Sunday, October 19, 2014

Lit Bits: Oct 19, 2014

From the recent medical literature…

1. ARISE Confirms ProCESS: “Usual Care” Is as Effective as EGDT in Septic Shock

Ali S. Raja. Journal Watch Emergency Medicine. October 1, 2014

Patients with early septic shock who received provider-directed usual care had similar mortality to those who received early goal-directed therapy.

The recent ProCESS trial, conducted at 31 U.S. academic centers, demonstrated that the specific monitoring strategies of early goal-directed therapy (EGDT) for septic shock did not provide any mortality benefit compared to protocol-based resuscitation or usual care (NEJM 2014). Whether the ProCESS results were generalizable was not clear. In a collaborative study with a harmonized protocol — the ARISE trial — researchers at 51 tertiary and nontertiary sites in five countries randomized 1600 patients with early septic shock to EGDT or provider-directed usual care.

The primary ARISE endpoint of 90-day all-cause mortality was similar in the EGDT and usual-care groups (18.6% and 18.8%). Patients in the EGDT group received slightly more intravenous fluids than those receiving usual care (mean, 2.0 L vs. 1.7 L) and were more likely to receive vasopressors (67% vs. 58%), blood transfusions (14% vs. 7%), and dobutamine (15% vs. 3%).

Comment: The ARISE results confirm those of the ProCESS trial at a diverse group of sites. However, all patients in ARISE received antibiotics before randomization, and even patients in the usual-care group received rapid fluid resuscitation during the first 6 hours after randomization. Mortality rates in ProCESS and ARISE were all significantly lower than the 57% rate in the control group of the original EGDT trial (NEJM 2001), thereby confirming that the strategies of rapid recognition, early antibiotics, and aggressive fluid resuscitation — rather than the exact monitoring strategies of EGDT — are the keys to more effectively treating septic shock.

The ARISE Investigators and the ANZICS Clinical Trials Group. Goal-directed resuscitation for patients with early septic shock. N Engl J Med. 2014 Oct 1 [Epub ahead of print]. 

Background: Early goal-directed therapy (EGDT) has been endorsed in the guidelines of the Surviving Sepsis Campaign as a key strategy to decrease mortality among patients presenting to the emergency department with septic shock. However, its effectiveness is uncertain.

Methods: In this trial conducted at 51 centers (mostly in Australia or New Zealand), we randomly assigned patients presenting to the emergency department with early septic shock to receive either EGDT or usual care. The primary outcome was all-cause mortality within 90 days after randomization.

Results: Of the 1600 enrolled patients, 796 were assigned to the EGDT group and 804 to the usual-care group. Primary outcome data were available for more than 99% of the patients. Patients in the EGDT group received a larger mean (±SD) volume of intravenous fluids in the first 6 hours after randomization than did those in the usual-care group (1964±1415 ml vs. 1713±1401 ml) and were more likely to receive vasopressor infusions (66.6% vs. 57.8%), red-cell transfusions (13.6% vs. 7.0%), and dobutamine (15.4% vs. 2.6%) (P less than 0.001 for all comparisons). At 90 days after randomization, 147 deaths had occurred in the EGDT group and 150 had occurred in the usual-care group, for rates of death of 18.6% and 18.8%, respectively (absolute risk difference with EGDT vs. usual care, -0.3 percentage points; 95% confidence interval, -4.1 to 3.6; P=0.90). There was no significant difference in survival time, in-hospital mortality, duration of organ support, or length of hospital stay.

Conclusions: In critically ill patients presenting to the emergency department with early septic shock, EGDT did not reduce all-cause mortality at 90 days.

2. Transfusion Thresholds (for 1 unit RBCs) Should Be Conservative (7 g/dL) for Patients with Septic Shock

Holst LB, et al. Lower versus higher hemoglobin threshold for transfusion in septic shock. Engl J Med. 2014;371(15):1381-91.

BACKGROUND: Blood transfusions are frequently given to patients with septic shock. However, the benefits and harms of different hemoglobin thresholds for transfusion have not been established.

METHODS: In this multicenter, parallel-group trial, we randomly assigned patients in the intensive care unit (ICU) who had septic shock and a hemoglobin concentration of 9 g per deciliter or less to receive 1 unit of leukoreduced red cells when the hemoglobin level was 7 g per deciliter or less (lower threshold) or when the level was 9 g per deciliter or less (higher threshold) during the ICU stay. The primary outcome measure was death by 90 days after randomization.

RESULTS: We analyzed data from 998 of 1005 patients (99.3%) who underwent randomization. The two intervention groups had similar baseline characteristics. In the ICU, the lower-threshold group received a median of 1 unit of blood (interquartile range, 0 to 3) and the higher-threshold group received a median of 4 units (interquartile range, 2 to 7). At 90 days after randomization, 216 of 502 patients (43.0%) assigned to the lower-threshold group, as compared with 223 of 496 (45.0%) assigned to the higher-threshold group, had died (relative risk, 0.94; 95% confidence interval, 0.78 to 1.09; P=0.44). The results were similar in analyses adjusted for risk factors at baseline and in analyses of the per-protocol populations. The numbers of patients who had ischemic events, who had severe adverse reactions, and who required life support were similar in the two intervention groups.

