Tuesday, August 12, 2014

Lit Bits: Aug 12, 2014

From the recent medical literature...

1. Is Oral Contrast Necessary with CT Scanning for Suspected Appy?

Allan S. Brett, MD, Journal Watch Emerg Medicine, July 31, 2014  

In an observational study, oral contrast did not improve accuracy in patients who received intravenous contrast.

In three single-center, randomized trials, oral contrast — given in addition to intravenous (IV) contrast — did not improve the diagnostic accuracy of computed tomographic (CT) scanning for suspected appendicitis. To determine whether this conclusion is generally valid, researchers analyzed a surgical database that represents 56 hospitals in Washington State. During a 2-year period, 8089 adults underwent nonelective appendectomy preceded by CT scanning; 54% received IV contrast only, 29% received both IV and enteral contrast, 13% received no contrast, and 4% received only enteral contrast.

Concordance between CT scan interpretations and pathology reports was 90% in both the IV-only and IV-plus-enteral contrast groups; concordance was slightly lower (86%) among patients who received no IV or enteral contrast. Accuracy of the two CT protocols remained similar after adjustment for potentially confounding variables and in a propensity-matched analysis. Accuracy was similar in all types of hospitals (urban or rural; teaching or nonteaching).

In this observational study that included a wide spectrum of hospitals, enteral contrast did not improve diagnostic accuracy of CT scanning in patients with suspected appendicitis who received IV contrast. The advantage of not giving enteral contrast is quicker disposition in the emergency department and avoidance of oral intake prior to general anesthesia. However, this study did not address whether enteral contrast adds useful information in patients who have abdominal pain and several plausible diagnostic alternatives to appendicitis.

Source: Drake FT et al. Enteral contrast in the computed tomography diagnosis of appendicitis: Comparative effectiveness in a prospective surgical cohort. Ann Surg 2014 Jul; 260:311.

2. Most Blood Cultures in Febrile Infants with Bacteremia Positive within 24 hours

Biondi EA, et al, for the Pediatric Research in Inpatient Settings (PRIS) Network

JAMA Pediatr. 2014 July 21 2014 [Epub ahead of print]

Importance  Blood cultures are often obtained as part of the evaluation of infants with fever and these infants are typically observed until their cultures are determined to have no growth. However, the time to positivity of blood culture results in this population is not known.

Objective  To determine the time to positivity of blood culture results in febrile infants admitted to a general inpatient unit.

Design, Setting, and Participants  Multicenter, retrospective, cross-sectional evaluation of blood culture time to positivity. Data were collected by community and academic hospital systems associated with the Pediatric Research in Inpatient Settings Network. The study included febrile infants 90 days of age or younger with bacteremia and without surgical histories outside of an intensive care unit.

Exposures  Blood culture growing pathogenic bacteria.

Main Outcomes and Measures  Time to positivity and proportion of positive blood culture results that become positive more than 24 hours after placement in the analyzer.

Results  A total of 392 pathogenic blood cultures were included from 17 hospital systems across the United States. The mean (SD) time to positivity was 15.41 (8.30) hours. By 24 hours, 91% (95% CI, 88-93) had turned positive. By 36 and 48 hours, 96% (95% CI, 95-98) and 99% (95% CI, 97-100) had become positive, respectively.

Conclusions and Relevance  Most pathogens in febrile, bacteremic infants 90 days of age or younger hospitalized on a general inpatient unit will be identified within 24 hours of collection. These data suggest that inpatient observation of febrile infants for more than 24 hours may be unnecessary in most infants.

3. Measurement type affects dosing errors in child medications

Summary: Parents who used a teaspoon or a tablespoon to measure doses of child medication had a twofold increased risk of making a dosing error compared with those who measured the medication in milliliters, a study in the journal Pediatrics showed. Among the 287 parents included in the study, 39% made an error in measuring out the dose, while 41% made a did not know the correct prescribed dose.

Yin HS, et al. Unit of Measurement Used and Parent Medication Dosing Errors. Pediatrics 2014 July 14 [Epub ahead of print]

BACKGROUND AND OBJECTIVES: Adopting the milliliter as the preferred unit of measurement has been suggested as a strategy to improve the clarity of medication instructions; teaspoon and tablespoon units may inadvertently endorse nonstandard kitchen spoon use. We examined the association between unit used and parent medication errors and whether nonstandard instruments mediate this relationship.

METHODS: Cross-sectional analysis of baseline data from a larger study of provider communication and medication errors. English- or Spanish-speaking parents (n = 287) whose children were prescribed liquid medications in 2 emergency departments were enrolled. Medication error defined as: error in knowledge of prescribed dose, error in observed dose measurement (compared to intended or prescribed dose); greater than 20% deviation threshold for error. Multiple logistic regression performed adjusting for parent age, language, country, race/ethnicity, socioeconomic status, education, health literacy (Short Test of Functional Health Literacy in Adults); child age, chronic disease; site.

RESULTS: Medication errors were common: 39.4% of parents made an error in measurement of the intended dose, 41.1% made an error in the prescribed dose. Furthermore, 16.7% used a nonstandard instrument. Compared with parents who used milliliter-only, parents who used teaspoon or tablespoon units had twice the odds of making an error with the intended (42.5% vs 27.6%, P = .02; adjusted odds ratio=2.3; 95% confidence interval, 1.2–4.4) and prescribed (45.1% vs 31.4%, P = .04; adjusted odds ratio=1.9; 95% confidence interval, 1.03–3.5) dose; associations greater for parents with low health literacy and non–English speakers. Nonstandard instrument use partially mediated teaspoon and tablespoon–associated measurement errors.

CONCLUSIONS: Findings support a milliliter-only standard to reduce medication errors.

4. Role of Troponin in Patients with Chronic Kidney Disease and Suspected ACS: A Systematic Review.

Stacy SR, et al. Ann Intern Med. 2014 Aug 12 [Epub ahead of print]

Diagnosis of acute coronary syndrome (ACS) is generally based on clinical symptoms, electrocardiographic (ECG) changes, and cardiac enzyme assays (1). Troponin is a protein complex released from cardiac muscle in proportion to the degree of muscle injury. Guidelines define a clinically relevant increase in troponin level as one that exceeds the 99th percentile of a normal reference population. Clinicians use this information to stratify patients according to risk and to choose treatment (2).

