1. Pig-tail caths better than chest tubes for evacuation of
traumatic PTX
Kulvatunyou
N, et al. RCT of pigtail catheter versus chest tube in injured patients with
uncomplicated traumatic PTX. Br J Surg. 2014 Jan;101(2):17-22.
BACKGROUND:
Small pigtail catheters appear to work as well as the traditional large-bore
chest tubes in patients with traumatic pneumothorax, but it is not known
whether the smaller pigtail catheters are associated with less tube-site pain.
This study was conducted to compare tube-site pain following pigtail catheter
or chest tube insertion in patients with uncomplicated traumatic pneumothorax.
METHODS:
This prospective randomized trial compared 14-Fr pigtail catheters and 28-Fr
chest tubes in patients with traumatic pneumothorax presenting to a level I
trauma centre from July 2010 to February 2012. Patients who required emergency
tube placement, those who refused and those who could not respond to pain
assessment were excluded. Primary outcomes were tube-site pain, as assessed by
a numerical rating scale, and total pain medication use. Secondary outcomes
included the success rate of pneumothorax resolution and insertion-related
complications.
RESULTS:
Forty patients were enrolled. Baseline characteristics of 20 patients in the
pigtail catheter group were similar to those of 20 patients in the chest tube
group. No patient had a flail chest or haemothorax. Pain scores related to
chest wall trauma were similar in the two groups. Patients with a pigtail
catheter had significantly lower mean(s.d.) tube-site pain scores than those
with a chest tube, at baseline after tube insertion (3.2(0.6) versus 7.7(0.6);
P less than 0.001), on day 1 (1.9(0.5) versus 6.2(0.7); P less than 0.001) and
day 2 (2.1(1.1) versus 5.5(1.0); P = 0.040). The decreased use of pain
medication associated with pigtail catheter was not significantly different.
The duration of tube insertion, success rate and insertion-related
complications were all similar in the two groups.
CONCLUSION:
For patients with a simple, uncomplicated traumatic pneumothorax, use of a
14-Fr pigtail catheter is associated with reduced pain at the site of
insertion, with no other clinically important differences noted compared with
chest tubes.
See also Kulvatunyou
N, et al. Two-year experience of using pigtail catheters to treat traumatic
pneumothorax: a changing trend. J Trauma. 2011;71(5):1104-7. http://www.ncbi.nlm.nih.gov/pubmed/22071915
2. They're Only as Old as They Feel: Frailty Predicts Outcome
Better Than Age in Trauma
Ali S.
Raja, MD, MBA, MPH, FACEP. Journal Watch Emerg Med 2014 June 11
Older
trauma patients who were frail were more likely to have in-hospital
complications and adverse discharge dispositions than those who were not frail.
Although
advancing age is associated with worse outcomes in trauma patients, some
studies indicate that patient health status also greatly influences outcome. To
determine whether frailty is associated with in-hospital complications and
adverse discharge dispositions (mortality or discharge to a skilled nursing
facility) in trauma patients aged 65 years or older, researchers used the
50-item Canadian Frailty Index, which assesses demographics, social activity,
activities of daily living, nutrition, and mood.
Of 250
patients (mean age, 78), 110 (44%) were frail. Frail patients were more likely
to have in-hospital complications (37% vs. 21%; most commonly urinary tract
infections) and adverse discharge dispositions (37% vs. 13%). Five patients
died, all of whom were frail. While other factors (including older age, male
sex, higher systolic blood pressure, lower Glasgow Coma Scale score, and higher
Injury Severity Score) were also associated with worse outcomes, only frailty
was significantly predictive in multivariate analysis.
Comment:
These results make sense, and the authors are to be commended for bringing
frailty into the spotlight. However, we cannot use a 50-item scale during the
acute management of trauma patients. Instead, these findings should remind us
to consider frailty rather than age alone when determining best treatment plans
for patients with trauma and to discuss the potential implications of frailty
with our less-active older patients and their families.
Citation: Joseph
B et al. Superiority of frailty over age in predicting outcomes among geriatric
trauma patients: A prospective analysis. JAMA Surg 2014 Jun 11 [E-pub ahead of
print].
3. Assessment of the Acute Psychiatric Patient in the ED: Legal
Cases and Caveats
Good B, et
al. West J Emerg Med. 2014;15(3):312–317.
When Dr B
Good (love that name) writes a med-legal review, I think we should pay
attention. J Below are the opening teasers to
three cases. The full-text link follows.
INTRODUCTION
Assessment
of the acute psychiatric emergency is challenging and fraught with error. This
paper, using legal cases, will discuss the assessment of new onset psychiatric illness,
exacerbation of chronic psychiatric disease, and the suicidal patient. We will
share diagnostic caveats, medical clearance, and suicide assessment tools.
METHODS
The
authors, who have significant medical legal experience, selectively chose
illustrative legal cases to discuss caveats of assessment of acute psychiatric
emergencies. We selected representative cases after reviewing legal journals
and publications. Cases involving restraint and sedation were excluded as they
were covered in a prior manuscript.
Assessing New Onset Psychiatric
Disorders
Psychosis
is a relatively common syndrome affecting 3% to 5% of the population at some
point in life.1,2 Encountering undiagnosed psychiatric conditions, such as
psychosis or bipolar disorder, is commonplace for the emergency physician (EP).
The following case illustrates the challenge and importance of the assessment
of new onset psychiatric disorders.
In Brown v
Carolina Emergency Physician (2001), Mr. Brown noted a gradual change in his
wife’s behavior as she became more lethargic and depressed. He presented to Greenville
Memorial Hospital’s emergency department (ED) on a Friday to obtain a
physician’s note that would excuse him from his 2-week National Guard annual
training session. Dr. Benjamin Crumpler examined Mrs. Brown and diagnosed her with
acute delusional psychosis….
Assessment of Suicide Risk
In Estate
of Elizabeth Kitchen v. Michael Dargay, D.O., et al (2005), a 45-year-old woman
was transported by ambulance after attempting to overdose on alprazolam and
hydrocodone/ acetaminophen. She claimed that the acute trigger for this event was
a breakup with a boyfriend. In the ED the patient allegedly endorsed wanting to
end her life to a nurse but then denied the same to both Dr. Dargay and the
social worker that Dr. Dargay consulted. The patient was discharged. The next
morning the patient threatened suicide to her adult daughter, who took no action.
Later in the day, the patient was found by her minor son after she had hung herself.
The plaintiff brought suit and claimed that the patient should have been
admitted involuntarily. The defendant argued that the patient had denied any
suicidal thoughts both to him and the social worker, and therefore discharge
was reasonable. The defendant also argued
that
suicide may have been prevented if emergency services had been called by the
family on the day of the patient’s death after she had threatened suicide. The
jury rendered a verdict for the defense….
