1. Thrombolysis in acute ischaemic stroke: time for a rethink?
A. Evidence Shaky for Efficacy beyond
3 Hours
Alper BS, et
al. BMJ 2015;350:h1075
As the UK
regulator reviews alteplase in ischaemic stroke, Brian Alper and colleagues
interpret the evidence to suggest increased mortality with uncertain benefit
for its use beyond three hours
Systematic
reviews and guidelines conclude that thrombolysis with alteplase (t-PA) up to
4.5 hours after the onset of ischaemic stroke is beneficial. It is reported to
increase the likelihood of being functionally independent and not increase the
90 day risk of mortality. In the US the licence, or marketing authorisation,
for alteplase is limited to 0-3 hours after onset of stroke,1 but some other
countries—including the UK and Australia—have extended the licence to 4.5
hours.2 3 4
Irrespective of licensing, most major stroke guidelines support use
of alteplase up to 4.5 hours after stroke onset,5 6 7 8 9 10 11 12 13 14 15 16
although several emergency medicine associations do not recommend it (box).17
18 19 20 21
We believe
that current guidance is based on uncertain evidence and that urgent
reconsideration of the available data is essential to guide policy decisions on
use of alteplase to manage acute stroke. In the UK the Medicines and Healthcare
Regulatory Agency is planning to establish an expert working group to analyse
all relevant sources of evidence and reassess the balance of benefits and risks
for alteplase.22
We examined
the most comprehensive sources of evidence and advice that working clinicians
are likely to turn to for guidance on whether to use alteplase after stroke: a
national clinical practice guideline published in 2013,5 the Cochrane review
updated in 2014,23 and an individual patient data meta-analysis published in
2014.24 Each of these sources suggests that alteplase is more beneficial than
harmful when given 3-4.5 hours after the onset of ischaemic stroke. We tried to
verify the data supporting these conclusions. We do not examine evidence or
recommendations for the use of alteplase up to three hours after stroke…
The remainder
of the review (full-text free): http://www.bmj.com/content/350/bmj.h1075
B. ACEP — Minus the Neurologists —
Tempers its tPA Policy
Shaw G. Emerg Med News.
2015;37(3):1,33
A draft of a
new clinical policy from the American College of Emergency Physicians (ACEP)
takes a much more conservative approach on using intravenous tPA for managing
acute ischemic stroke in the emergency department than the current guidelines,
which were approved in 2012.
Those guidelines
provoked a fair amount of controversy, with some emergency physicians saying
the treatment was too risky and had little potential for benefit. (“The
‘Biggest, Baddest’ Controversy in EM,” EMN 2013;35[4]:1; http://bit.ly/EMN12.)
A year later,
an article in the British Medical Journal questioned the reliability of
the guidelines, calling them more industry marketing than tools of
evidence-based medicine. (2013;346:f3830.) That report also questioned some of
the committee members' conflicts of interest, some undeclared, and the
“committee stacking” of the joint American Academy of Neurology-ACEP panel with
experts with known viewpoints on a particular side of an issue. Seven of eight
members of the AAN-ACEP committee, the BMJ article said, had previously
spoken or written on the benefits of tPA for stroke, and “[n]ot one skeptic was
included on the panel.” (“Conflicts of Interest on Guidelines Ramp Up tPA
Controversy,” EMN 2013;35[10]:1; http://bit.ly/1hAdtVi.)
ACEP
announced last year that it would begin working on an independent policy on tPA
for stroke, and that result, now in draft form, diverges from the policy it
formulated with the AAN. In answer to critical question 1, “Is IV tPA safe and
effective for acute ischemic stroke patients if given within 3 hours of symptom
onset?” the 2015 draft, obtained by Emergency Medicine News, offers the
following recommendations:
“Level
A recommendations. The increased risk of symptomatic intracerebral
hemorrhage (approximately 7% compared to a baseline of 1%) must be considered
when deciding whether to administer IV tPA to acute ischemic stroke patients.
“Level
B recommendations. With a goal to improve functional outcomes, IV tPA
may be given to carefully selected acute ischemic stroke patients within 3
hours after symptom onset at institutions where systems are in place to safely
administer the medication.
“Level
C recommendations. Shared decision-making between the patient (and/or
their surrogate) and a member of the healthcare team must include a discussion
of potential benefits and harms prior to the decision whether to administer IV
tPA for acute ischemic stroke. (Consensus recommendation.)” (Download the draft
at http://bit.ly/1yrT10e.)
The
front-loading of hemorrhage risk as a level A recommendation and the cautious “may
be given to carefully selected acute ischemic stroke patients” language in
the level B recommendation stand in stark contrast to the 2012 document, which
does not mention the increased risk of ICH in response to critical question 1
at all. Instead, it says: “In order to improve functional outcomes, IV tPA should
be offered to acute ischemic stroke patients who meet National Institute of
Neurological Disorders and Stroke (NINDS) inclusion/exclusion criteria and can
be treated within 3 hours after symptom onset.” (Italics added.)
Members of
the ACEP tPA policy subcommittee, chaired by Michael D. Brown, MD, MSc,
declined to comment on the draft because it is still being reviewed, and they
noted that revisions are likely before it is submitted to the ACEP Board of
Directors for consideration, something they speculated should happen by June.
Non-committee
members, however, weren't reluctant to share their opinions. David Newman, MD,
the director of clinical research in emergency medicine at Mt. Sinai School of
Medicine in New York City, praised the draft as a “tremendous improvement” in
process and content.
“The process
of developing this policy has been and is transparent. Anybody can take a good
look at how the document was developed step-by-step, and that wasn't the case
before,” he said. “This is an immense leap forward, and I think everybody's
happy about that, whether they agree or disagree with the actual product.
People are happy that the process adheres to the IOM's standards for the
development of clinical practice guidelines.” …
The remainder
of the essay is here: http://journals.lww.com/em-news/Fulltext/2015/03000/Breaking_News__ACEP___Minus_the_Neurologists__.2.aspx
2. Lost in Translation: Physician Understanding and
Communication of Risk to Patients with Possible ACS Is Unacceptable and in Dire
Need of Resuscitation
Hess EP. Ann
Emerg Med. 2015 Mar 6 [Epub ahead of print]
In this (forthcoming)
issue of Annals, Newman et al1 (link to abstract below) reports the results of
a matched-pair survey study designed to assess risk communication between
physicians and patients being admitted to the hospital for possible acute
coronary syndrome. Four hundred twenty-five such patients and their physicians
completed matched-pair surveys querying perceived and communicated current risk
for myocardial infarction and future risk of mortality from myocardial
infarction at home versus in the hospital. Post hoc application of risk
prediction models on the patient cohort indicated a mean risk for death or
myocardial infarction of less than 2% within 30 days. Physicians’ median
estimate of 30-day adverse event risk was 5% (95% confidence interval 3% to
7%), and patients’ median estimate was 8% (95% confidence interval 5% to 11%).
Despite physicians’ lower median estimate of risk, 63% of patients reported
that their estimate of risk remained the same or increased after speaking with
their physician. Patients’ median estimate of mortality risk after myocardial
infarction was 80% if they were to go home and 10% if they were to stay in the
hospital; physicians corresponding risk estimates were 15% and 10%,
respectively. So not only did both physicians and patients substantially
overestimate the current risk of myocardial infarction and future risk of
mortality but also the data suggest poor physician communication in that
agreement between patients and physicians did not improve after discussion.
