepsis Campaign
bundles,5 to date no study to my knowledge has reported any data on the new and
different 2012 care bundle, and no study has ever experimentally tested whether
implementation of and adherence to any of the Surviving Sepsis Campaign bundles
ever described is efficacious.
Another
consideration is that data on compliance with implementation of the Surviving
Sepsis Campaign bundles are dismal. Among early Surviving Sepsis Campaign
adopters, bundle compliance improved only 20% during 2 years and reached a
maximum of only 31% compliance.6 If this is the best that staunch advocates and
motivated adopters can achieve, then widespread compliance is not just going to
be difficult but is destined to fail. Some authors have compared implementing
bundles to the standard operating procedure and checks that pilots conduct on
planes before flight.7 The problem with that logic is that it fails to consider
that patients are different and unique, with different physiology and
composition, whereas planes are standardized and built to operate and function
the same. Thus, especially in severe sepsis, 1 checklist just does not fit all
patients.
One
hypothesis is that adherence to the bundle is just a surrogate for better
overall provision or quality of care. Maybe the ability of hospitals to routinely
achieve the bundle is the result of better organization, attention to detail,
communication, education, and awareness of the condition, and the potential
observed effect really has nothing to do with the bundle or its elements. I am
a believer in and advocate for early, aggressive recognition and quantitative
therapeutic intervention in severe sepsis that is delivered in an organized
manner. But I do not fly airplanes and my patients do not function like
airplanes, and achieving a checklist of elements that has never been proven to
be applicable to all, achievable in most, or experimentally efficacious in any
might just distract rather than direct.
C. Counterpoint: Clinicians Need to
Implement All Aspects of the Current Sepsis Bundles, Not Just the Ones They
Like
D. Sepsis: Still a major killer
Liu V, et
al. Hospital Deaths in Patients With Sepsis From 2 Independent Cohorts. JAMA 2014
May 18 [Epub ahead of print]
Discussion:
In 2 complementary hospital cohorts, we found that sepsis contributed to 1 in
every 2 to 3 deaths, and most of these patients had sepsis at admission. Given
the prominent role it plays in hospital mortality, improved treatment of sepsis
(potentially a final hospital pathway for multiple other underlying conditions)
could offer meaningful improvements in population mortality.
Patients
with initially less severe sepsis made up the majority of sepsis deaths.
Performance improvement efforts in the treatment of sepsis have primarily
focused on standardizing care for the most severely ill patients, whereas
interventions for treating other patients with sepsis are less well defined.
Given their prevalence, improving standardized care for patients with less
severe sepsis could drive future reductions in hospital mortality.
Full-text
(free): http://jama.jamanetwork.com/article.aspx?articleid=1873131
3. A Simple Clinical Decision Rule To Rule Out Appendicitis In
Patients With Nondiagnostic US Results
Leeuwenburgh
MMN, et al. Acad Emerg Med. 2014;21:488-496.
Objectives:
The objective was to identify a set of clinical features that can rule out
appendicitis in patients with suspected acute appendicitis and nondiagnostic
ultrasound (US) results, allowing safe discharge and next-day reevaluation
without initial computed tomography (CT) or magnetic resonance imaging (MRI).
Methods: Data
on clinical and US evaluation, including a number of prespecified variables
potentially associated with acute appendicitis, were prospectively collected in
two diagnostic accuracy studies of imaging. These studies included patients
with suspected appendicitis seen in the emergency department (ED). For
development and validation of the clinical decision rule (CDR), only patients
with inconclusive or negative US results were included. There were 199 (of 422)
patients in the development cohorts and 120 (of 211) patients in the validation
cohort. Logistic regression analysis was used for data from patients with
inconclusive or negative US results, and profiles were created of all possible
combinations of predictors retained in the multivariable model. A final
diagnosis was assigned by an expert panel based on perioperative data,
histopathology, and clinical follow-up of at least 3 months.
Results: The
CDR selected patients after negative or inconclusive US for discharge and
next-day reevaluation without initial CT or MRI if fewer than two of the
following predictors were present: male sex, migration of pain to the right
lower quadrant, vomiting, and white blood cell (WBC) count higher than 12.0 ×
109/L. Applying the CDR in the development set selected 126 of 199
(63%) patients with negative or inconclusive US results for discharge without
further imaging. This rule reduced the probability of appendicitis from 26% (51
of 199) in the total group of patients with negative or inconclusive US results
to 12% (15 of 126) in the group that would be discharged based on the rule (p =
0.001). In the validation set (n = 120), the decision rule selected 72 (60%)
patients for discharge and next-day reevaluation and reduced the probability of
appendicitis from 20% (24 of 120) in the total group to 6% (4 of 72) in the
patients selected on the rule (p = 0.001). The negative predictive value of the
decision rule in the validation set was 94% (95% confidence interval [CI] = 87%
to 98%). In comparison, the negative predictive value of CT in the same group
was 99% (95% CI = 93% to 100%, p = 0.14), and that of MRI was 99% (95% CI = 94%
to 100%, p = 0.12). Alternative decision rules based on combinations of the
present decision rule with C-reactive protein (CRP) results did not improve
selection.
Conclusions:
This newly developed CDR significantly reduces the probability of appendicitis
in a large subgroup of patients with negative or inconclusive US results. These
patients can be safely discharged for outpatient reevaluation without further
initial imaging if proper follow-up is available. This could assist in lowering
the number of ED imaging investigations in patients with suspected
appendicitis.
See also Ross MJ, et al. Outcomes of Children with Suspected
Appendicitis and Incompletely Visualized Appendix on US. Acad Emerg Med.
2014;21:538-542. http://www.ncbi.nlm.nih.gov/pubmed/24842505
4. Pre–Trauma Center Transfusions Reduce Mortality Rates
Blunt
trauma patients with hemorrhagic shock who received transfusions within 2 hours
of injury, and before arrival at the trauma center, had reduced mortality rates
at 24 hours and 30 days.
Brown JB,
et al. Pretrauma Center Red Blood Cell Transfusion Is Associated With Reduced
Mortality and Coagulopathy in Severely Injured Patients With Blunt Trauma. Ann
Surg. 2014 Mar 25. [Epub ahead of print]
OBJECTIVE: To
evaluate the association of pretrauma center (PTC) red blood cell (RBC)
transfusion with outcomes in severely injured patients.
BACKGROUND:
Hemorrhage remains a major driver of mortality. Little evidence exists
supporting PTC interventions to mitigate this.
METHODS: Blunt
injured patients in shock arriving at a trauma center within 2 hours of injury
were included from the Glue Grant database. Subjects were dichotomized by PTC
RBC transfusion. Outcomes included 24-hour mortality, 30-day mortality, and
trauma-induced coagulopathy [(TIC), admission international normalized ratio above
1.5]. Cox regression and logistic regression determined the association of PTC
RBC transfusion with outcomes. To address baseline differences, propensity
score matching was used.
