Friday, November 07, 2014

Lit Bits: Nov 7, 2014

From the recent medical literature...

1. Ibuprofen outperforms morphine for fracture pain in children

Ibuprofen was as effective as oral morphine in relieving the pain of children and teens with fractures and was linked to fewer severe adverse reactions, Canadian researchers wrote in Canadian Medical Association Journal. Morphine was associated with side effects such as nausea, vomiting and drowsiness.

Poonai N, et al. Oral administration of morphine versus ibuprofen to manage postfracture pain in children: a randomized trial. CMAJ 2014 October 27 [Epub ahead of print]. 

Background: Recent warnings from Health Canada regarding codeine for children have led to increased use of nonsteroidal anti-inflammatory drugs and morphine for common injuries such as fractures. Our objective was to determine whether morphine administered orally has superior efficacy to ibuprofen in fracture-related pain.

Methods: We used a parallel group, randomized, blinded superiority design. Children who presented to the emergency department with an uncomplicated extremity fracture were randomly assigned to receive either morphine (0.5 mg/kg orally) or ibuprofen (10 mg/kg) for 24 hours after discharge. Our primary outcome was the change in pain score using the Faces Pain Scale — Revised (FPS-R). Participants were asked to record pain scores immediately before and 30 minutes after receiving each dose.

Results: We analyzed data from 66 participants in the morphine group and 68 participants in the ibuprofen group. For both morphine and ibuprofen, we found a reduction in pain scores (mean pre–post difference ± standard deviation for dose 1: morphine 1.5 ± 1.2, ibuprofen 1.3 ± 1.0, between-group difference [δ] 0.2 [95% confidence interval (CI) –0.2 to 0.6]; dose 2: morphine 1.3 ± 1.3, ibuprofen 1.3 ± 0.9, δ 0 [95% CI –0.4 to 0.4]; dose 3: morphine 1.3 ± 1.4, ibuprofen 1.4 ± 1.1, δ –0.1 [95% CI –0.7 to 0.4]; and dose 4: morphine 1.5 ± 1.4, ibuprofen 1.1 ± 1.2, δ 0.4 [95% CI –0.2 to 1.1]). We found no significant differences in the change in pain scores between morphine and ibuprofen between groups at any of the 4 time points (p = 0.6). Participants in the morphine group had significantly more adverse effects than those in the ibuprofen group (56.1% v. 30.9%, p less than 0.01).

Interpretation: We found no significant difference in analgesic efficacy between orally administered morphine and ibuprofen. However, morphine was associated with a significantly greater number of adverse effects. Our results suggest that ibuprofen remains safe and effective for outpatient pain management in children with uncomplicated fractures. Trial registration:, no. NCT01690780.

2. Low-dose Ketamine Improves Pain Relief in Pts Receiving IV Opioids for Acute Pain in the ED: Results of a Randomized, Double-blind, Clinical Trial

Beaudoin FL, et al. Acad Emerg Med. 2014;21:1193-1202.

Low-dose ketamine has been used perioperatively for pain control and may be a useful adjunct to intravenous (IV) opioids in the control of acute pain in the emergency department (ED). The aim of this study was to determine the effectiveness of low-dose ketamine as an adjunct to morphine versus standard care with morphine alone for the treatment of acute moderate to severe pain among ED patients.

Methods: A double-blind, randomized, placebo-controlled trial with three study groups was conducted at a large, urban academic ED over a 10-month period. Eligible patients were 18 to 65 years old with acute moderate to severe pain (score of at least 5 out of 10 on the numerical pain rating scale [NRS] and pain duration less than 7 days) who were deemed by their treating physician to require IV opioids. The three study groups were: 1) morphine and normal saline placebo (standard care group), 2) morphine and 0.15 mg/kg ketamine (group 1), or 3) morphine and 0.3 mg/kg ketamine (group 2). Participants were assessed at 30, 60, and 120 minutes after study medication administration and received rescue analgesia as needed to target a 50% reduction in pain. The primary outcome measure of pain relief, or pain intensity reduction, was derived using the NRS and calculated as the summed pain-intensity (SPID) difference over 2 hours. The amount and timing of rescue opioid analgesia was evaluated as a secondary outcome. The occurrence of adverse events was also measured.

Results: Sixty patients were enrolled (n = 20 in each group). There were no differences between study groups with respect to age, sex, race/ethnicity, preenrollment analgesia, or baseline NRS. Over the 2-hour poststudy medication administration period, the SPIDs were higher (greater pain relief) for the ketamine study groups than the control group (standard care 4.0, interquartile range [IQR] = 1.8 to 6.5; group 1 7.0, IQR = 4.3 to 10.8; and group 2 7.8, IQR = 4.8 to 12.8; p less than 0.02). The SPIDs for the ketamine groups were similar (p less than 0.46). When compared to standard care, group 2 sustained the reduction in pain intensity up to 2 hours, whereas group 1 was similar to standard care by 2 hours. Similar numbers of patients received rescue analgesia: standard care group, seven of 20, 35%; group 1, four of 20, 20%; and group 2, four of 20, 20% (p = 0.48). Among those receiving rescue analgesia, those in the standard care group received analgesia sooner than either low-dose ketamine group, on average. More participants in the low-dose ketamine groups reported dysphoria and dizziness.

Conclusions: Low-dose ketamine is a viable analgesic adjunct to morphine for the treatment of moderate to severe acute pain. Dosing of 0.3 mg/kg is possibly more effective than 0.15 mg/kg, but may be associated with minor adverse events. Future studies should evaluate additional outcomes, optimum dosing, and use in specific populations.

3. Accuracy of Reduced-Dose CT for Ureteral Stones in ED Patients

Moore CL, et al. Ann Emerg Med 2014 Nov 04 [Epub ahead of print]

Study objective: Reduced-dose computed tomography (CT) scans have been recommended for diagnosis of kidney stone but are rarely used in the emergency department (ED) setting. Test characteristics are incompletely characterized, particularly in obese patients. Our primary outcome is to determine the sensitivity and specificity of a reduced-dose CT protocol for symptomatic ureteral stones, particularly those large enough to require intervention, using a protocol stratified by patient size.

Methods: This was a prospective, blinded observational study of 201 patients at an academic medical center. Consenting subjects underwent both regular- and reduced-dose CT, stratified into a high and low body mass index (BMI) protocol based on effective abdominal diameter. Reduced-dose CT scans were interpreted by radiologists blinded to regular-dose interpretations. Follow-up for outcome and intervention was performed at 90 days.