CONCLUSIONS: Among patients with septic shock, mortality at 90 days and rates of ischemic events and use of life support were similar among those assigned to blood transfusion at a higher hemoglobin threshold and those assigned to blood transfusion at a lower threshold; the latter group received fewer transfusions.

3. One Dose of Etomidate Does Not Increase Mortality in Patients with Sepsis

A meta-analysis finds no evidence of harm.

Gu WJ, et al. Single-Dose Etomidate Does Not Increase Mortality in Patients with Sepsis: A Systematic Review and Meta-Analysis of RCTs and Observational Studies. Chest. 2014 Sep 25 [Epub ahead of print]

Background: The effect of single-dose etomidate on mortality in patients with sepsis remains controversial. We systematically reviewed the literature to investigate whether a single-dose etomidate for rapid sequence intubation increased mortality in patients with sepsis.

Methods: PubMed, Embase, and CENTRAL were searched for randomized controlled trials (RCTs) and observational studies regarding the effect of single-dose etomidate on mortality in adults with sepsis. The primary outcome was all-cause mortality. The Mantel-Haenszel method with random effects model was used to calculate pooled relative risks (RRs) and 95% confidence intervals (CIs).

Results: Eighteen studies (two RCTs and sixteen observational studies), involving 5552 patients, were included. Pooled analysis suggested that single-dose etomidate was not associated with increased mortality in patients with sepsis, both in RCTs (RR, 1.20; 95% CI, 0.84 to 1.72; P = 0.31; I2 = 0%) and observational studies (RR, 1.05; 95% CI, 0.97 to 1.13; P = 0.23; I2 = 25%). When only adjusted RRs were pooled in five observational studies, RR for mortality was 1.05 (95% CI, 0.79 to 1.39; P = 0.748; I2= 71.3%). These findings also were consistent across all subgroup analyses for observational studies. Single-dose etomidate increased the risk of adrenal insufficiency in patients with sepsis (eight studies; RR, 1.42; 95% CI, 1.22 to 1.64; P less than 0.00001).

Conclusions: Current evidence indicates that single-dose etomidate does not increase mortality in patients with sepsis. However, this finding largely relies on data from observational studies, potentially subject to selection bias, and hence high-quality and adequately powered RCTs are warranted.

4. The sad truth about the SADPERSONS Scale: an evaluation of its clinical utility in self-harm patients.

Saunders K, et al. Emerg Med J. 2014 Oct;31(10):796-8.

BACKGROUND: The SADPERSONS Scale is commonly used as a screening tool for suicide risk in those who have self-harmed. It is also used to determine psychiatric treatment needs in those presenting to emergency departments. To date, there have been relatively few studies exploring the utility of SADPERSONS in this context.

OBJECTIVES: To determine whether the SADPERSONS Scale accurately predicts psychiatric hospital admission, psychiatric aftercare and repetition of self-harm at presentation to the emergency department following self-harm.

METHODS: SADPERSONS scores were recorded for 126 consecutive admissions to a general hospital emergency department. Clinical management outcomes following assessment were recorded, including psychiatric hospital admission, community psychiatric aftercare and repetition of self-harm in the following 6 months.

RESULTS: Psychiatric hospital admission was required in five cases (4.0%) and community psychiatric aftercare in 70 (55.5%). 31 patients (24.6%) repeated self-harm. While the specificity of the SADPERSONS scores was greater than 90% for all outcomes, sensitivity for admission was only 2.0%, for community aftercare was 5.8% and for repetition of self-harm in the following 6 months was just 6.6%.

CONCLUSIONS: For the purposes of suicide prevention, a low false negative rate is essential. SADPERSONS failed to identify the majority of those either requiring psychiatric admission or community psychiatric aftercare, or to predict repetition of self-harm. The scale should not be used to screen self-harm patients presenting to general hospitals. Greater emphasis should be placed on clinical assessment which takes account of the individual and dynamic nature of risk assessment.

5. Accuracy of US for Determining Successful Realignment of Pediatric Forearm Fractures

Dubrovsky AS, et al. Ann Emerg Med 2014 Oct 15 [Epub ahead of print]

Study objective: The primary objective of this study is to assess the accuracy of point-of-care ultrasonography compared with blinded orthopedic assessment of fluoroscopy in determining successful realignment of pediatric forearm fractures. The secondary objective is to determine the rate of agreement of ultrasonography and fluoroscopy in real-time by the treating physician.

Methods: A cross-sectional study was conducted in children younger than 18 years and presenting to an academic emergency department with forearm fractures requiring realignment of a single bone. Physicians performed closed reductions with ultrasonographic assessment of realignment until the best possible reduction was achieved. Fluoroscopy was then immediately performed and images were saved. A positive test result was defined as an inadequately reduced fracture on fluoroscopy by a blinded pediatric orthopedic surgeon (reference standard) and on ultrasonography (index test) and fluoroscopy in real-time by the treating physician.