RESULTS: Of
1415 subjects, 50 received PTC RBC transfusion. Demographics and injury
severity score were similar. The PTC RBC group received 1.3 units of RBCs
(median), and 52% were scene transports. PTC RBC transfusion was associated
with a 95% reduction in odds of 24-hour mortality [odds ratio (OR) = 0.05; 95%
confidence interval (CI), 0.01-0.48; P less than 0.01], 64% reduction in the
risk of 30-day mortality [hazard ratio = 0.36; 95% CI, 0.15-0.83; P = 0.02],
and 88% reduction in odds of TIC (OR = 0.12; 95% CI, 0.02-0.79; P = 0.03). The
matched cohort included 113 subjects (31% PTC RBC group). Baseline
characteristics were similar. PTC RBC transfusion was associated with a 98%
reduction in odds of 24-hour mortality (OR = 0.02; 95% CI, 0.01-0.69; P =
0.04), 88% reduction in the risk of 30-day mortality (hazard ratio = 0.12; 95%
CI, 0.03-0.61; P = 0.01), and 99% reduction in odds of TIC (OR = 0.01; 95% CI,
0.01-0.95; P = 0.05).
CONCLUSIONS:
PTC RBC administration was associated with a lower risk of 24-hour mortality,
30-day mortality, and TIC in severely injured patients with blunt trauma,
warranting further prospective study.
5. Traumatic Brain Injury ED Visits Up Nearly 30% in 5 Years
Larry Hand.
Medscape News. May 15, 2014
The rate of
trips to US emergency departments (EDs) resulting from traumatic brain injury
(TBI) rose almost 30% between 2006 and 2010, according to a research letter
published online May 13 in JAMA.
Jennifer R.
Marin, MD, from the Department of Pediatrics, University of Pittsburgh School
of Medicine, Pennsylvania, and colleagues conducted a population-based
epidemiological study of TBI visits to US EDs from 2006 through 2010. They analyzed
data from the Nationwide Emergency Department Sample database, which collects
data on 25 to 50 million ED visits from more than 950 hospitals yearly and
represents 20% of all US EDs.
The
researchers found that the rate of TBI visits per 100,000 person-years
increased 29.1% (95% confidence [CI], 18.9% - 39.2%), going from 637 (95% CI,
582 - 692) in 2006 to 822 (95% CI, 758 - 887) in 2010. By comparison, the rate
of total ED visits for the period rose 3.6% (95% CI, −0.7% to 8.0%), going from
40,228 (95% CI, 38,705 - 41,752) visits per 100,000 person-years in 2006 to 41
691 (95% CI, 39, 948 - 43,433) visits in 2010.
Children
younger than 3 years and adults older than 60 years accounted for most TBI ED
visits. The researchers suggest this may be because "these age groups do
not benefit as much from public health interventions, such as concussion and
helmet laws and safer sports' practices."
The total
number of ED visits coded as TBI in the Nationwide Emergency Department Sample
database came to more than 2.5 million in 2010.
Clinicians
coded most TBI visits as concussion or unspecified head injury, and 40% (95%
CI, 39.6% - 41.1%) of the visits involved at least 1 other injury such as open
wounds, sprains, and fractures.
Most visits
were to regular hospital EDs and not trauma centers, and although almost a
third of the visits were by children, very few visits were to pediatric EDs.
The
researchers write that the increase in TBI rates is possibly a result of
increased TBI awareness, diagnoses, or both. Public campaigns and legislation
during the past decade have been aimed at increasing awareness.
Limitations
of the study include a lack of data from federal hospitals and incidents
involving patients who died before reaching an ED, as well as possible
miscoding of diagnoses. "Nonetheless, our study suggests increasing trends
in ED-diagnosed rates of TBI," the researchers conclude.
This
research was supported by the National Heart, Lung, and Blood Institute. The
authors have disclosed no relevant financial relationships.
6. Should we advise patients with sutures not to swim?
Browne K. BMJ
2014;348:g3171
Patients
often ask when they can swim after a wound has been sutured. Despite such an
apparently simple query, evidence supporting any answer seems to be lacking.
Many patient information sites advise against swimming after the suturing of
wounds1 but fail to provide evidence to support this recommendation. Advice is
broad ranging and inconsistent.1 Current information ranges from waiting until
the sutures are removed and the wound has healed1 to abstaining from swimming
for six weeks postoperatively.2 Patients with external frame fixators are
advised that it is permissible to swim in a chlorinated pool or clean sea
water, although in practice this is difficult to ascertain and is far from an
objective measure, once the pin sites have healed.3 Evidence to back up the
advice is scarce.
Concerns
about the risks of swimming with a sutured wound primarily centre on the
potential for infection,4 5 as opposed to impaired wound healing. The risk of
infection depends on the type of wound (for example, an open wound might be
said to be at higher risk than an epithelialised wound), comorbidities, the
type and quality of water in which patients plan to swim, and the relative
risks of complications should the wound become infected. Wound infections can
result from exposure to aquatic microbes in treated swimming pools and fresh or
marine water.4 5 6 The infective organisms vary accordingly.
It is,
however, difficult to quantify the risk of infection in sutured wounds and
hence giving an evidence based answer when patients ask about swimming is
problematic.
What is the evidence of the
uncertainty?
To tackle
our dilemma on how to advise patients on swimming with sutures, we searched
PubMed, Embase, and Cochrane databases for articles on swimming related wound
infections using combinations of the key words “swimming”, “infection”, “wound
management”, “water”, “sutures”, “post operative”, and “skin”. No time or
language restrictions were applied, and we screened the references of selected
articles.
Out of over
250 screened articles, of all available published evidence, including
surveillance reports and case reports, we identified only one case report on
infection in a sutured wound attributed to water exposure, which occurred in a
hospital rehabilitation pool.7 Neither the Centers for Disease Control and
Prevention, which publishes rates of waterborne infections,5 8 nor the World
Health Organization guidelines for safe recreational water4 report any
infection of sutured wounds caused by swimming.
The highest
numbers of dermatological infections from exposure to water arise in swimming
pools,5 yet the greatest risk in this environment is from gastrointestinal
infections, related to organisms such as Escherichia coli and Cryptosporidium.8
The commonest dermatological bacterial pathogens in swimming pools are
Pseudomonas aeruginosa and Staphylococcus aureus.5 9 Marine organisms of
concern include Vibrio species and Mycobacteria.10 Skin associated illness
accounted for only 1.3% (46/3376) of cases of disease outbreaks from exposure
to recreational water, none attributed to infection of sutured wounds.
Aquatic
microbes can enter the body through breaks in the skin, resulting in a range of
conditions from skin irritation to systemic sepsis and limb threatening
necrotic infections.9 Reported infections from marine10 and fresh water
pathogens6 are predominantly caused by injury sustained within the water or
from pre-existing wounds that have not been sutured.10 Evidence to help in the
quantification of the risk of aquatic microbes entering the skin through an
adequately closed wound is lacking.
