1. Serious Bleeding Events due to Warfarin and Antibiotic
Co-prescription in a Cohort of Veterans
Lane MA, et
al. Amer J Med. 2014;127; 657–663.e2
Background:
Antibiotics may interact with warfarin, increasing the risk for significant
bleeding events.
Methods: This
is a retrospective cohort study of veterans who were prescribed warfarin for 30
days without interruption through the US Department of Veterans Affairs between
October 1, 2002 and September 1, 2008. Antibiotics considered to be high risk
for interaction with warfarin include: trimethoprim/sulfamethoxazole (TMP/SMX),
ciprofloxacin, levofloxacin, metronidazole, fluconazole, azithromycin, and
clarithromycin. Low-risk antibiotics include clindamycin and cephalexin. Risk
of bleeding event within 30 days of antibiotic exposure was measured using Cox
proportional hazards regression, adjusted for demographic characteristics,
comorbid conditions, and receipt of other medications interacting with
warfarin.
Results: A
total of 22,272 patients met inclusion criteria, with 14,078 and 8194 receiving
high- and low-risk antibiotics, respectively. There were 93 and 36 bleeding
events in the high- and low-risk groups, respectively. Receipt of a high-risk
antibiotic (hazard ratio [HR] 1.48; 95% confidence interval [CI], 1.00-2.19)
and azithromycin (HR 1.93; 95% CI, 1.13-3.30) were associated with increased
risk of bleeding as a primary diagnosis. TMP/SMX (HR 2.09; 95% CI, 1.45-3.02),
ciprofloxacin (HR 1.87; 95% CI, 1.42-2.50), levofloxacin (HR 1.77; 95% CI,
1.22-2.50), azithromycin (HR 1.64; 95% CI, 1.16-2.33), and clarithromycin (HR
2.40; 95% CI, 1.16-4.94) were associated with serious bleeding as a primary or
secondary diagnosis. International normalized ratio (INR) alterations were
common; 9.7% of patients prescribed fluconazole had INR value above 6. Patients
who had INR performed within 3-14 days of co-prescription were at a decreased
risk of serious bleeding (HR 0.61; 95% CI, 0.42-0.88).
Conclusions:
Warfarin users who are prescribed high-risk antibiotics are at higher risk for
serious bleeding events. Early INR evaluation may mitigate this risk.
2. Ondansetron and the Risk of Cardiac Arrhythmias: A Systematic
Review and Postmarketing Analysis
Freedman
SB, et al. Ann Emerg Med. 2014;64:19–25.e6
Study
objective: To explore the risk of cardiac arrhythmias associated with
ondansetron administration in the context of recent recommendations for
identification of high-risk individuals.
Methods: We
conducted a postmarketing analysis and systematically reviewed the published
literature, grey literature, manufacturer’s database, Food and Drug
Administration Adverse Events Reporting System, and the World Health
Organization Individual Safety Case Reports Database (VigiBase). Eligible cases
described a documented (or perceived) arrhythmia within 24 hours of ondansetron
administration. The primary outcome was arrhythmia occurrence temporally
associated with the administration of a single, oral ondansetron dose.
Secondary objectives included identifying all cases associating ondansetron
administration (any dose, frequency, or route) to an arrhythmia.
Results: Primary:
No reports describing an arrhythmia associated with single oral ondansetron
dose administration were identified. Secondary: Sixty unique reports were
identified. Route of administration was predominantly intravenous (80%). A
significant medical history (67%) or concomitant use of a QT-prolonging
medication (67%) was identified in 83% of reports. Approximately one third
occurred in patients receiving chemotherapeutic agents, many of which are known
to prolong the QT interval. An additional third involved administration to
prevent postoperative vomiting.
Conclusion:
Current evidence does not support routine ECG and electrolyte screening before
single oral ondansetron dose administration to individuals without known risk
factors. Screening should be targeted to high-risk patients and those receiving
ondansetron intravenously.
3. Skip the CT in Children c Minor Blunt Head Trauma and Isolated
Loss of Consciousness
Lee LK, et
al. for the PECARN. JAMA Pediatr. 2014 July 07 [Epub ahead of print]
Importance A history of loss of consciousness (LOC) is
frequently a driving factor for computed tomography use in the emergency
department evaluation of children with blunt head trauma. Computed tomography
carries a nonnegligible risk for lethal radiation-induced malignancy. The
Pediatric Emergency Care Applied Research Network (PECARN) derived 2
age-specific prediction rules with 6 variables for clinically important
traumatic brain injury (ciTBI), which included LOC as one of the risk factors.
Objective To determine the risk for ciTBIs in children
with isolated LOC.
Design,
Setting, and Participants This was a
planned secondary analysis of a large prospective multicenter cohort study. The
study included 42 412 children aged 0 to 18 years with blunt head trauma and
Glasgow Coma Scale scores of 14 and 15 evaluated in 25 emergency departments
from 2004-2006.
Exposure A history of LOC after minor blunt head
trauma.
Main
Outcomes and Measures The main outcome
measures were ciTBIs (resulting in death, neurosurgery, intubation beyond 24
hours, or hospitalization for ≥2 nights) and a comparison of the rates of
ciTBIs in children with no LOC, any LOC, and isolated LOC (ie, with no other
PECARN ciTBI predictors).
Results A total of 42 412 children were enrolled in
the parent study, with 40 693 remaining in the current analysis after
exclusions. Of these, LOC occurred in 15.4% (6286 children). The prevalence of
ciTBI with any history of LOC was 2.5% and for no history of LOC was 0.5%
(difference, 2.0%; 95% CI, 1.7-2.5). The ciTBI rate in children with isolated
LOC, with no other PECARN predictors, was 0.5% (95% CI, 0.2-0.8; 13 of 2780).
When comparing children who have isolated LOC with those who have LOC and other
PECARN predictors, the risk ratio for ciTBI in children younger than 2 years
was 0.13 (95% CI, 0.005-0.72) and for children 2 years or older was 0.10 (95%
CI, 0.06-0.19).
Conclusions
and Relevance Children with minor blunt
head trauma presenting to the emergency department with isolated LOC are at very
low risk for ciTBI and do not routinely require computed tomographic
evaluation.
The same goes for patients with minor
blunt head trauma and isolated vomiting: http://www.ncbi.nlm.nih.gov/pubmed/24559605
4. Continuous Capnography during Propofol Deep Sedation to
Little Advantage in Outpt GYN Procedures
Hypoxic
events occurred in similar numbers of patients with and without CO2 monitoring.
van Loon K
et al. Capnography During Deep Sedation with Propofol by Nonanesthesiologists:
A RCT. Anesth Analg 2014;119(1):49-55.
BACKGROUND:
Propofol, a short-acting hypnotic drug, is increasingly administered by a
diverse group of specialists (e.g., cardiologists, gastroenterologists) during
diagnostic and therapeutic procedures. Standard monitoring during sedation
comprises continuous pulse oximetry with visual assessment of the patient’s
breathing pattern. Because undetected hypoventilation is a common pathway for
complications, capnographic monitoring of exhaled carbon dioxide has been
advocated. We examined whether the use of capnography reduces the incidence of
hypoxemia during nonanesthesiologist-administered propofol sedation in patients
who did not receive supplemental oxygen routinely.
