1. Cardiac Arrest: ACC Treatment Algorithm for Emergent Invasive
Cardiac Procedures in the Resuscitated Comatose Patient
Rab T, et al.
J Am Coll Cardiol. July 07, 2015,66(1):62-73
Patients who
are comatose after cardiac arrest continue to be a challenge, with high
mortality. Although there is an American College of Cardiology
Foundation/American Heart Association Class I recommendation for performing
immediate angiography and percutaneous coronary intervention (when indicated)
in patients with ST-segment elevation myocardial infarction, no guidelines
exist for patients without ST-segment elevation. Early introduction of mild
therapeutic hypothermia is an established treatment goal. However, there are no
established guidelines for risk stratification of patients for cardiac
catheterization and possible percutaneous coronary intervention, particularly
in patients who have unfavorable clinical features in whom procedures may be
futile and affect public reporting of mortality. An algorithm is presented to
improve the risk stratification of these severely ill patients with an emphasis
on consultation and evaluation of patients prior to activation of the cardiac
catheterization laboratory.
Editor’s
audio summary: http://content.onlinejacc.org/mobile/article.aspx?articleid=2375089
2. NOAC Antidote Promising in Phase III Trial: Idarucizumab for
Dabigatran Reversal.
Pollack CV
Jr, et al. N Engl J Med. 2015 Jun 22
[Epub ahead of print].
Background
Specific reversal agents for non-vitamin K antagonist oral anticoagulants are
lacking. Idarucizumab, an antibody fragment, was developed to reverse the
anticoagulant effects of dabigatran.
Methods We
undertook this prospective cohort study to determine the safety of 5 g of
intravenous idarucizumab and its capacity to reverse the anticoagulant effects of
dabigatran in patients who had serious bleeding (group A) or required an urgent
procedure (group B). The primary end point was the maximum percentage reversal
of the anticoagulant effect of dabigatran within 4 hours after the
administration of idarucizumab, on the basis of the determination at a central
laboratory of the dilute thrombin time or ecarin clotting time. A key secondary
end point was the restoration of hemostasis.
Results This
interim analysis included 90 patients who received idarucizumab (51 patients in
group A and 39 in group B). Among 68 patients with an elevated dilute thrombin
time and 81 with an elevated ecarin clotting time at baseline, the median
maximum percentage reversal was 100% (95% confidence interval, 100 to 100).
Idarucizumab normalized the test results in 88 to 98% of the patients, an
effect that was evident within minutes. Concentrations of unbound dabigatran
remained below 20 ng per milliliter at 24 hours in 79% of the patients. Among
35 patients in group A who could be assessed, hemostasis, as determined by
local investigators, was restored at a median of 11.4 hours. Among 36 patients
in group B who underwent a procedure, normal intraoperative hemostasis was
reported in 33, and mildly or moderately abnormal hemostasis was reported in 2
patients and 1 patient, respectively. One thrombotic event occurred within 72
hours after idarucizumab administration in a patient in whom anticoagulants had
not been reinitiated.
Conclusions
Idarucizumab completely reversed the anticoagulant effect of dabigatran within
minutes. (Funded by Boehringer Ingelheim; RE-VERSE AD ClinicalTrials.gov
number, NCT02104947.).
Associated Editorial
Bauer KA. Targeted
Anti-Anticoagulants. N Engl J Med. 2015 Jun 22 [Epub ahead of print].
Four direct
oral anticoagulants have been approved for use in many countries. These drugs
are valuable alternatives to vitamin K antagonists, such as warfarin, for many
patients requiring anticoagulation to prevent stroke due to nonvalvular atrial
fibrillation and to treat and prevent venous thromboembolism. The mechanism of
these agents is to selectively inhibit either thrombin or factor Xa, which are
critical enzymes in the common pathway of blood coagulation. Dabigatran
etexilate inhibits thrombin, whereas apixaban, edoxaban, and rivaroxaban
inhibit factor Xa.
Direct oral
anticoagulants have several pharmacologic advantages over vitamin K
antagonists, including a wider therapeutic window, a rapid onset of action, and
shorter half-lives that range between 7 hours and 14 hours in healthy persons.
Direct oral anticoagulants are administered at fixed doses to adults without
laboratory monitoring, which is more convenient than warfarin with its
requirement for monitoring of the international normalized ratio and periodic
dose adjustments. In randomized trials with good anticoagulation management
(i.e., with international normalized ratios generally in the desired therapeutic
range of 2 to 3 for over 60% of the time), direct oral anticoagulants were
noninferior, and in some cases superior, to dose-adjusted warfarin for the
prevention and treatment of thrombosis. As compared with warfarin, direct oral
anticoagulants reduced the rate of major bleeding by 28% and the rates of
intracranial and fatal hemorrhage by 50%.1
Despite the
better bleeding profile of direct oral anticoagulants, as compared with
warfarin, some physicians and patients have been unwilling to consider these
drugs in the absence of an established way to reverse their anticoagulant
activity. Although the anticoagulant activity of warfarin can be reversed with
vitamin K, fresh-frozen plasma, and prothrombin complex concentrates, major
bleeding events that occur in patients taking this drug often lead to poor
outcomes; approximately 10% of patients who are hospitalized with
warfarin-related bleeding die within 90 days,2,3 and the mortality among
patients with intracranial hemorrhage can be as high as 50%.4,5 The high
mortality is attributable in part to coexisting conditions in this patient
population. Experimental data suggest that nonspecific reversal agents such as
prothrombin complex concentrates, activated prothrombin complex concentrates,
or recombinant factor VIIa can reduce the anticoagulant effect of direct oral
anticoagulants in vitro, in animal models, and in human volunteers.6 However,
these agents are of unproven benefit in improving hemostasis in patients with
bleeding related to direct oral anticoagulant use, and they carry a risk of
thrombosis; thus, they are currently reserved for patients with severe bleeding
who cannot be treated with supportive measures.
With the
growing use of direct oral anticoagulants, it would be advantageous to have
reversal agents that can rapidly and completely neutralize the anticoagulant
activity of the drug and restore normal hemostasis. Specific reversal agents in
clinical development include andexanet alfa, a recombinant factor Xa variant
that specifically binds all the oral factor Xa inhibitors but lacks coagulant
activity.7 There is also a nonspecific reversal agent in clinical development,
PER977, which binds to several of the direct oral anticoagulants by means of
electrostatic interactions.8 Given that there are no established reversal
strategies for the direct oral anticoagulants, it is appropriate to undertake
clinical trials of these agents without a control group.
Idarucizumab
is a humanized monoclonal antibody fragment with high affinity for the oral
direct thrombin inhibitor dabigatran that selectively and immediately
neutralizes its anticoagulant activity.9 Pollack et al.10 now report in the
Journal the results of an interim analysis of data from 90 patients who were
taking dabigatran and who presented with either serious bleeding or the need
for urgent surgery or intervention and received intravenous idarucizumab. This
multicenter observational study evaluated the effect of a single 5-g dose of
antibody in eligible patients who were judged by the treating clinician to
require a reversal agent. The major end points of the study were
pharmacodynamic assessments of the ability of idarucizumab to neutralize the
anticoagulant activity of dabigatran. The data are convincing that the antidote
effectively and immediately neutralized the activity of dabigatran with a
satisfactory safety profile. Normal hemostasis was reported in more than 90% of
the patients who underwent procedures after the administration of idarucizumab.