What is one
to make of these data? Despite several validated approaches to assessing
patients’ short-term risk of major adverse cardiac events that are readily
available and feasible to calculate,2-5 physicians’ risk estimates in this
study were grossly inaccurate. These data suggest that physicians are not using
validated prediction models in their usual clinical practice. In the absence of
reliable, quantifiable risk estimates to guide decisionmaking, by process of
elimination other factors must be influencing decisionmaking in regard to
patients with possible acute coronary syndrome, such as one’s usual pattern of
practice, local practice protocols, and fear of litigation, in addition to
other potentially perverse factors such as financial incentives.
Not only were
physicians’ risk estimates inaccurate but also they were not effectively
communicated to their patients. Risk communication in a busy emergency
department (ED) setting to patients with various levels of health literacy and
education who may have a different cultural and ethnic background than their
provider is far from straightforward. Both physicians and patients may have difficulty
understanding and using numeric information, leading to what has been referred
to as “collective statistical illiteracy.”6 Furthermore, in part because of
patients’ difficulty with health literacy and numeracy, physicians often resort
to using verbal qualifiers when communicating risk (eg, your future risk of
heart attack is “low”), and studies have shown that interpretation of these
imprecise terms is highly variable.7 For example, low risk to a physician might
mean less than 5%, whereas to a patient it might mean less than 25%. Though
beyond the scope of this editorial to describe in detail, there are several
evidence-based approaches for risk communication of health information, such as
use of absolute rather than relative risks, diagrams and pictographs to
communicate risk and benefit information, and a consistent denominator when
comparing risk and benefits of alternative management strategies, among
others.8
Risk
communication is a key element of shared decisionmaking, a collaborative
process in which patients and providers make health care decisions together,
taking into account the best scientific evidence available, as well as the
patient’s values and preferences.9 To facilitate shared decisionmaking for
patients with possible acute coronary syndrome, Newman et al1 suggests that
calibration of physician risk to improve accuracy is a key component.
Developing approaches that facilitate accurate risk communication and
comprehension and allaying patient anxiety before engaging them in the decisionmaking
process are also critical.
Decision
aids, interventions or tools that facilitate shared decisionmaking and patient
engagement in health care decisions have been developed for a number of medical
conditions and decisions, some of which are frequently encountered in the ED
setting.10-12 They have been shown to increase patient knowledge, increase the
accuracy of risk perception, and decrease patients’ uncertainty related to
feeling uninformed.13 Standards for decision aid design have been developed in
an effort to overcome several of the challenges pointed out by the current
investigation,14 including physician comprehension of risk, risk communication
using evidence-based approaches, and transparent communication of the risks and
benefits of alternative management strategies to patients. Additional work is
needed to determine which decisions in the ED setting are appropriate for
shared decisionmaking, to prioritize these conditions according to their
potential effect, and to develop and test contextually sensitive approaches to
risk communication.
3. Outcomes in presyncope patients: a prospective cohort study.
Thiruganasambandamoorthy
V, et al. Ann Emerg Med. 2015;65(3):268-276.e6
Serious
adverse events were noted in 5% of all patients presenting to the ED with
presyncope and in 2% of those discharged to home.
STUDY
OBJECTIVE: Presyncope is the sudden onset of a sense of impending loss of
consciousness without losing consciousness (which differentiates it from
syncope). Our goals are to determine the frequency of emergency department (ED)
presyncope visits, management, 30-day outcomes, and emergency physicians'
outcome prediction.
METHODS: Our
prospective study at 2 academic EDs included adults with presyncope and
excluded patients with syncope, mental status changes, seizure, and significant
trauma. We collected patient characteristics, ED management, cause (vasovagal,
orthostatic, cardiac, or unknown) at the end of the ED visit, and 30-day
outcomes. Serious outcomes included death, arrhythmia, myocardial infarction,
structural heart disease, pulmonary embolism, and hemorrhage. We also collected
physicians' confidence in assigning the cause and their prediction probability
for 30-day serious outcomes.
RESULTS:
Presyncope constituted 0.5% of ED visits. We enrolled 881 patients: mean age
55.5 years, 55.9% women, and 4.7% hospitalized. Among 780 patients with 30-day
follow-up, 40 (5.1%) experienced serious outcomes: death 0.3%, cardiovascular
3.1%, and noncardiac 1.8%. Of the 840 patients discharged home, 740 had
follow-up data and 14 patients (1.9%) experienced serious outcomes after ED
disposition. The area under the receiver operating characteristic curve for
physician prediction probability was 0.58 (95% confidence interval 0.38 to
0.78). The incidence of serious outcomes was similar, whereas physician
diagnostic confidence and prediction probability varied among the 4 causal
groups.
CONCLUSION:
Presyncope can be caused by serious underlying conditions. Emergency physicians
had difficulty predicting patients at risk for serious outcomes after ED
discharge. Future studies are needed to identify risk factors for serious
outcomes after ED disposition.
4. Endovascular Therapy for Ischemic Stroke Finally Looks Good
A. Endovascular Therapy for Ischemic
Stroke with Perfusion-Imaging Selection.
Campbell BC, et
al; EXTEND-IA Investigators. N Engl J Med. 2015 Mar 12;372(11):1009-1018.
Background
Trials of
endovascular therapy for ischemic stroke have produced variable results. We
conducted this study to test whether more advanced imaging selection, recently
developed devices, and earlier intervention improve outcomes.
Methods
We randomly
assigned patients with ischemic stroke who were receiving 0.9 mg of alteplase
per kilogram of body weight less than 4.5 hours after the onset of ischemic
stroke either to undergo endovascular thrombectomy with the Solitaire FR (Flow
Restoration) stent retriever or to continue receiving alteplase alone. All the
patients had occlusion of the internal carotid or middle cerebral artery and
evidence of salvageable brain tissue and ischemic core of less than 70 ml on
computed tomographic (CT) perfusion imaging. The coprimary outcomes were
reperfusion at 24 hours and early neurologic improvement (≥8-point reduction on
the National Institutes of Health Stroke Scale or a score of 0 or 1 at day 3).
Secondary outcomes included the functional score on the modified Rankin scale
at 90 days.
Results
The trial was
stopped early because of efficacy after 70 patients had undergone randomization
(35 patients in each group). The percentage of ischemic territory that had
undergone reperfusion at 24 hours was greater in the endovascular-therapy group
than in the alteplase-only group (median, 100% vs. 37%; P less than 0.001).
Endovascular therapy, initiated at a median of 210 minutes after the onset of
stroke, increased early neurologic improvement at 3 days (80% vs. 37%, P=0.002)
and improved the functional outcome at 90 days, with more patients achieving
functional independence (score of 0 to 2 on the modified Rankin scale, 71% vs.
40%; P=0.01). There were no significant differences in rates of death or
symptomatic intracerebral hemorrhage.
Conclusions
In patients
with ischemic stroke with a proximal cerebral arterial occlusion and
salvageable tissue on CT perfusion imaging, early thrombectomy with the
Solitaire FR stent retriever, as compared with alteplase alone, improved
reperfusion, early neurologic recovery, and functional outcome.
B. Randomized Assessment of Rapid
Endovascular Treatment of Ischemic Stroke.
Goyal M, et
al. N Engl J Med. 2015 Mar 12;372(11):1019-1030.
Background
Among
patients with a proximal vessel occlusion in the anterior circulation, 60 to
80% of patients die within 90 days after stroke onset or do not regain
functional independence despite alteplase treatment. We evaluated rapid
endovascular treatment in addition to standard care in patients with acute
ischemic stroke with a small infarct core, a proximal intracranial arterial
occlusion, and moderate-to-good collateral circulation.
