Saturday, September 27, 2014

Lit Bits: Sept 27, 2014

From the recent medical literature...

1. 2014 Non-ST Elevation (NSTE) ACS Clinical Practice Guidelines -- What's New?

New guidelines were released by the ACC/AHA Sept 23 (reference below). What follows is an excerpt from Spinler SA’s summary of “what’s new?”

Approximately 30% of patients presenting with acute coronary syndrome (ACS) have ST-segment elevation myocardial infarction (MI), and the remainder unstable angina or non--ST-segment elevation (NSTE) MI. Because the presentations of unstable angina and NSTE MI are similar, the guideline authors of new practice guidelines updated their terminology to NSTE ACS, rather than UA/NSTE MI, to reflect this similarity. This complete revision replaces the 2012 ACCF/AHA focused update incorporated into the 2007 ACCF/AHA guidelines.1  In general, the approach to the patient remains unchanged: risk stratify, select an initial management strategy, complete the diagnostic evaluation for MI, use medical therapy and revascularization in appropriate patients, and initiate secondary prevention therapies.

Selected differences between the 2012 combined guideline and the 2014 are described below. Notably, the authors are to be commended for including new Class I recommendations for patient discharge instructions as well as the recommendation for a plan of care for smooth transitions and systems to promote care coordination. These clear instructions include specific recommendations for patient education regarding cardiovascular risk factors (blood pressure, cholesterol levels, lifestyle modification such as exercise and smoking cessation, medications, management of recurrent angina, cardiovascular risk factors, and activity levels.  The hospital readmission rate for ACS remains high and having an organized well-written plan of attack helps hospitals and clinicians take the initiative to implement multidisciplinary teams to “attack” the problem.

Diagnosis of myocardial infarction:
1. A class III recommendation: No benefit is given for CK-MB assay for diagnosis of MI when using contemporary troponin assays and measurement should be reserved for estimation of infarct size.
2. The diagnosis of myocardial infarction is made when the troponin rises or falls. If the initial troponin is elevated (defined as greater than the 99th percentile of the upper value of the reference range), the diagnosis is made if a ≥ 20% rise or fall in subsequent troponins occurs.
3. Although no specific recommendation is made with respect to use of point-of-care troponins, their lower specificity is acknowledged and central laboratory testing is favored in addition to initial point-of-care testing.

4. A class IIb recommendation is made to remeasure troponin on day 3 or 4 to ascertain infarct size.
5. A class IIb recommendation is made to add B-type natriuretic peptide (BNP) as an additional prognostic tool.

Risk stratification:
6. A class IIa recommendation is given for coronary CT angiography in patients with possible ACS, a normal 12-lead ECG, negative troponins, and no history of coronary artery disease CAD.
7. The term “ischemia-guided strategy” replaces “initial conservative management.” An ischemia-guided approach is recommended for patients with a low-risk score (TIMI 0 or 1, GRACE less than 109).
8. The early invasive strategy recommendations are stratified by timing:
a. Immediate (within 2 hours): Patients with refractory or recurrent angina with initial treatment, signs/symptoms of heart failure, new/worsening mitral regurgitation, hemodynamic instability, sustained ventricular tachycardia, or ventricular fibrillation
b. Early (within 24 hours): None of the immediate characteristics but new ST-segment depression, a GRACE risk score > 140, or temporal change in troponin
c. Delayed invasive: None of the immediate or early characteristics but renal insufficiency, left ventricular ejection fraction (LVEF)  less than 40%, early post-infarct angina, history of percutaneous coronary intervention (PCI) within the past 6 months, prior coronary artery bypass surgery (CABG), GRACE risk score of 109-140, or TIMI score of 2 or higher.

The New Guidelines Themselves
Amsterdam EA, et al. 2014 AHA/ACC Guideline for the Management of Patients with NSTE ACS: Executive Summary: A Report of the ACC/AHA Task Force on Practice Guidelines. Circulation. 2014 Sep 23 [Epub ahead of print].

2. Patient Satisfaction Surveys and Quality of Care: An Information Paper.

Farley H, et al. Ann Emerg Med. 2014 Mar 20 [Epub ahead of print]

With passage of the Patient Protection and Affordable Care Act of 2010, payment incentives were created to improve the "value" of health care delivery. Because physicians and physician practices aim to deliver care that is both clinically effective and patient centered, it is important to understand the association between the patient experience and quality health outcomes. Surveys have become a tool with which to quantify the consumer experience. In addition, results of these surveys are playing an increasingly important role in determining hospital payment. Given that the patient experience is being used as a surrogate marker for quality and value of health care delivery, we will review the patient experience-related pay-for-performance programs and effect on emergency medicine, discuss the literature describing the association between quality and the patient-reported experience, and discuss future opportunities for emergency medicine.

“A review of the current academic literature appears to be divided on the relationship between the patient experience and objective measures of quality.”

“Review of HCAHPS data demonstrates that patients’ perception of the quality of nursing communication is more likely to influence overall patient satisfaction scores than physician communication.”

“…many, including the American Medical Association, criticize the use of patient satisfaction measures as a validated tool for judging physician performance.”

“We believe that current evidence demonstrates that patient satisfaction is not a validated proxy for quality and that other more sensitive and specific measures should be used to determine the quality of health care delivery.”

“Unfortunately, policymakers and hospital leadership have conflated satisfaction and quality where the association between a patient’s perception of care and the technical quality of services rendered and subsequent effect on desired patient outcomes are not validated.”

3. Reducing variation in hospital admissions from the ED for low-mortality conditions may produce savings.

Sabbatini AK, et al. Health Aff (Millwood). 2014 Sep 1;33(9):1655-63.

The emergency department (ED) is now the primary source for hospitalizations in the United States, and admission rates for all causes differ widely between EDs.

In this study we used a national sample of ED visits to examine variation in risk-standardized hospital admission rates from EDs and the relationship of this variation to inpatient mortality for the fifteen most commonly admitted medical and surgical conditions. We then estimated the impact of variation on national health expenditures under different utilization scenarios.

Risk-standardized admission rates differed substantially across EDs, ranging from 1.03-fold for sepsis to 6.55-fold for chest pain between the twenty-fifth and seventy-fifth percentiles of the visits. Conditions such as chest pain, soft tissue infection, asthma, chronic obstructive pulmonary disease, and urinary tract infection were low-mortality conditions that showed the greatest variation. This suggests that some of these admissions might not be necessary, thus representing opportunities to improve efficiency and reduce health spending.

Our data indicate that there may be sizeable savings to US payers if differences in ED hospitalization practices could be narrowed among a few of these high-variation, low-mortality conditions.

