1. Challenging the AAP 2014 Bronchiolitis Guidelines: Bonfire of
the Evidence
Walsh P, et
al. West J Emerg Med 2015;16:85-88.
The American
Academy of Pediatrics (AAP) 2014 Bronchiolitis guidelines (the guidelines) were
recently published in the official journal of the AAP, Pediatrics.1 The
committee that wrote the guidelines anticipates that these will form the basis
of bronchiolitis treatment throughout the house of medicine, not just in
pediatricians’ offices. Emergency physicians may well encounter pressure to
follow these guidelines from their pediatric colleagues who, not unreasonably,
rely on guidelines from their professional organization.
However, two
key recommendations in these guidelines could substantially change pediatric
emergency medicine practice. These recommendations are (1) to not use even a trial
of bronchodilators and (2) to regard oxygen saturations of 90% rather than
92%-94% as the degree of hypoxia at which oxygen should be administered.
Neither of
these recommendations is sufficiently justified by the evidence and both are
potentially harmful…
Full-text
(free): http://www.escholarship.org/uc/item/5w50g08m#
2. Diagnosing Acute HF in Patients with Undifferentiated
Dyspnea: A Lung and Cardiac Ultrasound (LuCUS) Protocol.
Russell FM,
et al. Acad Emerg Med. 2015 Feb;22(2):182-91.
OBJECTIVES:
The primary goal of this study was to determine accuracy for diagnosing acutely
decompensated heart failure (ADHF) in the undifferentiated dyspneic emergency
department (ED) patient using a lung and cardiac ultrasound (LuCUS) protocol.
Secondary objectives were to determine if US findings acutely change management
and if findings are more accurate than clinical gestalt.
METHODS: This
was a prospective, observational study of adult patients presenting to the ED
with undifferentiated dyspnea. The intervention consisted of a 12-view LuCUS
protocol performed by experienced emergency physician sonographers. The primary
objective was measured by comparing US findings to the final diagnosis
independently determined by two physicians blinded to the LuCUS result. Acute
treatment changes based on US findings were tracked in real time through a
standardized data collection form.
RESULTS: Data
on 99 patients were analyzed; ADHF was the final diagnosis in 36%. The LuCUS
protocol had sensitivity of 83% (95% confidence interval [CI] = 67% to 93%),
specificity of 83% (95% CI = 70% to 91%), positive likelihood ratio of 4.8 (95%
CI = 2.7 to 8.3), and negative likelihood ratio of 0.20 (95% CI = 0.09 to
0.42). Forty-seven percent of patients had changes in acute management, and 42%
had changes in acute treatment. Observed agreement for the LuCUS protocol was
93% between coinvestigators. Overall, accuracy improved by 20% (83% vs. 63%,
95% CI = 8% to 31% for the difference) over clinical gestalt alone.
CONCLUSIONS:
The LuCUS protocol may accurately identify ADHF and may improve acute clinical
management in dyspneic ED patients. This protocol has improved diagnostic
accuracy over clinical gestalt alone.
3. A randomized trial of icatibant in ACE-inhibitor-induced
angioedema.
Baş M, et al.
N Engl J Med. 2015 Jan 29;372(5):418-25.
BACKGROUND
Angioedema
induced by treatment with angiotensin-converting–enzyme (ACE) inhibitors
accounts for one third of angioedema cases in the emergency room; it is usually
manifested in the upper airway and the head and neck region. There is no
approved treatment for this potentially life-threatening condition.
METHODS
In this
multicenter, double-blind, double-dummy, randomized phase 2 study, we assigned
patients who had ACE-inhibitor–induced angioedema of the upper aerodigestive
tract to treatment with 30 mg of subcutaneous icatibant, a selective bradykinin
B2 receptor antagonist, or to the current off-label standard therapy consisting
of intravenous prednisolone (500 mg) plus clemastine (2 mg). The primary
efficacy end point was the median time to complete resolution of edema.
RESULTS
All 27
patients in the per-protocol population had complete resolution of edema. The
median time to complete resolution was 8.0 hours (interquartile range, 3.0 to
16.0) with icatibant as compared with 27.1 hours (interquartile range, 20.3 to
48.0) with standard therapy (P=0.002). Three patients receiving standard
therapy required rescue intervention with icatibant and prednisolone; 1 patient
required tracheotomy. Significantly more patients in the icatibant group than
in the standard-therapy group had complete resolution of edema within 4 hours
after treatment (5 of 13 vs. 0 of 14, P=0.02). The median time to the onset of
symptom relief (according to a composite investigator-assessed symptom score)
was significantly shorter with icatibant than with standard therapy (2.0 hours
vs. 11.7 hours, P=0.03). The results were similar when patient-assessed symptom
scores were used.
CONCLUSIONS
Among
patients with ACE-inhibitor–induced angioedema, the time to complete resolution
of edema was significantly shorter with icatibant than with combination therapy
with a glucocorticoid and an antihistamine. (Funded by Shire and the Federal
Ministry of Education and Research of Germany; ClinicalTrials.gov
number,NCT01154361.)
4. Transfuse Plasma, Platelets, and Red Blood Cells in a 1:1:1
Ratio in Trauma Patients
Daniel J. Pallin, MD, MPH reviewing Holcomb JB et al.
JAMA 2015 Feb 3.
Compared with a 1:1:2 ratio, the 1:1:1 ratio improved
hemostasis without causing more adverse effects, although mortality did not
differ.
In recent years, the dogma regarding large-volume
crystalloid resuscitation in trauma patients has changed, with increased
emphasis on including plasma and platelets in addition to red blood cells in
the immediate resuscitation protocol (NEJM JW Emerg Med May 8 2009 and NEJM JW
Emerg Med Oct 8 2014). The long-awaited PROPPR trial compared the safety and
efficacy of transfusion of plasma, platelets, and red blood cells in a 1:1:1
ratio versus a 1:1:2 ratio in 680 severely injured patients presenting to 12
North American trauma centers.
Mortality at 24 hours and 30 days (the primary outcomes)
did not differ significantly between the 1:1:1 group and the 1:1:2 group (13%
and 17% at 24 hours; 22% and 26% at 30 days). Significantly fewer patients in
the 1:1:1 group exsanguinated (9.2% vs. 14.6%) and significantly more patients
in the 1:1:1 group achieved hemostasis (86% vs. 78%). There were no significant
differences between groups in incidence of acute respiratory distress syndrome,
multiple organ failure, venous thromboembolism, sepsis, transfusion-related
complications, or other adverse effects.
5. Differentiation between traumatic tap and aneurysmal SAH:
prospective cohort study.
