1. Medical Expulsive Therapy for Ureteral Stones: Two New
Randomized Trials
A. Use of drug therapy in the
management of symptomatic ureteric stones in hospitalised adults: a
multicentre, placebo-controlled, RCT and cost-effectiveness analysis of a
calcium channel blocker (nifedipine) and an alpha-blocker (tamsulosin) (the
SUSPEND trial).
Pickard R, et
al. Health Technol Assess. 2015 Aug;19(63):1-172.
BACKGROUND:
Ureteric colic, the term used to describe the pain felt when a stone passes
down the ureter from the kidney to the bladder, is a frequent reason for people
to seek emergency health care. Treatment with the muscle-relaxant drugs
tamsulosin hydrochloride (Petyme, TEVA UK Ltd) and nifedipine (Coracten(®), UCB
Pharma Ltd) as medical expulsive therapy (MET) is increasingly being used to
improve the likelihood of spontaneous stone passage and lessen the need for
interventional procedures. However, there remains considerable uncertainty
around the effectiveness of these drugs for routine use.
OBJECTIVES:
To determine whether or not treatment with either tamsulosin 400 µg or nifedipine
30 mg for up to 4 weeks increases the rate of spontaneous stone passage for
people with ureteric colic compared with placebo, and whether or not it is
cost-effective for the UK NHS.
DESIGN: A
pragmatic, randomised controlled trial comparing two active drugs, tamsulosin
and nifedipine, against placebo. Participants, clinicians and trial staff were
blinded to treatment allocation. A cost-utility analysis was performed using
data gathered during trial participation.
SETTING:
Urology departments in 24 UK NHS hospitals.
PARTICIPANTS:
Adults aged between 18 and 65 years admitted as an emergency with a single
ureteric stone measuring ≤ 10 mm, localised by computerised tomography, who
were able to take trial medications and complete trial procedures.
INTERVENTIONS:
Eligible participants were randomised 1 : 1 : 1 to take tamsulosin 400 µg,
nifedipine 30 mg or placebo once daily for up to 4 weeks to make the following
comparisons: tamsulosin or nifedipine (MET) versus placebo and tamsulosin
versus nifedipine.
MAIN OUTCOME
MEASURES: The primary effectiveness outcome was the proportion of participants
who spontaneously passed their stone. This was defined as the lack of need for
active intervention for ureteric stones at up to 4 weeks after randomisation.
This was determined from 4- and 12-week case-report forms completed by research
staff, and from the 4-week participant self-reported questionnaire. The primary
economic outcome was the incremental cost per quality-adjusted life-year (QALY)
gained over 12 weeks. We estimated costs from NHS sources and calculated QALYs
from participant completion of the European Quality of Life-5 Dimensions health
status questionnaire 3-level response (EQ-5D-3L™) at baseline, 4 weeks and 12
weeks.
RESULTS:
Primary outcome analysis included 97% of the 1167 participants randomised
(378/391 tamsulosin, 379/387 nifedipine and 379/399 placebo participants). The
proportion of participants who spontaneously passed their stone did not differ
between MET and placebo [odds ratio (OR) 1.04, 95% confidence interval (CI)
0.77 to 1.43; absolute difference 0.8%, 95% CI -4.1% to 5.7%] or between
tamsulosin and nifedipine [OR 1.06, 95% CI 0.74 to 1.53; absolute difference
1%, 95% CI -4.6% to 6.6%]. There was no evidence of a difference in QALYs gained
or in cost between the trial groups, which means that the use of MET would be
very unlikely to be considered cost-effective. These findings were unchanged by
extensive sensitivity analyses around predictors of stone passage, including
sex, stone size and stone location.
CONCLUSIONS:
Tamsulosin and nifedipine did not increase the likelihood of stone passage over
4 weeks for people with ureteric colic, and use of these drugs is very unlikely
to be cost-effective for the NHS. Further work is required to investigate the
phenomenon of large, high-quality trials showing smaller effect size than
meta-analysis of several small, lower-quality studies.
B. Distal Ureteric Stones and
Tamsulosin: A Double-Blind, Placebo-Controlled, Randomized, Multicenter Trial.
Furyk JS, et
al. Ann Emerg Med. 2015 Jul 13 [Epub ahead of print]
STUDY
OBJECTIVE: We assess the efficacy and safety of tamsulosin compared with
placebo as medical expulsive therapy in patients with distal ureteric stones
less than or equal to 10 mm in diameter.
METHODS: This
was a randomized, double-blind, placebo-controlled, multicenter trial of adult
participants with calculus on computed tomography (CT). Patients were allocated
to 0.4 mg of tamsulosin or placebo daily for 28 days. The primary outcomes were
stone expulsion on CT at 28 days and time to stone expulsion.
RESULTS:
There were 403 patients randomized, 81.4% were men, and the median age was 46
years. The median stone size was 4.0 mm in the tamsulosin group and 3.7 mm in
the placebo group. Of 316 patients who received CT at 28 days, stone passage
occurred in 140 of 161 (87.0%) in the tamsulosin group and 127 of 155 (81.9%)
with placebo, a difference of 5.0% (95% confidence interval -3.0% to 13.0%). In
a prespecified subgroup analysis of large stones (5 to 10 mm), 30 of 36 (83.3%)
tamsulosin participants had stone passage compared with 25 of 41 (61.0%) with
placebo, a difference of 22.4% (95% confidence interval 3.1% to 41.6%) and
number needed to treat of 4.5. There was no difference in urologic
interventions, time to self-reported stone passage, pain, or analgesia
requirements. Adverse events were generally mild and did not differ between
groups.