The
location chosen for swimming is pertinent as concentrations of bacteria in
swimming, fresh, and marine water vary considerably. The bacterial count of the
bathing medium is important for calculating the risk of infections. The levels
of bacteria in public swimming pools are closely governed to minimise the
presence of faecal coliforms, Staphylococcus aureus, Pseudomonas aeruginosa,
and other pathogens. In addition, levels of faecal and non-faecal organisms in
marine and recreational fresh water are monitored.4 Despite this the
concentration of bacteria in swimming pools often exceeds recommended levels,11
and up to 100 million bacteria can be present in every litre of sea water.12
Overall, the risk of infection while swimming in open water seems less than
that of a sheltered or recreational pool.8 The risk of infection from swimming
with a wound of any type is, however, still unclear.
The risk of
infection depends not only on the nature of the wound5 and the water in which
the patient swims, but also on comorbidities and the virulence of the
pathogen.10 The range of comorbidities that might influence the risk of
infection are diffuse, including those that influence local conditions in the
skin (for example, eczema) and systemic immunodeficiency (for example, diabetes
mellitus).9 Certain immunodeficiencies are associated with a particular
predisposition to infection with aquatic pathogens (for example, iron overload)
and infections with Vibrio,13 cellular immunodeficiency (such as chronic
granulomatous disease), and mycobacterial infections.9 Aquatic derived wound
infections are rare but can be devastating, resulting in severe illness,
septicaemia, limb amputation, or death.5 Evidence to help in the quantification
of this risk for patients with comorbidities is lacking.
No systemic
reviews have assessed the risk of infection from swimming. In the absence of
any direct evidence on risks from swimming with sutured wounds, outcomes have
to be extrapolated from other evidence related to water and wounds in general.
Two Cochrane level meta-analyses can provide some insight.14 15 In a systematic
review of 11 trials, both randomised and quasirandomised, with 3449
participants combined and a variable risk of bias, infection rates did not
differ statistically among wounds cleaned with tap water (which has a known,
albeit low, quantity of bacteria) compared with those cleaned with sterile
saline solution.15 Furthermore, the risk of infection does not seem to be
increased by timing: another Cochrane review showed that the rate of infection
was similar between patients with surgical wounds who showered early (within 12
hours postoperatively) and those who showered late (beyond 48 hours postoperatively).14
However, this comprised only one prospective randomised trial with 857 patients
and was found to have a high risk of bias. The quality of the evidence was,
however, poor.14 15
Guidelines
from the National Institute for Health and Care Excellence on the postoperative
care of wounds recommend that sutured wounds should be sufficiently
epithelialised at 48 hours to sustain bathing and showering, but they do not
mention when swimming might be allowed.16 Although the rationale purported by
NICE for waiting 48 hours before cleansing is to allow time for wounds to
re-epithelialise and therefore the integrity of skin to be restored, the
evidence for this time point is not stated.16
Is ongoing research likely to
provide relevant evidence?
Although several
studies are underway to reduce the incidence of wound infection and look at
intraoperative and postoperative measures to reduce infection, we found none
directly relating to swimming. Our search of ClinicalTrials.gov, PubMed, and
Centerwatch.com found several studies underway on intraoperative and
postoperative measures to reduce infection, but none directly related to
swimming. The box outlines recommendations for further research.
Recommendations for further research
Population:
non-immunocompromised adults with sutures after elective minor surgical
procedures
Intervention:
allow swimming with sutures in situ
Comparison:
two groups, one allowed to swim with sutures and the other not
Outcome:
rates of surgical site infection and delays to wound healing
What should we do in the light of
the uncertainty?
In the
absence of quality evidence, common sense solutions have to be arrived at by
extrapolating evidence from allied specialties. Once a wound is epithelialised
(provided that edges are closely approximated) it can be cleansed, and
potentially patients should be able to swim either in the sea or in a swimming
pool. The timing is difficult to adequately quantify and so patients should be
advised that they can return to swimming once sutures have been removed and the
wound is fully healed. This ensures that the integrity of the skin has been
restored thereby decreasing the chance of infection from microbial entry
through the wound. Showering wounds before 48 hours does not seem to increase
the chance of infection.14 This advice can, conceivably, be viewed as overly
cautious.
The timing
of suture removal depends on the type and location of the wound, but it is
usually within seven to 10 days. Absorbable sutures may persist beyond this
time, and vigilance is required to ensure their removal before swimming.
Patients with comorbidities that increase the chance of infections are at
increased risk and therefore swimming should be discouraged. Swimming before
this time exposes patients to a small risk of waterborne infection, which,
although potentially tolerable in a healthy cohort of patients, presents an
increased risk in those with localised or systemic reasons for delayed wound
healing. In general, patients with open wounds or ulcers should refrain from swimming5;
this does not purport directly to surgical wounds, but through extrapolation
should include them.
7. Nasogastric Tube May Be Obsolete for GI Bleeds
By Ed
Susman, Contributing Writer, MedPage Today, May 7, 2014,
CHICAGO --
Placement of a nasogastric tube for determining treatment of patients with
upper gastrointestinal bleeding may be unnecessary since almost all these
patients will eventually undergo an endoscopic procedure, researchers argued
here.
"We
found that the clinical judgment of the clinician was just about as good as a
nasogastric tube examination -- and didn't cause harm to the patient,"
said Silvio Melo, MD, of Gastroenterology Consultants in San Antonio.
The
diagnosis by clinical judgment was confirmed in 52% of the patients in the
study, while the nasogastric tube analysis was correct 60% of the time --
results which achieved prespecified non-inferiority, said co-author Don Rockey,
MD, of the Medical University of South Carolina in Charleston.
"Since
there is going to be an endoscopic follow-up to confirm the diagnosis and
perform definitive treatment if necessary, there is no need to continue to
torture our patients with nasogastric tube placement," Rockey told MedPage
Today at the annual Digestive Disease Week. He and Melo said they no longer
routinely order it.
"We
found that that routine placement of an nasogastric tube is not helpful in
patients with upper gastrointestinal bleeding," he said.
Melo told
MedPage Today that placement of nasogastric tubes cause pain and epistaxis in
as many as 25% of patients undergoing the procedure; in another 10% of
patients, the tube cannot be inserted due to some form of anatomic problem. In
the study he performed, pain, nasal bleeding, or nasogastric tube failure
occurred in 49 of the 140 (35%) patients assigned to that procedure.
Rockey said
the use of the nasogastric tube for diagnosis and lavage of patients coughing
up blood or having blood in their stools has been commonplace as treatment for
suspected upper gastrointestinal bleeding for more than a century. But with the
advent of endoscopy use beginning in the 1980s, the nasogastric tube has
probably not been needed -- even though it is performed almost daily in many
U.S. hospitals.
Melo said
that use of the nasogastric tube in hospitals outside the U.S. and in less
developed countries such as his native Brazil may still be used because of the
lack of widespread endoscopists.