4. Contamination of Environmental Surfaces with Staphylococcus aureus in Households With Children Infected with MRSA

Fritz SA, et al. JAMA Pediatr. 2014 September 08 [Epub ahead of print]

Importance  Household environmental surfaces may serve as vectors for the acquisition and spread of methicillin-resistant Staphylococcus aureus (MRSA) among household members, although few studies have evaluated which objects are important reservoirs of MRSA.

Objectives  To determine the prevalence of environmental MRSA contamination in households of children with MRSA infection; define the molecular epidemiology of environmental, pet, and human MRSA strains within households; and identify factors associated with household MRSA contamination.

Design, Setting, and Participants  Fifty children with active or recent culture-positive community-associated MRSA infection were enrolled from 2012 to 2013 at St Louis Children’s Hospital and at community pediatric practices affiliated with the Washington University Pediatric and Adolescent Ambulatory Research Consortium in St Louis, Missouri.

Main Outcomes and Measures  Samples of participants’ nares, axillae, and inguinal folds were cultured to detect S aureus colonization. Samples of 21 household environmental surfaces, as well as samples obtained from pet dogs and cats, were cultured. Molecular typing of S aureus strains was performed by repetitive-sequence polymerase chain reaction to determine strain relatedness within households.

Results  Methicillin-resistant S aureus was recovered from samples of environmental surfaces in 23 of the 50 households (46%), most frequently from the participant’s bed linens (18%), television remote control (16%), and bathroom hand towel (15%). It colonized 12% of dogs and 7% of cats. At least 1 surface was contaminated with a strain type matching the participant’s isolate in 20 households (40%). Participants colonized with S aureus had a higher mean (SD) proportion of MRSA-contaminated surfaces (0.15 [0.17]) than noncolonized participants (0.03 [0.06]; mean difference, 0.12 [95% CI, 0.05-0.20]). A greater number of individuals per 1000 ft2 (93 m2) were also associated with a higher proportion of MRSA-contaminated surfaces (β = 0.34, P = .03). The frequency of cleaning household surfaces was not associated with S aureus environmental contamination.

Conclusions and Relevance  Methicillin-resistant S aureus strains concordant with infecting and colonizing strains are present on commonly handled household surfaces, a factor that likely perpetuates MRSA transmission and recurrent disease. Future studies are needed to determine methods to eradicate environmental contamination and prevent MRSA transmission in households.

5. Legal Marijuana and Pediatric Exposure: Pot Edibles Implicated in Spike in Child ED Visits

Eric Berger. Ann Emerg Med. 2014;64(4):A19–A21.

On a partly sunny Friday afternoon in August, the Denver County Fair opened its gates with the usual attractions one might expect at such gatherings. There were dog competitions, live music performances, everything you could want on a stick, and square dancing.

But this year, the fair, which expected to draw about 20,000 people to the National Western Complex, decided to add a new exhibit: the Pot Pavilion. In addition to offering a prize for the “best marijuana plant” there were “speed rolling” contests, Grateful Dead karaoke, and a best handmade bong contest. The celebration of pot culture also included an “edibles” category, which included such foods as brownies. The winning brownie was made of dark chocolate and walnuts.

This, perhaps, is where a bit of marijuana’s darker side became apparent. Colorado’s marijuana legalization has benefited some of the state’s residents, and it’s certainly proven a major attraction at events such as the Denver County Fair. There’s also some evidence it has cut crime rates. But the drug’s legalization has also had some unpleasant adverse effects, perhaps most notably the ease with which children can now access the product, especially through edibles. This has resulted in a spike in emergency department (ED) visits for childhood marijuana exposure.

In shops throughout the state, adults can purchase a variety of marijuana-infused goodies, from fudge, cookies, and brownies to hard candies, gelato, and gummy bears.

“It may be too late to stem the rush toward legalization of recreational marijuana use and the proliferation of products that comes with it,” David Sack, MD, chief executive of Elements Behavioral Health, and a specialist in addiction medicine, editorialized this summer in the Los Angeles Times. “Instead,” Dr. Sack wrote, “we need to focus on better ways to protect children, combat the notion that marijuana is harmless and fund the much-needed additional research on medical uses for marijuana's chemical components, such as the promising cannabidiol, which may prove effective without producing a high.”

In a historic departure from prohibition and punishment for marijuana use, Colorado’s Amendment 64 passed by a margin of 55% to 45% in 2012, allowing people aged 21 years or older to grow up to 3 immature and 3 mature cannabis plants and purchase up to an ounce of marijuana. Use of the drug is permitted in a manner similar to alcohol, with equivalent offenses to driving under the influence.

Colorado’s EDs have been on the front lines of assessing, understanding, and dealing with the unintended consequences of the state’s new marijuana law, which went into effect on January 1, 2014. Essentially 3 types of patients have presented to EDs since the law’s passage.

One of the groups, according to Andrew A. Monte, MD, an assistant professor of emergency medicine and medical toxicology at the University of Colorado–Denver and a toxicologist with the Rocky Mountain Poison and Drug Center, is patients in whom there’s been an exacerbation of chronic conditions, such as a seriously ill asthma patient coming in because he or she smoked marijuana.

A second group is patients who have acute effects from eating too many edibles, with conditions such as very fast pulse rates, hallucinations, or cyclic vomiting. EDs have also treated patients who have burns associated with making butane hash oil, a potent and increasingly popular form of marijuana known for a giving a quick high.

“In general when there’s increased availability of a drug, then there [are] increased health care encounters associated with that drug,” Dr. Monte said. “Let me quantify the amount of burden we’ve seen so far. It is not enormous. At the University of Colorado hospital, for example, I think we will see several patients on the weekend. For the most part, they are not overrunning the ED, and for the most part, they are easily treated with fluids and they go home.”

6. In-hospital mortality following treatment with RBC transfusion or inotropic therapy during EGDT for septic shock: a retrospective propensity-adjusted analysis.

Mark DG, et al. Crit Care. 2014 Sep 12;18(5):496. [Epub ahead of print]

Introduction: We sought to investigate whether treatment of subnormal (less than 70%) central venous oxygen saturation (ScvO2) with inotropes or red blood cell (RBC) transfusion during early goal-directed therapy (EGDT) for septic shock is independently associated with in-hospital mortality.

Methods: Retrospective analysis of a prospective EGDT patient database drawn from 21 emergency departments with a single standardized EGDT protocol. Patients were included if, during EGDT, patients concomitantly achieved a central venous pressure (CVP) of ≥8 mm Hg and a mean arterial pressure (MAP) of ≥65 mm Hg while registering a ScvO2 less than 70%. Treatment propensity scores for either RBC transfusion or inotrope administration were separately determined from independent patient sub-cohorts. Propensity-adjusted logistic regression analyses were conducted to test for associations between treatments and in-hospital mortality.

