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).
Comment
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]
Introduction
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.
Abstract
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.
Introduction
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]
Abstract
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.
Comment
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.
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.
For more
(full-text free): http://jama.jamanetwork.com/article.aspx?articleid=1895676
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.
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.
Full-text
(free): http://circoutcomes.ahajournals.org/content/early/2014/07/29/CIRCOUTCOMES.113.000740.full.pdf+html
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]
Background
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.
Methods
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.
Findings
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.
Interpretation
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
NNT:
·
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…
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.
NPR
Article: http://www.npr.org/blogs/health/2014/07/25/333726737/how-well-does-a-drug-work-look-beyond-the-fine-print
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
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
Pediatrics
(full-text free): http://pediatrics.aappublications.org/content/early/2014/07/29/peds.2014-0505.full.pdf+html
P. Subacromial Corticosteroid
Injection vs Manual Physical Therapy for the Management of the Unilateral
Shoulder Impingement Syndrome: A Pragmatic Randomized Trial
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.
