Thursday, June 19, 2014

Lit Bits: June 19, 2014

From the recent medical literature...

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.

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.

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.

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…

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…

For the rest of the article, see full-text (free):

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.

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…

The remainder of the essay:

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.

The story continues here:

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:
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.

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?