Results: One hundred patients were enrolled (median age 12.1 years; 74% male patients); the radius was involved in 98%, with 27% involving the growth plate. The sensitivity, specificity, positive predictive value, and negative predictive value were 50% (95% confidence interval [CI] 15.4% to 84.6%), 89.1% (95% CI 82.8% to 95.5%), 28.6% (95% CI 4.9% to 52.2%), and 95.3% (95% CI 90.9% to 99.8%), respectively. The treating physicians’ agreement rate of the real-time images was 98%.

Conclusion: Point-of-care ultrasonography can help emergency physicians determine when pediatric forearm fractures have been adequately realigned, but inadequate reductions should be confirmed by other imaging modalities.

6. Factors influencing the development of antibiotic associated diarrhea in ED patients discharged home: risk of administering IV antibiotics.

Haran JP, et al. Am J Emerg Med. 2014 Oct;32(10):1195-9.

OBJECTIVE: Antibiotic-associated diarrhea (AAD) and Clostridium difficile infection (CDI) are well-known outcomes from antibiotic administration. Because emergency department (ED) visits frequently result in antibiotic use, we evaluated the frequency of AAD/CDI in adults treated and discharged home with new prescriptions for antibiotics to identify risk factors for acquiring AAD/CDI.

METHODS: This prospective multicenter cohort study enrolled adult patients who received antibiotics in the ED and were discharged with a new prescription for antibiotics. Antibiotic-associated diarrhea was defined as 3 or more loose stools for 2 days or more within 30 days of starting the antibiotic. C difficile infection was defined by the detection of toxin A or B within this same period. We used multivariate logistic regression to assess predictors of developing AAD.

RESULTS: We enrolled and followed 247 patients; 45 (18%) developed AAD, and 2 (1%) developed CDI. Patients who received intravenous (IV) antibiotics in the ED were more likely to develop AAD/CDI than patients who did not: 25.7% (95% confidence interval [CI], 17.4-34.0) vs 12.3% (95% CI, 6.8-17.9). Intravenous antibiotics had adjusted odds ratio of 2.73 (95% CI, 1.38-5.43), and Hispanic ethnicity had adjusted odds ratio of 3.04 (95% CI, 1.40-6.58). Both patients with CDI had received IV doses of broad-spectrum antibiotics.

CONCLUSION: Intravenous antibiotic therapy administered to ED patients before discharge was associated with higher rates of AAD and with 2 cases of CDI. Care should be taken when deciding to use broad-spectrum IV antibiotics to treat ED patients before discharge home.

7. ED Crowding is Bad for Patients: Go Figure

A. The Effect of ED Crowding on Reassessment of Children With Critically Abnormal Vital Signs.

Depinet HE, et al. Acad Emerg Med. 2014 Oct;21(10):1116-1120.

OBJECTIVES: The objective was to determine whether several measures of emergency department (ED) crowding are associated with an important indicator of quality and safety: time to reevaluation of children with documented critically abnormal triage vital signs.

METHODS: This was a retrospective cross-sectional study of all patients with critically abnormal vital signs measured in triage over a 2.5-year period (September 1, 2006, to May 1, 2009). Cox proportional hazard analysis was used to determine rate ratios for time to critically abnormal vital sign reassessment, when controlled for potential confounders.

RESULTS: In this 2.5-year sample, 9,976 patients with critically abnormal vital signs in triage (representing 3.9% of 253,408 visits) were placed in regular ED rooms with electronic alerts prompting vital sign reassessment after 1 hour. Overall, the mean time to reassessment was 84 minutes. The rate of vital sign reassessment was reduced by 31% for each additional 10 patients waiting for admission (adjusted odds ratio [OR] = 0.98; 95% confidence interval [CI] = 0.98 to 0.99), by 10% for every 10 patients in the lobby (adjusted OR = 0.94; 95% CI = 0.93 to 0.96), and by 6% for every additional 10 patients in the overall ED census (adjusted OR = 0.97; 95% CI = 0.97 to 0.98).

CONCLUSIONS: Emergency department crowding was associated with delay in the reassessment of critically abnormal vital signs in children; further work is needed to develop systems to mitigate these delays.

B. Increases in ED Occupancy Are Associated with Adverse 30-day Outcomes.

McCusker J, et al. Acad Emerg Med. 2014 Oct;21(10):1092-1100.

OBJECTIVES: The associations between emergency department (ED) crowding and patient outcomes have not been investigated comprehensively in different types of ED. The study objective was to examine the associations of changes over time in ED occupancy with patient outcomes in a sample of EDs that vary by size and location. A secondary objective was to explore whether the relationship between ED occupancy and patient outcomes differed by ED characteristics (size/type and medical and nursing staffing ratios).

