1. Use of Oral Contrast for Abdominal CT in Children with Blunt
Torso Trauma.
Ellison AM,
et al. Pediatric Emergency Care Applied Research Network (PECARN). Ann Emerg
Med. 2015 Aug;66(2):107-114.e4.
STUDY
OBJECTIVE: We compare test characteristics of abdominal computed tomography
(CT) with and without oral contrast for identifying intra-abdominal injuries.
METHODS: This
was a planned subanalysis of a prospective, multicenter study of children (less
than 18 years) with blunt torso trauma. Children imaged in the emergency
department with abdominal CT using intravenous contrast were eligible. Oral
contrast use was based on the participating centers' guidelines and
discretions. Clinical courses were followed to identify patients with
intra-abdominal injuries. Abdominal CTs were considered positive for
intra-abdominal injury if a specific intra-abdominal injury was identified and
considered abnormal if any findings suggestive of intra-abdominal injury were
identified on the CT.
RESULTS: A
total of 12,044 patients were enrolled, with 5,276 undergoing abdominal CT with
intravenous contrast. Of the 4,987 CTs (95%) with documented use or nonuse of
oral contrast, 1,010 (20%) were with and 3,977 (80%) were without oral
contrast; 686 patients (14%) had intra-abdominal injuries, including 127 CTs
(19%) with and 559 (81%) without oral contrast. The sensitivity in the
detection of any intra-abdominal injury in the oral contrast versus no oral
contrast groups was sensitivity contrast 99.2% (95% confidence interval [CI]
95.7% to 100.0%) versus sensitivity no contrast 97.7% (95% CI 96.1% to 98.8%),
difference 1.5% (95% CI -0.4% to 3.5%). The specificity of the oral contrast
versus no oral contrast groups was specificity contrast 84.7% (95% CI 82.2% to
87.0%) versus specificity no contrast 80.8% (95% CI 79.4% to 82.1%), difference
4.0% (95% CI 1.3% to 6.7%).
CONCLUSION:
Oral contrast is still used in a substantial portion of children undergoing
abdominal CT after blunt torso trauma. With the exception of a slightly better
specificity, test characteristics for detecting intra-abdominal injury were
similar between CT with and without oral contrast.
2. The Relation between Patients' NRS Pain Scores and Their
Desire for Additional Opioids after Surgery.
van Dijk JF,
et al. Pain Pract. 2014 Apr 16 [Epub ahead of print]
BACKGROUND:
Postoperative pain is commonly assessed through a numerical rating scale (NRS),
an 11-point scale where 0 indicates no pain and 10 indicates the worst
imaginable pain. Guidelines advise the administration of analgesics at NRS pain
scores above 3 or 4. In clinical practice, not all patients with pain scores
above the treatment threshold are willing to accept additional analgesic
treatment, especially when opioids are offered. The objective of this study is
to measure the relation between patients' NRS pain scores and their desire for
additional opioids.
METHODS: This
cross-sectional study examined 1,084 patients in an academic hospital the day
after surgery between January 2010 and June 2010. The day after surgery,
patients were asked to score their pain and desire for opioids. Sensitivity,
specificity, positive predictive value, and negative predictive value of the
desire for opioids and the different NRS thresholds were calculated.
RESULTS: Only
when patients scored an 8 or higher on the NRS did the majority express a need
for opioids. Many patients did not desire opioids, because they considered
their pain tolerable, even at an NRS score above 4.
CONCLUSIONS:
With the current guidelines (ie, using pain scores above 3 or 4 for prescribing
opioids), many patients could be overtreated. Therefore, scores generated by
the NRS should be interpreted individually.
3. Perception vs Actual Performance in Timely tPA Administration
in the Management of Acute Ischemic Stroke.
Lin CB, et
al. J Am Heart Assoc. 2015 Jul 22;4(7).
BACKGROUND:
Timely thrombolytic therapy can improve stroke outcomes. Nevertheless, the
ability of US hospitals to meet guidelines for intravenous tissue plasminogen
activator (tPA) remains suboptimal. What is unclear is whether hospitals
accurately perceive their rate of tPA "door-to-needle" (DTN) time
within 60 minutes and how DTN rates compare across different hospitals.
METHODS AND
RESULTS: DTN performance was defined by the percentage of treated patients who
received tPA within 60 minutes of arrival. Telephone surveys were obtained from
staff at 141 Get With The Guidelines hospitals, representing top, middle, and
low DTN performance. Less than one-third (29.1%) of staff accurately identified
their DTN performance. Among middle- and low-performing hospitals (n=92), 56 sites
(60.9%) overestimated their performance; 42% of middle performers and 85% of
low performers overestimated their performance. Sites that overestimated tended
to have lower annual volumes of tPA administration (median 8.4 patients [25th
to 75th percentile 5.9 to 11.8] versus 10.2 patients [25th to 75th percentile
8.2 to 17.3], P=0.047), smaller percentages of eligible patients receiving tPA
(84.7% versus 89.8%, P=0.008), and smaller percentages of DTN ≤60 minutes among
treated patients (10.6% versus 16.6%, P=0.002).
CONCLUSIONS:
Hospitals often overestimate their ability to deliver timely tPA to treated
patients. Our findings indicate the need to routinely provide comparative
provider performance rates as a key step to improving the quality of acute
stroke care.
4. The Diagnosis of Ectopic Pregnancy
Barker LT, et
al. Ann Emerg Med. 2015;66:192-3.
Bottom Line: Transvaginal
sonography should be used in conjunction with quantitative serum β-hCG testing
to rule out ectopic pregnancy in hemodynamically stable patients. No single
level of β-hCG can be used in isolation to rule out ectopic pregnancy.
