1. NEJM Journal Watch Emergency Medicine Top Stories of 2014
A perspective on the most important
research in the field from the past year
1. Post–Cardiac
Arrest Cooling — Colder Is Not Better
2. Five Ways
to Reduce Emergency Care Costs
3. Early
Antibiotics and Fluids Are More Important than Strict Protocol Adherence in the
Treatment of Sepsis
4. Management
of Lacerations: The Dogma Is Changing
5. When
Diagnosing Appendicitis, Skip the Enteral Contrast
6. If
Patients with Renal Colic Need Imaging, Use Ultrasound First
7. ARISE
Confirms ProCESS: Usual Care Is as Effective as EGDT in Septic Shock
8. Who Does
Not Need Repeat Imaging for Traumatic Intracranial Hemorrhage?
9. Two
Studies Offer More Support for Nonoperative Management of Uncomplicated
Appendicitis
10. Prehospital
Noninvasive Positive-Pressure Ventilation Saves Lives
Full
summaries available here: http://www.jwatch.org/na36578/2014/12/24/nejm-journal-watch-emergency-medicine-top-stories-2014
2. Rapid Administration Technique of Ketamine for Pediatric
Forearm Fracture Reduction: A Dose-Finding Study
Chinta SS, et
al. Ann Emerg Med. 2015 Jan 14 [Epub ahead of print]
Study
objective
We estimate
the minimum dose and total sedation time of rapidly infused ketamine that
achieves 3 to 5 minutes of effective sedation in children undergoing forearm
fracture reduction in the emergency department.
Methods
We used the
up-down method to estimate the median dose of intravenous ketamine infused
during less than or equal to 5 seconds that provided effective sedation in 50%
(ED50) and 95% (ED95) of healthy children aged 2 to 5, 6 to 11, or 12 to 17
years who were undergoing forearm fracture reduction. Most patients were
pretreated with opioids. Three investigators blinded to ketamine dose
independently graded sedation effectiveness by viewing a video recording of the
first 5 minutes of sedation. Recovery was assessed by modified Aldrete score.
Results
We enrolled
20 children in each age group. The estimated ED50 was 0.7, 0.5, and 0.6 mg/kg
and the estimated ED95 was 0.7, 0.7, and 0.8 mg/kg for the groups aged 2 to 5,
6 to 11, and 12 to 17 years, respectively. For the group aged 2 to 5 years, an
empirically derived ED95 was 0.8 mg/kg. All patients who received the
empirically derived ED95 in the group aged 2 to 5 years or the estimated ED95
in the groups aged 6 to 11 and 12 to 17 years had effective sedation. The median
total sedation time for the 3 age groups, respectively, was 25, 22.5, and 25
minutes if 1 dose of ketamine was administered and 35, 25, and 45 minutes if
additional doses were administered. No participant experienced serious adverse
events.
Conclusion
We estimated
ED50 and ED95 for rapidly infused ketamine for 3 age groups undergoing fracture
reduction. Total sedation time was shorter than that in most previous studies.
3. Adjunct prednisone therapy for patients with
community-acquired pneumonia: a multicentre, double-blind, randomised,
placebo-controlled trial
Blum CA, et
al. The Lancet. 2015 Jan 18 [Epub ahead of print]
Background
Clinical
trials yielded conflicting data about the benefit of adding systemic
corticosteroids for treatment of community-acquired pneumonia. We assessed
whether short-term corticosteroid treatment reduces time to clinical stability
in patients admitted to hospital for community-acquired pneumonia.
Methods
In this
double-blind, multicentre, randomised, placebo-controlled trial, we recruited
patients aged 18 years or older with community-acquired pneumonia from seven
tertiary care hospitals in Switzerland within 24 h of presentation. Patients
were randomly assigned (1:1 ratio) to receive either prednisone 50 mg daily for
7 days or placebo. The computer-generated randomisation was done with variable
block sizes of four to six and stratified by study centre. The primary endpoint
was time to clinical stability defined as time (days) until stable vital signs
for at least 24 h, and analysed by intention to treat. This trial is registered
with ClinicalTrials.gov, number NCT00973154.
Findings
From Dec 1,
2009, to May 21, 2014, of 2911 patients assessed for eligibility, 785 patients
were randomly assigned to either the prednisone group (n=392) or the placebo
group (n=393). Median time to clinical stability was shorter in the prednisone
group (3·0 days, IQR 2·5–3·4) than in the placebo group (4·4 days, 4·0–5·0;
hazard ratio [HR] 1·33, 95% CI 1·15–1·50, p less than 0·0001). Pneumonia-associated
complications until day 30 did not differ between groups (11 [3%] in the
prednisone group and 22 [6%] in the placebo group; odds ratio [OR] 0·49 [95% CI
0·23–1·02]; p=0·056). The prednisone group had a higher incidence of
in-hospital hyperglycaemia needing insulin treatment (76 [19%] vs 43 [11%]; OR
1·96, 95% CI 1·31–2·93, p=0·0010). Other adverse events compatible with
corticosteroid use were rare and similar in both groups.
Interpretation
Prednisone
treatment for 7 days in patients with community-acquired pneumonia admitted to
hospital shortens time to clinical stability without an increase in
complications. This finding is relevant from a patient perspective and an
important determinant of hospital costs and efficiency.
Methods
explained (from an earlier publication): http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4083867/
4. Should the 48-hour Cardioversion Window Be Revised?
Posted by Ryan
Radecki. EM Literature of Note August
18, 2014
Review of Nuotio
I, et al. Time to cardioversion for acute atrial fibrillation and
thromboembolic complications. JAMA. 2014 Aug 13;312(6):647-9.
It has become
generally accepted practice to treat new-onset atrial fibrillation and atrial
flutter with electrical cardioversion in the acute setting – provided the known
onset of atrial fibrillation is less than 48 hours. Beyond that, caution tends to be advised –
whether through use of transesophageal echocardiography to rule out left atrial
thrombus, or through pre- and post-procedural anticoagulation.
However, this
data from a research letter in JAMA suggests – possibly we ought to be even
more cautious regarding time-of-onset.