Methods
We randomly
assigned participants to receive standard care (control group) or standard care
plus endovascular treatment with the use of available thrombectomy devices
(intervention group). Patients with a proximal intracranial occlusion in the
anterior circulation were included up to 12 hours after symptom onset. Patients
with a large infarct core or poor collateral circulation on computed tomography
(CT) and CT angiography were excluded. Workflow times were measured against
predetermined targets. The primary outcome was the score on the modified Rankin
scale (range, 0 [no symptoms] to 6 [death]) at 90 days. A proportional odds
model was used to calculate the common odds ratio as a measure of the
likelihood that the intervention would lead to lower scores on the modified
Rankin scale than would control care (shift analysis).
Results
The trial was
stopped early because of efficacy. At 22 centers worldwide, 316 participants
were enrolled, of whom 238 received intravenous alteplase (120 in the
intervention group and 118 in the control group). In the intervention group,
the median time from study CT of the head to first reperfusion was 84 minutes.
The rate of functional independence (90-day modified Rankin score of 0 to 2)
was increased with the intervention (53.0%, vs. 29.3% in the control group; P less
than 0.001). The primary outcome favored the intervention (common odds ratio,
2.6; 95% confidence interval, 1.7 to 3.8; P less than 0.001), and the
intervention was associated with reduced mortality (10.4%, vs. 19.0% in the
control group; P=0.04). Symptomatic intracerebral hemorrhage occurred in 3.6%
of participants in intervention group and 2.7% of participants in control group
(P=0.75).
Conclusions
Among
patients with acute ischemic stroke with a proximal vessel occlusion, a small
infarct core, and moderate-to-good collateral circulation, rapid endovascular
treatment improved functional outcomes and reduced mortality.
C. Christmas Comes Early for
Endovascular Therapy in Stroke
Radecki R. EM Lit of Note. Posted February 12, 2015
…Conclusion
The key
take-home, however, is endovascular therapy for acute stroke has probably
finally arrived. After a
decade-and-a-half of generally failed trials, it seems the devices and patient
selection have finally improved to the point of clinical utility. For patients with collateral flow and one of
these accessible lesions, it seems clear this therapy should be provided – and
neither time of onset or tPA use matter as much as viable brain tissue. But the obvious key, as shown in MR-CLEAN, is
patient selection – ESCAPE only managed to enroll 1.4 patients per month per
center, while EXTEND-IA screened 7,798 stroke patients over two years to come
up with 70. This therapy is very much so
not for everyone – though, no doubt, Covidien hopes it will become so beyond
the eligibility population identified here.
But, for the
first time ever, if I were to have one of these specific types of heavily
disabling strokes, this is probably the first advanced stroke intervention I'd
willingly choose.
The full
discussion (free): http://www.emlitofnote.com/2015/02/christmas-comes-early-for-endovascular.html
5. Better performance on length-of-stay benchmarks associated
with reduced risk following ED discharge: an observational cohort study
Schull M, et
al. CJEM 2015 Feb 09 [Epub ahead of print]
Introduction
Emergency department (ED) crowding is associated with adverse outcomes. Several
jurisdictions have established benchmarks and targets for length-of-stay (LOS)
to reduce crowding. An evaluation has been conducted on whether performance on
Ontario’s ED LOS benchmarks is associated with reduced risk of death or
hospitalization.
Methods A
retrospective cohort study of discharged ED patients was conducted using
population-based administrative data from Ontario (April 2008 to February
2012). For each ED visit, the proportion of patients seen during the same shift
that met ED LOS benchmarks was determined. Performance was categorized as less
than 80%, 80% to 90%, 90% to 95%, and 95%–100% of same-shift ED patients
meeting the benchmark. Logistic regression models analysed the association
between performance on ED LOS benchmarks and 7-day death or hospitalization,
controlled for patient and ED characteristics and stratified by patient acuity.
Results From
122 EDs, 2,295,256 high-acuity and 1,626,629 low-acuity visits resulting in
discharge were included. Deaths and hospitalizations within 7 days totalled
1,429 (0.062%) and 49,771 (2.2%) among high-acuity, and 220 (0.014%) and 9,005
(0.55%) among low-acuity patients, respectively. Adverse outcomes generally
increased among patients seen during shifts when a lower proportion of ED
patients met ED LOS benchmarks. The adjusted odds ratios (and 95% confidence
intervals) among high- and low-acuity patients seen on shifts when less than 80%
met ED benchmarks (compared with ≥95%) were, respectively, 1.32 (1.05–1.67) and
1.84 (1.21–2.81) for death, and 1.13 (1.08–1.17) and 1.40 (1.31–1.49) for
hospitalization.
Conclusions
Better performance on Ontario’s ED LOS benchmarks for each shift is associated
with a 10%–45% relative reduction in the odds of death or admission 7 days
after ED discharge.
Full-text
(free): http://dx.doi.org/10.1017/cem.2014.39 Then select pdf or HTML for full-text.
6. The Use of Subdissociative-dose Ketamine for Acute Pain in
the ED.
Sin B, et al.
Acad Emerg Med. 2015 Mar;22(3):251-7.
OBJECTIVES:
Ketamine is a well-known anesthetic with its use trailing back to the 1960s. It
has antagonistic effects at the N-methyl-d-aspartate receptor. There is
emerging literature to suggest the use of subdissociative-dose ketamine (SDDK)
for pain reduction. This evidence-based review evaluates the evidence regarding
the use of SDDK for acute pain control in the emergency department (ED).
METHODS: The
MEDLINE and EMBASE databases were searched. Randomized controlled trials (RCTs)
that described or evaluated the use of SDDK for acute pain in the ED were
included. Literature was excluded if it was not published in English. Duplicate
articles, unpublished reports, abstracts, and review articles were also
excluded. Quality assessment and evaluation of literature were evaluated based
on the GRADE criteria. The primary outcome of interest in this review was the
difference in pain score from baseline to cutoff time as specified in the
studies. Secondary outcome measures were the incidence of adverse events and
reduction in the amount of adjuvant opioids consumed by patients who received
SDDK.
RESULTS: Four
RCTs met the inclusion criteria, which enrolled a total of 428 patients. Three
adult trials and one pediatric trial were identified. The level of evidence for
the individual trials ranged from low to moderate. A significant reduction in
pain scores was only found in two of the four trials. One trial found a
significant reduction in mean pain scores when ketamine was compared to
morphine (p less than 0.05). Another trial reported a significant decrease in
mean distress scores, favoring SDDK over fentanyl (1.0 vs. 2.7, p less than
0.05). One trial found a significant reduction in the amount of morphine
consumed, favoring ketamine over placebo (0.14 mg/kg, 95% confidence interval
[CI] = 0.13 to 0.16 mg/kg vs. 0.2 mg/kg, 95% CI = 0.18 to 0.22 mg/kg; p less
than 0.001). An emergence phenomenon was reported in one trial.
CONCLUSIONS:
Four RCTs with methodologic limitations failed to provide convincing evidence
to either support or refute the use of SDDK for acute pain control in the ED.
7. Changes in ED Use among Young Adults after the Patient
Protection and Affordable Care Act’s Dependent Coverage Provision
Antwi YA, et
al. Ann Emerg Med. 2015 Mar 10 [Epub ahead of print]
Study
objective
Since
September 2010, the Patient Protection and Affordable Care Act has allowed
young adults to remain as dependents on their parents’ private health plans
until age 26 years. This insurance expansion could improve the efficiency of
medical care delivery by reducing unnecessary emergency department (ED) use. We
evaluated the effect of this provision on ED use among young adults.
Methods
We used a
nationally representative ED visit database of more than 17 million visits from
2007 to 2011. Our analysis compared young adults aged 19 to 25 years (the age
group targeted by the law) with slightly older adults aged 27 to 29 years
(control group), before and after the implementation of the law.