Commentary
Ectopic pregnancy
is estimated to affect 20.7 of every 1,000 pregnancies,2 and delayed diagnosis increases maternal
morbidity and mortality.3 This meta-analysis demonstrated the value of
transvaginal sonography in the diagnostic evaluation of possible ectopic pregnancy
and suggested that β-hCG levels may provide supporting evidence, but only when
followed serially. Only identification of intrauterine pregnancy by
transvaginal sonography safely rules out ectopic pregnancy in patients at low
risk for heterotopic pregnancy,4 and transvaginal sonography is accurate when
performed by emergency physicians.5 For hemodynamically stable patients,
therefore, inconclusive ultrasonography results should prompt close follow-up
with serial β-hCG and ultrasonography to both protect an undetectable
intrauterine pregnancy and ensure early detection of ectopic pregnancy.
5. Can a Clinical Prediction Rule Reliably Predict Pediatric
Bacterial Meningitis?
Ostermayer
DG, et al. Ann Emerg Med. 2015;66:123-4.
Bottom Line: No
current clinical prediction rule can reliably determine which children should
be hospitalized and treated with intravenous antibiotics for bacterial
meningitis.
Commentary
Currently,
decisions about empiric treatment for suspected bacterial meningitis are based
on physical examination findings and results of cerebrospinal fluid testing.
However, the majority of initially treated suspected bacterial meningitis is
actually aseptic, with only 6% to 18% of patients receiving a final diagnosis
of bacterial meningitis.6
The
decreasing prevalence of bacterial meningitis is largely due to vaccinations
against Haemophilus influenza type B and Streptococcus pneumonia, decreasing
the likelihood that an elevated cerebrospinal fluid WBC count correlates with a
bacterial cause.7
A clinical
prediction rule that incorporates a patient’s clinical status in addition to
laboratory values has the potential to efficiently guide the use of empiric
intravenous antibiotics in children with suspected meningitis. However, the
majority of the rules included in this review used chart review, an ultimately
unreliable methodology for prediction rule development.
In general,
decision rules accurate and reliable enough to allow providers and parents to
forgo testing, empiric treatment, or admission when bacterial meningitis is a
consideration should be developed and validated prospectively. None of the
currently derived and validated clinical prediction rules for bacterial
meningitis follow these methods or have been shown adequate to recommend their
use. The Bacterial Meningitis Score reported the best performance but has not
been prospectively validated or replicated. Impact studies on the most
effective and safe method for determining whether a child with suspected
bacterial meningitis requires intravenous antibiotics are still needed.
6. Diltiazem vs. Metoprolol in the Management of Atrial
Fibrillation or Flutter with Rapid Ventricular Rate in the ED
Fromm C, et
al. J Emerg Med, 2015;49:175-82.
Background: Diltiazem
(calcium channel blocker) and metoprolol (beta-blocker) are both commonly used
to treat atrial fibrillation/flutter (AFF) in the emergency department (ED).
However, there is considerable regional variability in emergency physician
practice patterns and debate among physicians as to which agent is more
effective. To date, only one small prospective, randomized trial has compared
the effectiveness of diltiazem and metoprolol for rate control of AFF in the ED
and concluded no difference in effectiveness between the two agents.
Objective: Our
aim was to compare the effectiveness of diltiazem with metoprolol for rate
control of AFF in the ED.
Methods: A
convenience sample of adult patients presenting with rapid atrial fibrillation
or flutter was randomly assigned to receive either diltiazem or metoprolol. The
study team monitored each subject's systolic and diastolic blood pressures and
heart rates for 30 min.
Results: In
the first 5 min, 50.0% of the diltiazem group and 10.7% of the metoprolol group
reached the target heart rate (HR) of less than 100 beats per minute (bpm) (p less
than 0.005). By 30 min, 95.8% of the diltiazem group and 46.4% of the
metoprolol group reached the target HR less than 100 bpm (p less than 0.0001).
Mean decrease in HR for the diltiazem group was more rapid and substantial than
that of the metoprolol group. From a safety perspective, there was no
difference between the groups with respect to hypotension (systolic blood
pressure less than 90 mm Hg) and bradycardia (HR less than 60 bpm).
Conclusions: Diltiazem
was more effective in achieving rate control in ED patients with AFF and did so
with no increased incidence of adverse effects.
7. Evaluation of online “symptom checkers” for self-diagnosis
and triage: audit study
Semigran HL. BMJ
2015;351:h3480
Introduction
Members of
the public are increasingly using the internet to research their health
concerns. For example, the United Kingdom’s online patient portal for national
health information, NHS Choices, reports over 15 million visits per month.1
More than a third of adults in the United States regularly use the internet to
self diagnose their ailments, using it both for non-urgent symptoms and for
urgent symptoms such as chest pain.2 3 While there is a wealth of online
resources to learn about specific conditions, self diagnosis usually starts
with search engines like Google, Bing, or Yahoo.2 However, internet search
engines can lead users to confusing and sometimes unsubstantiated information,
and people with urgent symptoms may not be directed to seek emergent care.3 4 5
6 Recently there has been a proliferation of more sophisticated programs called
symptom checkers that attempt to more effectively provide a potential diagnosis
for patients and direct them to the appropriate care setting.3 6 7 8 9 10 11 12
13
Using
computerized algorithms, symptom checkers ask users a series of questions about
their symptoms or require users to input details about their symptoms
themselves. The algorithms vary and may use branching logic, bayesian
inference, or other methods. Private companies and other organizations,
including the National Health Service, the American Academy of Pediatrics, and
the Mayo Clinic, have launched their own symptom checkers. One symptom checker,
iTriage, reports 50 million uses each year.14 Typically, symptom checkers are
accessed through websites, but some are also available as apps for smart phones
or tablets.
