Tuesday, July 28, 2015

Lit Bits: July 28, 2015

From the recent medical literature...

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.

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.

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

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.

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.

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.

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…

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

Full-text (subscription required): http://www.bmj.com/content/351/bmj.h3601

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?