Monday, April 27, 2015

Lit Bits: April 27, 2015

From the recent medical literature…

1. Low-dose ketamine vs morphine for acute pain in the ED: a randomized controlled trial

Miller JP, et al. Amer J Emerg Med 2015;33:402-8.

Objectives: To compare the maximum change in numeric rating scale (NRS) pain scores, in patients receiving low-dose ketamine (LDK) or morphine (MOR) for acute pain in the emergency department.

Methods: We performed an institutional review board–approved, randomized, prospective, double-blinded trial at a tertiary, level 1 trauma center. A convenience sample of patients aged 18 to 59 years with acute abdominal, flank, low back, or extremity pain were enrolled. Subjects were consented and randomized to intravenous LDK (0.3 mg/kg) or intravenous MOR (0.1 mg/kg). Our primary outcome was the maximum change in NRS scores. A sample size of 20 subjects per group was calculated based on an 80% power to detect a 2-point change in NRS scores between treatment groups with estimated SDs of 2 and an α of .05, using a repeated-measures linear model.

Results: Forty-five subjects were enrolled (MOR 21, LDK 24). Demographic variables and baseline NRS scores (7.1 vs 7.1) were similar. Ketamine was not superior to MOR in the maximum change of NRS pain scores, MOR = 5 (confidence interval, 6.6-3.5) and LDK = 4.9 (confidence interval, 5.8-4). The time to achieve maximum reduction in NRS pain scores was at 5 minutes for LDK and 100 minutes for MOR. Vital signs, adverse events, provider, and nurse satisfaction scores were similar between groups.

Conclusion: Low-dose ketamine did not produce a greater reduction in NRS pain scores compared with MOR for acute pain in the ED. However, LDK induced a significant analgesic effect within 5 minutes and provided a moderate reduction in pain for 2 hours.

2. Midstream clean-catch urine collection in newborns: a randomized controlled study.

Altuntas N, et al. Eur J Pediatr. 2014 Oct 17. [Epub ahead of print]

We aimed to evaluate a recently defined technique based on bladder stimulation and paravertebral lumbar massage maneuvers in collecting a midstream clean-catch urine sample in newborns.

A total of 127 term newborns were randomly assigned either to the experimental group or the control group. Twenty-five minutes after feeding, the genital and perineal areas of the babies were cleaned. The babies were held under the armpits with legs dangling. Bladder stimulation and lumbar paravertebral massage maneuvers were only applied to the babies in the experimental group. Success was defined as collection of a urine sample within 5 min of starting the stimulation maneuvers in the experimental group and of holding under the armpits in the control group.

The success rate of urine collection was significantly higher in the experimental group (78 %) than in the control group (33 %; p  less than  0.001). The median time (interquartile range) for sample collection was 60 s (64.5 s) in the experimental group and 300 s (95 s) in the control group (p  less than  0.0001). Contamination rates were similar in both groups (p = 0.770).

Conclusion: We suggest that bladder stimulation and lumbar paravertebral massage is a safe, quick, and effective way of collecting midstream clean-catch urine in newborns.

3. Annals of EM’s Literature Reviews

A. What Is the Most Effective Treatment for Relieving the Pain of a Jellyfish Sting?

Hot-water application may relieve the pain from a bluebottle jellyfish sting better than ice packs; however, this is based on a single trial. There is insufficient evidence to recommend for or against other pain treatment regimens for jellyfish stings.

B. Are Colloids Better Than Crystalloids for Fluid Resuscitation in Critically Ill Patients?

No. Colloid solutions offer no advantage over crystalloids for the resuscitation of critically ill patients.

C. Does Tranexamic Acid Improve Outcomes in Patients Undergoing Urgent or Emergency Surgery?

The use of tranexamic acid before surgery of hip or femur shaft fractures may reduce the need for blood transfusion; however, inferences are limited due to the small number of trials.

D. Is Rhythm Control Better Than Rate Control for New-Onset A Fib in the ED?

In patients with new-onset atrial fibrillation and symptom onset within 48 hours, rhythm control is preferred over rate control if the patient is younger than 65 years. For patients with congestive heart failure, valvular heart disease, hypertension, or permanent atrial fibrillation, rate control remains the favored strategy.

E. Does the Choice of Antibiotic Affect Outcome in Strep Throat?

There is insufficient evidence to show clinically meaningful differences between antibiotics for group A beta hemolytic streptococci tonsillopharyngitis. Penicillin or amoxicillin is recommended as first choice, given the absence of resistance and low cost.

4. Properties of serial US clinical diagnostic pathway in suspected appendicitis and related CT use.

Schuh S, et al. Acad Emerg Med. 2015 Apr;22(4):406-14.

OBJECTIVES: The primary objective was to determine the diagnostic accuracy of a serial ultrasound (US) clinical diagnostic pathway to detect appendicitis in children presenting to the emergency department (ED). The secondary objective was to examine the diagnostic performance of the initial and interval US and to compare the accuracy of the pathway to that of the initial US.

METHODS: This was a prospective cohort study of 294 previously healthy children 4 to 17 years old with suspected appendicitis and baseline pediatric appendicitis scores of ≥2, who were managed with the serial US clinical diagnostic pathway. This pathway consisted of an initial US followed by a clinical reassessment in each patient and an interval US and surgical consultation in patients with equivocal initial US and persistent concern about appendicitis. The USs were interpreted by published criteria as positive, negative, or equivocal for appendicitis. Children in whom this pathway did not rule in or rule out appendicitis underwent computed tomography (CT). Cases with missed appendicitis, negative operations, and CTs after the pathway were considered inaccurate. The primary outcome was the diagnostic accuracy of the serial US clinical diagnostic pathway. The secondary outcomes included the test performance of the initial and interval US imaging studies.