Symptom
checkers serve two main functions: to facilitate self diagnosis and to assist
with triage. The self diagnosis function provides a list of diagnoses, usually
rank ordered by likelihood. The diagnosis function is typically framed as
helping educate patients on the range of diagnoses that might fit their
symptoms. The triage function informs patients whether they should seek care at
all and, if so, where (that is, emergency department, general practitioner’s
clinic) and with what urgency (that is, emergently or within a few days).
Symptom checkers may supplement or replace telephone triage lines, which are
common in primary care.15 16 17 18 To ensure the safety of medical mobile apps,
the US Congress is considering the regulation of apps that “provide a list of
possible medical conditions and advice on when to consult a health care
provider.”19 20
Symptom
checkers have several potential benefits. They can encourage patients with a
life threatening problem such as stroke or heart attack to seek emergency
care.21 For patients with a non-emergent problem that does not require a
medical visit, these programs can reassure people and recommend they stay home.
For approximately a quarter of visits for acute respiratory illness such as
viral upper respiratory tract infection, patients do not receive any
intervention beyond over the counter treatment,22 and over half of patients
receive unnecessary antibiotics.23 24 25 Reducing the number of visits saves
patients’ time and money, deters overprescribing of antibiotics, and may
decrease demand on primary care providers—a critical problem given that the
workload for general practitioners in the United Kingdom increased by 62% from
1995 to 2008.17 However, there are several key concerns. If patients with a
life threatening problem are misdiagnosed and not told to seek care, their
health could worsen, increasing morbidity and mortality. Alternatively, if patients
with minor illnesses are told to seek care, in particular in an emergency
department, such programs could increase unnecessary visits and therefore
result in increased time and costs for patients and society.
The impact of
symptom checkers will depend to a large degree on their clinical performance.
To measure the accuracy of diagnosis and triage advice provided by symptom
checkers, we used 45 standardized patient vignettes to audit 23 symptom
checkers. The vignettes reflected a range of conditions from common to less
common and low acuity to life threatening.
Abstract
OBJECTIVE: To
determine the diagnostic and triage accuracy of online symptom checkers (tools
that use computer algorithms to help patients with self diagnosis or self
triage).
DESIGN: Audit
study.
SETTING:
Publicly available, free symptom checkers.
PARTICIPANTS:
23 symptom checkers that were in English and provided advice across a range of
conditions. 45 standardized patient vignettes were compiled and equally divided
into three categories of triage urgency: emergent care required (for example,
pulmonary embolism), non-emergent care reasonable (for example, otitis media),
and self care reasonable (for example, viral upper respiratory tract
infection).
MAIN OUTCOME
MEASURES: For symptom checkers that provided a diagnosis, our main outcomes
were whether the symptom checker listed the correct diagnosis first or within
the first 20 potential diagnoses (n=770 standardized patient evaluations). For
symptom checkers that provided a triage recommendation, our main outcomes were
whether the symptom checker correctly recommended emergent care, non-emergent
care, or self care (n=532 standardized patient evaluations).
RESULTS: The
23 symptom checkers provided the correct diagnosis first in 34% (95% confidence
interval 31% to 37%) of standardized patient evaluations, listed the correct
diagnosis within the top 20 diagnoses given in 58% (55% to 62%) of standardized
patient evaluations, and provided the appropriate triage advice in 57% (52% to
61%) of standardized patient evaluations. Triage performance varied by urgency
of condition, with appropriate triage advice provided in 80% (95% confidence
interval 75% to 86%) of emergent cases, 55% (47% to 63%) of non-emergent cases,
and 33% (26% to 40%) of self care cases (P less than 0.001). Performance on
appropriate triage advice across the 23 individual symptom checkers ranged from
33% (95% confidence interval 19% to 48%) to 78% (64% to 91%) of standardized
patient evaluations.
CONCLUSIONS:
Symptom checkers had deficits in both triage and diagnosis. Triage advice from
symptom checkers is generally risk averse, encouraging users to seek care for
conditions where self care is reasonable.
8. Low-Value Care for Acute Sinusitis Encounters: Who’s Choosing
Wisely?
Sharp AL, et
al. Am J Manag Care. 2015;21(7):479-485.
Objectives:
To assess acute sinusitis (AS) encounters in primary care (PC), urgent care
(UC), and emergency department (ED) settings for adherence to recommendations
to avoid low-value care. Study Design: A retrospective, observational study of
adult AS encounters (2010-2012) within a large integrated healthcare system.
Methods: We
compared ED and UC encounters with PC visits, adjusting for differences in
patient characteristics. Primary outcomes: adherence to recommendations to
avoid antibiotics and a computed tomography (CT) scan of the face, head, or
sinuses. Secondary outcomes: length of symptoms and adherence with AS
recommendations.
Results: Of
152,774 AS encounters, 89.2% resulted in antibiotics and 1.1% resulted in a CT
scan. Compared with PC encounters, ED encounters were less likely to result in
antibiotics (adjusted odds ratio [AOR], 0.57; 95% CI, 0.50-0.65) but more
likely to result in a CT scan (AOR, 59.4; 95% CI, 51.3-68.7), while UC
encounters were more likely to result in both antibiotics (AOR, 1.12; 95% CI,
1.08-1.17) and CT imaging (AOR, 2.4; 95% CI, 2.1-2.7). Chart review of
encounters resulting in antibiotics found that 50% were inappropriately
prescribed for symptoms of ≤7 days’ duration (95% CI, 41%-58%), while 35% were
appropriately prescribed for symptoms of ≥14 days’ duration (95% CI, 27%-44%).