CONCLUSION:
We found no benefit overall of 0.4 mg of tamsulosin daily for patients with
distal ureteric calculi less than or equal to 10 mm in terms of spontaneous
passage, time to stone passage, pain, or analgesia requirements. In the
subgroup with large stones (5 to 10 mm), tamsulosin did increase passage and
should be considered.
2. Antimicrobial Susceptibility of E coli in Uncomplicated
Cystitis in the ED: Is the Hospital Antibiogram an Effective Treatment Guide?
Smith SC, et
al. Acad Emerg Med. 2015 Aug;22(8):998-1000.
OBJECTIVES:
The objective was to compare the rates of antimicrobial susceptibility in
strains of Escherichia coli isolated from uncomplicated cystitis cases
presenting to the emergency department (ED) of a tertiary care center to those
reported on that institution's hospital-wide antibiogram. The hypothesis was
that cases of uncomplicated cystitis presenting to the ED will exhibit higher
antimicrobial susceptibility than is reported by the hospital-wide antibiogram.
METHODS: A
retrospective chart review of patients who were diagnosed with uncomplicated
cystitis in the ED of a large, academic tertiary care center was conducted. Due
to an error in the implementation of a new electronic medical record system at
this institution in 2009, all urine samples with any abnormality were
reflexively sent for culture. The authors were then able to review and record
the antibiotic susceptibility patterns of all cultures that grew E. coli.
Exclusion criteria included fever, subsequent hospital admission, treatment of
suspected pyelonephritis, receiving current cystitis treatment, male sex,
indwelling catheters, recent surgery or hospitalization, or asymptomatic for
cystitis. Culture isolate antimicrobial susceptibility was then compared with the
hospital-wide antibiogram of the same period. Empiric treatment regimens were
also recorded as secondary data.
RESULTS:
Greater susceptibility to trimethoprim-sulfamethoxazole (TMP-SMX; 80% vs. 71%),
cefazolin (97% vs. 87%), and ciprofloxacin (89% vs. 73%) was found in our
population than was published in the hospital antibiogram. These differences
were shown to be statistically significant using Fisher's exact test (p less
than 0.05). A very high sensitivity to nitrofurantoin (99%), similar to the
hospital antibiogram (98%), was also found. Also noted was a high rate of
antimicrobial susceptibility when specific empiric treatment was initiated with
TMP-SMX or ciprofloxacin: 92 and 89%, respectively.
CONCLUSIONS:
The greater susceptibility of E. coli to TMP-SMX, cefazolin, and ciprofloxacin
observed in this population supports the hypothesis that antimicrobial
susceptibility rates in uncomplicated cystitis presenting to the ED are greater
than those reported in the hospital-wide antibiogram. This could affect
treatment guidelines by confirming that antimicrobials currently recommended
for use in uncomplicated cystitis are more effective in this setting than
currently reported by the hospital-wide antibiogram.
3. Idarucizumab for Dabigatran Reversal
Pollack CP,
et al. N Engl J Med 2015; 373:511-520
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.)
4. After HF Hospital Stay: Symptoms Linger, Palliative Care Is
Rare
Marlene Busko,
Heartwire from Medscape, August 19, 2015
NEW HAVEN, CT
— Soon after patients are discharged from the hospital following acute heart
failure (HF), they often still have traditional symptoms of decompensated
HF—decreased well-being, fatigue, and dyspnea—as well as lingering pain,
anxiety, and depression, a new study reports[1].
"Our findings
suggest that patients who are hospitalized for HF often present with symptoms
that are not traditionally associated with HF and that current management
approaches may fail to adequately address symptoms," Dr Rabeea F Khan
(Yale School of Medicine, New Haven, CT) and colleagues conclude in a research
letter published online August 17, 2015 in JAMA Internal Medicine.
"We are
coming to appreciate that many [HF] patients have a prolonged period of
recovery that continues well after hospital discharge—'posthospitalization syndrome' is the term developed by Dr Harlan
Krumholz (Yale School of Medicine) to describe this," Dr Sarwat I Chaudhry
(Yale School of Medicine) explained to heartwire from Medscape.
Moreover, few
patients in the current study were familiar with palliative care (which can
ease symptoms and stress and be given alongside treatment of the disease), but
after patients learned about this, 68% were interested in receiving these
services.
Addressing
this gap in follow-up care is important, since "patients living with heart
failure are growing in number and complexity and suffer from significant
disease-related morbidity and mortality," Chaudhry said. "We feel
that all patients with advanced HF should be offered palliative care both in
acute care and outpatient settings. . . . to ensure the highest quality of life
for them and for their families."
Fewer Than
10% of HF Patients Receive Palliative Care
Heart failure
is a leading cause of 30-day readmissions, but little is known about symptoms during
hospitalization and those that persist after hospital discharge (and could lead
to readmission).
Khan and
colleagues performed a prospective study of 91 patients who were hospitalized
for HF at their center from 2013 through 2014. The patients had a mean age of
71.5, 52% were female, and 75% had an ejection fraction less than 50%.
Patients
replied to a questionnaire about symptoms at a mean of 2.5 days after they were
admitted to the hospital and 9.9 days after they were discharged. About half of
the patients reported no improvement in fatigue (58%), dyspnea (42%), anxiety
(41%), and pain (41%).