METHODS: An
open, stratified, randomized controlled trial was conducted in 427 healthy
adult women during minor gynecology procedures in an outpatient clinic in the
Netherlands. Patients were randomly assigned to receive either standard
respiratory monitoring (standard care) or standard respiratory monitoring
combined with capnography (capnography group). To replicate usual clinical
practice, capnography monitoring was performed by the same medical team that
provided sedation. The primary end point was the incidence of hypoxemia,
defined as oxygen saturations less than 91%.
RESULTS:
From April 2010 to January 2011, 427 patients were enrolled. In the capnography
group, 206 patients and in the standard care group, 209 patients were analyzed.
The percentage of patients with a hypoxemic episode was 25.7% (53 of 206) in
the capnography group and 24.9% (52 of 209) in the standard care group,
resulting in an absolute difference of 0.8% (−7.5 to 9.2%).
CONCLUSIONS:
We were unable to confirm an additive role for capnography in preventing
hypoxemia during elective nonanesthesiologist-administered propofol
(monotherapy) sedation in healthy women in whom supplemental oxygen is not
routinely administered. Based on the confidence interval, the benefit of adding
capnography is at most an absolute hypoxemia reduction of 7.5%, suggesting that
adding it in this practice setting to the routine monitoring strategy does not
necessarily improve patient safety in daily practice.
5. Death of a Child in the Emergency Department
O'Malley
PJ, et al. Ann Emerg Med. 2014;64:102-5.
The death
of a child in the emergency department (ED) is an event with emotional,
cultural, procedural, and legal challenges. The original policy statement,
“Death of a Child in the Emergency Department: Joint Statement by the American
Academy of Pediatrics and the American College of Emergency Physicians,” was
first published in 2002.1
The
infrequency of child death in the ED and the enormity of the tragedy magnify
the challenges in simultaneously providing clinical care, holistic support for
families, and care of the team delivering care while attending to significant
operational, legal, ethical, and spiritual issues. The evidence basis for these
recommendations is detailed in the accompanying technical report of the same
title.
The
American Academy of Pediatrics, American College of Emergency Physicians, and
Emergency Nurses Association have collaborated to identify practices and
principles to guide the care of children, families, and staff in the
challenging and uncommon event of the death of a child in the emergency
department in this policy statement and in an accompanying technical report.
6. Central venous catheterization: attitudes and complications
A. Emergency physician perspectives
on CVC in septic patients: a survey-based study.
Ballard DW,
et al. Acad Emerg Med. 2014;21(6):623-630.
Objectives:
The objective was to assess clinician experience, training, and attitudes
toward central venous catheterization (CVC) in adult emergency department (ED)
patients in a health system promoting increased utilization of CVC for severely
septic ED patients.
Methods: The
authors surveyed all emergency physicians (EPs) within a 21-hospital integrated
health care delivery system that had recently instituted a modified Rivers
protocol for providing early goal-directed therapy (EGDT) to patients with
severe sepsis or septic shock, including CVC if indicated. This initiative was
accompanied by a structured, but optional, systemwide hands-on training for EPs
in real-time ultrasound-guided CVC (US CVC). EPs’ responses to questions
regarding self-reported experience with CVC in the ED are reported. Data
included frequency of CVC (by type) and US CVC training opportunities: both
during and after residency and informal (“on-the-job training involving actual
ED patients under the oversight of someone more experienced than yourself”) and
formal (“off-the-job training not involving actual ED patients”). The survey
also asked respondents to report their comfort levels with different types of
CVC as well as their agreement with possible barriers (philosophical,
time-related, equipment-related, and complication-related) to CVC in the ED.
Multivariable ordinal logistic regression was used to identify provider
characteristics and responses associated with higher yearly CVC volumes.
Results: The
survey response rate among eligible participants was 365 of 465 (78%). Overall,
154 of 365 (42%) respondents reported performing 11 or more CVCs a year, while
46 of 365 (13%) reported doing two or fewer. Concerning CVC techniques, 271 of
358 (76%) of respondents reported being comfortable with the internal jugular
approach with US guidance, compared to 200 of 345 (58%) with the subclavian
approach without US. Training rates were reported as 1) in residency, formal
167 of 358 (47%) and informal 189 of 364 (52%); and 2) postresidency, formal
236 of 359 (66%) and informal 260 of 365 (71%). The most commonly self-reported
barriers to CVC were procedural time (56%) and complication risk (61%). After
multivariate adjustment, the following were significantly associated with
greater self-reported CVC use (p less than 0.01): 1) informal bedside CVC
training after residency, 2) male sex, 3) disagreement with
complication-related barrier questions, and 4) self-reported comfort with
placing US-guided internal jugular catheters.
Conclusions:
In this cross-sectional survey-based study, EPs reported varying experience
with CVC in the ED and reported high comfort with the US CVC technique.
Postresidency informal training experience, male sex, negative responses to
complication-related barrier questions, and comfort with placing US-guided
internal jugular catheters were associated with yearly CVC volume. These
results suggest that higher rates of CVC in eligible patients might be achieved
by informal training programs in US and/or by disseminating existing evidence
about the low risk of complications associated with the procedure.
B. Bleeding complications of CVC uncommon
in septic patients with abnormal hemostasis.
Vinson DR,
et al. Am J Emerg Med. 2014 Jul;32(7):737-42.
OBJECTIVES:
Central venous catheterization (CVC) is thought to be relatively
contraindicated in patients with thrombocytopenia or coagulopathy. We measured
the 24-hour incidence of bleeding in septic emergency department (ED) patients
undergoing CVC.
METHODS:
This multicenter, retrospective cohort study included septic ED patients
undergoing CVC with one of the following: platelets less than 100 000/μL,
international normalized ratio at least 1.3, or partial thromboplastin time at
least 35 seconds. Major bleeding included radiographically confirmed
intrathoracic, mediastinal, or internal neck hemorrhage or line-related
bleeding causing hemodynamic compromise. Minor bleeding included local oozing
or superficial hematoma. Multivariable regression analysis was performed to
determine the association between candidate variables and hemorrhagic
complications.
RESULTS: Of
the 936 cases, mean age was 68.1 years; 535 (57.2%) were male. Two or more
qualifying laboratory abnormalities were present in 204 cases (21.8%). The
proceduralists were predominately attendings (790; 84.4%). The initial veins
were the internal jugular (n = 800; 85.5%), subclavian (n = 123; 13.1%), and
femoral (n = 13; 1.4%). Initial access was successful in 872 cases (93.2%). We
found one case (95% upper confidence limit: 0.6%) of major bleeding and 37
cases (4.0%; 95% confidence interval [CI], 2.8%-5.4%) of minor bleeding. Only
failed access at the initial site was independently associated with hemorrhagic
outcomes: adjusted odds ratio 8.2 (95% CI, 3.7-18.0).