This is a
re-analysis of FinCV, a 7 year trial registry of cardioversion for atrial
fibrillation from Finland. The study
cohort is comprised of 2,481 patients undergoing 5,116 electrical
cardioversions, all without peri-procedural anticoagulation for symptom onset less
than 48 hours. Outcomes were gathered from
vital records review, evaluating for cerebrovascular thrombotic complications
within 30 days.
Of these
patients undergoing cardioversion, there were 38 definite thrombotic
complications. 30 of these 38 occurred
in patients whose symptom onset was beyond 12 hours. There were few apparent pro-thrombotic
differences between groups, and thus, the authors very reasonably conclude – we
should be cautious regarding cardioversion after 12 hours. Other predisposing factors in their
multivariate analysis include female sex, heart failure, and diabetes – but
increasing length of time showed the strongest association.
The 12-48
hour window in this study still only represented a 1.1% risk for 30-day
thromboembolism, compared to the ~2% risk after 48 hours. However, it still exceeds the ~0.3% risk of
thromboembolism with peri-procedural anticoagulation. There are other risks associated with
anticoagulation, but it is reasonable to suggest the management strategy is no
longer as clear-cut around 48 hours.
5. Docs Tend to Over-test Patients in order to Reassure Themselves
and their Patients
Overuse of Testing in Preoperative
Evaluation and Syncope: A Survey of Hospitalists
Kachalia K,
et al. Ann Intern Med. 2015;162(2):100-108.
Background:
Health care reform efforts and initiatives seek to improve quality and reduce
costs by eliminating unnecessary care. However, little is known about overuse
and its drivers, especially in hospitals.
Objective: To
assess the extent of and factors associated with overuse of testing in U.S.
hospitals.
Design:
National survey of practice patterns for 2 common clinical vignettes:
preoperative evaluation and syncope. Respondents were randomly selected and
randomly provided 1 of 4 versions of each vignette. Each version contained
identical clinical information but varied in factors that could change physician
behavior. Respondents were asked to identify what they believed most
hospitalists at their institution would recommend in each vignette.
Setting:
Mailed survey conducted from June through October 2011.
Participants:
Physicians practicing adult hospital medicine in the United States.
Measurements:
Responses indicating overuse (more testing than recommended by American College
of Cardiology/American Heart Association guidelines).
Results: 68%
(1020 of 1500) of hospitalists responded. They reported overuse in 52% to 65%
of the preoperative evaluation vignettes and 82% to 85% of the syncope
vignettes. Overuse more frequently resulted from a physician's desire to
reassure patients or themselves than an incorrect belief that it was clinically
indicated (preoperative evaluation, 63% vs. 37%; syncope, 69% vs. 31%; P less
than 0.001 for each).
Limitation:
Survey responses may not represent actual clinical choices.
Conclusion:
Physicians reported substantial overuse in 2 common clinical situations in the
hospital. Improving provider knowledge of guidelines may help reduce overuse,
but despite awareness of the guidelines, physicians often deviate from them to
reassure patients or themselves.
6. Routine urinalysis in patients with a blunt abdominal trauma
mechanism is not valuable to detect urogenital injury
Olthof DC, et
al. Emerg Med J 2015;32:119-123
Objective To
investigate whether the routine performance of urinalysis in patients with a
blunt trauma mechanism is still valuable.
Methods
Consecutive patients aged ≥16 years, admitted to a Dutch Level 1 trauma centre
between January 2008 and August 2011, were included in this retrospective
cohort study. Results of urinalysis (erythrocytes per µL) were divided into no,
microscopic or macroscopic haematuria. Patients were divided into four groups
based on whether a urinalysis was performed or not, with or without imaging for
urogenital injury. Main outcome measures were the presence of urogenital injury
and whether the findings on urine specimen and/or imaging led to clinical
consequences.
Results A
total of 1815 patients were included. The prevalence of intra-abdominal and
urogenital injuries was 13% and 8%, respectively. In 1363 patients (75%),
urinalysis was performed and 1031 patients (57%) underwent imaging for
urogenital injury as well. The presence of macroscopic haematuria (n=16) led to
clinical consequences in 73% of the patients (11 out of 15), regardless of the
findings on imaging. Microscopic haematuria on urinalysis in combination with
no findings on imaging led to clinical consequences in 8 out of 212 patients
(4%). Microscopic haematuria on urinalysis in patients who did not have imaging
for urogenital injury did not lead to clinical consequences (0 out of 54
patients; 0%). All the 8 patients who underwent an intervention had positive
findings on imaging.
Conclusions
The results do not support the routine performance of urinalysis in patients
admitted with a blunt trauma mechanism. Although urinalysis could be valuable
in specific patient populations, we should consider omitting this investigation
as a routine part of the assessment of trauma patients.
7. An ED Decision-Support Program That Increased Physician
Office Visits, Decreased Emergency Room Visits, and Saved Money
Navratil-Strawn
JL, et al. Population Health Management 2014;17:257–264
The objective
of this study was to evaluate an Emergency Room having a Decision-Support
(ERDS) program designed to appropriately reduce ER use among frequent users,
defined as 3 or more visits within a 12-month period.
To achieve
this, adults with an AARP Medicare Supplement Insurance plan insured by
UnitedHealthcare Insurance Company (for New York residents, UnitedHealthcare
Insurance Company of New York) were eligible to participate in the program.
These included 7070 individuals who elected to enroll in the ERDS program and
an equal number of matched nonparticipants who were eligible but either
declined or were unreachable. Program-related benefits were estimated by
comparing the difference in downstream health care utilization and expenditures
between engaged and not engaged individuals after using propensity score
matching to adjust for case mix differences between these groups.
As a result,
compared with the not engaged, engaged individuals experienced better care
coordination, evidenced by a greater reduction in ER visits (P=0.033) and
hospital admissions (P=0.002) and an increase in office visits (P less than 0.001).
The program was cost-effective, with a return on investment (ROI) of 1.24, which
was calculated by dividing the total program savings ($3.41 million) by the
total program costs ($2.75 million). The ROI implies that for every dollar
invested in this program, $1.24 was saved, most of which was for the federal
Medicare program.
In conclusion,
the decrease in ER visits and hospital admissions and the increase in office
visits may indicate the program helped individuals to seek the appropriate
levels of care.