Perry JJ, et
al. BMJ. 2015 Feb 18;350:h568.
OBJECTIVES:
To describe the findings in cerebrospinal fluid from patients with acute
headache that could distinguish subarachnoid hemorrhage from the effects of a
traumatic lumbar puncture.
DESIGN: A
substudy of a prospective multicenter cohort study.
SETTING: 12
Canadian academic emergency departments, from November 2000 to December 2009.
PARTICIPANTS:
Alert patients aged over 15 with an acute non-traumatic headache who underwent
lumbar puncture to rule out subarachnoid hemorrhage.
MAIN OUTCOME
MEASURE: Aneurysmal subarachnoid hemorrhage requiring intervention or resulting
in death.
RESULTS: Of
the 1739 patients enrolled, 641 (36.9%) had abnormal results on cerebrospinal
fluid analysis with more than 1×10(6)/L red blood cells in the final tube of
cerebrospinal fluid and/or xanthochromia in one or more tubes. There were 15
(0.9%) patients with aneurysmal subarachnoid hemorrhage based on abnormal
results of a lumbar puncture. The presence of fewer than 2000×10(6)/L red blood
cells in addition to no xanthochromia excluded the diagnosis of aneurysmal
subarachnoid hemorrhage, with a sensitivity of 100% (95% confidence interval
74.7% to 100%) and specificity of 91.2% (88.6% to 93.3%).
CONCLUSION:
No xanthochromia and red blood cell count below 2000×10(6)/L reasonably
excludes the diagnosis of aneurysmal subarachnoid hemorrhage. Most patients
with acute headache who meet this cut off will need no further investigations
and aneurysmal subarachnoid hemorrhage can be excluded as a cause of their
headache.
6. Effect of an ED Fast Track on Press-Ganey Patient
Satisfaction Scores
Hwang CE, et
al. West J Emerg Med 12015;16:34-38.
Introduction:
Mandated patient surveys have become an integral part of Medicare remuneration,
putting hundreds of millions of dollars in funding at risk. The Centers for
Medicare & Medicaid Services (CMS) recently announced a patient experience
survey for the emergency department (ED). Development of an ED Fast Track,
where lower acuity patients are rapidly seen, has been shown to improve many of
the metrics that CMS examines. This is the first study examining if ED Fast
Track implementation affects Press-Ganey scores of patient satisfaction.
Methods: We
analyzed returned Press-Ganey questionnaires from all ESI 4 and 5 patients seen
11AM - 11PM, August-December 2011 (pre-fast track), and during the identical
hours of fast track, August-December 2012. Raw ordinal scores were converted to
continuous scores for paired student t-test analysis. We calculated an odds
ratio with 100% satisfaction considered a positive response.
Results: An
academic ED with 52,000 annual visits had 140 pre-fast track and 85 fast track
respondents. Implementation of a fast track significantly increased patient
satisfaction with the following: wait times (68% satisfaction to 88%, OR 4.13,
95% CI [2.32-7.33]), doctor courtesy (90% to 95%, OR 1.97, 95% CI [1.04-3.73]),
nurse courtesy (87% to 95%, OR 2.75, 95% CI [1.46-5.15]), pain control (79% to
87%, OR 2.13, 95% CI [1.16-3.92]), likelihood to recommend (81% to 90%, OR
2.62, 95% CI [1.42-4.83]), staff caring (82% to 91%, OR 2.82, 95% CI
[1.54-5.19]), and staying informed about delays (66% to 83%, OR 3.00, 95% CI
[1.65-5.44]).
Conclusion:
Implementation of an ED Fast Track more than doubled the odds of significant
improvements in Press-Ganey patient satisfaction metrics and may play an important
role in improving ED performance on CMS benchmarks.
Full-text
(free): http://www.escholarship.org/uc/item/0zw7297z#
7. Survival to Hospital Discharge after Out-Of-Hospital Cardiac
Arrest Is Increasing
Unadjusted
survival to hospital discharge among adults increased from 8.2% in 2006 to
10.4% in 2010.
Daya MR, et
al. Out-of-hospital cardiac arrest survival improving over time: Results from
the Resuscitation Outcomes Consortium (ROC). Resuscitation. 2015 Feb 9 [Epub
ahead of print].
BACKGROUND:
Out-of-hospital cardiac arrest (OHCA) remains a leading cause of death and a
2010 meta-analysis concluded that outcomes have not improved over several
decades. However, guidelines have changed to emphasize CPR quality,
minimization of interruptions, and standardized post-resuscitation care. We
sought to evaluate whether OHCA outcomes have improved over time among agencies
participating in the Resuscitation Outcomes Consortium (ROC) cardiac arrest
registry (Epistry) and randomized clinical trials (RCTs).
METHODS:
Observational cohort study of 47,148 EMS-treated OHCA cases in Epistry from 139
EMS agencies at 10 ROC sites that participated in at least one RCT between
1/1/2006 and 12/31/2010. We reviewed patient, scene, event characteristics, and
outcomes of EMS-treated OHCA over time, including subgroups with initial rhythm
of pulseless ventricular tachycardia or ventricular fibrillation (VT/VF).
RESULTS: Mean
response interval, median age and male proportion remained similar over time.
Unadjusted survival to discharge increased between 2006 and 2010 for treated
OHCA (from 8.2% to 10.4%), as well as for subgroups of VT/VF (21.4% to 29.3%)
and bystander witnessed VT/VF (23.5% to 30.3%). Compared with 2006, adjusted
survival to discharge was significantly higher in 2010 for treated cases
(OR=1.72; 95% CI 1.53, 1.94), VT/VF cases (OR=1.69; 95% CI 1.45, 1.98) and
bystander witnessed VT/VF cases (OR=1.65; 95% CI 1.36, 2.00). Tests for trend
in each subgroup were significant (p less than 0.001).
CONCLUSIONS:
ROC-wide survival increased significantly between 2006 and 2010. Additional
research efforts are warranted to identify specific factors associated with
this improvement.
8. Underuse of pregnancy testing for women prescribed
teratogenic medications in the ED
Goyal MK, et
al. Acad Emerg Med. 2015 Feb;22(2):192-6.
OBJECTIVES:
The objectives were to estimate the frequency of pregnancy testing in emergency
department (ED) visits by reproductive-aged women administered or prescribed
teratogenic medications (Food and Drug Administration categories D or X) and to
determine factors associated with nonreceipt of a pregnancy test.