Fewer than
one in four patients claimed to be familiar with palliative care. Many of these
patients mistakenly believed that palliative care is only for cancer patients,
or is the same as hospice care (which is actually for patients with a 6-month
or shorter life expectancy), or is incompatible with life-sustaining/curative
therapies.
Aging
patients with HF have multiple comorbidities that may make HF-related symptoms
difficult to assess, Khan and colleagues note. Also, clinicians treating
patients for HF may be ill-prepared to treat pain, anxiety, depression, and
fatigue. Furthermore, "once patients no longer meet the clinical criteria
for hospitalization (eg, hypoxia or hemodynamic instability), there is an
impetus for discharge even if troublesome symptoms persist," they add.
Although
other studies have shown that fewer than 10% of patients with HF receive
palliative care, HF is well-suited to this care, since it is a progressive
disease that impairs quality of life and has a high mortality rate, according
to the researchers.
Currently,
"at Yale, our palliative team is now integrally involved in the care of
patients with advanced heart failure," Chaudhry said.
To meet the
needs of the growing population of patients living with advanced heart failure,
the work force would need to be expanded, she added. "We would like to see
heart-failure clinicians—physicians, advanced practice registered nurses, and
physician assistants—trained in the delivery of . . . provisioned primary
palliative care."
More studies
are also needed to determine whether palliative care in patients who have been
hospitalized with heart failure will reduce patients' symptoms and hospital
readmission, Khan et al conclude.
Symptom Burden Among Patients Who Were
Hospitalized for Heart Failure
Khan RF, et
al. JAMA Intern Med. 2015 August 17 [Epub ahead of print]
This study
evaluated the spectrum of symptoms, improvement in symptoms after discharge,
and perceptions of palliative care among patients who were hospitalized for
heart failure.
Heart failure
(HF) is a leading cause of 30-day readmission.1 Missing from our understanding
of decompensated HF is the range and natural history of the symptoms that
affect patients. Residual symptoms are known to be a powerful driver of health
care use after hospitalization for HF.2 Intensive symptom management, including
palliative care, may represent a promising approach to improving patient
outcomes after hospitalization for HF. Our objectives were to evaluate the
spectrum of symptoms experienced by patients hospitalized for HF, the
improvement in symptoms after discharge, and patients’ perceptions of
palliative care…
5. Debunking the biggest genetic myth of the human tongue
BY Catherine
Woods PBS News August 5, 2015
Roll it, flip
it, fold it and even mold it into a squiggle. Your tongue can be an acrobat,
regardless of whether your parents are capable of the same tricks.
Every
semester, John McDonald, a evolutionary biologist at the University of
Delaware, asks his undergraduate students the following question: How many of
you were taught in biology class that rolling the tongue is a genetic trait?
Most of the
students raise their hands. They’re wrong.
In 1940, the
prominent geneticist Alfred Sturtevant published a paper saying the ability to
roll one’s tongue is based on a dominant gene. In 1952, Philip Matlock
disproved Sturtevant’s findings, demonstrating that seven out of 33 identical
twins didn’t share their sibling’s gift. If rolling the tongue was genetic,
then identical twins would share the trait. Sturtevant later acknowledged his
mistake.
“I am
embarrassed to see it listed in some current works as an established Mendelian
case,” he wrote in 1965 in his book, “A History of Genetics.” Yet, McDonald
says, the myth is still taught in science textbooks and classrooms. See this
and this, for example.
Don’t be
discouraged if you aren’t a member of the tongue-rolling elite — some can train
their tongues to obey. In fact, one of McDonald’s undergraduate students
conducted a small study asking 10 non-tongue-rolling participants to try
rolling their tongue each day. After a week of practice, one participant
achieved a successful tongue roll.
This doesn’t
mean tongue rolling has no genetic “influence,” McDonald says. More than one
gene could contribute to tongue-rolling abilities. Perhaps the same genes that
determine the tongue’s length or muscle tone are involved. But there isn’t a
single dominant gene that’s responsible.
While you may
think this myth is harmless, McDonald says he’s received emails from kids who
don’t share the tongue-rolling status of their parents. Are my parents really
my parents, they want to know? He quickly puts their fears to rest. If mom and
dad can’t roll their tongues, but you can, don’t worry — chances are you’re
still their kid.
6. Community-acquired pneumonia as medical emergency: predictors
of early deterioration.
Kolditz M, et
al. Thorax. 2015 Jun;70(6):551-8.
BACKGROUND:
Early organ dysfunction determines the prognosis of community-acquired
pneumonia (CAP), and recognition of CAP as a medical emergency has been
advocated.
OBJECTIVE: To
characterise patients with 'emergency CAP' and evaluate predictors for very
early organ failure or death.
METHODS: 3427
prospectively enrolled patients of the CAPNETZ cohort were included. Emergency
CAP was defined as requirement for mechanical ventilation or vasopressor
support (MV/VS) or death within 72 h and 7 days after hospital admission,
respectively. To determine independent predictors, multivariate Cox regression
was employed. The ATS/IDSA 2007 minor criteria were evaluated for prediction of
emergency CAP in patients without immediate need of MV/VS.
RESULTS: 140
(4%) and 173 (5%) patients presented with emergency CAP within 3 and 7 days,
respectively. Hospital mortality of patients presenting without immediate need
of MV/VS was highest. Independent predictors of emergency CAP were the presence
of focal chest signs, home oxygen therapy, multilobar infiltrates, altered
mental status and altered vital signs (hypotension, raised respiratory or heart
rate, hypothermia). The ATS/IDSA 2007 minor criteria showed a high sensitivity
and negative predictive value, whereas the positive predictive value was low.