Results: CT scans with both regular and reduced doses were conducted for 201 patients, with 63% receiving the high BMI reduced-dose protocol. Ureteral stone was identified in 102 patients (50.7%) of those receiving regular-dose CT, with a ureteral stone greater than 5 mm identified in 26 subjects (12.9%). Sensitivity of the reduced-dose CT for any ureteral stone was 90.2% (95% confidence interval [CI] 82.3% to 95.0%), with a specificity of 99.0% (95% CI 93.7% to 100.0%). For stones greater than 5 mm, sensitivity was 100% (95% CI 85.0% to 100.0%). Reduced-dose CT identified 96% of patients who required intervention for ureteral stone within 90 days. Mean reduction in size-specific dose estimate was 18.6 milligray (mGy), from 21.7 mGy (SD 9.7) to 3.4 mGy (SD 0.9).

Conclusion: CT with substantial dose reduction was 90.2% (95% CI 82.3% to 95.0%) sensitive and 98.9% (95% CI 85.0% to 100.0%) specific for ureteral stones in ED patients with a wide range of BMIs. Reduced-dose CT was 96.0% (95% CI 80.5% to 99.3%) sensitive for ureteral stones requiring intervention within 90 days.

4. U.S. Emergency Physicians Announce New List of Procedures That Deserve A Second Look

Robert Glatter, MD, Forbes Magazine, Oct 28, 2014 

The American College of Emergency Physicians (ACEP) today announced a second list of five tests and procedures that should be discussed with patients seeking care in an emergency department who require further diagnostic evaluation. The goal is to help patients make smart decisions about the most appropriate testing based on their individual situation.  In the end, the aim is twofold — reducing health care costs, but ultimately improving patient care.

These recommendations were announced at the annual ACEP meeting in Chicago, and are part of ACEP’s participation in the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely campaign.

The goal of the Choosing Wisely campaign is to help patients and physicians develop a dialogue about the importance of using appropriate evaluations and treatments and avoiding certain modes of treatments when harm may outweigh potential benefits.

Over 80 national, regional and state medical specialty societies and consumer groups have joined the Choosing Wisely campaign as partners, after launching in April of 2012. ACEP became part of the campaign in February of 2013.

ACEP’s five latest recommendations were developed through a multi-step process that included research and input from an expert panel of emergency physicians and the ACEP Board of Directors.  These are recommendations that physicians have control over and are not dictated by hospitals or trauma system protocols.  Also, they do not expose patients to danger or physicians to medical liability risks.

As all clinical situations are unique, the recommendations serve as guidelines to help guide treatment decisions between patients and their treating physicians.

The following is a list of the five most recent “Choosing Wisely” evidence based recommendations approved by ACEP’s Board of Directors.

1.  Avoid CT of the head in asymptomatic adult patients in the emergency department with syncope, insignificant trauma and a normal neurological evaluation. Syncope (passing out or fainting) or near syncope (lightheadedness or almost passing out) is a common reason for visiting an emergency department and most of those visits are not serious.  Many tests may be ordered to identify the cause of the problem.  However, these tests should not be routinely ordered, and the decision to order them should be guided by information obtained from the patient’s history or physical examination. 

2.  Avoid CT pulmonary angiography in emergency department patients with a low-pretest probability of pulmonary embolism and either a negative Pulmonary Embolism Rule-Out Criteria (PERC) or a negative D-dimer. Advances in medical technology have increased the ability to diagnose even small blood clots in the lung.  Now, the most commonly used test is known as a CT pulmonary angiogram (CTPA).  It is readily available in most hospitals and emergency departments.  However, disadvantages of the CTPA include patient exposure to radiation, the use of dye in the veins that can damage kidneys and high cost.

3.  Avoid lumbar spine imaging in the emergency department for adults with atraumatic back pain unless the patient has severe or progressive neurologic deficits or is suspected of having a serious underlying condition, such as vertebral infection or cancer with bony metastasis. Low back pain without trauma is a common presenting complaint in the emergency department.  Most of the time, such pain is caused by conditions such as a muscle strain or a bulging disc that cannot be identified on an x-ray or CT scan.

4.  Avoid prescribing antibiotics in the emergency department for uncomplicated sinusitis. Sinusitis is a common reason for patients to visit the emergency department. Most patients with acute sinusitis do not require antibiotic treatment, because 98 percent of acute sinusitis cases are caused by a viral infection and resolve in 10-14 days without treatment.

5.  Avoid ordering CT of the abdomen and pelvis in young otherwise health emergency department patients with known histories of ureterolithiasis presenting with symptoms consistent with uncomplicated kidney stones. Many patients in the emergency department who are less than 50 years old and who have symptoms of recurrent kidney stones do not need a CT scan unless these symptoms persist or worsen, of if there is a fever, or a history of severe obstruction with previous stones.  CT scans of patients in the emergency department with symptoms of a recurrent kidney stone usually don’t change treatment decisions, and the cost and radiation exposure can often be avoided in these cases.

In 2013, ACEP released the first five Choosing Wisely recommendations of tests and procedures to question.  ACEP had initially decided not to be part of the campaign due to potential concerns about the unique way emergency medicine is practiced compared with office-based practice, along with concerns that advocacy for medical liability reform was not part of the messaging of the initial campaign.

5. Dabigatran: More Bleeds in Practice Than Expected

By Crystal Phend, Senior Staff Writer, MedPage Today. Nov 5, 2014
  • Note that this analysis of Medicare data revealed that dabigatran has a higher overall bleeding risk compared with warfarin treatment of atrial fibrillation.
  • This study reveals the importance of careful postmarketing research to elucidate risks that may not have been seen in primary efficacy trials.
Dabigatran (Pradaxa) was associated with higher risk of bleeding than warfarin (Coumadin) in a large Medicare population sample, unlike the equal risk seen in the pivotal RE-LY trial.

The relative risk was 30% higher for any bleeding with the direct thrombin inhibitor than warfarin and 58% higher for major bleeding (propensity adjusted rate 9.0% versus 5.9%, P less than 0.001), Yuting Zhang, PhD, of the University of Pittsburgh, and colleagues reported online in JAMA Internal Medicine.