CONCLUSIONS:
Major bleeding from CVC in ED patients with abnormal hemostasis is rare. Minor
bleeding is uncommon and infrequently requires intervention. Successful
catheterization on the initial attempt is associated with fewer hemorrhagic
complications. These results can inform the risk/benefit calculus for CVC in
this population.
7. FDA warns of lidocaine to ease teething pain in infants
Prescription
oral viscous lidocaine 2% solution should not be used to relieve teething pain
in infants and toddlers because it can lead to serious injuries, even death,
FDA officials warned Thursday. The warning was issued after the agency received
22 reports so far this year of serious adverse reactions to the pain
medication, including deaths.
8. NAC + IVF vs NaHCO3 + IVF vs IVFs Alone: All Equally
Effective in the Prevention of Contrast-induced Nephropathy in the ED
Kama A, et
al. Acad Emerg Med 2014;21:615-622.
Background:
There is no evidence regarding the several short-term prophylaxis protocols for
contrast-induced nephropathy (CIN) that may be most feasibly convenient in
emergency settings.
Objectives:
The purpose of this study was to compare the efficacies of short-term CIN
prophylaxis protocols of normal saline, N-acetylcysteine (NAC) plus saline, and
sodium bicarbonate plus saline in emergency department (ED) patients at
moderate or high risk of CIN after receiving intravenous (IV) contrast agent.
Methods: This
single-center, randomized, nonblinded clinical trial was conducted in the ED
with adult patients requiring contrast-enhanced computed tomography (CT).
Patients with moderate to high risk of CIN according to the Mehran risk score,
who consented to participate, were eligible. Patients with continuous renal
replacement therapy or who reported contrast allergy were excluded. Enrolled
patients were randomly assigned to receive 150 mg/kg NAC in 1000 mL of 0.9%
sodium chloride (NaCl), 150 mEq of sodium bicarbonate in 1000 mL of 0.9% NaCl,
or 1000 mL of IV saline infusion, all given at 350 mL/hr for 3 hours. All of
the patients were administered less than 100 mL of nonionic, low-osmolality
contrast agent. The primary outcome of CIN was defined as a 25% increase or a
greater than 0.5 mg/dL increase in the serum creatinine level 48 to 72 hours
later compared with the baseline measurement.
Results: A
total of 107 patients were randomized to NAC (n = 36), sodium bicarbonate (n =
36), and saline prophylaxis (n = 35). The mean age of the patients was 71 years
(95% confidence interval [CI] = 65 to 77 years), and 58 (54.2%) were male. The
groups were similar regarding baseline characteristics and nephropathy risks.
Of the 16 (14.9%) patients who eventually developed CIN, seven (19.4%) were in
the NAC plus saline group, four (11.1%) were in the sodium bicarbonate plus
saline group, and five (14.2%) were in the saline group. There were no
significant differences between the groups in terms of the prevention of CIN (p
= 0.60).
Conclusions:
None of the short-term protocols with normal saline, NAC, or sodium bicarbonate
was superior in ED patients requiring contrast-enhanced CT who had a moderate
or high risk of CIN.
9. Identifying Patients with Problematic Drug Use in the ED:
Results of a Multisite Study
Konstantopoulos
WL, et al. Ann Emerg Med. 2014; in press
INTRO
Importance:
Studies have shown that drug-using individuals are more likely to use the
emergency department (ED) for their medical care and are more likely to require
hospitalization than their non–drug-using counterparts.9, 10, 11 The Drug Abuse
Warning Network, a public health surveillance system that monitors drug-related
morbidity and mortality, estimated that of the 5.1 million drug-related ED
visits nationwide in 2011, 2.5 million visits were directly related to use of
illicit substances, nonmedical use of pharmaceuticals, or a combination of
these.12 In 2008, the total annual cost of illicit drug use (excluding tobacco
and alcohol) was calculated at $151.4 billion. Not inclusive of substance use
treatment, medical care costs alone accounted for $5.4 billion of the total
annual cost.13
Substance
use–related health events leading to ED visits may constitute opportunistic
“teachable moments” for delivering brief but meaningful interventions. In fact,
the American College of Emergency Physicians issued a policy statement in 2011
promoting the use of screening, brief intervention, and referral to treatment
(SBIRT) in the ED for problematic alcohol use.14 Although numerous studies have
demonstrated the effectiveness of SBIRT in reducing high-risk alcohol use,
associated injury recidivism, and driving under the influence,15 , 16, 17, 18,
19 its effectiveness in addressing problematic drug use remains to be
definitively demonstrated, though preliminary studies in ED populations show
promise.20, 21, 22, 23
One
significant challenge in addressing drug use disorders in the ED is the
difficulty in detecting problematic drug use. Studies have shown that patients
tend to deny or underreport illicit drug use.24, 25, 26, 27 Improving the
ability of emergency providers to identify patients with drug use problems is
critical to their role in mitigating the health effects of illicit drug use.
Determining clinically relevant characteristics that may be indicative of drug
use problems may assist emergency providers in identifying patients in most
need of comprehensive ED-based screening, intervention, and referral to
substance use treatment.
Goals of This
Investigation: The present study aims to identify demographic and clinical
characteristics associated with problematic drug use in patients who report
past 30 day drug use during an ED visit.
ABSTRACT
Study
objective: Drug-related emergency department (ED) visits have steadily
increased, with substance users relying heavily on the ED for medical care. The
present study aims to identify clinical correlates of problematic drug use that
would facilitate identification of ED patients in need of substance use
treatment.
Methods: Using
previously validated tests, 15,224 adult ED patients across 6 academic
institutions were prescreened for drug use as part of a large randomized
prospective trial. Data for 3,240 participants who reported drug use in the
past 30 days were included. Self-reported variables related to demographics,
substance use, and ED visit were examined to determine their correlative value
for problematic drug use.
Results: Of
the 3,240 patients, 2,084 (64.3%) met criteria for problematic drug use (Drug
Abuse Screening Test score ≥3). Age greater than or equal to 30 years, tobacco
smoking, daily or binge alcohol drinking, daily drug use, primary noncannabis
drug use, resource-intense ED triage level, and perceived drug-relatedness of
ED visit were highly correlated with problematic drug use. Among primary
cannabis users, correlates of problematic drug use were age younger than 30
years, tobacco smoking, binge drinking, daily drug use, and perceived
relatedness of the ED visit to drug use.
Conclusion:
Clinical correlates of drug use problems may assist the identification of ED
patients who would benefit from comprehensive screening, intervention, and
referral to treatment. A clinical decision rule is proposed. The correlation
between problematic drug use and resource-intense ED triage levels suggests
that ED-based efforts to reduce the unmet need for substance use treatment may
help decrease overall health care costs.
10. Efficacy
and Safety of Early Dexmedetomidine during NIV for Pts c Acute Respiratory
Failure: A RCT
Devlin JW,
et al. Chest. 2014;145(6):1204-1212.