Without a
control group, it is difficult to assess the clinical benefit that is conferred
by the administration of idarucizumab in patients with dabigatran-related
bleeding…
3. Societies recommend thrombectomy for eligible stroke patients
after thrombolytics
by Crystal
Phend. Senior Staff Writer, MedPage Today
Stent
retriever thrombectomy should be performed for selected stroke patients at
specialized centers after tissue plasminogen activator (tPA), the American
Heart Association/American Stroke Association recommended.
That focused
update to 2013 guidelines, published online in Stroke, included acute ischemic
stroke patients meeting all of the following criteria:
- Prestroke modified Rankin Scale score 0 to 1
- IV tPA given within 4.5 hours of onset
- Causative occlusion of the internal carotid artery or proximal middle cerebral artery (M1)
- National Institutes of Health Stroke Scale (NIHSS) score of 6 or higher
- Alberta Stroke Program Early CT score (ASPECTS) of at least 6
- Groin puncture for endovascular treatment feasible within 6 hours of symptom onset
"Use of
stent retrievers is indicated in preference to the MERCI device," the
update noted, also with a Class I, level of Evidence A recommendation.
The update
came as no surprise to J Mocco, MD, director of the Cerebrovascular Center at
Mount Sinai Health System in New York City. “These guidelines reflect the
recent avalanche of positive trials demonstrating the overwhelming benefit of
removing clots from clogged brain arteries for patients that are suffering from
stroke,” he told MedPage Today in an email. “There have been many of us who
have long believed in the benefit of this approach, but the positive data
published over the past year have now convinced the larger community of the
importance of this approach.”
William J.
Powers, MD, of the University of North Carolina at Chapel Hill, and colleagues
analyzed results from eight randomized clinical trials of endovascular
treatment published since 2013 as "pivotal new evidence that justifies
changes in current recommendations."
The first
three were done primarily with intra-arterial fibrinolysis and first generation
thrombectomy devices without showing any advantage either as a substitute for
tPA or subsequent to it.
The latest
five -- MR CLEAN, EXTEND-IA, ESCAPE, SWIFT-PRIME, and REVASCAT -- almost
exclusively used stent retrievers with uniformly higher recanalization rates
and benefits in functional outcome compared with thrombolysis or usual care
alone.
While two of
those allowed salvage intra-arterial fibrinolysis, the data wasn't sufficient
to say more than it "may be reasonable to employ in some clinical
circumstances," the guideline noted.
Although the
time window for enrollment in the positive trials varied, the recommendations
settled on 6 hours as the best supported thrombectomy window. Beyond that
point, the guidelines didn't say endovascular treatment is pointless but did
note that its effectiveness is "uncertain."
Likewise, for
other criteria outside the recommended set, such as mechanical clot removal in
strokes from occlusion of the M2 or M3 or in people under age 18, the updated
guide suggested treatment could be appropriate in carefully selected
individuals.
The data
wasn't definitive on anesthesia use, but the guide concluded: "On balance,
data from published data broadly indicate that conscious sedation might be
safer and more effective than general anesthesia in the setting of endovascular
therapy for acute ischemic stroke."
The
guidelines still recommended transport of patients to the closest certified
primary stroke center or comprehensive stroke center, but now also argued for
regional systems of care to be organized around endovascular treatment as well.
"This
additional treatment is more difficult than tPA, which can be given by most
doctors in the emergency room," Powers said in a press release.
The update
was endorsed by the American Association of Neurological Surgeons, Congress of
Neurological Surgeons, American Society of Neuroradiology, and Society of
Vascular and Interventional Neurology, while the American Academy of Neurology
"affirms the value" as an educational tool.
Stroke
Guidelines (full-text free): http://stroke.ahajournals.org/content/early/2015/06/26/STR.0000000000000074.full.pdf+html
4. Patient controlled analgesia better than routine care for ED
pts with non-traumatic abdominal pain—but not for pts with trauma pain: two
RCTs
A. PAin SoluTions In the Emergency
Setting (PASTIES)-patient controlled analgesia versus routine care in emergency
department patients with non-traumatic abdominal pain: randomised trial.
Smith JE, et
al. PASTIES research team. BMJ. 2015 Jun 21;350:h3147.
OBJECTIVE: To
determine whether patient controlled analgesia (PCA) is better than routine
care in providing effective analgesia for patients presenting to emergency
departments with moderate to severe non-traumatic abdominal pain.
DESIGN:
Pragmatic, multicentre, parallel group, randomised controlled trial
SETTING: Five
English hospitals.
PARTICIPANTS:
200 adults (66% (n=130) female), aged 18 to 75 years, who presented to the
emergency department requiring intravenous opioid analgesia for the treatment
of moderate to severe non-traumatic abdominal pain and were expected to be
admitted to hospital for at least 12 hours.
INTERVENTIONS:
Patient controlled analgesia or nurse titrated analgesia (treatment as usual).
MAIN OUTCOME
MEASURES: The primary outcome was total pain experienced over the 12 hour study
period, derived by standardised area under the curve (scaled from 0 to 100) of
each participant's hourly pain scores, captured using a visual analogue scale.
Pre-specified secondary outcomes included total morphine use, percentage of
study period in moderate or severe pain, percentage of study period asleep,
length of hospital stay, and satisfaction with pain management.
RESULTS: 196
participants were included in the primary analyses (99 allocated to PCA and 97
to treatment as usual). Mean total pain experienced was 35.3 (SD 25.8) in the
PCA group compared with 47.3 (24.7) in the treatment as usual group. The
adjusted between group difference was 6.3 (95% confidence interval 0.7 to
11.9). Participants in the PCA group received significantly more morphine (mean
36.1 (SD 22.4) v 23.6 (13.1) mg; mean difference 12.3 (95% confidence interval
7.2 to 17.4) mg), spent less of the study period in moderate or severe pain
(32.6% v 46.9%; mean difference 14.5% (5.6% to 23.5%)), and were more likely to
be perfectly or very satisfied with the management of their pain (83% (73/88) v
66% (57/87); adjusted odds ratio 2.56 (1.25 to 5.23)) in comparison with
participants in the treatment as usual group.
CONCLUSIONS:
Significant reductions in pain can be achieved by PCA compared with treatment
as usual in patients presenting to the emergency department with non-traumatic
abdominal pain.Trial registration European Clinical Trials Database
EudraCT2011-000194-31; Current Controlled Trials ISRCTN25343280.
B. PAin SoluTions In the Emergency
Setting (PASTIES)-patient controlled analgesia versus routine care in emergency
department patients with pain from traumatic injuries: randomised trial.
Smith JE, et
al. BMJ. 2015 Jun 21;350:h2988.
Conclusion: PCA
provided no statistically significant reduction in pain compared with routine
care for emergency department patients with traumatic injuries.
