Saturday, January 24, 2015

Lit Bits: Jan 24, 2015

From the recent medical literature...

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

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.

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.

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.

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]

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.

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, number NCT00973154.

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.

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):

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.

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 ….

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. 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.

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

There is little evidence to guide physicians on management of patients who sustain head injuries while on warfarin.

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).

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.

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.

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.

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.

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.

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).

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.

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