The diagnosis of ACS—including acute myocardial infarction (AMI) and unstable angina—is outlined by the Global MI Task Force's Third Universal Definition of Myocardial Infarction (3), which requires increasing or decreasing troponin levels plus additional evidence of myocardial ischemia. The diagnosis can be particularly challenging in patients with advanced chronic kidney disease (CKD). High prevalence of persistently elevated troponin levels in these patients may reduce the specificity of troponin for diagnosing AMI. Elevated troponin levels in patients with CKD may be explained by cardiac injury associated with chronic structural heart disease (such as coronary artery disease or heart failure) rather than acute ischemia, especially when levels do not change rapidly over time (4). Reduced renal clearance is probably not the primary mechanism of persistently elevated troponin levels in patients with CKD, although this issue is controversial (5).

Thus, diagnosing ACS in patients with CKD and elevated troponin levels presents a dilemma to the clinician and often requires extended evaluation for an accurate diagnosis. A change in troponin level greater than 20% within 9 hours (with ≥1 value exceeding the 99th percentile) is recommended for AMI diagnosis among patients with end-stage renal disease and suspected ACS (6). No consensus exists on whether the criteria for AMI diagnosis with the use of a troponin assay should differ for patients with and without CKD or whether baseline elevated troponin levels reduce the ability to diagnose AMI in patients with end-stage renal disease but not in those with earlier stages of CKD (5). Whether troponin levels in patients with CKD (vs. those without it) and suspected ACS are associated with differences in the comparative effectiveness of interventions or treatment strategies is also unknown.

In addition to their use in diagnosing and managing ACS, troponin assays have been investigated as independent predictors of morbidity and mortality after an acute ischemic event. Previous reviews have examined the prognostic performance of troponin testing in patients with CKD but excluded studies of those with ACS (7–8). Therefore, the prognostic significance of elevated troponin levels with regard to short- and long-term major adverse cardiovascular events (MACEs) for patients with CKD and ACS is uncertain. Given that the prevalence of CKD in the United States reached 15% in 2008, interpretation of troponin levels in this population is an important issue (9–10).

We aimed to systematically review the evidence for the diagnostic performance of elevated troponin levels for the detection of ACS in patients with CKD, the extent to which elevated troponin level modifies the comparative effectiveness of interventions or management strategies for ACS in this population, and the prognostic value of elevated troponin levels in estimating short- and long-term outcomes in patients with CKD and suspected ACS.

Background: Patients with chronic kidney disease (CKD) have high prevalence of elevated serum troponin levels, which makes diagnosis of acute coronary syndrome (ACS) challenging.

Purpose: To evaluate the utility of troponin in ACS diagnosis, treatment, and prognosis among patients with CKD.

Data Sources: MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials through May 2014.

Study Selection: Studies examining elevated versus normal troponin levels in terms of their diagnostic performance in detection of ACS, effect on ACS management strategies, and prognostic value for mortality or cardiovascular events after ACS among patients with CKD.

Data Extraction: Paired reviewers selected articles for inclusion, extracted data, and graded strength of evidence (SOE).

Data Synthesis: Twenty-three studies met inclusion criteria. The sensitivity of troponin T for ACS diagnosis ranged from 71% to 100%, and specificity ranged from 31% to 86% (6 studies; low SOE). The sensitivity and specificity of troponin I ranged from 43% to 94% and from 48% to 100%, respectively (8 studies; low SOE). No studies examined how troponin levels affect management strategies. Twelve studies analyzed prognostic value. Elevated levels of troponin I or troponin T were associated with higher risk for short-term death and cardiac events (low SOE). A similar trend was observed for long-term mortality with troponin I (low SOE), but less evidence was found for long-term cardiac events for troponin I and long-term outcomes for troponin T (insufficient SOE). Patients with advanced CKD tended to have worse prognoses with elevated troponin I levels than those without them (moderate SOE).

Limitation: Studies were heterogeneous in design and in ACS definitions and adjudication methods.

Conclusion: In patients with CKD and suspected ACS, troponin levels can aid in identifying those with a poor prognosis, but the diagnostic utility is limited by varying estimates of sensitivity and specificity.

5. Systemic antibiotics not necessary after I&D of simple abscesses: a meta-analysis

Singer AJ, et al. Emerg Med J 2014;31:576-578

Background: Over the last decade, there has been a significant increase in the number of cutaneous abscesses. While there is general agreement that abscesses should be treated with incision and drainage, it is unclear whether systemic antibiotics should be routinely prescribed.

Objective: To evaluate whether systemic antibiotics, when compared with a placebo, improve cure rates in patients with simple abscesses after incision and drainage.

Methods: Design Systematic review and meta-analysis using RevMan5.
Patients and settings Children and adults with simple abscesses treated in outpatient clinics or emergency departments.

Data sources: Cochrane Central, Medline, Embase and bibliographies.

Outcome measures: Percentage of patients with complete resolution of abscess without the need for recurrent incision and drainage, additional antibiotics, or hospital admission within 7–10 days of treatment.

Results: We included four trials, consisting of 589 patients in total (428 adults and 161 children). Patients were randomised to one of three antibiotics ([cephradine] (27), cephalexin (82), or trimethoprim sulfamethoxazole (161)) or to placebo (285), with 34 lost to follow-up or having incomplete data. When given in addition to incision and drainage, systemic antibiotics did not significantly improve the percentage of patients with complete resolution of their abscesses 7–10 days after treatment (88.1% vs 86.0%; OR 1.17 (95% CI 0.70 to 1.95)).

Conclusions: When given in addition to incision and drainage, systemic antibiotics do not significantly improve the percentage of patients with complete resolution of their abscesses.

6. Diagnosis of Necrotizing Faciitis with Bedside Ultrasound: the STAFF Exam.

Castleberg E, et al. West J Emerg Med. 2014;15(1):111-3.