Results: Of 2595 EGDT patients, 572 (22.0%) met study inclusion criteria. The overall in-hospital mortality rate was 20.5%. Inotropes or RBC transfusions were administered for an ScvO2 less than 70% to 51.9% patients. Patients were not statistically more likely to achieve an ScvO2 of ≥70% if they were treated with RBC transfusion alone (29/59, 49.2%, P=0.19), inotropic therapy alone (104/226, 46.0%, P=0.15) or both RBC and inotropic therapy (7/12, 58.3%, P=0.23) as compared to no therapy (108/275, 39.3%). Following adjustment for treatment propensity score, RBC transfusion was associated with a decreased adjusted odds ratio (aOR) of in-hospital mortality among patients with hemoglobin values less than 10 g/dL (aOR 0.42, 95% CI 0.18-0.97, P=0.04) while inotropic therapy was not associated with in-hospital mortality among patients with hemoglobin values of 10 g/dL or greater (aOR 1.16, 95% CI 0.69 to 1.96, P=0.57).

Conclusions: Among patients with septic shock treated with EGDT in the setting of subnormal ScvO2 values despite meeting CVP and MAP target goals, treatment with RBC transfusion may be independently associated with decreased in-hospital mortality.

7. Automated UA and Urine Dipstick in the Emergency Evaluation of Young Febrile Children

Kanegaye JT, et al. Pediatr 2014;134:523-529.

OBJECTIVE: The performance of automated flow cytometric urinalysis is not well described in pediatric urinary tract infection. We sought to determine the diagnostic performance of automated cell counts and emergency department point-of-care (POC) dipstick urinalyses in the evaluation of young febrile children.

METHODS: We prospectively identified a convenience sample of febrile pediatric emergency department patients less than 48 months of age who underwent urethral catheterization to obtain POC and automated urinalyses and urine culture. Receiver operating characteristic analyses were performed and diagnostic indices were calculated for POC dipstick and automated cell counts at different cutpoints.

RESULTS: Of 342 eligible children, 42 (12%) had urinary bacterial growth ≥50 000/mL. The areas under the receiver operating characteristic curves were: automated white blood cell count, 0.97; automated bacterial count, 0.998; POC leukocyte esterase, 0.94; and POC nitrite, 0.76. Sensitivities and specificities were 86% and 98% for automated leukocyte counts ≥100/μL and 98% and 98% for bacterial counts ≥250/μL. POC urine dipstick with ≥1+ leukocyte esterase or positive nitrite had a sensitivity of 95% and a specificity of 98%. Combinations of white blood cell and bacterial counts did not outperform bacterial counts alone.

CONCLUSIONS: Automated leukocyte and bacterial counts performed well in the diagnosis of urinary tract infection in these febrile pediatric patients, but POC dipstick may be an acceptable alternative in clinical settings that require rapid decision-making.

8. The proper way to go AMA: 8 Elements to Address

By Matthew DeLaney, MD; Acad Life in Emerg Med, January 13th, 2014.

Case Example: 42 y/o male presents with right lower quadrant abdominal pain and has significant tenderness at McBurney’s point on exam. While waiting for a CT scan to evaluate for possible appendicitis the patient rips out his IV and tells the nurse “I’m leaving, I don’t want to sit here all night, and you can’t make me stay.” The nurse pulls you out of another room and hands you the standard against medical advice (AMA) paperwork.

Leaving AMA
In 1992, about 0.1% of patients seen in the Emergency Department (ED) left AMA. In the years since, this number has increased significantly with recent studies showing that up to 2% of ED patients leave AMA. These patients pose a particular challenge for ED providers from both a diagnostic and risk management standpoint.

Risks to the Patient
From a medical standpoint, patients who leave AMA tend to have an increased risk of having an adverse outcome. Baptist et al. found that asthma patients who left AMA had an increased risk of both relapse and subsequent ICU admissions [1]. Similarly patients with chest pain who left AMA had a higher risk of myocardial infarction than other patients with similar characteristics who stayed in the ED to complete their workup [2].

Risks to the Provider
Patients who leave against medical advice are up to 10x more likely to sue the emergency physician when compared to other ED patients. Some estimate that 1 in 300 AMA cases results in a lawsuit compared to 1 in 30,000 standard ED visits [3].

While posing a particular challenge to providers, there are several basic steps that can be taken when dealing with a patient leaving AMA that can help improve patient outcomes while providing significant medicolegal protection to the providers.

How to do it properly…

9. Lactulose vs PEG 3350-Electrolyte Solution for Treatment of Overt Hepatic Encephalopathy: The HELP RCT

Rahimi RS, et al. JAMA Intern Med. 2014 September 22 [Epub ahead of print]

Importance  Hepatic encephalopathy (HE) is a common cause of hospitalization in patients with cirrhosis. Pharmacologic treatment for acute (overt) HE has remained the same for decades.

Objective  To compare polyethylene glycol 3350–electrolyte solution (PEG) and lactulose treatments in patients with cirrhosis admitted to the hospital for HE. We hypothesized that rapid catharsis of the gut using PEG may resolve HE more effectively than lactulose.

Design, Setting, and Participants  The HELP (Hepatic Encephalopathy: Lactulose vs Polyethylene Glycol 3350-Electrolyte Solution) study is a randomized clinical trial in an academic tertiary hospital of 50 patients with cirrhosis (of 186 screened) admitted for HE.

Interventions  Participants were block randomized to receive treatment with PEG, 4-L dose (n = 25), or standard-of-care lactulose (n = 25) during hospitalization.

Main Outcomes and Measures  The primary end point was an improvement of 1 or more in HE grade at 24 hours, determined using the hepatic encephalopathy scoring algorithm (HESA), ranging from 0 (normal clinical and neuropsychological assessments) to 4 (coma). Secondary outcomes included time to HE resolution and overall length of stay.

Results  A total of 25 patients were randomized to each treatment arm. Baseline clinical features at admission were similar in the groups. Thirteen of 25 patients in the standard therapy arm (52%) had an improvement of 1 or more in HESA score, thus meeting the primary outcome measure, compared with 21 of 23 evaluated patients receiving PEG (91%) (P  less than  .01); 1 patient was discharged before final analysis and 1 refused participation. The mean (SD) HESA score at 24 hours for patients receiving standard therapy changed from 2.3 (0.9) to 1.6 (0.9) compared with a change from 2.3 (0.9) to 0.9 (1.0) for the PEG-treated groups (P = .002). The median time for HE resolution was 2 days for standard therapy and 1 day for PEG (P = .01). Adverse events were uncommon, and none was definitely study related.