RESULTS: Of the 294 study children, 111 (38%) had appendicitis. Using the serial US clinical diagnostic pathway, 274 of 294 children (93%, 95% confidence interval [CI] = 90% to 96%) had diagnostically accurate results: 108 of the 111 (97%) appendicitis cases were successfully identified by the pathway without CT scans (two missed and one CT), and 166 of the 183 (91%) negative cases were ruled out without CT scans (14 negative operations and three CTs). The sensitivity of this pathway was 108 of 111 (97%, 95% CI = 94% to 100%), specificity 166 of 183 (91%, 95% CI = 87% to 95%), positive predictive value 108 of 125 (86%; 95% CI = 79% to 92%), and negative predictive value 166 of 169 (98%, 95% CI = 96% to 100%). The diagnostic accuracy of the pathway was higher than that of the initial US alone (274 of 294 vs. 160 of 294; p less than 0.0001). Of 123 patients with equivocal initial US, concern about appendicitis subsided on clinical reassessment in 73 (no surgery and no missed appendicitis). Of 50 children with persistent symptoms, 40 underwent interval US and 10 had surgical consultation alone. The interval US confirmed or ruled out appendicitis in 22 of 40 children (55.0%) with equivocal initial US, with one false-positive interval US.

CONCLUSIONS: The serial US clinical diagnostic pathway in suspected appendicitis has an acceptable diagnostic accuracy that is significantly higher than that of the initial US and results in few CT scans. This approach appears most useful in children with equivocal initial US, in whom the majority of negative cases were identified at clinical reassessment and appendicitis was diagnosed by interval US or surgical consultation in most study patients.

5. Prospective validation of a 1-hour algorithm to rule-out and rule-in AMI using a high-sensitivity cardiac troponin T assay.

Reichlin T, et al. CMAJ. 2015 Apr 13 [Epub ahead of print]

BACKGROUND: We aimed to prospectively validate a novel 1-hour algorithm using high-sensitivity cardiac troponin T measurement for early rule-out and rule-in of acute myocardial infarction (MI).

METHODS: In a multicentre study, we enrolled 1320 patients presenting to the emergency department with suspected acute MI. The highsensitivity cardiac troponin T 1-hour algorithm, incorporating baseline values as well as absolute changes within the first hour, was validated against the final diagnosis. The final diagnosis was then adjudicated by 2 independent cardiologists using all available information, including coronary angiography, echocardiography, follow-up data and serial measurements of high-sensitivity cardiac troponin T levels.

RESULTS: Acute MI was the final diagnosis in 17.3% of patients. With application of the high-sensitivity cardiac troponin T 1-hour algorithm, 786 (59.5%) patients were classified as "rule-out," 216 (16.4%) were classified as "rule-in" and 318 (24.1%) were classified to the "observational zone." The sensitivity and the negative predictive value for acute MI in the rule-out zone were 99.6% (95% confidence interval [CI] 97.6%-99.9%) and 99.9% (95% CI 99.3%-100%), respectively. The specificity and the positive predictive value for acute MI in the rule-in zone were 95.7% (95% CI 94.3%-96.8%) and 78.2% (95% CI 72.1%-83.6%), respectively. The 1-hour algorithm provided higher negative and positive predictive values than the standard interpretation of high-sensitivity cardiac troponin T using a single cut-off level (both p less than 0.05). Cumulative 30-day mortality was 0.0%, 1.6% and 1.9% in patients classified in the rule-out, observational and rule-in groups, respectively (p = 0.001).

INTERPRETATION: This rapid strategy incorporating high-sensitivity cardiac troponin T baseline values and absolute changes within the first hour substantially accelerated the management of suspected acute MI by allowing safe rule-out as well as accurate rule-in of acute MI in 3 out of 4 patients.

6. Outcomes in Adults with Acute PE who are Discharged from EDs: The Cardiovascular Research Network VTE Study

Fang MC, et al. JAMA Intern Med. 2015 Apr 20 [Epub ahead of print].

Patients with acute pulmonary embolism (PE) have conventionally been hospitalized for their initial management and initiation of anticoagulant treatment.1 A clinical trial2 found that patients with PE who were considered at low risk by the PE Severity Index could be safely treated as outpatients.3 However, it is unclear how often outpatient PE treatment occurs in real-world settings or whether outcomes are as favorable as in the clinical trial. Our study describes the short-term rates of death and hospital admission for patients with acute PE who were discharged from emergency department (ED) settings…

Patients with acute PE who were discharged from ED settings in4geographically diverse health care delivery systems had mortality rates comparable with outcomes observed in a clinical trial3 that examined outpatient management of PE. Although still representing relatively few patients with PE, the proportion of discharges from ED settings nearly doubled during the 7-year study. Shifting appropriate patients to outpatient treatment may have benefits in terms of improved quality of life, enhanced physical and social functioning, and reduced costs of medical care.5 We note that at least 23.4% of the patients in our study would not have been eligible for outpatient treatment in the clinical trial because they had a higher PE Severity Index risk class.3

7. ED Patients With A Fib or Flutter and an Acute Underlying Medical Illness May Not Benefit From Attempts to Control Rate or Rhythm.