When Assessment and/or Disposition
Are Not Completed
In Jinkins
v Evangelical Hospitals Corp., (2002) an adult male, George Jinkins, was
evaluated at Christ Hospital after being discovered lying face down in a muddy
puddle with his clothes partially removed and blood staining his underwear. While
being evaluated in the ED, Mr. Jinkin’s family reported that he had been
intentionally walking in front of cars and talking about death, in addition to
describing several examples of paranoid behavior. Notable in his evaluation
were a blood alcohol level (BAL) of 0.203% and a positive urine screen for marijuana.
The EP and social worker completed initial paperwork for involuntary
psychiatric hospitalization. The patient was boarded in the ED while his BAL
decreased and the patient was subsequently transferred to an outside
psychiatric facility. A board-certified psychiatrist and a licensed professional
counselor each interviewed the patient and his family. Mr. Jinkins and his
family recanted their suicidal histories, and Mr. Jinkins was discharged with
outpatient follow up for an alcohol-related disorder. Once he got home that
evening, Mr. Jinkins shot himself in the head and died. Mr. Jinkins’s widow
sued the EP and the Christ Hospital ED claiming that their care was negligent
in so far that the transfer to the psychiatric hospital was the proximate cause
of Mr. Jinkins’s death. The court found that the interview and the ensuing
release of Mr. Jinkins was an intervening event and subsequently absolved the
defendants of liability…
DISCUSSION
We have
reported several legal cases that illustrate pitfalls and general trends in
assessing the acute psychiatric patient in the ED. It is clear in the
literature that assessment of this population is difficult and fraught with
error. EPs should have a low threshold for obtaining psychiatric specialty
consultation, especially in new-onset disease.
The ED is
universally used to provide medical clearance for psychiatric patients. The
physician should have a systematic approach and a broad differential diagnosis
when a behavioral emergency presents. Agitated behavior often occurs in association
with head trauma, hypoxia, hypoglycemia, electrolyte imbalance, infections
(particularly herpes encephalitis), drug intoxication or withdrawal or adverse reaction,
and metabolic and endocrine derangements. The absence of these should be
insured before psychiatric disposition occurs.
In
assessing the risk of suicide, the courts have been lenient and sympathetic in
recognizing the difficulty of predicting future suicide. It is imperative to
gather as much history from the patient, family, authorities, and records, as
well as optimally interview the patient. EPs should have comfort in realizing
that after a good evaluation, they will not likely be held liable for a successful
suicidal outcome.
Likewise,
EPs often fear that a patient escape, or discharge from a subsequent facility,
will expose them to liability. In the majority of cases, the hospital via the
nursing staff is responsible for monitoring and prevention of escape, as well
as successful transport to another facility if transfer occurs…
4. Antiemetic Use for Nausea and Vomiting in Adult ED Patients: RCT
Comparing Ondansetron, Metoclopramide, and Placebo
Spoiler: They all tied!
Egerton-Warburton
D, et al. Ann Emerg Med 2014 May 09
[Epub ahead of print]
Study
objective: We compare efficacy of ondansetron and metoclopramide with placebo
for adults with undifferentiated emergency department (ED) nausea and vomiting.
Methods: A
prospective, randomized, double-blind, placebo-controlled trial was conducted
in 2 metropolitan EDs in Melbourne, Australia. Eligible patients with ED nausea
and vomiting were randomized to receive 4 mg intravenous ondansetron, 20 mg
intravenous metoclopramide, or saline solution placebo. Primary outcome was
mean change in visual analog scale (VAS) rating of nausea severity from
enrollment to 30 minutes after study drug administration. Secondary outcomes
included patient satisfaction, need for rescue antiemetic treatment, and
adverse events.
Results: Of
270 recruited patients, 258 (95.6%) were available for analysis. Of these
patients, 87 (33.7%) received ondansetron; 88 (34.1%), metoclopramide; and 83
(32.2%), placebo. Baseline characteristics between treatment groups and
recruitment site were similar. Mean decrease in VAS score was 27 mm (95% confidence
interval [CI] 22 to 33 mm) for ondansetron, 28 mm (95% CI 22 to 34 mm) for
metoclopramide, and 23 mm (95% CI 16 to 30 mm) for placebo. Satisfaction with
treatment was reported by 54.1% (95% CI 43.5% to 64.5%), 61.6% (95% CI 51.0% to
71.4%), and 59.5% (95% CI 48.4% to 69.9%) for ondansetron, metoclopramide, and
placebo, respectively; rescue medication was required by 34.5% (95% CI 25.0% to
45.1%), 17.9% (95% CI 10.8% to 27.2%), and 36.3% (95% CI 26.3% to 47.2%),
respectively. Nine minor adverse events were reported.
Conclusion:
Reductions in nausea severity for this adult ED nausea and vomiting population
were similar for 4 mg intravenous ondansetron, 20 mg intravenous
metoclopramide, and placebo. There was a trend toward greater reductions in VAS
ratings and a lesser requirement for rescue medication in the antiemetic drug
groups, but differences from the placebo group did not reach significance. The
majority of patients in all groups were satisfied with treatment.
5. Risk Factors for
Serious Underlying Pathology in ED Nontraumatic LBP Patients
Thiruganasambandamoorthy
V, Stiell I, et al. J Emerg Med. 2014;47:1-11.
Background:
Nontraumatic low back pain (LBP) is a common emergency department (ED)
complaint and can be caused by serious pathologies that require immediate
intervention or that lead to death.
Objective: The
primary goal of this study is to identify risk factors associated with serious
pathology in adult nontraumatic ED LBP patients.
Methods: We
conducted a health records review and included patients aged ≥ 16 years with
nontraumatic LBP presenting to an academic ED from November 2009 to January
2010. We excluded those with previously confirmed nephrolithiasis and typical
renal colic presentation. We collected 56 predictor variables and outcomes
within 30 days. Outcomes were determined by tracking computerized patient
records and performance of univariate analysis and recursive partitioning.
Results: There
were 329 patients included, with a mean age of 49.3 years; 50.8% were women. A
total of 22 (6.7%) patients suffered outcomes, including one death, five compression
fractures, four malignancies, four disc prolapses requiring surgery, two
retroperitoneal bleeds, two osteomyelitis, and one each of epidural abscess,
cauda equina, and leaking abdominal aortic aneurysm graft. Risk factors
identified for outcomes were: anticoagulant use (odds ratio [OR] 15.6; 95%
confidence interval [CI] 4.2–58.5), decreased sensation on physical examination
(OR 6.9; CI 2.2–21.2), pain that is worse at night (OR 4.3; CI 0.9–20.1), and
pain that persists despite appropriate treatment (OR 2.2; CI 0.8–5.6). These
four predictors identified serious pathology with 91% sensitivity (95% CI
70–98%) and 55% specificity (95% CI 54–56%).