Necrotizing fasciitis is a severe soft-tissue infection with significant morbidity and mortality, reported between 25% and 75%.[1] In the United States, the annual age-adjusted incidence is approximately 4.3 infections per 100,000 of the population. This produces a heavy financial toll, with a mean hospital length of stay of 36 days, resulting in an average cost per patient of $62,846.[2]

Although necrotizing fasciitis is primarily a clinical diagnosis, patient presentations can be ambiguous. While a computed tomography (CT) is traditionally used to confirm the diagnosis prior to surgery in uncertain cases, newer research shows ultrasound may be a specific modality in confirming the diagnosis and preventing delays in definitive surgical treatment.[3]

The early diagnosis of necrotizing fasciitis is often ambiguous. Computed tomography and magnetic resonance imaging, while sensitive and specific modalities, are often time consuming or unavailable. We present a case of necrotizing fasciitis that was rapidly diagnosed using bedside ultrasound evaluating for subcutaneous thickening, air, and fascial fluid (STAFF). We propose the STAFF ultrasound exam may be beneficial in the rapid evaluation of unstable patients with consideration of necrotizing fasciitis, in a similar fashion to the current use of a focused assessment with sonography for trauma exam in the setting of trauma.

Related article: Point-of-Care Ultrasound Diagnosis of Necrotizing Fasciitis Missed By Computed Tomography and Magnetic Resonance Imaging

7. Poor Adherence to DC Instructions for Pediatric Concussion

Katherine Bakes, MD,  Journal Watch Emerg Medicine, Aug 4, 2014

Of patients who returned to activities 2 weeks after emergency-department discharge, 35% reported continued concussive symptoms.

Prior studies have shown that adolescent athletes with concussions often do not follow guidelines governing when they can return to play. To further examine this issue, investigators conducted a prospective cohort study of 150 pediatric patients (median age, 13 years) diagnosed with concussion during a 1-year period at a single pediatric emergency department (ED).

At discharge, patients received instructions developed from the third international Consensus Statement on Concussion in Sport. Follow-up phone surveys assessing nonadherence — returning to play or normal activities on or before resolution of symptoms or without medical clearance — were completed by 83% of patients at 2 weeks and by 77% at 4 weeks.

Results were as follows:
·         39% reported returning to play on the same day as the injury.
·         Of the 44% who returned to activities at 2 weeks, 58% had not received medical clearance and 35% were still symptomatic.
·         Of the 64% who returned to activities at 4 weeks, 46% had not received medical clearance and 23% were symptomatic.
·         Patients with sports concussions were more likely than those with non-sports concussions to have received medical clearance before returning to play at 2 weeks (54% vs. 20%), but not at 4 weeks.
·         Returning to play with symptoms and without medical clearance was not associated with age.

Despite a national campaign to improve long-term outcomes from pediatric concussions, adherence to discharge instructions is dismal. ED providers can be a strong voice in educating parents and, at discharge, should stress the importance of compliance with guidelines.

Source: Hwang V et al. Are pediatric concussion patients compliant with discharge instructions? J Trauma Acute Care Surg 2014 Jul; 77:117

8. Fluid Resuscitation in Sepsis: A Systematic Review and Network Meta-analysis

Rochwerg B, et al, for the Fluids in Sepsis and Septic Shock Group

Ann Intern Med.  22 July 2014 [Epub ahead of print]

Background: Fluid resuscitation is the cornerstone of sepsis treatment. However, whether balanced or unbalanced crystalloids or natural or synthetic colloids confer a survival advantage is unclear.

Purpose: To examine the effect of different resuscitative fluids on mortality in patients with sepsis.

Data Sources: MEDLINE, EMBASE, ACP Journal Club, CINAHL, HealthSTAR, the Allied and Complementary Medicine Database, and the Cochrane Central Register of Controlled Trials through March 2014.

Study Selection:  Randomized trials that evaluated different resuscitative fluids in adult patients with sepsis or septic shock and death. No language restrictions were applied.

Data Extraction: Two reviewers extracted data on study characteristics, methods, and outcomes. Risk of bias for individual studies and quality of evidence were assessed.

Data Synthesis: 14 studies (18 916 patients) were included with 15 direct comparisons. Network meta-analysis at the 4-node level showed higher mortality with starches than with crystalloids (high confidence) and lower mortality with albumin than with crystalloids (moderate confidence) or starches (moderate confidence). Network meta-analysis at the 6-node level showed lower mortality with albumin than with saline (moderate confidence) and low-molecular-weight starch (low confidence) and with balanced crystalloids than with saline (low confidence) and low- and high-molecular-weight starches (moderate confidence).

Limitations: These trials were heterogeneous in case mix, fluids evaluated, duration of fluid exposure, and risk of bias. Imprecise estimates for several comparisons in this network meta-analysis contribute to low confidence in most estimates of effect.

Conclusion: Among patients with sepsis, resuscitation with balanced crystalloids or albumin compared with other fluids seems to be associated with reduced mortality.

What’s a “balanced solution”? See the editorial: http://annals.org/article.aspx?articleID=1889549

9. Ann Emerg Med Synopses

A. Does Advanced Airway Management Improve Outcomes in Adult Out-of-Hospital Cardiac Arrest?

Maybe. Or, in their words, “Advanced airway management in adult out-of-hospital cardiac arrest lacks clear benefit, but available studies are unable to control for many confounders in this population.”

B. Does the Use of Video Laryngoscopy Improve Intubation Outcomes?

Maybe. Or, in their words, “Video laryngoscopy provides superior views of the glottic opening compared with direct laryngoscopy but does not improve the overall rate of intubation success. For difficult airways, video laryngoscopy decreases the time required for intubation.”

C. Does Calcium Administration During Cardiopulmonary Resuscitation Improve Survival for Patients in Cardiac Arrest?

Nope. Irrespective of presenting rhythm, in patients with cardiac arrest there is no conclusive evidence that administration of calcium during cardiopulmonary resuscitation (CPR) improves survival.

D. Does Active Chest Compression-Decompression Cardiopulmonary Resuscitation Decrease Mortality, Neurologic Impairment, or Cardiopulmonary Resuscitation–Related Complications After Cardiac Arrest?

There is no clear benefit from active compression-decompression cardiopulmonary resuscitation (CPR) in out-of-hospital or inhospital cardiac arrest.