Scheuermeyer FX, et al. Ann Emerg Med. 2015 May;65(5):511-522.e2.

STUDY OBJECTIVE: Although the management and outcomes of emergency department (ED) patients with atrial fibrillation or flutter have been explored, such studies have typically excluded patients with acute underlying medical illnesses. We seek to describe the ED treatment and outcomes of these complex patients with atrial fibrillation or flutter.

METHODS: This retrospective descriptive cohort study used an ECG database from 2 urban EDs to identify consecutive ED patients with an ECG demonstrating atrial fibrillation or flutter from January 1, 2009, to December 31, 2009. We categorized patients with atrial fibrillation or flutter as "complex" according to prespecified criteria and then grouped them as being managed with rate or rhythm control attempts, or not. The primary outcome was safety of rate or rhythm control, measured by whether patients had a predefined adverse event or not. The secondary outcome was the success of rate or rhythm control, defined as rate control decreasing the pulse rate by 20 beats/min and successful rhythm control, both within 4 hours of treatment initiation. Descriptive statistics were used to compare the 2 groups.

RESULTS: Four hundred sixteen complex patients with atrial fibrillation or flutter were identified. Patients managed with rate or rhythm control were similar in all baseline characteristics and illness distribution to patients who were not managed in this manner. The 135 patients with attempted rate control (105) or rhythm control (30) had 55 adverse events (40.7%; 95% confidence interval [CI] 32.5% to 49.5%), whereas the 281 patients not managed with rate or rhythm control had 20 adverse events (7.1%; 95% CI 4.5% to 10.9%), for a risk difference of 33.6% (95% CI 24.3% to 42.5%) and a relative risk of 5.7 (95% CI 3.6 to 9.1). Twenty of 105 patients (19.1%; 95% CI 12.3% to 28.1%) were successfully rate controlled, whereas 4 of 30 (13.3%; 95% CI 4.4% to 31.6%) were successfully rhythm controlled.

CONCLUSION: In ED patients with complex atrial fibrillation or flutter, attempts at rate and rhythm control are associated with a nearly 6-fold higher adverse event rate than that for patients who are not managed with rate or rhythm control. Success rates of rate or rhythm control attempts appear low.

8. Isolated transient aphasia at emergency presentation is associated with a high rate of cardioembolic embolism

Wassermanan JK, et al. CJEM. 2015 March 18 [Epub ahead of print]

Objective A cardiac source is often implicated in strokes where the deficit includes aphasia. However, less is known about the etiology of isolated aphasia during transient ischemic attack (TIA). Our objective was to determine whether patients with isolated aphasia are likely to have a cardioembolic etiology for their TIA.

Methods We prospectively studied a cohort of TIA patients in eight tertiary-care emergency departments. Patients with isolated aphasia were identified by the treating physician at the time of emergency department presentation. Patients with dysarthria (i.e., a phonation disturbance) were not included. Potential cardiac sources for embolism were defined as atrial fibrillation on history, electrocardiogram, Holter monitor, atrial fibrillation on echocardiography, or thrombus on echocardiography.

Results Of the 2,360 TIA patients identified, 1,155 had neurological deficits at the time of the emergency physician assessment and were included in this analysis, and 41 had isolated aphasia as their only neurological deficit. Patients with isolated aphasia were older (73.9±10.0 v. 67.2±14.5 years; p=0.003), more likely to have a history of heart failure (9.8% v. 2.6%; p=0.027), and were twice as likely to have any cardiac source of embolism (22.0% v. 10.6%; p=0.037).

Conclusions Isolated aphasia is associated with a high rate of cardioembolic sources of embolism after TIA. Emergency patients with isolated aphasia diagnosed with a TIA warrant a rapid and thorough assessment for a cardioembolic source.

Full-text (free):

9. Predictive value of the usual clinical signs and laboratory tests in the diagnosis of septic arthritis

Couderca M, et al. CJEM 2015 March 30 [Epub ahead of print]

Objective To determine the sensitivity and specificity of clinical and laboratory signs for the diagnosis of septic arthritis (SA).

Patients and methods This prospective study included all adult patients with suspected SA seen in the emergency department or rheumatology department at the University Hospital, Clermont-Ferrand, France, over a period of 18 months.

Results In total, 105 patients with suspected SA were included, 38 (36%) presenting with SA (29 [28%] with bacteriologically documented SA). In the univariate analysis, chills (p=0.015), gradual onset (p=0.04), local redness (p=0.01), as well as an entry site for infection (p=0.01) were most often identified in SA. A history of crystal-induced arthritis (p=0.004) was more frequent in non-SA cases. An erythrocyte sedimentation rate (ESR) above 50 mm (p=0.005), a C-reactive protein (CRP) level above 100 mg/L (p=0.019), and radiological signs suggestive of SA (p=0.001) were more frequent in the SA cases. Synovial fluid appearance: purulent (p less than 0.001) and clear (p=0.007), synovial white blood cell (WBC) count above 50,000/μL (p less than 0.001), differentiated between SA and non-SA.