METHODS: Using linked administrative databases, the authors constructed a cohort of 677,475 patients who visited one of 42 hospital EDs with complete data for 2005 on ED bed and waiting room occupancy. Crowding was measured with the relative occupancy ratio separately for ED bed and waiting room patients, defined as the ratio of ED occupancy on the day of the index ED visit to the average annual occupancy at that same ED. Multivariable logistic regression (adjusting for patient and ED characteristics) was used to analyze 30-day outcomes: mortality, return ED visits, and hospital admission at the first return ED visit.

RESULTS: After adjustment for ED and patient characteristics, a 10% increase in ED bed relative occupancy ratio was associated with 3% increases in death and hospital admission at a return visit. A 10% increase in ED waiting room crowding was associated with a small decrease in return visits. There was a stronger association between bed crowding and mortality among larger EDs.

CONCLUSIONS: In Quebec EDs, increases in bed occupancy are associated with an increase in the rates of 30-day adverse outcomes, even after adjustment for patient and ED characteristics. The results raise important concerns about the quality of care during periods of ED crowding.

8. Repeat Neuroimaging of Mild Traumatic Brain-injured Patients with Acute Traumatic ICH: Clinical Outcomes and Radiographic Features.

Kreitzer N, et al. Acad Emerg Med. 2014 Oct;21(10):1083-1091.

OBJECTIVES: Emergency department (ED) management of mild traumatic brain injury (TBI) patients with any form of traumatic intracranial hemorrhage (ICH) is variable. Since 2000, our center's standard practice has been to obtain a repeat head computed tomography (CT) at least 6 hours after initial imaging. Patients are eligible for discharge if clinical and CT findings are stable. Whether this practice is safe is unknown. This study characterized clinical outcomes in mild TBI patients with acute traumatic ICH seen on initial ED neuroimaging.

METHODS: This retrospective cohort study included patients presenting to the ED with blunt mild TBI with Glasgow Coma Scale (GCS) scores of 14 or 15 and stable vital signs, during the period from January 2001 to January 2010. Patients with any ICH on initial head CT and repeat head CT within 24 hours were eligible. Cases were excluded for initial GCS less than 14, injury beyond 24 hours old, pregnancy, concomitant nonminor injuries, and coagulopathy. A single investigator abstracted data from records using a standardized case report form and data dictionary. Primary endpoints included death, neurosurgical procedures, and for discharged patients, return to the ED within 7 days. Differences in proportions were computed with 95% confidence intervals (CIs).

RESULTS: Of 1,011 patients who presented to the ED and had two head CTs within 24 hours, 323 (32%) met inclusion criteria. The median time between CT scans was 6 hours (interquartile range = 5 to 7 hours). A total of 153 (47%) patients had subarachnoid hemorrhage, 132 (41%) patients had subdural hemorrhage, 11 (3%) patients had epidural hemorrhage, 78 (24%) patients had cerebral contusions, and 59 (18%) patients had intraparenchymal hemorrhage. Four of 323 (1.2%, 95% CI = 0.3% to 3.2%) patients died within 2 weeks of injury. Three of the patients who died had been admitted from the ED on their initial visits, and one had been discharged home. There were 206 patients (64%) discharged from the ED, 28 (13.6%) of whom returned to the ED within 1 week. Of the 92 who were hospitalized, three (0.9%, 95% CI = 0.2% to 2.7%) required neurosurgical intervention.

CONCLUSION: Discharge after a repeat head CT and brief period of observation in the ED allowed early discharge of a cohort of mild TBI patients with traumatic ICH without delayed adverse outcomes. Whether this justifies the cost and radiation exposure involved with this pattern of practice requires further study.

9. Diagnosing Appendicitis: An Evidence-Based Review of the Diagnostic Approach to Appendicitis in 2014

Shogilev DJ, et al. West J Emerg Med. 2014 [Epub ahead of print]

Introduction: Acute appendicitis is the most common abdominal emergency requiring emergency surgery. However, the diagnosis is often challenging and the decision to operate, observe or further work-up a patient is often unclear. The utility of clinical scoring systems (namely the Alvarado score), laboratory markers, and the development of novel markers in the diagnosis of appendicitis remains controversial. This article presents an update on the diagnostic approach to appendicitis through an evidence-based review.

Methods: We performed a broad Medline search of radiological imaging, the Alvarado score, common laboratory markers, and novel markers in patients with suspected appendicitis.

Results: Computed tomography (CT) is the most accurate mode of imaging for suspected cases of appendicitis, but the associated increase in radiation exposure is problematic. The Alvarado score is a clinical scoring system that is used to predict the likelihood of appendicitis based on signs, symptoms and laboratory data. It can help risk stratify patients with suspected appendicitis and potentially decrease the use of CT imaging in patients with certain Alvarado scores. White blood cell (WBC), C-reactive protein (CRP), granulocyte count and proportion of polymorphonuclear (PMN) cells are frequently elevated in patients with appendicitis, but are insufficient on their own as a diagnostic modality. When multiple markers are used in combination their diagnostic utility is greatly increased. Several novel markers have been proposed to aid in the diagnosis of appendicitis; however, while promising, most are only in the preliminary stages of being studied.