In the
study, 280 patients with suspected upper gastrointestinal bleeding were
randomized into two groups -- one in which a nasogastric tube was placed in the
patient and a diagnosis was derived from the aspiration and lavage, and a
second group of 140 patients whose diagnosis was determined through a clinical
evaluation and patient history. The study was conducted at the University of
Texas Southwestern Medical Center in Dallas, when Melo and Rockey were both
working at that facility.
"Recruitment
of patients for the study was a challenge," Rockey sad. "Many
patients refused to undergo the nasogastric tube placement." Those
patients who refused were also followed as to their outcomes, and their
clinical diagnosis turned out to be similar to the others, he said.
The
patients were about 50 years old, and 35% were women. The patients were matched
for pre-endoscopic vital signs and laboratory tests. The clinicians' prediction
for the need for endoscopic repair was correct 32% of the time; the prediction
based on nasogastric findings was correct 38% of the time (P=0.7).
"Although
nasogastric tube placement, aspiration, and lavage is often used in patients
with upper gastrointestinal bleeding, its clinical utility remains
unproven," Rockey said.
Reference: Rockey
D, et al "A randomized controlled trial of nasogastric tube placement in
patients with upper gastrointestinal bleeding" DDW 2014; Abstract 1035. http://www.gastrojournal.org/article/S0016-5085(14)60654-5/pdf
8. Managing Skin Infections
A. Predictors of Failure of Empiric
Outpatient Antibiotic Therapy in ED Patients with Uncomplicated Cellulitis
Peterson D,
et al. Acad Emerg Med. 2014;21:526–531.
Background:
Despite several expert panel recommendations and cellulitis treatment
guidelines, there are currently no clinical decision rules to assist clinicians
in deciding which emergency department (ED) patients should be treated with
oral antibiotics and which patients require intravenous (IV) therapy at first
presentation of cellulitis amenable to outpatient treatment.
Objectives:
The objective was to determine risk factors associated with adult patients
presenting to the ED with cellulitis who fail initial antibiotic therapy as
outpatients and require a change of antibiotics or admission to hospital.
Methods: This
was a prospective cohort study of patients 18 years of age or older presenting
with cellulitis to one of two tertiary care EDs (combined annual census
140,000). Patients were excluded if they had been treated with antibiotics for
the cellulitis before presenting to the ED, if they were admitted to the
hospital, or if they had an abscess only. Trained research personnel
administered a questionnaire at the initial ED visit with telephone follow-up 2
weeks later. Multivariable logistic regression models determined predictor
variables independently associated with treatment failure (failed initial
antibiotic therapy and required a change of antibiotics or admission to hospital).
Results: A
total of 598 patients were enrolled, 52 were excluded, and 49 were lost to
follow-up. The mean (±standard deviation [SD]) age was 53.1 (±18.4) years and
56.4% were male. A total of 185 patients (37.2%) were given oral antibiotics,
231 (46.5%) were given IV antibiotics, and 81 patients (16.3%) received both
oral and IV antibiotics in the ED. A total of 102 (20.5%, 95% confidence [CI] =
17.2% to 24.2%) patients had treatment failures. Fever (temperature above 38°C)
at triage (odds ratio [OR] = 4.3, 95% CI = 1.6 to 11.7), chronic leg ulcers (OR
= 2.5, 95% CI = 1.1 to 5.2), chronic edema or lymphedema (OR = 2.5, 95% CI =
1.5 to 4.2), prior cellulitis in the same area (OR = 2.1, 95% CI = 1.3 to 3.5),
and cellulitis at a wound site (OR = 1.9, 95% CI = 1.2 to 3.0) were
independently associated with treatment failure.
Conclusions:
These risk factors should be considered when initiating empiric antibiotic
therapy for ED patients with cellulitis amenable to outpatient treatment.
B. The Massachusetts Abscess Rule: A
Clinical Decision Rule Using US to Identify MRSA in Skin Abscesses
Gaspari RJ,
et al. Acad Emerg Med. 2014;21:558–567.
Objectives:
Treatment failure rates for incision and drainage (I&D) of skin abscesses
have increased in recent years and may be attributable to an increased
prevalence of community-acquired methicillin-resistant Staphylococcus aureus
(CA-MRSA). Previous authors have described sonographic features of abscesses,
such as the presence of interstitial fluid, characteristics of abscess debris,
and depth of abscess cavity. It is possible that the sonographic features are
associated with MRSA and can be used to predict the presence of MRSA. The
authors describe a potential clinical decision rule (CDR) using sonographic
images to predict the presence of CA-MRSA.
Methods: This
was a pilot CDR derivation study using databases from two emergency departments
(EDs) of patients presenting to the ED with uncomplicated skin abscesses who
underwent I&D and culture of the abscess contents. Patients underwent
ultrasound (US) imaging of the abscesses prior to I&D. Abscess contents
were sent for culture and sensitivity. Two independent physicians experienced
in soft tissue US blinded to the culture results and clinical data reviewed the
images in a standardized fashion for the presence or absence of the
predetermined image characteristics. In the instance of a disagreement between
the initial two investigators, a third reviewer adjudicated the findings prior
to analysis. The association between the primary outcome (presence of MRSA) and
each sonographic feature was assessed using univariate and multivariate
analysis. The reliability of each sonographic feature was measured by
calculating the kappa (κ) coefficient of interobserver agreement. The decision
tree model for the CDR was created with recursive partitioning using variables
that were both reliable and strongly associated with MRSA.
Results: Of
the total of 2,167 patients who presented with skin and soft tissue infections
during the study period, 605 patients met inclusion criteria with US imaging
and culture and sensitivity of purulence. Among the pathogenic organisms, MRSA
was the most frequently isolated, representing 50.1% of all patients. Six of
the sonographic features were associated with the presence of MRSA, but only
four of these features were reliable using the kappa analysis. Recursive
partitioning identified three independent variables that were both associated
with MRSA and reliable: 1) the lack of a well-defined edge, 2) small volume,
and 3) irregular or indistinct shape. This decision rule demonstrates a
sensitivity of 89.2% (95% confidence interval [CI] = 84.7% to 92.7%), a
specificity of 44.7% (95% CI = 40.9% to 47.8%), a positive predictive value of
57.9 (95% CI = 55.0 to 60.2), a negative predictive value of 82.9 (95% CI =
75.9 to 88.5), and an odds ratio (OR) of 7.0 (95% CI = 4.0 to 12.2).
Conclusions:
According to our putative CDR, patients with skin abscesses that are small,
irregularly shaped, or indistinct, with ill-defined edges, are seven times more
likely to demonstrate MRSA on culture.
9. Who Does Not Need Repeat Imaging for Traumatic Intracranial
Hemorrhage?
Among
patients with normal neurologic examinations, none required neurosurgical
intervention — regardless of repeat head CT results.