Only 29% (95% CI, 22%-36%) of encounters were consistent with
guideline-adherent care.
Conclusions:
AS encounters in an integrated health system infrequently result in CT imaging,
but antibiotic treatment is common. Differences exist across acute care
settings, but improved antibiotic stewardship is needed in all settings. Am J
Manag Care. 2015;21(7):479-485
Take-Away
Points
Acute
sinusitis (AS) impacts millions annually and presents an opportunity to assess
and improve the quality of care individuals receive. Our study is the first to
report computed tomography (CT) and antibiotic prescribing practices for acute
sinusitis comparing different care settings.
Our primary
results are summarized below:
·
Less
than 1% of patients receive CT imaging contrary to recommendations.
·
Nine
in 10 initial AS encounters result in antibiotics.
·
Primary
care orders fewer CT scans and antibiotics than urgent care.
·
Primary
care orders fewer CT scans but more antibiotics than the emergency department.
·
All
settings could significantly improve antibiotic stewardship for AS.
Full-text
(free): http://www.ajmc.com/journals/issue/2015/2015-vol21-n7/Low-Value-Care-for-Acute-Sinusitis-Encounters-Choosing-Wisely
9. Hallway Patients Reduce Overall ED Satisfaction
Stiffler KA,
et al. J Emerg Med 2015;49:211-6.
Background: Patient
satisfaction impacts emergency medicine in multiple ways, including
patient−physician rapport, patient compliance with medical recommendations, and
individual physician and hospital reimbursement issues.
Objective: The
objective of this study was to assess the differences, if any, in satisfaction
scores among patients treated in regular treatment rooms vs. those treated in
hallway treatment areas.
Methods: A
cross-sectional survey study of conveniently sampled participants from both
regular treatment rooms and hallway treatment areas in an urban, adult
community teaching emergency department (ED) was performed confidentially,
measuring overall satisfaction, as well as satisfaction with regard to
treatment location only, medical care only, and their willingness to return to
or recommend the ED in the future based on their experience. Each of these four
outcomes was measured on a 100-mm visual analog scale.
Results: Overall
satisfaction scores were 8 mm lower for those patients treated in hallway
treatment areas, and there was a 20-mm difference with regard to location only.
After controlling for apparent baseline differences between the groups, a 7.6-mm
difference for overall satisfaction remained.
Conclusions: Despite
differences between patients placed in regular treatment rooms vs. hallway
treatment areas, overall satisfaction levels are lower for those patients
treated in hallway treatment areas. This difference is likely attributable
primarily to their hallway location, and stakeholders should therefore take
appropriate steps to address such discrepancies.
10. Is the stethoscope becoming outdated?
Frishman WH.
Amer J Cardiol. 2015;128:668-9.
During the
past hundred years, the three major symbols representing the bedside physician
have been the "black bag," the white coat, and the stethoscope. It
was a badge of honor during my second year of medical school to obtain all
three items in anticipation of seeing patients on the hospital wards after the
preclinical lecture hall experience. The stethoscope dangling from the pocket
of the white coat or wrapped around the back of the neck meant to the outside
world that you were now a member of the healing profession.
The “black
bag” is no longer a physician symbol because house calls are no longer part of
routine clinical care. Will the stethoscope also meet the same fate, given that
handheld ultrasound devices have now become available to better define cardiac
anatomy, hemodynamics, and pathophysiology?1
Since the
time of its introduction in 1816, the stethoscope has been an invaluable
bedside tool for auscultating heart sounds.2 During the golden age of early
19th century French medicine, with the use of the stethoscope, the physical
examination became an integral part of clinical assessment.3 Dr. René Laennec
would become the leading proponent of this diagnostic approach. Laennec was a
student of Dr. Jean-Nicolas Corvisart at the Charité in Paris, one of the
leading teaching hospitals in Europe.3 Subsequently, as an attending physician
at the Necker-Enfants Malades Hospital in Paris, Laennec introduced a
cylindrical device, open at each end, to auscultate the thorax. He called this
device a stethoscope, whose name derived from the Greek word for chest,
stethos, and the word for observer, skopos.3 With his discovery, Laennec, an
accomplished musician, was able to differentiate various diseases of the chest
by physical examination and correlate his findings with autopsy studies.3 He
reported on his work with the early stethoscope in the classic text De
l'Auscultation Médiate,4 which was published in 2 editions. Ultimately, the
cylindrical stethoscope was improved upon by Dr. George Cammann 40 years later,
after the introduction of rubber, by introducing a device having hearing pieces
that fit into the examiner's ears.5 Other refinements included the bell to
discern low-pitched sounds, and the diaphragm, to better hear high-pitched
sounds. Most recently electronic stethoscopes with microphone amplifiers have
become available. For almost 200 years the stethoscope, the first bedside
diagnostic tool, has remained a central part of the thoracic examination. Many
of the great clinicians made their reputations as masters of auscultation.
Whether these physicians actually heard everything they claimed to hear was
always a question.
During my
career in academic cardiology, the introduction of ultrasound devices has
provided the ability to visualize both anatomic structures of the heart and to
assess myocardial function, technologies going well beyond the capabilities of
the stethoscope. Most recently handheld ultrasound devices, which can fit into
the pocket of a physician's white coat, have demonstrated the ability to make
more accurate diagnoses at the bedside when compared with standard examination
using the stethoscope.6 In some medical schools students are being trained to
use these handheld devices as part of their curriculum.7 Physicians working in
the emergency room and critical care units are being trained on this
technology.8 Primary care physicians are also potential operators of these
handheld devices.9, 10
The
stethoscope may indeed be replaced by handheld ultrasound devices, at least for
cardiac examination. It will still be necessary to use the stethoscope for
pulmonary examination and for auscultation of the abdomen to hear bowel sounds
and bruits.