8. D-Dimer and the Workup of PE: A Teachable Moment
Wray C. JAMA Intern Med. 2015;175(1):14-15.
Excerpt
In the bustle
of the modern emergency department, patients are sometimes whisked off to the
computed tomography scanner prior to being properly evaluated for risk factors
for acquiring PE. Guidelines have long recommended that an assessment of the
clinical probability of PE be calculated prior to any diagnostic studies.1
Clinical prediction rules, such as the Wells criteria2 or the revised Geneva
score, have been well validated and are recommended as the first step in the evaluation
of possible PE. Both the American College of Emergency Physicians and European
Society of Cardiology agree that no further imaging workup should be performed
in patients with a low pretest probability of PE and a negative D-dimer test
result.3,4 In addition, the American Board of Internal Medicine Foundation’s
Choosing Wisely campaign has stated that in the absence of an elevated D-dimer
level, imaging studies should not be used for patients with low pretest
probability of PE.5
To assess
adherence to current guidelines, Adams et al6 reviewed 3500 cases in which CTPA
was performed in 2 urban emergency departments. Only 45% of all cases followed
current recommendations.1 A CTPA was performed in 55% of cases, even when
clinical prediction scores indicated a low pretest probability. Furthermore,
almost 10% of all CTPA examinations were performed in patients with a low
pretest probability and negative D-dimer test result.6
In another
recent study of almost 6000 emergency department patients in whom PE was
suspected, imaging was performed in 38% of low-risk patients; 36% had no
D-dimer test ordered and 18% had a normal D-dimer test result.7 ….
References
1. Stein
PD, et al; PIOPED II investigators.
Diagnostic pathways in acute pulmonary embolism: recommendations of the
PIOPED II investigators. Am J Med. 2006;119:1048-1055.
2. Wells
PS, et al. Use of a clinical
model for safe management of patients with suspected pulmonary embolism. Ann
Intern Med. 1998;129:997-1005.
3. Torbicki
A, et al; ESC Committee for Practice Guidelines (CPG). Guidelines on the diagnosis and management of
acute pulmonary embolism: the Task Force for the Diagnosis and Management of
Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart
J. 2008;29:2276-2315.
4. Fesmire
FM, et al; American College of Emergency Physicians. Critical issues in the evaluation and
management of adult patients presenting to the emergency department with
suspected pulmonary embolism. Ann Emerg Med. 2011;57:628-652.
5. American College of Radiology. Five things
physicians and patients should question.
http://www.choosingwisely.org/doctor-patient-lists/american-college-of-radiology/.
Accessed July 25, 2014.
6. Adams
DM, et al. Adherence to PIOPED II
investigators’ recommendations for computed tomography pulmonary angiography.
Am J Med. 2013;126:36-42.
7. Venkatesh
AK, et al. Evaluation of
pulmonary embolism in the emergency department and consistency with a national
quality measure: quantifying the opportunity for improvement. Arch Intern Med.
2012;172:1028-1032.
9. Early Management of Patients With Acute Heart Failure: State
of the Art and Future Directions-A Consensus Document from the SAEM/HFSA Acute
Heart Failure Working Group.
Collins SP,
et al. Acad Emerg Med. 2015 Jan;22(1):94-112.
Heart failure
(HF) afflicts nearly 6 million Americans, resulting in 1 million emergency
department (ED) visits and over 1 million annual hospital discharges.[1, 2] An
aging population and improved survival from cardiovascular diseases is expected
to further increase HF prevalence.[3] By 2030 an estimated 25% increase in HF
prevalence will result in an additional 3 million affected individuals.[1, 4]
Of the $39.2 billion spent on HF care in the US in 2010, inpatient admissions
accounted for the single largest proportion. By 2030, the amount spent on
hospital care for HF will be even greater as annual total costs are expected to
be close to $70 billion.
Emergency
providers play a significant role in the management of patients with acute
heart failure (AHF). Therapeutic and disposition decisions made by emergency
providers have direct impact on morbidity, mortality, and hospital length of
stay, all of which affect health care costs.[5-9] Over 80% of ED patients with
AHF are admitted to the hospital, a proportion that has remained largely
unchanged over the past 5 years.[2] It is crucial that emergency physicians and
other providers involved in early management understand the latest developments
in diagnostic testing, therapeutics, and alternatives to hospitalization.
Equally important are partnerships between emergency providers and HF
specialists along with the entire interdisciplinary team caring for HF patients
to streamline care from the ED to the inpatient and outpatient settings.
Topics
Current
approaches to diagnosis
Current
guideline recommendations for AHF therapy
Current ED
therapy: applicability of recent evidence and ongoing trials
Disposition
decision making: can a subset of ED patients be sent home?
Observation
units and observation services: their role in ED patients with AHF
Unanswered
questions and future research agenda
10. Intracranial Bleeds after Minor and Minimal Head Injury in
Patients on Warfarin
Alrajhi KN,
et al. J Emerg Med 2015;48:137–142
Background
There is
little evidence to guide physicians on management of patients who sustain head
injuries while on warfarin.
Objectives
Our objective
was to determine the rate of intracranial bleeding in anticoagulated patients
with minor and minimal head injuries and the association with clinical features
and international normalized ratio (INR).
Methods
We conducted
a historical cohort study of adult patients, taking warfarin, at two tertiary
care emergency departments over 2 years with minor (Glasgow Coma Score 13–15,
with loss of consciousness, amnesia, or confusion) or minimal (Glasgow Coma
Score 15 without loss of consciousness, amnesia, or confusion) head injuries.
Patients with penetrating injuries, INR less than 1.5, or a new focal
neurological deficit were excluded. Our outcome, intracranial bleeding, was
determined by the radiologist’s final computed tomography (CT) report for
imaging performed within 2 weeks.
Results
There were
176 patients enrolled, of which 157 (89.2%) had CT and 28 (15.9%) had
intracranial bleeding. Comparing patients with and without intracranial
bleeding found no significant differences in INR, and loss of consciousness was
associated with higher rate of intracranial bleeding. The rate of intracranial
bleeding in the minor and minimal head injury groups was 21.9% and 4.8%,
respectively.