In multivariate analysis, only chills (odds ration [OR]=4.7, 95% confidence interval [CI] 1.3–17.1), a history of crystal-induced arthritis (OR=0.09, 95% CI 0.01–0.9), purulent appearance of the joint fluid (OR=8.4, 95% CI 2.4–28.5), synovial WBC count above 50,000/mm3 (OR=6.8, 95% CI 1.3–36), and radiological findings (OR=7.1, 95% CI 13–37.9) remained significant.
Conclusion No clinical sign or laboratory test (excluding bacteriological test), taken alone, is conclusive for the differentiation between SA and non-SA, but the association of several signs, notably chills, history of crystal-induced arthritis, radiological findings, and the appearance and cellularity of joint fluid may be suggestive.

Full-text (free):

10. Images in Clinical Practice

Rectus sheath hematoma

Disseminated Zoster


Epiglottitis in an Adult

Incisional Keloid

Arachnoid Cyst

STEMI—in a 19-year-old! (from a coronary artery embolism)

Elderly Man with Syncope

Elderly Woman with Headache

Woman with Severe Dyspnea

Neonate with Pustular Rash

Male with Throat Pain and Neck Swelling

11. Efficacy and safety of paracetamol (acetaminophen) for spinal pain and osteoarthritis: systematic review and meta-analysis of randomised placebo controlled trials.

(Pssst: It doesn’t work!) An analysis of data from 13 clinical trials found acetaminophen may not be an effective treatment for lower back pain and may offer limited help for osteoarthritis, researchers reported in The BMJ. Researchers said guidelines recommending acetaminophen as a first-line analgesic treatment for these conditions should be updated.

Machado GC, et al. BMJ. 2015 Mar 31;350:h1225.

OBJECTIVE: To investigate the efficacy and safety of paracetamol (acetaminophen) in the management of spinal pain and osteoarthritis of the hip or knee.

DESIGN: Systematic review and meta-analysis.

DATA SOURCES: Medline, Embase, AMED, CINAHL, Web of Science, LILACS, International Pharmaceutical Abstracts, and Cochrane Central Register of Controlled Trials from inception to December 2014.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Randomised controlled trials comparing the efficacy and safety of paracetamol with placebo for spinal pain (neck or low back pain) and osteoarthritis of the hip or knee.

DATA EXTRACTION: Two independent reviewers extracted data on pain, disability, and quality of life. Secondary outcomes were adverse effects, patient adherence, and use of rescue medication. Pain and disability scores were converted to a scale of 0 (no pain or disability) to 100 (worst possible pain or disability). We calculated weighted mean differences or risk ratios and 95% confidence intervals using a random effects model. The Cochrane Collaboration's tool was used for assessing risk of bias, and the GRADE approach was used to evaluate the quality of evidence and summarise conclusions.

RESULTS: 12 reports (13 randomised trials) were included. There was "high quality" evidence that paracetamol is ineffective for reducing pain intensity (weighted mean difference -0.5, 95% confidence interval -2.9 to 1.9) and disability (0.4, -1.7 to 2.5) or improving quality of life (0.4, -0.9 to 1.7) in the short term in people with low back pain. For hip or knee osteoarthritis there was "high quality" evidence that paracetamol provides a significant, although not clinically important, effect on pain (-3.7, -5.5 to -1.9) and disability (-2.9, -4.9 to -0.9) in the short term. The number of patients reporting any adverse event (risk ratio 1.0, 95% confidence interval 0.9 to 1.1), any serious adverse event (1.2, 0.7 to 2.1), or withdrawn from the study because of adverse events (1.2, 0.9 to 1.5) was similar in the paracetamol and placebo groups. Patient adherence to treatment (1.0, 0.9 to 1.1) and use of rescue medication (0.7, 0.4 to 1.3) was also similar between groups. "High quality" evidence showed that patients taking paracetamol are nearly four times more likely to have abnormal results on liver function tests (3.8, 1.9 to 7.4), but the clinical importance of this effect is uncertain.

CONCLUSIONS: Paracetamol is ineffective in the treatment of low back pain and provides minimal short term benefit for people with osteoarthritis. These results support the reconsideration of recommendations to use paracetamol for patients with low back pain and osteoarthritis of the hip or knee in clinical practice guidelines.

12. The bubble study: US confirmation of CVC placement

Duran-Gehring PE, et al. Amer J Emerg Med 2015;33:315-9.

Study objective
The objective was to determine if ultrasound (US) can more rapidly confirm central venous catheter (CVC) position in comparison to chest radiography (CXR) in the emergency department.

The study included a convenience sample of emergency department patients with supradiaphragmatic CVCs and a CXR for confirmation. Ultrasound was used for CVC confirmation by visualizing microbubble artifact in the right atrium after injection of saline through the distal port. To evaluate for pneumothorax (PTX), “sliding sign” of the pleura was noted on US of the anterior chest. Blinded chart review was performed to assess CXR timing, catheter position and CVC complications. Student's t test was used to compare US time to CXR performance time and radiologist reading time.

Fifty patients were enrolled; 4 were excluded because of inadequate views. Forty-six patients were included in the final analysis. Mean total US time was 5.0 minutes (95% confidence interval [CI], 4.2-5.9) compared to 28.2 minutes (95% CI, 16.8-39.4) for CXR performance with a mean difference of 23.1 minutes (95% CI, −34.5 to −11.8; P less than .0002). When comparing only US CVC confirmation time to CXR time, US was an average of 24.0 minutes (95% CI, −35.4 to −12.7; P less than .0001) faster. Comparing total US time to radiologist CXR reading time, US was an average of 294 minutes faster (95% CI, −384.5 to -203.5; P less than .0000). There were a total of 3 misplaced lines and 2 patients with PTX, all of which were identified correctly on US.