By contrast, the pivotal RE-LY trial had shown no difference in major bleeding risk between the two drugs, with an annual rate of 3.36% for warfarin versus 3.11% with the approved 150-mg dose of dabigatran, for a relative risk of 0.93 (P=0.31).

The nationally-representative, 5%-sample Medicare analysis did agree qualitatively with the trial results on higher risk of GI bleeds and lower likelihood of intracranial bleeding than warfarin.

The hazard ratio for GI bleeding on dabigatran was 1.85 (95% confidence interval 1.64-2.07) versus warfarin, whereas the hazard ratio for intracranial hemorrhage of 0.32 (95% CI 0.20-0.50) favored dabigatran over the older drug. In RE-LY, the hazard ratio for major GI bleeding with the 150-mg dabigatran dose versus warfarin was considerably lower, at 1.50.

A prior FDA analysis of Medicare data had agreed with the trial on overall bleeding risk, but Zhang's group argued that its lack of adjustment for patient factors was a major flaw. "Dabigatran and warfarin users are very different in several factors that directly affect the risk of bleeding, and failing to adjust would bias the results, as our unadjusted estimates indicate," they wrote.

Their results were propensity weighted to account for demographic variables (age, sex, race, and Medicaid eligibility) and clinical characteristics, including the stroke risk CHADS2 score, chronic kidney disease, hypertension, history of stroke or transient ischemic attack, history of acute myocardial infarction, diabetes, congestive heart failure, acquired hypothyroidism, the number of other CMS-priority comorbidities, and history of bleeding in the year prior to treatment initiation.

And there was a significantly higher prevalence of chronic kidney disease, congestive heart failure, diabetes, and history of stroke or transient ischemic attack in those who took warfarin. Propensity score weighting balanced out those characteristics.

The retrospective analysis of pharmacy and medical claims from a random 5% sample of Medicare beneficiaries newly diagnosed with atrial fibrillation from Oct. 1, 2010, through Oct. 31, 2011 included 1,302 starting on dabigatran and 8,102 initiating warfarin within 60 days of initial diagnosis.

Clinical Implications
"Thus, dabigatran should be prescribed with caution, especially among high-risk patients," they cautioned. The risk of major bleeding on dabigatran was particularly high for African Americans (HR 2.12, 95% confidence interval 1.39-3.24) and patients with chronic kidney disease (HR 2.07, 95% CI 1.66-2.58).

The findings were cause for concern, according to an editor's note accompanying the paper from Rita F. Redberg, MD, calling the bleeding risks of dabigatran "significantly greater than originally appeared at the time of the FDA approval."

"Dabigatran was approved by the FDA in 2010 via the accelerated pathway after a 6-month review. The haste to approve novel drugs places an increasing importance on post-approval data to help better understand risks and benefits," wrote Redberg, a cardiologist at the University of California San Francisco. "This study reminds us of the importance of postmarketing data and of having adequate data on risks and benefits to advise our patients accurately."

Judy Mackall, MD, section chief for cardiac electrophysiology at University Hospitals Case Medical Center in Cleveland, was less convinced that the data were influential for practice. "A lot of what's in this study we were already aware of from RE-LY study," she told MedPage Today. As far as the increased risk of GI bleeding, Mackall pointed to one theory. "Dabigatran is delivered as a pro-drug," she said. "About 6% gets absorbed and the rest passes through the GI tract as an inactive anticoagulant."

But the lower risk of intracranial bleeding outweighs the concern about GI bleeds, she suggested. "GI bleed is significant, yes, it's treatable most often. Getting a lower risk of intracranial bleeding is a big safety concern," she said. "Intracranial bleeding is the major bleeding that we worry about because that's not easily correctable."

The researchers urged that because of the GI bleeding risk across all subgroups "it is important for physicians to explain to patients how to detect gastrointestinal bleeding so that it can be controlled as early as possible." But "intracranial hemorrhage is the most feared complication associated with warfarin," they agreed, "thus, patients at high risk of intracranial hemorrhage may be willing to accept the higher risk of other bleeding events associated with dabigatran for a lower likelihood of intracranial bleeding. Arguably, this is the subgroup in which dabigatran is most likely to be a favorable choice in terms of safety."

6. Benign syncope in long QT syndrome family members

The data indicate that family members from families with long QT syndrome have a benign form of syncope, most likely related to vasovagal syncope and not ventricular tachyarrhythmic syncope.

Nordkamp O, et al.  Syncope in Genotype-Negative Long QT Syndrome Family Members. Am J Cardiol. 2014 Oct 15;114(8):1223-8

•Syncope occurred in 11% of family members of patients with LQTS.
•These syncope events occurred mainly in female family members during midadolescence.
•None of the family members had life-threatening events after the syncope episodes.
•These data suggest that family members most likely have benign vasovagal syncope.

Unaffected long-QT syndrome family members (FMs) frequently experience syncope. The aims of this study were to test the hypothesis that syncope events in FMs are benign events and to compare clinical characteristics, triggers eliciting the syncope events, and long-term outcomes between FMs and those with LQT1 or LQT2 mutations from the international Long QT Syndrome Registry.

A total of 679 FMs, 864 LQT1 patients, and 782 LQT2 patients were included. Seventy-eight FMs (11%) experienced cardiovascular events. Almost all cardiovascular events were nonfatal syncope; only 1 FM, with an additional mitral valve prolapse, experienced aborted cardiac arrest during exercise. The mean age at first syncope in FMs was 17 years, and female FMs experienced syncope more frequently than male FMs (14% vs 9%, p = 0.027). Syncope was more frequently triggered by exercise in LQT1 patients (43% in LQT1 patients vs 5% in FMs, p less than 0.001), while syncope triggered by a variety of other triggers was more frequent in FMs (54% in FMs vs 22% in LQT1 patients and 30% in LQT2 patients, p less than 0.001 for both). None of the FMs experienced aborted cardiac arrest or sudden cardiac death after the first syncopal episode.

In conclusion, syncope is frequently present in FMs, and these syncopal events occurred more frequently in female than in male FMs, with an increased incidence in midadolescence. Triggers eliciting the syncopal events were different between FMs and patients with long-QT syndrome mutations. Hence, the type of trigger is useful in distinguishing between high- and low-risk syncope. These data indicate that FMs from families with LQTS have a benign form of syncope, most likely related to vasovagal syncope and not ventricular tachyarrhythmic syncope.