Conclusions
The rate of
intracranial bleeding in patients on warfarin is considerable. Loss of
consciousness is associated with high rates of intracranial bleeding. This
study supports a low threshold for ordering CT scans for anticoagulated
patients with head injuries.
11. Images in Clinical Practice
Woman With
Rash and Weakness
Trust Me,
This Is the Worst “Acne” of Your Life!
Making Sense
of Drug Rashes: An Overview
Female With
Recurrent Oral Lesions
Young Male
With Severe Traumatic Brain Injury
Acute Colonic
Pseudo-Obstruction
Intracranial
Arteriovenous Malformation
Kussmaul's
Sign
Wellens'
Syndrome
Mobile Large
Left Atrial Thrombus
13-Year-Old
with Cryptic Abdominal Pain
Pulmonary
Embolus in Transit
12. (Over) Use of Cardiac Biomarker Testing in the ED
Makam AN, et
al. JAMA Intern Med. 2015;175(1):67-75.
Importance Cardiac biomarker testing is not routinely
indicated in the emergency department (ED) because of low utility and potential
downstream harms from false-positive results. However, current rates of testing
are unknown.
Objective To determine the use of cardiac biomarker
testing overall, as well as stratified by disposition status and selected
characteristics.
Design,
Setting, and Participants Retrospective
study of ED visits by adults (≥18 years old) selected from the 2009 and 2010
National Hospital Ambulatory Medical Care Survey, a probability sample of ED
visits in the United States.
Exposures Selected patient, visit, and ED
characteristics.
Main Outcomes
and Measures Receipt of cardiac
biomarker testing during the ED visit.
Results Of 44 448 ED visits, cardiac biomarkers were
tested in 16.9% of visits, representing 28.6 million visits. Biomarker testing
occurred in 8.2% of visits in the absence of acute coronary syndrome
(ACS)–related symptoms, representing 8.5 million visits, almost one-third of
all visits with biomarker testing. Among individuals subsequently hospitalized,
cardiac biomarkers were tested in 47.0% of all visits. In this group,
biomarkers were tested in 35.4% of visits despite the absence of ACS-related
symptoms. Among all ED visits, the number of other tests or services performed
was the strongest predictor of biomarker testing independent of symptoms of
ACS. Compared with 0 to 5 other tests or services performed, more than 10 other
tests or services performed was associated with 59.55 (95% CI, 39.23-90.40)
times the odds of biomarker testing. The adjusted probabilities of biomarker
testing if 0 to 5, 6 to 10, or more than 10 other tests or services performed
were 6.3%, 34.3%, and 62.3%, respectively.
Conclusions
and Relevance Cardiac biomarker testing
in the ED is common even among those without symptoms suggestive of ACS.
Cardiac biomarker testing is also frequently used during visits with a high
volume of other tests or services independent of the clinical presentation.
More attention is needed to develop strategies for appropriate use of cardiac
biomarkers.
13. The Diagnostic Accuracy of Bedside Ocular Ultrasonography
for the Diagnosis of Retinal Detachment: A Systematic Review and Meta-analysis
Vrablik ME,
et al. Ann Emerg Med 2015;65:199–203.e1
The
diagnostic accuracy of emergency department (ED) ocular ultrasonography may be
sufficient for diagnosing retinal detachment. We systematically reviewed the
literature to determine the diagnostic accuracy of ED ocular ultrasonography
for the diagnosis of retinal detachment. This review conformed to the
recommendations from the Meta-analysis of Observational Studies in Epidemiology
statement. An experienced medical librarian searched the following databases from
their inception, without language restrictions: Ovid MEDLINE, PubMed, EMBASE,
the Cochrane Library, Emergency Medical Abstracts, and Google Scholar. Content
experts were contacted and bibliographies of relevant studies were reviewed to
identify additional references. Evidence quality was independently assessed by
2 investigators using the revised Quality Assessment Tool for Diagnostic
Accuracy Studies (QUADAS-2). Discrepancies were resolved by consensus or
adjudication by a third reviewer. Diagnostic test characteristics were
summarized and reported with 95% confidence intervals.
Of 7,771
unique citations identified, 78 were selected for full-text review, resulting
in 4 trials assessed for quality. Agreement between authors’ QUADAS-2 scoring
was good (κ=0.63). Three trials were deemed to have a low risk of bias. They
enrolled ED-based patients (N=201) and evaluated clinician-performed bedside
ocular ultrasonography, using either a 7.5- or 10-MHz linear-array probe. Two
trials included patients who had retinal detachment from trauma. The prevalence
of retinal detachment ranged from 15% to 38%. Sensitivity and specificity
ranged from 97% to 100% and 83% to 100%, respectively. The results of the
bedside ocular ultrasonography were compared with the reference standard of an
ophthalmologic evaluation; one trial also included orbital computed tomography
findings suggestive of retinal detachment.
Bedside
ocular ultrasonography has a high degree of accuracy in identifying retinal
detachment, according to 3 small prospective investigations. Larger prospective
validation of these findings would be valuable.
14. Diagnosing paediatric myocarditis: what really matters
Chong S, et
al. Emerg Med J 2015;32:138-143
Objective
Paediatric myocarditis has remained a diagnostic challenge. We aim to identify
distinct characteristics and derive a scoring system that will trigger further
investigations to be performed among paediatric patients presenting to the
emergency department (ED) with clinically suspected myocarditis.
Design We
performed an age-matched case-control study of children seen in a large
tertiary institution. Cases and controls were patients less than 16 years’ old
who presented to the ED over a 10-year period from Jan 2001 to Dec 2010. Cases
were identified with a final discharge or postmortem diagnosis of acute
myocarditis. Controls were those who presented to the ED in the same period and
were initially diagnosed with acute myocarditis, but who were later found to
have other diagnoses. We compared their vital signs, presenting symptoms,
physical examination findings, electrocardiogram and chest radiograph findings.
Results Based
on domain-specific stepwise conditional logistic regression analyses, five
characteristics were found to be potentially discriminating: respiratory
distress, poor perfusion, hypotension, an abnormal chest radiograph and any
electrocardiogram abnormalities. Satisfactory discrimination was attained using
these five parameters. The estimated area under receiver operating
characteristic curve was 90% (95% CI 0.83 to 0.97). A cut-off score of 3 would
give a positive likelihood ratio of 13 (95% CI 3.31 to 51.06) and a negative
likelihood ratio of 0.35 (95% CI 0.22 to 0.55).