Conclusion: While CT is the most accurate mode of imaging in suspected appendicitis, the accompanying radiation is a concern. Ultrasound may help in the diagnosis while decreasing the need for CT in certain circumstances. The Alvarado Score has good diagnostic utility at specific cutoff points. Laboratory markers have very limited diagnostic utility on their own but show promise when used in combination. Further studies are warranted for laboratory markers in combination and to validate potential novel markers.

10. Surviving Sepsis Campaign: Association between Performance Metrics and Outcomes in a 7.5-Year Study.

Levy MM, et al. Crit Care Med. 2014 Oct 1. [Epub ahead of print]

PURPOSE: To determine the association between compliance with the Surviving Sepsis Campaign (SSC) performance bundles and mortality.

DESIGN: Compliance with the SSC performance bundles, which are based on the 2004 SSC guidelines, was measured in 29,470 subjects entered into the SSC database from January 1, 2005, through June 30, 2012. Compliance was defined as evidence that all bundle elements were achieved.

SETTING: Two hundred eighteen community, academic, and tertiary care hospitals in the United States, South America, and Europe.

PATIENTS: Patients from the emergency department, medical and surgical wards, and ICU who met diagnosis criteria for severe sepsis and septic shock.

METHODS: A multifaceted, collaborative change intervention aimed at facilitating adoption of the SSC resuscitation and management bundles was introduced. Compliance with the SSC bundles and associated mortality rate was the primary outcome variable.

RESULTS: Overall lower mortality was observed in high (29.0%) versus low (38.6%) resuscitation bundle compliance sites (p less than 0.001) and between high (33.4%) and low (32.3%) management bundle compliance sites (p = 0.039). Hospital mortality rates dropped 0.7% per site for every three months (quarter) of participation (p less than 0.001). Hospital and intensive care unit length of stay decreased 4% (95% CI: 1% - 7%; p = 0.012) for every 10% increase in site compliance with the resuscitation bundle.

CONCLUSIONS: This analysis demonstrates that increased compliance with sepsis performance bundles was associated with a 25% relative risk reduction in mortality rate. Every 10% increase in compliance and additional quarter of participation in the SSC initiative was associated with a significant decrease in the odds ratio for hospital mortality. These results demonstrate that performance metrics can drive change in clinical behavior, improve quality of care, and may decrease mortality in patients with severe sepsis and septic shock.

11. Images in Clinical Practice

Hypoglossal Nerve Palsy during Meningococcal Meningitis

Evolving Infarction in the Anterior Circulation

Catastrophic Gastroduodenal Pneumatosis

Old Man with Groin Bruising

Acute Neck Infection

Tracheoesophageal Fistula in a Newborn

12. Who gets post-concussion syndrome? An ED-based prospective analysis

Ganti L, et al. Internat J Emerg Med 2014;7:31

Background: The objective of this study was to determine who gets post-concussion syndrome (PCS) after mild traumatic brain injury or head injury.

Methods: Patients presented within an hour of mild traumatic brain injury (mTBI). Written informed consent was obtained from all patients, who then provided detailed answers to surveys at the time of injury as well as at 1 week and 1 month follow-up. Statistical analyses were performed using JMP 11.0 for the Macintosh.

Results: The cohort consisted of 412 patients, 49% women and 51% men with a median age of 44, IQR 26 to 60, and range 18 to 102 years. Patients presented to the ED within an hour of their head injury (mean 35 min, std dev 21 min) and enrolled upon arrival. The most commonly reported symptoms of PCS at first follow-up were headache (27%), trouble falling asleep (18%), fatigue (17%), difficulty remembering (16%), and dizziness (16%). Furthermore, only 61% of the cohort was driving at 1 week follow-up, compared to 100% prior to the injury.

Linear regression analysis revealed the consumption of alcohol prior to head injury, the mechanism of head injury being a result of motor vehicle collision (MVC) or fall, and the presence of a post-injury headache to be significantly associated with developing PCS at 1 week follow-up, while the occurrence of a seizure post-injury or having an alteration in consciousness post-injury was significantly associated with developing PCS at 1 month follow-up. On multivariate regression analysis, the presence of a headache post-injury was the most robust predictor, retaining statistical significance even after controlling for age, gender, and presence of loss of consciousness (LOC), alteration of consciousness (AOC), post-traumatic amnesia (PTA), seizure, or vomiting.

Conclusions: The results of this prospective study suggest that headache right after the head injury, an alteration of consciousness after the head injury, and alcohol consumption prior to the head injury are significant predictors of developing PCS, which occurs with equal frequency in men and women. Early identification of those who are at risk of developing PCS would diminish the burden of the injury and could potentially reduce the number of missed work and school days.