METHODS: This
was a retrospective cross-sectional study using 2005 through 2009 National Hospital
Ambulatory Medical Care Survey data of ED visits by females ages 14 to 40
years. The number of visits was estimated where teratogenic medications were
administered or prescribed and pregnancy testing was not conducted. The
association of demographic and clinical factors with nonreceipt of pregnancy
testing was assessed using multivariable logistic regression.
RESULTS: Of
39,859 sampled visits, representing an estimated 141.0 million ED visits by
reproductive-aged females nationwide, 10.1 million (95% confidence interval
[CI] = 8.9 to 11.3 million) estimated visits were associated with
administration or prescription of teratogenic medications. Of these, 22.0% (95%
CI = 19.8% to 24.2%) underwent pregnancy testing. The most frequent teratogenic
medications administered without pregnancy testing were benzodiazepines (52.2%;
95% CI = 31.1% to 72.7%), antibiotics (10.7%; 95% CI = 5.0% to 16.3%), and
antiepileptics (7.7%; 95% CI = 0.12% to 15.5%). The most common diagnoses
associated with teratogenic drug prescription without pregnancy testing were
psychiatric (16.1%; 95% CI = 13.6% to 18.6%), musculoskeletal (12.7%; 95% CI =
10.8% to 14.5%), and cardiac (9.5%; 95% CI = 7.6% to 11.3%). In multivariable
analyses, visits by older (adjusted odds ratio [AOR] = 0.57, 95% CI = 0.42 to
0.79), non-Hispanic white females (AOR = 0.71; 95% CI = 0.54 to 0.93); visits
in the Northeast region (AOR = 0.60; 95% CI = 0.42 to 0.86); and visits during
which teratogenic medications were administered in the ED only (AOR = 0.74; 95%
CI = 0.57 to 0.97) compared to prescribed at discharge only were less likely to
have pregnancy testing.
CONCLUSIONS:
A minority of ED visits by reproductive-aged women included pregnancy testing
when patients were prescribed category D or X medications. Interventions are
needed to ensure that pregnancy testing occurs before women are prescribed
potentially teratogenic medications, as a preventable cause of infant
morbidity.
9. HA in Traumatic Brain Injuries from Blunt Head Trauma.
Dayan PS, et
al. for the Pediatric Emergency Care Applied Research Network (PECARN).
Pediatrics. 2015 Feb 2 [Epub ahead of print]
OBJECTIVE: To
determine the risk of traumatic brain injuries (TBIs) in children with
headaches after minor blunt head trauma, particularly when the headaches occur
without other findings suggestive of TBIs (ie, isolated headaches).
METHODS: This
was a secondary analysis of a prospective observational study of children 2 to
18 years with minor blunt head trauma (ie, Glasgow Coma Scale scores of 14-15).
Clinicians assessed the history and characteristics of headaches at the time of
initial evaluation, and documented findings onto case report forms. Our outcome
measures were (1) clinically important TBI (ciTBI) and (2) TBI visible on
computed tomography (CT).
RESULTS: Of
27 495 eligible patients, 12 675 (46.1%) had headaches. Of the 12 567 patients
who had complete data, 2462 (19.6%) had isolated headaches. ciTBIs occurred in
0 of 2462 patients (0%; 95% confidence interval [CI]: 0%-0.1%) in the isolated
headache group versus 162 of 10 105 patients (1.6%; 95% CI: 1.4%-1.9%) in the
nonisolated headache group (risk difference, 1.6%; 95% CI: 1.3%-1.9%). TBIs on
CT occurred in 3 of 456 patients (0.7%; 95% CI: 0.1%-1.9%) in the isolated
headache group versus 271 of 6089 patients (4.5%; 95% CI: 3.9%-5.0%) in the
nonisolated headache group (risk difference, 3.8%; 95% CI: 2.3%-4.5%). We found
no significant independent associations between the risk of ciTBI or TBI on CT
with either headache severity or location.
CONCLUSIONS:
ciTBIs are rare and TBIs on CT are very uncommon in children with minor blunt
head trauma when headaches are their only sign or symptom.
10. A simple tool to predict admission at the time of triage.
Cameron A, et
al. Emerg Med J. 2015 Mar;32(3):174-9
AIM: To
create and validate a simple clinical score to estimate the probability of
admission at the time of triage.
METHODS: This
was a multicentre, retrospective, cross-sectional study of triage records for
all unscheduled adult attendances in North Glasgow over 2 years. Clinical
variables that had significant associations with admission on logistic
regression were entered into a mixed-effects multiple logistic model. This
provided weightings for the score, which was then simplified and tested on a separate
validation group by receiving operator characteristic (ROC) analysis and
goodness-of-fit tests.
RESULTS:
215 231 presentations were used for model derivation and 107 615 for
validation. Variables in the final model showing clinically and statistically
significant associations with admission were: triage category, age, National
Early Warning Score (NEWS), arrival by ambulance, referral source and admission
within the last year. The resulting 6-variable score showed excellent
admission/discharge discrimination (area under ROC curve 0.8774, 95% CI 0.8752
to 0.8796). Higher scores also predicted early returns for those who were
discharged: the odds of subsequent admission within 28 days doubled for every
7-point increase (log odds=+0.0933 per point, p less than 0.0001).
CONCLUSIONS:
This simple, 6-variable score accurately estimates the probability of admission
purely from triage information. Most patients could accurately be assigned to
'admission likely', 'admission unlikely', 'admission very unlikely' etc., by setting
appropriate cut-offs. This could have uses in patient streaming, bed management
and decision support. It also has the potential to control for demographics
when comparing performance over time or between departments.
A simple tool
to predict admission at the time of triage
Table 4
Admission prediction score
|
Variable
|
Points
|
|
|
Age
|
1 point per decade
|
|
|
NEWS
|
1 point per point on NEWS score
|
|
|
Triage category:
|
3
|
5
|
|
2 (or 3+)
|
10
|
|
|
1
|
20
|
|
|
Referred by GP
|
10
|
|
|
Arrived in ambulance
|
5
|
|
|
Admitted less
than 1 year ago
|
5
|
NEWS, National Early
Warning Score.
Full-text
(free): http://emj.bmj.com/content/32/3/174.long
11. Images in Clinical Practice
Young Male with
Rapidly Swelling Jaw
Young Man with
Shortness of Breath and Why Does Your Dandruff Smell Like Urine?
Young Man with
Pain in Finger
Myxedema
Contagious
Ecthyma
Acute
Lymphangitis
Lung
Herniation with Coughing
Complications
of New Medications
Tense Bullae
and Urticaria in a Woman in Her Sixties
12. Ultrasound Corner
A. Ultrasound guidance versus
anatomical landmarks for subclavian or femoral vein catheterization
On the basis
of available data, we conclude that two-dimensional ultrasound offers small
gains in safety and quality when compared with an anatomical landmark technique
for subclavian (arterial puncture, haematoma formation) or femoral vein
(success on the first attempt) cannulation for central vein catheterization.