Conclusions A
cut-off risk score of 3, though not yet validated, may be potentially useful in
future to trigger further investigations for children with suspected
myocarditis. It allows for the appropriate use of resources, while minimising
on misdiagnosis.
15. Happiness Tip: Stop Checking Your Freaking Phone
"I
would love some help figuring out a tiny habit to help me unplug from my phone.
It's the first thing I reach for in the morning, when I'm stopped at red
lights, when I get home from work--my brain has become used to checking my
email, text messages, facebook, playing plants vs. zombies constantly. It's
hard because I use my phone for so many things throughout the day (except of
course as a phone!), so its constant presence makes it hard to forget it's
there at the times that I'm not really using it. Any ideas?" --Pamela
Pamela,
you've got a great goal for the New Year. Two new studies support your sense
that you will be happier (and less stressed) if you check your phone less. A study of
college students at Kent State University found that people who check their phones frequently tend
to experience higher levels of distress during their leisure time (when they
intend to relax!).
In another
study, Elizabeth Dunn
and Kostadin Kushlev
regulated how frequently participants checked their email throughout the day.
Those aiming to reduce their email checking to only three times a day (vs. an
average of 15 times) were less tense and less stressed overall.
Unfortunately,
it usually doesn't work to just will ourselves to stop a compulsive
behavior. We check our phones and our email because it provides us with what
researchers call "variable-ratio" reinforcement--once in a while we
get an email or message that is particularly rewarding, and that once in a
while is enough to keep us checking compulsively. (Slot machines also provide
variable-ratio rewards.)
Instead of
willing ourselves to just check less often, we can configure our devices and
work time so that we are tempted less often. The goal is to check email, social
media, and messages on your phone just a few times a day--intentionally, not
impulsively. Our devices are thus returned to their status as tools we use
strategically-- not slot machines that randomly demand our energy and
attention.
Take Action. Here's a plan to lower your stress and tension:
1. Make a strategic decision about when you will check your email and messages. I check my email quickly before work to delete or unsubscribe from junk and respond to anything urgent. I respond to everything else in my work email at 3:00pm and my home email at 7:45pm. I actually block this time out on my calendar as a recurring task, and then move it around as necessary -- that way I check strategically, not impulsively. I look at (and maybe post to) social media once in the morning before work, if I have time, and then I close it for the day. I respond to texts and voicemails once mid-morning and once mid-afternoon (between calls and meetings).
2. Tell your family and colleagues that you are establishing a strategic checking schedule. Worried that people will see you as unresponsive or slacking at work? Leslie Perlow's research indicates otherwise; in fact, your colleagues will likely notice your increased productivity and see you as more collaborative, efficient, and effective when you reduce constant phone and email monitoring.
3. Remove distractions. Set your mobile devices to automatically go into sleep mode an hour before you go to bed until your first pre-determined checking time. Consider removing email from your phone, or at least moving it to a back "page" of apps, so that you don't see it if you are turning off your alarm or using another app. I think of this as hiding the Halloween candy: If you wanted to eat less candy, you wouldn't put a bowl of it on your bedside table, bathroom counter, kitchen table, dashboard, and desk at work--right? So don't do that with the slot machine that is your smartphone. While you are on your computer working (or in the car driving), keep your email program closed. Turn all notifications off. Put your phone in sleep mode. This may seem drastic, but trust me. Your life is about to get way better.
4. Focus on other things. Now, do your most important work or something that brings you peace, or joy. Replace checking your smartphone constantly with something better. I set reminders for two-minute relaxation breaks three times a day, when I take a dozen deep breaths (breathing in for 5 seconds, and out for 5 seconds). This triggers my vagus nerve, inducing a feeling of calm, and reversing the ill-effects of stress.
5. Savor the benefits of this effort. You will likely start sleeping better. You'll be more focused, productive, and efficient at work. You'll have a heck of a lot more time to do the things that really matter in your life, things that bring lasting happiness. But none of those benefits really matter unless you take the time to enjoy them. Studies by Fred Bryant suggest that by consciously and deliberately savoring positive events in our life, we can increase the amount of happiness we derive from them in the short and long run. So enjoy being less stressed and less tense--relish your new life.
Take Action. Here's a plan to lower your stress and tension:
1. Make a strategic decision about when you will check your email and messages. I check my email quickly before work to delete or unsubscribe from junk and respond to anything urgent. I respond to everything else in my work email at 3:00pm and my home email at 7:45pm. I actually block this time out on my calendar as a recurring task, and then move it around as necessary -- that way I check strategically, not impulsively. I look at (and maybe post to) social media once in the morning before work, if I have time, and then I close it for the day. I respond to texts and voicemails once mid-morning and once mid-afternoon (between calls and meetings).
2. Tell your family and colleagues that you are establishing a strategic checking schedule. Worried that people will see you as unresponsive or slacking at work? Leslie Perlow's research indicates otherwise; in fact, your colleagues will likely notice your increased productivity and see you as more collaborative, efficient, and effective when you reduce constant phone and email monitoring.
3. Remove distractions. Set your mobile devices to automatically go into sleep mode an hour before you go to bed until your first pre-determined checking time. Consider removing email from your phone, or at least moving it to a back "page" of apps, so that you don't see it if you are turning off your alarm or using another app. I think of this as hiding the Halloween candy: If you wanted to eat less candy, you wouldn't put a bowl of it on your bedside table, bathroom counter, kitchen table, dashboard, and desk at work--right? So don't do that with the slot machine that is your smartphone. While you are on your computer working (or in the car driving), keep your email program closed. Turn all notifications off. Put your phone in sleep mode. This may seem drastic, but trust me. Your life is about to get way better.
4. Focus on other things. Now, do your most important work or something that brings you peace, or joy. Replace checking your smartphone constantly with something better. I set reminders for two-minute relaxation breaks three times a day, when I take a dozen deep breaths (breathing in for 5 seconds, and out for 5 seconds). This triggers my vagus nerve, inducing a feeling of calm, and reversing the ill-effects of stress.