Ultrasound can confirm CVC placement and rule out PTX significantly faster than CXR, expediting the use of CVCs in the critically ill.

13. Therapeutic Hypothermia after Out-of-Hospital Cardiac Arrest in Children

This study of targeted temperature interventions in 295 children who were comatose after cardiac arrest showed no significant difference between the hypothermia group (33.0°C) and the normothermia group (36.8°C) with respect to 1-year survival with a good functional outcome.

Moler FW, et al. N Engl J Med 2015 Apr 25 [Epub ahead of print]

Therapeutic hypothermia is recommended for comatose adults after witnessed out-of-hospital cardiac arrest, but data about this intervention in children are limited.

We conducted this trial of two targeted temperature interventions at 38 children's hospitals involving children who remained unconscious after out-of-hospital cardiac arrest. Within 6 hours after the return of circulation, comatose patients who were older than 2 days and younger than 18 years of age were randomly assigned to therapeutic hypothermia (target temperature, 33.0°C) or therapeutic normothermia (target temperature, 36.8°C). The primary efficacy outcome, survival at 12 months after cardiac arrest with a Vineland Adaptive Behavior Scales, second edition (VABS-II), score of 70 or higher (on a scale from 20 to 160, with higher scores indicating better function), was evaluated among patients with a VABS-II score of at least 70 before cardiac arrest.

A total of 295 patients underwent randomization. Among the 260 patients with data that could be could be evaluated and who had a VABS-II score of at least 70 before cardiac arrest, there was no significant difference in the primary outcome between the hypothermia group and the normothermia group (20% vs. 12%; relative likelihood, 1.54; 95% confidence interval [CI], 0.86 to 2.76; P=0.14). Among all the patients with data that could be evaluated, the change in the VABS-II score from baseline to 12 months was not significantly different (P=0.13) and 1-year survival was similar (38% in the hypothermia group vs. 29% in the normothermia group; relative likelihood, 1.29; 95% CI, 0.93 to 1.79; P=0.13). The groups had similar incidences of infection and serious arrhythmias, as well as similar use of blood products and 28-day mortality.

In comatose children who survived out-of-hospital cardiac arrest, therapeutic hypothermia, as compared with therapeutic normothermia, did not confer a significant benefit in survival with a good functional outcome at 1 year.

14. Systemic inflammatory response syndrome criteria in defining severe sepsis (not the ultimate definition).

Kaukonen KM, et al. N Engl J Med. 2015 Apr 23;372(17):1629-38.

BACKGROUND: The consensus definition of severe sepsis requires suspected or proven infection, organ failure, and signs that meet two or more criteria for the systemic inflammatory response syndrome (SIRS). We aimed to test the sensitivity, face validity, and construct validity of this approach.

METHODS: We studied data from patients from 172 intensive care units in Australia and New Zealand from 2000 through 2013. We identified patients with infection and organ failure and categorized them according to whether they had signs meeting two or more SIRS criteria (SIRS-positive severe sepsis) or less than two SIRS criteria (SIRS-negative severe sepsis). We compared their characteristics and outcomes and assessed them for the presence of a step increase in the risk of death at a threshold of two SIRS criteria.

RESULTS: Of 1,171,797 patients, a total of 109,663 had infection and organ failure. Among these, 96,385 patients (87.9%) had SIRS-positive severe sepsis and 13,278 (12.1%) had SIRS-negative severe sepsis. Over a period of 14 years, these groups had similar characteristics and changes in mortality (SIRS-positive group: from 36.1% [829 of 2296 patients] to 18.3% [2037 of 11,119], P less than 0.001; SIRS-negative group: from 27.7% [100 of 361] to 9.3% [122 of 1315], P less than 0.001). Moreover, this pattern remained similar after adjustment for baseline characteristics (odds ratio in the SIRS-positive group, 0.96; 95% confidence interval [CI], 0.96 to 0.97; odds ratio in the SIRS-negative group, 0.96; 95% CI, 0.94 to 0.98; P=0.12 for between-group difference). In the adjusted analysis, mortality increased linearly with each additional SIRS criterion (odds ratio for each additional criterion, 1.13; 95% CI, 1.11 to 1.15; P less than 0.001) without any transitional increase in risk at a threshold of two SIRS criteria.

CONCLUSIONS: The need for two or more SIRS criteria to define severe sepsis excluded one in eight otherwise similar patients with infection, organ failure, and substantial mortality and failed to define a transition point in the risk of death.

15. Incidence of "never events" among weekend admissions versus weekday admissions to US hospitals: national analysis.

Attenello FJ, et al. BMJ. 2015 Apr 15;350:h1460.

OBJECTIVE: To evaluate the association between weekend admission to hospital and 11 hospital acquired conditions recently considered by the Centers for Medicare and Medicaid as "never events" for which resulting healthcare costs are not reimbursed.

DESIGN: National analysis.

SETTING: US Nationwide Inpatient Sample discharge database.

PARTICIPANTS: 351 million patients discharged from US hospitals, 2002-10.

MAIN OUTCOME MEASURES: Univariate rates and multivariable likelihood of hospital acquired conditions among patients admitted on weekdays versus weekends, as well as the impacts of these events on prolonged length of stay and total inpatient charges.