Data on insertion by inexperienced or experienced users, or on patients at high
risk for complications, are lacking. The results for Doppler ultrasound
techniques versus anatomical landmark techniques are uncertain.
B. The Utility of Transvaginal
Ultrasound in the ED Evaluation of Complications of First Trimester Pregnancy
Panebianco
NL, et al. Am J Emerg Med 2015 Feb 20 [Epub ahead of print]
Background
For patients
with early intrauterine pregnancy (IUP) the sonographic signs of the gestation
may be below the resolution of transabdominal ultrasound (TAU), however may be
identified by transvaginal ultrasound (TVU). We sought to determine how often
TVU performed in the ED (ED TVU) reveals a viable IUP after a nondiagnostic ED
TAU. and the impact of ED TVU on patient length of stay (LOS.
Methods
This was a
retrospective cohort study of women presenting to our ED with complications of
early pregnancy from 01/01/2007 to 02/28/2009 in a single urban adult ED.
Abstractors recorded clinical and imaging data in a database. Patient imaging
modality and results were recorded and compared with respect to ultrasound (US)
findings and LOS.
Results
Of 2,429
subjects identified, 795 required TVU as part of their care. ED TVU was
performed in 528 patients, and 267 went to radiology (RAD). ED TVU identified a
viable IUP in 261 patients (49.6%). Patients having initial ED US had shorter
LOS that patients with initial RAD US (median 4.0 vs. 6.0 hours; p less than 0.001).
ED LOS was shorter for women who had ED TVU performed compared to those sent
for RAD TVU regardless of the findings of the US (median 4.9 vs. 6.7 hours p less
than 0.001). There was no increased LOS for patients who needed further
radiology US after an indeterminate ED TVU (7.0 vs. 7.1 hours; p=0.43). There
was no difference in LOS for those who had a viable IUP confirmed on ED TAU vs
ED (median 3.1 vs 3.2 hours respectively; p less than 0.32).
Conclusion
When an ED
TVU was performed, a viable IUP was detected 49.6% of the time. ED LOS was
significantly shorter for women who received ED TVU after indeterminate ED TAU
compared to those sent to radiology for TVU, with more marked time savings
among those with live IUP diagnosed on ED TVU. For patients who do not receive
a definitive diagnosis of IUP on ED TVU, this approach does not result in
increased LOS.
C. The utility of IVC diameter and the
degree of inspiratory collapse in patients with systolic HF
Besli F, et
al. Am J Emerg Med 2015 Feb 9 [Epub ahead of print]
Introduction
Both inferior
vena cava (IVC) diameter and the degree of inspiratory collapse are used in the
estimation of right atrial pressure.
Aim
The purpose
of this study is to evaluate the utility of IVC diameter, using
echocardiography as a marker of volume overload and the relationship between
these parameters and N-terminal pro-B natriuretic peptide (NT-proBNP) in
patients with systolic heart failure (HF).
Methods
We included 136
consecutive patients with systolic HF (left ventricular ejection fraction, less
than 50%), including 80 patients with acutely decompensated HF and 56 patients
with compensated HF as well as 50 subjects without a diagnosis of HF. All
patients underwent transthoracic echocardiography to assess both their IVC
diameters and the degree of inspiratory collapse (≥50%, less than 50%, and no
change [absence] groups); NT-proBNP levels were measured, and these data were
compared between the 2 groups.
Results
Inferior vena
cava diameter and NT-proBNP were significantly higher among the patients with
HF than among the control subjects (21.7 ± 2.6 vs 14.5 ± 1.6 mm, P less than
.001 and 4789 [330-35000] vs 171 [21-476], P less than .001). The mean IVC
diameter was higher among the patients with decompensated HF than among the
patients with compensated HF (23.2 ± 2.1 vs 19.7 ± 1.9 mm, P less than .001).
The values of NT-proBNP were associated with different collapsibility of IVC
subgroups among HF patients. The NT-proBNP levels were 2760 (330-27336), 5400
(665-27210), and 16806 (1786-35000), regarding the collapsibility of the IVC
subgroups: greater than or equal to 50%, less than 50%, and absence groups, P less
than .001, respectively, among HF patients. There was a significant positive
correlation between IVC diameter and NT-proBNP (r = 0.884, P less than .001). A
cut off value of an IVC diameter greater than or equal to 20.5 mm predicted a
diagnosis of compensated HF with a sensitivity of 90% and a specificity of 73%.
Conclusions
Inferior vena
cava diameter correlated significantly with NT-proBNP in patients with HF.
Inferior vena cava diameter may be a useful variable in determining a patient's
volume status in the setting of HF and may also enable clinicians to
distinguish patients with decompensated HF from those with compensated HF.
D. A Review of Lawsuits Related to
Point-of-Care Emergency Ultrasound Applications
Stolz L, et
al. West J Emerg Med 2015;16:1-4.
Introduction:
New medical technology brings the potential of lawsuits related to the usage of
that new technology. In recent years the use of point-of-care (POC) ultrasound
has increased rapidly in the emergency department (ED). POC ultrasound creates
potential legal risk to an emergency physician (EP) either using or not using
this tool. The aim of this study was to quantify and characterize reported
decisions in lawsuits related to EPs performing POC ultrasound.
Methods: We
conducted a retrospective review of all United States reported state and
federal cases in the Westlaw database. We assessed the full text of reported
cases between January 2008 and December 2012. EPs with emergency ultrasound
fellowship training reviewed the full text of each case. Cases were included if
an EP was named, the patient encounter was in the emergency department, the
interpretation or failure to perform an ultrasound was a central issue and the
application was within the American College of Emergency Physician (ACEP)
ultrasound core applications. In order to assess deferred risk, cases that
involved ultrasound examinations that could have been performed by an EP but
were deferred to radiology were included.
Results: We
identified five cases. All reported decisions alleged a failure to perform an
ultrasound study or a failure to perform it in a timely manner. All studies
were within the scope of emergency medicine and were ACEP emergency ultrasound
core applications. A majority of cases (n=4) resulted in a patient death. There
were no reported cases of failure to interpret or misdiagnoses.
Conclusion:
In a five-year period from January 2008 through December 2012, five malpractice
cases involving EPs and ultrasound examinations that are ACEP core emergency
ultrasound applications were documented in the Westlaw database. All cases were
related to failure to perform an ultrasound study or failure to perform a study
in a timely manner and none involved failure to interpret or misdiagnosis when
using of POC ultrasound.