10. CDC: Major Disparities in Opioid Prescribing Among States: Some States Crack Down on Excess Prescribing

Bridget M. Kuehn, MSJ. JAMA. Published online August 06, 2014.

The first few months of 2010 marked a dramatic turn in Florida’s efforts to curb rampant “pill mills,” clinics that inappropriately prescribe large quantities of opioids for nonmedical reasons. The state required all pain clinics within its borders to register no later than January 2010. In that year, federal, state, and local law enforcement began a major crackdown, called Operation Pill Nation.

By February 2011, undercover officers had made 340 purchases of medication from 60 physicians at more than 40 pain clinics without showing evidence of a valid medical complaint, according to the US Drug Enforcement Administration. Ultimately, officials arrested 22 people and seized $2.2 million in cash as well as 70 vehicles (http://1.usa.gov/1qnV9UV).

In a recent publication, Florida public health leaders credited this law enforcement effort and a slew of recent laws with reducing drug overdose deaths in the state. From 2003 to 2009, the number of overdose deaths increased 61%, from 1804 to 2905, driven mostly by overdoses involving painkillers or the antianxiety medication alprazolam (Johnson H et al. MMWR Morb Mortal Wkly Rep. 2014;63[16]:347-351). Most of the deaths involved more than 1 drug, according to the report. Since the crackdown began, however, the state has begun to see a decline in deaths, from 3201 in 2010 to 2666 in 2012, based on data from state medical examiners.

11. Images in Clinical Practice

Intermittent Facial Flushing and Diarrhea 

Dahl’s Sign of Severe Chronic COPD

Baby with a Rash

Young Child with Strabismus

Phototoxic Dermatitis

Barium Concretion Causing Obstipation

12. Systematic Review and Meta-analysis of the Benefits of Out-of-Hospital 12-Lead ECG and Advance Notification in STEMI Patients.

Nam J, et al. Ann Emerg Med. 2014 Aug;64(2):176-186.e9.

STUDY OBJECTIVE: To present a review of out-of-hospital identification of ST-segment elevation myocardial infarction patients transported by emergency medical services with 12-lead ECG and advance notification versus standard or no cardiac monitoring.

METHODS: EMBASE, PubMed, and the Cochrane Library were searched, using controlled vocabulary and keywords. Randomized controlled trials and observational studies were included. Outcomes included short-term mortality (≤30 days), door-to-balloon/needle time and/or first medical contact-to-balloon/needle time. Pooled estimates were determined, where appropriate. Results were stratified by percutaneous coronary intervention or fibrinolysis.

RESULTS: The search yielded 1,857 citations, of which 68 full-texts were reviewed and 16 studies met the final criteria: 15 included data on percutaneous coronary intervention and 3 on fibrinolysis (2 included both). Where percutaneous coronary intervention was performed, out-of-hospital 12-lead ECG and advance notification was associated with a 39% reduction in short-term mortality (8 studies; n=6,339; risk ratio 0.61; 95% confidence interval 0.42 to 0.89; P=.01; I2=30%) compared with standard or no cardiac monitoring. Where fibrinolysis was performed, out-of-hospital 12-lead ECG and advance notification was associated with a 29% reduction in short-term mortality (1 study; n=17,026; risk ratio 0.71; 95% confidence interval 0.54 to 0.93; P=.01). First medical contact-to-balloon, door-to-balloon, and door-to-needle times were consistently reduced, though large heterogeneity generally precluded pooling.

CONCLUSION: The present study adds to previous reviews by identifying and appraising the strength and quality of a larger body of evidence. Out-of-hospital identification with 12-lead ECG and aadvance notification was found to be associated with reductions in short-term mortality and first medical contact-to-balloon, door-to-balloon, and door-to-needle time.

13. Predicting risk of UGI bleed and ICH with anticoagulants

Welcome to the QBleed® risk calculator

Welcome to the QBleed® Web Calculator. You can use this calculator to work out your risk of having a haemorrhage, and how this is affected by starting anticoagulants, by answering some simple questions.

The QBleed® algorithms have been developed by Julia Hippisley-Cox and Carol Coupland and are based on routinely collected data from many thousands of GPs across the country who have freely contributed data to the QResearch database for medical research, linked to hospital and mortality data.

QBleed® has been developed for the UK population, and is intended for use in the UK. This website is primarily intended for doctors and nurses working in general practice and for academics who are interested in the underlying research. Patients are welcome to read this information and use the calculator together with their doctor so that any symptoms or concerns can be addressed within a health care setting. All medical decisions need to be taken by a patient in consultation with their doctor. The authors and the sponsors accept no responsibility for clinical use or misuse of this score.

The science underpinning the new QBleed® equations has been published in the BMJ.

Online tool: http://www.qbleed.org/

Evidence-base: Hippisley-Cox J, et al. Predicting risk of upper gastrointestinal bleed and intracranial bleed with anticoagulants: cohort study to derive and validate the QBleed scores. BMJ 2014;349:g4606. Full-text (free): http://www.bmj.com/content/349/bmj.g4606

14. Nonintravenous Therapy for Acute Renal Colic Pain

The analgesic effect of sublingual buprenorphine was comparable to that of intravenous morphine.

Payandemehr P, et al. Int J Emerg Med 2014;7(1):1   

BACKGROUND: The aim of this study was to compare the efficacy and safety of sublingual buprenorphine with intravenous morphine sulfate for acute renal colic in the emergency department.

METHODS: In this double-dummy, randomized controlled trial, we enrolled patients aged 18 to 55 years who had a clinical diagnosis of acute renal colic. Patients received either 2 mg sublingual buprenorphine with an IV placebo, or 0.1 mg/kg IV morphine sulfate with a sublingual placebo. Subjects graded their pain with a standard 11-point numeric rating scale (NRS) before medication administration and 20 and 40 minutes after that. The need for rescue analgesia and occurrence of side effects were also recorded in the two groups.

RESULTS: Of 69 patients analyzed, 37 had received buprenorphine, and 32 had taken morphine. Baseline characteristics were similar in both groups. NRS pain scores were reduced across time by administration of both buprenorphine (from 9.8 to 5.22 and then 2.30) and morphine (from 9.78 to 4.25 and then 1.8), significantly (P less than 0.0001). The two regimens did not differ significantly for pain reduction (P=0.260). Dizziness was more frequently reported by the buprenorphine group (62.1% versus 37.5%, P less than 0.05) but other adverse effects observed within 40 minutes were similar in the two groups.