7. Association between the Seat Belt Sign and Intra-abdominal Injuries in Children with Blunt Torso Trauma in Motor Vehicle Collisions

Borgialli DA, et al, for the Pediatric Emergency Care Applied Research Network (PECARN). Acad Emerg Med. 2014;21:1240-8.

Objectives: The objective was to determine the association between the abdominal seat belt sign and intra-abdominal injuries (IAIs) in children presenting to emergency departments with blunt torso trauma after motor vehicle collisions (MVCs).

Methods: This was a planned subgroup analysis of prospective data from a multicenter cohort study of children with blunt torso trauma after MVCs. Patient history and physical examination findings were documented before abdominal computed tomography (CT) or laparotomy. Seat belt sign was defined as a continuous area of erythema, ecchymosis, or abrasion across the abdomen secondary to a seat belt restraint. The relative risk (RR) of IAI with 95% confidence intervals (CIs) was calculated for children with seat belt signs compared to those without. The risk of IAI in those patients with seat belt sign who were without abdominal pain or tenderness, and with Glasgow Coma Scale (GCS) scores of 14 or 15, was also calculated.

Results: A total of 3,740 children with seat belt sign documentation after blunt torso trauma in MVCs were enrolled; 585 (16%) had seat belt signs. Among the 1,864 children undergoing definitive abdominal testing (CT, laparotomy/laparoscopy, or autopsy), IAIs were more common in patients with seat belt signs than those without (19% vs. 12%; RR = 1.6, 95% CI = 1.3 to 2.1). This difference was primarily due to a greater risk of gastrointestinal injuries (hollow viscous or associated mesentery) in those with seat belt signs (11% vs. 1%; RR = 9.4, 95% CI = 5.4 to 16.4). IAI was diagnosed in 11 of 194 patients (5.7%; 95% CI = 2.9% to 9.9%) with seat belt signs who did not have initial complaints of abdominal pain or tenderness and had GCS scores of 14 or 15.

Conclusions: Patients with seat belt signs after MVCs are at greater risk of IAI than those without seat belt signs, predominately due to gastrointestinal injuries. Although IAIs are less common in alert patients with seat belt signs who do not have initial complaints of abdominal pain or tenderness, the risk of IAI is sufficient that additional evaluation such as observation, laboratory studies, and potentially abdominal CT scanning is generally necessary.

8. Dual Antibiotic Treatment Best for Moderately Severe Pneumonia

By Megan Brooks. October 07, 2014

NEW YORK (Reuters Health) - Dual antibiotic therapy is needed for patients hospitalized with moderately severe community-acquired pneumonia (CAP), suggests a randomized controlled trial.

The study team tried and failed to demonstrate noninferiority of a beta-lactam alone over a beta-lactam-macrolide combination in this patient population.

There is ongoing debate about optimal antibiotic therapy for patients hospitalized with CAP. North American guidelines currently advise dual antibiotic therapy that covers typical and atypical bacterial pathogens for all patients hospitalized for CAP (i.e., beta-lactam plus macrolide or fluoroquinolone monotherapy), while British guidelines reserve such therapy for moderately to severely ill patients.

Dr. Nicolas Garin, from Hopital Riviera-Chablais, Switzerland, and colleagues conducted an open-label, multicenter noninferiority trial of 580 patients admitted to six hospitals in Switzerland for moderately severe CAP. Patients were randomly allocated to receive monotherapy with a beta-lactam or dual therapy with a beta-lactam and a macrolide. Legionella pneumophila infection was diagnosed using urinary antigen testing, and macrolide therapy was added for patients in the monotherapy arm testing positive.

On hospital day 7, more patients in the monotherapy arm compared with the dual therapy arm had not reached clinical stability (the primary outcome: 41.3% vs 33.4%; p=0.07). "The upper limit of the 1-sided 90% CI was 13.0%, exceeding the predefined noninferiority boundary of 8%," the authors say.

In subgroup analyses, patients infected with atypical pathogens (hazard ratio, 0.33) or with Pneumonia Severity Index (PSI) category IV (HR 0.81) were less likely to reach clinical stability with one antibiotic. Outcomes were similar in patients not infected with atypical pathogens (HR 0.99) or with PSI category I to III pneumonia (HR 1.06).

A smaller proportion of patients treated with dual therapy were readmitted at 30 days (3.1% vs 7.9%; p=0.01), but none of the other secondary outcomes (mortality, ICU admission, complications, length of stay or pneumonia recurrence within 90 days) varied between the treatment arms.

In email to Reuters Health, Dr. Garin said, "I think the take home message is: for empiric treatment of CAP, beta-lactam monotherapy should be reserved for patients with PSI class I to III severity (or CURB-65 score 0-1). A macrolide should be combined with a beta-lactam for patients in PSI class IV or V or with a CURB-65 score above 1."

In an editorial, Dr. Jonathan Lee and Dr. Michael Fine of the University of Pittsburgh School of Medicine in Pennsylvania say the evidence from this trial "pushes the pendulum further in favor of antibiotic therapy covering atypical and typical bacterial pathogens for patients hospitalized for CAP. Lessons learned from its design and results should inform future trials required to definitively settle this debate."

Until then, they conclude, "dual therapy should remain the recommended treatment for patients hospitalized for CAP."

9. McGyver Goes to the ED: Rewiring a VAD Driveline

Cubillo EI 4th, et al. Emergent Reconnection of a Transected Left Ventricular Assist Device Driveline. J Emerg Med. 2014;47:546–551.

BACKGROUND: Recent clinical advances with new mechanical circulatory systems have led to additional strategies in the treatment of end-stage heart failure. The third-generation HeartWare Left Ventricular Device (LVAD) System utilizes a blood pump and a driveline (cable) that exits the patient's skin connecting the implanted pump to an externally worn controller. We report a rare case of a HeartWare LVAD driveline rewiring after accidental (presumed) transection of the driveline system.

CASE REPORT: A 67-year-old male with a medical history of ischemic cardiomyopathy status post HeartWare LVAD implantation presented to the emergency department (ED) after acute LVAD failure. On the morning of presentation, he attempted to cut the paper tape off of his adult diaper with scissors and accidentally (presumed) and unwitnessed severed the driveline system. The patient immediately went into cardiac arrest and was transported to a regional medical center. On arrival, he exhibited no appreciable vital signs and was subsequently intubated, vascular access was placed, and inotropic support initiated. The emergency physician individually stripped and reconnected the color-coded driveline wires using multiple hemostats, electrical tape, and cardboard, which resulted in regeneration of positive LVAD flows.

WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: VAD patients will present in extremis typically to the ED with manifestations of pump dysfunction ranging from diminished flows needing fluid management or pump adjustments to full pump failure manifesting as cardiogenic shock, needing rapid resuscitation and transfer to a cardiothoracic surgical unit with on-site VAD-perfusion specialists.

10. Airway Management

A. Airway Management for Adults with Prehospital Cardiac Arrest: Is Intubation Passé?

Patients who were intubated had similar outcomes to those who had a supraglottic airway device inserted.

Tiah L et al. Does Pre-hospital Endotracheal Intubation Improve Survival Outcomes among Adults with Non-traumatic Out-of-hospital Cardiac Arrest? A Systematic Review. West J Emerg Med 2014 Oct 28 [Epub ahead of print]  

Objective: Endotracheal intubation (ETI) is currently considered superior to supraglottic airway devices (SGA) for survival and other outcomes among adults with non-traumatic out-of-hospital cardiac arrest (OHCA). We aimed to determine if the research supports this by conducting a systematic review.

Methods: We searched the MEDLINE, Scopus and CINAHL databases for studies published between 1 January 1980 and 30 April 2013 that compared pre-hospital use of ETI with SGA for outcomes of return of spontaneous circulation (ROSC); survival to hospital admission; survival to hospital discharge; and favourable neurological or functional status. Studies were selected using pre-specified criteria. Included studies were independently screened for quality using the Newcastle-Ottawa scale. Results were not pooled because of study variability. Study outcomes were extracted and results presented as summed odds ratios with 95% confidence intervals.

Results: We identified five eligible studies: one quasi-randomised controlled trial and four cohort studies, involving 303,348 patients in total. Only three of the five studies reported a higher proportion of ROSC with ETI versus SGA with no difference reported in the remaining two. None found significant differences between ETI and SGA for survival to hospital admission or discharge. One study reported better functional status at discharge for ETI versus SGA. Two studies reported no significant difference for favourable neurological status between ETI and SGA.

Conclusion: Current evidence does not conclusively support the superiority of ETI over SGA for multiple outcomes among adults with OHCA.

B. A Dose of Ketamine Can Facilitate Preoxygenation before Emergency Intubation

In a new technique called “delayed sequence intubation,” ketamine facilitated preoxygenation in patients with altered mental status.

Weingart SD et al. Delayed Sequence Intubation: A Prospective Observational Study.
Ann Emerg Med 2014 Oct 22 [Epub ahead of print]

Study objective: We investigate a new technique for the emergency airway management of patients with altered mental status preventing adequate preoxygenation.

Methods: This was a prospective, observational, multicenter study of patients whose medical condition led them to impede optimal preintubation preparation because of delirium. A convenience sample of emergency department and ICU patients was enrolled. Patients received a dissociative dose of ketamine, allowing preoxygenation with high-flow nonrebreather mask or noninvasive positive pressure ventilation (NIPPV). After preoxygenation, patients were paralyzed and intubated. The primary outcome of this study was the difference in oxygen saturations after maximal attempts at preoxygenation before delayed sequence intubation compared with saturations just before intubation. Predetermined secondary outcomes and complications were also assessed.

Results: A total of 62 patients were enrolled: 19 patients required delayed sequence intubation to allow nonrebreather mask, 39 patients required it to allow NIPPV, and 4 patients required it for nasogastric tube placement. Saturations increased from a mean of 89.9% before delayed sequence intubation to 98.8% afterward, with an increase of 8.9% (95% confidence interval 6.4% to 10.9%). Thirty-two patients were in a predetermined group with high potential for critical desaturation (pre–delayed sequence intubation saturations ≤93%). All of these patients increased their saturations post–delayed sequence intubation; 29 (91%) of these patients increased their post–delayed sequence intubation saturations to greater than 93%. No complications were observed in the patients receiving delayed sequence intubation.

Conclusion: Delayed sequence intubation could offer an alternative to rapid sequence intubation in patients requiring emergency airway management who will not tolerate preoxygenation or peri-intubation procedures. It is essentially procedural sedation, with the procedure being preoxygenation. Delayed sequence intubation seems safe and effective for use in emergency airway management.

11. Images in Clinical Practice

Destructive Ulcerated Lesions of the Hard Palate 

Herpetic Whitlow 

Carotid Cavernous Fistula

Ectopia Lentis in Marfan's Syndrome

12. Can emergency physicians ‘rule in’ and ‘rule out’ AMI with clinical judgement?

Body R, et al. Emerg Med J  2014;31:872-876

Objective To determine the diagnostic accuracy of emergency physician gestalt in emergency department (ED) patients with suspected cardiac chest pain, both alone and in combination with initial troponin level and ECG findings.

Methods We prospectively included patients presenting to the ED with suspected cardiac chest pain. Clinicians recorded their ‘gestalt’ at the time of presentation using a five-point Likert scale, blinded to outcome. Troponin T and high-sensitivity troponin T (hs-cTnT; both Roche Diagnostics Elecsys) levels were measured in admission blood samples. All patients underwent troponin testing at least 12 h after peak symptoms. The primary outcome was acute myocardial infarction (AMI).

Results 458 patients were included in this study, 81 (17.7%) of whom had AMI. Clinician gestalt alone had an area under the receiver operating characteristic curve of 0.76 (95% CI 0.70 to 0.82) for AMI. Immediately discharging patients with normal initial troponin and ECG in whom the clinician felt the diagnosis was ‘probably not’ or ‘definitely not’ acute coronary syndrome (ACS) would have avoided admission for 23.1% (95% CI 19% to 28%) patients with 100% sensitivity (95% CI 95.6% to 100%). With hs-cTnT, 100% sensitivity could have been achieved even if only patients with ‘probable’ or ‘definite’ ACS were investigated further, which would have allowed 41.7% patients to be discharged immediately.

Conclusions Gestalt alone cannot be used to ‘rule in’ or ‘rule out’ ACS. By combining clinician gestalt with the admission ECG and troponin level, we found 100% sensitivity without the need for serial troponin testing. These findings have the potential to reduce unnecessary hospital admissions for suspected ACS but must be prospectively validated before considering clinical implementation.