5. Twiddle Me This! A Look at Twiddler’s Syndrome
Shoenberger
J, et al. Ann Emerg Med. 2015;66:20–22
Annals Case
“A 53-year-old
female 3 days status post pacemaker/defibrillator placement presented to the
emergency department (ED) after a syncopal episode. The pacemaker was placed
for intermittent complete heart block leading to recurrent syncope. Since
discharge, she had complained of incisional pain but denied fever, erythema, or
exudate from her incision. On arrival an ECG showed an intermittently paced
regular rhythm. The patient became symptomatic with light-headedness when her
pulse rate decreased to the rage of 38-42 beats/min. The physical examination
result was unremarkable. However, the patient was noted by nursing to be
frequently touching her incision.”1
Riddle me
this: have you heard of twiddler’s syndrome? Does it have to do with Twizzlers?
Tiddlywinks? Twitter? None of those? Troubleshooting a dysfunctional pacemaker
can be a challenge, and arriving at a diagnosis that you’ve never heard of can
be even more difficult. Fortunately, a simple chest radiograph can help you
rule out this problem in a matter of seconds!
Mom Was
Right: Keep Your Hands at Your Side!
The first
implantable pacemaker was placed in the United States in 1960.2
It was only a
matter of time before problems with pacemakers started to arise, including
battery failure, lead fracture and displacement, failure to pace, oversensing,
and a host of other issues. It took 8 years for the medical literature to
publish the first case of a pacer lead being displaced as a result of the pulse
generator rotating in its implanted site.3
This rotation
typically occurs accidentally because the subcutaneous pocket, in which the
pulse generator is placed, is generously sized. This allows the generator
enough room to rotate on its own or, more likely, with the help of a patient
who fiddles with or “twiddles” it intentionally or subconsciously, causing it
to rotate. That being said, perhaps we shouldn’t be so quick to judge because
the rotation may also occur as a result of arm movement.4
Regardless,
given that the leads are attached to the generator, twisting of the generator
may cause the leads to also twist and coil up like a fishing reel line,
displacing the pacer lead from its intended site. Voilà! You’ve now got pacer
dysfunction and a diagnosis of twiddler’s syndrome…
The remainder
of the full-text (free): http://www.annemergmed.com/article/S0196-0644(15)00423-0/fulltext
The image
(free): Woman with Syncope
6. Emergency physician perceptions of medically unnecessary
advanced diagnostic imaging.
Kanzaria HK,
et al. Acad Emerg Med. 2015;22(4):390-8.
OBJECTIVES:
The objective was to determine emergency physician (EP) perceptions regarding
1) the extent to which they order medically unnecessary advanced diagnostic
imaging, 2) factors that contribute to this behavior, and 3) proposed solutions
for curbing this practice.
METHODS: As
part of a larger study to engage physicians in the delivery of high-value
health care, two multispecialty focus groups were conducted to explore the
topic of decision-making around resource utilization, after which qualitative
analysis was used to generate survey questions. The survey was extensively
pilot-tested and refined for emergency medicine (EM) to focus on advanced
diagnostic imaging (i.e., computed tomography [CT] or magnetic resonance
imaging [MRI]). The survey was then administered to a national, purposive
sample of EPs and EM trainees. Simple descriptive statistics to summarize
physician responses are presented.
RESULTS: In
this study, 478 EPs were approached, of whom 435 (91%) completed the survey;
68% of respondents were board-certified, and roughly half worked in academic
emergency departments (EDs). Over 85% of respondents believe too many
diagnostic tests are ordered in their own EDs, and 97% said at least some (mean
= 22%) of the advanced imaging studies they personally order are medically
unnecessary. The main perceived contributors were fear of missing a
low-probability diagnosis and fear of litigation. Solutions most commonly felt
to be "extremely" or "very" helpful for reducing
unnecessary imaging included malpractice reform (79%), increased patient
involvement through education (70%) and shared decision-making (56%), feedback
to physicians on test-ordering metrics (55%), and improved education of
physicians on diagnostic testing (50%).
CONCLUSIONS:
Overordering of advanced imaging may be a systemic problem, as many EPs believe
a substantial proportion of such studies, including some they personally order,
are medically unnecessary. Respondents cited multiple complex factors with
several potential high-yield solutions that must be addressed simultaneously to
curb overimaging.
Commentary: Pro/Con: ‘Unnecessary’ Testing
by William
Sullivan, DO, JD, Jerome Hoffman, MD, Hemal Kanzaria, MD, Marc Probst, MD &
Judith Tintinalli, MD. Emergency
Physicians Monthly, June 29, 2015
In March, the
Journal of Academic Emergency Medicine
published a study entitled ‘Emergency Physician Perceptions of Medically
Unnecessary Advanced Diagnostic Imaging’. The study, authored by Kanzaria, Hoffman,
Probst, Caloyeras, Berry & Brook, concluded that “many EPs believe a
substantial proportion of [advanced imaging] studies, including some they
personally order, are medically unnecessary.” This garnered headlines in the
lay press, as well as a blog post on EPM’s site, which prompted a response from
Jerry Hoffman, one of the study authors. Hoffman asserted that the study’s
conclusions had been “slightly distorted” in the mainstream media.
To address
the concerns, and potential distortion, we asked EPM senior editor William
Sullivan, DO, JD and editor-in-chief Judith Tintinalli, MD, to explain their
concerns with the way this study characterizes “unnecessary” testing. We then
asked study co-authors Jerome Hoffman, MD, Hemal Kanzaria, MD, and Marc Probst,
MD to respond.
Full-text
(free): http://www.epmonthly.com/www.epmonthly.com/features/current-features/pro-con-unnecessary-testing/?utm
Editorial: Throwing Stones
by Mark Plaster
One of the most memorable scenes in the iconic movie Jerry Maguire is when Tom Cruise comes to Cuba Gooding Jr. in the locker room and gives his imploring, desperate “Help me help you” speech. When Gooding finally erupts in laughter and Cruise starts to walk away, the camera pans back to the now-naked Gooding, who says, “Oh come on Jerry, you think we’re fighting and I think we’re finally talking!.” I’ve tried to reference this scene with my wife when we have been locked in an argument before, but for some reason it doesn’t seem to land. Maybe she’d listen if I had Cuba’s abs. But let’s be honest: she sees me more as the Cuba Gooding Jr. from Daddy Day Camp.
The remainder of the essay:
http://www.epmonthly.com/www.epmonthly.com/features/current-features/throwing-stones/
One of the most memorable scenes in the iconic movie Jerry Maguire is when Tom Cruise comes to Cuba Gooding Jr. in the locker room and gives his imploring, desperate “Help me help you” speech. When Gooding finally erupts in laughter and Cruise starts to walk away, the camera pans back to the now-naked Gooding, who says, “Oh come on Jerry, you think we’re fighting and I think we’re finally talking!.” I’ve tried to reference this scene with my wife when we have been locked in an argument before, but for some reason it doesn’t seem to land. Maybe she’d listen if I had Cuba’s abs. But let’s be honest: she sees me more as the Cuba Gooding Jr. from Daddy Day Camp.