Results
The quarterly
ED-visit rate decreased by 1.6 per 1,000 population (95% confidence interval
1.2 to 2.1) among targeted young adults after the implementation of the
provision, relative to a comparison group. The decrease was concentrated among
women, weekday visits, nonurgent conditions, and conditions that can be treated
in other settings. We found no effect among weekend visits or visits due to
injuries or urgent conditions. The provision also changed the health insurance
composition of ED visits; the fraction of privately insured young adults
increased, whereas the fraction of those insured through Medicaid and those
uninsured decreased.
Conclusion
The Patient
Protection and Affordable Care Act dependent coverage expansion was associated
with a statistically significant yet modest decrease in ED use, concentrated in
the types of ED visits that were likely to be responsive to changes to insurance
status. In response to the law, young adults appeared to have altered their
visit pattern to reflect a more efficient use of medical care.
8. Comparative effectiveness of diagnostic testing strategies in
ED patients with CP: an analysis of downstream testing, interventions, and
outcomes.
Foy AJ, et
al. JAMA Intern Med. 2015 Mar 1;175(3):428-36.
IMPORTANCE:
Patients presenting to the emergency department (ED) with chest pain whose
evaluation for ischemia demonstrates no abnormalities receive further
functional or anatomical studies for coronary artery disease; however,
comparative evidence for the various strategies is lacking and multiple testing
options exist.
OBJECTIVE: To
compare chest pain evaluation pathways based on their association with
downstream testing, interventions, and outcomes for patients in EDs.
DESIGN,
SETTING, AND PARTICIPANTS: Retrospective analysis of health insurance claims
data for a national sample of privately insured patients from January 1 to
December 31, 2011. Individuals with a primary or secondary diagnosis of chest
pain in the ED were selected and classified into 1 of 5 testing strategies: no
noninvasive testing, exercise electrocardiography, stress echocardiography,
myocardial perfusion scintigraphy, or coronary computed tomography angiography.
MAIN OUTCOMES
AND MEASURES: The proportion of patients in each group who received a cardiac
catheterization, coronary revascularization procedure, or future noninvasive
test as well as those who were hospitalized for an acute myocardial infarction
(MI) during 7 and 190 days of follow-up.
RESULTS: In
2011, there were 693 212 ED visits with a primary or secondary diagnosis of
chest pain, accounting for 9.2% of all ED encounters. After application of the
inclusion and exclusion criteria, 421 774 patients were included in the final
analysis; 293 788 individuals did not receive an initial noninvasive test and
127 986 did, representing 1.7% of all ED encounters. Overall, the percentage of
patients hospitalized with an MI was very low during both 7 and 190 days of
follow-up (0.11% and 0.33%, respectively). Patients who did not undergo initial
noninvasive testing were no more likely to experience an MI than were those who
did receive testing. Compared with no testing, exercise electrocardiography,
myocardial perfusion scintigraphy, and coronary computed tomography angiography
were associated with significantly higher odds of cardiac catheterization and
revascularization procedures without a concomitant improvement in the odds of
experiencing an MI.
CONCLUSIONS
AND RELEVANCE: Patients with chest pain evaluated in the ED who do not have an
MI are at very low risk of experiencing an MI during short- and longer-term
follow-up in a cohort of privately insured patients. This low risk does not
appear to be affected by the initial testing strategy. Deferral of early noninvasive
testing appears to be reasonable.
Here’s the
opener of the related editorial:
Stress Testing in the ED: Not Which
Test but Whether Any Test Should Be Done
Redberg RF. JAMA
Intern Med. 2015;175(3):436.
Chest pain is
one of the most challenging symptoms for emergency medicine physicians to
evaluate. They must identify patients with cardiac ischemia without subjecting
all patients, the overwhelming majority of whom do not have ischemia, to
unnecessary testing. Most patients evaluated in the emergency department (ED)
for chest pain who have normal electrocardiogram findings and negative results
of cardiac biomarker tests do not have cardiac ischemia. Thus, the question
should not be what further testing to perform, but should any further testing
be done in the ED…
9. Young Patients with Suspected Uncomplicated Renal Colic are
Unlikely to Have Dangerous Alternative Diagnoses or Need Emergent Intervention
Schoenfeld
EM, et al. West J Emerg Med 2015 Mar 13 [Epub ahead of print]
Introduction:
In the United States there is debate regarding the appropriate first test for
new-onset renal colic, with non-contrast helical computed tomography (CT)
receiving the highest ratings from both Agency for Healthcare Research and
Quality and the American Urological Association. This is based not only on its
accuracy for the diagnosis of renal colic, but also its ability to diagnose
other surgical emergencies, which have been thought to occur in 10-15% of
patients with suspected renal colic, based on previous studies. In younger
patients, it may be reasonable to attempt to avoid immediate CT scan if concern
for dangerous alternative diagnosis is low, based on the risks of radiation
from CT scans, and particularly in light of evidence that patients with renal
colic have a very high likelihood of having multiple CT scans in their
lifetimes. The objective is to determine the proportion of patients with a
dangerous alternative diagnosis in adult patients age 50 and under presenting
with uncomplicated (non-infected) suspected renal colic, and also to determine
what proportion of these patients undergo emergent urologic intervention.
Methods:
Retrospective chart review of 12 months of patients age 18-50 presenting with
“flank pain,” excluding patients with end stage renal disease, urinary tract
infection, pregnancy and trauma. Dangerous alternative diagnosis was determined
by CT scan.
Results: Two
hundred and ninety-one patients met inclusion criteria. One hundred and fifteen
patients had renal protocol CT scans, and zero alternative emergent or urgent
diagnoses were identified (one-sided 95% CI 0-2.7%). Of the 291 encounters,
there were 7 urologic procedures performed upon first admission (2.4%, 95% CI
[1.0-4.9%]). The prevalence of kidney stone by final diagnosis was 58.8%.
Conclusion:
This small sample suggests that in younger patients with uncomplicated renal
colic, the benefit of immediate CT scan for suspected renal colic should be
questioned. Further studies are needed to determine which patients benefit from
immediate CT scan for suspected renal colic, and which patients could undergo
alternate imaging such as ultrasound.
Full-text
(free): http://escholarship.org/uc/item/3p36m20f#
10. Arterial puncture using insulin needle is less painful than
with standard needle: a randomized crossover study.
Ibrahim I, et
al. Acad Emerg Med. 2015 Mar;22(3):315-20.
OBJECTIVES:
Arterial punctures are important procedures performed by emergency physicians
in the assessment of ill patients. However, arterial punctures are painful and
can create anxiety and needle phobia in patients. The pain score of radial
arterial punctures were compared between the insulin needle and the standard
23-gauge hypodermic needle.
METHODS: In a
randomized controlled crossover design, healthy volunteers were recruited to
undergo bilateral radial arterial punctures. They were assigned to receive
either the insulin or the standard needle as the first puncture, using blocked
randomization. The primary outcome was the pain score measured on a 100-mm
visual analogue scale (VAS) for pain, and secondary outcomes were rate of
hemolysis, mean potassium values, and procedural complications immediately and
24 hours postprocedure.
RESULTS:
Fifty healthy volunteers were included in the study. The mean (±standard
deviation) VAS score in punctures with the insulin needle was lower than the
standard needle (23 ± 22 mm vs. 39 ± 24 mm; mean difference = -15 mm; 95%
confidence interval = -22 mm to -7 mm; p less than 0.001). The rates of
hemolysis and mean potassium value were greater in samples obtained using the
insulin needle compared to the standard needle (31.3% vs. 11.6%, p = 0.035; and
4.6 ±0.7 mmol/L vs. 4.2 ±0.5 mmol/L, p = 0.002). Procedural complications were
lower in punctures with the insulin needle both immediately postprocedure (0%
vs. 24%; p less than 0.001) and at 24 hours postprocedure (5.4% vs. 34.2%; p =
0.007).