RESULTS: From 2002 to 2010, 351 170 803 patients were admitted to hospital, with 19% admitted on a weekend. Hospital acquired conditions occurred at an overall frequency of 4.1% (5.7% among weekend admissions versus 3.7% among weekday admissions). Adjusting for patient and hospital cofactors the probability of having one or more hospital acquired conditions was more than 20% higher in weekend admissions compared with weekday admissions (odds ratio 1.25, 95% confidence interval 1.24 to 1.26, P less than 0.01). Hospital acquired conditions have a negative impact on both hospital charges and length of stay. At least one hospital acquired condition was associated with an 83% (1.83, 1.77 to 1.90, P less than 0.01) likelihood of increased charges and 38% likelihood of prolonged length of stay (1.38, 1.36 to 1.41, P less than 0.01).

CONCLUSION: Weekend admission to hospital is associated with an increased likelihood of hospital acquired condition, cost, and length of stay. Future protocols and staffing regulations must be tailored to the requirements of this high risk subgroup.

16. Giant Cell Arteritis: Read the Fine Print!

Jhun P, et al. Ann Emerg Med 2015;65:615-617.

Annals Case: A 75 year-old female presented to the emergency department (ED) complaining of 11 days of a stabbing headache in the right temporal region, without associated jaw claudication or vision changes. She sought evaluation four times in the week prior, but those evaluation results were negative, including head computed tomography, magnetic resonance imaging, and laboratory testing. Physical examination in the ED showed prominent, nontender temporal arteries. Erythrocyte sedimentation rate (ESR) was 10 mm/hour.1

This time around, instead of ending with the diagnosis, we start with the final diagnosis: giant cell arteritis (GCA), also known as temporal arteritis. We skip right to the answer in immature retribution for the patient’s not fully conforming to our handy medical school mnemonic.

First, let’s take a step back and recall what some of us have been taught about GCA. A mnemonic sometimes used is the “rule of 50s”: consider GCA in headache patients who are at least 50 years old and have a serum ESR greater than or equal to 50 mm/hour and then prescribe 50 mg of oral prednisone once a day. Patients should undergo urgent temporal artery biopsy for definitive confirmation, as they say. Not that we expect a mnemonic to carry the full weight of our jobs as diagnosticians, but clearly this “rule” failed us. Let’s dig a little bit deeper…

17. Critical reappraisal of IV metoclopramide in migraine attack: a systematic review and meta-analysis

Eken C. Amer J Emerg Med 2015;33:331–337.

Migraine is one of the most common causes of headache presentations to emergency departments (EDs). Patients with migraine attack need rapid pain relief rather than diagnostic modalities. Metoclopramide, a dopamine antagonist with a primary use of antiemetic, has been used commonly in ceasing migraine attack. An earlier meta-analysis favors metoclopramide over placebo but includes studies with significant methodological errors and heterogeneity. The present article aimed to review the literature to reveal studies comparing metoclopramide to either placebo or active comparators.

A literature search including PubMed, Cochrane Database, and Google Scholar was performed by using the evidence-based process for determining the study quality. Although the studies comparing parenteral metoclopramide to placebo in ceasing migraine headache favor metoclopramide to placebo and lower rates of rescue drug need, however, they lack high methodological quality even to perform a meta-analysis. Meanwhile, the effect of metoclopramide in ceasing migraine headache is also comparable to active comparators.

It seems reasonable to use metoclopramide in migraine attacks in EDs according to the current literature. However, further studies with high methodological quality are needed to reveal whether and how much metoclopramide is superior to placebo.

18. Evaluation of the PE rule-out criteria (PERC) in a retrospective cohort at an urban academic hospital

Bozarth AL, et al. Amer J Emerg Med. 2105;33:483-7.

The pulmonary embolism rule-out criteria (PERC) is an 8-variable clinical decision rule that identifies patients at low risk for pulmonary embolism (PE) to prevent unnecessary diagnostic testing in the evaluation of suspected PE in the emergency department (ED). The objective of this study was to determine PERC's safety and diagnostic use in our institution's ED population.

We performed a retrospective analysis on consecutive adult patients evaluated with computed tomographic angiography (CTA) for suspicion of PE at our ED during the dates January 1, 2011, to December 31, 2011. Patients negative for all 8 PERC criteria (ie, “PERC [−]”) were considered to be at low risk for PE. All data were analyzed using SPSS-20 (SPSS Inc, Chicago, IL) to calculate the variables of interest and their respective 95% confidence intervals (95% CIs).

During the 12-month study period, 729 subjects were evaluated with CTA for suspicion of PE. Ten subjects were excluded because of nondiagnostic imaging studies. After exclusion, 719 subjects were available for analysis. Prevalence of PE was 4.5%. PERC (−) had a sensitivity of 96.9% (95% CI, 84.3%-99.4%), a negative predictive value of 98.8% (95% CI, 93.5%-99.8%), and a negative likelihood ratio of 0.26 (95% CI, 0.04-1.82) when used as an independent diagnostic test to exclude PE.

Use of PERC could have safely avoided 11.5% of CTAs, reducing potential patient harm, health care costs, and unnecessary diagnostic testing. Consistent with prior studies, PERC can be safely used to identify low-risk patients for whom further testing can be deferred.

19. Randomized, Double-Blinded, Clinical Trial of Propofol, 1:1 Propofol/Ketamine, and 4:1 Propofol/Ketamine for Deep Procedural Sedation in the ED.