Background: Successful application of noninvasive
ventilation (NIV) for acute respiratory failure (ARF) requires patient
cooperation and comfort. The efficacy and safety of early IV dexmedetomidine
when added to protocolized, as-needed IV midazolam and fentanyl remain unclear.
Methods: Adults with ARF and within 8 h of starting
NIV were randomized to receive IV dexmedetomidine (0.2 μg/kg/h titrated every
30 min to 0.7 μg/kg/h to maintain a Sedation-Agitation Scale [SAS] score of 3
to 4) or placebo in a double-blind fashion up to 72 h, until NIV was stopped
for ≥ 2 h, or until intubation. Patients with agitation (SAS ≥ 5) or pain
(visual analog scale ≥ 5 of 10 cm) 15 min after each dexmedetomidine and
placebo increase could receive IV midazolam 0.5 to 1.0 mg or IV fentanyl 25 to
50 μg, respectively, at a minimum interval of every 3 h.
Results: The dexmedetomidine (n = 16) and placebo (n =
17) groups were similar at baseline. Use of early dexmedetomidine did not
improve NIV tolerance (score, 1 of 4; OR, 1.44; 95% CI, 0.44-4.70; P = .54)
nor, vs placebo, led to a greater median (interquartile range) percent time
either tolerating NIV (99% [61%-100%] vs 67% [40%-100%], P = .56) or remaining
at the desired sedation level (SAS score = 3 or 4, 100% [86%-100%] vs 100%
[100%-100%], P = .28], or fewer intubations (P = .79). Although use of
dexmedetomidine was associated with a greater duration of NIV vs placebo (37
[16-72] vs 12 [4-22] h, P = .03), the total ventilation duration (NIV +
invasive) was similar (3.3 [2-4] days vs 3.8 [2-5] days, P = .52). More
patients receiving dexmedetomidine had one or more episodes of deep sedation vs
placebo (SAS ≤ 2, 25% vs 0%, P = .04). Use of midazolam (P = .40) and episodes
of either severe bradycardia (heart rate ≤ 50 beats/min, P = .18) or
hypotension (systolic BP ≤ 90 mm Hg, P = .64) were similar.
Conclusions: Initiating dexmedetomidine soon after NIV
initiation in patients with ARF neither improves NIV tolerance nor helps to
maintain sedation at a desired goal. Randomized, multicenter trials targeting
patients with initial intolerance are needed to further elucidate the role for
dexmedetomidine in this population.
11. Images in Clinical Practice
Arm
Weakness and Deformity
Man with
Altered Mentation after Trauma
Man with
Abdominal Distension
Giant
Hydronephrosis
Chemosis
from Trauma
“Whirl
Sign” of Primary Small Bowel Volvulus
Pediatric
Patient with a Rash
Sudden
unilateral painless loss of vision
Bilateral
Corneal Abrasions from Airbag Deployment
Tuberculous
Abscess
Elderly
Woman With Tongue Swelling
Woman With
Bleeding Lesion on Her Back
12. Unrecognized Hypoxia and Respiratory Depression in ED Pts Sedated
for Psychomotor Agitation: A Pilot Study
Deitch K,
et al. West J Emerg Med. 2014;15(4):430-437.
Introduction:
The incidence of respiratory depression in patients who are chemically sedated
in the emergency department (ED) is not well understood. As the drugs used for
chemical restraint are respiratory depressants, improving respiratory
monitoring practice in the ED may be warranted. The objective of this study is
to describe the incidence of respiratory depression in patients chemically
sedated for violent behavior and psychomotor agitation in the ED.
Methods:
Adult patients who met eligibility criteria with psychomotor agitation and
violent behavior who were chemically sedated were eligible. SpO2 and ETCO2
(end-tidal CO2) was recorded and saved every 5 seconds. Demographic data,
history of drug or alcohol abuse, medical and psychiatric history, HR and BP every
5 minutes, any physician intervention for hypoxia or respiratory depression, or
adverse events were also recorded. We defined respiratory depression as an
ETCO2 of above 50 mmHg, a change of 10% above or below baseline, or a loss of
waveform for more than 15 seconds. Hypoxia was defined as a SpO2 of less than 93%
for more than 15 seconds.
Results: We
enrolled 59 patients, and excluded 9 because of greater than 35% data loss.
Twenty-eight (28/50) patients developed respiratory depression at least once
during their chemical restraint (56%, 95% CI 42-69%); the median number of
events was 2 (range 1-6). Twenty-one
(21/50) patients had at least one hypoxic event during their chemical restraint
(42%, 95% CI 29-55%); the median number of events was 2 (range 1-5). Nineteen
(19/21) (90%, 95% CI 71-97%) of the patients that developed hypoxia had a
corresponding ETCO2 change. Fifteen (15/19) (79%, 95% CI 56-91%) patients who
became hypoxic met criteria for respiratory depression before the onset of
hypoxia. The sensitivity of ETCO2 to predict the onset of a hypoxic event was
90.48% (95% CI: 68-98%) and specificity 69% (95% CI: 49-84%). Five patients received respiratory
interventions from the healthcare team to improve respiration [Airway
repositioning: (2), Verbal stimulation: (3)]. Thirty-seven patients had a
history of concurrent drug or alcohol abuse and 24 had a concurrent psychiatric history. None of these patients had a major adverse
event.
Conclusion: About half of the patients in this study
exhibited respiratory depression. Many of these patients went on to have a
hypoxic event, and most of the incidences of hypoxia were preceded by
respiratory depression. Few of these events were recognized by their treating
physicians.
13. The Latest in Medical Convenience: ER Appointments
By Anna
Gorman and Victoria Colliver. Kaiser Health News. Jul 03, 2014
In an era
of increased competition driven by the nation’s Affordable Care Act, hospital
executives around the country are hoping online appointments will attract
patients eager to avoid long waits in a crowded and often chaotic environment.
Scott Paul
knew he needed to head to the emergency room on a recent Sunday after his foot
became so painful he couldn't walk. The one thing that gave him pause was the
thought of having to wait several hours next to a bunch of sick people.
But his
wife, Jeannette, remembered she'd seen Dignity Health television commercials
featuring a woman sitting in a hospital waiting room and then cutting to the
same woman sitting on her living room couch as words come up on the screen:
"Wait for the ER from home."
"I've
been in emergency rooms before, so I thought I'd see if this worked out,"
she said, and went online to book an appointment for her husband at Dignity's
St. Mary's Medical Center in San Francisco.
"They
actually had an appointment that was within the hour. It was fast, it was
convenient and there was also immediately confirmation we had the
appointment," she said.
Dignity
Health, which runs a large network of hospitals out of its San Francisco
headquarters, also offers online ER booking at Saint Francis Memorial Hospital
in San Francisco and Sequoia Hospital in Redwood City as a way to overcome the
frequently grueling emergency room wait times.