Reduction to 6 minor criteria did not alter accuracy.
CONCLUSIONS:
Emergency CAP is a rare but prognostic relevant condition, mortality is highest
in patients presenting without immediate need of MV/VS. Vital sign
abnormalities and parameters indicating acute organ dysfunction are independent
predictors, and the ATS/IDSA 2007 minor criteria show a high negative
predictive value.
7. Does My Mother Really Need That Central Line?
Manasco AT,
et al. JAMA Intern Med. 2015;175(8):1267.
Her name was
Claire. She resided in a local nursing home and had advanced dementia, coronary
artery disease, diabetes mellitus, and hypertension. She was nonverbal from
multiple prior cerebrovascular accidents and her worsening dementia. When I
opened her medical record, an orange Do Not Resuscitate/Intubate sheet shined
through her thick stack of medical records. She had come to the emergency
department because her nurse noted hypoxia and tachypnea earlier that day.
While in the emergency department, Claire’s blood pressure dropped, despite
adequate volume resuscitation. The indication was clear: septic shock secondary
to pneumonia. As an intern, I had absorbed the principles of sepsis care that
my attending physicians inculcated into me. I knew the next step; she needed
vasopressors.
I brought a
consent form to the patient’s 2 daughters, who were at her bedside. They
visited Claire multiple times a week and were present at every one of her
increasingly frequent visits to our emergency department. They nodded and
listened politely as I discussed the benefits of the central line and
vasopressors: increasing their mother’s blood pressure, ease of blood draws,
increased chance of survival. The risks were also understood: pneumothorax,
bleeding, accidental arterial puncture, thrombosis. This was not new for them.
I asked what questions they had for me.
“Does my
mother really need this?” one daughter asked.
I was
surprised. This was a new question for me. I attempted to maintain my
composure, nodded, and explained the need to increase blood pressure in
critically ill patients. I stopped before discussing goal-directed therapy and
the finer points of the sepsis literature; it was clear that such things were
not important to them. My attending physician, understanding where the
conversation was going, deftly changed the subject. “What would Claire want, if
she could join this conversation?”
Suddenly, her
family opened up. Claire was a vibrant person. Before her illness had advanced,
she walked every day and knew everyone at her church. She was outgoing, and her
distinctive laugh could be heard from across the room. Claire would not want to
be on a ventilator or kept alive in this condition. We discussed palliative
care, but the family was not ready to make a decision. They needed time.
Together, we decided to defer the central line placement and vasopressor
therapy. Claire was admitted to the intensive care unit while the family
discussed their options. The next day, she was given comfort measures only and
died with her family at the bedside.
The Choosing
Wisely initiative, developed by the American Board of Internal Medicine (ABIM),
is a set of specialty-specific recommendations to decrease overuse of
unnecessary tests and procedures. One emergency medicine–specific
recommendation is not to “delay engaging available palliative and hospice care
services in the emergency department for patients likely to benefit.”1 Similar
to the treatment of sepsis or stroke, emergency medicine clinicians are in a
unique position to initiate appropriate early discussion of palliative care.
Claire could
have traveled down the path taken by many frail, chronically ill septic
patients: fluids, central line, vasopressors, intensive care unit admission,
complications, and for many, death in the hospital. Her daughter spoke up and
did her job as health care proxy, questioning the utility of further
interventions. I realized it is part of my job to ask these difficult questions
and, when appropriate, discuss palliative care.
As emergency
physicians, we are quick to intervene in critical moments. These moments do not
have to be a gunshot wound, heart attack, or stroke. The intervention may be
starting a difficult family dialogue about end-of-life care. Having seen
firsthand the potential power of an earnest goals-of-care discussion, I believe
that emergency physicians can add dignity and quality to our patients’ last
stage of life.
1. Choosing
Wisely: An Initiative of the ABIM Foundation. American College of Emergency
Physicians. http://www.choosingwisely.org/doctor-patient-lists/american-college-of-emergency-physicians/
8. CT Does Not Improve Detection of Occult Cancer in Patients
with Unprovoked Venous Thromboembolism
This trial,
published in the N Engl J Med, showed that the addition of abdominopelvic CT to
routine measures in patients with unprovoked venous thrombosis did not detect
additional occult cancers. The incidence of cancer in first unprovoked venous
thrombosis was 4%, not 10% as had been previously reported.
Editorial: Cancer Workup after
Unprovoked Clot — Less Is More
9. Could Your Smartphone Help Boost Your Heart Health?
Special apps,
trackers may boost weight loss, exercise, quitting smoking, early studies
suggest
THURSDAY,
Aug. 13, 2015 (HealthDay News) -- Smartphones could become a high-tech tool to
help boost heart health, experts say.
The apps and
wearable sensors on many cellphones can track exercise, activity and heart
rates, and while evidence of their effectiveness in reducing risk factors for
heart disease and stroke is limited, they could prove useful, a new American
Heart Association scientific statement said.
Currently, 20
percent of American adults use some type of technology to track their health
data. The most popular health apps are associated with exercise, counting steps
or tracking your heart rate, the heart association said.
The authors
of the statement reviewed the small number of published, peer-reviewed studies
about the effectiveness of mobile health technologies in managing weight,
boosting physical activity, quitting smoking, and controlling high blood
pressure, high cholesterol and diabetes.