At present
the handheld devices are expensive when compared with the cost of a
stethoscope. However, their use could save money for the healthcare system if
the need for conventional ultrasound studies or other diagnostic tests can be
lowered.6, 10
We may also
see a return of the “black bag,” to store the handheld ultrasound devices when
they are not being used.
11. Revisiting the "Golden Hour": An Evaluation of
Out-of-Hospital Time in Shock and Traumatic Brain Injury.
Newgard CD,
et al. ROC Investigators. Ann Emerg Med. 2015 Jul;66(1):30-41.e3.
STUDY
OBJECTIVE: We evaluate patients with shock and traumatic brain injury who were
previously enrolled in an out-of-hospital clinical trial to test the
association between out-of-hospital time and outcome.
METHODS: This
was a secondary analysis of patients with shock and traumatic brain injury who
were aged 15 years or older and enrolled in a Resuscitation Outcomes Consortium
out-of-hospital clinical trial by 81 emergency medical services agencies
transporting to 46 Level I and II trauma centers in 11 sites (May 2006 through
May 2009). Inclusion criteria were systolic blood pressure less than or equal
to 70 mm Hg or systolic blood pressure 71 to 90 mm Hg with pulse rate greater
than or equal to 108 beats/min (shock cohort) and Glasgow Coma Scale score less
than or equal to 8 (traumatic brain injury cohort); patients meeting both
criteria were placed in the shock cohort. Primary outcomes were 28-day
mortality (shock cohort) and 6-month Glasgow Outcome Scale-Extended score less
than or equal to 4 (traumatic brain injury cohort).
RESULTS:
There were 778 patients in the shock cohort (26% 28-day mortality) and 1,239
patients in the traumatic brain injury cohort (53% 6-month Glasgow Outcome
Scale-Extended score ≤4). Out-of-hospital time greater than 60 minutes was not
associated with worse outcomes after accounting for important confounders in
the shock cohort (adjusted odds ratio [aOR] 1.42; 95% confidence interval [CI]
0.77 to 2.62) or traumatic brain injury cohort (aOR 0.77; 95% CI 0.51 to 1.15).
However, shock patients requiring early critical hospital resources and
arriving after 60 minutes had higher 28-day mortality (aOR 2.37; 95% CI 1.05 to
5.37); this finding was not observed among a similar traumatic brain injury
subgroup.
CONCLUSION:
Among out-of-hospital trauma patients meeting physiologic criteria for shock
and traumatic brain injury, there was no association between time and outcome.
However, the subgroup of shock patients requiring early critical resources and
arriving after 60 minutes had higher mortality.
12. Images in Clinical Practice
Female with
Leg Lesion
Pyoderma
Gangrenosum: An Inside Job
Abdominal
Pain in an Adolescent Female
Neck
Impalement during Mountain Biking
Cervical
Meningocele
Secondary
Palatal Myoclonus
Diffuse Soft
Tissue Calcinosis
Coral
Dermatitis
Pneumomediastinum
diagnosed on ultrasound in the Emergency Department: a case report
Leukocytoclastic
Vasculitis
Inferior
Mesenteric Vein Thrombosis
13. The prevalence of PE among patients suffering from acute
exacerbations of COPD
Shapira-Rootman
M, et al. Emerg Radiol. 2015 Jun;22(3):257-60.
The clinical
diagnosis of acute pulmonary embolism (PE) in patients with acute exacerbation
of chronic obstructive pulmonary disease (COPD) is often difficult due to the
similarity in the presenting symptoms of the two conditions. The purpose of
this study was to determine the prevalence of PE in patients with acute
exacerbation of COPD.
Forty-nine
consecutive patients admitted to our medical center for acute exacerbation of
COPD were investigated for PE (whether or not clinically suspected), following
a standardized algorithm based on D-dimer testing and computed tomography
pulmonary angiography (CTPA). PE was ruled out by a D-dimer value less than 500
μg/L in 20 (41 %) patients and by negative CTPA in 40 (82 %). PE was confirmed
in 9 patients. The prevalence of PE was 18 %. One patient with normal D-dimer
had PE. Presenting symptoms and signs were similar between patients who did and
did not have PE. PE was detected in 18 % of COPD patients who were hospitalized
for an acute exacerbation.
This finding
supports the systematic evaluation of PE in hospitalized COPD exacerbated
patients.
14. ED Extremity Radiographs in the Setting of Pain Without
Trauma: Are They Worth the Pain?
Friedman A,
et al. J Emerg Med. 2015;49:152–158.
Background: Few
data exist that correlate acute radiographic findings of extremity imaging with
patients' complaints in the acute care setting.
Objective: We
hypothesize that plain radiographs performed for a complaint of pain in the
absence of trauma or signs and symptoms of infection are of low yield.
Methods: We
retrospectively analyzed the imaging and charts of 1331 patients who presented
to our emergency department (ED) and received extremity radiographs with
complaints related to limb trauma, infection, and pain alone. Imaging and
outcomes of cases interpreted as positive for acute pathology and those
interpreted as indeterminate were analyzed using Fisher's exact tests to
evaluate the value of extremity radiographs in the setting of isolated limb
pain.