Dignity
isn't the only network employing the strategy. In an era of increased
competition driven by the nation's Affordable Care Act, hospital executives
around the country are hoping online appointments will attract patients eager
to avoid long waits in a crowded and often chaotic environment.
"It makes
for a happier camper," said Susan Dubuque, a national expert in hospital
marketing. "When it comes to health care, consumers want more control over
everything."
Not for
everyone
Emergency
room appointments are not intended for patients with serious emergencies --
those with life-threatening, debilitating or urgent medical conditions.
Patients
with chest pain, persistent bleeding or trouble breathing, for instance, are
instructed to call 911 or go directly to an emergency room. Those with an ankle
sprain or a fever, for instance, might be able to make an appointment.
At UCSF
Medical Center, patients must explain in an online form the reason for their
visit and check a box indicating they can wait for treatment until their
scheduled appointment. Even then, they may be bumped by more seriously ill
patients, but in most cases they will be seen soon after arrival.
The
approach makes business sense for hospitals because it lets medical staff know
who may be coming through the emergency room door and helps reduce crowding and
decrease wait times, hospital executives say. They say the service also helps
build a loyal clientele among patients.
Patients
want to access health care the same way they do services in other industries,
such as retail or travel, said Chris Song, a spokesman for InQuicker, a
Nashville company that offers the online scheduling in California and 25 other
states.
"When
is the last time someone bought plane tickets at the gate?" he said.
UCSF
Medical Center started using InQuicker in its emergency department in 2012 and
expanded it a year later to its acute care clinic, where less-critical cases
are handled on a same-day, walk-in basis. Now the system is also being used to
book primary care appointments.
Under the
former way of doing things, Eva Turner, assistant director of ambulatory
services for UCSF's primary care department, said patients were often
frustrated because they had no way of knowing in advance if same-day acute-care
appointments were still available. "Before (InQuicker), patients would
park their car, pay the garage fee only to find out we can't see them,"
she said.
For the
remainder of the essay: http://www.kaiserhealthnews.org/stories/2014/july/03/the-latest-in-medical-convenience-er-appointments.aspx
14. Noninvasive Ventilation Has a Favorable Role in Chest Trauma
Pts
Hua A, et
al. Ann Emerg Med. 2014;64:82-83
Take-Home Message: Noninvasive ventilation in chest
trauma patients may reduce the requirement for intubation and may reduce
mortality.
Commentary
Chest
trauma composes 10% to 15% of all traumas and is responsible for 17% to 25% of
all deaths caused by trauma.1, 2 For
decades, invasive mechanical ventilation has been posited to be the only route
of ventilator support to improve gas exchange, and it has been used in up to
50% of patients with significant chest trauma.3
Although
intubation and mechanical ventilation can be lifesaving, they can also induce
barotrauma, ventilator-associated infections, and other adverse events.4
Noninvasive
ventilation has similarly been shown to reduce work of breathing and improve
gas exchange, without the associated complications from intubations; it has
been particularly effective for patients with chronic obstructive pulmonary
disease exacerbation and cardiogenic pulmonary edema.5
In this
systematic review, 4 of the 5 studies addressing mortality found a reduction in
mortality rate for chest trauma patients with the use of noninvasive
ventilation. Noninvasive ventilation's effect on mortality seemed unrelated to
the treatment modality (continuous positive airway pressure, bilevel positive
airway pressure, and noninvasive intermittent-pressure support ventilation),
suggesting the benefit derives from positive-pressure ventilation. It is
thought that noninvasive ventilation increases transpulmonary pressure,
recruiting collapsed and poorly ventilated lung regions, thereby reducing the
work of breathing and ameliorating gas exchange. This review indeed found
improved gas exchange and oxygenation in trauma patients. One concern raised
was the risk of tension pneumothorax from positive-pressure ventilation because
lung contusions from chest trauma are frequently associated with pneumothorax.
The meta-analysis found no significant associated increase in the incidence of
pneumothorax with noninvasive ventilation.
There are
several limitations in this meta-analysis. First, and most important, there was
no set standard criterion for use of noninvasive ventilation in chest trauma
across the various studies; therefore, it is not entirely clear exactly when
and for whom noninvasive ventilation should be initiated.
Second, the
number of eligible studies included in the analysis was relatively small (10
studies; 368 patients); fortunately, 4 of the 10 studies were randomized
controlled trials, but the other 6 were observational studies.
Third,
because of the paucity of studies, it was not possible to separate the effects
of continuous positive airway pressure, bilevel positive airway pressure, and
noninvasive intermittent-pressure support ventilation. Because of these
limitations, there was a high heterogeneity of effect across studies for a
number of variables. However, for the binary outcomes (ie, mortality,
complications, infections, intubation rate), which are more pertinent to
emergency physicians, there was a high homogeneity among the studies.
Fourth, an
important limitation is the inherent selection bias with noninvasive
ventilation treatment insofar as patients must be able to tolerate the
noninvasive ventilation apparatus. Patients who are obtunded or too severely in
respiratory distress to tolerate noninvasive ventilation are excluded from that
strategy. Thus, the patients who are intubated may be more critically ill and
therefore have higher mortality rates.
Overall,
this meta-analysis suggests that early use of noninvasive ventilation in chest
trauma patients may reduce mortality and the intubation rate without increasing
complications. However, further studies are needed to better define the patient
selection criteria and timing for noninvasive ventilation, as well as to
elucidate factors that would predict success or failure on noninvasive ventilation.
A randomized controlled trial of noninvasive ventilation for validation would
be ideal before it can be incorporated into daily clinical practice for chest
trauma patients.
15. Current management of migraine in US EDs: An analysis of the
National Hospital Ambulatory Medical Care Survey.
Friedman
BW, et al Cephalalgia. 2014 Jun 19. [Epub ahead of print].
BACKGROUND:
Published data from 1998 revealed that most patients treated for migraine in an
emergency department received opioids. Over the intervening years, a large body
of evidence has emerged demonstrating the efficacy and safety of non-opioid
alternatives. Expert opinion during these years has cautioned against use of
opioids for migraine. Our objectives were to compare current frequency of use
of various medications for acute migraine in US emergency departments with use
of these same medications in 1998 and to identify factors independently
associated with opioid use.
METHODS: We
analyzed National Hospital Ambulatory Medical Care Survey data from 2010, the
most current dataset available. The National Hospital Ambulatory Medical Care
Survey is a public dataset collected and distributed by the Centers for Disease
Control and Prevention. It is a multi-stage probability sample from randomly
selected emergency departments across the country, designed to be
representative of all US emergency department visits. We included in our
analysis all patients with the ICD9 emergency department discharge diagnosis of
migraine. We tabulated frequency of use of specific medications in 2010 and
compared these results with the 1998 data. Using a logistic regression model,
into which all of the following variables were entered, we explored the
independent association between any opioid use in 2010 and sex, age,
race/ethnicity, geographic region, type of hospital, triage pain score and
history of emergency department use within the previous 12 months.