13. Patients in Cardiac Arrest Report Conscious Awareness

Nearly 40% of 140 cardiac arrest survivors claimed memories from when they were in cardiac arrest.

Parnia S, et al. AWARE-AWAreness during REsuscitation-A prospective study.
Resuscitation 2014 Oct 6 [Epub ahead of print].

BACKGROUND: Cardiac arrest (CA) survivors experience cognitive deficits including post-traumatic stress disorder (PTSD). It is unclear whether these are related to cognitive/mental experiences and awareness during CPR. Despite anecdotal reports the broad range of cognitive/mental experiences and awareness associated with CPR has not been systematically studied.

METHODS: The incidence and validity of awareness together with the range, characteristics and themes relating to memories/cognitive processes during CA was investigated through a 4 year multi-center observational study using a three stage quantitative and qualitative interview system. The feasibility of objectively testing the accuracy of claims of visual and auditory awareness was examined using specific tests. The outcome measures were (1) awareness/memories during CA and (2) objective verification of claims of awareness using specific tests.

RESULTS: Among 2060 CA events, 140 survivors completed stage 1 interviews, while 101 of 140 patients completed stage 2 interviews. 46% had memories with 7 major cognitive themes: fear; animals/plants; bright light; violence/persecution; deja-vu; family; recalling events post-CA and 9% had NDEs, while 2% described awareness with explicit recall of 'seeing' and 'hearing' actual events related to their resuscitation. One had a verifiable period of conscious awareness during which time cerebral function was not expected.

CONCLUSIONS: CA survivors commonly experience a broad range of cognitive themes, with 2% exhibiting full awareness. This supports other recent studies that have indicated consciousness may be present despite clinically undetectable consciousness. This together with fearful experiences may contribute to PTSD and other cognitive deficits post CA.

14. Bayesian principles or Gestalt perception for clinical judgment?

Both! Dual-process cognition at work

Vancheri F. Intern Emerg Med. 2014 Oct 7. [Epub ahead of print]

I agree with the distinction between Bayesian and Gestalt patterns in clinical judgment described by Gianfranco Cervellin et al. [1]. This corresponds to the dual-process theory of thinking [2]. According to cognitive psychological studies, there are two fundamental approaches to decision-making: intuitive and analytical [3, 4]. The intuitive approach, also termed System 1, is unconscious, “fast and frugal,” characterized by heuristics, or strategies that provide shortcuts to quick decisions, and vulnerable to biases [5]. This model implies non-analytical reasoning, based on pattern recognition. This is the process of matching the presentation of symptoms and signs of a new patient with disease features of a previously encountered patient retrieved from memory. This process is based on pre-stored networks of disease characteristics produced by clinicians’ knowledge and past experiences, which is termed illness script. It often leads to good judgments, but when the patient presentation is atypical, it may fail. Moreover, the system is highly influenced by the context, which includes patient and physicians non-medical factors, such as appearance, age, gender, or workload.

On the other hand, the analytical process, or System 2, is based on conscious and rational reasoning. It is a step by step process where hypotheses are generated or discarded at each step; hypothetic-deductive, as each hypothesis is used to predict which additional findings ought to be present if it is true; probabilistic and Bayesian, in the sense that hypotheses are confirmed or dismissed according to their probability. The analytical process is slow but effective when a patient presentation is not readily recognized, and previous experience cannot inform judgments. The two components of the dual-process model are not independent but there is a continuum between them with reciprocal influences. These observations indicate that clinical judgment is a complex process. This should be taken into account in clinical practice. For this reason, medical teaching should involve problem-solving strategies and hypothesis generation and testing [6].

15. ED patient knowledge and physician communication regarding CT scans.

Zwank MD, et al. Emerg Med J. 2014 Oct;31(10):824-6.

OBJECTIVES: This study evaluated several aspects of patients' and providers' knowledge and attitude regarding emergency CT scan use. Specifically, is patient awareness of radiation risks changing over time and do levels of education affect this knowledge? Meanwhile, do emergency medicine providers discuss risks with patients and do patients want to know about these risks?

METHODS: We conducted a survey of clinically stable patients in the emergency department (ED) after undergoing a CT scan.

RESULTS: 200 patients were surveyed. 82 (41%) were aware that CT scans are associated with radiation exposure. 50 (25%) patients were aware that radiation from CT can increase overall lifetime risk of cancer compared with only 2/76 (3%) conducted in 2002. 29 (14.5%) providers specifically discussed radiation risk with patients prior to the CT. There was a significant trend towards knowledge that CT uses x-rays among those with more education. However, there was no association between level of education and knowledge of cancer risk associated with radiation risk from CT. 82 (41%) would have liked more information regarding radiation risks from the provider.

CONCLUSIONS: ED patient knowledge has increased significantly over the past 8 years. At the same time, there is a trend towards ED providers more commonly discussing these risks. Level of education is associated with knowledge that CT uses x-rays, but not with knowledge that this is associated with a greater risk of cancer. Patients often want to be informed of these risks.