Full-text
(free): http://www.escholarship.org/uc/item/8jz5x3w2#
E. Half-dose Alteplase for Sub-massive
PE Directed by ED Point-of-care Ultrasound
Amini R, et
al. West J Emerg Med. 2015;16:181-183.
This report
describes a patient with sub-massive pulmonary embolism (PE) who was
successfully treated with half-dose thrombolytics guided by the use of
point-of-care (POC) ultrasound. In this case, POC ultrasound was the only
possible imaging since computed tomography was contraindicated. POC ultrasound
demonstrated a deep vein thrombosis and evidence of cardiac strain. In
situations or locations where definitive imaging is unobtainable, POC
ultrasound can help diagnose submassive PE and direct the use of half-dose
tissue plasminogen activator.
Full-text
(free): http://www.escholarship.org/uc/item/0b7598kc#
13. A comparison of acute treatment regimens for pediatric migraine
in the ED
Bachur RG, et
al. Pediatrics. 2015 Feb;135(2):232-8.
BACKGROUND
AND OBJECTIVES: Migraine headache is a common pediatric complaint among
emergency department (ED) patients. There are limited trials on abortive
therapies in the ED. The objective of this study was to apply a comparative
effectiveness approach to investigate acute medication regimens for the
prevention of ED revisits.
METHODS:
Retrospective study using administrative data (Pediatric Health Information
System) from 35 pediatric EDs (2009-2012). Children aged 7 to 18 years with a
principal diagnosis of migraine headache were studied. The primary outcome was
a revisit to the ED within 3 days for discharged patients. The primary analysis
compared the treatment regimens and individual medications on the risk for
revisit.
RESULTS: The
study identified 32 124 children with migraine; 27 317 (85%) were discharged,
and 5.5% had a return ED visit within 3 days. At the index visit, the most
common medications included nonopioid analgesics (66%), dopamine antagonists
(50%), diphenhydramine (33%), and ondansetron (21%). Triptans and opiate
medications were administered infrequently (3% each). Children receiving
metoclopramide had a 31% increased odds for an ED revisit within 3 days
compared with prochlorperazine. Diphenhydramine with dopamine antagonists was
associated with 27% increased odds of an ED revisit compared with dopamine
antagonists alone. Children receiving ondansetron had similar revisit rates to
those receiving dopamine antagonists.
CONCLUSIONS:
The majority of children with migraines are successfully discharged from the ED
and only 1 in 18 required a revisit within 3 days. Prochlorperazine appears to
be superior to metoclopramide in preventing a revisit, and diphenhydramine use
is associated with increased rates of return.
14. Ann Emerg Med
Evidence-based Reviews
A. Should Nerve Blocks Be Used for
Pain Control in Children With Femur Fractures?
Take-home: Although
nerve blocks show potential to be a superior method of pain control in children
with femur fractures, the available evidence is limited. No definitive
conclusion or recommendation can be made until higher-quality studies are
performed.
B. Does Endovascular Therapy Benefit
Patients With Acute Ischemic Stroke?
Take-home: In
management of acute ischemic stroke, there is no evidence that endovascular
therapy improves functional outcomes over that achieved with intravenous tissue
plasminogen activator (tPA).
C. What Physical Examination Findings
and Diagnostic Imaging Modalities Are Most Useful in the Diagnosis of Scaphoid
Fractures?
Take-home: When
a patient with acute wrist pain is evaluated, the absence of snuffbox
tenderness substantially decreases the probability of a scaphoid fracture.
Alternatively, to definitively diagnose a scaphoid fracture, advanced imaging
such as computed tomography (CT) or magnetic resonance imaging (MRI) may be
necessary.
D. Are Antibiotics Beneficial for the
Treatment of Symptomatic Dental Infections?
Take-home: There
is insufficient evidence to draw a conclusion about the benefit or harm
associated with prescribing antibiotics for symptomatic dental infections.
15. Outcome after resuscitation beyond 30 minutes in drowned
children with cardiac arrest and hypothermia: Dutch nationwide retrospective
cohort study.
Kieboom JK, BMJ.
2015 Feb 10;350:h418
OBJECTIVES:
To evaluate the outcome of drowned children with cardiac arrest and
hypothermia, and to determine distinct criteria for termination of
cardiopulmonary resuscitation in drowned children with hypothermia and absence
of spontaneous circulation.
DESIGN:
Nationwide retrospective cohort study.
SETTING:
Emergency departments and paediatric intensive care units of the eight
university medical centres in the Netherlands.
PARTICIPANTS:
Children aged up to 16 with cardiac arrest and hypothermia after drowning, who
presented at emergency departments and/or were admitted to intensive care.
MAIN OUTCOME
MEASURE: Survival and neurological outcome one year after the drowning
incident. Poor outcome was defined as death or survival in a vegetative state
or with severe neurological disability (paediatric cerebral performance
category (PCPC) ≥4).
RESULTS: From
1993 to 2012, 160 children presented with cardiac arrest and hypothermia after
drowning. In 98 (61%) of these children resuscitation was performed for more
than 30 minutes (98/160, median duration 60 minutes), of whom 87 (89%) died
(95% confidence interval 83% to 95%; 87/98). Eleven of the 98 children survived
(11%, 5% to 17%), but all had a PCPC score ≥4. In the 62 (39%) children who did
not require prolonged resuscitation, 17 (27%, 16% to 38%) survived with a PCPC
score ≤3 after one year: 10 (6%) had a good neurological outcome (score 1),
five (3%) had mild neurological disability (score 2), and two (1%) had moderate
neurological disability (score 3). From the original 160 children, only 44 were
alive at one year with any outcome.
CONCLUSIONS:
Drowned children in whom return of spontaneous circulation is not achieved
within 30 minutes of advanced life support have an extremely poor outcome. Good
neurological outcome is more likely when spontaneous circulation returns within
30 minutes of advanced life support, especially when the drowning incident
occurs in winter. These findings question the therapeutic value of
resuscitation beyond 30 minutes in drowned children with cardiac arrest and
hypothermia.
Full-text
(free): http://www.bmj.com/content/350/bmj.h418
16. Pediatric Cervical Spine Injury Evaluation after Blunt
Trauma: A Clinical Decision Analysis.
Hannon M, et
al. Ann Emerg Med. 2015;65: 239–247.