RESULTS: In
2010, there were 1.2 (95% confidence interval 0.9, 1.4) million migraine visits
to US emergency departments. Including opioid-containing oral analgesic
combinations, opioids were administered in 59% of visits (95% confidence
interval 51, 67). The most commonly used parenteral agent, hydromorphone, was
used in 25% (95% confidence interval 19, 33) of visits in 2010 versus less than
1% (95% confidence interval 0, 3) in 1998. Conversely, use of meperidine had
decreased markedly over the same timeframe. In 2010, it was used in just 7%
(95% confidence interval 4, 12) of visits compared to 37% (95% confidence
interval 29, 45) in 1998. Metoclopramide, the most commonly used
anti-dopaminergic, was administered in 17% (95% confidence interval 12, 23) of
visits in 2010 and 3% (95% confidence interval 1, 6) of visits in 1998. Use of
any triptan was relatively uncommon in 2010 (7% (95% confidence interval 4, 11)
of visits) and in 1998 (10% (95% confidence interval 6, 15) of visits). Of the
predictor variables listed above, only emergency department use within the
previous 12 months was associated with opioid administration (adjusted odds
ratio: 2.87 (95% confidence interval 1.03, 7.97)).
CONCLUSIONS:
In spite of recommendations to the contrary, opioids are still used in more
than half of all emergency department visits for migraine. Though use of
meperidine has decreased markedly between 1998 and 2010, it has largely been
replaced by hydromorphone. Opioid use in migraine visits is independently
associated with prior visits to the same emergency department in the previous
12 months.
16. Characteristics and 30d Outcomes of ED Pts c Elevated CK in
Pts c Rhabdo
Grunau BE,
et al. Acad Emerg Med. 2014;21:631-636.
Objectives:
Rhabdomyolysis, as defined by an elevation in creatine kinase (CK), may lead to
hemodialysis and death in emergency department (ED) patients, but the patient
characteristics, associated conditions, and 30-day outcomes of patients with CK
values over 1,000 U/L have not been described.
Methods: All
consecutive ED patients with serum CK values over 1,000 U/L between January 1,
2006, and December 31, 2008, were retrospectively identified from two urban
hospitals. Patient characteristics, ED treatment, and ED discharge diagnoses
were determined by medical record review. Provincial databases were linked to
identify patients who died or were treated with hemodialysis within 30 days.
The primary outcome was the combined occurrence of death or need for
hemodialysis within 30 days. Secondary outcomes included the incidence of acute
kidney injury (AKI) and the proportion of patients with initial estimated
glomerular filtration rates (eGFR) beyond 60 mL/min/1.73 m2 who died or
required hemodialysis.
Results: Four-hundred
patients were identified, the median age was 50 years (interquartile range
[IQR] = 35 to 69 years), and 77% were male, with 35% of patients discharged
home from the ED. The most common ED discharge diagnoses were related to
recreational drug use, infections, and traumatic or musculoskeletal complaints.
Within 30 days, 32 (8.0%, 95% confidence interval [CI] = 5.3% to 11%) experienced
primary outcomes, with 18 (4.5%, 95% CI = 2.55% to 6.5%) requiring hemodialysis
and 21 deaths (5.3%, 95% CI = 3.1% to 7.4%). AKI occurred in 151 patients (38%,
95% CI = 33% to 43%). Of the 257 patients (64%) with initial eGFRs over 60
mL/min/1.73 m2, none required hemodialysis.
Conclusions:
In ED patients with initial CK over 1,000 U/L, the incidence of death or
hemodialysis was 8% within 30 days. Patients with initial eGFRs over 60
mL/min/1.73 m2 appear to be at a low risk of these outcomes from rhabdomyolysis.
17. Skin Infections: Practical Guide for Clinicians from the IDSA
By Michael
Smith, MedPage Today. Jun 19, 2014
Accurate
diagnosis is the key to treating skin and soft tissue infections, according to
new practice guidelines from the Infectious Diseases Society of America.
While
antibiotic treatment is life-saving in some cases, the guidelines stress that
most skin and soft tissue infections (SSTIs) -- including those caused by
drug-resistant bacteria -- are mild and will heal on their own.
Antibiotics
"should only be given when needed, and these guidelines will help
physicians know when they are and are not necessary," commented Dennis
Stevens, MD, PhD, of the Veterans Affairs Medical Center in Boise, Idaho, and
lead author of the guidelines, appearing online in Clinical Infectious
Diseases.
The
guidelines, an update of the 2005 version, are designed to be "concordant
with" the society's 2011 recommendations on the treatment of infections
caused by methicillin-resistant Staphylococcus aureus (MRSA), the authors
noted.
Full-text
(free) of IDSA guidelines: http://cid.oxfordjournals.org/content/early/2014/06/14/cid.ciu296.full
18. Isolated Free Fluid on Abdominal CT Imaging in Blunt Trauma:
Operative Exploration or Observation?
Patients
with minimal free fluid and no abdominal tenderness can be observed, while
patients with significant free fluid and abdominal tenderness should undergo
operative exploration.
Gonser-Hafertepen
LN et al. J Am Coll Surg 2014 Jun 5. [Epub ahead of print]
Background:
Isolated free fluid (FF) on abdominal computed tomography (CT) in stable blunt
trauma patients may indicate the presence of hollow viscus injury. No criteria
exist to differentiate treatment by operative exploration versus observation.
The goals of this study were to determine the incidence of isolated FF and to
identify factors that discriminate between patients who should undergo
operative exploration versus observation.
Study
Design: A review of blunt trauma patients at a Level I Trauma Center from
7/2009-3/2012 was performed. Patients with a CT showing isolated FF after blunt
trauma were included. Data collected included demographics, injury severity,
physical examination, CT, and operative findings.
Results: 2,899
patients had CT scans of which 156 patients (5.4%) had isolated FF. The
therapeutic operative (TO) group had 13 patients; 9 had immediate operation and
4 failed non-operative management. The non-operative/non-therapeutic operation
group (NO/NT) consisted of 142 patients with successful non-operative
management and 1 patient with a non-therapeutic operation. Abdominal tenderness
was documented in 69% of TO group and 23% of NO/NT group (OR 7.5, p less than 0.001).
The presence of moderate-large amount of FF was increased in the TO group (85%
vs. 8%, OR 66, p less than 0.001).
Conclusions:
Isolated FF was noted in 5.4% of stable blunt trauma patients. Blunt trauma
patients with moderate-large amount of FF without solid organ injury on CT and
abdominal tenderness should undergo immediate operative exploration. Patients
with neither of these findings can be safely observed.
19. Marijuana-Using Drivers, Alcohol-Using Drivers, and Their
Passengers: Prevalence and Risk Factors among Underage College Students
Whitehill
JM, et al. JAMA Pediatr.
2014;168(7):618-624.
Importance Driving after marijuana use increases the
risk of a motor vehicle crash. Understanding this behavior among young drivers
and how it may differ from alcohol-related driving behaviors could inform
prevention efforts.