CONCLUSIONS:
Arterial punctures using insulin needles cause less pain and fewer procedural
complications compared to standard needles. However, due to the higher rate of
hemolysis, its use should be limited to conditions that do not require a
concurrent potassium value in the same blood sample.
11. Images (and a Video) in Clinical Practice
Adult Intussusception
This report
presents the case of a 37-year-old man with multiple Emergency Department
visits for abdominal pain and with negative results for prior imaging studies,
who was eventually diagnosed with intussusception after 5 years of recurrent
symptoms. The case is followed by a review of the literature.
Cecal Diverticulitis
Descending Necrotizing Mediastinitis
in an Infant
Acute PEG Tube Erosion
Penile Fracture
Passage of a Sialolith
Femoral-Head Dislocation to the
Scrotum
Disseminated Zoster
Putting On and Removing Personal
Protective Equipment
12. Targeted temperature management: It is not yet time to
change your target temperature
Clinkarda D,
et al. CJEM 2015 Feb 05 [Epub ahead of print]
Bottom Line: Based
on previous RCTs showing survival benefit, a strong safety profile, and the
failure of this study to show superiority, a change in the current target
temperature aiming at 33°C (91.4°F) may not be warranted.
Background: Two
randomized control trials (RCTs) suggested that targeted temperature management
(TTM) (previously referred to as therapeutic hypothermia) to a target of
32°C–34°C (89.6°F–93.2°F) post-cardiac arrest is associated with improved
mortality and neurologic function in ventricular fibrillation and ventricular
tachycardia arrests.1,2 One trial failed to show the benefit from cooling
patients presenting with pulseless electrical activity (PEA) and asystole.3
Both the 2009 and 2012 Cochrane Reviews concluded: “With conventional cooling
methods... patients were 55% more likely to leave the hospital without major
brain damage.”4 However, a meta-analysis by Nielson et al.5 (2012) described
the overall quality of evidence as low and suggested that a large-scale
clinical trial should be conducted. Nielson et al.5 hypothesized that the
benefits demonstrated by TTM may come from the prevention of fever rather than
from the induction of hypothermia.5 The reviewed study was designed to evaluate
whether the degree of temperature reduction affects outcomes…
[Then follows
a review of the design, methods, and results of Nielson N, et al. Targeted
temperature management at 33°C versus 36°C after cardiac arrest. N Engl J Med
2013;369:2197-2206.]
Commentary
This study
addresses a contentious issue in post-resuscitative care of whether the
benefits of current protocols are due to hypothermia or simply fever
prevention. The trial included more TTM patients than all previous studies
combined due to an impressive international collaboration.
This
superiority trial was powered to detect an 11% absolute mortality difference
between the 36°C (96.8°F) group and the 33°C (91.4°F) group (a relative risk
reduction of 20%). A negative superiority trial should not be interpreted as
proof that no difference exists between interventions. For example, there may
have been an absolute risk reduction of 5%, but this would not have been
detected with the given sample size. An equivalence or noninferiority trial
design is necessary to correctly conclude that 33°C (91.4°F) is not better than
36°C (96.8°F).6 Failure to demonstrate superiority is not the same as proving
equivalence; therefore, the proper interpretation of this failed superiority
trial would be that there was no benefit from raising the target temperature
from 33°C (91.4°F) to 36°C (96.8°F). This finding may be the result of a number
of design features that make the 33°C (91.4°F) and 36°C (96.8°F) groups appear
similar, potentially minimizing the effect of temperature on the primary
outcome.
[Then follows
a critique of the patient population and treatment.]
Conclusions
Despite the
impressive trial size and other aforementioned strengths, clinicians should be
cautious about changing their practices from the current American Heart
Association guidelines of cooling to 32°C–34°C (89.6°F–93.2°F).8 There are now
two positive and two negative trials on the survival benefit of TTM
post-cardiac arrest, each with methodologic differences.1,2,4,9 Both negative
trials included PEA and asystolic arrests, whereas both positive trials
excluded them. This study does suggest important clinical concepts that deserve
further investigation, in particular, the optimal temperature of therapeutic
hypothermia and the acceptable delay in achieving the target temperature.
Full-text
(free): http://dx.doi.org/10.1017/cem.2014.35
Then select pdf or HTML for the full-text.
13. Outcomes of Anatomical versus Functional Testing for
Coronary Artery Disease
Douglas PS,
et al. New Engl J Med 2015 Mar 14 [Epub ahead of print]
Background
Many patients
have symptoms suggestive of coronary artery disease (CAD) and are often
evaluated with the use of diagnostic testing, although there are limited data
from randomized trials to guide care.
Methods
We randomly
assigned 10,003 symptomatic patients to a strategy of initial anatomical
testing with the use of coronary computed tomographic angiography (CTA) or to
functional testing (exercise electrocardiography, nuclear stress testing, or
stress echocardiography). The composite primary end point was death, myocardial
infarction, hospitalization for unstable angina, or major procedural
complication. Secondary end points included invasive cardiac catheterization
that did not show obstructive CAD and radiation exposure.
Results
The mean age
of the patients was 60.8±8.3 years, 52.7% were women, and 87.7% had chest pain
or dyspnea on exertion. The mean pretest likelihood of obstructive CAD was
53.3±21.4%. Over a median follow-up period of 25 months, a primary end-point
event occurred in 164 of 4996 patients in the CTA group (3.3%) and in 151 of
5007 (3.0%) in the functional-testing group (adjusted hazard ratio, 1.04; 95%
confidence interval, 0.83 to 1.29; P=0.75). CTA was associated with fewer
catheterizations showing no obstructive CAD than was functional testing (3.4%
vs. 4.3%, P=0.02), although more patients in the CTA group underwent
catheterization within 90 days after randomization (12.2% vs. 8.1%). The median
cumulative radiation exposure per patient was lower in the CTA group than in
the functional-testing group (10.0 mSv vs. 11.3 mSv), but 32.6% of the patients
in the functional-testing group had no exposure, so the overall exposure was
higher in the CTA group (mean, 12.0 mSv vs. 10.1 mSv; P less than 0.001).
Conclusions
In
symptomatic patients with suspected CAD who required noninvasive testing, a
strategy of initial CTA, as compared with functional testing, did not improve
clinical outcomes over a median follow-up of 2 years.
Full-text
(free): http://www.nejm.org/doi/full/10.1056/NEJMoa1415516#t=article
14. Comparison of long-term neurological outcomes in adults with
traumatic ICH admitted to the ICU versus the floor
Nishijima DK,
et al. West J Emerg Med 2015 March 2 [Epub ahead of print]
Background
The objective
of this study was to compare long-term neurological outcomes in low-risk
patients with traumatic intracranial hemorrhage (tICH) admitted to the ICU
versus patients admitted to the floor.
Methods This
retrospective study was conducted at a Level 1 trauma center from October 1,
2008 to February 1, 2013. We defined low-risk patients as: age less than 65
years, isolated head injury, normal admission mental status, and no shift or
swelling on initial head CT. Clinical data were abstracted from a trauma
registry and linked to a brain injury database. Extended Glasgow Outcome Scale
(GOS-E) score at six months was compared between patients admitted to the ICU
and patients admitted to the floor. We did a risk-adjusted analysis of the
influence of floor admission on a normal GOS-E.
Results
One hundred
fifty one patients were identified; 45 (30%) were admitted to the floor and 106
(70%) to the ICU. Twenty-three (51%; 95% CI 36-66%) patients admitted to the
floor and 55 (52%; 95% CI 42-62%) patients admitted to the ICU had a normal
GOS-E. On adjusted analysis, the odds ratio for floor admission was 0.77 (95%
CI 0.36-1.64) for a normal GOS-E at six months.