STUDY
OBJECTIVE: Although many adult algorithms for evaluating cervical spine injury
use computed tomography (CT) as the initial screening modality, this may not be
appropriate in low-risk children, considering radiation risks. We determine the
optimal initial evaluation strategy for cervical spine injury in pediatric
blunt trauma.
METHODS: We
constructed a decision analysis tree for a hypothetical population of patients
younger than 19 years with blunt trauma, using 3 strategies: clinical stratification,
screening radiographs followed by focused CT if the radiograph result was
positive, and CT. For the model inputs, we used the current literature to
determine the probabilities of cervical spine injury and estimate the long-term
risks of malignancy after CT, as well as test characteristics of radiographic
imaging. We used published utilities and conducted 1- and 2-way sensitivity
analyses to determine the optimal strategy for evaluation of pediatric cervical
spine injury.
RESULTS: In
our model of a population with blunt trauma, the expected value of a clinical
stratification strategy was the highest of the 3 strategies, making it the
overall preferred management. One-way sensitivity analysis of several
contributing factors revealed that the only independent factor that altered the
dominant strategy was the sensitivity of clinical clearance criteria, lowering
the threshold at which screening-radiograph strategy is optimal. Within the
patient population considered as having non-negligible risk by clinical
stratification and thus requiring imaging, the preferred imaging modality was
screening radiograph/focused CT. The probability of cervical spine injury above
which CT became the preferred strategy was 24.9%.
CONCLUSION:
The model highlights that clinical clearance and screening radiographs in a
hypothetical trauma pediatric population are preferred strategies, whereas CT
scanning is rarely the initial optimal evaluation.
17. ED Intubations Are Increasingly Successful
First-pass ED
intubation success increased from 80% in 2002 to 86% in 2012, with concomitant
increases in the use of video laryngoscopy and rocuronium.
Brown CA, et
al. Techniques, Success, and Adverse Events of Emergency Department Adult
Intubations. Ann Emerg Med. 2014 Dec 19 [Epub ahead of print].
STUDY
OBJECTIVE: We describe the operators, techniques, success, and adverse event
rates of adult emergency department (ED) intubation through multicenter
prospective surveillance.
METHODS:
Eighteen EDs in the United States, Canada, and Australia recorded intubation
data onto a Web-based data collection tool, with a greater than or equal to 90%
reporting compliance requirement. We report proportions with binomial 95%
confidence intervals (CIs) and regression, with year as the dependent variable,
to model change over time.
RESULTS: Of
18 participating centers, 5 were excluded for failing to meet compliance
standards. From the remaining 13 centers, we report data on 17,583 emergency
intubations of patients aged 15 years or older from 2002 to 2012. Indications
were medical in 65% of patients and trauma in 31%. Rapid sequence intubation
was the first method attempted in 85% of encounters. Emergency physicians
managed 95% of intubations and most (79%) were physician trainees. Direct
laryngoscopy was used in 84% of first attempts. Video laryngoscopy use
increased from less than 1% in the first 3 years to 27% in the last 3 years
(risk difference 27%; 95% CI 25% to 28%; mean odds ratio increase per year [ie,
slope] 1.7; 95% CI 1.6 to 1.8). Etomidate was used in 91% and succinylcholine
in 75% of rapid sequence intubations. Among rapid sequence intubations,
rocuronium use increased from 8.2% in the first 3 years to 42% in the last 3
years (mean odds ratio increase per year 1.3; 95% CI 1.3 to 1.3). The first-attempt
intubation success rate was 83% (95% CI 83% to 84%) and was higher in the last
3 years than in the first 3 (86% versus 80%; risk difference 6.2%; 95% CI 4.2%
to 7.8%). The airway was successfully secured in 99.4% of encounters (95% CI
99.3% to 99.6%).
CONCLUSION:
In the EDs we studied, emergency intubation has a high and increasing success
rate. Both drug and device selection evolved significantly during the study
period.
18. The effect of traumatic LP on hospitalization rate for
febrile infants 28 to 60 days of age.
Pingree EW,
et al. Acad Emerg Med. 2015 Feb;22(2):240-3.
OBJECTIVES:
The authors measured the effect of a traumatic or unsuccessful lumbar puncture
(LP) on the management of febrile infants.
METHODS: This
was a 10-year retrospective cross-sectional study of low-risk infants by the
"Boston" criteria 28 to 60 days of age presenting to the emergency
department for evaluation of fever. "Normal LP" infants had
cerebrospinal fluid (CSF) WBC less than 10 × 10(6) cells/L.
"Traumatic" or "unsuccessful LP" infants had CSF red blood
cell count ≥ 10 × 10(9) cells/L or no CSF cell counts obtained, respectively. A
serious bacterial infection (SBI) was defined as growth of a bacterial pathogen
from culture. The hospitalization and SBI rates were compared between infants
with normal versus traumatic or unsuccessful LPs.
RESULTS: Of
the 929 study infants, 756 (81.4%) had normal LPs, and 173 (18.6%) had
traumatic or unsuccessful LPs. Infants with traumatic or unsuccessful LPs had a
higher hospitalization rate (72.3% traumatic or unsuccessful LP vs. 18.1%
normal LP; difference = 54.1%; 95% confidence interval [CI] = 46.4% to 60.8%),
but a similar SBI rate (2.9% vs. 4.1%; difference = 1.2%; 95% CI = -2.7% to
3.6%). No infant had proven bacterial meningitis (0% risk, 95% CI = 0 to 0.3%).
CONCLUSIONS:
Low-risk infants aged 28 to 60 days with traumatic or unsuccessful LPs are more
frequently hospitalized, although SBI rates were similar to those of infants
with normal LPs.
19. Dispelling an urban legend: frequent ED users have
substantial burden of disease.
Billings J,
Raven MC. Health Aff (Millwood). 2013;32(12):2099-108.
Urban legend
has often characterized frequent emergency department (ED) patients as mentally
ill substance users who are a costly drain on the health care system and who
contribute to ED overcrowding because of unnecessary visits for conditions that
could be treated more efficiently elsewhere.
This study of
Medicaid ED users in New York City shows that behavioral health conditions are
responsible for a small share of ED visits by frequent users, and that ED use
accounts for a small portion of these patients' total Medicaid costs. Frequent
ED users have a substantial burden of disease, and they have high rates of
primary and specialty care use. They also have linkages to outpatient care that
are comparable to those of other ED patients. It is possible to use predictive
modeling to identify who will become a repeat ED user and thus to help target
interventions. However, policy makers should view reducing frequent ED use as
only one element of more-comprehensive intervention strategies for frequent
health system users.