16. Clinical evolution, management, and resolution of type II necrotizing fasciitis.

Makadia J, et al. Intern Emerg Med. 2014 Oct 8. [Epub ahead of print]

A 60-year-old woman with a history of pre-diabetes and hyperlipidemia, presented to a local hospital with severe left flank pain and skin discoloration on the same area for 2 days. She had been taking care of her grandson who was diagnosed with streptococcal sore throat.

On examination, the patient was hypotensive and tachycardic. There was a large grayish blue area over the left flank, extending to the left lower back (Fig. 1a, b). This area was very tender to palpation. There were no bullae, crepitus, or external drainage. A CT scan of the abdomen revealed a diffuse inflammatory process within the skin and soft tissue without any gas in the adjacent area. A diagnosis of necrotizing fasciitis was pursued. Broad-spectrum intravenous antibiotics (vancomycin, piperacillin–tazobactam, and clindamycin), and vasopressors were initiated, and she was transferred to our institution for further management.

Upon arrival, she was immediately taken to the operating room for surgery. The operative ...

17. Recommendations for beta-blockers after AMI: Should guidelines be reassessed?

In contemporary practice of treatment of myocardial infarction, β-blockers have no mortality benefit but reduce recurrent myocardial infarction and angina (short-term) at the expense of increase in heart failure, cardiogenic shock and drug discontinuation. The guidelines should reconsider the strength of recommendations for β-blockers post-myocardial infarction.

Bangalore S, et al. Clinical Outcomes with β-Blockers for Myocardial Infarction: A Meta-analysis of Randomized Trials. Am J Med. 2014 Oct;127(10):939-53.

18. Management of Bell palsy: clinical practice guideline.

de Almeida JR, et al, for Bell Palsy Working Group, Canadian Society of Otolaryngology – Head and Neck Surgery and Canadian Neurological Sciences Federation. CMAJ. 2014 Sep 2;186(12):917-22.

We recommend the use of corticosteroids for all patients with Bell palsy. (Strong recommendation: moderate confidence in effect estimate.)

We recommend against antiviral treatment alone. (Strong recommendation: moderate confidence in effect estimate.)

We suggest against the addition of antivirals to corticosteroids for patients with mild to moderate severity. (Weak recommendation: moderate confidence in effect estimate.)

We suggest the combined use of antivirals and corticosteroids in patients with severe to complete paresis. (Weak recommendation: moderate confidence in effect estimate.)

We recommend the routine use of eye-protective measures for patients with incomplete eye closure. (Strong recommendation: very low confidence in estimates.)

We recommend referral to a specialist for patients with no improvement or progressive weakness. (Strong recommendation: very low confidence in estimates.)

We recommend imaging to rule out neoplasms or alternative diagnoses for patients with no improvement or progressive weakness. (Strong recommendation: very low confidence in effect estimate.)

19. Low-Dose vs Standard-Dose Insulin in Pediatric DKA: A RCT

Nallasamy K, et al. JAMA Pediatr. Published online September 29, 2014.

Importance  The standard recommended dose (0.1 U/kg per hour) of insulin in diabetic ketoacidosis (DKA) guidelines is not backed by strong clinical evidence. Physiologic dose-effect studies have found that even lower doses could adequately normalize ketonemia and acidosis. Lowering the insulin dose may be advantageous in the initial hours of therapy when a gradual decrease in glucose, electrolytes, and resultant osmolality is desired.

Objective  To compare the efficacy and safety of low-dose insulin against the standard dose in children with DKA.

Design, Setting, and Participants  This was a prospective, open-label randomized clinical trial conducted in the pediatric emergency department and intensive care unit of a tertiary care teaching hospital in northern India from November 1, 2011, through December 31, 2012. A total of 50 consecutive children 12 years or younger with a diagnosis of DKA were randomized to low-dose (n = 25) and standard-dose (n = 25) groups.

Interventions  Low-dose (0.05 U/kg per hour) vs standard-dose (0.1 U/kg per hour) insulin infusion.

Main Outcomes and Measures  The primary outcome was the rate of decrease in blood glucose until a level of 250 mg/dL or less is reached (to convert to millimoles per liter, multiply by 0.0555). The secondary outcomes included time to resolution of acidosis, episodes of treatment failures, and incidences of hypokalemia and hypoglycemia.

Results  The mean (SD) rate of blood glucose decrease until a level of 250 mg/dL or less is reached (45.1 [17.6] vs 52.2 [23.4] mg/dL/h) and the mean (SD) time taken to achieve this target (6.0 [3.3] vs 6.2 [2.2] hours) were similar in the low- and standard-dose groups, respectively. Mean (SD) length of time to achieve resolution of acidosis (low vs standard dose: 16.5 [7.2] vs 17.2 [7.7] hours; P = .73) and rate of resolution of acidosis were also similar in the groups. Hypokalemia was seen in 12 children (48%) receiving the standard dose vs 5 (20%) of those receiving the low dose (P = .07); the tendency was more pronounced in malnourished children (7 [88%] vs 2 [28%]). Five children (20%) and 1 child (4%) receiving standard- and low-dose infusion (P = .17), respectively, developed hypoglycemia. Treatment failure was rare and comparable. One child in the standard-dose group developed cerebral edema, and no deaths occurred during the study period.