5. Savor the benefits of this effort. You will likely start sleeping better. You'll be more focused, productive, and efficient at work. You'll have a heck of a lot more time to do the things that really matter in your life, things that bring lasting happiness. But none of those benefits really matter unless you take the time to enjoy them. Studies by Fred Bryant suggest that by consciously and deliberately savoring positive events in our life, we can increase the amount of happiness we derive from them in the short and long run. So enjoy being less stressed and less tense--relish your new life.
16. The acute treatment of migraine in adults: the American
Headache Society evidence assessment of migraine pharmacotherapies.
Marmura MJ,
et al. Headache. 2015 Jan;55(1):3-20.
The study
aims to provide an updated assessment of the evidence for individual
pharmacological therapies for acute migraine treatment. Pharmacological therapy
is frequently required for acutely treating migraine attacks. The American
Academy of Neurology Guidelines published in 2000 summarized the available
evidence relating to the efficacy of acute migraine medications. This review,
conducted by the members of the Guidelines Section of the American Headache
Society, is an updated assessment of evidence for the migraine acute
medications.
A
standardized literature search was performed to identify articles related to
acute migraine treatment that were published between 1998 and 2013. The
American Academy of Neurology Guidelines Development procedures were followed.
Two authors reviewed each abstract resulting from the search and determined
whether the full manuscript qualified for review. Two reviewers studied each
qualifying full manuscript for its level of evidence. Level A evidence requires
at least 2 Class I studies, and Level B evidence requires 1 Class I or 2 Class
II studies.
The specific
medications - triptans (almotriptan, eletriptan, frovatriptan, naratriptan,
rizatriptan, sumatriptan [oral, nasal spray, injectable, transcutaneous patch],
zolmitriptan [oral and nasal spray]) and dihydroergotamine (nasal spray,
inhaler) are effective (Level A). Ergotamine and other forms of
dihydroergotamine are probably effective (Level B). Effective nonspecific
medications include acetaminophen, nonsteroidal anti-inflammatory drugs
(aspirin, diclofenac, ibuprofen, and naproxen), opioids (butorphanol nasal
spray), sumatriptan/naproxen, and the combination of
acetaminophen/aspirin/caffeine (Level A). Ketoprofen, intravenous and
intramuscular ketorolac, flurbiprofen, intravenous magnesium (in migraine with
aura), and the combination of isometheptene compounds, codeine/acetaminophen
and tramadol/acetaminophen are probably effective (Level B). The antiemetics
prochlorperazine, droperidol, chlorpromazine, and metoclopramide are probably
effective (Level B). There is inadequate evidence for butalbital and butalbital
combinations, phenazone, intravenous tramadol, methadone, butorphanol or
meperidine injections, intranasal lidocaine, and corticosteroids, including
dexamethasone (Level C). Octreotide is probably not effective (Level B). There
is inadequate evidence to refute the efficacy of ketorolac nasal spray,
intravenous acetaminophen, chlorpromazine injection, and intravenous
granisetron (Level C).
There are
many acute migraine treatments for which evidence supports efficacy. Clinicians
must consider medication efficacy, potential side effects, and potential
medication-related adverse events when prescribing acute medications for
migraine. Although opioids, such as butorphanol, codeine/acetaminophen, and tramadol/acetaminophen,
are probably effective, they are not recommended for regular use.
17. Factors Associated with the Decision to Hospitalize ED
Patients with a Skin and Soft Tissue Infection
Talan DA, et
al. West J Emerg Med 2015; 16:89-97.
Introduction:
Emergency department (ED) hospitalizations for skin and soft tissue infection
(SSTI) have increased, while concern for costs has grown and outpatient
parenteral antibiotic options have expanded. To identify opportunities to
reduce admissions, we explored factors that influence the decision to
hospitalize an ED patient with a SSTI.
Methods: We
conducted a prospective study of adults presenting to 12 U.S. EDs with a SSTI
in which physicians were surveyed as to reason(s) for admission, and clinical
characteristics were correlated with disposition. We employed chi-square binary
recursive partitioning to assess independent predictors of admission. Serious
adverse events were recorded.
Results:
Among 619 patients, median age was 38.7 years. The median duration of symptoms
was 4.0 days, 96 (15.5%) had a history of fever, and 46 (7.5%) had failed
treatment. Median maximal length of erythema was 4.0cm (IQR, 2.0-7.0). Upon
presentation, 39 (6.3%) had temperature over 38oC, 81 (13.1%) tachycardia, 35
(5.7%), tachypnea, and 5 (0.8%) hypotension; at the time of the ED disposition
decision, these findings were present in 9 (1.5%), 11 (1.8%), 7 (1.1%), and 3
(0.5%) patients, respectively. Ninety-four patients (15.2%) were admitted, 3
(0.5%) to the intensive care unit (ICU). Common reasons for admission were need
for intravenous antibiotics in 80 (85.1%; the only reason in 41.5%), surgery in
23 (24.5%), and underlying disease in 11 (11.7%). Hospitalization was
significantly associated with the following factors in decreasing order of
importance: history of fever (present in 43.6% of those admitted, and 10.5%
discharged; maximal length of erythema beyond 10cm (43.6%, 11.3%); history of
failed treatment (16.1%, 6.0%); any co-morbidity (61.7%, 27.2%); and age over 65
years (5.4%, 1.3%). Two patients required amputation and none had ICU transfer
or died.
Conclusion:
ED SSTI patients with fever, larger lesions, and co-morbidities tend to be
hospitalized, almost all to non-critical areas and rarely do they suffer
serious complications. The most common reason for admission is administration
of intravenous antibiotics, which is frequently the only reason for
hospitalization. With the increasing outpatient intravenous antibiotic therapy
options, these results suggest that many hospitalized patients with SSTI could
be managed safely and effectively as outpatients.
18. Timing discharge follow-up for acute PE: a retrospective
cohort study.
Vinson DR, et
al. West J Emerg Med. 2015 Jan 12 [Epub ahead of print].