Objective To describe the prevalence, sex differences,
and risk factors associated with underage college students’ driving after using
marijuana, driving after drinking alcohol, or riding with a driver using these
substances.
Design,
Setting, and Participants
Cross-sectional telephone survey of a random sample of 315 first-year
college students (aged 18-20 years) from 2 large public universities, who were
participating in an ongoing longitudinal study. At recruitment, 52.8% of
eligible individuals consented to participate; retention was 93.2% one year
later when data for this report were collected.
Main
Outcomes and Measures Self-reported
past-28-day driving after marijuana use, riding with a marijuana-using driver,
driving after alcohol use, and riding with an alcohol-using driver.
Results In the prior month, 20.3% of students had
used marijuana. Among marijuana-using students, 43.9% of male and 8.7% of
female students drove after using marijuana (P less than .001), and 51.2% of
male and 34.8% of female students rode as a passenger with a marijuana-using
driver (P = .21). Most students (65.1%) drank alcohol, and among this group
12.0% of male students and 2.7% of female students drove after drinking
(P = .01), with 20.7% and 11.5% (P = .07), respectively, reporting riding with
an alcohol-using driver. Controlling for demographics and substance use
behaviors, driving after substance use was associated with at least a 2-fold
increase in risk of being a passenger with another user; the reverse was also
true. A 1% increase in the reported percentage of friends using marijuana was
associated with a 2% increased risk of riding with a marijuana-using driver
(95% CI, 1.01-1.03). Among students using any substances, past-28-day use of
only marijuana was associated with a 6.24-fold increased risk of driving after
substance use compared with using only alcohol (95% CI, 1.89-21.17).
Conclusions
and Relevance Driving and riding after
marijuana use is common among underage, marijuana-using college students. This
is concerning given recent legislation that may increase marijuana
availability.
20. When Doctors Ignore ‘DNR’ Orders
Russell
Saunders. The Daily Beast. June 3, 2014
Over 88
percent of physicians don’t want to be kept alive in a situation where doing so
only prolongs their existence. So why aren’t they listening to patients who ask
for the same?
When it’s
my time to go, I hope it happens without a fuss.
In the
event that I suffer from a terminal illness, once the point has been passed
where a return to health or meaningful quality of life is no longer a realistic
possibility, when further treatment will do nothing but fill my days with more
of itself, then I want that treatment to end. Though I hope such plans are a
long, long way from ever being enacted, my husband and other loved ones know
that I would not want “heroic” measures to prolong my life, and would choose a
peaceful rather than a protracted death.
I am not
alone in this. A new study in the online journal PLOS One reports that most of
my fellow physicians feel the same way. The authors of the study surveyed over
a thousand doctors, and just over 88 percent of them reported wanting an
advance directive that would stipulate “do not resuscitate” (or DNR) status at
the ends of their lives. I would have answered precisely the same way.
Those
results do not surprise me in the least.
I cannot
imagine going all the way through medical school, to say nothing of residency,
without witnessing cases where patients received medical care that prolonged
their existences but not their lives. It is a common enough occurrence that I
would generalize it to essentially every graduate of medical school. We’ve all
seen patients given interventions that preserved the functioning of their
organs without any hope that the people themselves would have anything but
misery to number out their days.
Why is this
so? Why does the same study report that doctors will often override an advance
directive if it conflicts with their clinical decisions that further treatment
is warranted? Why would we order medical care that we do not want for
ourselves?
The rest of
the essay: http://www.thedailybeast.com/articles/2014/06/03/when-doctors-ignore-do-not-resuscitate-orders.html
The PLoS
One article (full-text free): http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0098246
21. Experimental evidence of massive-scale emotional contagion
through social networks
Kramera
ADI, et al. PNAS 2014;111:8788–8790
Emotional
states can be transferred to others via emotional contagion, leading people to
experience the same emotions without their awareness. Emotional contagion is
well established in laboratory experiments, with people transferring positive
and negative emotions to others. Data from a large real-world social network,
collected over a 20-y period suggests that longer-lasting moods (e.g.,
depression, happiness) can be transferred through networks [Fowler JH,
Christakis NA (2008) BMJ 337:a2338], although the results are controversial. In
an experiment with people who use Facebook, we test whether emotional contagion
occurs outside of in-person interaction between individuals by reducing the
amount of emotional content in the News Feed. When positive expressions were
reduced, people produced fewer positive posts and more negative posts; when
negative expressions were reduced, the opposite pattern occurred. These results
indicate that emotions expressed by others on Facebook influence our own
emotions, constituting experimental evidence for massive-scale contagion via
social networks. This work also suggests that, in contrast to prevailing
assumptions, in-person interaction and nonverbal cues are not strictly
necessary for emotional contagion, and that the observation of others’ positive
experiences constitutes a positive experience for people.
Comment of
Facebook’s role in this study: http://www.forbes.com/sites/gregorymcneal/2014/06/28/facebook-manipulated-user-news-feeds-to-create-emotional-contagion/
22. Understanding our culturally-imbibed unconscious biases
about race and age
Mahzarin R.
Banaji and Anthony Greenwald, Blindspot:
Hidden Biases of Good People (New York: Delacorte Press, 2013). http://spottheblindspot.com/the-book/
Written by
two leaders in this fascinating field of research
Clinical research
has demonstrated an implicit race bias among emergency physicians and our
prediction of thrombolysis decisions
Green AR, J
Gen Intern Med. 2007 Sep;22(9):1231-8.
CONTEXT:
Studies documenting racial/ethnic disparities in health care frequently
implicate physicians' unconscious biases. No study to date has measured
physicians' unconscious racial bias to test whether this predicts physicians'
clinical decisions.
OBJECTIVE:
To test whether physicians show implicit race bias and whether the magnitude of
such bias predicts thrombolysis recommendations for black and white patients
with acute coronary syndromes.
DESIGN, SETTING,
AND PARTICIPANTS: An internet-based tool comprising a clinical vignette of a
patient presenting to the emergency department with an acute coronary syndrome,
followed by a questionnaire and three Implicit Association Tests (IATs). Study
invitations were e-mailed to all internal medicine and emergency medicine
residents at four academic medical centers in Atlanta and Boston; 287 completed
the study, met inclusion criteria, and were randomized to either a black or
white vignette patient.
MAIN
OUTCOME MEASURES: IAT scores (normal continuous variable) measuring physicians'
implicit race preference and perceptions of cooperativeness. Physicians'
attribution of symptoms to coronary artery disease for vignette patients with
randomly assigned race, and their decisions about thrombolysis. Assessment of
physicians' explicit racial biases by questionnaire.
RESULTS:
Physicians reported no explicit preference for white versus black patients or
differences in perceived cooperativeness. In contrast, IATs revealed implicit
preference favoring white Americans (mean IAT score = 0.36, P less than .001,
one-sample t test) and implicit stereotypes of black Americans as less
cooperative with medical procedures (mean IAT score 0.22, P less than .001),
and less cooperative generally (mean IAT score 0.30, P less than .001). As
physicians' prowhite implicit bias increased, so did their likelihood of
treating white patients and not treating black patients with thrombolysis (P =
.009).
