Sunday, July 13, 2014

Lit Bits: July 13, 2014

From the recent medical literature...

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:

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

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.

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.

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.

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.

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?

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.

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).

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

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. x1See all References x2Larsen, P.O. and von Ins, M. The rate of growth in scientific publication and the decline in coverage provided by Science Citation Index. Scientometrics. 2010; 84: 575–603

CrossRef | PubMed | Scopus (61)See all ReferencesFortunately, 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). x3Nickson, C.P. and Cadogan, M.D. Free open access medical education (FOAM) for the emergency physician. Emerg Med Australas. 2014; 26: 76–83

CrossRef | PubMed | Scopus (2)See all References3 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 1Table 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.

G. Put down your smartphone and pick up a book

Tobin MJ. BMJ 2014;349:g4521

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