"The
fact that mobile health technologies haven't been fully studied doesn't mean
that they are not effective. Self-monitoring is one of the core strategies for
changing cardiovascular health behaviors," statement lead author Lora
Burke, professor of nursing and epidemiology, University of Pittsburgh, said in
an AHA news release.
"If a
mobile health technology, such as a smartphone app for self-monitoring diet,
weight or physical activity, is helping you improve your behavior, then stick
with it," Burke added.
She and her
colleagues found that people who used mobile technology as part of an overall
weight-loss program had more short-term weight loss than those who tried to
lose weight on their own.
Many studies
found that people who used an online program for physical activity had larger
increases in exercise than those who didn't use such programs, but the
effectiveness of wearable exercise monitoring devices was unclear.
The statement
authors also found that the use of mobile phone apps that use text messaging to
help people quit smoking nearly doubled the chances of quitting, but 90 percent
of people who used these apps did not quit smoking after six months.
The statement
was published Aug. 13 in the journal Circulation.
Full-text
(free): http://circ.ahajournals.org/content/early/2015/08/13/CIR.0000000000000232.full.pdf+html
10. A Preprocedural Checklist Improves the Safety of ED
Intubation of Trauma Patients.
Smith KA, et
al. Acad Emerg Med. 2015 Aug;22(8):989-92.
OBJECTIVES:
Endotracheal intubation of trauma patients is a vital and high-risk procedure
in the emergency department (ED). The hypothesis was that implementation of a
standardized, preprocedural checklist would improve the safety of this
procedure.
METHODS: A
preprocedural intubation checklist was developed and then implemented in a
prospective pre-/postinterventional study in an academic trauma center ED. The
proportions of trauma patients older than 16 years who experienced
intubation-related complications during the 6 months before checklist
implementation and 6 months after implementation were compared.
Intubation-related complications included oxygen desaturation, emesis,
esophageal intubation, hypotension, and cardiac arrest. Additional outcomes included
time from paralysis to intubation and adherence to safety process measures.
RESULTS:
During the study, 141 trauma patients were intubated, including 76 in the
prechecklist period and 65 in the postchecklist period. A lower proportion of
patients experienced intubation-related complications in the postchecklist
period (1.5%) than the prechecklist period (9.2%), representing a 7.7% (95%
confidence interval = 0.5% to 14.8%) absolute risk reduction.
Paralysis-to-intubation time was also lower in the postchecklist period (median
= 82 seconds, interquartile range [IQR] = 68 to 101 seconds) compared to the
prechecklist period (median = 94 seconds, IQR = 78 to 115 seconds; p = 0.02).
Adherence to safety process measures also improved, with all safety measures performed
in 69.2% in the postchecklist period compared to 17.1% before the checklist (p less
than 0.01).
CONCLUSIONS:
Implementation of a preintubation checklist for ED intubation of trauma
patients was associated with a reduction in intubation-related complications,
decreased paralysis-to-intubation time, and improved adherence to recognized
safety measures.
11. Corticosteroid Therapy for Patients Hospitalized With
Community-Acquired Pneumonia: A Systematic Review and Meta-analysis
Siemieniuk
RAC, et al. Ann Intern Med. 11 August
2015 [Epub ahead of print]
Background:
Community-acquired pneumonia (CAP) is common and often severe.
Purpose: To
examine the effect of adjunctive corticosteroid therapy on mortality,
morbidity, and duration of hospitalization in patients with CAP.
Data Sources:
MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials through
24 May 2015.
Study
Selection: Randomized trials of systemic
corticosteroids in hospitalized adults with CAP.
Data
Extraction: Two reviewers independently extracted study data and assessed risk
of bias. Quality of evidence was assessed with the Grading of Recommendations
Assessment, Development and Evaluation system by consensus among the authors.
Data
Synthesis: The median age was typically in the 60s, and approximately 60% of
patients were male. Adjunctive corticosteroids were associated with possible
reductions in all-cause mortality (12 trials; 1974 patients; risk ratio [RR],
0.67 [95% CI, 0.45 to 1.01]; risk difference [RD], 2.8%; moderate certainty),
need for mechanical ventilation (5 trials; 1060 patients; RR, 0.45 [CI, 0.26 to
0.79]; RD, 5.0%; moderate certainty), and the acute respiratory distress
syndrome (4 trials; 945 patients; RR, 0.24 [CI, 0.10 to 0.56]; RD, 6.2%;
moderate certainty). They also decreased time to clinical stability (5 trials;
1180 patients; mean difference, −1.22 days [CI, −2.08 to −0.35 days]; high
certainty) and duration of hospitalization (6 trials; 1499 patients; mean
difference, −1.00 day [CI, −1.79 to −0.21 days]; high certainty). Adjunctive
corticosteroids increased frequency of hyperglycemia requiring treatment (6
trials; 1534 patients; RR, 1.49 [CI, 1.01 to 2.19]; RD, 3.5%; high certainty)
but did not increase frequency of gastrointestinal hemorrhage.
Limitations:
There were few events and trials for many outcomes. Trials often excluded
patients at high risk for adverse events.
Conclusion:
For hospitalized adults with CAP, systemic corticosteroid therapy may reduce
mortality by approximately 3%, need for mechanical ventilation by approximately
5%, and hospital stay by approximately 1 day.
12. How to Live Wisely (A Primer for College Students)
By RICHARD J.