Introduction:
Historically, emergency department (ED) patients with pulmonary embolism (PE)
have been admitted for several days of inpatient care. Growing evidence
suggests that selected ED patients with PE can be safely discharged home after
a short length of stay. However, the optimal timing of follow up is unknown. We
hypothesized that higher-risk patients with short length of stay (less than 24
hours from ED registration) would more commonly receive expedited follow up (≤3
days).
Methods: This
retrospective cohort study included adults treated for acute PE in six
community EDs. We ascertained the PE Severity Index risk class (for 30-day
mortality), facility length of stay, the first follow-up clinician encounter,
unscheduled return ED visits ≤3 days, 5-day PE-related readmissions, and 30-day
all-cause mortality. Stratifying by risk class, we used multivariable analysis
to examine age- and sex-adjusted associations between length of stay and
expedited follow up.
Results: The
mean age of our 175 patients was 63.2 (±16.8) years. Overall, 93.1% (n=163) of
our cohort received follow up within one week of discharge. Fifty-six patients
(32.0%) were sent home within 24 hours and 100 (57.1%) received expedited
follow up, often by telephone (67/100). The short and longer length-of-stay
groups were comparable in age and sex, but differed in rates of low-risk status
(63% vs 37%; p less than 0.01) and expedited follow up (70% vs 51%; p=0.03).
After adjustment, we found that short length of stay was independently
associated with expedited follow up in higher-risk patients (adjusted odds
ratio [aOR] 3.5 [95% CI, 1.0-11.8; p=0.04]), but not in low-risk patients (aOR
2.2 [95% CI, 0.8-5.7; P=0.11]). Adverse outcomes were uncommon (less than 2%)
and were not significantly different between the two length-of-stay groups.
Conclusion:
Higher-risk patients with acute PE and short length of stay more commonly
received expedited follow up in our community setting than other groups of
patients. These practice patterns are associated with low rates of 30-day
adverse events.
19. Association of ED Opioid Initiation With Recurrent Opioid Use
Hoppe JA, et
al. Ann Emerg Med 2014 Dec 17 [Epub ahead of print]
Study
objective
Acute pain
complaints are commonly treated in the emergency department (ED). Short courses
of opioids are presumed to be safe for acute pain; however, the risk of recurrent
opioid use after receipt of an ED opioid prescription is unknown. We describe
the risk of recurrent opioid use in patients receiving an opioid prescription
from the ED for an acute painful condition.
Methods
This is a
retrospective cohort study of all patients discharged from an urban academic ED
with an acute painful condition during a 5-month period. Clinical information
was linked to data from Colorado’s prescription drug monitoring program. We
compared opioid-naive patients (no opioid prescription during the year before
the visit) who filled an opioid prescription or received a prescription but did
not fill it to those who did not receive a prescription. The primary outcome
was the rate of recurrent opioid use, defined as filling an opioid prescription
within 60 days before or after the first anniversary of the ED visit.
Results
Four thousand
eight hundred one patients were treated for an acute painful condition; of
these, 52% were opioid naive and 48% received an opioid prescription. Among all
opioid-naive patients, 775 (31%) received and filled an opioid prescription,
and 299 (12%) went on to recurrent use. For opioid-naive patients who filled a
prescription compared with those who did not receive a prescription, the
adjusted odds ratio for recurrent use was 1.8 (95% confidence interval 1.3 to
2.3). For opioid-naive patients who received a prescription but did not fill it
compared with those who did not receive a prescription, the adjusted odds ratio
for recurrent use was 0.8 (95% confidence interval 0.5 to 1.3).
Conclusion
Opioid-naive
ED patients prescribed opioids for acute pain are at increased risk for
additional opioid use at 1 year.
20. FDA Drug Safety Communication: FDA has reviewed possible
risks of pain medicine use during pregnancy
Jan 9, 2015
The U.S. Food
and Drug Administration (FDA) is aware of and understands the concerns arising
from recent reports questioning the safety of prescription and over-the-counter
(OTC) pain medicines when used during pregnancy. As a result, we evaluated research studies
published in the medical literature and determined they are too limited to make
any recommendations based on these studies at this time. Because of this uncertainty, the use of pain
medicines during pregnancy should be carefully considered. We urge pregnant women to always discuss all
medicines with their health care professionals before using them.
Severe and
persistent pain that is not effectively treated during pregnancy can result in
depression, anxiety, and high blood pressure in the mother.1 Medicines
including nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and
acetaminophen can help treat severe and persistent pain. However, it is important to carefully weigh
the benefits and risks of using prescription and OTC pain medicines during
pregnancy.
The published
studies we reviewed reported on the potential risks associated with the
following three types of pain medicines used during pregnancy (see Data Summary
section for more information about these studies):
• Prescription
NSAIDs and the risk of miscarriage in the first half of pregnancy.2-6 Examples
of prescription NSAIDs include ibuprofen, naproxen, diclofenac, and celecoxib.
• Opioids,
which are available only by prescription, and the risk of birth defects of the
brain, spine, or spinal cord in babies born to women who took these products
during the first trimester of pregnancy.7, 8 Examples of opioids include
oxycodone, hydrocodone, hydromorphone, morphine, and codeine.
• Acetaminophen
in both OTC and prescription products and the risk of attention deficit
hyperactivity disorder (ADHD) in children born to women who took this medicine
at any time during pregnancy.9 Acetaminophen is a common pain reducer and fever
reducer found in hundreds of medicines including those used for colds, flu,
allergies, and sleep.
We found all
of the studies we reviewed to have potential limitations in their designs;
sometimes the accumulated studies on a topic contained conflicting results that
prevented us from drawing reliable conclusions.
As a result, our recommendations on how pain medicines are used during
pregnancy will remain the same at this time.
Pregnant
women should always consult with their health care professional before taking
any prescription or OTC medicine. Women
taking pain medicines who are considering becoming pregnant should also consult
with their health care professionals to discuss the risks and benefits of pain
medicine use. Health care professionals
should continue to follow the recommendations in the drug labels when
prescribing pain medicines to pregnant patients.
We will
continue to monitor and evaluate the use of pain medicines during pregnancy and
will update the public as new safety information becomes available.
21. Rate of preventable early unplanned ICU transfer was no
higher for direct admissions compared with ED admissions.