Conclusion
Long-term
neurological outcomes in low-risk patients with tICH were not markedly
different between patients admitted to the ICU and those admitted to the floor.
However, we were unable to demonstrate non-inferiority on adjusted analysis.
Future work aimed at a larger, prospective cohort may better evaluate the
relative impacts of admission type on outcomes.
Full-text
(free): http://escholarship.org/uc/item/0zm0b6br#
15. Four-factor PCC vs plasma for rapid vitamin K antagonist
reversal in patients needing urgent surgical or invasive interventions: a phase
3b, open-label, non-inferiority, randomised trial
Goldstein JN,
et al. The Lancet 2015 February 26 [Epub ahead of print]
Background
Rapid
reversal of vitamin K antagonist (VKA)-induced anticoagulation is often
necessary for patients needing urgent surgical or invasive procedures. The
optimum means of VKA reversal has not been established in comparative clinical
trials. We compared the efficacy and safety of four-factor prothrombin complex
concentrate (4F-PCC) with that of plasma in VKA-treated patients needing urgent
surgical or invasive procedures.
Methods
In a
multicentre, open-label, phase 3b randomised trial we enrolled patients aged 18
years or older needing rapid VKA reversal before an urgent surgical or invasive
procedure. We randomly assigned patients in a 1:1 ratio to receive vitamin K
concomitant with a single dose of either 4F-PCC (Beriplex/Kcentra/Confidex; CSL
Behring, Marburg, Germany) or plasma, with dosing based on international
normalised ratio (INR) and weight. The primary endpoint was effective
haemostasis, and the co-primary endpoint was rapid INR reduction (≤1·3 at 0·5 h
after infusion end). The analyses were intended to evaluate, in a hierarchical
fashion, first non-inferiority (lower limit 95% CI greater than −10% for group
difference) for both endpoints, then superiority (lower limit 95% CI above 0%)
if non-inferiority was achieved. Adverse events and serious adverse events were
reported to days 10 and 45, respectively. This trial is registered at
ClinicalTrials.gov, number NCT00803101.
Findings
181 patients
were randomised (4F-PCC n=90; plasma n=91). The intention-to-treat efficacy
population comprised 168 patients (4F-PCC, n=87; plasma, n=81). Effective
haemostasis was achieved in 78 (90%) patients in the 4F-PCC group compared with
61 (75%) patients in the plasma group, demonstrating both non-inferiority and
superiority of 4F-PCC over plasma (difference 14·3%, 95% CI 2·8–25·8). Rapid
INR reduction was achieved in 48 (55%) patients in the 4F-PCC group compared
with eight (10%) patients in the plasma group, demonstrating both
non-inferiority and superiority of 4F-PCC over plasma (difference 45·3%, 95% CI
31·9–56·4). The safety profile of 4F-PCC was generally similar to that of
plasma; 49 (56%) patients receiving 4F-PCC had adverse events compared with 53
(60%) patients receiving plasma. Adverse events of interest were thromboembolic
adverse events (six [7%] patients receiving 4F-PCC vs seven [8%] patients
receiving plasma), fluid overload or similar cardiac events (three [3%]
patients vs 11 [13%] patients), and late bleeding events (three [3%] patients
vs four [5%] patients).
Interpretation
4F-PCC is
non-inferior and superior to plasma for rapid INR reversal and effective
haemostasis in patients needing VKA reversal for urgent surgical or invasive
procedures.
16. Trial of Early, Goal-Directed Resuscitation for Septic Shock
The Promise Study confirms what we
learned from Process and Arise
Mouncey PR,
et al. N Engl J Med. 2015 Mar 17. [Epub ahead of print]
Background
Early, goal-directed therapy (EGDT) is recommended in international guidelines
for the resuscitation of patients presenting with early septic shock. However,
adoption has been limited, and uncertainty about its effectiveness remains.
Methods We
conducted a pragmatic randomized trial with an integrated cost-effectiveness
analysis in 56 hospitals in England. Patients were randomly assigned to receive
either EGDT (a 6-hour resuscitation protocol) or usual care. The primary
clinical outcome was all-cause mortality at 90 days.
Results We
enrolled 1260 patients, with 630 assigned to EGDT and 630 to usual care. By 90
days, 184 of 623 patients (29.5%) in the EGDT group and 181 of 620 patients
(29.2%) in the usual-care group had died (relative risk in the EGDT group,
1.01; 95% confidence interval [CI], 0.85 to 1.20; P=0.90), for an absolute risk
reduction in the EGDT group of -0.3 percentage points (95% CI, -5.4 to 4.7).
Increased treatment intensity in the EGDT group was indicated by increased use
of intravenous fluids, vasoactive drugs, and red-cell transfusions and
reflected by significantly worse organ-failure scores, more days receiving
advanced cardiovascular support, and longer stays in the intensive care unit.
There were no significant differences in any other secondary outcomes,
including health-related quality of life, or in rates of serious adverse
events. On average, EGDT increased costs, and the probability that it was
cost-effective was below 20%.
Conclusions
In patients with septic shock who were identified early and received
intravenous antibiotics and adequate fluid resuscitation, hemodynamic
management according to a strict EGDT protocol did not lead to an improvement
in outcome.
Full-text
(free): http://www.nejm.org/doi/full/10.1056/NEJMoa1500896#t=articleTop
17. Clindamycin versus trimethoprim-sulfamethoxazole for uncomplicated
skin infections.
Miller LG, et
al. N Engl J Med. 2015 Mar 19;372(12):1093-103.
BACKGROUND:
Skin and skin-structure infections are common in ambulatory settings. However,
the efficacy of various antibiotic regimens in the era of community-acquired
methicillin-resistant Staphylococcus aureus (MRSA) is unclear.
METHODS: We
enrolled outpatients with uncomplicated skin infections who had cellulitis,
abscesses larger than 5 cm in diameter (smaller for younger children), or both.
Patients were enrolled at four study sites. All abscesses underwent incision
and drainage. Patients were randomly assigned in a 1:1 ratio to receive either
clindamycin or trimethoprim-sulfamethoxazole (TMP-SMX) for 10 days. Patients
and investigators were unaware of the treatment assignments and microbiologic
test results. The primary outcome was clinical cure 7 to 10 days after the end
of treatment.
RESULTS: A
total of 524 patients were enrolled (264 in the clindamycin group and 260 in
the TMP-SMX group), including 155 children (29.6%). One hundred sixty patients
(30.5%) had an abscess, 280 (53.4%) had cellulitis, and 82 (15.6%) had mixed
infection, defined as at least one abscess lesion and one cellulitis lesion. S.
aureus was isolated from the lesions of 217 patients (41.4%); the isolates in
167 (77.0%) of these patients were MRSA. The proportion of patients cured was
similar in the two treatment groups in the intention-to-treat population (80.3%
in the clindamycin group and 77.7% in the TMP-SMX group; difference, -2.6 percentage
points; 95% confidence interval [CI], -10.2 to 4.9; P=0.52) and in the
populations of patients who could be evaluated (466 patients; 89.5% in the
clindamycin group and 88.2% in the TMP-SMX group; difference, -1.2 percentage
points; 95% CI, -7.6 to 5.1; P=0.77). Cure rates did not differ significantly
between the two treatments in the subgroups of children, adults, and patients
with abscess versus cellulitis. The proportion of patients with adverse events
was similar in the two groups.
CONCLUSIONS:
We found no significant difference between clindamycin and TMP-SMX, with
respect to either efficacy or side-effect profile, for the treatment of
uncomplicated skin infections, including both cellulitis and abscesses.