LIGHT, JULY 31, 2015; The New York Times
Imagine you
are Dean for a Day. What is one actionable change you would implement to
enhance the college experience on campus?
I have asked
students this question for years. The answers can be eye-opening. A few years
ago, the responses began to move away from “tweak the history course” or
“change the ways labs are structured.” A different commentary, about learning
to live wisely, has emerged.
What does it
mean to live a good life? What about a productive life? How about a happy life?
How might I think about these ideas if the answers conflict with one another?
And how do I use my time here at college to build on the answers to these tough
questions?
A number of
campuses have recently started to offer an opportunity for students to grapple
with these questions. On my campus, Harvard, a small group of faculty members
and deans created a noncredit seminar called “Reflecting on Your Life.” The
format is simple: three 90-minute discussion sessions for groups of 12
first-year students, led by faculty members, advisers or deans. Well over 100
students participate each year.
Here are five
exercises that students find particularly engaging. Each is designed to help
freshmen identify their goals and reflect systematically about various aspects
of their personal lives, and to connect what they discover to what they actually
do at college.
1. For the
first exercise, we ask students to make a list of how they want to spend their
time at college. What matters to you? This might be going to class, studying,
spending time with close friends, perhaps volunteering in the off-campus
community or reading books not on any course’s required reading list. Then
students make a list of how they actually spent their time, on average, each
day over the past week and match the two lists.
Finally, we
pose the question: How well do your commitments actually match your goals?
A few
students find a strong overlap between the lists. The majority don’t. They are
stunned and dismayed to discover they are spending much of their precious time
on activities they don’t value highly. The challenge is how to align your time
commitments to reflect your personal convictions.
The remainder
of the article: http://www.nytimes.com/2015/08/02/education/edlife/how-to-live-wisely.html
13. Images in Clinical Practice
The Strawberry
Tongue of Kawasaki Disease
A Giant
Aneurysm of the Anterior Communicating Artery
Electrical
Alternans with Pericardial Tamponade
Mesenteric
Ischemia Mimicking ST-Segment Elevation Myocardial Infarction
14. Addressing barriers to emergency anaphylaxis care: from EMS
to ED to outpatient follow-up
Fineman SM,
et al. Ann Allergy Asthma Immunol 2015 August 06 [Epub ahead of print]
Background: Anaphylaxis
is a systemic life-threatening allergic reaction that presents unique
challenges for emergency care practitioners. Allergists and emergency
physicians have a history of collaborating to promote an evidence-based,
multidisciplinary approach to improve the emergency management and follow-up of
patients with or at risk of anaphylaxis.
Objectives: To
review recent scientific literature about anaphylaxis, discuss barriers to
care, and recommend strategies to support improvement in emergency anaphylaxis
care.
Methods: An
expert panel of allergists and emergency physicians was convened by the
American College of Allergy, Asthma and Immunology in November 2014 to discuss
current knowledge about anaphylaxis, identify opportunities for emergency
practitioners and allergists to partner to address barriers to care, and recommend
strategies to improve medical management of anaphylaxis along the continuum of
care: from emergency medical systems and emergency department practitioners for
acute management through appropriate outpatient follow-up with allergists to
confirm diagnosis, identify triggers, and plan long-term care.
Results: The
panel identified key barriers to anaphylaxis care, including difficulties in
making an accurate diagnosis, low rates of epinephrine administration during
acute management, and inadequate follow-up. Strategies to overcome these
barriers were discussed and recommendations made for future allergist/emergency
physician collaborations, and key messages to be communicated to emergency
practitioners were proposed.
Conclusion: The
panel recommended that allergists and emergency physicians continue to work in
partnership, that allergists be proactive in outreach to emergency care
practitioners, and that easy-to-access educational programs and materials be
developed for use by emergency medical systems and emergency department
practitioners in the training environment and in practice.
15. The Inaccuracy of Using Landmark Techniques for Cricothyroid
Membrane Identification: A Comparison of Three Techniques.
Bair AE, et
al. Acad Emerg Med. 2015 Aug;22(8):908-14.
OBJECTIVES:
Successful cricothyrotomy is predicated on accurate identification of the
cricothyroid membrane (CTM) by palpation of superficial anatomy. However,
recent research has indicated that accuracy of the identification of the CTM
can be as low as 30%, even in the hands of skilled providers. To date, there
are very little data to suggest how to best identify this critical landmark.
The objective was to compare three different methods of identifying the CTM.
METHODS: A
convenience sample of patients and physician volunteers who met inclusion
criteria was consented. The patients were assessed by physician volunteers who
were randomized to one of three methods for identifying the CTM (general
palpation of landmarks vs. an approximation based on four finger widths vs. an
estimation based on overlying skin creases of the neck). Volunteers would then
mark the skin with an invisible but florescent pen. A single expert evaluator
used ultrasound to identify the superior and inferior borders of the CTM. The
variably colored florescent marks were then visualized with ultraviolet light
and the accuracy of the various methods was recorded as the primary outcome.
Additionally, the time it took to perform each technique was measured.
Descriptive statistics and report 95% confidence intervals (CIs) are reported.