Conclusion:
We successfully identified risk factors associated with serious pathology among
ED LBP patients. Future prospective studies are required to derive a robust
clinical decision rule.
6. Thrombolysis for PE and risk of all-cause mortality, major
bleeding, and intracranial hemorrhage: a meta-analysis.
Chatterjee
S, et al. JAMA. 2014;311(23):2414-21.
IMPORTANCE:
Thrombolytic therapy may be beneficial in the treatment of some patients with
pulmonary embolism. To date, no analysis has had adequate statistical power to
determine whether thrombolytic therapy is associated with improved survival,
compared with conventional anticoagulation.
OBJECTIVE: To
determine mortality benefits and bleeding risks associated with thrombolytic
therapy compared with anticoagulation in acute pulmonary embolism, including
the subset of hemodynamically stable patients with right ventricular
dysfunction (intermediate-risk pulmonary embolism).
DATA
SOURCES: PubMed, the Cochrane Library, EMBASE, EBSCO, Web of Science, and
CINAHL databases from inception through April 10, 2014.
STUDY
SELECTION: Eligible studies were randomized clinical trials comparing
thrombolytic therapy vs anticoagulant therapy in pulmonary embolism patients.
Sixteen trials comprising 2115 individuals were identified. Eight trials
comprising 1775 patients specified inclusion of patients with intermediate-risk
pulmonary embolism.
DATA
EXTRACTION AND SYNTHESIS: Two reviewers independently extracted trial-level
data including number of patients, patient characteristics, duration of
follow-up, and outcomes.
MAIN
OUTCOMES AND MEASURES: The primary outcomes were all-cause mortality and major
bleeding. Secondary outcomes were risk of recurrent embolism and intracranial
hemorrhage (ICH). Peto odds ratio (OR) estimates and associated 95% CIs were
calculated using a fixed-effects model.
RESULTS: Use
of thrombolytics was associated with lower all-cause mortality (OR, 0.53; 95%
CI, 0.32-0.88; 2.17% [23/1061] vs 3.89% [41/1054] with anticoagulants; number
needed to treat [NNT] = 59) and greater risks of major bleeding (OR, 2.73; 95%
CI, 1.91-3.91; 9.24% [98/1061] vs 3.42% [36/1054]; number needed to harm
[NNH] = 18) and ICH (OR, 4.63; 95% CI, 1.78-12.04; 1.46% [15/1024] vs 0.19%
[2/1019]; NNH = 78). Major bleeding was not significantly increased in patients
65 years and younger (OR, 1.25; 95% CI, 0.50-3.14). Thrombolysis was associated
with a lower risk of recurrent pulmonary embolism (OR, 0.40; 95% CI, 0.22-0.74;
1.17% [12/1024] vs 3.04% [31/1019]; NNT = 54). In intermediate-risk pulmonary
embolism trials, thrombolysis was associated with lower mortality (OR, 0.48;
95% CI, 0.25-0.92) and more major bleeding events (OR, 3.19; 95% CI,
2.07-4.92).
CONCLUSIONS
AND RELEVANCE: Among patients with pulmonary embolism, including those who were
hemodynamically stable with right ventricular dysfunction, thrombolytic therapy
was associated with lower rates of all-cause mortality and increased risks of
major bleeding and ICH. However, findings may not apply to patients with
pulmonary embolism who are hemodynamically stable without right ventricular
dysfunction.
7. Prednisone of No Benefit for ED LBP: A RCT
Eskin B, et
al. J Emerg Med 2014;47:65-70.
Background:
Although oral corticosteroids are commonly given to emergency department (ED)
patients with musculoskeletal low back pain (LBP), there is little evidence of
benefit.
Objective: To
determine if a short course of oral corticosteroids benefits LBP ED patients.
Methods: Design:
Randomized, double-blind, placebo-controlled trial. Setting: Suburban New
Jersey ED with 80,000 annual visits. Participants: 18–55-year-olds with
moderately severe musculoskeletal LBP from a bending or twisting injury ≤ 2
days prior to presentation. Exclusion criteria were suspected
nonmusculoskeletal etiology, direct trauma, motor deficits, and local
occupational medicine program visits. Protocol: At ED discharge, patients were
randomized to either 50 mg prednisone daily for 5 days or identical-appearing
placebo. Patients were contacted after 5 days to assess pain on a 0–3 scale
(none, mild, moderate, severe) as well as functional status.
Results: The
prednisone and placebo groups had similar demographics and initial and
discharge ED pain scales. Of the 79 patients enrolled, 12 (15%) were lost to
follow-up, leaving 32 and 35 patients in the prednisone and placebo arms,
respectively. At follow-up, the two arms had similar pain on the 0–3 scale
(absolute difference 0.2, 95% confidence interval [CI] −0.2, 0.6) and no
statistically significant differences in resuming normal activities, returning
to work, or days lost from work. More patients in the prednisone than in the
placebo group sought additional medical treatment (40% vs. 18%, respectively,
difference 22%, 95% CI 0, 43%).
Conclusion:
We detected no benefit from oral corticosteroids in our ED patients with
musculoskeletal LBP.
8. External validation of the Blunt Abdominal Trauma in Children
(BATiC) score: ruling out significant abdominal injury in children.
de Jong WJ,
et al. J Trauma Acute Care Surg. 2014 May;76(5):1282-7.
BACKGROUND:
The aim of this study was to validate the use of the Blunt Abdominal Trauma in
Children (BATiC) score. The BATiC score uses only readily available laboratory
parameters, ultrasound results, and results from physical examination and does
therefore not carry any risk of additional radiation exposure.
METHODS:
Data of pediatric trauma patients admitted to the shock room between 2006 and
2010 were retrospectively analyzed. Blunt abdominal trauma was defined
radiologically or surgically. The BATiC score was computed using 10 parameters
as follows: abnormal abdominal ultrasound finding, abdominal pain, peritoneal
irritation, hemodynamic instability, aspartate aminotransferase greater than 60
U/L, alanine aminotransferase greater than 25 U/L, white blood cell count
greater than 10 × 10/L, lactate dehydrogenase greater than 330 U/L, amylase
greater than 100 U/L, and creatinine greater than 110 μmol/L. Sensitivity,
specificity, negative predictive value, and positive predictive value were
computed. Missing values were replaced using multiple imputation, and BATiC
scores were calculated based on imputed values.