18. The Screened & Examined Podcast Takes on Dr. Oz
In an earlier
Lit Bits (Dec 27, 2014), we included this important article from the BMJ: Televised
medical talk shows—what they recommend and the evidence to support their
recommendations: a prospective observational study. Full-text: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4269523/
Dustin
Ballard, MD, MBE, emergency physician, clinical researcher, author, and
co-chair of the KP CREST Network, explores this topic further on the opening
session of his new podcast.
Ballard D.
Emerg Med News. 2015;37(3A).
Podcasting is
the new blogging — it's easy, virtually free, and anyone can do it. That does
not mean, of course, that anyone will actually listen. Since I am as much of a
sucker for a fad as the next guy, I have decided to join the podcasting
movement. But I am also savvy enough to just go ahead and skip the part where
no one listens. So while you can choose to listen [http://bit.ly/1MlOJ58], this pod is going to print no
matter what. Here goes....
DB: Welcome
to The Medically Clear Podcast. You are fortunate enough to join us for our
inaugural broadcast. And depending on how this goes, perhaps you will be
joining us for our final one as well. I am Dustin Ballard, an emergency
physician, writer, and researcher, and “it” is known quite simply as the
Fabulous “Creature” of the Literature.
Each episode
I will be asking the “Creature” to pick a notable recent addition to the
literature, and then flush and suss it out for us. We'll get to our inaugural
article in a moment, but first, Creature, can you tell us a little bit more
about yourself and your prolific podcasting resume?
CREATURE:
Well, thanks, Dustin. You are too kind. I must admit that today does represent
a milestone in my podcasting career. It's, in fact, my very first podcast.
DB: Excellent
and welcome to the world of podcasting. So Creature, our featured science this
week is from the British Medical Journal (2014;349:g7346), and addresses how
medical television media packages evidence for health consumers. OK, let's
start our Knowledge Translate segment and ask you to drop a Synopsis Bomb
regarding this study.
CREATURE: A
synopsis bomb? That sounds explosive. How about instead I just skim the paper
and point out any methodological land mines I come across?
DB: That'll
do…
The
conversation continues (free): http://journals.lww.com/em-news/Fulltext/2015/03111/Screened___Examined__The_Screened___Examined.1.aspx
19. Harms of CT scanning prior to surgery for suspected
appendicitis
Rogers W, et
al. Evid Based Med 2015;20:3-4
Introduction
Abdominal
pain in young adults is a common symptom in the emergency department (ED) and
most young patients who require surgery are suffering from appendicitis. Ten
years ago patients suspected of having appendicitis went to surgery without any
sort of imaging; today however CT scanning has become a reflexive part of the
workup of young people with suspected appendicitis. In this commentary, we
raise concerns about the harm/benefit ratio of routinely performing an
abdominal CT scan on an otherwise healthy patient who presents to the ED with
lower abdominal pain suggestive of appendicitis. We use published data to
compare the long-term mortality risks from abdominal CT scanning in individuals
younger than 50 with the mortality risks associated with an appendectomy that
removes a normal appendix (a ‘negative’ appendectomy).
Morbidity and mortality risks of
negative appendectomy
Although it
is commonly assumed that there are significant risks associated with a negative
appendectomy, the actual risk is negligible. The safety of negative
appendectomy is evident in data describing surgical mortality from the UK
National Health Service (NHS) laparoscopic appendectomy study, in which there
were no deaths in 234 402 patients below the age of 49 who underwent that
surgery.1 Appendectomies are associated with a 2–5% incidence of postoperative
intra-abdominal wound infections.2 The risk of infection after a negative
appendectomy is probably much lower since the resected appendix is not infected
but the incidence of deep infection in these cases has not been studied. The
other major morbidity of appendectomy is small bowel obstruction which occurs
in less than 1% of cases. The advent of newer, less invasive surgical
techniques and the broad range of anaesthesia safety initiatives have dramatically
decreased the mortality and morbidity associated with appendectomy.
Morbidity and mortality risks of
abdominal CT scan
Abdominal CT
scanning is not without risks. The Board on Radiation Effect Research is
sponsored by the National Research Council of the National Academies of
Sciences. This board has studied data describing populations exposed to
medical, environmental and occupational radiation as well as those exposed to
radiation from the two atomic bomb explosions in Japan at the end of WW II. Based
on this long term, large scale follow-up data the board has concluded that a
45-year-old patient exposed to 15 mSv of radiation experiences a 1:1250
additional risk for future mortality from cancer.3 Though the radiation dosage
of CT scans varies, the average effective radiation dose of a single abdominal
CT scan is 8–11 mSv.4
Of note, this
risk statistic does not account for the increased risk of developing non-fatal
cancer. Furthermore the risk of later cancer is much higher for younger
patients. Acute appendicitis occurs most frequently in patients aged 10–19 years
old,5 a group which is 10 times more sensitive to risk from radiation when
compared to adults.6 An Israeli study investigating the relationship between CT
scans in patients under the age of 18 and future cancer mortality risk
concluded that CT scans alone performed on the paediatric population will cause
a 0.29% increase in baseline future cancer mortality.7
Harms of CT
scans are not limited to the increased future cancer mortality risk. Other
potential harms include contrast dye-induced nephropathy and hypersensitivity
reactions. Contrast dye-induced nephropathy, defined as a greater than 25%
increase in serum creatinine levels after contrast administrations, occurs in
11% of patients undergoing CT scans. Renal failure occurs in 1% of those
patients, 0.7% of those who develop renal failure die as a result.8
Estimating the risks and benefits of
routine CT scanning for suspected appendicitis in young people
Extrapolation
of data from a recent retrospective study of CT scanning and negative
appendectomy9 rates allow us to estimate the risks and benefit of routine CT
imaging of young patients with suspected appendicitis. At the institution
studied in the article 2000 abdominal CT scans lead to 58 appendectomies. The
Biological Effects of Ionizing Radiations (BEIR V) exposure data predict that
2000 CT scans would lead to at least one cancer death. Before CT scanning began
at this institution approximately 23% of appendectomies showed no evidence of
appendicitis, now the preoperative scan rate is 97.5% and as a result only 1.7%
of appendectomies show no evidence of appendicitis. The benefit therefore of
universal scanning was to avoid 12 negative appendectomies, this at the cost of
one radiation-induced cancer death. One cancer death from imaging to prevent no
surgical deaths from negative appendectomy is a trade-off that should lead us
to question reflexive CT scanning of patients we suspect of having
appendicitis.
It is
unfortunate that there are no randomised trials comparing the management of
suspected appendicitis with and without CT scanning. As CT scanners capable of
imaging the abdomen became more available, their use in the evaluation of
patients with abdominal pain grew rapidly and the advantages of increased
diagnostic precision were far more evident than the risks. It is clear that
from a diagnostic perspective the 98.3% specificity of CT scanning is far
better than the 77% specificity achieved by clinician based purely on clinical
judgment.9 A randomised study to compare risks and benefits of CT scanning versus
clinical judgment would only be instructive if it followed patient outcomes for
decades to make sure that the long-term complications of radiation exposure
were accurately assessed.
The best
diagnosticians among us rely on a detailed history, a careful examination,
judicious use of testing and imaging and an intuition which can only be gained
by experience. Unfortunately this approach to diagnosis has been supplanted by
a blind faith in technology and a belief that an incorrect diagnosis represents
a failure on the part of the clinician that could have been avoided if only a
few more tests had been run. This reliance on testing and quest for perfection
represents a new risk to patients. The principle stated in the Hippocratic
oath, to do no harm, suggests that we should avoid routine CT scanning for
likely cases of appendicitis in youth.