Be that as it
may, it is true that sometimes we have to really get into an argument to start
talking about the important topics. Drs. Hemal Kanzaria, Jerry Hoffman and Marc
Probst et al touched a nerve with their study confirming what we all have had
queasy feelings about for a long time. Don’t tell anybody, but it’s possible
that doctors sometimes order tests where they already know the result, feel
that the test result is irrelevant to the treatment of the case, or are only
ordering the test in case someone sues for some unknown reason. That is what
many of us would call an “unnecessary” test. But as Bill Sullivan points out on
page 24, maybe the test isn’t really “unnecessary” after all, even if we kinda
sorta feel it could be. After all, every now and then the test results surprise
us. If I had a hundred dollars for every surprise test result I’ve ordered, I’d
have, well, at least a few hundred dollars. But he is right that we need to
count the cost of blabbing to the whole world that emergency physicians are
knowingly ordering countless expensive tests that they themselves don’t think
are necessary.
This argument
is, however, worth having – behind closed doors – because it involves several
great principles of our practice…
The remainder of the essay:
http://www.epmonthly.com/www.epmonthly.com/features/current-features/throwing-stones/
7. What’s a sensible, evidence-based approach to the diagnosis
of PE?
Here’s how Jeff Kline and Chris Kabrhel read the literature.
Here’s how Jeff Kline and Chris Kabrhel read the literature.
1. Emergency
Evaluation for Pulmonary Embolism, Part 1: Clinical Factors that Increase Risk.
J Emerg Med. 2015 Jun;48(6):771-80.
2. Emergency
Evaluation for Pulmonary Embolism, Part 2: Diagnostic Approach. J Emerg Med.
2015 Jul;49(1):104-117.
Related article: Chen YA, et al. Variation in the
utilization and positivity rates of CT pulmonary angiography among emergency
physicians at a tertiary academic ED. Emerg Radiol 2015;22(3):221-9
Summary: This
single-center cross-sectional study observed considerable inter-physician
variability in the utilization and PE positivity rates of CTPA. These results
suggest an opportunity for a more standardized approach to the use of CTPA
among EPs.
8. Comparison of traditional otoscope to iPhone otoscope in the
pediatric ED.
Richards JR,
et al. Am J Emerg Med. 2015 Aug;33(8):1089-92.
OBJECTIVE:
Acute otitis media (AOM) is a common diagnosis under age 5 years. The primary
objective was to determine if the CellScope Oto (CSO) improves tympanic
membrane (TM) visualization and diagnostic precision compared to traditional
otoscope. The secondary objective was to determine physician, patient, and
parent device preference.
METHODS: This
is a prospective cross-sectional study of patients younger than 18 years
presenting with ear pain, fever, or upper respiratory infection symptoms.
Patients were examined by a resident then attending physician with a
traditional wall-mounted otoscope followed by CSO. Each was blinded to the
other's findings. Intrarater and interrater diagnostic agreement was compared.
Physicians, parents, and patients were surveyed regarding their experience.
RESULTS: A
total of 51 patients completed the study. There was substantial intrarater
agreement between traditional otoscope and CSO for residents: right ear (κ =
0.74) and left ear (κ = 0.74); CSO use changed reported view for 16 of 102 TM
examinations (16%), of which 7 (7%) had clinically relevant change in diagnosis
to/from AOM. There was substantial to almost-perfect agreement for attending
physicians: right: (κ = 0.86) and left (κ = 0.79); CSO use changed reported
view for 12 (12%), with 6 (6%) clinically relevant. Resident/attending
physician interrater agreement was moderate for both traditional otoscope (κ =
0.40) and CSO (κ = 0.47). Physicians agreed CSO was easy to use, enhanced TM
visualization and diagnostic precision, and was a good teaching tool. Patients
and parents also found the CSO images very helpful.
CONCLUSION:
CellScope Oto was preferred by physicians, patients, and parents. Use of the
CSO changed final diagnosis a significant number of times, including clinically
relevant changes to/from AOM.
9. The Diseconomies of Queue Pooling: An Empirical Investigation
of ED Length of Stay
Song H,
Tucker AL, Murrell KL. Man Sci. 2015 May 28 [Epub ahead of print].
We conduct an
empirical investigation of the impact of queue management on patients’ average
wait time and length of stay (LOS). Using an emergency department’s (ED)
patient-level data from 2007 to 2010, we find that patients’ average wait time
and LOS are longer when physicians are assigned patients under a pooled queuing
system with a fairness constraint compared to a dedicated queuing system with
the same fairness constraint. Using a difference-in-differences approach, we
find the dedicated queuing system is associated with a 17% decrease in average
LOS and a 9% decrease in average wait time relative to the control group—a
39-minute reduction in LOS and a four-minute reduction in wait time for an
average patient of medium severity in this ED.
Interviews
and observations of physicians suggest that the improved performance stems from
the physicians’ increased ownership over patients and resources that is
afforded by a dedicated queuing system, which enables physicians to more
actively manage the flow of patients into and out of ED beds. Our findings
suggest that the benefits from improved flow management in a dedicated queuing
system can be large enough to overcome the longer wait time predicted to arise
from nonpooled queues. We conduct additional analyses to rule out alternate
explanations for the reduced average wait time and LOS in the dedicated system,
such as stinting and decreased quality of care. Our paper has implications for
healthcare organizations and others seeking to reduce patient wait time and LOS
without increasing costs.
DRV note: So, what do they mean by
queue pooling? In their
words: “In this paper, we consider two different types of queuing systems in
the context of an ED. In a pooled queuing system—which is typical for most EDs
in the United States—a physician is assigned to a patient only once the patient
is placed in an ED bed. This means patients in the waiting room remain in a
pooled queue while waiting for an open bed. In a dedicated queuing system,
physicians are assigned to patients at the point of triage. Here, patients in
the waiting room are, in effect, waiting to be seen by a specific physician. In
the dedicated queuing system, each physician thus has a greater ownership over
his or her workload even before the patient is placed in an ED bed.”
This is akin
to the Team Assignment System, published in Ann Emerg Med in 2005: http://www.ncbi.nlm.nih.gov/pubmed/16308063
10. Annals Brief Lit Reviews
A. Do Glycoprotein IIb/IIIa Inhibitors
Improve Outcomes in Acute Ischemic Stroke?
Bottom Line: Given
the lack of benefit and the significantly increased risk of bleeding,
glycoprotein IIb/IIIa inhibitors cannot be recommended for acute ischemic
stroke. Moreover, the rate of harms appears high enough that future trials
investigating their use in stroke are unlikely.
B. Does a Restricted Fluid
Resuscitation Strategy Decrease Mortality in Trauma Patients?
Take home: There
is currently insufficient evidence to recommend for or against restricted fluid
resuscitation in trauma patients.
C. Do Intravenous Nitrates Improve
Dyspnea in Acute Heart Failure Syndromes More Than Alternative Pharmacologic
Interventions?
Take home: Intravenous
nitrate vasodilators produce similar symptom improvement in acute heart failure
syndromes compared with alternative therapies, though evidence is limited.
D. What Is the Role of Procalcitonin
in Early Diagnosis of Infective Endocarditis?
Take home: Evidence
is inadequate to support the use of procalcitonin as a test to rule in or rule
out the diagnosis of endocarditis.