CONCLUSIONS: Sublingual buprenorphine (2 mg) is as effective as morphine sulfate (0.1 mg/kg) in acute renal colic pain management.

15. NSAIDs are associated with nonunion and infection rates in long-bone fractures.

Jeffcoach DR, et al. J Trauma Acute Care Surg. 2014 Mar;76(3):779-83.

BACKGROUND: There is a dearth of clinical data regarding the effect of nonsteroidal anti-inflammatory drugs (NSAIDs) on long-bone fracture (LBF) healing in the acute trauma setting. The orthopedic community believes that the use of NSAIDs in the postoperative period will result in poor healing and increased infectious complications. We hypothesized that, first, NSAID use would not increase nonunion/malunion and infection rates after LBF. Second, we hypothesized that tobacco use would cause higher rates of these complications.

METHODS: A retrospective study of all patients with femur, tibia, and/or humerus fractures between October 2009 and September 2011 at a Level 1 academic trauma center was performed . In addition to nonunion/malunion and infection rates, patient records were reviewed for demographic data, mechanism of fracture, type of fracture, tobacco use, Injury Severity Score (ISS), comorbidities, and medications given.

RESULTS: During the 24-month period, 1,901 patients experienced LBF; 231 (12.1%) received NSAIDs; and 351 (18.4%) were smokers. The overall complication rate including nonunion/malunion and infection was 3.2% (60 patients). Logistic regression analysis with adjusted odds ratios were calculated on the risk of complications given NSAID use and/or smoking, and we found that a patient is significantly more likely to have a complication if he or she received an NSAID (odds ratio, 2.17; 95% confidence interval, 1.15-4.10; p less than 0.016) in the inpatient postoperative setting. Likewise, smokers are significantly more likely to have complications (odds ratio, 3.19; 95% confidence interval, 1.84-5.53; p less than 0.001).

CONCLUSION: LBF patients who received NSAIDs in the postoperative period were twice as likely and smokers more than three times likely to suffer complications such as nonunion/malunion or infection. We recommend avoiding NSAID in traumatic LBF.

16. Heart attack care during off hours is improving, study suggests

A study in the journal Circulation: Cardiovascular Quality and Outcomes found that patients with a heart attack who seek medical assistance at the hospital on weeknights, weekends or holidays continue to be less likely to survive compared with those who arrive during business hours. But off-hour treatment times and survival rates were better than in past studies, researchers said.

Dasari TW, et al. Impact of Time of Presentation on Process Performance and Outcomes in ST-Segment–Elevation Myocardial Infarction. A Report From the American Heart Association: Mission Lifeline Program. Circ Cardiovasc Qual Outcomes. 2014 July 29 [Epub ahead of print]

Background—Prior studies demonstrated that patients with ST-segment–elevation myocardial infarction presenting during off-hours (weeknights, weekends, and holidays) have slower reperfusion times. Recent nationwide initiatives have emphasized 24/7 quality care in ST-segment–elevation myocardial infarction. It remains unclear whether patients presenting off-hours versus on-hours receive similar quality care in contemporary practice.

Methods and Results—Using Acute Coronary Treatment and Intervention Outcomes Network-Get With The Guidelines (ACTION-GWTG) database, we examined ST-segment–elevation myocardial infarction performance measures in patients presenting off-hours (n=27 270) versus on-hours (n=15 972; January 2007 to September 2010) at 447 US centers. Key quality measures assessed were aspirin use within first 24 hours, door-to-balloon time, door-to-ECG time, and door-to-needle time. In-hospital risk-adjusted all-cause mortality was calculated. Baseline demographic and clinical characteristics were similar. Aspirin use within 24 hours approached 99% in both groups. Among patients undergoing primary percutaneous coronary intervention (n=41 979; 97.1%), median door-to-balloon times were 56 versus 72 minutes (P less than 0.0001) for on-hours versus off-hours. The proportion of patients achieving door-to-balloon time ≤90 minutes was 87.8% versus 79.2% (P less than 0.0001), respectively. There were no differences attaining door-to-ECG time ≤10 minutes (73.4% versus 74.3%, P=0.09) and door-to-needle time ≤30 minutes (62.3% versus 58.7%; P=0.44) between on-hours versus off-hours. Although in-hospital all-cause mortality was similar (4.2%) in both groups, the risk-adjusted all-cause mortality was higher for patients presenting off-hours (odds ratio, 1.13; 95% confidence interval, 1.02–1.26).

Conclusions—In contemporary community practice, achievement of quality performance measures in patients presenting with ST-segment–elevation myocardial infarction was high, regardless of time of presentation. Door-to-balloon time was, however, slightly delayed (by an average of 16 minutes), and risk-adjusted in-hospital mortality was 13% higher in patients presenting off-hours.

17. The effect of inclined step stool on the quality of chest compression during in-hospital CPR

Yun S, et al. Amer J Emerg Med. 2014;32:851-855.

Purpose: A step stool is an ordinary device to improve the quality of chest compression (CC) during in-hospital cardiopulmonary resuscitation (CPR). We investigated the effect of an inclined step stool on the quality of CC during CPR on a hospital bed.

Methods: We conducted a randomized crossover study of simulation using a manikin. Two different methods of CC were performed and compared: CC using a flat stool and CC using an inclined (20°) stool. Each session of CC was performed for 2 minutes using a metronome at a rate of 110 beats per minute. The primary outcome was the depth of CC. The adequate CC rate, duty cycle, rate of incomplete recoil, and the angle between the arm of the participants and the bed were also measured.

Results: The median value of the mean depth of CC was 50.5 mm (45.0-57.0 mm) in the flat stool group and 54.5 mm (47.0-58.3 mm) in the inclined stool group (P = .014). The adequate CC rate was significantly higher in the inclined stool group (84.2% [37.6%-99.1%] vs 57.0% [15.2%-95.0%]; P = .016). The duty cycle and the rate of incomplete recoil were comparable between the 2 groups. The angles between the arm of the participants and the bed were more vertical in the inclined stool group (84.0° ± 5.2° vs 81.0° ± 4.8°; P = .014).