13. Diagnosing Appendicitis

A. A Lit Review

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

Shogilev DJ, et al. West J Emerg Med 2014 Oct 7 [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.

B. During Pregnancy

Thompson MM, et al. West J Emerg Med. 2014 Sep;15(6):652-4.

Abdominal pain frequently represents a diagnostic challenge in the acute setting. In pregnant patients, the gravid abdomen and concern for ionizing radiation exposure further limit evaluation. If undiagnosed, appendicitis may cause disastrous consequences for the mother and fetus.

We present the case of a pregnant female who was admitted for right lower quadrant abdominal pain. Advanced imaging of the abdomen and pelvis was interpreted to be either indeterminate or normal and a diagnosis of acute appendicitis was made on purely clinical grounds. This patient’s management and a literature review of diagnostic techniques for acute appendicitis during pregnancy are discussed.

C. False Positive Appendicitis on Bedside US

Full-text (with image, free):

14. Comparison of parenteral treatments of acute primary HA in a large academic ED cohort.

McCarthy LH, et al. Cephalalgia. 2014 Nov 3 [Epub ahead of print].

OBJECTIVE: The objective of this article is to compare acute primary headache patient outcomes in those initially treated with parenteral opiates or non-opiate recommended headache medications in a large academic medical emergency department (ED).

BACKGROUND: Many acute primary headache patients are not diagnosed with a specific headache type and are treated with opiates and nonspecific pain medications in the ED setting. This is inconsistent with multiple expert recommendations.

METHODS: Electronic charts were reviewed from 574 consecutive patients who visited the ED for acute primary headache (identified by chief complaint and ICD9 codes) and were treated with parenteral medications.

RESULTS: Non-opiate recommended headache medications were given first line to 52.6% and opiates to 22.8% of all participants. Patients given opiates first had significantly longer length of stays (median 5.0 vs. 3.9 hours, p  less than  0.001) and higher rates of return ED visits within seven days (7.6% vs. 3.0%, p = 0.033) compared with those given non-opiate recommended medications in univariate analysis. Only the association with longer length of stay remained significant in multivariable regression including possible confounding variables.

CONCLUSIONS: Initial opiate use is associated with longer length of stay compared with non-opiate first-line recommended medications for acute primary headache in the ED. This association remained strong and significant even after multivariable adjustment for headache diagnosis and other possible confounders.

Associated editorial: Friedman B, et al. Convincing the skeptic. How to fix emergency department headache management.

In their analysis of a research database from an academic emergency department (ED) in California (1), Drs McCarthy and Cowan identify three features of emergency headache care that have been reported by multiple clinical investigators from a multitude of North American EDs (2–7): (i) emergency physicians often fail to assign specific primary headache diagnoses to their headache patients; (ii) emergency physicians frequently treat migraine in particular and headaches in general with opioids; (iii) emergency physicians use triptans infrequently and dihydroergotamine rarely.

These practices seem difficult to understand. In the outpatient setting, an accurate headache diagnosis will lead to appropriate treatment. Parenteral opioid use has been associated with undesirable headache outcomes, such as headache recurrence and ED recidivism (3). Long-term problems associated with recurrent use of opioids include refractoriness to standard headache medications (8) and chronification of migraine (9). Triptans and dihydroergotamine on the other hand are evidence-based therapies. The number needed to treat for subcutaneous sumatriptan, for example, is a very impressive ‘2’ (10).

Unfortunately, there are no data available to help us comprehend and contextualize emergency practice—why do emergency physicians practice as they do? It is clear that time has not changed long-held practice patterns—opioid use for management of migraine in the ED is as prevalent today as it was 15 years ago (4). As demonstrated by Drs McCarthy and Cowan and elsewhere (1,4), this practice is highly prevalent in academic settings, the setting in which one might most expect to see appropriate practice.

Use of opioids in the ED for migraine may be an education issue—it could be that emergency physicians simply do not appreciate the long-term sequelae of repeated opioid use. Alternatively, it may be an informed choice. Consider how a skeptic might respond to the American Headache Society’s Choosing Wisely guidelines (11): ‘Parenteral opioids are a guideline-supported, evidence-based therapy (12). There are no high quality clinical data demonstrating detrimental effects of parenteral opioids when compared to alternative therapy. Much of the data come from non-randomized studies, which failed to account for important baseline factors’. For example, Drs McCarthy and Cowan did indeed find an association between parenteral opioid use and length of stay. However, is this because of opioid administration, or are there plausible unmeasured confounders, such as the severity of the underlying headache disorder or duration of the acute attack? Could it be that the patients treated with parenteral non-steroidal anti-inflammatory drugs (NSAIDs) in Drs McCarthy and Cowan’s database were some of the many patients who present to the ED having not taken any medication at all, while the ones given opioids were the patients with chronic migraine and medication overuse headache who had already exceeded recommended doses of triptans and NSAIDs? Failure to account for these baseline differences is a limitation encountered in many retrospective ED analyses. There are compelling data demonstrating an association between outpatient oral opioids and progression of episodic to chronic migraine (9). However, it is not clear if these data are relevant to patients who receive a single dose of parenteral hydromorphone in the ED.

Consider the dilemma of the busy emergency physician when deciding among acute headache therapeutics; metoclopramide, droperidol and ketorolac each have FDA black box warnings. All the parenteral anti-dopaminergics can cause akathisia, which is often an unpleasant experience for the patient and, at least theoretically, may cause tardive dyskinesia. Subcutaneous sumatriptan causes adverse medication effects in more than 50% of patients when administered in the ED setting (13). While triptans are probably safe in pregnant or mildly hypertensive patients, unknown pregnancy status and high blood pressure certainly might give the emergency physician pause before administering one of these medications. Early pregnancy cannot be excluded by history alone. One-quarter of ED headache patients present with at least moderately elevated blood pressure (14). In our ED-based sumatriptan trials, we have excluded more than 25% of potential subjects for pregnancy and elevated cardiovascular risk. Finally, some patients may have recently taken large enough doses of triptans or NSAIDs that further administration of these agents would be both contraindicated and unlikely to succeed.