Cheryl Lynn
Horton, MD reviewing Joseph B et al. J Am Coll Surg 2014 Mar 1. Journal Watch May 15, 2014
Consensus
is lacking about routine repeat head computed tomography (CT) in patients with
intracranial hemorrhage; however, recent research suggests that, in the absence
of neurologic deterioration, repeat imaging is unnecessary (Nayak NV, et al. J
Trauma Acute Care Surg 2013 Aug). Now, researchers in Arizona have
prospectively evaluated 1129 adult patients admitted to a single trauma center
with intracranial hemorrhage on initial head CT. All patients received
neurologic examinations every 2 hours and routine repeat head CT at 6 hours or
for neurologic deterioration. No patient was anticoagulated or on antiplatelet
therapy.
Of 1099
patients who underwent routine repeat imaging, 216 had a new or enlarged
hemorrhage. Only four of these patients (all of whom had Glasgow Coma Scale
scores less than 8 on presentation and were intubated) required neurosurgery
for enlarging epidural or subdural hemorrhages. Of 30 patients who required
repeat imaging for new altered mental status, neurologic deficits, or pupillary
changes, 16 had new or enlarged hemorrhage; of this subset of patients, 12
required neurosurgery. Deteriorating neurologic examination was an independent
predictor of need for neurosurgical intervention (odds ratio, 3.98).
10. Palliative Care in the ED
Mierendorf
SM, et al. Perm J 2014; 18(2):77-85
Introduction
Although
not considered an ideal place to begin palliative care, in reality the
Emergency Department (ED) is the most frequent place where urgent care is
sought. Whether there are gaps in the outpatient setting or failure to predict
and plan for crisis intervention, the ED experience may be pivotal in
determining a patient’s trajectory. The culture of emergency medicine to
provide stabilization of acute medical urgencies is now shifting to a more
patient- goal-centered culture. There has been a large movement to educate
emergency physicians on end-of-life care and improve palliative care in
emergency medicine, leading to clinical practice guidelines.1 In reality,
because of the acute symptoms that are often accompanied by significant
emotional overtones and disposition issues, a hospitalist or intensivist is
quickly consulted. Many patients present with serious and unrelieved symptoms
such as pain, dyspnea, nausea, and vomiting that were not well controlled in the
outpatient setting. The ED or hospital may be the only option for them to
receive intravenous (IV) fluids or medications, as well as immediate access for
acute imaging or access to specialists, for example, radiation oncologists.
Even if the patient’s goals are clearly nonaggressive, the patient may arrive
in the ED because of family distress over symptoms.
Abstract
The
Emergency Department (ED) is the place where people most frequently seek urgent
care. For patients living with chronic disease or malignancy who may be in a
crisis, this visit may be pivotal in determining the patients’ trajectory.
There is a large movement in education of emergency medicine physicians,
hospitalists, and intensivists from acute aggressive interventions to
patient-goal assessment, recognizing last stages of life and prioritizing
symptom management. Although the ED is not considered an ideal place to begin
palliative care, hospital-based physicians may assist in eliciting the
patient’s goals of care and discussing prognosis and disease trajectory. This
may help shift to noncurative treatment. This article will summarize the
following: identification of patients who may need palliation, discussing
prognosis, eliciting goals of care and directives, symptom management in the
ED, and making plans for further care. These efforts have been shown to improve
outcomes and to decrease length of stay and cost. The focus of this article is
relieving “patient” symptoms and family distress, honoring the patient’s goals
of care, and assisting in transition to a noncurative approach and placement
where this may be accomplished…
11. Avoiding Potential Harm by Improving Appropriateness of
Urinary Catheter Use in 18 EDs
Fakih MG,
et al. Ann Emerg Med. 2014;63:761–768.e1
Study
objective: Urinary catheters are often placed in the emergency department (ED)
and are associated with an increased safety risk for hospitalized patients. We
evaluate the effect of an intervention to reduce unnecessary placement of
urinary catheters in the ED.
Methods: Eighteen
EDs from 1 health system underwent the intervention and established
institutional guidelines for urinary catheter placement, provided education,
and identified physician and nurse champions to lead the work. The project
included baseline (7 days), implementation (14 days), and postimplementation (6
months, data sampled 1 day per month). Changes in urinary catheter use,
indications for use, and presence of physician order were evaluated, comparing
the 3 periods.
Results: Sampled
patients (13,215) admitted through the ED were evaluated, with 891 (6.7%; 95%
confidence interval [CI] 6.3% to 7.2%) having a catheter placed. Newly placed
catheters decreased from 309 of 3,381 (9.1%) baseline compared with 424 of
6,896 (6.1%) implementation (Δ 3.0%; 95% CI 1.9% to 4.1%), and 158 of 2,938
(5.4%) postimplementation periods (Δ 3.8%; 95% CI 2.5% to 5.0%). The
appropriateness of newly placed urinary catheters improved from baseline
(228/308; 74%) compared with implementation (385/421; 91.4%; Δ 17.4%; 95% CI
11.9% to 23.1%) and postimplementation periods (145/158; 91.8%; Δ 23.9%; 95% CI
18% to 29.3%). Physician order documentation in the presence of the urinary
catheter was 785 of 889 (88.3%), with no visible change over time. Improvements
were noted for different-size hospitals and were more pronounced for hospitals
with higher urinary catheter placement baseline.
Conclusion:
The implementation of institutional guidelines for urinary catheter placement
in the ED, coupled with the support of clearly identified physician and nurse
champions, is associated with a reduction in unnecessary urinary catheter
placement. The effort has a substantial potential of reducing patient harm
hospital-wide.
12. Images in Clinical Practice
ST-Elevation
Myocardial Infarction.
Type I
Atrial Flutter.
Herpes
Zoster Involving the S1 Dermatome
Tinea
Faciei
Abdominal-Wall
Varices in the Budd–Chiari Syndrome
Traumatic
Tension Pneumothorax Causing Heart Rotation
A Jammed
Finger and Bloody Nail
Young Man
With Nausea and Vomiting
13. A comparison of suprascapular nerve block and procedural
sedation analgesia in shoulder dislocation reduction
Tezel O, et
al. Amer J Emerg Med. 2014;32:549–552
Objectives:
Dislocation of the shoulder joint is one of the most common dislocations. The
reduction procedure is a painful procedure. In this study, 2 different
treatment groups were compared for pain control during shoulder dislocation
reduction. It was aimed to evaluate the differences between the groups in
reduction, success, length of hospital stay, complications, side effects,
patient-physician satisfaction, and ease of application.
Methods: The
study was planned to be prospective and randomized. As procedural sedation
analgesia (SA), titration of ketamine 1 to 2 mg/kg was administered
intravenously to group 1. Suprascapular nerve block (SNB) was applied under
ultrasound guidance (USG) to group 2. Conformity to normal distribution of
variables was examined with the Kolmogorov-Smirnov test. The χ2 test and Fisher
test were used to evaluate differences between the groups in categorical
variables and the Mann-Whitney U test, and a value of P less than .05 was
accepted as statistically significant.