20. Clinical features for diagnosis of pneumonia in children
younger than 5 years: a systematic review and meta-analysis
Rambaud-Althaus
C, et al. Lancet 2015 Mar 10 [Epub ahead of print]
Background
Pneumonia is
the biggest cause of deaths in young children in developing countries, but
early diagnosis and intervention can effectively reduce mortality. We aimed to
assess the diagnostic value of clinical signs and symptoms to identify
radiological pneumonia in children younger than 5 years and to review the
accuracy of WHO criteria for diagnosis of clinical pneumonia.
Methods
We searched
Medline (PubMed), Embase (Ovid), the Cochrane Database of Systematic Reviews,
and reference lists of relevant studies, without date restrictions, to identify
articles assessing clinical predictors of radiological pneumonia in children.
Selection was based on: design (diagnostic accuracy studies), target disease
(pneumonia), participants (children aged less than 5 years), setting
(ambulatory or hospital care), index test (clinical features), and reference
standard (chest radiography). Quality assessment was based on the 2011 Quality
Assessment of Diagnostic Accuracy Studies (QUADAS-2) criteria. For each index
test, we calculated sensitivity and specificity and, when the tests were
assessed in four or more studies, calculated pooled estimates with use of
bivariate model and hierarchical summary receiver operation characteristics
plots for meta-analysis.
Findings
We included
18 articles in our analysis. WHO-approved signs age-related fast breathing (six
studies; pooled sensitivity 0·62, 95% CI 0·26–0·89; specificity 0·59,
0·29–0·84) and lower chest wall indrawing (four studies; 0·48, 0·16–0·82; 0·72,
0·47–0·89) showed poor diagnostic performance in the meta-analysis. Features
with the highest pooled positive likelihood ratios were respiratory rate higher
than 50 breaths per min (1·90, 1·45–2·48), grunting (1·78, 1·10–2·88), chest
indrawing (1·76, 0·86–3·58), and nasal flaring (1·75, 1·20–2·56). Features with
the lowest pooled negative likelihood ratio were cough (0·30, 0·09–0·96),
history of fever (0·53, 0·41–0·69), and respiratory rate higher than 40 breaths
per min (0·43, 0·23–0·83).
Interpretation
Not one
clinical feature was sufficient to diagnose pneumonia definitively. Combination
of clinical features in a decision tree might improve diagnostic performance,
but the addition of new point-of-care tests for diagnosis of bacterial
pneumonia would help to attain an acceptable level of accuracy.
21. Cervical Spine Clearance in Obtunded Patients after Blunt
Traumatic Injury: A Systematic Review
Badhiwala JH,
et al. Ann Intern Med.
2015;162(6):429-437.
Background:
Cervical spine clearance protocols are controversial for unconscious patients
after blunt traumatic injury and negative findings on computed tomography (CT).
Purpose: To
review evidence about the utility of different cervical spine clearance
protocols in excluding significant cervical spine injury after negative CT
results in obtunded adults with blunt traumatic injury.
Data Sources:
MEDLINE, EMBASE, CINAHL, Google Scholar, and the Cochrane Library were searched
from January 2000 through November 2014.
Study
Selection: English-language studies that examined patients with negative CT
results having confirmatory routine testing with magnetic resonance imaging
(MRI), dynamic radiography, or clinical examination and that reported outcome
measures of missed cervical spine injury, need for operative stabilization, or
prolonged use of cervical collars.
Data
Extraction: Independent reviewers evaluated the quality of studies and
abstracted the data according to a predefined protocol.
Data
Synthesis: Of 28 observational studies (3627 patients) that met eligibility
criteria, 7 were prospective studies (1686 patients) with low risk of bias and
well-interpreted, high-quality CT scans. These 7 studies showed that 0% of
significant injuries were missed after negative CT results. The overall studies
using confirmatory routine testing with MRI showed incidence rates of 0% to
1.5% for cervical spine instability (16 studies; 1799 patients), 0% to 7.3% for
need for operative fixation (17 studies; 1555 patients), and 0% to 29.5% for
prolonged collar use (16 studies; 1453 patients).
Limitations:
Most studies were retrospective. Approaches to management of soft tissue
changes with collars varied markedly.
Conclusion:
Cervical spine clearance in obtunded adults after blunt traumatic injury with
negative results from a well-interpreted, high-quality CT scan is probably a
safe and efficient practice.
22. Investigating and managing suspected PE in an outpatient [clinic!]
setting: the Leicester experience
Vali Y, et
al. Thorax. 2015 Mar;70(3):291-3..
Having
established an ambulatory service for patients with suspected and proven PE, we
reviewed our outcomes. All patients referred from June 2010 to May 2012 were
analysed. Of 971 patients referred, 905 underwent complete assessment (66
admitted as ineligible). 754 (77.7%) patients were discharged and required no
follow-up. 96 (10.6%) patients had PE confirmed of whom 70 (72.9%) were managed
as outpatients. 14 (1.6%) patients have died since attending the clinic; no
death was related to PE. This audit shows that ambulatory investigation and
management of selected low risk patients with suspected PE is safe and reduces
hospital admissions.
23. Micro Bits
A. Iodinated Contrast Prior to
Thrombolysis Was Not Associated With Worse Intracranial Hemorrhage
B. Randomized Trial of Peanut
Consumption in Infants at Risk for Peanut Allergy
Kids can't
take peanut butter to school. Some airlines no longer serve peanuts because of
fear of anaphylaxis among passengers. These developments are just the tip of
the iceberg as the prevalence of peanut allergy among children continues to
increase worldwide, especially in westernized countries. In the United States
alone, the prevalence has more than quadrupled in the past 13 years, growing
from 0.4% in 1997 to 1.4% in 20081 to more than 2% in 2010.2 Peanut allergy has
become the leading cause of anaphylaxis and death related to food allergy in
the United States.3
C. A 2 year multidomain intervention
of diet, exercise, cognitive training, and vascular risk monitoring versus
control to prevent cognitive decline in at-risk elderly people (FINGER): a
randomised controlled trial
D. Improving patient knowledge and
safe use of opioids: a randomized controlled trial.
E. Operative versus non-operative
treatment for closed, displaced, intra-articular fractures of the calcaneus:
randomised controlled trial.
F. Ambulatory vital signs in the
workup of pulmonary embolism using a standardized 3-minute walk test
G. Cardiac Screening With
Electrocardiography, Stress Echocardiography, or Myocardial Perfusion Imaging:
Advice for High-Value Care From the American College of Physicians
Full-text
(free): http://annals.org/article.aspx?articleID=2197181
H. AMI: What’s in a name?
Type 1 and
Type 2 MIs
Full-text
(most of it): http://annals.org/article.aspx?articleID=2197182
More on Type
2: http://www.medscape.com/viewarticle/838693
I. ADHD medications are misused by 1
in 6 college students
Seventeen
percent of college students have used stimulants prescribed to treat attention-deficit/hyperactivity
disorder without a prescription or taken bigger doses than prescribed,
according to a meta-analysis published in Clinical Child and Family Psychology
Review. Students often got the medications from their friends.
J. Viruses account for majority of
childhood pneumonia cases in U.S.
A study in
the New England Journal of Medicine revealed 66% of pneumonia cases in more
than 2,000 children were associated with viral infections, while 8% were linked
to bacterial infection and 7% were tied to both. Researchers also found
patients younger than 2 years were at higher risk of the lung infection, with
cases reaching up to 62 per 10,000 children annually.
K. Music as Medicine
Music is
important for many physicians -- but can doctors use music to promote the
health and well-being of their patients? A variety of studies suggest the
answer may be yes. Some are blinded, randomized trials, but most are relatively
small and brief. Still, they present an interesting group of observations.
Full-text
(free): http://www.amjmed.com/article/S0002-9343(14)00924-3/fulltext