RESULTS:
Fifty adult patients were enrolled, 52% were female, and mean body mass index
was 28 kg/m(2) (95% CI = 26 to 29 kg/m(2) ). The general palpation method was
successful 62% of the time (95% CI = 48% to 76%) and took an average of 14
seconds to perform (range = 5 to 45 seconds). In contrast, the four-finger
technique was successful 46% of the time (95% CI = 32% to 60%) and took an
average of 12 seconds to perform (range = 6 to 40 seconds). Finally, the neck
crease method was successful 50% of the time (95% CI = 36% to 64%) and took an
average of 11 seconds to perform (range = 5 to 15 seconds).
CONCLUSIONS:
All three methods performed poorly overall. All three techniques might
potentially be even less accurate in instances where the superficial anatomy is
not palpable due to body habitus. These findings should alert clinicians to the
significant risk of a misplaced cricothyrotomy and highlight the critical need
for future research.
16. Bystander CPR and Defibrillation Are Associated with Improved
Survival
Daniel J.
Pallin, MD, MPH Journal Watch Emerg Med. July 21, 2015
Reviewing
Nakahara S et al. JAMA 2015 Jul 21. Hansen CM et al. JAMA 2015 Jul 21. Nichol G
and Kim F. JAMA 2015 Jul 21
Two large observational studies suggest that recent
efforts to improve bystander resuscitation have been successful.
After many decades of abysmal — and unchanging — rates of
survival from out-of-hospital cardiac arrest (OHCA), two innovations hold promise.
First, the automated external defibrillator (AED) has made bystander
defibrillation possible. Second, cardiopulmonary resuscitation (CPR) has become
more evidence-based, with an emphasis on compressions instead of ventilation.
In addition, efforts to educate the public to perform CPR have been
increasingly robust. Now, two large observational studies add to the evidence
that these efforts have paid off.
Using a Japanese registry, researchers studied nearly
168,000 cases of bystander-witnessed OHCA of presumed primary cardiac etiology
from 2005 to 2012. Japan expanded access to AEDs in 2004. During the study
period, rates of bystander chest compression increased from 39% to 51% and
rates of bystander-only defibrillation increased from 0.1% to 2.3%. Neurologically
intact survival increased from 3% to 8%. Compared with no chest compression,
bystander chest compression was associated with increased neurologically intact
survival (adjusted odds ratio, 1.5). Compared with emergency medical services
(EMS)-only defibrillation, both bystander-only defibrillation and combined
bystander/EMS defibrillation were associated with increased neurologically
intact survival (ORs, 2.2 and 1.5, respectively).
In a separate study of a North Carolina registry,
investigators evaluated nearly 5000 OHCA cases with attempted resuscitation
from 2010 to 2013. In 2010 the state initiated efforts to improve bystander and
first-responder use of CPR and AEDs. During the study period, rates of
bystander-initiated CPR and defibrillation did not change significantly,
whereas bystander-initiated CPR plus first-responder defibrillation increased
from 14% to 23%. Overall, survival with favorable neurological outcome was 34%
among patients who received bystander-initiated CPR and defibrillation.
Compared with EMS-initiated CPR and defibrillation, bystander-initiated CPR and
defibrillation was associated with increased survival with favorable
neurological outcome, (age- and sex-adjusted OR, 3.4), as was
bystander-initiated CPR plus first-responder–initiated defibrillation (aOR,
1.6). -
Comment
Decades of effort by local communities, the American Heart Association, first
responders, and others seem to be paying off. Everyone should know to shout
“call 911” when someone collapses and then push hard and push fast. The
cost-effectiveness of AEDs in public places is debatable, but these studies
show evidence of their effectiveness.
17. When it comes to immunity, natural really isn’t better
Dustin
Ballard, MD, MBE. Marin Independent Journal. 21 June 2015
According to
a new study, measles vaccines have benefits that extend beyond just protecting
against measles itself.
On sale
today! All natural, preservative-free immunity!! Yes sir and yes ma’am, get
your completely natural protection from deadly infectious disease! Come on in
and meet our 100 percent rashy, snotty, cough-ridden viral vectors of vaccine
preventable disease. If you survive your resultant infection, you’ll be
stronger than ever!
As a health
professional, I tend to be rather jaded regarding the perception that “natural”
treatments are inherently better and safer. Consider that while water is
natural, and essential for life, it is still of dubious value if consumed in
massive quantities. Unadulterated mercury is good for thermometers but not for
the human brain. And artificial-free tetrodotoxin is useful for pufferfish, but
not for dinner.
And then
there is “natural” immunity as parodied above. Earlier this year, we heard
quite a bit about natural immunity in the context of our nation’s measles
outbreak (linked to substandard vaccination rates and international visitors to
Disneyland). Some in the anti-vaxx movement took the spate of measles cases as
an opportunity to espouse the supposed benefits of natural immunity over
vaccine-induced immunity, i.e. that which does not kill us makes us stronger.
Among Marin parents, based on survey data presented last week by Dr. Matthew
Willis at the annual Conference of the Council of State Epidemiologists in
Boston, we know that a parental preference for natural immunity can play a key
role in decisions to opt out of required vaccines.
Many of us in
the medical community believe such a preference for natural immunity is
misdirected and irresponsible. And, thanks to a recent study published in the
journal Science, our intuition is now supported by high-quality scientific
data.
The study is
called “Long-term measles-induced immunomodulation increases overall childhood
infectious disease mortality,” and was conducted by Michael Mina, a medical
student at Emory University, along with collaborators at Princeton and the
department of Viroscience at Erasmus University, Netherlands.