RESULTS:
Included were 216 patients, with 144 males, 72 females, and a median age of 12
years. Eighteen patients (8%) sustained abdominal injury. Median BATiC scores
of patients with and without intra-abdominal injury were 9.2 (range, 6.6-15.4)
and 2.2 (range, 0.0-10.6) respectively (p less than 0.001). When the BATiC
score is used with a cutoff point of 6, the test showed a sensitivity of 100%
and a specificity of 87%. Negative and positive predictive values were 100% and
41% respectively. The area under the curve was 0.98.
CONCLUSION:
The BATiC score can be a useful adjunct in the assessment of the presence of
abdominal trauma in children and can help determine which patients might
benefit from a computed tomographic scan and/or further treatment and which
might not.
The
derivation article is Karam O, et al. J Pediatr 2009;154:912-7. Full-text
(free): http://www.researchgate.net/publication/24028757_Blunt_abdominal_trauma_in_children_a_score_to_predict_the_absence_of_organ_injury/file/d912f50aa0acb22f2e.pdf
9. IV Lidocaine Fails for the ED Treatment of Acute Radicular
Low Back Pain, a RCT
Tanen DA,
et al. J Emerg Med 204;47:119-124.
Background:
Acute radicular back pain is a frequent complaint of patients presenting to the
Emergency Department.
Study
Objective: Determine the efficacy of intravenous lidocaine when compared to
ketorolac for the treatment of acute radicular low back pain.
Methods: Randomized
double-blind study of 41 patients aged 18–55 years presenting with acute
radicular low back pain. Patients were randomized to receive either 100 mg
lidocaine or 30 mg ketorolac intravenously over 2 min. A 100-mm visual analog
scale (VAS) was used to assess pain at Time 0 (baseline), and 20, 40, and 60
minutes. Changes in [median] VAS scores were compared over time (within groups)
by the signed-rank test and between groups by the rank-sum test. A 5-point Pain
Relief Scale (PRS) was administered at the conclusion of the study (60 min) and
again at 1 week by telephone follow-up; [median] scores were compared between
groups by rank-sum.
Results: Forty-four
patients were recruited; 41 completed the study (21 lidocaine, 20 ketorolac).
Initial VAS scores were not significantly different between the lidocaine and
ketorolac groups (83; 95% confidence interval [CI] 74–98 vs. 79; 95% CI 64–94;
p = 0.278). Median VAS scores from baseline to 60 min significantly declined in
both groups (lidocaine [8; 95% CI 0–23; p = 0.003]; ketorolac [14; 95% CI 0–28;
p = 0.007]), with no significant difference in the degree of reduction between
groups (p = 0.835). Rescue medication was required by 67% receiving lidocaine,
compared to 50% receiving ketorolac. No significant change in PRS between
groups was found at the conclusion or at the follow-up.
Conclusion:
Intravenous lidocaine failed to clinically alleviate the pain associated with
acute radicular low back pain.
10. Lack of Association between Press Ganey ED Patient
Satisfaction Scores and Emergency Department Administration of Analgesic
Medications
Schwartz
TM, et al. Ann Emerg Med 2014 march 26 [Epub ahead of print]
Study objective:
We explore the relationship between Press Ganey emergency department (ED)
patient satisfaction scores and ED administration of analgesic medications,
including amount of opioid analgesics received, among patients who completed a
patient satisfaction survey.
Methods: We
conducted a secondary data analysis of Press Ganey ED patient satisfaction
surveys from patients discharged from 2 academic, urban EDs October 2009 to
September 2011. We matched survey responses to data on opioid and nonopioid analgesics
administered in the ED, demographic characteristics, and temporal factors from
the ED electronic medical records. We used polytomous logistic regression to
compare quartiles of overall Press Ganey ED patient satisfaction scores to
administration of analgesic medications, opioid analgesics, and number of
morphine equivalents received. We adjusted models for demographic and hospital
characteristics and temporal factors.
Results: Of
the 4,749 patients who returned surveys, 48.5% received analgesic medications,
and 29.6% received opioid analgesics during their ED visit. Mean overall Press
Ganey ED patient satisfaction scores for patients receiving either analgesic
medications or opioid analgesics were lower than for those who did not receive
these medications. In the univariable polytomous logistic regression analysis,
receipt of analgesic medications, opioid analgesics, and a greater number of
morphine equivalents were associated with lower overall scores. However, in the
multivariable analysis, receipt of analgesic medications or opioid analgesics
was not associated with overall scores, and receipt of greater morphine
equivalents was inconsistently associated with lower overall scores.
Conclusion:
Overall Press Ganey ED patient satisfaction scores were not primarily based on
in-ED receipt of analgesic medications or opioid analgesics; other factors
appear to be more important.
11. Association of Azithromycin with Mortality and
Cardiovascular Events among Older Patients Hospitalized With Pneumonia
Mortensen
EM, et al. JAMA. 2014;311(21):2199-2208.
Importance Although clinical practice guidelines
recommend combination therapy with macrolides, including azithromycin, as
first-line therapy for patients hospitalized with pneumonia, recent research
suggests that azithromycin may be associated with increased cardiovascular
events.
Objective To examine the association of azithromycin
use with all-cause mortality and cardiovascular events for patients
hospitalized with pneumonia.
Design Retrospective cohort study comparing older
patients hospitalized with pneumonia from fiscal years 2002 through 2012
prescribed azithromycin therapy and patients receiving other
guideline-concordant antibiotic therapy.
Setting This study was conducted using national Department
of Veterans Affairs administrative data of patients hospitalized at any
Veterans Administration acute care hospital.
Participants Patients were included if they were aged 65
years or older, were hospitalized with pneumonia, and received antibiotic therapy
concordant with national clinical practice guidelines.
Main
Outcomes and Measures Outcomes included
30- and 90-day all-cause mortality and 90-day cardiac arrhythmias, heart
failure, myocardial infarction, and any cardiac event. Propensity score
matching was used to control for the possible effects of known confounders with
conditional logistic regression.
Results Of 73 690 patients from 118 hospitals
identified, propensity-matched groups were composed of 31 863 patients exposed
to azithromycin and 31 863 matched patients who were not exposed. There were no
significant differences in potential confounders between groups after matching.
Ninety-day mortality was significantly lower in those who received azithromycin
(exposed, 17.4%, vs unexposed, 22.3%; odds ratio [OR], 0.73; 95% CI,
0.70-0.76). However, we found significantly increased odds of myocardial
infarction (5.1% vs 4.4%; OR, 1.17; 95% CI, 1.08-1.25) but not any cardiac
event (43.0% vs 42.7%; OR, 1.01; 95% CI, 0.98-1.05), cardiac arrhythmias (25.8%
vs 26.0%; OR, 0.99; 95% CI, 0.95-1.02), or heart failure (26.3% vs 26.2%; OR,
1.01; 95% CI, 0.97-1.04).