Miner JR, et al. Ann Emerg Med. 2015 May;65(5):479-488.e2

STUDY OBJECTIVE: We compare the frequency of airway and respiratory adverse events leading to an intervention between propofol with 1:1 and 4:1 mixtures of propofol and ketamine (ketofol).

METHODS: We performed a randomized, double-blinded trial in which emergency department adults undergoing deep sedation received propofol, 1:1 propofol and ketamine, or 4:1 propofol and ketamine. Our primary outcome was the frequency of airway and respiratory adverse events leading to an intervention. Other outcomes included sedation depth, efficacy, procedure and recovery time, patient satisfaction, pain, and procedural recall.

RESULTS: Two hundred seventy-one subjects completed the trial, 90 receiving propofol, 85 receiving 1:1 propofol and ketamine, and 96 receiving 4:1 propofol and ketamine. Airway or respiratory adverse events leading to an intervention were similar between groups: 29%, 19%, and 32%, respectively (P=.21). There were no serious adverse events in any group. Secondary outcomes were generally similar between groups, with greater recovery agitation observed in the 1:1 ketofol group (8%, 21%, and 10%, respectively).

CONCLUSION: We found a similar frequency of airway and respiratory adverse events leading to intervention between propofol alone and either 1:1 or 4:1 ketofol.

20. Abx treatment strategies for community-acquired pneumonia in adults.

Postma DF, et al. N Engl J Med. 2015 Apr 2;372(14):1312-23.

BACKGROUND: The choice of empirical antibiotic treatment for patients with clinically suspected community-acquired pneumonia (CAP) who are admitted to non-intensive care unit (ICU) hospital wards is complicated by the limited availability of evidence. We compared strategies of empirical treatment (allowing deviations for medical reasons) with beta-lactam monotherapy, beta-lactam-macrolide combination therapy, or fluoroquinolone monotherapy.

METHODS: In a cluster-randomized, crossover trial with strategies rotated in 4-month periods, we tested the noninferiority of the beta-lactam strategy to the beta-lactam-macrolide and fluoroquinolone strategies with respect to 90-day mortality, in an intention-to-treat analysis, using a noninferiority margin of 3 percentage points and a two-sided 90% confidence interval.

RESULTS: A total of 656 patients were included during the beta-lactam strategy periods, 739 during the beta-lactam-macrolide strategy periods, and 888 during the fluoroquinolone strategy periods, with rates of adherence to the strategy of 93.0%, 88.0%, and 92.7%, respectively. The median age of the patients was 70 years. The crude 90-day mortality was 9.0% (59 patients), 11.1% (82 patients), and 8.8% (78 patients), respectively, during these strategy periods. In the intention-to-treat analysis, the risk of death was higher by 1.9 percentage points (90% confidence interval [CI], -0.6 to 4.4) with the beta-lactam-macrolide strategy than with the beta-lactam strategy and lower by 0.6 percentage points (90% CI, -2.8 to 1.9) with the fluoroquinolone strategy than with the beta-lactam strategy. These results indicated noninferiority of the beta-lactam strategy. The median length of hospital stay was 6 days for all strategies, and the median time to starting oral treatment was 3 days (interquartile range, 0 to 4) with the fluoroquinolone strategy and 4 days (interquartile range, 3 to 5) with the other strategies.

CONCLUSIONS: Among patients with clinically suspected CAP admitted to non-ICU wards, a strategy of preferred empirical treatment with beta-lactam monotherapy was noninferior to strategies with a beta-lactam-macrolide combination or fluoroquinolone monotherapy with regard to 90-day mortality.

21. Poisoning in the United States: 2012 Emergency Medicine Report of the National Poison Data System

Dart RC, et al. Ann Emerg Med. 2015;65:416–422.

Deaths from drug overdose have become the leading cause of injury death in the United States, where the poison center system is available to provide real-time advice and collect data about a variety of poisonings. In 2012, emergency medical providers were confronted with new poisonings, such as bath salts (substituted cathinones) and Spice (synthetic cannabinoid drugs), as well as continued trends in established poisonings such as from prescription opioids. This article addresses current trends in opioid poisonings; new substances implicated in poisoning cases, including unit-dose laundry detergents, bath salts, Spice, and energy drinks; and the role of poison centers in public health emergencies such as the Fukushima radiation incident.

22. Career benefits associated with mentoring for mentors: a meta-analysis

Ghosha R, et al. J Vocational Behav 2013;83:106-116.

Mentoring has been studied extensively as it is linked to protégé career development and growth. Recent mentoring research is beginning to acknowledge however that mentors also can accrue substantial benefits from mentoring.

A meta-analysis was conducted where the provision of career, psychosocial and role modeling mentoring support were associated with five types of subjective career outcomes for mentors: job satisfaction, organizational commitment, turnover intent, job performance, and career success.

The findings indicated that mentors versus non-mentors were more satisfied with their jobs and committed to the organization. Providing career mentoring was most associated with career success, psychosocial mentoring with organizational commitment, and role modeling mentoring with job performance. Turnover intent was not linked significantly with any of the subjective career outcome variables.

The findings support mentoring theory in that mentoring is reciprocal and collaborative and not simply beneficial for protégés. Longitudinal research is needed however to determine the degree to which providing mentoring impacts a mentor’s career over time. By alerting prospective mentors to the possible personal benefits of providing career, psychosocial, and role modeling mentoring support for protégés, HRD professionals can improve recruitment efforts for mentoring programs.