11. Images in Clinical Practice
Esophageal
Intubation in an Infant
Measles
Blue skin
(gotta answer a multiple choice question first)
Visual loss
(gotta answer a multiple choice question first)
Abdominal
wall signs (gotta answer a multiple choice question first)
Ping-Pong
Gaze
Elderly
Female With Abdominal Pain
Diffuse Soft
Tissue Calcinosis
Coral
Dermatitis
12. Placebo Effects in Medicine
Kaptchuk TJ,
et al. N Engl J Med 2015; 373:8-9.
Placebo
effects are often considered the effects of an “inert substance,” but that
characterization is misleading. In a broad sense, placebo effects are
improvements in patients' symptoms that are attributable to their participation
in the therapeutic encounter, with its rituals, symbols, and interactions.
These effects are distinct from those of discrete therapies and are
precipitated by the contextual or environmental cues that surround medical
interventions, both those that are fake and lacking in inherent therapeutic
power and those with demonstrated efficacy. This diverse collection of signs
and behaviors includes identifiable health care paraphernalia and settings,
emotional and cognitive engagement with clinicians, empathic and intimate
witnessing, and the laying on of hands.
Placebo
effects rely on complex neurobiologic mechanisms involving neurotransmitters
(e.g., endorphins, cannabinoids, and dopamine) and activation of specific,
quantifiable, and relevant areas of the brain (e.g., prefrontal cortex,
anterior insula, rostral anterior cingulate cortex, and amygdala in placebo
analgesia).1 Many common medications also act through these pathways. In
addition, genetic signatures of patients who are likely to respond to placebos
are beginning to be identified.2 Such basic mechanistic discoveries have
greatly enhanced the credibility of placebo effects. Moreover, recent clinical
research into placebo effects has provided compelling evidence that these
effects are genuine biopsychosocial phenomena that represent more than simply
spontaneous remission, normal symptom fluctuations, and regression to the
mean.1 So what have we learned about placebo effects to date, and what does our
current understanding say about medicine?
First, though
placebos may provide relief, they rarely cure. Although research has revealed
objective neurobiologic pathways and correlates of placebo responses, the
evidence to date suggests that the therapeutic benefits associated with placebo
effects do not alter the pathophysiology of diseases beyond their symptomatic
manifestations; they primarily address subjective and self-appraised symptoms.
For example, there is no evidence that placebos can shrink tumors; however,
experiments demonstrate that common symptoms of cancer and side effects of
cancer treatment (e.g., fatigue, nausea, hot flashes, and pain) are responsive
to placebo treatments. Similarly, an experiment in patients with asthma showed
that placebos do not affect patients' forced expiratory volume in 1 second
(FEV1) but can nonetheless dramatically relieve perceived symptoms.3 This conclusion
tracks evidence related to many conditions, such as musculoskeletal,
gastrointestinal, and urogenital disorders.
Second,
placebo effects are not just about dummy pills: the effects of symbols and
clinician interactions can dramatically enhance the effectiveness of
pharmaceuticals. For example, a recent study of episodic migraine demonstrated
that when patients took rizatriptan (10 mg) that was labeled “placebo” (a
treatment that theoretically had “pure pharmacologic effects”), the outcomes
did not differ from those in patients given placebos deceptively labeled
“rizatriptan” (pure expectation effect). However, when ritzatriptan was
correctly labeled “rizatriptan,” its analgesic effect increased by 50%.4
Similar results have been observed when other drugs, including morphine,
fentanyl, and diazepam, have been administered openly and covertly and with
procedures such as deep-brain stimulation for mobility symptoms in Parkinson's
disease.
Third, the
psychosocial factors that promote therapeutic placebo effects also have the
potential to cause adverse consequences, known as nocebo effects. Not
infrequently, patients perceive side effects of medications that are actually
caused by anticipation of negative effects or heightened attentiveness to
normal background discomforts of daily life in the context of a new therapeutic
regimen. For example, nocebo effects were demonstrated in a study of benign
prostatic hypertrophy treated with finasteride: patients informed of the sexual
side effect of this drug reported sexual side effects at three times the rate
that patients who were not so informed did. In trials of anticonvulsants for
migraine, patients receiving placebos report memory problems and anorexia,
whereas in trials of triptans for migraine, patients receiving placebos report
different side effects. Research reviews have estimated that 4 to 26% of
patients who are randomly assigned to placebos in trials discontinue their use
because of perceived adverse effects. It thus seems not unlikely that patients
are often treated for adverse medication effects that are actually anticipatory
nocebo effects. Finding a way to balance the need for full disclosure of
potential adverse effects of drugs with the desire to avoid inducing nocebo
effects is a pressing issue in health care…
Audio interview
with Prof. Ted Kaptchuk on the outlook for harnessing the benefits of placebo
effects in medicine (12:51)—link above.
13. Supplemental Oxygen Is Not Needed for STEMI Patients with
Normal Oxygen Saturations
Outcomes were
either similar or worse for STEMI patients given supplemental oxygen, compared
with those who maintained a saturation ≥94% on their own
Stub D, et
al. AVOID Investigators*. Air Versus Oxygen in ST-Segment-Elevation Myocardial
Infarction. Circulation. 2015 Jun 16;131(24):2143-50.
BACKGROUND:
Oxygen is commonly administered to patients with ST-elevation-myocardial
infarction despite previous studies suggesting a possible increase in
myocardial injury as a result of coronary vasoconstriction and heightened
oxidative stress.
METHODS AND
RESULTS: We conducted a multicenter, prospective, randomized, controlled trial
comparing oxygen (8 L/min) with no supplemental oxygen in patients with
ST-elevation-myocardial infarction diagnosed on paramedic 12-lead ECG. Of 638
patients randomized, 441 patients had confirmed ST-elevation-myocardial
infarction and underwent primary end-point analysis. The primary end point was
myocardial infarct size as assessed by cardiac enzymes, troponin I, and
creatine kinase. Secondary end points included recurrent myocardial infarction,
cardiac arrhythmia, and myocardial infarct size assessed by cardiac magnetic
resonance imaging at 6 months. Mean peak troponin was similar in the oxygen and
no oxygen groups (57.4 versus 48.0 μg/L; ratio, 1.20; 95% confidence interval,
0.92-1.56; P=0.18). There was a significant increase in mean peak creatine
kinase in the oxygen group compared with the no oxygen group (1948 versus 1543
U/L; means ratio, 1.27; 95% confidence interval, 1.04-1.52; P=0.01). There was
an increase in the rate of recurrent myocardial infarction in the oxygen group
compared with the no oxygen group (5.5% versus 0.9%; P=0.006) and an increase
in frequency of cardiac arrhythmia (40.4% versus 31.4%; P=0.05). At 6 months,
the oxygen group had an increase in myocardial infarct size on cardiac magnetic
resonance (n=139; 20.3 versus 13.1 g; P=0.04).
CONCLUSION:
Supplemental oxygen therapy in patients with ST-elevation-myocardial infarction
but without hypoxia may increase early myocardial injury and was associated
with larger myocardial infarct size assessed at 6 months.