Conclusions
and Relevance Among older patients
hospitalized with pneumonia, treatment that included azithromycin compared with
other antibiotics was associated with a lower risk of 90-day mortality and a
smaller increased risk of myocardial infarction. These findings are consistent
with a net benefit associated with azithromycin use.
12. Images in Clinical Practice
Roth Spots
in Infective Endocarditis
Morgagnian
Cataract
A Blinking
Knee (ya gotta see the video)
Gastric
Emphysema
13. Inpt Resuscitation That's (Un)Shockable: Time to Get the
Adrenaline Flowing?
Inpatients
who experience nonshockable cardiac arrest are more likely to survive when
epinephrine is administered early.
Donnino MW,
et al. Time to administration of epinephrine and outcome after in-hospital
cardiac arrest with non-shockable rhythms: retrospective analysis of large
in-hospital data registry. BMJ. 2014 May 20;348:g3028.
OBJECTIVE:
To determine if earlier administration of epinephrine (adrenaline) in patients
with non-shockable cardiac arrest rhythms is associated with increased return
of spontaneous circulation, survival, and neurologically intact survival.
DESIGN:
Post hoc analysis of prospectively collected data in a large multicenter
registry of in-hospital cardiac arrests (Get With The
Guidelines-Resuscitation).
SETTING: We
utilized the Get With The Guidelines-Resuscitation database (formerly National
Registry of Cardiopulmonary Resuscitation, NRCPR). The database is sponsored by
the American Heart Association (AHA) and contains prospective data from 570
American hospitals collected from 1 January 2000 to 19 November 2009.
PARTICIPANTS:
119 978 adults from 570 hospitals who had a cardiac arrest in hospital with
asystole (55%) or pulseless electrical activity (45%) as the initial rhythm. Of
these, 83 490 arrests were excluded because they took place in the emergency
department, intensive care unit, or surgical or other specialty unit, 10 775
patients were excluded because of missing or incomplete data, 524 patients were
excluded because they had a repeat cardiac arrest, and 85 patients were
excluded as they received vasopressin before the first dose of epinephrine. The
main study population therefore comprised 25 095 patients. The mean age was 72,
and 57% were men.
MAIN
OUTCOME MEASURES: The primary outcome was survival to hospital discharge.
Secondary outcomes included sustained return of spontaneous circulation, 24
hour survival, and survival with favorable neurologic status at hospital
discharge.
RESULTS:
25 095 adults had in-hospital cardiac arrest with non-shockable rhythms. Median
time to administration of the first dose of epinephrine was 3 minutes
(interquartile range 1-5 minutes). There was a stepwise decrease in survival
with increasing interval of time to epinephrine (analyzed by three minute
intervals): adjusted odds ratio 1.0 for 1-3 minutes (reference group); 0.91
(95% confidence interval 0.82 to 1.00; P=0.055) for 4-6 minutes; 0.74 (0.63 to
0.88; P less than 0.001) for 7-9 minutes; and 0.63 (0.52 to 0.76; P less than 0.001)
for more than 9 minutes. A similar stepwise effect was observed across all
outcome variables.
CONCLUSIONS:
In patients with non-shockable cardiac arrest in hospital, earlier
administration of epinephrine is associated with a higher probability of return
of spontaneous circulation, survival in hospital, and neurologically intact
survival.
14. Association of ED and Hospital Characteristics with
Elopements and Length of Stay
Handel DA,
et al. J Emerg Med 2014;46:839-846.
Background:
As the Centers for Medicare & Medicaid Services (CMS) core measures in 2013
compare Emergency Department (ED) treatment time intervals, it is important to
identify ED and hospital characteristics associated with these metrics to
facilitate accurate comparisons.
Study
Objectives: The objective of this study is to assess differences in operational
metrics by ED and hospital characteristics. ED-level characteristics included
annual ED volume, percentage of patients admitted, percentage of patients
presenting by ambulance, and percentage of pediatric patients. Hospital-level
characteristics included teaching hospital status, trauma center status,
hospital ownership (nonprofit or for-profit), inpatient bed capacity, critical
access status, inpatient bed occupancy, and rural vs. urban location area.
Methods: Data
from the ED Benchmarking Alliance from 2004 to 2009 were merged with the
American Hospital Association's Annual Survey Database to include hospital characteristics
that may impact ED throughput. Overall median length of stay (LOS) and left
before treatment is complete (LBTC) were the primary outcome variables, and a
linear mixed model was used to assess the association between outcome variables
and ED and hospital characteristics, while accounting for correlations among
multiple observations within each hospital. All data were at the hospital level
on a yearly basis.
Results: There
were 445 EDs included in the analysis, from 2004 to 2009, with 850 observations
over 6 years. Higher-volume EDs were associated with higher rates of LBTC and
LOS. For-profit hospitals had lower LBTC and LOS. Higher inpatient bed
occupancies were associated with a higher LOS. Increasing admission percentages
were positively associated with overall LOS for EDs, but not with rates of
LBTC.
Conclusions:
Higher-volume EDs are associated with higher LBTC and LOS, and for-profit
hospitals appear more favorably in these metrics compared with their nonprofit
counterparts. It is important to appreciate that hospitals have different
baselines for performance that may be more tied to volume and capacity, and
less to quality of care.
15. The Pitfalls of Giving Free Advice to Family and Friends
Shelly
Reese. Medscape. April 10, 2014
Everyone
Wants Free Advice
There are
some situations for which medical school simply doesn't prepare you. Consider
Thanksgiving dinner, when Aunt Myrtle buttonholes you about a recurring rash
that's been bothering her. Or the sideline consult that one of the parents at
your kid's football game wants to have, right after her son lands awkwardly
trying to catch a pass.
When you're
a physician, informal requests for information are simply part of the
conversational landscape. Sometimes those requests are a quick and easy way to
help someone out with a bit of information, a simple clarification, or a
reassuring affirmation. Other times they can escalate and become annoyances: A
simple question can result in a follow-up phone call and more requests. And, in
a worst-case scenario, they can present ethical landmines that may tempt
physicians to cross professional boundaries.
How do you
address or deflect such requests? Unfortunately, there are no easy answers. It
depends a lot on you, your boundaries, and the situation.
The
American Medical Association (AMA) Code of Medical Ethics is clear, however:
"Physicians generally should not treat themselves or members of their
immediate families."[1] The statement goes on to provide an extensive list
of good reasons why, including personal feelings that may unduly influence
medical judgment, difficulty discussing sensitive topics during a medical
history, and concerns over patient autonomy.