CONCLUSIONS:
This study represents the first evidence of unconscious (implicit) race bias
among physicians, its dissociation from conscious (explicit) bias, and its
predictive validity. Results suggest that physicians' unconscious biases may
contribute to racial/ethnic disparities in use of medical procedures such as thrombolysis
for myocardial infarction.
23. Tid Bits
A. Five Strategies to Effectively
Use Online Resources in Emergency Medicine
Thoma B, et
al. Ann Emerg Med. 2014; in press
Introduction
For health
professions learners of all levels, staying abreast of the literature can seem
like an insurmountable task as the number of clinically oriented articles
continues to grow at an increasing rate. Fortunately,
there has been a veritable explosion of online secondary resources that
endeavor to digest the expanding medical literature and present it in a format
that is optimized for adult learners. Particularly in emergency medicine, these
resources have been dubbed “free open access medical education,” also known as
free open access meducation (FOAM).
The FOAM movement has figured prominently in the proliferation of blogs and
podcasts made available online by practicing clinicians. As an unintended
consequence, learners must now contend with an exponentially expanding library
of both primary literature and secondary online resources.
To make
effective use of this stream of knowledge, learners must filter and choose from
myriad resources. Simple digital tools can be used to organize and manage
this otherwise overwhelming amount of information. This article outlines
5 strategies to help learners and practicing physicians stay abreast of
both foundational and cutting-edge literature by using digital solutions.
Table 1
provides an overview of each step…
B. CDC: Excessive drinking is tied
to 1 in 10 deaths among adults
From 2006
to 2010, heavy drinking claimed the lives of about 88,000 working-age adults
each year, according to a CDC study published in the journal Preventing Chronic
Disease. Men faced greater risk than women, and people 20 to 64 were more
susceptible than those of other ages.
C. 2014 AHA Heart and Stroke
Statistics
Each year,
the American Heart Association, in conjunction with the Centers for Disease
Control and Prevention, National Institutes of Health and other government
agencies, compiles up-to-date statistics on heart disease, stroke and other vascular
diseases in the Heart Disease and Stroke Statistical Update. This is a valuable
resource for researchers, clinicians, healthcare policy makers, media
professionals, the public and others who seek the best national data available
on disease morbidity, mortality and risks; quality of care; medical procedures
and operations; and costs associated with the management of these diseases. The
2014 Statistical Update is a major source for monitoring cardiovascular health
and disease in the population, with a focus on progress toward the American
Heart Association’s 2020 Impact Goals.
D. Screening for AAA: U.S.
Preventive Services Task Force Recommendation Statement
The USPSTF
recommends 1-time screening for AAA with ultrasonography in men aged 65 to 75
years who have ever smoked. (B recommendation)
The USPSTF
recommends that clinicians selectively offer screening for AAA in men aged 65
to 75 years who have never smoked. (C recommendation)
The USPSTF
concludes that the current evidence is insufficient to assess the balance of
benefits and harms of screening for AAA in women aged 65 to 75 years who have
ever smoked. (I statement)
The USPSTF
recommends against routine screening for AAA in women who have never smoked. (D
recommendation)
E. Lack of Training Hampers Domestic
Abuse Screening
NASHVILLE,
Tenn. -- One-quarter of clinicians reported that they never received any
training in dealing with intimate partner violence, and more than three-fourths
said they had not received such training in the previous 6 months, according to
a single-center study presented here.
F. Analysis: Vaccine benefits
outweigh adverse event risks
The overall
benefits of childhood vaccinations are greater than the risks of adverse
events, according to a data analysis from Rand Corp. that included multiple
studies. The report in Pediatrics, commissioned by the Agency for Healthcare
Research and Quality, found some vaccines were linked to rare serious events,
such as febrile seizures from the measles, mumps and rubella vaccine or
complications in immunodeficient patients who received the varicella vaccine.
Full-text
(free): http://pediatrics.aappublications.org/content/early/2014/06/26/peds.2014-1079.full.pdf+html
G. Put down your smartphone and pick
up a book
Tobin MJ. BMJ
2014;349:g4521
Excerpts
Online
reading involves a different form of literacy than that of the printed page.
The eyes bounce and flicker as they dart promiscuously, searching for nuggets
of information and quick wins. It is almost as if people go online to avoid
reading in the traditional sense.2 The instant presentation of expansive
information threatens the more demanding task of the formation of in depth
knowledge.3 Literacy—the most empowering achievement of our civilisation—is
being replaced by screen savviness.
Neuroscientists
have been studying the effects of reading on the brain for decades. The brain
is infinitely malleable, and reading plays an important part in shaping
neuronal circuits and expanding the ways we think. Media not only serve as
passive channels of information, they also shape the process of thought.8
Investigators have found we don’t so much read online as quickly scan short
passages, bouncing from one site to the next. Reading has taken on a “staccato”
quality, rather than performing the heavy lifting of concentration, analysis,
and contemplation.
In a recent
randomised trial, Mangen and colleagues found that teenagers who read material
on a printed page understood the text significantly better than those who read
the same material on a screen.9
H. Risks may outweigh benefits of
post-MI beta blockers
A
meta-analysis of more than 100,000 subjects found that beta-blockers offered no
reduction in mortality risk in post-myocardial infarction patients and resulted
in a 10% increased risk of heart failure and 29% increased risk of cardiogenic
shock in some patients. In light of these findings, clinical guidelines for the
use of beta-blockers in post-MI patients should be reconsidered, researchers
said.
I. Avoiding Nocebo Effects to
Optimize Treatment Outcome
Bingel U,
et al. JAMA. Published online July 07, 2014.
Converging
evidence suggests that the occurrence of unwanted adverse events during drug
treatment is in part determined by nonpharmacological effects. For instance,
the majority of unwanted adverse effects and symptoms reported by patients in
clinical trials often are not caused by the medication, because unwanted
adverse effects can also occur to a comparable degree in the placebo group of
the study.1 Similarly, the switch from brand name to generic drugs with
identical compounds is frequently associated with an increase in unwanted
adverse effects and therefore could lead to treatment discontinuation. These
examples highlight that patients’ expectations regarding adverse effects are
important determinants of unwanted adverse effects during drug treatment.
Negative
expectations not only determine the occurrence of unwanted adverse effects but
can affect the therapeutic efficacy of the drug. A pharmacological study using
functional magnetic resonance imaging showed that negative treatment expectancy
abolished the analgesic effect of the potent µ-opioid remifentanil at the
behavioral and neural level.2 Similarly, a recent study of acute migraine
treatment revealed that falsely labeling the 5HT1B/1D agonist rizatriptan as
placebo significantly reduced its efficacy.3 Observations from clinical
crossover trials and experimental evidence indicate that negative expectations
or prior experience transfer over time, and treatment can hamper the effect of
subsequent treatment.4