Conclusion: Using an inclined stool resulted in an improvement in the depth of CC and the adequate CC rate without increasing the rate of incomplete chest recoil.

18. Lung Ultrasound on ED Arrival for Major Trauma Patients

Leblanc D et al. Intensive Care Med 2014 Jul 15 [Epub ahead of print]

PURPOSE: Extent of lung contusion on initial computed tomography (CT) scan predicts the occurrence of acute respiratory distress syndrome (ARDS) in blunt chest trauma patients. We hypothesized that lung ultrasonography (LUS) on admission could also predict subsequent ARDS.

METHODS: Forty-five blunt trauma patients were prospectively studied. Clinical examination, chest radiography, and LUS were performed on arrival at the emergency room. Lung contusion extent was quantified using a LUS score and compared to CT scan measurements. The ability of the LUS score to predict ARDS was tested using the area under the receiver operating characteristic curve (AUC-ROC). The diagnostic accuracy of LUS was compared to that of combined clinical examination and chest radiography for pneumothorax, lung contusion, and hemothorax, with thoracic CT scan as reference.

RESULTS: Lung contusion extent assessed by LUS on admission was predictive of the occurrence of ARDS within 72 h (AUC-ROC = 0.78 [95 % CI 0.64-0.92]). The extent of lung contusion on LUS correlated well with CT scan measurements (Spearman's coefficient = 0.82). A LUS score of 6 out of 16 was the best threshold to predict ARDS, with a 58 % [95 % CI 36-77] sensitivity and a 96 % [95 % CI 76-100] specificity. The diagnostic accuracy of LUS was higher than that of combined clinical examination and chest radiography: (AUC-ROC) 0.81 [95 % CI 0.50-1.00] vs. 0.74 [0.48-1.00] (p = 0.24) for pneumothorax, 0.88 [0.76-1.00] vs. 0.69 [0.47-0.92] (p less than 0.05) for lung contusion, and 0.84 [0.59-1.00] vs. 0.73 [0.51-0.94] (p less than 0.05) for hemothorax.

CONCLUSIONS: LUS on admission identifies patients at risk of developing ARDS after blunt trauma. In addition, LUS allows rapid and accurate diagnosis of common traumatic thoracic injuries.

19. ED Diagnosis and Management of Skin Diseases with Real-Time Teledermatologic Expertise

Duong TA, et al. JAMA Dermatol. 2014;150(7):743-747.

Importance  Skin conditions are a common reason for patients to consult emergency department (ED) physicians.

Objective  To evaluate real-time teledermatologic expertise with the use of mobile telephones for the diagnosis and management of skin conditions in patients seen in the ED.

Design, Setting, and Participants  This observational study of adults who consecutively consulted in the ED for a dermatologic condition was conducted under routine conditions in the ED from May 1, 2008, through June 30, 2010.

Main Outcomes and Measures  Diagnosis agreement and management concordance.

Results  One hundred eleven patients were enrolled in the study. Eighty-three patients (74.8%) were evaluated using videoconferencing. Dermatologic remote expertise invalidated, enlarged, or clarified ED physicians’ diagnosis and management in 75 of 110 cases (68.2%). Videoconferencing improved the diagnostic performance in 57 of 83 cases (68.7%). Management concordance was moderate between ED physicians and dermatologists for specialist consultation within 24 hours (κ, 0.49; 95% CI, 0.14-0.84) and immediate hospitalization (κ, 0.49; 95% CI, 0.41-0.57). Patients were significantly more often discharged by dermatologists (46.8% vs 39.1%).

Conclusions and Relevance  Compared with standard hardware, new-generation mobile devices reduce the cost of videoconferencing, increase the versatility of teledermatology, and decrease general practitioner investment time.

20. Acetaminophen does not shorten course of disease with back pain

Williams CM, et al. Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial. Lancet 2014 July 24 [Epub ahead of print]

Regular paracetamol is the recommended first-line analgesic for acute low-back pain; however, no high-quality evidence supports this recommendation. We aimed to assess the efficacy of paracetamol taken regularly or as-needed to improve time to recovery from pain, compared with placebo, in patients with low-back pain.

We did a multicentre, double-dummy, randomised, placebo controlled trial across 235 primary care centres in Sydney, Australia, from Nov 11, 2009, to March 5, 2013. We randomly allocated patients with acute low-back pain in a 1:1:1 ratio to receive up to 4 weeks of regular doses of paracetamol (three times per day; equivalent to 3990 mg paracetamol per day), as-needed doses of paracetamol (taken when needed for pain relief; maximum 4000 mg paracetamol per day), or placebo. Randomisation was done according to a centralised randomisation schedule prepared by a researcher who was not involved in patient recruitment or data collection. Patients and staff at all sites were masked to treatment allocation. All participants received best-evidence advice and were followed up for 3 months. The primary outcome was time until recovery from low-back pain, with recovery defined as a pain score of 0 or 1 (on a 0—10 pain scale) sustained for 7 consecutive days. All data were analysed by intention to treat. This study is registered with the Australian and New Zealand Clinical Trial Registry, number ACTN 12609000966291.

550 participants were assigned to the regular group (550 analysed), 549 were assigned to the as-needed group (546 analysed), and 553 were assigned to the placebo group (547 analysed). Median time to recovery was 17 days (95% CI 14—19) in the regular group, 17 days (15—20) in the as-needed group, and 16 days (14—20) in the placebo group (regular vs placebo hazard ratio 0·99, 95% CI 0·87—1·14; as-needed vs placebo 1·05, 0·92—1·19; regular vs as-needed 1·05, 0·92—1·20). We recorded no difference between treatment groups for time to recovery (adjusted p=0·79). Adherence to regular tablets (median tablets consumed per participant per day of maximum 6; 4·0 [IQR 1·6—5·7] in the regular group, 3·9 [1·5—5·6] in the as-needed group, and 4·0 [1·5—5·7] in the placebo group), and number of participants reporting adverse events (99 [18·5%] in the regular group, 99 [18·7%] in the as-needed group, and 98 [18·5%] in the placebo group) were similar between groups.