Black-and-white
though that guidance may be, queries from family and friends are often far more
opaque. Friends and loved ones don't just seek treatment; often they ask for
informal second opinions, help navigating the medical system, help with
referrals, interpretation of medical language, or simply factual information,
among other things. What's more, while the AMA may discourage doctors from
treating their family members, it really doesn't help you deal with Aunt Myrtle
as she doggedly pursues your opinion over pumpkin pie…
16. A Randomized Trial of US versus CT for Imaging Patients with
Suspected Nephrolithiasis
Stoller M,
et al. Abstract: PD4-03. American Urological Association 2014
Funding: Agency
for Healthcare Research and Quality
Introductions
and Objectives: Patients presenting to the emergency department (ED) with
suspected acute renal colic frequently undergo imaging to confirm their
diagnosis. Computed tomography (CT) imaging has increasingly been used to
exclude other diagnoses and confirm urinary stone disease but is frequently
associated with duplicate imaging and increased patient radiation exposure. To
address the utility of CT imaging compared to ultrasonography (US) imaging in the
ED setting in patients suspected of acute renal colic a prospective randomized
study was undertaken.
Methods: 15
centers participated in a randomized comparative effectiveness trial. Patients
aged 18 - 75 years (n=2759 with complete data) presenting to ED’s with
suspected nephrolithiasis were randomly assigned to receive imaging with US
performed by the emergency physician (point-of-care US), US performed by a
radiologist (radiology US), or abdominal CT as their initial diagnostic test.
Subsequent medical management including receipt of additional imaging, was
performed at the discretion of the patients’ physicians. The incidence of
serious adverse events (SAE) diagnosed within 30 days, cumulative radiation
exposure and imaging costs during the subsequent 6 months were compared.
Secondary outcomes, including pain on a 10-point visual analogue scale and
return ED visits and hospitalizations were also measured.
Results: SAE
occurred in 112 of 908 (12.3%) patients assigned to point-of-care US, 95 of 893
(10.6%) assigned to radiology US and 106 of 958 (11.1%) assigned to CT. Severe
SAE occurred in 5 of 908 (0.55%) patients assigned to point-of-care US, 3 of
893 (0.34%) assigned to radiology US and 4 of 958 (0.42%) assigned to CT
(p=0.76). Average imaging costs were lower in patients assigned to
point-of-care ultrasound ($150) than radiology ultrasound ($200) or CT ($300, p
less than .0001). Average cumulative radiation exposures were significantly
lower for point-of-care (10.5 mSv) and radiology ultrasound (9.3 mSv) arms than
CT arm (17.5 mSv, p less than 0.0001). Average pain ratings showed no
significant differences: by 7 days, average pain scores were 2.1, 1.9, and 2.0
for point-of-care ultrasound, radiology ultrasound, and CT arms, p=0.75. Return
ED visits or hospitalizations were not different by arm at 1 week or 30 days.
Conclusions:
For ED patients with suspected nephrolithiasis, initial evaluation with
ultrasonography was associated with lower cumulative radiation exposure and
imaging costs with no significant difference in the risk of subsequent serious
adverse events, pain resolution, return ED visits or hospitalizations.
17. Comparison of PECARN, CATCH, and CHALICE Rules for Children
With Minor Head Injury: A Prospective Cohort Study
Easter JS,
et al. Ann Emerg Med. 2014 March 10 [Epub ahead of print]
Study
objective: We evaluate the diagnostic accuracy of clinical decision rules and
physician judgment for identifying clinically important traumatic brain
injuries in children with minor head injuries presenting to the emergency
department.
Methods: We
prospectively enrolled children younger than 18 years and with minor head
injury (Glasgow Coma Scale score 13 to 15), presenting within 24 hours of their
injuries. We assessed the ability of 3 clinical decision rules (Canadian
Assessment of Tomography for Childhood Head Injury [CATCH], Children's Head
Injury Algorithm for the Prediction of Important Clinical Events [CHALICE], and
Pediatric Emergency Care Applied Research Network [PECARN]) and 2 measures of
physician judgment (estimated of less than 1% risk of traumatic brain injury
and actual computed tomography ordering practice) to predict clinically
important traumatic brain injury, as defined by death from traumatic brain
injury, need for neurosurgery, intubation greater than 24 hours for traumatic
brain injury, or hospital admission greater than 2 nights for traumatic brain
injury.
Results: Among
the 1,009 children, 21 (2%; 95% confidence interval [CI] 1% to 3%) had
clinically important traumatic brain injuries. Only physician practice and
PECARN identified all clinically important traumatic brain injuries, with
ranked sensitivities as follows: physician practice and PECARN each 100% (95% CI
84% to 100%), physician estimates 95% (95% CI 76% to 100%), CATCH 91% (95% CI
70% to 99%), and CHALICE 84% (95% CI 60% to 97%). Ranked specificities were as
follows: CHALICE 85% (95% CI 82% to 87%), physician estimates 68% (95% CI 65%
to 71%), PECARN 62% (95% CI 59% to 66%), physician practice 50% (95% CI 47% to
53%), and CATCH 44% (95% CI 41% to 47%).
Conclusion:
Of the 5 modalities studied, only physician practice and PECARN identified all
clinically important traumatic brain injuries, with PECARN being slightly more
specific. CHALICE was incompletely sensitive but the most specific of all
rules. CATCH was incompletely sensitive and had the poorest specificity of all
modalities.
18. Is the Allen Test Necessary Before Transradial Artery
Catheterization?
No,
according to a prospective study in which postprocedural concentration of thumb
capillary lactate was used as the primary endpoint.
Valgimigli
M, et al. Transradial coronary catheterization and intervention across the
whole spectrum of Allen test results. J Am Coll Cardiol. 2014 May
13;63(18):1833-41.
OBJECTIVES:
The aim of this study was to investigate the safety and feasibility of
transradial coronary catheterization across the whole spectrum of Allen test
(AT) results.
BACKGROUND:
Whether the AT can predict ischemic complications after transradial access
(TRA) is controversial. No prospective assessment exists on the safety and
feasibility of TRA across the whole spectrum of AT results.
METHODS:
From October 2007 to June 2009, a total of 942 patients undergoing TRA were
screened, and 203 were recruited, of whom 83, 60, and 60 had normal,
intermediate, and abnormal AT results, respectively. Patients underwent serial
assessments of thumb capillary lactate (the primary endpoint), thumb
plethysmography, and ulnar frame count to investigate the patency of the
ulnopalmar arches, as well as handgrip strength tests to examine the isometric
strength of the hand and forearm muscles and discomfort ratings.
RESULTS:
Lactate did not differ among the 3 study groups after the procedure (1.85 ±
0.93 mmol/l in patients with normal AT results, 1.85 ± 0.66 mmol/l in those
with intermediate results, and 1.97 ± 0.71 mmol/l in those with abnormal
results; p = 0.59) or at other time points during the study. Plethysmographic
readings showed improvements of ulnopalmar collateralization in patients with
non-normal AT results, whereas the ulnar frame count was decreased, suggesting
enhanced ulnar flow, in patients with abnormal AT results after TRA. Handgrip
strength test results and discomfort ratings did not differ across AT groups.