20. WebM&M: Morbidity and Mortality Cases on the Web by AHRQ
A. The Case
of an IO Line Misadventure
A 72-year-old
woman with a history of asthma, congestive heart failure, and medication
noncompliance presented to the emergency department with 2 weeks of lower
extremity edema, fatigue, and progressively worsening dyspnea. She reported
shortness of breath at rest and with exertion, as well as a dry cough. On
initial examination, she was wheezing and had notable right lower extremity
erythema and bilateral lower extremity pitting edema greater on the right side
with weeping from her skin. She was admitted for asthma exacerbation and lower
extremity cellulitis. She improved with fluids, albuterol nebulizers,
methylprednisolone, and ceftriaxone/doxycycline. During her next 2 hospital
days, she had a lower extremity ultrasound that was negative for a deep vein
thrombosis and a transthoracic echocardiogram that was normal except for
biatrial enlargement.
At midnight
of her second hospital day, the patient's son noted that his mother was feeling
dizzy. Four hours later, the patient suddenly became bradycardic to a heart
rate of 20 beats per minute. Walking to the bathroom, she was notably dyspneic,
with an oxygen saturation of 87%. She then became unresponsive. Her initial
rhythm was pulseless electrical activity. During the code, a senior resident
placed an intraosseous (IO) line in the left tibia following several
unsuccessful attempts to obtain peripheral venous access. After 10 minutes of
chest compressions and advanced cardiovascular life support protocol,
spontaneous circulation returned and the patient was transferred to the
intensive care unit (ICU).
Three hours
after the IO line was placed, a nurse notified the primary team that the left
leg was a dusky purple, and on examination the leg was bluish and tensely
edematous with sluggish distal pulses. Vascular surgery diagnosed compartment
syndrome, removed the IO line, and performed a bedside fasciotomy later that
morning. The fasciotomy wounds were slow to heal and required ongoing complex
care. After 2 months in the ICU and multiple complications, the patient was
discharged.
The Commentary
by Raymond L.
Fowler, MD, and Melanie J. Lippmann, MD (July/August 2014)
Vascular
access is a cornerstone of modern medical therapeutics. In a crisis situation,
particularly one in which large volumes of fluids or vasoactive medications are
required, physicians have been trained to access the vascular system through
large veins in the neck or groin. Yet, particularly when the blood pressure or
volume is low, or in children, intravenous (IV) access can be difficult, and
many patients have died over the years because of inability to achieve access
in a timely way.
Placing a
vascular access device directly into the marrow cavity for medical treatment
dates as far back as the 1920s.(1) These devices were used during World War II
for the treatment of shock (2), but later fell out of favor in many countries
until their reintroduction in the United States to pediatric resuscitations in
the late 1980s. Their resurgence in adult medicine lagged and only regained
popularity in the past decade.(3) The modern development of rapid and
easy-to-use intraosseous (IO) placement devices has recently placed IO access
within the grasp of the broad realm of advanced life support providers.(4)
The technique
of IO line placement is now a well-accepted component of modern advanced life
support algorithms.(3) Intraosseous access requires either drilling or punching
through the bone cortex and placing a hollow needle in the marrow cavity,
within which is a rich network of marrow vasculature that will rapidly
transport fluids and medications into the vascular system at large (Figure).
Generally, the penetrated bony cortex holds the IO device firmly, making the
line more difficult to accidentally displace (though displacements may occur).
After
establishing a favorable safety and efficacy profile, IO access is endorsed as
a preferred first alternative to failed IV access by numerous professional
bodies including the American Heart Association (AHA), American College of
Emergency Physicians (ACEP), International Liaison Committee on Resuscitation
(ILCOR), and National Association of EMS Physicians (NAEMSP). Intraosseous
access placement by nonphysician providers is commonly employed and is proven
to be time-saving in emergency resuscitation cases that frequently arise in
both the prehospital and emergency department settings.(3,5)
B. Pitfalls in Diagnosing Necrotizing
Fasciitis
A 49-year-old
previously healthy man presented to the emergency department (ED) after falling
from his truck at work 3 days before. He had gone to a different ED the day
prior with diffuse pain on his left side (the side of his impact) and was given
nonsteroidal anti-inflammatory medications and sent home. He presented to this
new ED with persistent and worsening left arm, chest, abdomen, and thigh pain.
On physical
examination, he was afebrile but tachycardic. He had diffuse, tender ecchymoses
involving his left shoulder, upper chest, lateral abdomen, and thigh. Although
the ED physicians felt he had simple bruising from the fall, they noted that he
was in severe pain requiring intravenous (IV) opiates and that he was unable to
independently ambulate. Because of these symptoms, blood tests were obtained
and results showed a white blood cell count of 2.8 × 109/L (normal range:
3.5–10.5 × 109/L) and acute renal insufficiency with a creatinine of 1.4 mg/dL
(normal range: 0.6–1.2 mg/dL). A computed tomography scan of the abdomen and
pelvis showed "induration in the left quadriceps muscle and fluid layering
in the abdominal wall." He was seen by the trauma surgical service, who
felt the findings were due to diffuse bruising. The patient was admitted to an
internal medicine service.
Due to ED
crowding, he remained in the ED overnight, receiving only IV fluids and opiates
for his pain. Over the course of the night, his pain worsened and he had a
persistent tachycardia. Early morning lab results showed a white blood cell
count of 1.6 × 109/L, a creatinine of 1.6 mg/dL, a creatine kinase of 2650 U/L
(normal range 55–170 U/L) (evidence of muscle breakdown), and a lactate of 6.2
mg/dL (normal range 0.5–2.2 mmol/L) (evidence of tissue hypoxia). He was seen
by the internal medicine team mid-morning and diagnosed with rhabdomyolysis
from trauma and acute renal failure. He continued to receive IV fluids. His
pain had become so severe that he was switched to hydromorphone hydrochloride,
administered through a patient-controlled analgesia pump.
Later that
day, the patient had progressive respiratory distress and developed septic
shock. He was re-evaluated by the surgical service and felt to have probable
necrotizing fasciitis with pyomyositis. He was urgently taken to the operating
room, where he required debridement of 7300 cm/sq (an area roughly 2 ft by 4
ft) of skin and soft tissue from his left arm and axilla, anterior chest wall,
abdominal wall, thigh, and leg.
After
surgery, he was progressively hypotensive despite multiple vasopressors. He
developed multi-organ dysfunction and ultimately, after discussions with his
family, care was withdrawn and he died peacefully. He underwent autopsy, which
showed necrotizing fasciitis with pyomyositis secondary to
methicillin-resistant Staphylococcus aureus.