Our findings suggest that regular or as-needed dosing with paracetamol does not affect recovery time compared with placebo in low-back pain, and question the universal endorsement of paracetamol in this patient group.

HealthDay News Article. WEDNESDAY, July 23, 2014
Effect of advice and reassurance
According to the study, there were no differences in the amount of time it took any of the patients involved in the study to feel better. The median time to recovery for those taking acetaminophen was 17 days, compared to 16 days for patients in the placebo group.
The researchers suggested that the medical reassurance the patients received during the study -- something many won't get in a "real world" setting -- could have had a more significant effect on their lower back pain than the medication.
"It would be interesting to see whether advice and reassurance [as provided in our trial] might be more effective than pharmacological strategies for acute episodes of low-back pain," Williams said.
Another expert agreed that encouragement and counseling can be key.
Everyone involved in the study received ongoing " 'good-quality advice and reassurance,' which appears to be a big factor in recovery," said Dr. Michael Mizhiritsky, a physiatrist and specialist in pain relief at Lenox Hill Hospital in New York City.
"In my opinion, positive reinforcement about treatments -- including medications and physical therapy -- in the management of low back pain is vital to a quicker and successful recovery," he added.

Over-ambitious outcome
Both Danesh and Mizhiritsky also took issue with some of the study's methods.

"The drawback I see is there was no group that did not receive any treatment -- meaning there could be a placebo effect" at work, Mizhiritsky said.

And Danesh said people could still get relief from acetaminophen/Tylenol -- just not the kind of relief outlined in the study.

"The criteria was to be pain-free for seven continuous days when using Tylenol," he pointed out. "It does not address if Tylenol will give you a few hours of relief or a few days."

In the meantime, the prognosis for most people with lower back pain is actually quite good, Danesh stressed.

"Most back pain patients improve in 6-8 weeks," he said. "It is important to note that the best treatment of back pain involves not only pain medication, but also physical therapy to address muscle imbalances. Acupuncture for back pain has also been researched by the U.S. National Institute of Health, and after reviewing the literature they state that there is evidence to support the use of acupuncture for back pain."

The study was partially funded by drug maker GlaxoSmithKline Australia.

21. What’s the best evidence for ED asthma management? An NNT Review

Quick summaries of evidence-based medicine by the NNT Team (Number Needed to Treat)

For ED patients with asthma exacerbations, treat with continuous nebulized albuterol, with nebulized ipratropium, early systemic steroids (oral just as good as IV), and IV mag for those with moderate-to-severe asthma.

A. Continuous versus Intermittent Beta Agonists Given During an Asthma Attack

NNT: 1 in 10 were helped (preventing hospital admission)

B. Nebulized Ipratropium Given During an Asthma Attack

NNT: 1 in 11 were helped (preventing hospitalization)

C. Systemic Steroids Given During an Asthma Attack

·         1 in 8 were helped (preventing hospital admission)
·         1 in 10 were helped (preventing asthma relapse)
·         1 in 11 were helped (preventing a later hospital admission)

D. Intravenous Magnesium Sulfate Given During an Asthma Attack

NNT: 1 in 3 were helped (preventing hospital admission if patient is a "severe asthmatic")

22. Can you safely withhold anticoagulation for patients with asymptomatic subsegmental PE?

Nobody knows…

Yoo HH, et al. Anticoagulant treatment for subsegmental pulmonary embolism. Cochrane Database Syst Rev. 2014 Apr 28;4:CD010222.

BACKGROUND: Acute pulmonary embolism (PE) is a common cause of death, accounting for 50,000 to 200,000 deaths annually. It is the third most common cause of mortality among the cardiovascular diseases, after coronary artery disease and stroke.The advent of multi-detector computed tomographic pulmonary angiography (CTPA) has allowed better assessment of PE regarding visualisation of the peripheral pulmonary arteries, increasing its rate of diagnosis. More cases of peripheral PEs, such as isolated subsegmental PE (SSPE) and incidental PE, have thereby been identified. These two conditions are usually found in patients with few or none of the classic PE symptoms such as haemoptysis or pleuritic pain, acute dyspnoea or circulatory collapse. However, in patients with reduced cardio-pulmonary (C/P) reserve the classic PE symptoms can be found with isolated SSPEs. Incidental SSPE is found casually in asymptomatic patients, usually by diagnostic imaging performed for other reasons (for example routine CT for cancer staging in oncologic patients).Traditionally, all PEs are anticoagulated in a similar manner independent of the location, number and size of the thrombi. It has been suggested that many patients with SSPE may be treated without benefit, increasing adverse events by possible unnecessary use of anticoagulants.Patients with isolated SSPE or incidental PE may have a more benign clinical presentation compared with those with proximal PEs. However, the clinical significance in patients and their prognosis have to be studied to evaluate whether anticoagulation therapy is required.

OBJECTIVES: To assess the effectiveness and safety of anticoagulation therapy versus no intervention in patients with isolated subsegmental pulmonary embolism (SSPE) or incidental SSPE.

SEARCH METHODS: The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched October 2013) and CENTRAL (2013, Issue 9). MEDLINE, EMBASE, LILACS and clinical trials databases were also searched (October 2013).

SELECTION CRITERIA: Randomised controlled trials of anticoagulation therapy versus no intervention in patients with SSPE or incidental SSPE.

DATA COLLECTION AND ANALYSIS: Two review authors inspected all citations to ensure reliable selection. We planned for two review authors to independently extract data and to assess the methodological quality of identified trials using the criteria recommended in the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS: No studies were identified that met the inclusion criteria.

AUTHORS' CONCLUSIONS: There is no randomised controlled trial evidence for the effectiveness and safety of anticoagulation therapy versus no intervention in patients with isolated subsegmental pulmonary embolism (SSPE) or incidental SSPE, and therefore we can not draw any conclusions. Well-conducted research is required before informed practice decisions can be made.

23. Tid Bits

A. CDC finds inappropriate prescribing of antivirals, antibiotics

Among patients at high risk for flu complications, only 19% were prescribed antiviral medications, while 30% were given antibiotics, which are ineffective against flu, according to a CDC report published in the journal Clinical Infectious Diseases. The findings suggest that "antiviral medications were underprescribed and antibiotics may have been inappropriately prescribed to a large proportion of outpatients with influenza," researchers said.