No hand ischemic complications occurred.
CONCLUSIONS:
This study provides proof of concept for a paradigm shift in cardiovascular
intervention, suggesting the safety and feasibility of TRA across the whole
spectrum of AT results. Given the multiple implications of our findings, a
broader clinical validation is needed. (Predictive Value of Allen's Test Result
in Elective Patients Undergoing Coronary Catheterization Through Radial
Approach [RADAR]; NCT00597324).
19. Time to treatment with recombinant tPA and outcome of stroke
in clinical practice: retrospective analysis of hospital quality assurance data
compared with that of RCTs
Gumbinger
C, et al. BMJ 2014;348:g3429
Objective
To study the time dependent effectiveness of thrombolytic therapy for acute
ischaemic stroke in daily clinical practice.
Design A
retrospective cohort study using data from a large scale, comprehensive
population based state-wide stroke registry in Germany.
Setting All
148 hospitals involved in acute stroke care in a large state in southwest
Germany with 10.4 million inhabitants.
Participants
Data from 84 439 patients with acute ischaemic stroke were analysed, 10 263
(12%) were treated with thrombolytic therapy and 74 176 (88%) were not treated.
Main
outcome measures Primary endpoint was the dichotomised score on a modified
Rankin scale at discharge (“favourable outcome” score 0 or 1 or “unfavourable
outcome” score 2-6) analysed by binary logistic regression. Patients treated
with recombinant tissue plasminogen activator (rtPA) were categorised according
to time from onset of stroke to treatment. Analogous analyses were conducted
for the association between rtPA treatment of stroke and in-hospital mortality.
As a co-primary endpoint the chance of a lower modified Rankin scale score at
discharge was analysed by ordinal logistic regression analysis (shift
analysis).
Results
After adjustment for characteristics of patients, hospitals, and treatment,
rtPA was associated with better outcome in a time dependent pattern. The number
needed to treat ranged from 4.5 (within first 1.5 hours after onset; odds ratio
2.49) to 18.0 (up to 4.5 hours; odds ratio 1.26), while mortality did not vary
up to 4.5 hours. Patients treated with rtPA beyond 4.5 hours (including
mismatch based approaches) showed a significantly better outcome only in
dichotomised analysis (odds ratio 1.25, 95% confidence interval 1.01 to 1.55)
but the mortality risk was higher (1.45, 1.08 to 1.92).
Conclusion
The effectiveness of thrombolytic therapy in daily clinical practice might be
comparable with the effectiveness shown in randomised clinical trials and
pooled analysis. Early treatment was associated with favourable outcome in
daily clinical practice, which underlines the importance of speeding up the
process for thrombolytic therapy in hospital and before admission to achieve
shorter time from door to needle and from onset to treatment for thrombolytic
therapy.
20. Delayed Sequence Intubation (DSI)
Scott
Weingart, EM CRIT Podcast
The Case
You have a
50 y/o male with bad bilateral pneumonia. BP 108/70, HR 96, RR 28. He is
delirious, agitated, and looks sick, sick, sick! Saturation is 70% on a nasal
cannula; when you try to place the patient on a non-rebreather (NRB) he just
swats your hand away and rips off the mask. It is obvious to everyone in the
room that this patient needs intubation, but the question is how are you going
to do it?
Your first
impulse may be to perform RSI, maybe with some bagging during the paralysis
period. This is essentially a gamble. If you have first pass success, you (and
your patient) may just luck out, allowing you to get the tube in and start
ventilation before critical desaturation and the resultant hemodynamic
instability. However, the odds are against you: bagging during RSI predisposes
to aspiration, conventional BVM without a PEEP valve is unlikely to raise the
saturation in this shunted patient, and if there is any difficulty in
first-pass tube placement your patient will be in a very bad place.
A Better Way
Sometimes
patients like this one, who desperately require preoxygenation will impede its
provision. Hypoxia and hypercapnia can lead to delirium, causing these patients
to rip off their NRB or non-invasive ventilation (NIV) masks. This delirium,
combined with the low oxygen desaturation on the monitor, often leads to
precipitous attempts at intubation without adequate preoxygenation.
Standard
RSI consists of the simultaneous administration of a sedative and a paralytic
agent and the provision of no ventilations until after endotracheal intubation
(1). This sequence can be broken to allow for adequate preoxygenation without
risking gastric insufflation or aspiration; we call this method “delayed
sequence intubation” (DSI). DSI consists of the administration of specific
sedative agents, which do not blunt spontaneous ventilations or airway
reflexes; followed by a period of preoxygenation before the administration of a
paralytic agent.(2)
Another way
to think about DSI is as a procedural sedation, the procedure in this case
being effective preoxygenation. After the completion of this procedure, the
patient can be paralyzed and intubated. Just like in a procedural sedation, we
want our patients to be calm, but still spontaneously breathing and protecting
their airway.
The ideal
agent for this use is ketamine. This medication will not blunt patient
respirations or airway reflexes and provides a dissociative state, allowing the
application of preoxygenation. A dose of 1–2 mg/kg by slow intravenous push
will produce a calmed patient within ~ 30 seconds. Preoxygenation can then
proceed in a safe controlled fashion. This can be accomplished with a NRB, or
preferably in a patient exhibiting shunt, by use of a non-invasive mask hooked
up to ventilator with a CPAP setting of 5-15 cm H20 (or some of the new masks
that don’t require a machine, but more on that soon). After a saturation above
95% is achieved, the patient is allowed to breathe the high fiO2 oxygen for an
additional 2–3 min to achieve adequate denitrogenation. A paralytic is then
administered and after the 45–60 second apneic period, the patient can be
intubated.
22. Head CT Scan Overuse in Frequently Admitted Medical Patients
Owlia M, et
al. Amer J Med. 2014; 127: 406–410
Background:
Patients frequently admitted to medical services undergo extensive computed
tomography (CT) imaging. Some of this imaging may be unnecessary, and in
particular, head CT scans may be over-used in this patient population. We
describe the frequency of abnormal head CT scans in patients with multiple
medical hospitalizations.
Methods: We
retrospectively reviewed all CT scans done in 130 patients with 7 or more
admissions to medical services between January 1 and December 31, 2011 within
an integrated health care system. We calculated the number of CT scans,
anatomic site of imaging, and source of ordering (emergency department,
inpatient floor). We scored all head CT scans on a 0-4 scale based on the
severity of radiographic findings. Higher scores signified more clinically
important findings.