Conclusions and Relevance  PEG led to more rapid HE resolution than standard therapy, suggesting that PEG may be superior to standard lactulose therapy in patients with cirrhosis hospitalized for acute HE.

10. No Appointment Necessary? Ethical Challenges in Treating Friends and Family

Gold KJ, et al.  N Engl J Med 2014; 371:1254-1258.

Physicians may be asked or choose to provide medical care to family members or to give informal or undocumented care to friends, neighbors, or colleagues who are not their patients. Treatment can range from refilling a prescription, discussing a recent injury, or ordering a test to performing major surgeries. The ethical risks of caring for relatives or friends or providing informal and undocumented care are substantial but may be overlooked. Although there may be limited situations in which providing medical treatment for friends and family is acceptable, these situations are often nuanced. We review guidance from professional medical organizations, summarize research on the prevalence and attitudes about physicians' treatment of friends and family, and review the ethical issues and offer guidance for making decisions about when to provide care…

Ethical Guidance from Professional Organizations
Not all medical organizations have issued guidelines on this topic. However, all those that have published guidelines recommend against care for self or family other than in exceptional situations, and we are aware of no professional organization that condones this practice. The very first code of medical ethics drafted by the American Medical Association (AMA) in 1847 recommended against physicians treating family members, stating that “the natural anxiety and solicitude which he [the physician] experiences at the sickness of a wife, a child . . . tend to obscure his judgment, and produce timidity and irresolution in his practice.”1

The 1993 guidelines of the AMA Code of Medical Ethics state that physicians “generally should not treat themselves or members of their immediate families.”2 The code describes many potential pitfalls in the care of family members, including failure to ask about sensitive areas of the medical history or social situation, avoiding important or sensitive aspects of the physical examination, a lack of professional objectivity, conflict among roles with potential complications if the medical care does not go well, practicing outside the scope of training, the possibility that the patient will not be forthcoming, and lack of informed consent and assent by the patient. The American College of Physicians recently updated its ethical principles and asserted that physicians should “usually not enter into the dual relationship of physician-family member or physician-friend.”3 Similarly, the American Academy of Pediatrics states that “caring for one's own children presents significant ethical issues.”4 All these organizations recognize that there may be minor care or emergency situations for which no other physician is available in which acute and limited care may be appropriate.

Prevalence and Attitudes
In several studies assessing the prevalence of medical treatment of friends or family by physicians, there is a substantial gap between what professional organizations recommend and what physicians actually do. A 1993 survey of physician-parents in Iowa reported that 4% of children had a parent as the physician of record, and two thirds of these physicians prescribed medications for their child.5 A 1991 study showed that 99% of surveyed physicians reported having received requests from family members for medical advice, diagnosis, or treatment, and 83% had prescribed medications for relatives.6 Physicians cite convenience as a key reason to provide this care, but other explanations have included a wish to save the relative money as well as a belief that “I provide the best care.”7

The actual treatments that physicians provide to friends and family range dramatically from acute and minor care to care for serious chronic illnesses and invasive procedures.6,8 In one study, 15% of hospital physicians reported serving as the attending for a loved one, and 9% had performed elective surgery on a relative.6 Although most surveys suggest medications such as antibiotics, birth-control pills, and analgesics are the most commonly prescribed drugs in these encounters, there are substantial numbers of prescriptions for antidepressants, sedatives, narcotic pain medications, and other addictive substances.8-10 Studies have shown that physicians often feel pressured and conflicted about requests to treat friends and family and that most physicians have declined at least one request or indicated that they would consider declining, as observed in clinical vignettes.11,12

On the basis of our clinical experience, we developed three realistic case vignettes as examples of different types of care a physician might be asked or tempted to provide to family members or friends…

The remainder of the article (full-text free):

11. Images in Clinical Practice

Elderly Male with Abdominal Pain

Young Woman with Abdominal Pain

Superior Vena Cava Syndrome

Aortic Dissection

Congenital Duodenal Obstruction and Double-Bubble Sign

12. Prophylactic Antibiotics for Epistaxis: Where’s the Evidence?

by  Brian Cohn, MD. Emergency Physicians Monthly, September 16, 2014

One more case of unnecessary antibiotic administration? Check the research. 

Epistaxis is a common problem, with a lifetime incidence of about 60% (Gifford 2008). While the majority of cases do not require medical attention, epistaxis remains a common presenting complaint in the ED. The management of epistaxis can be highly variable, with the most frequently utilized technique being nasal packing with either coagulant impregnated balloons, nasal tampons, or petroleum gauze.

The role of prophylactic systemic antibiotics when anterior nasal packing is employed remains highly controversial. Concern for the development of toxic shock syndrome (TSS) seems to have motivated the clinical recommendations of the authors of the American College of Emergency Physicians 2009 Focus on Treatment of Epistaxis, who noted that while direct evidence is lacking, “most sources recommend TMP/SMX, cephalexin, or amoxicillin/clavulanic acid to prevent sinusitis and toxic shock syndrome [TSS].” But this serious complication is exceedingly rare. The incidence of TSS with nasal packing following nasal surgery is approximately 16.5 in 100,000, or 1 in approximately 6000 cases (Jacobson 1986). But there have been no cases of toxic shock syndrome reported in the literature following nasal packing for epistaxis. Of 61 cases of TSS identified in the Minneapolis-St. Paul area between 2000 and 2006, none were attributed to an upper respiratory source (Devries 2011).

American EPs seemed to adopt the conservatism of their British counterparts who, when surveyed in 2005, revealed that 78% of interviewees believed that the use of prophylactic antibiotics with anterior nasal packing reduced the incidence of infection (Biswas 2006). But there seemed to be scant evidence that this was actually true. One large randomized trial evaluating the use of prophylactic antibiotics with nasal packing following septoplasty found no difference in post-operative pain, infectious symptoms, or the amount of purulent nasal discharge with or without prophylactic antibiotics (Ricci 2012).

The applicability of these results to patients with anterior nasal packing for epistaxis is unclear. While site of packing (anterior vs. posterior), sterility of the environment (operative room vs. ED), and entry into nasal cavity (post-surgical vs. non-instrumented) may have some effect on the incidence of infectious outcomes, the overall effectiveness of antibiotics in epistaxis patients who have undergone anterior nasal packing remains unclear.

Unfortunately, no randomized controlled trials evaluating the effect of antibiotics on outcomes following epistaxis could be identified. What evidence does exist, however, suggests that antibiotics are unnecessary and potentially harmful. One prospective observational trial showed that anterior nasal packing and antibiotic administration had no effect on the microbiological flora of the nasal cavity following epistaxis (Biswas 2009). Folllowing removal of anterior nasal packs, patients had bacterial cultures sent from nasal swabs from both nares. The microbiological results were similar for both packed and unpacked sides, and were similar between those patients who received antibiotics and those who did not.