Results: Of
the patients analyzed, 935 presented with trauma, 234 presented with
nontraumatic pain, and 161 presented with signs or symptoms of infection. The
rate of definitively positive cases was 30.6% for trauma, 20.6% for infection,
and 1.3% for pain. When indeterminate cases were included in the analysis, the
rate of acutely positive cases rose to 33.4% for trauma, 28.0% for infection,
and 3.0% for pain. Among the three definitively positive pain cases, all three
were fractures, none of which resulted in emergent surgery or orthopedic
consults. Among the four indeterminately positive pain cases, three proved to
be false positives.
Conclusions: Our
data suggest that ED imaging of patients presenting with nontraumatic pain is
of extremely low yield, resulting in few acute positive findings that require
immediate attention in the ED.
15. Interunit handoffs from ED to inpatient care: A
cross-sectional survey of physicians at a university medical center
Smith CJ, et
al. J Hosp Med. 2015 July 22 [Epub ahead of print].
BACKGROUND: Emergency
department (ED) to inpatient physician handoffs are subject to complex
challenges. We assessed physicians' perceptions of the ED admission handoff
process and identified potential barriers to safe patient care.
METHODS: We
conducted a cross-sectional survey at a 627-bed tertiary care academic medical
center. Eligible participants included all resident, fellow, and faculty
physicians directly involved in admission handoffs from emergency medicine (EM)
and 5 medical admitting services. The survey addressed communication quality,
clinical information, interpersonal perceptions, assignment of
responsibilities, organizational factors, and patient safety. Participants
reported their responses via a 5-point Likert scale and an open-ended
description of handoff-related adverse events.
RESULTS: Response
rates were 63% for admitting (94/150) and 86% for EM physicians (32/37).
Compared to EM respondents, admitting physicians reported that vital clinical
information was communicated less frequently for all 8 content areas (P less
than 0.001). Ninety-four percent of EM physicians felt defensive at least
“sometimes.” Twenty-nine percent of all respondents reported handoff-related
adverse events, most frequently related to ineffective communication.
Sequential handoffs were common for both EM and admitting services, with 78% of
physicians reporting they negatively impacted patient care.
CONCLUSION: Physicians
reported that patient safety was often at risk during the ED admission handoff
process. Admitting and EM physicians had divergent perceptions regarding
handoff communication, and sequential handoffs were common. Further research is
needed to better understand this complex process and to investigate strategies
for improvement. Journal of Hospital Medicine 2015. © 2015 Society of Hospital
Medicine
16. Stroke Mimics and Acute Stroke Evaluation: Clinical
Differentiation and Complications after Intravenous tPA.
Nguyen PL, et
al. J Emerg Med. 2015;49:244-252.
BACKGROUND:
Intravenous tissue-plasminogen activator remains the only U.S. Food and Drug
Administration-approved treatment for acute ischemic stroke. Timely
administration of fibrinolysis is balanced with the need for accurate
diagnosis. Stroke mimics represent a heterogeneous group of patients presenting
with acute-onset focal neurological deficits. If these patients arrive within the
extended time window for acute stroke treatment, these stroke mimics may
erroneously receive fibrinolytics.
OBJECTIVE:
This review explores the literature and presents strategies for differentiating
stroke mimics.
DISCUSSION:
Clinical outcome in stroke mimics receiving fibrinolytics is overwhelmingly
better than their stroke counterparts. However, the risk of symptomatic
intracranial hemorrhage remains a real but rare possibility. Certain presenting
complaints and epidemiological risk factors may help differentiate strokes from
stroke mimics; however, detection of stroke often depends on presence of
posterior vs. anterior circulation strokes. Availability of imaging modalities
also assists in diagnosing stroke mimics, with magnetic resonance imaging offering
the most sensitivity and specificity.
CONCLUSION:
Stroke mimics remain a heterogeneous entity that is difficult to identify. All
studies in the literature report that stroke mimics treated with intravenous
fibrinolysis have better clinical outcome than their stroke counterparts.
Although symptomatic intracranial hemorrhage remains a real threat, literature
searches have identified only two cases of symptomatic intracranial hemorrhage
in stroke mimics treated with fibrinolytics.
17. Improving patient satisfaction through physician education,
feedback, and incentives
Banka G, et
al. J Hosp Med. 2015;10:497-502.
BACKGROUND:
Patient satisfaction has been associated with improved outcomes and become a
focus of reimbursement.
OBJECTIVE:
Evaluate an intervention to improve patient satisfaction.
DESIGN:
Nonrandomized, pre-post study that took place from 2011 to 2012.
SETTING:
Large tertiary academic medical center.
PARTICIPANTS:
Internal medicine (IM) resident physicians, non-IM resident physicians, and
adult patients of the resident physicians.
INTERVENTION:
IM resident physicians were provided with patient satisfaction education
through a conference, real-time individualized patient satisfaction score
feedback, monthly recognition, and incentives for high patient-satisfaction
scores.
MAIN
MEASURES: Patient satisfaction on physician-related and overall satisfaction
questions on the HCAHPS survey. We conducted a difference-in-differences
regression analysis comparing IM and non-IM patient responses, adjusting for
differences in patient characteristics.
KEY RESULTS:
In our regression analysis, the percentage of patients who responded positively
to all 3 physician-related Hospital Consumer Assessment of Healthcare Providers
and Systems (HCAHPS) questions increased by 8.1% in the IM and 1.5% in the
control cohorts (absolute difference 6.6%, P = 0.04). The percentage of
patients who would definitely recommend this hospital to friends and family
increased by 7.1% in the IM and 1.5% in the control cohorts (absolute
difference 5.6%, P = 0.02). The national average for the HCAHPS outcomes
studied improved by no more than 3.1%.
LIMITATIONS:
This study was nonrandomized and was conducted at a single site.