Results: The
study comprised a total of 41 patients; 20 in the group 1 and 21 in the group
2. No statistically significant difference was determined between the groups in
terms of age (P = .916), sex (P = .972), reduction success (P = .540), and
patient-physician satisfaction (P = .198). The time spent in the emergency
department (ED) by patients in the SA group was signficantly longer compared
with the SNB group. No side effects were observed in the SNB group.
Conclusions:
Suprascapular nerve block, which can be easily applied under USG in the ED, can
be evaluated as a good alternative to SA in the reduction of shoulder
dislocations.
14. A randomized, controlled trial of oral versus IV fluids for
lowering blood glucose in ED patients with hyperglycemia
Arora S, et
al. CJEM 2014;16(3):214-219
Objectives:
Blood glucose can be lowered via insulin and/or fluid administration. Insulin,
although efficacious, can cause hypoglycemia and hypokalemia. Fluids do not
cause hypoglycemia or hypokalemia, but the most effective route of fluid
administration has not been well described. This study compared the efficacy
and safety of oral versus intravenous fluids for reducing blood glucose in
patients with hyperglycemia.
Methods: We
conducted a prospective, nonblinded, randomized, controlled trial. Inclusion
criteria were blood glucose above 13.9 mmol/L, age over 18 years, and ability
to tolerate oral fluids. Subjects were excluded for critical illness, contraindication
to fluids, and/or hyperglycemia therapy prior to enrolment. Subjects were
randomized to receive oral bottled water or intravenous normal saline (maximum
2 L) over 2 hours. The primary outcome of interest was a change in blood
glucose at 2 hours across treatment arms.
Results: The
48 subjects were randomized. Baseline blood glucose levels and total amount of
fluid received were similar between the two groups. The mean decrease in blood
glucose at 2 hours was similar for both treatment arms: a mean decrease of 3.4
mmol/L (20.2 mmol/L to 16.8 mmol/L) in the oral fluid group versus a mean
decrease of 4.0 mmol/L (19.7 mmol/L to 15.7 mmol/L) in the intravenous fluid
group. The mean difference between groups was −0.6 mmol/L (95% confidence interval
−2.3–1.2; p = 0.51). No adverse events were observed in either group.
Conclusion:
In this unblinded randomized trial, oral and intravenous fluids were equally
efficacious in lowering blood glucose levels in stable hyperglycemic patients
and no adverse events were noted. Physicians should be mindful that, although
similar, the reduction in blood glucose was modest in both groups.
15. ED visits for palpitations: 1/3 cardiac and 1/4 admitted
This study
found that palpitations are responsible for a significant minority of emergency
department visits and are associated with a cardiac diagnosis roughly one-third
of the time. This was associated with a relatively high admission rate,
although significant regional variation in these rates exists.
Probst MA,
et al. Analysis of Emergency Department Visits for Palpitations (from the
National Hospital Ambulatory Medical Care Survey). Amer J Cardiol
2014;113:1685-1690.
Palpitations
is a common complaint in patients who visit the emergency department (ED), with
causes ranging from benign to life threatening.
We analyzed
the ED component of the National Hospital Ambulatory Medical Care Survey for
2001 through 2010 for visits with a chief complaint of palpitations and
calculated nationally representative weighted estimates for prevalence,
demographic characteristics, and admission rates. ED and hospital discharge
diagnoses were tabulated and categorized, and recursive partitioning was used
to identify factors associated with admission.
An
estimated 684,000 visits had a primary reason for visit of “palpitations”
representing a national prevalence of 5.8 per 1,000 ED visits (0.58%, 95%
confidence interval 0.52 to 0.64). Women and non-Hispanic whites were
responsible for most visits. A cardiac diagnosis made up 34% of all ED
diagnoses. The overall admission rate was 24.6% (95% confidence interval 21.2
to 28.1), with higher rates seen in the Midwest and Northeast compared with the
West.
Survey-weighted
recursive partitioning revealed several factors associated with admission
including age over 50 years, male gender, cardiac ED diagnosis, tachycardia,
hypertension, and Medicare insurance. In conclusion, palpitations are
responsible for a significant minority of ED visits and are associated with a
cardiac diagnosis roughly 1/3 of the time. This was associated with a
relatively high admission rate, although significant regional variation in
these rates exists.
16. TMP-Sulfa for Skin and Soft Tissue Infections—Let Us Not
Forget the Risks
Jenkins TC,
et al. Ann Emerg Med. 2014;63:783-4.
To the
Editor: In the emergency department (ED), treatment of skin infections with
trimethoprim-sulfamethoxazole has markedly increased1 and trimethoprim-sulfamethoxazole–related
adverse events have become more frequent.2 We report a case of severe
hyperkalemia associated with trimethoprim-sulfamethoxazole prescribed for a
possible wound infection, highlighting the need for ED providers to recognize
and mitigate the risks associated with this antibiotic.
Case: An
83-year-old woman with chronic cardiopulmonary disease and diabetes mellitus
presented for evaluation of a 2- to 3-cm wound on her lower extremity. The
assessment was a “laceration which may have early signs of cellulitis.” The
treatment plan included local wound care, elevation, and
trimethoprim-sulfamethoxazole 160 mg/800 mg orally twice daily for 10 days. Notable
concomitant medications included lisinopril, spironolactone, and furosemide.
Laboratory values 5 weeks before included a serum potassium level of 5.2 mEq/L
and creatinine level of 1.1 mg/dL (clearance ≈28 mL/minute).
Nine days
later, routine laboratory monitoring revealed a serum potassium level of 7.5
mEq/L and creatinine level of 1.7 mg/dL, necessitating admission to the ICU.
The elevated potassium and creatinine rapidly normalized with medical therapy
and discontinuation of trimethoprim-sulfamethoxazole, lisinopril, and
spironolactone.
Since the
emergence of community-associated methicillin-resistant Staphylococcus aureus
(MRSA), trimethoprim-sulfamethoxazole has become the most frequently prescribed
antibiotic for skin infections.1,3 Hyperkalemia is a well-known adverse effect
of trimethoprim-sulfamethoxazole, with risk factors including older age, higher
trimethoprim-sulfamethoxazole doses, renal insufficiency, and concomitant use
of medications that increase serum potassium levels such as angiotensin-converting
enzyme inhibitors, angiotensin-receptor blockers, and potassium-sparing
diuretics.4, 5 Trimethoprim-sulfamethoxazole is associated with numerous other
potential drug interactions. Among these, trimethoprim-sulfamethoxazole
potentiates the effect of warfarin, leading to an elevation in the
international normalized ratio. Trimethoprim-sulfamethoxazole also interacts
with sulfonylureas (increased hypoglycemic effect) and increases serum
concentrations of digoxin and phenytoin. Drug interactions should therefore
always be considered before trimethoprim-sulfamethoxazole is prescribed.
The
majority of patients treated with trimethoprim-sulfamethoxazole experience a
transient decrease in creatinine clearance; the resultant increase in serum
creatinine level is not usually indicative of reduced glomerular filtration.