Results: There
were 795 CT scans performed in total, with a mean of 6.7 (± SD 5.8) CT scans
per patient. Abdominal/pelvis (39%), chest (30%), and head (22%) CT scans were
the most frequently obtained. The mean number of head CT scans performed was
2.9 (SD ± 4.2). Inpatient floors were the major site of CT scan ordering
(53.7%). Of 172 head CT scans, only 4% had clinically significant findings
(scores of 3 or 4).
Conclusions:
Patients with frequent medical admissions are medically complex and undergo
multiple CT scans in a year. The vast majority of head CT scans lack clinically
significant findings and should be ordered less frequently. Interdisciplinary
measures should be advocated by hospitalists, emergency departments, and
radiologists to decrease unnecessary imaging in this population.
23. Summer Reading
Here are a
few reads I’ve enjoyed of late:
- Malcolm Gladwell, David & Goliath:
Underdogs, Misfits, and the Art of Battling Giants (New York:
Penguin Books, 2013).
- Barbara Ehrenreich’s Nickel and
Dimed: On (Not) Getting By in America (New York: Metropolitan
Books, 2001).
- Richard H. Thaler and Cass R. Sunstein, Nudge: Improving Decisions About Health, Wealth, and Happiness (New Haven: Yale University Press, 2008).
- Svante Pääbo, Neanderthal Man: In Search of Lost Genomes (New York: Basic Books, 2014).
- Hazel Rose Markus and Alana Conner, Clash!: 8 Cultural Conflicts
That Make Us Who We Are (New York: Hudson Street Press, 2013).
- Sonia Sotomayor, My Beloved World
(Vintage, 2014).
- Chris Ballard, “Haverford Hoops”, Sports Illustrated, April 2014
On the
video front, here’s a 16-minute TEDx presentation by yours truly: “Evolution and Religion: The Battle and
Beyond”
24. Tid Bits
A. Prophylactic Implantable
Cardioverter-Defibrillators Improves Survival in Patients With Left Ventricular
Ejection Fraction Between 30% and 35%
B. Informed Consent Documentation
for Lumbar Puncture in the Emergency Department
C. PTSD Common Following ICU
Stay
SAN DIEGO
-- Even a year after a stay in an intensive care unit for non-traumatic
illness, a high percentage of ICU patients exhibit signs of post-traumatic
stress disorder, researchers said here.
Abstract: http://www.atsjournals.org/doi/abs/10.1164/ajrccm-conference.2014.189.1_MeetingAbstracts.A2534
D. NIDA Review Catalogs Cannabis Risks
Regular
and/or heavy recreational use of cannabis has been strongly linked with
addictive behaviors, motor vehicle accidents, lung dysfunction, and
"diminished lifetime achievement" according to a review by top
officials at the National Institute on Drug Abuse.
Note that
the review of studies found an increased likelihood of anxiety and depression,
increased likelihood of psychosis, worsened symptoms of schizophrenia, and
earlier onset of psychotic events.
E. Exposure to dirt and germs may
protect infants from asthma, allergies
Research
published in the Journal of Allergy and Clinical Immunology showed that
children who were exposed to animal dander, cockroach droppings and certain
bacteria before their first birthday had a reduced risk of developing allergies
or wheezing by age 3. The findings support the "hygiene hypothesis,"
researchers said.
F. Lack of Exercise Tops Women’s CV
Risk
Physical
inactivity had the greatest impact on a woman’s lifetime risk for heart disease
after age 30, according to an Australian study.
G. Guidelines, Online Training Aim
to Teach Physicians to Weigh Costs of Care, Become Better Stewards of Medical
Resources
Kuehn BM.
JAMA published online June 04, 2014.
With health
care spending now accounting for 18% of the US gross domestic product,
physicians—like everyone else—are concerned about it, said Neel Shah, MD,
executive director of Costs of Care, a nonprofit organization working “to
deflate” medical bills.
But
physicians may be unaware how decisions they make contribute to patient or
societal health costs, he said, noting that “nobody goes to school to treat
GDP.”
In fact,
many physicians were explicitly trained not to consider costs or came to equate
overtesting or unnecessary treatment with being thorough. Some may be unaware
what tests or procedures cost or are unsure how to integrate cost-effectiveness
into practice. But the strain of spiraling health care costs on individuals and
the economy has become hard for physicians to ignore.
“There was
the overall realization that we could not continue to spend the amount we were
spending and still provide all appropriate care,” said Paul Heidenreich, MD,
MS, a professor of medicine at Stanford University who coauthored an American
College of Cardiology (ACC) and American Heart Association (AHA) statement on
the need to integrate cost and value information in the groups’ joint
guidelines.
H. Death of loved one linked to
onset of psychiatric disorders
A study in
the American Journal of Psychiatry found that sudden death of a loved one was
associated with a greater risk of developing multiple psychiatric disorders,
particularly among older people. The most common disorders were alcohol use
disorder and major depressive episodes, researchers found.
I. Candy Flavorings in Tobacco
J.
Findings of Chronic Sinusitis on Brain Computed Tomography Are Not
Associated with Acute Headaches
K. Off Balance: NEJM Interactive
Case
L. The Political Polarization of
Physicians in the United States; An Analysis of Campaign Contributions to
Federal Elections, 1991 Through 2012
M. Early beta-blocker effects
Early
beta-blocker use is common in patients presenting with ST-elevation myocardial
infarction, with oral administration being the most prevalent. Oral
beta-blockers were associated with a decrease in the risk of cardiogenic shock,
ventricular arrhythmias, and acute heart failure. However, the early receipt of
any form of beta-blockers was associated with an increase in hospital
mortality.
N. YouTube Videos Not Ideal for
Medical Advice
NEW YORK
CITY -- Patients with hypertension might want to be careful about trusting
health information from the Internet, a study of YouTube videos suggested.
O. Prolonged sitting tied to
increased risk of certain cancers
For every
additional two hours spent sitting, a person's likelihood of developing colon
cancer and endometrial cancer increased by 8% and 10%, respectively, according
to an analysis of 43 studies in the Journal of the National Cancer Institute.
People who spent the most time watching TV had a 54% increased risk of having
colon cancer than those with the least TV time.
P. Pediatric asthma protocol yields
fewer readmissions
A study of
more than 500 2- to 18-year-olds who were hospitalized because of an asthma
attack found that compliance with an asthma management protocol, which included
a home management plan of care, was linked to a 70% decline in readmission
rates.
Q. ED Visits and Smoking Cessation
R. Lactate to predict GIB mortality?
Abstract: http://www.ajemjournal.com/article/S0735-6757(14)00101-6/abstract
Abstract: http://www.ajemjournal.com/article/S0735-6757(14)00101-6/abstract