14. Motor Vehicle Crash Fatalities in States with Primary versus
Secondary Seat Belt Laws: A Time-Series Analysis
Lee LK, et
al. Ann Intern Med. 2015 23 June [Epub ahead of print]
Background:
Motor vehicle crashes (MVCs) remain a leading cause of U.S. injury-related
deaths. Primary seat belt laws allow vehicle occupants to be ticketed solely
for not wearing seat belts, and secondary laws allow ticketing only for failure
to wear seat belts in the setting of other violations.
Objective: To
determine the association between MVC fatality rates and primary versus
secondary seat belt laws.
Design:
Retrospective time-series analysis.
Setting:
United States, 2001 to 2010.
Participants:
MVC fatalities in occupants aged 10 years or older identified in the Fatality
Analysis Reporting System.
Measurements:
Population-based rates of fatal crashes.
Results:
There were 283 183 MVC fatalities in occupants aged 10 years or older from 2001
to 2010 (overall rate, 13.0 per 100 000 persons). In 2001, the mean fatality
rate was 14.6 per 100 000 persons, 16 states had primary seat belt laws, and 33
states had secondary laws. In 2010, the mean fatality rate was 9.7 per 100 000
persons, 30 states had primary seat belt laws, and 19 states had secondary
laws. In the multivariate regression model, states with primary seat belt laws
had lower MVC fatality rates than states with secondary laws (adjusted
incidence rate ratio, 0.83 [95% CI, 0.78 to 0.90]).
Limitation:
Only fatalities were analyzed from the database, and the degree of law
enforcement could not be ascertained.
Conclusion:
States with primary seat belt laws had lower rates of MVC fatalities than those
with secondary laws. Adoption of primary seat belt laws may offer optimal
occupant protection.
15. Prochlorperazine-Induced Hemidystonia Mimicking Acute Stroke
You EM-RAP
fans may remember the LIN Session from January this year when she interviewed
Zlatan Coralic, PharmD, (UCSF) about the role of tPA for stroke in pregnancy. Here’s
how she opened the interview: “You work in a busy Emergency Department. You are
notified that there is a stroke patient being transported by EMS. The patient
arrives. It is a woman in her mid-thirties presenting with slurred speech. The
only thing she can say is, ‘Help me.’ She has obvious left-sided paralysis.”
We decided to
publish this as a case report.
Coralic Z, et
al. West J Emerg Med. 2015 July 2 [Epub ahead of print].
Prochlorperazine
is frequently used in the treatment of refractory nausea and migraines. Known
side effects include extrapyramidal symptoms such as akathisia and dystonia. We
report a pregnant patient taking prochlorperazine for hyperemesis gravidarum
who developed hemidystonia, which triggered an acute code stroke response from
prehospital, emergency medicine and neurology providers. We suspect this report
to be the first case of prochlorperazine-induced hemidystonia as a stroke
mimic.
16. Researchers ID Predictors of Biphasic Reactions in Children with
Anaphylaxis
OTTAWA,
Ontario -- June 22, 2015 -- Children are more likely to have a repeat, delayed
anaphylactic reaction from the same allergic cause, depending on the severity
of the initial reaction. The first paediatric study to look at the predictors
for this phenomenon was published today in Annals of Allergy, Asthma &
Immunology.
Some children
are at risk of biphasic anaphylactic reactions. Delayed reactions occur when
the initial symptoms of allergic reaction go away but then return hours or days
later without exposure to the initial substance that caused the reaction.
Researchers
at the Children's Hospital of Eastern Ontario (CHEO) Research Institute,
Ottawa, Ontario, looked at the frequency and severity of biphasic allergic
reactions. From a sample size of 484 patient records, the incidence of biphasic
reaction occurred in 15% of the study population, and two thirds occurred
within 6 hours from the onset of the initial reaction. At least half of the
biphasic reactions were serious in nature, and required treatment with
epinephrine.
The study
unveiled that biphasic reactions were more likely to happen if the initial
allergic reaction was severe or if it was not treated with epinephrine.
Furthermore, the anaphylaxis tended to be more severe when the administration
of epinephrine was delayed.
“The key
message here for patients, parents, caregivers, teachers, and first-responder
health professionals is: to prevent an anaphylactic reaction from worsening,
administer epinephrine immediately after the onset of the early symptoms of an
allergic reaction,” said Waleed Alqurashi, MD, CHEO, and the University of
Ottawa. “Our team has created an evidence-based prognostic tool so that
physicians can monitor the more serious cases appropriately.”
The team
identified 5 independent, evidence-based predictors of biphasic reactions in
children, including:
• Delay in
presentation to the emergency department (ED) or delay in epinephrine
administration of more than 90 minutes from the onset of the initial allergic
reaction.
• Wide pulse
pressure at triage.
• Treatment
of the initial allergic reaction with more than 1 dose of epinephrine.
• Respiratory
distress that requires administration of inhaled salbutamol in the ED.
• Children
aged 6 to 9 years.
“It's clear
that children with severe initial reactions would benefit from a prolonged
period of observation in the Emergency Department,” said Dr. Alqurashi. “On the
flip side, knowing what to look for helps to better utilise resources so that
children with mild allergic reaction, who do not match any of the identified
predictors can go home faster.”
17. Study shows how efficient information exchange use could cut
hospital costs by reducing ED radiology and lab tests
A study in
the Journal of the American Medical Informatics Association found that
effective use of health information exchanges could provide savings to
hospitals by cutting the number of examinations and tests ordered for ED
patients. Researchers revealed that health information exchange use could cut
the number of ordered radiology tests per patient by 36% and laboratory tests
by 52%.
An Empirical analysis of the financial
benefits of health information exchange in emergency departments
Yaraghi N. J
Amer Med Inform Assn. 2015 June 27 [Epub ahead of print]
Abstract
Objective To
examine the impact of health information exchange (HIE) on reducing laboratory
tests and radiology examinations performed in an emergency department (ED).
Materials and
Methods The study was conducted in an ED setting in Western New York over a
period of 2 months. The care of the patients in the treatment group included an
HIE query for every encounter, while the care of other patients in the control
group did not include such queries. A group of medical liaisons were hired to
query the medical history of patients from an HIE and provide it to the ED
clinicians. Negative binomial regression was used to analyze the effects of HIE
queries on the number of performed laboratory tests and radiology examinations.
The log files of the HIE system since 1 year before the ED admission were used
to analyze the differences in outcome measures between the 2 groups of
patients.
Results
Ceteris paribus, HIE usage is associated with, respectively, 52% and 36%
reduction in the expected total number of laboratory tests and radiology
examinations ordered per patient at the ED.
Conclusions
The results indicate that access to additional clinical data through the HIE
will significantly reduce the number of laboratory tests and radiology
examinations performed in the ED settings and thus support the ongoing HIE
efforts.
18. Quantifying Patient-Physician Communication and Perceptions
of Risk during Admissions for Possible ACS.
Newman DH, et
al. Ann Emerg Med. 2015 Jul;66(1):13-18.e1.