B. What makes a good physician, according to patients

According to patients, the ability to listen attentively is a key attribute of high-quality physicians, followed by diagnostic accuracy. The Associated Press-NORC Center for Public Affairs Research survey respondents said markers of poor-quality physicians include not listening to patients and not spending enough time with patients. Physician experience, initial impressions after meeting and appointment scheduling all contribute to whether patients will select a given physician, according to the findings.

C. Emotional intelligence training positively influences patient satisfaction

D. The Glasgow Coma Scale at 40 years: standing the test of time

Teasdale G, et al. The Lancet Neurology,  2014;13:844 - 854,

Since 1974, the Glasgow Coma Scale has provided a practical method for bedside assessment of impairment of conscious level, the clinical hallmark of acute brain injury. The scale was designed to be easy to use in clinical practice in general and specialist units and to replace previous ill-defined and inconsistent methods. 40 years later, the Glasgow Coma Scale has become an integral part of clinical practice and research worldwide. Findings using the scale have shown strong associations with those obtained by use of other early indices of severity and outcome. However, predictive statements should only be made in combination with other variables in a multivariate model. Individual patients are best described by the three components of the coma scale; whereas the derived total coma score should be used to characterise groups. Adherence to this principle and enhancement of the reliable practical use of the scale through continuing education of health professionals, standardisation across different settings, and consensus on methods to address confounders will maintain its role in clinical practice and research in the future.

E. Concussion and Female Middle School Athletes

In JAMA: “Concussion rates in young female soccer players are greater than those reported in older age groups, and most of those concussed report playing with symptoms. Heading the ball is a frequent precipitating event. Awareness of recommendations to not play and seek medical attention is lacking for this age group.”

F. Survey shows many people get unwanted, excessive care

A survey of 1,007 adults ages 50 and older found 12% reported they or a family member had experienced unwanted medical care and 19% categorized treatments they or a family member had received as excessive. The study, sponsored by the nonprofit group Compassion & Choices, found 82% said it was very important to honor end-of-life medical wishes, and 50% supported withholding physician or facility pay if treatments did not adhere to those decisions.

G. Potential Benefits of Calorie Labeling in Restaurants

Provisions in the 2010 Affordable Care Act will require chain restaurants with 20 or more US locations to display calorie information on their menus, including drive-through menu boards. The US Food and Drug Administration released preliminary regulations in April 2011, and the long-delayed final regulations are expected soon, perhaps as early as summer 2014. The documented effects of menu labeling on consumer and restaurant industry behavior suggest that menu labeling will likely encourage some consumers to eat more healthfully some of the time, and the policy is likely an important first step toward improving the public’s eating habits.

This Viewpoint discusses the reasons public health advocates have pressed for menu labeling and the state of evidence regarding its likely effectiveness. Consumers often fail to recognize the high calorie content of most restaurant foods, and people are more likely to overeat at restaurants. Restaurant foods also account for a large and increasing proportion of calories consumed in the United States. For these reasons, advocates have maintained that consumers have the right to readily usable calorie information at the point of purchase and have called for complementary changes to nutrition facts labels on packaged foods…

H. Docs lobby FDA to include clearer info, data in drug fact boxes

Drs. Steven Woloshin and Lisa Schwartz are encouraging the FDA to require drugmakers to include statistics on drug labels such as the percentage of clinical trial participants who experienced certain side effects and how well the drug worked compared with a placebo. They have designed a prototype label and launched the company Informulary, funded by the Robert Wood Johnson Foundation, where prescribers and patients can find such information.

I. AAP: Toxic Stress Threatens Kids’ Long-term Health

Kuehn BM, et al. JAMA. 2014 July 30

Pediatricians have long had a window into the troubles facing young patients and their families. Now, emerging data on how early exposure to adversity can impair long-term health and development have led the American Academy of Pediatrics (AAP) and other thought leaders to call for more effective and aggressive intervention for children in distress.

In June, the AAP convened a symposium on the long-term dangers of childhood toxic stress—early exposure to chronic unmitigated stress—and urged pediatricians, policy makers, and federal agencies to develop a stronger national response. To facilitate these efforts, the AAP announced it will launch the Center on Healthy, Resilient Children to help pediatricians and others identify toxic stress in children and connect them with appropriate resources.

“We are now recognizing in medical science and practice that there are real and significant effects when children grow up with toxic and persistent stress,” said Robert W. Block, MD, past president of the AAP, in an interview. “Those effects take a toll on the ability to learn in school and informally.”

The Science of Stress (full-text free):  http://jama.jamanetwork.com/article.aspx?articleID=1892631

J. Albumin for sepsis?

Not that helpful:

K. Pediatric group updates meningococcal vaccine guidelines

Meningococcal vaccines should be given to children older than 2 months of age who have certain health conditions that increase their risk of getting meningococcal disease, the American Academy of Pediatrics said. The updated policy, published in the journal Pediatrics, also recommends that teens and college students continue to receive meningitis shots.

L. The cost-effectiveness analysis of video capsule endoscopy compared to other strategies to manage acute UGI hemorrhage in the ED

M.  The Prevalence of Confirmed Maltreatment Among US Children, 2004 to 2011

N. The Political Polarization of Physicians in the United States: An Analysis of Campaign Contributions to Federal Elections, 1991 Through 2012

O. Influenza: Complications in 1 in 3 Previously Healthy Kids

P. Subacromial Corticosteroid Injection vs Manual Physical Therapy for the Management of the Unilateral Shoulder Impingement Syndrome: A Pragmatic Randomized Trial

Equal outcomes. Ann Intern Med abstract: http://annals.org/article.aspx?articleID=1892614

Q. 4% of Medicaid spending is for emergency care

Only 4% of Medicaid spending is for hospital emergency department usage, according to a data review by the Medicaid and CHIP Payment and Access Commission. The report said 10% of ED visits by nonelderly patients were for nonemergency reasons, and the data did not consistently link Medicaid status with disproportionate use of ED services for nonurgent care.

MACPAC homepage: http://www.macpac.gov/home