Antibiotics also seem to have no effect on patient outcomes. One study of 149 patients showed no infectious complications (sinusitis, otitis, toxic shock syndrome) in patients who underwent anterior nasal packing regardless of whether they received antibiotics (Pepper 2012). Another study compared infectious symptoms in patients undergoing anterior nasal packing before and after instituting a protocol to reduce antibiotic use. While antibiotic use decreased from 74% of patients to 16% of patients, there was no difference in infectious symptoms between the groups at 6-week telephone follow-up (Biggs 2013). No patient in either of these studies developed otitis media or sinusitis…

13. Suspected Ureteral Colic: US or CT?

1. Ultrasonography versus CT for suspected nephrolithiasis.

Smith-Bindman R, et al. N Engl J Med. 2014 Sep 18;371(12):1100-10.

BACKGROUND: There is a lack of consensus about whether the initial imaging method for patients with suspected nephrolithiasis should be computed tomography (CT) or ultrasonography.

METHODS: In this multicenter, pragmatic, comparative effectiveness trial, we randomly assigned patients 18 to 76 years of age who presented to the emergency department with suspected nephrolithiasis to undergo initial diagnostic ultrasonography performed by an emergency physician (point-of-care ultrasonography), ultrasonography performed by a radiologist (radiology ultrasonography), or abdominal CT. Subsequent management, including additional imaging, was at the discretion of the physician. We compared the three groups with respect to the 30-day incidence of high-risk diagnoses with complications that could be related to missed or delayed diagnosis and the 6-month cumulative radiation exposure. Secondary outcomes were serious adverse events, related serious adverse events (deemed attributable to study participation), pain (assessed on an 11-point visual-analogue scale, with higher scores indicating more severe pain), return emergency department visits, hospitalizations, and diagnostic accuracy.

RESULTS: A total of 2759 patients underwent randomization: 908 to point-of-care ultrasonography, 893 to radiology ultrasonography, and 958 to CT. The incidence of high-risk diagnoses with complications in the first 30 days was low (0.4%) and did not vary according to imaging method. The mean 6-month cumulative radiation exposure was significantly lower in the ultrasonography groups than in the CT group (P less than 0.001). Serious adverse events occurred in 12.4% of the patients assigned to point-of-care ultrasonography, 10.8% of those assigned to radiology ultrasonography, and 11.2% of those assigned to CT (P=0.50). Related adverse events were infrequent (incidence, 0.4%) and similar across groups. By 7 days, the average pain score was 2.0 in each group (P=0.84). Return emergency department visits, hospitalizations, and diagnostic accuracy did not differ significantly among the groups.

CONCLUSIONS: Initial ultrasonography was associated with lower cumulative radiation exposure than initial CT, without significant differences in high-risk diagnoses with complications, serious adverse events, pain scores, return emergency department visits, or hospitalizations. (Funded by the Agency for Healthcare Research and Quality.).

2. Associated editorial: Imaging in the ED for Suspected Nephrolithiasis

Curhan G.  N Engl J Med 2014; 371:1154-1155.

The excruciating pain of renal colic often drives the affected patient to the emergency department. Given the increasing prevalence of nephrolithiasis,1 more patients than ever before are arriving for evaluation and treatment — nearly 1 million emergency department visits for upper-tract stone disease per year.2 In the emergency department, rapid diagnosis should facilitate the most appropriate therapy.

Patients with a previous episode of colic will often make the diagnosis themselves, but those who have renal colic for the first time rarely do. Laboratory tests are nondiagnostic. The urine sediment will occasionally reveal crystals, but more commonly there will be nonspecific findings of leukocyturia and hematuria. Diagnostic certainty typically rests on imaging studies. A plain radiograph of the kidneys, ureters, and bladder is neither sensitive nor specific and does not provide information about other potentially important diagnoses. Ultrasonography and computed tomography (CT) each have advantages and disadvantages. The advantages of ultrasonography include the fact that the patient is not exposed to radiation and the possibility that the imaging can be performed at the bedside, but ultrasonography is less sensitive than CT for identifying the number and size of kidney stones and rarely identifies the location of a ureteral stone. CT has been widely considered to be the best available imaging method for diagnosis because it can detect stones as small as 1 mm, provides information on location and possibly composition, and detects the presence of other asymptomatic stones. However, CT is more expensive than ultrasonography and exposes the patient to radiation. A common belief is that CT leads to more rapid diagnosis, thereby reducing the time spent in the emergency department.

The report by Smith-Bindman and colleagues in this issue of the Journal 3 provides valuable information about the choice of the first imaging study for patients presenting to the emergency department with suspected nephrolithiasis. The strengths of the study include its multicenter, randomized, pragmatic design and the large sample size and excellent retention rate. Participants were randomly assigned to undergo ultrasonography performed by an emergency physician (point-of-care ultrasonography), ultrasonography performed by a radiologist, or abdominal CT, but the treating physician could order additional imaging studies if clinically indicated. Among patients with suspected nephrolithiasis, the clinical outcomes did not differ substantially according to the first imaging method used, but the ultrasonography group had lower cumulative radiation exposure. Although ultrasonography was not as sensitive as CT when used initially, the diagnostic accuracy for nephrolithiasis among patients who were randomly assigned initially to ultrasonography was essentially the same as that among patients assigned initially to CT.

Several issues should be considered in the interpretation of this important study. The diagnosis of nephrolithiasis was based either on the patient's report of stone passage or on a medical record that a stone was surgically removed. Because many patients pass their stone after an episode of renal colic without actually seeing the stone, their reports could have been influenced by the information given by the emergency department providers, thereby increasing the apparent diagnostic accuracy of the imaging studies.

Interpretation of the ultrasound examination could have been influenced by the patient's history and by previous imaging. It is possible that the characteristic shadowing or hydronephrosis would have been more likely to be reported in a patient with a history of stone disease, particularly if a recent imaging study had identified a stone. This latter possibility is supported by the study's findings that among persons in the ultrasonography groups, those with a history of nephrolithiasis were less likely than those without such a history to undergo subsequent CT. In addition, there is no mention in the article about whether a patient had had a recent stone-related procedure, which would also greatly influence the probability that a diagnosis of nephrolithiasis would be made.

On the basis of the study findings, it is reasonable for a physician to use ultrasonography as the initial imaging method for a patient presenting to the emergency department with suspected nephrolithiasis, remembering that additional imaging studies should be used when clinically indicated. Although CT had higher sensitivity than ultrasonography, this increased sensitivity did not lead to better clinical outcomes. Importantly, patients assigned to ultrasonography performed by a radiologist actually spent more time in the emergency department than did patients in either of the other two groups, supporting the long-held belief that CT would lead to quicker disposition (although the length of stay with point-of-care ultrasonography was similar to that with CT). 