Now consider the appeal of opioids. Emergency physicians know this class of medication well. Opioids are quite potent, but are safe when administered in a monitored setting (15). Importantly, opioids can be administered in successive doses until a patient’s pain is controlled………

For the remainder of the essay (full-text free):

15. Evaluating the Pediatric Early Warning Score (PEWS) System for Admitted Patients in the Pediatric ED

Gold DL, et al. Acad Emerg Med. 21:1249-56.

Objectives: The Pediatric Early Warning Score (PEWS) systems were developed to provide a reproducible assessment of a child's clinical status while hospitalized. Most studies investigating the PEWS evaluate its usefulness in the inpatient setting. Limited studies evaluate the effectiveness and integration of PEWS in the pediatric emergency department (ED). The goal of this study was to explore the test characteristics of an ED-assigned PEWS score for intensive care unit (ICU) admission or clinical deterioration in admitted patients.

Methods: This was a prospective 12-month observational study of patients, aged 0 to 21 years, admitted from the ED of an urban, tertiary care children's hospital. ED nurses were instructed in PEWS assignment and electronic medical record (EMR) documentation. Interrater reliability between nurses was evaluated. PEWS scores were measured at initial assessment (P0) and time of admission (P1). Patients were stratified into outcome groups: those admitted to the ICU either from the ED or as transfers from the floor and those admitted to the floor only. Clinical deterioration was defined as transfer to the ICU within 6 hours or within 6 to 24 hours of admission. PEWS scores and receiver operating characteristic (ROC) curves were compared for patients admitted to the floor, ICU, and with clinical deterioration.

Results: The authors evaluated 12,306 consecutively admitted patients, with 99% having a PEWS documented in the EMR. Interrater reliability was excellent (intraclass coefficient = 0.91). A total of 1,300 (10.6%) patients were admitted to the ICU and 11,066 (89.4%) were admitted to the floor. PEWS scores were higher for patients in the ICU group (P0 = 2.8, SD ± 2.4; P1 = 3.2, SD ± 2.4; p less than 0.0001) versus floor patients (P0 = 0.7, SD ± 1.2; P1 = 0.5, SD ± 0.9; p less than 0.0001). To predict the need for ICU admission, the optimal cutoff points on the ROC are P0 = 1 and P1 = 2, with areas under the ROC curve (AUCs) of 0.79 and 0.86, respectively. The likelihood ratios (LRs) for these optimal cutoff points were as follows: P0 +LR = 2.5 (95% confidence interval [CI] = 2.4 to 2.6, p less than 0.05), –LR = 0.32 (95% CI = 0.28 to 0.36, p less than 0.05); and P1 +LR = 6.2 (95% CI = 5.8 to 6.6, p less than 0.05), –LR = 0.32 (95% CI = 0.29 to 0.35, p less than 0.05). For every unit increase in P0 and P1, the odds of admission to the ICU were 1.9 times greater (95% CI = 1.8 to 1.9, p less than 0.0001) and 2.9 times greater (95% CI = 2.7 to 3.1, p less than 0.0001) than to the floor. There were 89 patients in the clinical deterioration group, with 36 (0.3%) patients transferred to the ICU within 6 hours of admission and 53 (0.4%) patients transferred within 6 to 24 hours. In this group, an elevated P0 and P1 were statistically associated with an increased risk of transfer with optimal cutoff points similar to above; however, there were poorer AUCs and test characteristics.

Conclusions: A PEWS system was implemented in this pediatric ED with excellent data capture and nurse interrater reliability. The study found that an elevated PEWS is associated with need for ICU admission directly from the ED and as a transfer, but lacks the necessary test characteristics to be used independently in the ED environment.

16. Pediatric Procedural Sedation with Propofol Using a Higher Initial Bolus Dose

Young TP, et al. Pediatr Emerg Care. 2014 Oct;30(10):689-93.

Objectives: We sought to describe the doses of propofol used for sedation in our pediatric emergency department, along with the range of procedures performed under propofol sedation. We also planned to describe clinically important physiologic changes seen and physician satisfaction with propofol at the doses observed.

Methods: This was a prospective observational case series. Physicians completed a data collection form after the propofol sedation. The physicians were asked to report physiologic changes that occurred during sedation and rate their satisfaction with propofol as a sedation agent on a 100-mm visual analog scale.

Results: Eight hundred eighty-six sedation events were reported. The median initial dose of propofol given was 2.0 mg/kg and the median total dose was 3.6 mg/kg. Propofol was used for a wide range of procedures. The most common physiologic change was desaturation/hypoxia (desaturation to less than 90% in 7.2%). No deaths, unplanned intubations, or surgical airway placements were reported. Treating physicians reported a median satisfaction score of 97 mm.

Conclusions: A 2-mg/kg initial bolus dose of propofol for pediatric sedation was well tolerated and useful for a wide range of procedures. Physicians should expect to find a high level of satisfaction with this dose.

17. Contribution of verbal suggestion to the therapeutic efficacy of an analgesic agent for acute primary headache

[DRV comment: If the simple suggestion to a pt “Hey, this is really gonna work great!” had boosted the medication’s analgesic effect, we could really have put this to use in the ED. But it didn’t work. Too bad.]

Oktay C, et al. Cephalalgia 2014 Sept 8 [Epub ahead of print]

Objective The therapeutic response of a patient cannot purely be explained by the method of therapy or the efficacy of a drug. Clinician-patient interaction, psychosocial factors, patients’ expectations, hopes, beliefs and fears are all related to the healing outcome. Malleability and suggestibility are also important in the placebo or nocebo effect. The purpose of this study was to evaluate whether adding brief verbal suggestions for pain relief could change the magnitude of an analgesic’s efficacy.

Methods This prospective study was performed in the emergency department of a university hospital. Patients who were ordered analgesia with diclofenac sodium for primary headache were divided into three groups. All groups were informed that they would be administered a pain killer by intramuscular injection. The second and third groups were given positive and reduced treatment expectations about the therapeutic efficacy, respectively. Patients were asked to rate their pain on a VAS at 0 and 45 minutes and if they needed any additional analgesic 45 minutes after the injection.

Results A total of 153 patients were included in the study. The paired univariate analyses showed significant differences for all groups between 0- and 45-minute VAS scores. However, there was no difference between the three groups according to the differences in VAS scores between 45 and 0 minutes and according to the administration of an additional drug.

Conclusion Simple verbal suggestions did not alter the efficacy of an analgesic agent for headache in an emergency setting. The contributions of suggestibility, desire and expectation in acute primary headache patients should be further investigated.