Commentary by
Terence Goh, MBBS, and Lee Gan Goh, MBBS
Infections of
the skin and soft tissues are incredibly common in pediatric and adult
medicine. The classic presentation of erythema, warmth, edema, tenderness, and
fever may suggest such an infection. However, physicians must also be mindful
of other non-infective diseases that can mimic skin and soft tissue infections
(SSTIs), including drug eruptions, foreign body reactions, gout, deep vein
thrombosis, contact dermatitis, and muscle contusion. SSTIs involve suppurative
bacterial or fungal invasion of the epidermis, dermis, or subcutaneous tissues
and can range in severity from benign to very serious (as in this case). An
expert panel (1) has classified skin infections into four classes of severity to
help guide treatment. The classes range from simple cellulitis (class 1) to
life-threatening infections such as necrotizing fasciitis (class 4). This case
provides an opportunity to focus on necrotizing fasciitis as this diagnosis is
often missed or delayed with devastating consequences…
21. New Study Brings NIH Attention to Bear on ED Crowding
Millard WB.
Ann Emerg Med 2015;65:A11–A15.
Crowding, the
bane of any emergency department (ED), has been recognized as a nationwide
problem and a marker of an individual hospital's performance quality.
Anecdotally, patients who face delays in receiving emergency care describe it
as one of the worst aspects of the hospital experience; published accounts
since the 1980s have translated those subjective impressions into quantitative
terms. Crowding is more than a contributor to patients' dissatisfaction; it
correlates with poorer clinical outcomes.
Yet as
serious and prevalent as the problem is, it has been a relatively low priority
at the National Institutes of Health (NIH) until recently.
Benjamin C.
Sun, MD, MPP, associate professor of emergency medicine at Oregon Health &
Science University in Portland, is now leading a large NIH-supported study of
possible solutions to crowding in different types and sizes of hospitals.
The
$3.8-million, 5-year, R01 grant is funded by the National Heart, Lung, and
Blood Institute.
Using data
from the Centers for Medicare & Medicaid Services’ Hospital Compare survey
of more than 4,000 Medicare-certified hospitals, Dr. Sun and colleagues at
Oregon Health & Science University's Center for Policy and Research in
Emergency Medicine are pursuing a 2-phase investigation, first profiling
hospitals' performance according to Hospital Compare's metrics for ED
throughput and then analyzing practices used at 4 to 12 high-performing
hospitals to determine what measures effectively control boarding times and
length of stay under different conditions.
The first
phase is approaching completion, Dr. Sun reported, and recruitment for the
second is under way; once second-phase work begins, the Center for Policy and
Research in Emergency Medicine team aims to complete interviews by December
2015, with publishable results appearing around mid-2016. This study should add
several important elements to the knowledge base on crowding, including scale,
methodologic and statistical sophistication, and attention to practical
solutions, as well as causes. It also marks a milestone in the ability of the
Office of Emergency Care Research, a relatively new entity within the National
Institute of General Medical Sciences, to help emergency medicine investigators
address clinically relevant aspects of hospital organization with the rigor
that NIH branches have long brought to basic biomedical topics.
“There's a
body of evidence that suggests that emergency department crowding is dangerous
to patient safety,” noted Dr. Sun. Specialists outside and inside NIH agree
that the new study is promising and timely, appearing in a context in which
specific causes and remedies of crowding require increasingly detailed
attention…
22. Micro Bits
A. PBS News: How the response to Ebola
here and abroad has improved our infrastructure and tactics
B. ED Transfers and Transfer Relationships
in United States Hospitals
Dana
Kindermann Sax et al. Acad Emerg Med 2015
C. Depilatory agents dissolve hair
under tension within minutes. However, they do not dissolve cotton, polyester,
and rayon even after many hours of application.
D. Efficacy and Safety of
Out-of-Hospital IV Metoprolol Administration in Anterior ST-Segment Elevation
AMI: Insights from the METOCARD-CNIC Trial
E. Take your prophylactic aspirin at
night
Morning
platelet reactivity scores associated with preventive aspirin are lower when
patients take the medication at night to reduce risks of a second stroke and
heart disease, compared with a morning dose, according to a study from the
Netherlands. Researchers did not find a difference in 24-hour ambulatory blood
pressure rates between patients who took the aspirin in the morning or evening.
F. Nutrition committee urges Americans
to cut back on sugar
The Dietary
Guidelines Advisory Committee on Thursday eased some restrictions on
cholesterol and fat intake, stating that Americans should focus more on eating
patterns rather than individual nutrients. The panel also stressed that
Americans are consuming too much added sugar and recommended a daily intake of roughly
12 teaspoons.
NYTs article:
http://well.blogs.nytimes.com/2015/02/19/nutrition-panel-calls-for-less-sugar-and-eases-cholesterol-and-fat-restrictions/
G. 2 antibiotics may lead to GI
condition in newborns, study finds
Newborns
given oral azithromycin and erythromycin may be at increased risk of the
gastrointestinal condition pyloric stenosis, researchers from the Uniformed
Services University of the Health Sciences reported in Pediatrics. The study
found the biggest risk comes in the first two weeks of life, with reduced risk
for babies ages 2 weeks to 6 weeks.
H. Divorce among U.S. Physicians
Divorce among
physicians is less common than among non-healthcare workers and several health
professions. Female physicians have a substantially higher prevalence of
divorce than male physicians, which may be partly attributable to a
differential effect of hours worked on divorce.
Full-text
(free): http://www.bmj.com/content/350/bmj.h706
I. Anticoagulation Drug Therapy: A
Review
Written for
the emergency physician.
Full-text
(free): http://www.escholarship.org/uc/item/8kc1p3rt#page-1
J. Bad is more powerful than good: The
nocebo response
K. Daily Pill? No Thanks, I'll Take
Early Death
One-third of
survey respondents preferred shortened lifespan to daily cardiovascular meds.
L. Anticholinergics may increase
dementia risk, study says
University of
Washington research identified a dose-response relationship between
anticholinergic drugs and the risk of dementia. The 3,434-person population
study in JAMA Internal Medicine said even low doses taken over long periods of
time were linked with increased rates of dementia compared with not taking the
drugs at all.
M. Study: 4.6% of elderly hospitalized
after ED discharge
A study from
the University of California, Los Angeles, found 4.6% of Medicare beneficiaries
discharged from a hospital emergency department were admitted to a hospital
within seven days. The study in the Journal of the American Geriatrics Society
linked an increased risk of admissions to diagnoses such as heart failure and
end-stage renal disease, age, skilled nursing facility use and leaving the ED
against medical advice.