CONCLUSION:
To our knowledge, this is the first intervention associated with a significant
improvement in HCAHPS scores. This may serve as a model to increase patient
satisfaction, hospital revenue, and train resident physicians.
18. Risk Factors Associated with Urologic Intervention in ED
Patients with Suspected Renal Colic.
Yan JW, et
al. J Emerg Med. 2015;49:130-5.
BACKGROUND:
Whereas most patients with urolithiasis pass their stones spontaneously and
require only symptomatic management, a minority will require urologic
intervention.
OBJECTIVE:
Our primary objective was to confirm previously reported risk factors and to
identify additional predictors of urologic intervention within 90 days, for
emergency department (ED) patients with suspected renal colic.
METHODS: We
conducted a prospective cohort study of adult patients presenting to one of two
tertiary care EDs with suspected renal colic over a 20-month period.
Multivariate logistic regression models determined predictor variables
independently associated with urologic intervention.
RESULTS: Of
the 565 patients included in the analysis, 220 (38.9%) patients had a ureteric
stone visualized on diagnostic imaging. Eighty-four patients (14.9%) had
urologic intervention within 90 days of their initial ED visit. Urinary
nitrites (odds ratio [OR] 4.2, 95% confidence interval [CI] 1.3-13.6), stone
size ≥ 5 mm (OR 4.2, 95% CI 2.4-7.4), proximal ureteric stone (OR 3.1, 95% CI
1.5-6.4), age ≥ 50 years (OR 2.8, 95% CI 1.5-5.0), tachycardia at triage (OR
2.5, 95% CI 1.1-5.4), urinary leukocyte esterase (OR 2.3, 95% CI 1.2-4.5),
abnormal serum white blood cells (OR 2.0, 95% CI 1.2-3.3), and history of renal
colic (OR 1.8, 95% CI 1.1-3.1) were factors independently associated with urologic
intervention within 90 days.
CONCLUSIONS:
Our study reports eight risk factors associated with urologic intervention
within 90 days in patients presenting to the ED with renal colic. These risk
factors should be considered when making management, prognostic, and
disposition decisions for patients with suspected urolithiasis.
19. Families on Medicaid make more incorrect assumptions about
antibiotics
Parents of
children insured by Medicaid, the U.S. health program for the poor, are more
likely to incorrectly assume antibiotics can treat colds and flu and seek these
drugs when kids don’t actually need them, a study suggests.
Vaz LE, et
al. Prevalence of Parental Misconceptions About Antibiotic Use. Pediatrics.
2015 Jul 20. pii: peds.2015-0883. [Epub ahead of print]
BACKGROUND:
Differences in antibiotic knowledge and attitudes between parents of
Medicaid-insured and commercially insured children have been previously
reported. It is unknown whether understanding has improved and whether
previously identified differences persist.
METHODS: A
total of 1500 Massachusetts parents with a child less than 6 years old insured
by a Medicaid managed care or commercial health plan were surveyed in spring
2013. We examined antibiotic-related knowledge and attitudes by using χ2 tests.
Multivariable modeling was used to assess current sociodemographic predictors
of knowledge and evaluate changes in predictors from a similar survey in 2000.
RESULTS:
Medicaid-insured parents in 2013 (n = 345) were younger, were less likely to be
white, and had less education than those commercially insured (n = 353), P less
than .01. Fewer Medicaid-insured parents answered questions correctly except
for one related to bronchitis, for which there was no difference (15% Medicaid
vs 16% commercial, P less than .66). More parents understood that green nasal
discharge did not require antibiotics in 2013 compared with 2000, but this
increase was smaller among Medicaid-insured (32% vs 22% P = .02) than
commercially insured (49% vs 23%, P less than .01) parents. Medicaid-insured
parents were more likely to request unnecessary antibiotics in 2013 (P less
than .01). Multivariable models for predictors of knowledge or attitudes
demonstrated complex relationships between insurance status and
sociodemographic variables.
CONCLUSIONS:
Misconceptions about antibiotic use persist and continue to be more prevalent
among parents of Medicaid-insured children. Improvement in understanding has
been more pronounced in more advantaged populations. Tailored efforts for
socioeconomically disadvantaged populations remain warranted to decrease
parental drivers of unnecessary antibiotic prescribing.
Full-text
(free): http://pediatrics.aappublications.org/content/early/2015/07/15/peds.2015-0883.long
Accompanying
essay in Reuters Health: http://www.reuters.com/article/2015/07/20/us-health-parenting-antibiotics-idUSKCN0PU23520150720
20. With the Proliferation of Mobile Medical Apps, Which Ones
Work Best in the ED?
Huffman A.
Ann Emerg Med. 2015;66:A13–A15
When Wake
Forest physician and teacher Iltifat Husain, MD, used his first medical app 5
years ago, he was in medical school and downloaded a diagnostic tool called
Diagnosaurus DDX to his smartphone.
Medical apps
were popular with students, and early adopters among medical practitioners had
been using them for a decade or so. But the industry has since exploded,
including thousands of apps for wellness, reference, and diagnostics, some free
and some fee based, and is changing the way medicine is practiced across the
board.
Apps for
smartphones, tablets, and other mobile devices can influence treatment before a
patient even arrives in the emergency department (ED), and some apps actually
turn telephones into diagnostic devices, such as AliveCor, which snaps onto the
back of an iPhone and transforms it into an ECG machine.
Today, in
addition to his job as assistant professor of emergency medicine and director
of the mobile app curriculum at the Wake Forest School of Medicine, Dr. Husain
is editor-in-chief of the Web site iMedicalApps.com, which reviews apps and
offers advice on their relative pros and cons. Despite some concerns about
security and privacy issues with certain apps, Dr. Husain sees more benefit
than risk with apps in general.