18. US-Assisted Pediatric Forearm Fracture Reduction Doesn't Supplant Radiography

Ultrasound assessment missed 50% of inadequately reduced fractures and classified 11% of properly reduced fractures as misaligned.

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.

19. Physical Pain is More than Just a Metaphor for Social Pain

Exit Wounds by The Script

My hands are cold, my body's numb
I'm still in shock, what have you done?
My head is pounding, my vision's blurred
Your mouth is moving, I don't hear a word

And it hurts so bad that I search my skin
For the entry point, where love went in
And ricocheted and bounced around
And left a hole when you walked out

I'm falling through the doors of the emergency room
Can anybody help me with these exit wounds?
I don't know how much more love this heart can lose
And I'm dying, dying from the exit wounds…

The remainder of the lyrics (along with the music) is here:

For the science underlying the analogy between social pain and physical pain:        
20. Study links years of shift work to impaired cognition

French researchers found people whose vocations require shift work may face elevated risk of memory and thinking problems. Working nonstandard hours for more than a decade was linked to the equivalent of 6.5 additional years of age-related cognition declines, and the effect lasts even after workers return to normal schedules, according to the findings. Data were reported in Occupational and Environmental Medicine.

21. Recommended Reading

Nicholas D. Kristof, Sheryl WuDunn, A Path Appears: Transforming Lives, Creating Opportunity (New York: Knopf, 2014).

Roman Krznaric, Empathy: Why It Matters, and How to Get It Hardcover (New York: Perigee Trade, 2014).

R. J. Palacio, Wonder (New York: Knopf, 2012).

22. Micro Lit Bits

A. U.S. lags behind other rich nations in terms of health care access

A 2013 survey by the Commonwealth Fund revealed the U.S. ranked last in terms of health care access compared with 10 other industrialized nations. The U.S. also showed the poorest performance in addressing patient needs outside regular business hours, the poll found. The findings were published in the New England Journal of Medicine.

B. Prognostic value of automatically detected early repolarization

The authors concluded that early repolarization was not associated with an increased risk of death, regardless of race or sex, and should not trigger additional diagnostic testing. The American Journal of Cardiology.

C. Three Wearables that Could Change Afib Screening

Atrial fibrillation is an increasingly prevalent arrhythmia; it currently affects 3 to 6 million of Americans and that number is expected to rise. And unlike many other medical conditions, it is often silent until discovered either incidentally or after a serious complication like a stroke.

Recently, the EMBRACE and CRYSTAL-AF trials looked at the use of continuous long-term cardiac monitoring in a high-risk patient population -- individuals with recent cryptogenic cerebrovascular accident (CVA). Both trials found an increase in the detection of atrial fibrillation as well as the use of oral anticoagulant therapy.

There were however notable limitations in the screening strategies used. In EMBRACE, patients had to wear a cumbersome chest strap with several wires attached to a belt-clipped event monitor. Not unexpectedly, the compliance rates were less than stellar. In CRYSTAL-AF, the $5,000 price-tag of the Reveal XT monitor coupled with its complication rate, albeit low, are important limitations when considering whether this strategy can be applied on a large scale.

Here, we'll look at some of the growing cadre of wearable devices that can provide continuous cardiac monitoring options to address those limitations…

D. Co-trimoxazole and sudden death in patients receiving inhibitors of renin-angiotensin system: population based study

Conclusions In older patients receiving angiotensin converting enzyme inhibitors or angiotensin receptor blockers, co-trimoxazole is associated with an increased risk of sudden death. Unrecognized severe hyperkalemia may underlie this finding. When appropriate, alternative antibiotics should be considered in such patients.

E. Cardiologist calls stethoscope a "relic" amid new technologies

The stethoscope is a "relic" because physicians now have technology to visualize the heart instead of just listen to it, cardiologist Eric Topol, M.D., told attendees of the 2014 AAFP Assembly. Topol said new innovations include a glucose monitor that works with a smartphone and earbuds that track heart rate and blood pressure, but patients will continue to need the experience and treatment only physicians can offer.

F. Morality in everyday life.

Hoffman W, et al. Science 2014;345:1340-3.

The science of morality has drawn heavily on well-controlled but artificial laboratory settings. To study everyday morality, we repeatedly assessed moral or immoral acts and experiences in a large (N = 1252) sample using ecological momentary assessment. Moral experiences were surprisingly frequent and manifold. Liberals and conservatives emphasized somewhat different moral dimensions. Religious and nonreligious participants did not differ in the likelihood or quality of committed moral and immoral acts. Being the target of moral or immoral deeds had the strongest impact on happiness, whereas committing moral or immoral deeds had the strongest impact on sense of purpose. Analyses of daily dynamics revealed evidence for both moral contagion and moral licensing. In sum, morality science may benefit from a closer look at the antecedents, dynamics, and consequences of everyday moral experience.

G. Point-and-shoot memories: the influence of taking photos on memory for a museum tour.

Henkel LA. Psychol Sci. 2014 Feb;25(2):396-402.

Two studies examined whether photographing objects impacts what is remembered about them. Participants were led on a guided tour of an art museum and were directed to observe some objects and to photograph others. Results showed a photo-taking-impairment effect: If participants took a photo of each object as a whole, they remembered fewer objects and remembered fewer details about the objects and the objects' locations in the museum than if they instead only observed the objects and did not photograph them.

However, when participants zoomed in to photograph a specific part of the object, their subsequent recognition and detail memory was not impaired, and, in fact, memory for features that were not zoomed in on was just as strong as memory for features that were zoomed in on. This finding highlights key differences between people's memory and the camera's "memory" and suggests that the additional attentional and cognitive processes engaged by this focused activity can eliminate the photo-taking-impairment effect.

H. Current evidence does support the use of a negative D-dimer to rule out suspected pulmonary embolism in pregnancy

Emerg Med J  2014;31:946-947  

A short cut review was carried out to establish whether a negative D-dimer could be used to rule out pulmonary embolism in the presence of clinical suspicion in a pregnant patient. Five studies were considered directly relevant to the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes and study weaknesses were tabulated. The clinical bottom line was that a negative D-dimer result was considered sensitive enough to rule out pulmonary embolism in patients who were in the first two trimesters of pregnancy but that the false positive rate was so high as to render the test useless in patients in the third trimester if standard cut-off values were used.