STUDY
OBJECTIVE: Disposition decision for patients with possible acute coronary
syndrome in the emergency department (ED) is driven primarily by perception of
short-term risks. We sought to evaluate communication between patient and
physician about these risks by ascertaining the content of discussions
surrounding disposition decision.
METHODS: We
conducted matched-pair surveys of patients admitted for possible acute coronary
syndrome and their physicians in 2 academic, inner-city EDs. After disposition
conversation, trained research assistants administered surveys querying
perceived and communicated risk estimates and purpose of admission. Primary
exclusion criteria were ECG or troponin value diagnostic of acute coronary
syndrome. The primary outcome measure was agreement in assessment of the risk
of myocardial infarction, defined as the proportion of patient-physician pairs whose
risk estimates were within 10% of each other.
RESULTS: A
total of 425 patient-physician survey pairs were collected. Fifty-three percent
of patients were men. Patients reported discussing the likelihood of their
symptoms' being due to myocardial infarction in 65% of cases, whereas
physicians reported this in 46%. After their discussion, physicians' (n=415)
median estimate of short-term risk was 5% (95% confidence interval [CI] 3% to
7%), whereas patients' (n=401) was 8% (95% CI 5% to 11%). Most patients (63%;
95% CI 57% to 67%) reported that this estimate remained the same or increased
after their conversation. Risk agreement within 10% occurred in 36% of cases
(n=404; 95% CI 32% to 41%). Patients' median estimates of the mortality of
myocardial infarction at home versus in the hospital were 80% (n=398; 95% CI
76% to 84%) and 10% (n=390; 95% CI 7% to 13%), respectively, whereas physician
estimates were 15% (n=403; 95% CI 12% to 18%) and 10% (n=398; 95% CI 7% to
13%).
CONCLUSION:
Our survey demonstrates poor communication, with overestimation of both the
risks of myocardial infarction and potential benefit of hospital admission.
These findings suggest that communication surrounding disposition decisions in
chest pain patients may at times be ineffective or misleading.
19. A Stinging Sensation: An Interactive Case from the NEJM
Lee-Sarwar K,
et al. N Engl J Med 2015; 372:e35
Approximately
10 minutes after being stung on the right lower leg by a yellow jacket (a type
of wasp), a 45-year-old man began to feel light-headed and nauseated. He called
emergency medical services, and paramedics arrived 10 minutes later. They found
him to be alert but anxious, with scattered areas of erythema on his trunk and
a small, localized area of tenderness, swelling, and erythema . . .
20. A Sea Change in Treating Heart Attacks
The death
rate from coronary heart disease has dropped 38 percent in a decade. One reason
is that hospitals rich and poor have streamlined emergency treatment.
By GINA
KOLATA. New York Times. JUNE 19, 2015
CAMDEN, N.J.
— Yvette Samuels was listening to jazz late one night when she felt a stabbing
pain down her left shoulder. She suspected a heart attack — she had heard about
the symptoms from watching a Rosie O’Donnell standup routine on television —
and managed to scratch on the door that connected her single room to her
neighbor’s. He found her collapsed on the floor.
Paramedics
arrived minutes later and slapped electrocardiogram leads on her chest,
transmitting the telltale pattern of a heart attack to Our Lady of Lourdes
Medical Center here.
As the
ambulance raced through the streets, lights swirling, sirens screaming, Ms.
Samuels, who took phone orders for a company that delivers milk, asked the
paramedic, “Can this kill me?” He murmured yes, then told the driver, “Step on
it!” She thought to herself, “This will be my last view of the world, the last
time I will see the night sky.”
Instead, she
survived, her heart undamaged, the beneficiary of the changing face of heart
attack care. With no new medical discoveries, no new technologies, no payment
incentives — and little public notice — hospitals in recent years have slashed
the time it takes to clear a blockage in a patient’s arteries and get blood
flowing again to the heart.
The changes
have been driven by a detailed analysis of the holdups in treating patients and
a nationwide campaign led by the American College of Cardiology, a professional
society for specialists in heart disease, and the American Heart Association.
Hospitals across the country have adopted common-sense steps that include
having paramedics transmit electrocardiogram readings directly from ambulances
to emergency rooms and summoning medical teams with a single call that sets off
all beepers at once.
From 2003 to
2013, the death rate from coronary heart disease fell about 38 percent,
according to the American Heart Association citing data from the Centers for
Disease Control and Prevention. The National Heart, Lung and Blood Institute,
the primary federal agency that funds heart research, says this decline has
been spurred by better control of cholesterol and blood pressure, reduced smoking
rates, improved medical treatments — and faster care of people in the throes of
a heart attack.
“It may not
be long before cardiovascular disease is no longer the leading cause of death”
in the United States, said Dr. Michael Lauer, the director of the Division of
Cardiovascular Sciences at the National Heart, Lung and Blood Institute.
And care has
improved not just in elite medical centers, but in local hospitals like Our
Lady of Lourdes, here in a city littered with abandoned buildings and boarded-up
homes that is among the poorest in America, according to the Census Bureau.
Disparities that used to exist, with African-Americans, Hispanics and older
people facing the slowest treatment times, have disappeared, Dr. Harlan
Krumholz, a cardiologist at Yale, and his colleagues said in a paper in
Archives of Internal Medicine.
The
reinvention of protocols to hasten treatment is part of a broad rethinking of
how to tackle coronary heart disease, which accounts for one of every seven
deaths in the United States or 375,000 a year. Just this month, powerful drugs
from the first new class of medicines to lower bad cholesterol levels in a
generation neared approval by the Food and Drug Administration, raising hopes
that they will further reduce the death rate from heart disease. At the same
time, new, less invasive methods for replacing aged heart valves are raising
hopes that ailing patients will be able to live longer. And researchers are
immersed in resolving issues that remain unsettled: the utility of stents to
treat the heart pain known as angina and the ideal level for blood pressure…
The remainder
of the essay (free): http://www.nytimes.com/2015/06/21/health/saving-heart-attack-victims-stat.html
21. No Surprise: ED Crowding Leads to Lower Quality of Care
A systematic
review found three measures have been most frequently linked to quality:
waiting room volume, ED occupancy, and number of ED boarders.
Stang AS, et
al. Crowding Measures Associated With the Quality of Emergency Department Care:
A Systematic Review. Acad Emerg Med. 2015 Jun;22(6):643-56
OBJECTIVES:
Despite the substantial body of literature on emergency department (ED)
crowding, to the best of our knowledge, there is no agreement on the measure or
measures that should be used to quantify crowding. The objective of this
systematic review was to identify existing measures of ED crowding that have
been linked to quality of care as defined by the Institute of Medicine (IOM)
quality domains (safe, effective, patient-centered, efficient, timely, and
equitable).
METHODS: Six
major bibliographic databases were searched from January 1980 to January 2012,
and hand searches were conducted of relevant journals and conference
proceedings. Observational studies (cross-sectional, cohort, and case-control),
quality improvement studies, quasi-experimental (e.g., before/after) studies,
and randomized controlled trials were considered for inclusion. Studies that
did not provide measures of ED crowding were excluded. Studies that did not
provide quantitative data on the link between crowding measures and quality of
care were also excluded. Two independent reviewers assessed study eligibility,
completed data extraction, and assessed study quality using the
Newcastle-Ottawa Quality Assessment Scale (NOS) for observational studies and a
modified version of the NOS for cross-sectional studies.