However, acute kidney injury is a recognized complication of
trimethoprim-sulfamethoxazole. Most cases of acute kidney injury are caused by
acute interstitial nephritis and are usually reversible on discontinuation of
trimethoprim-sulfamethoxazole.6
In the case
described herein, trimethoprim-sulfamethoxazole was a suboptimal choice in
light of the patient's numerous risk factors for hyperkalemia, including
advanced age, use of lisinopril and spironolactone, renal insufficiency, and a
recent elevated potassium level. The relatively long duration (10 days) of
trimethoprim-sulfamethoxazole may have been a contributing factor. Such
prolonged treatment courses are frequently prescribed3 despite that a treatment duration as short as
5 days is supported by national guidelines.7
The use of
combination therapy with trimethoprim-sulfamethoxazole and a β-lactam in the
treatment of skin infections has become common in the era of
community-associated MRSA.3 This
presumably reflects the desire to adequately cover both MRSA and β-hemolytic
streptococci. However, a recent trial of outpatients with cellulitis
demonstrated that trimethoprim-sulfamethoxazole plus cephalexin did not improve
outcomes compared with cephalexin alone, suggesting combination therapy may not
be warranted.8
In summary,
increasing use of trimethoprim-sulfamethoxazole for skin infections has led to
an increase in adverse events. To prevent complications of
trimethoprim-sulfamethoxazole, ED providers must recognize risk factors and
potential drug interactions and use alternative agents when appropriate,
prescribe shorter courses of therapy, and avoid unnecessary combination
therapy.
17. Racial bias in pain perception and response
Racial Bias
in Pain Perception and Response: Experimental Examination of Automatic and Deliberate
Processes
Mathur VA,
et al. J Pain 2014;15:476-484.
Racial
disparities in pain treatment pose a significant public problem. Prior studies
demonstrate that clinicians and non-clinicians are less perceptive, and suggest
less treatment for pain in African-Americans. These authors investigated the
effects of explicit/implicit patient race presentation, patient race and
perceiver race on pain perception and response. African-American and
European-American participants rated pain perception, empathy, helping
motivation and treatment suggestion in response to vignettes about patients'
pain. Vignettes were accompanied by a rapid (implicit) or static (explicit)
presentation of an African- or European-American patient's face. Results
suggest that known disparities in pain treatment may be largely due to
automatic rather than deliberate biases. Biases were not associated with
traditional implicit measures of racial attitudes, suggesting that biases in
pain perception and response may be independent of general prejudice.
18. Concussion: Kids' Symptoms May Linger and Change Over Time
Children
who suffer a concussion may experience symptoms for several weeks after the
injury, and those symptoms may differ from the ones seen at presentation, new
findings suggest.
Eisenberg
MA, et al. Duration and Course of Post-Concussive Symptoms. Pediatrics. 2014
May 12. [Epub ahead of print]
OBJECTIVES:
To examine the incidence, duration, and clinical course of individual
post-concussive symptoms in patients presenting to a pediatric emergency
department (ED) with a concussion.
METHODS: We
conducted secondary analysis of a prospective cohort study of patients 11 to 22
years old presenting to the ED of a children's hospital with an acute
concussion. The main outcome measure was duration of symptoms, assessed by the
Rivermead Post-Concussion Symptoms Questionnaire (RPSQ). Patients initially
completed a questionnaire describing mechanism of injury, associated symptoms,
past medical history, and the RPSQ, then were serially administered the RPSQ
for 3 months after the concussion or until all symptoms resolved.
RESULTS:
Headache, fatigue, dizziness, and taking longer to think were the most common
symptoms encountered at presentation, whereas sleep disturbance, frustration,
forgetfulness, and fatigue were the symptoms most likely to develop during the
follow-up period that had not initially been present. Median duration of
symptoms was the longest for irritability (16 days), sleep disturbance (16
days), frustration (14 days), and poor concentration (14 days), whereas nausea,
depression, dizziness, and double-vision abated most quickly. One month after
injury, nearly a quarter of children still complained of headache, more than 20%
suffered from fatigue, and nearly 20% reported taking longer to think.
CONCLUSIONS:
Among patients presenting to a pediatric ED after a concussion, physical symptoms
such as headache predominate immediately after the injury, emotional symptoms
tend to develop later in the recovery period, and cognitive symptoms may be
present throughout.
Full-text
(free): http://pediatrics.aappublications.org/content/early/2014/05/07/peds.2014-0158.long
19. National ED crowding and hospital quality: results from the
2013 Hospital Compare data
Mullins PM,
Pines JM. Amer J Emerg Med. 2014;32:634-9.
Objectives:
We explored Hospital Compare data on emergency department (ED) crowding metrics
to assess characteristics of reporting vs nonreporting hospitals, whether
hospitals ranked as the US News Best Hospitals (2012-2013) vs unranked
hospitals differed in ED performance and relationships between ED crowding and
other reported hospital quality measures.
Methods: An
ecological study was conducted using data from Hospital Compare data sets
released March 2013 and from a popular press publication, US News Best
Hospitals 2012 to 2013. We compared hospitals on 5 ED crowding measures:
left-without-being-seen rates, waiting times, boarding times, and length of
stay for admitted and discharged patients.
Results: Of
4810 hospitals included in the Hospital Compare sample, 2990 (62.2%) reported
all ED 5 crowding measures. Median ED length of stay for admitted patients was
262 minutes (interquartile range [IQR], 215-326), median boarding was 88
minutes (IQR, 60-128), median ED length of stay for discharged patients was 139
minutes (IQR, 114-168), and median waiting time was 30 minutes (IQR, 20-44).
Hospitals ranked as US News Best Hospitals 2012 to 2013 (n = 650) reported
poorer performance on ED crowding measures than unranked hospitals (n = 4160)
across all measures. Emergency department boarding times were associated with
readmission rates for acute myocardial infarction (r = 0.14, P less than .001)
and pneumonia (r = 0.17, P less than .001) as well as central line–associated
bloodstream infections (r = 0.37, P less than .001).
Conclusions:
There is great variation in measures of ED crowding across the United States.
Emergency department crowding was related to several measures of in-patient
quality, which suggests that ED crowding should be a hospital-wide priority for
quality improvement efforts.
20. Banning the Handshake from the Health Care Setting?
Sklansky M,
et al. JAMA. Published online May 15, 2014.
The
handshake represents a deeply established social custom. In recent years,
however, there has been increasing recognition of the importance of hands as
vectors for infection, leading to formal recommendations and policies regarding
hand hygiene in hospitals and other health care facilities.1 Such programs have
been limited by variable compliance and efficacy.1,2 In an attempt to avoid
contracting or spreading infection, many individuals have made their own
efforts to avoid shaking hands in various settings but, in doing so, may face
social, political, and even financial risks.