Although we want to limit radiation exposure from all sources, the decision to use ultrasonography needs to be balanced against the additional information obtained by CT, which may influence subsequent clinical decisions. For example, additional renal stones may be seen on CT but not on ultrasonography, leading to a more aggressive regimen to prevent new stone formation. It should be emphasized, as the authors note, that ultrasonography when used alone is not very sensitive for detecting stones; more than 40% of stones were not detected by initial ultrasonography. However, the approach of starting with ultrasonography and then proceeding to CT if indicated resulted in similar levels of sensitivity in the three groups. It is reassuring that high-risk diagnoses were rarely missed with this approach.

In the future, the wider use of low-dose CT,4-6 which exposes the patient to substantially less radiation than conventional CT, may change the risk–benefit balance of these imaging methods, but low-dose CT will need to be examined as carefully as the imaging methods in the current study. Regardless of which imaging method is used, providers should remember to tell their patients that new stone formation can be prevented and to give them preventive strategies that should reduce the number of future emergency department visits for renal colic.

14. Evaluation of Acute Appendicitis by Pediatric Emergency Physician Sonography

Sivitz AB, et al. Ann Emerg Med. 2014;64:358–364.e4

Study objective: We investigate the accuracy of pediatric emergency physician sonography for acute appendicitis in children.

Methods: We prospectively enrolled children requiring surgical or radiology consultation for suspected acute appendicitis at an urban pediatric emergency department. Pediatric emergency physicians performed focused right lower-quadrant sonography after didactics and hands-on training with a structured scanning algorithm, including the graded-compression technique. We compared their sonographic interpretations with clinical and radiologic findings, as well as clinical outcomes as defined by follow-up or pathologic findings.

Results: Thirteen pediatric emergency medicine sonographers performed 264 ultrasonographic studies, including 85 (32%) in children with pathology-verified appendicitis. Bedside sonography had a sensitivity of 85% (95% confidence interval [CI] 75% to 95%), specificity of 93% (95% CI 85% to 100%), positive likelihood ratio of 11.7 (95% CI 6.9 to 20), and negative likelihood ratio of 0.17 (95% CI 0.1 to 0.28).

Conclusion: With focused ultrasonographic training, pediatric emergency physicians can diagnose acute appendicitis with substantial accuracy.

15. Emergency Hospitalizations for Unsupervised Prescription Medication Ingestions by Young Children.

Lovegrove MC, et al. Pediatrics. 2014 Sep 15 [Epub ahead of print]

BACKGROUND: Emergency department visits and subsequent hospitalizations of young children after unsupervised ingestions of prescription medications are increasing despite widespread use of child-resistant packaging and caregiver education efforts. Data on the medications implicated in ingestions are limited but could help identify prevention priorities and intervention strategies.

METHODS: We used nationally representative adverse drug event data from the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance project and national retail pharmacy prescription data from IMS Health to estimate the frequency and rates of emergency hospitalizations for unsupervised prescription medication ingestions by young children (2007-2011).

RESULTS: On the basis of 1513 surveillance cases, 9490 estimated emergency hospitalizations (95% confidence interval: 6420-12 560) occurred annually in the United States for unsupervised prescription medication ingestions among children aged less than 6 years from 2007 through 2011; 75.4% involved 1- or 2-year old children. Opioids (17.6%) and benzodiazepines (10.1%) were the most commonly implicated medication classes. The most commonly implicated active ingredients were buprenorphine (7.7%) and clonidine (7.4%). The top 12 active ingredients, alone or in combination with others, were implicated in nearly half (45.0%) of hospitalizations. Accounting for the number of unique patients who received dispensed prescriptions, the hospitalization rate for unsupervised ingestion of buprenorphine products was significantly higher than rates for all other commonly implicated medications and 97-fold higher than the rate for oxycodone products (200.1 vs 2.1 hospitalizations per 100 000 unique patients).

CONCLUSIONS: Focusing unsupervised ingestion prevention efforts on medications with the highest hospitalization rates may efficiently achieve large public health impact. From 2007 to 2011, more than 9,000 children younger than age 6 were hospitalized each year for accidentally taking prescription medications, according to a study in the journal Pediatrics. Among the adult prescription drugs implicated in childhood poisonings, buprenorphine had the highest rate of emergency hospitalizations.

Related ABC news report

9,000 children hospitalized for Rx drug poisonings annually in U.S.
An anti-addiction drug used to fight the nation's heroin and painkiller abuse epidemics poses a threat to young children who accidentally swallow relatives' prescriptions, a federal study says. Some children have died.

The study found that the drug, buprenorphine, was the adult prescription medication most commonly implicated in emergency hospitalizations of children aged 6 and younger.

For every 100,000 patients prescribed buprenorphine, 200 young children were hospitalized for taking it, the study found. That rate is more than four times higher than the statistic for next most commonly implicated drug, a blood pressure medicine. Almost 800 youngsters a year were hospitalized after swallowing buprenorphine, the study found.

16. Lack of improved outcomes with increased use of targeted temperature management following out-of-hospital cardiac arrest: A multicenter retrospective cohort study.

Mark DG, et al. Resuscitation. 2014;85:1549- 1556.

STUDY AIMS: To assess whether increased use of targeted temperature management (TTM) within an integrated healthcare delivery system resulted in improved rates of good neurologic outcome at hospital discharge (Cerebral Performance Category score of 1 or 2).

METHODS: Retrospective cohort study of patients with OHCA admitted to 21 medical centers between January 2007 and December 2012. A standardized TTM protocol and educational program were introduced throughout the system in early 2009. Comatose patients eligible for treatment with TTM were included. Adjusted odds of good neurologic outcome at hospital discharge and survival to hospital discharge were assessed using multivariate logistic regression.

RESULTS: A total of 1119 patients were admitted post-OHCA with coma, 59.1% (661 of 1119) of which were eligible for TTM. The percentage of patients treated with TTM markedly increased during the study period: 10.5% in the years preceding (2007-2008) vs. 85.1% in the years following (2011-2012) implementation of the practice improvement initiative. However, unadjusted in-hospital survival (37.3% vs. 39.0%, p=0.77) and good neurologic outcome at hospital discharge (26.3% vs. 26.6%, p=1.0) did not change. The adjusted odds of survival to hospital discharge (AOR 1.0, 95% CI 0.85-1.17) or a good neurologic outcome (AOR 0.94, 95% CI 0.79-1.11) were likewise non-significant.