Reese J, et
al. Hosp Pediatr. 2015 Jan;5(1):27-34.
BACKGROUND
AND OBJECTIVE: Appropriate patient placement at the time of admission to avoid
unplanned transfers to the ICU and codes outside of the ICU is an important
safety goal for many institutions. The objective of this study was to determine
if the overall rate of unplanned ICU transfers within 12 hours of admission to
the inpatient medical/surgical unit was higher for direct admissions compared
with emergency department (ED) admissions.
METHODS: This
was a retrospective cohort study of all unplanned ICU transfers within 12 hours
of admission to an inpatient unit at a tertiary care children's hospital from
January 2010 to December 2012. Proportions of preventable unplanned transfers
from the ED and from direct admission were calculated and compared.
RESULTS: Over
the study period, there were a total of 46 998 admissions; 279 unplanned ICU
transfers occurred during the study period of which 101 (36%) were preventable.
Preventable unplanned transfers from each portal of entry were calculated and
compared with the total number of admissions from those portals. The portals of
entry evaluated included admissions from our internal ED versus all outside
facility transfers. The rates of early unplanned transfer (per 1000 admissions)
by portal of entry were 3.50 for direct admissions and 3.18 for ED. There was
no difference between direct admissions and ED admissions resulting in
preventable unplanned transfers to the ICU (P = .64).
CONCLUSIONS:
Rates of unplanned ICU transfers within 12 hours of admission to an inpatient
unit are not higher for direct admissions compared with ED admissions. Further
studies are required to determine clinical risk factors associated with
unplanned ICU transfer after admission, thus allowing for more accurate initial
patient placement.
22. Micro Lit Bits
A. Does Hugging Provide
Stress-Buffering Social Support? A Study of Susceptibility to Upper Respiratory
Infection and Illness
Sheldon
Cohen, Denise Janicki-Deverts, Ronald B. Turner, and William J. Doyle
Psychol
Sci 2014 December 19 [Epub ahead of print]
Can
receiving social support, such as daily hugs, reduce your risk of infection
from common viruses? Participants reported their level of perceived social
support and were interviewed for 14 consecutive days about their experiences of
interpersonal stress and whether they had received a hug on that particular
day. Participants were then exposed to a mild virus and were assessed for the
development of cold-like symptoms and antibodies to the virus. More frequent hugs
and greater levels of perceived social support predicted less severe signs of
illness in participants. Hugging may be one way of conveying social support,
which, in turn, may reduce the signs of stress and illness.
B. Study: Fitness apps
fall short on evidence of efficacy
Half
of smartphone users in the U.S. use some form of fitness application, a study
in the American Journal of Preventive Medicine says. Data showed that 48% of
health apps examined focused on social support and feedback, while 52% focused
on support and education. One expert said that while health apps use some evidence-based
strategies, many don't do enough to motivate inactive users.
Reuters
article: http://www.reuters.com/article/2015/01/20/us-apps-fitness-behavior-idUSKBN0KT2GU20150120
C. Red Bull
cardiovascular and cerebrovascular effects
This
study found that the combination of Red Bull and mental stress impose a
cumulative cardiovascular load and reduces cerebral blood flow even under a
mental challenge.
D. Beyond Belief — How
People Feel about Taking Medications for Heart Disease
A
few years ago, when I began studying medication nonadherence among patients
who'd had a myocardial infarction, I aimed not to change minds but to
understand. As many as half of U.S. patients don't take medications as
prescribed,1 and the rates are similar after myocardial infarction.2
Observational studies have identified some factors associated with nonadherence
among patients with coronary disease, such as nonwhite race, depression, and
female sex.3 Little is understood, however, about how patients feel about
taking medications for heart disease. Are there emotional barriers? Where do
they come from? Can we find better ways of increasing adherence if we
understand them?
E. Goal-Directed
Resuscitation in Septic Shock: Letters to the Editor re: the ARISE Study on
EGDT
F. Ultrasonography vs.
CT for Suspected Nephrolithiasis: Letters to the Editor
G. Gender disparities in
cardiac evaluation
Male
physicians appear less likely to utilize stress testing in female patients even
after controlling for objective clinical variables, including TIMI score.
Although adverse outcomes are uncommon in this patient cohort, further
investigation into provider-specific practice patterns based on patient gender
is necessary.
H. Initial validation of
the International Crowding Measure in EDs (ICMED) to measure emergency
department crowding
I. Anticoagulation Drug
Therapy: A Review
Historically,
most patients who required parenteral anticoagulation received heparin, whereas
those patients requiring oral anticoagulation received warfarin. Due to the
narrow therapeutic index and need for frequent laboratory monitoring associated
with warfarin, there has been a desire to develop newer, more effective
anticoagulants. Consequently, in recent years many novel anticoagulants have
been developed.
The
emergency physician may institute anticoagulation therapy in the short term
(e.g. heparin) for a patient being admitted, or may start a novel
anticoagulation for a patient being discharged. Similarly, a patient on a novel
anticoagulant may present to the emergency department due to a hemorrhagic
complication. Consequently, the emergency physician should be familiar with the
newer and older anticoagulants. This review emphasizes the indication, mechanism
of action, adverse effects, and potential reversal strategies for various
anticoagulants that the emergency physician will likely encounter. [West J
Emerg Med. 2015;16(1):–0.]
J. Should
Triple Rule-Out CT Angiography Be Used in Patients With Suspected Acute
Coronary Artery Disease, Aortic Dissection, or Pulmonary Embolus?
Landry A, et
al Ann Emerg Med 2015;65: 216–217
Take home: Triple
rule-out computed tomographic (CT) angiography is accurate for detecting
coronary artery disease; however, the evidence is insufficient to support the
routine use of triple rule-out CT to diagnose aortic dissection and pulmonary
embolism.
K. Acute Idiopathic
Compartment Syndrome of the Forearm in an Adolescent
L. What's the Optimal
Period of Rest After Pediatric Concussion?
Thomas
DG et al. Pediatrics 2015 Jan 5.
Patients
assigned to 5 days of strict rest reported more symptoms over the 10-day study
period than those assigned to usual care.
M. Clinical practice
guideline on diagnosis and treatment of hyponatraemia