Conclusions and Relevance  Low dose is noninferior to standard dose with respect to rate of blood glucose decrease and resolution of acidosis. We advocate a superiority trial with a larger sample size before 0.05 U/kg per hour replaces 0.1 U/kg per hour in the practice recommendations.

20. The Effect of Malpractice Reform on ED Care

Waxman DA, et al. N Engl J Med 2014; 371:1518-1525.

Background: Many believe that fear of malpractice lawsuits drives physicians to order otherwise unnecessary care and that legal reforms could reduce such wasteful spending. Emergency physicians practice in an information-poor, resource-rich environment that may lend itself to costly defensive practice. Three states, Texas (in 2003), Georgia (in 2005), and South Carolina (in 2005), enacted legislation that changed the malpractice standard for emergency care to gross negligence. We investigated whether these substantial reforms changed practice.

Methods: Using a 5% random sample of Medicare fee-for-service beneficiaries, we identified all emergency department visits to hospitals in the three reform states and in neighboring (control) states from 1997 through 2011. Using a quasi-experimental design, we compared patient-level outcomes, before and after legislation, in reform states and control states. We controlled for characteristics of the patients, time-invariant hospital characteristics, and temporal trends. Outcomes were policy-attributable changes in the use of computed tomography (CT) or magnetic resonance imaging (MRI), per-visit emergency department charges, and the rate of hospital admissions.

Results: For eight of the nine state–outcome combinations tested, no policy-attributable reduction in the intensity of care was detected. We found no reduction in the rates of CT or MRI utilization or hospital admission in any of the three reform states and no reduction in charges in Texas or South Carolina. In Georgia, reform was associated with a 3.6% reduction (95% confidence interval, 0.9 to 6.2) in per-visit emergency department charges.

Conclusions: Legislation that substantially changed the malpractice standard for emergency physicians in three states had little effect on the intensity of practice, as measured by imaging rates, average charges, or hospital admission rates. (Funded by the Veterans Affairs Office of Academic Affiliations and others.)

21. Micro Bits

A. Feasibility of Optic Nerve Sheath Diameter Measured on Initial Brain Computed Tomography as an Early Neurologic Outcome Predictor After Cardiac Arrest

B. Exercise: An underfilled prescription

This review emphasizes the importance of education for both patients and providers to enhance participation in lifestyle physical activity, structured exercise or both.

C. Study finds improper selection of antibiotics for pediatric pharyngitis

Researchers who looked at data from nearly 12 million pediatric pharyngitis visits per year in the U.S. from 1997 to 2010 found that 60% of visits led to a prescription for antibiotics. Eighteen percent of prescribed antibiotics were second- and third-generation cephalosporins and amoxicillin-clavulanate, which are not recommended for use in treating pharyngitis. The findings appeared in JAMA Pediatrics.

D. PTSD symptoms may follow transient ischemic attack

People who suffer a transient ischemic attack are at risk of developing post-traumatic stress disorder, according to a study in the journal Stroke. A third of the 108 volunteers who completed questionnaires three months following a TIA experienced PTSD symptoms such as anxiety, depression and lower quality of life, researchers said.

E. Researchers say Vanco is effective for Staph

University of Nebraska researchers are advising physicians that vancomycin, an older antibiotic, still works against Staphylococcus aureus bloodstream infections. The report in the Journal of the American Medical Association said physicians do not necessarily have to choose a newer antibiotic to treat these infections.

F. Prevalence of persistent pain in U.S. adults

This article presents a secondary analysis of the 2010 Quality of Life Supplement of the National Health Interview Survey and determines that about 19% of adults in the U.S. report persistent pain – 50.5% of whom call the pain "unbearable and excruciating." The authors note that persistent pain, defined as self-reported pain "every day" or "most days" in the preceding three months, is a useful way to characterize health-related quality of life in the general population. Policymakers should consider including this core measure in ongoing health surveys like the National Health Interview Survey and the Medical Expenditure Panel Survey.

G. NEJM’s Latest Interactive Case: 30-yo c Fever in ED

A 30-year-old man living in Boston presented to the emergency department in late March with fevers and shaking chills. He had been feeling well and in his usual state of health, which included participation in regular outdoor exercise, until approximately 1 week before presentation, when he began to have daily fevers, with temperatures as high as 39.4°C. The fevers were associated with . . .

H. Study finds men, women react differently to mental stress

A study in the Journal of the American College of Cardiology showed mental stress affects women with stable ischemic heart disease differently than men with the condition. Duke University researchers said women were more likely to experience depression and anxiety while men were more likely to have changes in blood pressure and other physiological measures.