INTERPRETATION: Despite a marked increase in TTM rates across hospitals in an integrated delivery system, there was no appreciable change in the crude or adjusted odds of in-hospital survival or good neurologic outcomes at hospital discharge among eligible post-arrest patients.


17. Review: Most anti-clotting drugs are comparable in safety

A study in JAMA compared the safety outcomes from nearly 50 trials of eight blood-thinning regimens. Apixaban use for three months was associated with a 0.28% chance of major bleeding, the lowest rate among the treatments studied. Rivaroxaban was associated with a 0.49% risk, compared to risks of about 0.89% for the other treatments.

18. Ketamine and Intraocular Pressure in Children.

Wadia S, et al. Ann Emerg Med. 2014;64(4):385–388.e1.

STUDY OBJECTIVE: We determine the increase in intraocular pressure during pediatric procedural sedation with ketamine, and the proportion of children whose increase might be clinically important (at least 5 mm Hg).

METHODS: We prospectively enrolled children aged 8 to 18 years, chosen to receive ketamine sedation in a pediatric emergency department. We measured intraocular pressure before sedation, immediately after ketamine administration, 2 minutes post-drug administration, and every 5 minutes thereafter until recovery or 30 minutes after the final dose. We descriptively report our observations.

RESULTS: For the 60 children enrolled, the median intraocular pressure increase was 3 mm Hg (range 0 to 8 mm Hg). Fifteen children had a brief greater than or equal to 5 mm Hg increase in intraocular pressure from baseline.

CONCLUSION: In this study of ketamine sedation in children with healthy eyes, we observed mild increases in intraocular pressure that at times transiently exceeded our bounds for potential clinical importance (5 mm Hg).

19. NSAIDs Are a Major Cause of Anaphylaxis-Related ED Visits

David J. Amrol, MD. Journal Watch Emerg Med September 16, 2014

Epinephrine is first-line treatment for drug-induced anaphylaxis, but it is underutilized.

Anaphylaxis is a life-threatening hypersensitivity reaction that can be allergic or nonallergic. Allergic causes of drug-induced anaphylaxis generally are IgE mediated (e.g., hives and angioedema within 1 hour of penicillin administration), whereas in nonallergic anaphylaxis, inflammatory mediators are released by nonspecific immunological mechanisms (e.g., leukotrienes in aspirin-associated respiratory disease, with reactions delayed up to 2–3 hours). In this study, researchers assessed the rate of anaphylaxis among 806 patients who presented to a Brazilian emergency department with drug-induced hypersensitivity reactions.

Of 117 patients who met criteria for anaphylaxis, culprit drugs were identified in 76%. Almost 50% of reactions were caused by nonsteroidal anti-inflammatory drugs (NSAIDs), followed by latex (12%), antibiotics (4%), and neuromuscular blockers, radiocontrast agents, and midazolam (3% combined). All NSAID reactions were nonallergic, and most featured urticaria or angioedema and bronchospasm or dyspnea; reactions to antibiotics, hypnotics, neuromuscular blockers, and latex were mostly IgE mediated. IgE-mediated reactions were more severe and involved in all cases of cardiogenic shock. Only 34% of patients with moderate-to-severe anaphylaxis received epinephrine in the emergency department.

Comment: Physicians should be aware that medications can cause both allergic and nonallergic anaphylactic reactions. Although the most severe reactions involving cardiogenic shock are IgE mediated, non–IgE-mediated causes such as NSAIDs and radiocontrast still are life-threatening and actually might be more common. Epinephrine is underutilized: Regardless of cause or mechanism, it is always first-line treatment for anaphylaxis.

Citation: Aun MV et al. Nonsteroidal anti-inflammatory drugs are major causes of drug-induced anaphylaxis. J Allergy Clin Immunol Pract 2014 Jul/Aug; 2:414.

20. US EDs: Timely Care and LOS Studies

1. Timeliness of Care in US EDs: An Analysis of Newly Released Metrics From the Centers for Medicare & Medicaid Services

Le ST, et al. JAMA Intern Med. 2014 September 15 [Epub ahead of print]

The relationship between increasing emergency department (ED) crowding and worse outcomes for patients has been well documented.1,2 This evidence has created growing recognition among federal policy makers that the quality of emergency care should be measured. In July 2013, the Centers for Medicare & Medicaid Services3 made several quality measures of ED timeliness publicly available online. These data provide a national portrait of the ability of EDs to provide timely care, an essential concern given the severity and time sensitivity of many acute illnesses and injuries.

We investigated how hospital EDs perform on measurements of timely care and whether certain hospital characteristics or patient populations are associated with poor timeliness of ED care. Previous literature on ED timeliness of care has been limited to investigations with non–nationally representative samples or to 1 or 2 measures of timeliness of care.1,4- 7

Results (excerpt)
Our sample consisted of 3692 hospitals with EDs that reported at least 1 ED measure to the Centers for Medicare & Medicaid Services. Most were nonteaching (72.1%), private nonprofit (63.4%) hospitals located in urban areas (52.2%). For patients discharged from the ED, the median wait time to see a health care professional was approximately half an hour, and the length of stay was just over 2 hours. For admitted patients, the median length of stay in the ED was more than 4 hours, approximately one-third of which was accounted for by boarding time. Extreme variability existed for all measures…

Our findings provide a crucial starting point for discussion on the status quo of ED quality and on ED quality metrics. Given the variation in hospital ED performance, our results suggest a potential for improvement in ED timeliness. However, if these measures are translated into pay-for-performance incentives, the financial pressures faced by larger, urban, major teaching, public hospitals may be exacerbated.

2. Association Between ED Length of Stay and Rates of Admission to Inpatient and Observation Services

Carrier E, et al. JAMA Intern Med. 2014 September 15 [Epub ahead of print]

In the United States, quality measures have recently been developed to evaluate emergency department (ED) length of stay (LOS). As of 2012, hospitals are expected to report their median ED LOS to the Centers for Medicare and Medicaid Services, which reports these data to the public on their Hospital Compare database.1 However, a concern is that, in the future, maximum LOS intervals will be tied to reimbursements; such measures could lead to adverse consequences, including rising numbers of brief admissions, as have been observed in other nations with similar programs.

Results (excerpt)
Most visits (51.9%) resulting in admission were to hospitals that met the 8-hour target for 90% of admissions, while only 22.5% of visits resulting in discharge were to hospitals that met the 4-hour target for 90% of discharges (Table 1). Visits to hospitals that met the 8-hour targets for admitted patients had higher adjusted odds of inpatient admission. Visits to hospitals that met the 4-hour targets for discharged patients had no significantly different odds of admission than visits to hospitals that did not.