Ultimately,
he said, “They help us do our jobs more effectively.”
Apps enable
ED personnel to perform tasks ranging from referencing dosages to monitoring
multiple patients’ treatments simultaneously and even evaluating live photos of
automobile crash scenes to prepare for specific types of injuries long before
the patients arrive at the ED. Other apps can enhance patient-physician
relationships by enabling the sharing of images to help explain conditions and
treatments. There are also apps for non-ED personnel, such as those that enable
patients to monitor ED wait times or find the nearest ED.
This
burgeoning array of apps represents only the tip of the iceberg, according to a
blog posted by Kevin R. Campbell, MD, on KevinMD.com. Dr. Campbell predicts the
technology will eventually help guide and expedite every aspect of medicine.
As medical
apps flood the market, the question facing ED personnel is how to winnow the
list to determine which ones are most valuable, user friendly, and reliable.
Some of the apps listed in the “medical” category on the Apple store, for example,
are of little or no use to ED personnel, such as Sex-Facts, Marijuana Truth,
Dream Meaning, and Best Diet foods, Dr. Husain said.
Among Dr.
Husain’s recommendations for the ED is an app called ERres, a clinical
reference tool that he calls “a game changer” and “the Swiss army knife of apps
for emergency medicine providers,” because of the breadth of content it
provides.
Top Ten List
In accordance
with Dr. Husain’s and others’ experience working in EDs, iMedicalApps has
created a top 10 list of the most useful apps in the ED, including the
following…
The remainder
of the essay (full-text free): http://www.annemergmed.com/article/S0196-0644(15)00510-7/fulltext
21. Micro Bits
A. Biologists manufacture bacteria
that may one day treat an unhealthy stomach
BY Catherine
Woods July 9, 2015
Biologists at
the Massachusetts Institute of Technology have created a genetically modified
version of a common bacteria found in the gut that can sense the environment
there and fight disease. And when this designer bacteria works, the proof is in
the poop — glowing poop. (In this case, mouse poop.)
We wanted to
equip this bacteria with the ability to do new things, like turn on the
production of therapeutic molecules or sense disease inside guts, said Timothy
Lu, a biologist and senior author on the study. The designer bacteria is
modeled after a common gut bacteria called Bacteroides Thetaiotaomicron.
In the past,
clinical studies and lab experiments made use of manmade modified bacteria,
like E. coli and Listeria, to deliver medicine to treat cancer or obesity. But
E. coli and Listeria have a downside. They’re cleared from the body rapidly.
Bacteroides thetaiotaomicron is already highly abundant in the human gut,
meaning that an altered version of this bacteria designed for therapeutic
treatment would last longer within the intestines. This designer bacteria, in
other words, could play an important role in drug treatment.
But to
monitor whether it was working, Lu’s team had to see the results first.
To do that,
they used a technique called bacterial conjugation to insert a gene called
luciferase that codes for fluorescence into the gut bacteria’s genome…
Full-text: http://www.pbs.org/newshour/rundown/biologists-create-frankengut-bacteria-treat-unhealthy-stomach/
B. Not All Placebos are Created
Equally: Topicals and Shots Beat Out Orals
C. CT scans can cause DNA damage, cell
death, study finds
A study
published in the Journal of American College of Cardiology: Cardiovascular
Imaging found that computed tomography scans are associated with DNA damage,
although cells also initiate repair mechanisms, and sometimes cellular death.
The findings come from 67 patients who had heart CT scans. The team found that
scans using the lowest radiation dose did not adversely affect the cells of
healthy patients, and they recommend clinicians minimize use of radiation when
possible.
D. Cardiorespiratory fitness protects
against depression
Adolescents
with greater cardiorespiratory fitness have fewer depressive symptoms at any
given point in time. In addition, cardiorespiratory fitness, particularly among
girls, may help prevent the onset of new depressive symptoms during middle
school.
E. Pills' appearances color patients'
expectations, study finds
Patients in
the U.S., China and Colombia estimate a pill's effectiveness and ease of use
based on its color and shape, according to a study in the journal Food Quality
and Preference. Study participants viewed white pills as most effective for
headaches and rated red and blue pills as harder to swallow.
F. A Spotlight on the FDA and
Sunscreen Regulation
There may be
nothing new under the sun, but the U.S. Food and Drug Administration (FDA) is
facing calls for something new under the agency's authority over sunscreens. In
recent months, the FDA has declined to permit use of eight new sunscreen
ingredients without additional data, although those ingredients have been used
in Europe for more than 5 years and despite the recent passage of a U.S. law
intended to expedite the marketing-approval process for new products. The
controversy says as much about the challenges facing the agency as it does
about sunscreen regulation.
G. Ear Wax: What do the data say?
The bottom
line (from the BMJ)
-Ear wax only
needs to be removed if it causes hearing impairment, other symptoms, or if view
of the tympanic membrane is required for diagnostic reasons or for taking
impressions for hearing aids or ear plugs
-Ear
irrigation (syringing) is generally considered to be effective, but evidence is
limited and it may be associated with adverse effects
-There is
insufficient data on other mechanical methods of wax removal or on use of wax
softeners to draw robust conclusions on their effectiveness
H. Sugar sweetened beverages cause
diabetes
I. FDA Orders Across-the-board Risk
Updates to NSAIDs Labels
July 13, 2015
— FDA officials recently directed manufacturers of non-aspirin nonsteroidal
anti-inflammatory drugs to update their product labels to warn users of the
risk for cardiovascular thrombotic events linked to the medications.
J. Does Consuming Sugar and Artificial
Sweeteners Change Taste Preferences?
Yes!