23. Use of ondansetron during pregnancy and congenital malformations in the infant.

Danielsson B, et al. Repro Tox 2014;50:134-7

The study investigates teratogenic risks with ondansetron (Zofran®). Data from the Swedish Medical Birth Register combined with the Swedish Register of Prescribed Drugs were used to identify 1349 infants born of women who had taken ondansetron in early pregnancy, 1998-2012. Presence of congenital malformations in the offspring was identified with three national health registers.

In a Mantel-Haenszel analysis adjustment was made for year of delivery, maternal age, parity, smoking in early pregnancy and pre-pregnancy body mass index. Risks were expressed as odds or risk ratios with 95% confidence intervals.

No statistically significantly increased risk for a major malformation was found. The risks for a cardiovascular defect and notably a cardiac septum defect were increased and statistically significant (OR=1.62, 95% CI 1.04-2.14, and RR 2.05, 95% CI 1.19-3.28, respective). The teratogenic risk with ondansetron is low but an increased risk for a cardiac septum defect is likely.

24. Canadian Association of Emergency Physicians Position Statement on Acute Ischemic Stroke 

Harris D, et al. CJEM; 2015;17:217 – 226.

Stroke systems of care should be developed to optimize prehospital triage and transport to designated stroke centers. We recommend intravenous thrombolysis for eligible acute ischemic stroke patients who can be treated within three hours of stroke symptom onset. We suggest against intravenous thrombolysis for eligible patients who would receive treatment between 3 to 4.5 hours after symptom onset until further research is available. The majority of stroke patients should be managed in dedicated stroke units. Telestroke should be supported as a means of providing acute stroke expertise where local support is limited. Rural settings represent unique challenges to the safe and effective administration of thrombolytic therapy within the three hour time window. In some of these settings adherence to a 3 hour mark may not be possible.

25. Micro Bits

A. New study refutes link between MMR vaccine, autism

A large study published in the Journal of the American Medical Association found that the measles, mumps and rubella vaccine does not increase the risk of autism spectrum disorder, even in children who are considered to be at an increased risk because of an older sibling with the disorder. The findings revealed that among the 95,727 children followed, the 2% with an older sibling with ASD had a greater risk of developing the disorder themselves, but the risk was not affected by whether or not they received the MMR vaccine.

B. Getting the Right Medical Students — Nature versus Nurture

Schwartzstein RM. N Engl J Med 2015; 372:1586-1587

The video shows a fourth-year medical student interviewing a patient. The student is a bit awkward and is using technical terms and inappropriate body language. A leading medical educator asks, “How did we let this student into medical school?” “Wherever I travel,” he continues, “I hear from public officials that doctors demonstrate little empathy and don't communicate well with patients. We have to fix the problem. We have to screen for more humanistic students in our admissions processes.”

With many patients complaining about doctors' poor interpersonal skills, it's hard to deny that there's a problem. No admissions process is perfect, and some students admitted to medical school may well demonstrate little empathy or lack the requisite communication skills to be effective doctors — but is that the primary cause of the problem?

C. Recognizing Measles: A Patient Handout

D. Acute Stroke Intervention: A Systematic Review

Prabhakaran S, et al. JAMA. 2015;313(14):1451-1462.

Conclusions: Intravenous rtPA remains the standard of care for patients with moderate to severe neurological deficits who present within 4.5 hours of symptom onset. Outcomes for some patients with acute ischemic stroke and moderate to severe neurological deficits due to proximal artery occlusion are improved with endovascular reperfusion therapy. Efforts to hasten reperfusion therapy, regardless of the mode, should be undertaken within organized stroke systems of care.

E. A Randomized Trial on Subject Tolerance and the Adverse Effects Associated With Higher- versus Lower-Flow Oxygen through a Standard Nasal Cannula

Participants were able to tolerate higher-flow nasal cannula oxygen for 10 minutes without difficulty. Higher-flow nasal cannula oxygen at 15 L/minute was associated with some discomfort, but the discomfort quickly dissipated and caused no adverse events.

F. Workplace Violence in the ED: Giving Nursing Staff the Tools and Support to Report

Workplace violence is increasing across the nation's Emergency Departments, and nurses often perceive it as part of their job. Reporting processes were inconsistent, and nurses often did not know what acts constitute violence and underreported it. A staff nurse-led workgroup developed an initial survey and a reporting tool, and education was provided. A posteducation survey documented the reporting of violent acts has increased, and staff perceived the Emergency Department to be a safer environment.

G. Noninvasive Sphenopalatine Ganglion Block for Acute Headache in the ED: A Randomized Placebo-Controlled Trial

CONCLUSION: For patients with acute anterior headache, sphenopalatine ganglion block with the Tx360 device with bupivacaine did not result in a significant increase in the proportion of patients achieving a greater than or equal to 50% reduction in headache severity at 15 minutes compared with saline solution applied in the same manner.

H. High blood pressure overtreatment bad for the cognition of impaired patients

I. Patients with health coaches more likely to hit goals, study says

Patients who had health coaches were more likely than those receiving usual care to meet clinical goals for hemoglobin A1C, blood pressure and cholesterol, according to a study from the University of California at San Francisco. The study, published in the Annals of Family Medicine, used medical assistants trained to be health coaches in primary care clinics.