The results of our analysis do not mirror the experience of some countries that have adopted formal LOS guidelines, where observation admissions were most affected2- 4,8,9; however, they demonstrate an association between ED LOS and rates of admissions to inpatient services. These cross-sectional findings do not illustrate the precise nature of this association, but they suggest that potential associations between LOS targets and admission decisions may merit further investigation before EDs are rewarded for achieving specific targets on LOS quality measures. Emergency department patients require varied services, and an LOS that is adequate for one patient may be insufficient for the evaluation of another. If the pressure of LOS measures encourages otherwise avoidable inpatient admissions, this could increase health care costs and unnecessary hospital-acquired conditions. Policy makers should consider these unintended consequences before adopting ED LOS quality measures.

21. Patient Flow in the ED: A Classification and Analysis of Admission Process Policies.

Kang H, et al. Ann Emerg Med. 2014;64(4):335–342.e8.

STUDY OBJECTIVE: We investigate the effect of admission process policies on patient flow in the emergency department (ED).

METHODS: We surveyed an advisory panel group to determine approaches to admission process policies and classified them as admission decision is made by the team of providers (attending physicians, residents, physician extenders) (type 1) or attending physicians (type 2) on the admitting service, team of providers (type 3), or attending physicians (type 4) in the ED. We developed discrete-event simulation models of patient flow to evaluate the potential effect of the 4 basic policy types and 2 hybrid types, referred to as triage attending physician consultation and remote collaborative consultation on key performance measures.

RESULTS: Compared with the current admission process policy (type 1), the alternatives were all effective in reducing the length of stay of admitted patients by 14% to 26%. In other words, patients may spend 1.4 to 2.5 hours fewer on average in the ED before being admitted to internal medicine under a new admission process policy. The improved flow of admitted patients decreased both the ED length of stay of discharged patients and the overall length of stay by up to 5% and 6.4%, respectively. These results are framed in context of teaching mission and physician experience.

CONCLUSION: An efficient admission process can reduce waiting times for both admitted and discharged ED patients. This study contributed to demonstrating the potential value of leveraging admission process policies and developing a framework for pursuing these policies.

22. Do Glucocorticoids Provide Benefit to Children With Bronchiolitis?

Ng C, et al. Ann Emerg Med. 2014;64(4):389-391.  

Bottom-line: The use of systemic or inhaled glucocorticoids in children aged 2 years or younger with acute bronchiolitis does not decrease admission rate or length of hospitalization.

23. Micro Lit Bits

A. Rural family physicians more likely to provide ER, urgent care

A study found 8% of family physicians in frontier settings and 3% of those in urban areas spent at least 80% of their time providing emergency or urgent care, according to researchers at the Robert Graham Center for Policy Studies in Family Medicine and Primary Care. Graham Center medical director for health policy Kathleen Klink, M.D., commented that the results were not surprising because rural physicians tend to have a broader scope of practice. The study was published in the Journal of the American Board of Family Medicine.

B. Experts issue framework for managing sickle cell disease

A National Heart, Lung, and Blood Institute panel co-chaired by family physician Barbara Yawn, M.D., has released updated recommendations for managing sickle cell disease in children and adults. The guidelines, published in JAMA, advise daily oral penicillin until age 5, vaccination against pneumonia as early as age 6 weeks and annual transcranial Doppler for ages 2 to 16. Adults who experience at least three serious blood flow crises in a year should be treated with hydroxyurea, which the guidelines say is also suitable for children.

C. Are weight-loss supplements counterproductive?

The use of weight-loss supplements may encourage counterproductive eating habits.  In this study, women who were taking a supposed weight-loss supplement ate more unhealthy foods at a buffet than those aware they were receiving a placebo. This may help explain why the growing use of weight-loss supplements does not seem to be contributing to a reduction in weight.

D. Health Confidence: A Simple, Essential Measure for Patient Engagement and Better Practice

Asking patients this one question can lead to better outcomes.

Wasson J, et al. Fam Pract Manag. 2014 Sep-Oct;21(5):8-12.

E. Aerobic exercise improves children's attention, mood

Among children at risk for attention-deficit/hyperactivity disorder, aerobic exercises before the beginning of the school day led to greater improvements in attention and mood than sedentary classroom activities, U.S. researchers found. Aerobic physical activity also benefited typically developing children, according to the study in the Journal of Abnormal Child Psychology.

F. Study shows placebo may work as well as antidepressant

A University of California, Los Angeles, study found little difference in clinical outcomes between patients given an antidepressant drug or a placebo, but both therapies led to better results than supportive care alone. Lead investigator Andrew Leuchter, M.D., said the efficacy in both the placebo and antidepressant arms of the study may be due to participants' belief that the treatment will be effective. The findings were published in the British Journal of Psychiatry.

G. HHS: Hospitals to save $5.7B because more people have insurance

HHS estimated U.S. hospitals will save $5.7 billion in 2014 because of fewer unpaid bills for uninsured patients who now have coverage through the Affordable Care Act. About 74% of the savings will be in states that have expanded their Medicaid programs.

H. Nonprescription racemic epinephrine for asthma

In this study, the authors sought to determine the dose of Inhaled racepinephrine (RE) that is equivalent to nebulized albuterol. Inhaled racepinephrine (Asthmanefrin®) became available in September 2012 as a non-prescription treatment for bronchospasm. The authors report on four adult subjects with mild, stable asthma that completed a series of methacholine challenges on different days. A significant dose response for RE was noted, but the bronchoprotection from methacholine provided by RE was significantly less than that provided by albuterol. The authors concluded that RE may be less effective than albuterol in treating acute bronchospasm.

I. U.S. sees decline in new diabetes cases, CDC finds

CDC officials found the number of new diabetes cases in the U.S. declined to 7.1 per 1,000 people in 2012, following an increase from 3.2 per 1,000 people in 1990 to 8.8 per 1,000 people in 2008. However, researchers noted a persistent increase among Hispanics, blacks and those with lower education levels. The findings were published in the Journal of the American Medical Association.

J. Study links healthy lifestyles to reduced heart attack risk in men

A study in the Journal of the American College of Cardiology says practicing five healthy behaviors, including exercising and drinking moderately, could save 4 in 5 middle-aged and older men from possible heart attacks. Compared with overweight patients and those who ate poorly, exercised little, drank too much alcohol and smoked, participants who followed the recommended health behaviors were 86% less likely to experience heart attacks.

K. Care coordination cuts hospital admissions, ED visits, for frequent fliers

Canadian researchers found patients who were recipients of a care coordination quality improvement strategy had a 20% decline in hospitalizations compared with those in the standard care cohort. Data also showed care coordination initiatives resulted in 31% fewer emergency department visits among older patients. The findings appear in the Canadian Medical Association Journal.