RESULTS: The
search identified 7,413 articles. Thirty-two articles were included in the
review: six cross-sectional, one case-control, 23 cohort, and two retrospective
reviews of performance improvement data. Methodologic quality was moderate,
with weaknesses in the reporting of study design and methodology. Overall, 15
of the crowding measures studied had quantifiable links to quality of care. The
three measures most frequently linked to quality of care were the number of
patients in the waiting room, ED occupancy (percentage of overall ED beds
filled), and the number of admitted patients in the ED awaiting inpatient beds.
None of the articles provided data on the link between crowding measures and
the IOM domains reflecting equitable and efficient care.
CONCLUSIONS:
The results of this review provide data on the association between ED crowding
measures and quality of care. Three simple crowding measures have been linked
to quality of care in multiple publications.
22. Micro Bits
A. The science of sleeping in, and why
you probably shouldn’t
Nsikan Akpan,
PBS News, July 3, 2015
I hate
sleeping in, but that’s mainly because I can’t. Almost every day, since I was a
teen, regardless of whether it’s a weekday, weekend or holiday, I wake up at 6
am.
As an early
bird, I admit to some delusions of morning grandeur — “Let’s wake up early Saturday
and climb a mountain!” — but being a morning lark has proved annoying to others
in my life, particularly those who function by “catching up” on sleep over the
weekends.
Maybe you’ve
experienced this too? Your boyfriend/girlfriend/life partner/spouse groans as
you roll out of bed at the crack of dawn, eager to climb mountains. Brunch
invitations are a logistical quagmire; do you starve yourself for hours or eat
breakfast twice in one morning?
Night owls
have the opposite problem. I’ve heard them hoot, “If only I could go to bed
early and wake up early. I’d be so productive!”
Is this true
though? Does waking early improve productivity? Is there a downside to shifting
the sleep schedule from weekday to weekend? Would we be better off if we could
switch our sleep schedule preference, known as our chronotype? PBS NewsHour
tracked down two sleep experts to explain the science of sleep.
B. New CDC STD Guidelines
These updated
guidelines discuss 1) alternative treatment regimens for Neisseria gonorrhoeae;
2) the use of nucleic acid amplification tests for the diagnosis of
trichomoniasis; 3) alternative treatment options for genital warts; 4) the role
of Mycoplasma genitalium in urethritis/cervicitis and treatment-related
implications; 5) updated HPV vaccine recommendations and counseling messages;
6) the management of persons who are transgender; 7) annual testing for
hepatitis C in persons with HIV infection; 8) updated recommendations for
diagnostic evaluation of urethritis; and 9) retesting to detect repeat
infection.
C. Trainees Using Video Laryngoscopy
Are Less Likely to End Up in the Esophagus
The odds of
an emergency medicine resident intubating a patient's esophagus were nearly
seven times higher with direct, rather than video, laryngoscopy.
D. ED Clinicians Struggle to Diagnose
Influenza on Clinical Grounds Alone
With PCR as
the gold standard, clinical diagnosis had a sensitivity of only 36%.
Dugas AF et
al. Am J Emerg Med 2015 Jun.
E. National trends in resource
utilization associated with ED visits for syncope
Conclusions: Despite
substantial efforts by medical researchers and professional societies, resource
utilization associated with ED visits for syncope appears to have actually increased.
There have been no apparent improvements in diagnostic yield for admissions.
Novel strategies may be needed to change practice patterns for such patients.
F. Revisiting the “Golden Hour”: An
Evaluation of Out-of-Hospital Time in Shock and Traumatic Brain Injury
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.
G. Preventable risk factors tied to
50% of CVD deaths in U.S. adults
Between 50%
and 54% of heart disease deaths among U.S. adults ages 45 to 79 in 2010 could
have been prevented if risk factors such as diabetes, obesity, high
cholesterol, high blood pressure and smoking were completely eliminated,
according to a study in the Annals of Internal Medicine. Researchers also said that
nearly 5% of these deaths would have been prevented if all states were able to
lower the levels of those risk factors to that of states with the lowest
levels, such as Colorado.
H. Patients with diabetes may reduce
dementia risk with pioglitazone, study finds
German
researchers found that patients with type 2 diabetes who had prescriptions for
pioglitazone for at least two years reduced their risk of dementia by 47%,
compared with those without the disease. The findings in the Annals of
Neurology also revealed that patients with diabetes who did not take the
peroxisome proliferator-activated receptor agonist had a 23% increased dementia
risk.
I. Kaiser Permanente’s Tyson in AJMC:
Shift Focus To Maximize “Healthy Life” Years
In the June
issue of The American Journal of Managed Care, Kaiser Permanente Chairman and
CEO Bernard J. Tyson calls for shifting healthcare resources forward in the
life span to improve quality deliver more value for the healthcare dollar. His
commentary is part of a series marking the 20th year of the journal’s
publication.
J. Bariatric Surgery Bests Diet and
Exercise Against Diabetes
Up to 40%
partial or full diabetes remission versus none with lifestyle intervention.
K. ACIP: All patients ages 16-23
should get MenB vaccination
The CDC’s
Advisory Committee on Immunization Practices issued a recommendation that all
patients ages 16-23 receive serogroup B meningococcal vaccine. Previously, the
recommendation covered only patients ages 10 and older at high risk of
contracting MenB. "[T]his is a very deadly disease that's devastating for
families, and if we didn't have a B recommendation (and, consequently,
mandatory insurance coverage), there would be inequity as to who could afford
it," said AAFP liaison to the ACIP Jamie Loehr, M.D. ACIP also issued
recommendations for the influenza and pneumococcal vaccines.
L. Gluten-free not recommended for
people who don't have celiac disease
Up to a third
of Americans may have reduced their consumption of gluten-containing foods, but
for people who do not have celiac disease, a gluten-free diet could result in
nutritional deficiencies, damage to healthy gut flora and weight gain, doctors
say. Some people do have non-celiac gluten sensitivity, but there is no
definitive test for the condition and the only way to confirm it is through a
gluten challenge. People who suspect they may have celiac disease or NCGS
should not alter their diet, which can result in inaccurate test results, and
should see a doctor for a celiac disease test, doctors say.
M. Stroke's effect
on cognition is like aging 8 years, study finds
A stroke
slows cognitive speed and impairs the memory to an extent equal to aging almost
eight years, a study in the journal Stroke found. Researchers revealed that
test results of participants who had suffered a stroke fell as much as if they
had aged 7.9 years. The study included data on 4,900 patients who participated
in cognitive and memory testing from 1998 to 2012.
N. Survey: Most doctors continue
working while sick despite risk to patients
A survey of
480 attending physicians and 256 advanced practice clinicians found that while
nearly all respondents believe working while sick raises potential risk for
patients, 83% revealed they still went to work while feeling ill at least once
in the last year. Doctors who worked while they were sick expressed concern
over continuity of patient care and professional responsibility, with 98% of
respondents worried about their co-workers and 94% citing staffing concerns.