Particularly
in the current era of health care reform, innovative, practical, and fiscally
prudent approaches toward the prevention of disease will assume increasingly
important roles. Regulations to restrict the handshake from the health care
setting, in conjunction with more robust hand hygiene programs, may help limit
the spread of disease and thus could potentially decrease the clinical and
economic burden associated with hospital-acquired infections and antimicrobial
resistance. Effective development and implementation of such a handshake ban
will likely require further study to confirm and describe the link between
handshakes and the transmission of pathogens and disease; the promotion of an
alternative, health-conscious gesture to substitute for the handshake; and
widespread media and educational programs.
CULTURAL
CONTEXT.
The
handshake has evolved over centuries into its currently profound cultural role.
Artifacts from ancient Greece suggest that the handshake began as a general
gesture of peace, revealing one’s open palm as a symbol of honesty and trust.
The custom and technique of this open-palm gesture subsequently evolved into
the modern form of the handshake, now representing an international symbol of
greeting/departure, reconciliation, respect, friendship, peace, congratulations,
good sportsmanship, or formal agreement. Beyond its interpersonal significance,
the handshake commonly assumes commercial or political importance. In the
health care setting, where patient encounters commonly begin and end with a
handshake, the handshake has been shown to have the capability of improving the
perception of the physician’s empathy and compassion. Handshakes between health
care practitioners and their patients have the potential to comfort and to calm…
21. A Guide to Reading Health Care News Stories
Schwitzer
G, et al. JAMA Intern Med. Published online May 05, 2014.
Vested
interests, marketing, politics and media hype often have more influence on how
new medical advances get used than the best scientific evidence.
From April
16, 2006, through May 30, 2013, a team of reviewers from HealthNewsReview.org,
many of whom were physicians, evaluated the reporting by US news organizations
on new medical treatments, tests, products, and procedures. After reviewing
1889 stories (approximately 43% newspaper articles, 30% wire or news services
stories, 15% online pieces [including those by broadcast and magazine
companies], and 12% network television stories), the reviewers graded most
stories unsatisfactory on 5 of 10 review criteria: costs, benefits, harms,
quality of the evidence, and comparison of the new approach with alternatives.
Drugs, medical devices, and other interventions were usually portrayed
positively; potential harms were minimized, and costs were ignored. Our
findings can help journalists improve their news stories and help physicians
and the public better understand the strengths and weaknesses of news media
coverage of medical and health topics.
22. Tamsulosin for treatment of unilateral distal
ureterolithiasis: a systematic review and meta-analysis
Malo C, et
al. CJEM 2014;16(3):229-242
Objectives:
The lifetime prevalence of ureterolithiasis is approximately 13% for men and 7%
for women in the United States. Tamsulosin, an α-antagonist, has been used as
therapy to facilitate the expulsion of lithiasis. Whether it is a good
treatment for distal lithiasis remains controversial. We conducted a systematic
review and meta-analysis to evaluate the effect of tamsulosin on the passage of
distal ureterolithiasis.
Methods: A
systematic search was conducted using MEDLINE, EMBASE, and Cochrane Central.
Trial eligibility was evaluated by two investigators. All randomized controlled
trials (RCTs) comparing tamsulosin to standard therapy or placebo for the
treatment of a single distal ureterolithiasis ≤ 10 mm in adult patients with
renal colic confirmed by radiographic imaging were included. Data extraction was
conducted in duplicate. Primary outcome was the expulsion rate, and secondary
outcomes were the mean time for ureterolithiasis expulsion, analgesic
requirements, and side effects. Mantel-Haenszel random effect models were used,
and heterogeneity was assessed using I2 statistics. Data were presented with
relative risks (RRs).
Results: The
search strategy identified 685 articles, of which 22 studies were included.
Combined results suggested a benefit for the expulsion of ureterolithiasis (≤
10 mm) when tamsulosin was used compared to a standard treatment (RR 1.50 [95%
CI 1.31–1.71], I2 = 70%). A decrease in the average time of expulsion of the
ureterolithiasis of 3.33 days in favour of tamsulosin was observed (95% CI
−4.23, −2.44], I2 = 67%).
Conclusion:
Tamsulosin increases the rate of spontaneous passage of distal ureterolithiasis
(≤ 10 mm).
23. Tid Bits
A. Does Initial Hydromorphone
Relieve Pain Best if Dosing Is Fixed or Weight Based?
Conclusion:
Pain response to a fixed 1 mg intravenous dose of hydromorphone did not vary by
total body weight in this sample of adults aged 18 to 65 years, suggesting no
advantage to weight-based over fixed opioid dosing.
B. The FLUSH Study—Flush the Line
and Ultrasound the Heart: Ultrasonographic Confirmation of Central Femoral
Venous Line Placement
Conclusion:
The FLUSH test is simple and reliable, and appears to accurately confirm
femoral venous line placement.
Corroborating
study: Weekes AJ, et al. CVC Placement Evaluation Using Saline Flush and
Bedside Echo Acad Emerg Med. 2014;21:65-72. http://www.ncbi.nlm.nih.gov/pubmed/24552526
C. What is REBOA: resuscitative
endovascular balloon occlusion of the aorta?
Crit Care Podcast: http://emcrit.org/podcasts/reboa/
Crit Care Podcast: http://emcrit.org/podcasts/reboa/
D. Most Prescribed, Top Selling
Drugs in U.S.
E. A Cross-sectional Study of
Emergency Department Boarding Practices in the United States
F. Improving Adherence to PALS
Septic Shock Guidelines
G. Medication-Assisted Therapies —
Tackling the Opioid-Overdose Epidemic
H. Safety Net Hospitals Already
Benefit from ACA
Kaiser
Health News: http://www.kaiserhealthnews.org/stories/2014/may/27/safety-net-hospitals-seeing-more-patients-and-money.aspx
I. Nearly 30% of world's population
is obese or overweight
J. Depression
following concussion
In a
national sample of adolescents, a history of concussion was associated with a
threefold increase in risk for a depression diagnosis. Clinicians should screen
concussed youths for depression so that they may effectively treat these individuals.
K. Compression-only cardiopulmonary
resuscitation vs standard cardiopulmonary resuscitation: an updated
meta-analysis of observational studies
L. A Review of Methylene Blue Treatment
for Cardiovascular Collapse
Lo JCY, et
al. J Emerg Med. 2014;46:670-679.
Background:
Historically, methylene blue (MB) has been used for multiple purposes,
including as an antidote for toxin-induced and hereditary methemoglobinemia,
ifosfamide-induced encephalopathy, and ackee fruit and cyanide poisoning; as an
aniline dye derivative, antimalarial agent, and antidepressant.
Discussion:
Most recently, the use of MB has been advocated as a potential adjunct in the
treatment of shock states. Our article reviews the role of MB in septic shock,
anaphylactic shock, and toxin-induced shock. MB is proposed to increase blood
pressure in these shock states by interfering with guanylate cyclase activity,
and preventing cyclic guanosine monophosphate production and vasodilatation.
Summary: MB
may be an adjunct in the treatment of septic shock, anaphylactic shock, and
toxin-induced shock.
