Saturday, May 31, 2014

Lit Bits: May 31, 2014

From the recent medical literature...

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.

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.

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, PubMed, and 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.

BMJ link for references (subscription required):

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.

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

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.

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.

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.


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, 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.

C. What is REBOA: resuscitative endovascular balloon occlusion of the aorta?

Crit Care Podcast:

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

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.