Inspiration
for Mina’s study came from earlier primate research out of Erasmus that found
associations between measles infection and subsequent drops in the immune
system’s memory cells. In particular, these studies demonstrated that measles
attacks B and T lymphocytes and that even though peripheral blood lymphocytes
rebound to normal levels within a few weeks, the new cells are mostly measles
specific — good at detecting and fighting measles, but not so good at
remembering and fighting other infectious agents. Remember, starting around age
6 months, antibodies from an infant’s mother start to wear off and a child has
to forge his or her own immune system — one exposure at a time. The implication
is that after measles infection, the immune system becomes less effective at
fighting previously encountered diseases.
To
investigate whether such “immune amnesia” might also be present in human
populations, Mina et al. looked at childhood deaths between the ages of 1 and 9
in the United Kingdom and Denmark, and 1 and 14 in the United States, in both
pre- and post-vaccine eras. They looked quite broadly, at all infection types,
but attempted to focus on infections (like strep throat) that were acute, not
vaccine preventable at the time of the study, and common enough that most
subjects would likely have had some prior exposure to them. They excluded
infections due to specific types of trauma (like animal bites) and from acute
events (like food poisoning.)
Their results
uncovered a strong correlation between measles infection and death from a
different infectious disease. These findings were consistent in all age groups
across the three nations studied and in both pre- and post-vaccine eras.
Extensive modeling (as detailed in the 41-page manuscript supplement) adjusted
for time trends and confirmed this link between measles infection and risk of
death from a different infectious diseases for up to 28 months after measles
infection.
With these
results in mind, let’s come back to the question of natural immunity as being
naturally better. We’ve all heard arguments from vaccine skeptics that kids
should get their measles immunity naturally and that, if they do, their
“wild-type” immunity will be better than vaccine immunity. And in one way it’s
true; having and recovering from measles is better protection against future
measles disease than being vaccinated against it (just like having and
recovering from Ebola is protective against future Ebola infection but I, for
one, am not jumping at that opportunity).
But, while
vaccine skeptics may be right about the protection against measles afforded by
natural immunity, they are wrong (based on this study) about immunity against
virtually everything else. Even if a parent is willing to take the risk that
her child might die from measles, or be disabled by encephalitis (swelling of
the brain), this study’s results strongly suggest that overall immunity is
depleted for more than two years after measles infection. In this case, that
which does not kill us makes us weaker.
Bottom line,
to quote Mina: “Our findings suggest that measles vaccines have benefits that
extend beyond just protecting against measles itself … It is one of the most
cost-effective interventions for global health.”
Dr. Matt
Willis, Marin’s public health officer, brings this back home: “It is remarkable
that with all the known benefits, we are still finding new reasons to
vaccinate. Hopefully this new evidence will lead to even more parents offering
their kids the full protection of vaccinations.”
Naturally, I
agree.
Available
today, routine childhood vaccinations! Effective and natural immunity (Yes, the
immunity the human body produces after a vaccine is natural, too!), which
protects your child and others. Yes sir and yes ma’am.
18. Primary Care Policies Reduce ED Visits
A. In California, Primary Care
Continuity Was Associated With Reduced ED Use And Fewer Hospitalizations.
If you want
to keep patients from visiting the ER on a regular basis, make sure they see
their primary care physician whenever necessary.
Pourat N, et
al. Health Aff (Millwood). 2015 Jul 1;34(7):1113-20.
The expansion
of health insurance to millions of Americans through the Affordable Care Act
has given rise to concerns about increased use of emergency department (ED) and
hospital services by previously uninsured populations. Prior research has
demonstrated that continuity with a regular source of primary care is
associated with lower use of these services and with greater patient
satisfaction. We assessed the impact of a policy to increase patients'
adherence to an individual primary care provider or clinic on subsequent use of
ED and hospital services in a California coverage program for previously
uninsured adults called the Health Care Coverage Initiative. We found that the
policy was associated with a 42 percent greater probability of adhering to
primary care providers. Furthermore, patients who were always adherent had a
higher probability of having no ED visits (change in probability: 2.1 percent)
and no hospitalizations (change in probability: 1.7 percent), compared to those
who were never adherent. Adherence to a primary care provider can reduce the
use of costly care because it allows patients' care needs to be managed within
the less costly primary care setting.
B. Federally Qualified Health Center
Use Among Dual Eligibles: Rates Of Hospitalizations And ED Visits.
Wright B, et
al. Health Aff (Millwood). 2015 Jul 1;34(7):1147-55.
People who
are eligible for both Medicare and Medicaid, known as "dual
eligibles," disproportionately are members of racial or ethnic minority
groups. They face barriers accessing primary care, which in turn increase the
risk of potentially preventable hospitalizations and emergency department (ED)
visits for ambulatory care-sensitive conditions. Federally qualified health
centers provide services known to address barriers to primary care. We analyzed
2008-10 Medicare data for elderly and nonelderly disabled dual eligibles
residing in Primary Care Service Areas with nearby federally qualified health
centers. Among our findings: There were fewer hospitalizations for ambulatory
care-sensitive conditions among blacks and Hispanics who used these health
centers than among their counterparts who did not use them (16 percent and 13
percent fewer, respectively). Use of the health centers was also associated
with 3 percent and 12 percent fewer hospitalizations for ambulatory
care-sensitive conditions among nonelderly disabled blacks and Hispanics,
respectively. These findings suggest that federally qualified health centers
can reduce disparities in preventable hospitalizations for some dual eligibles.
However, further efforts are needed to reduce preventable ED visits among dual
eligibles receiving care in the health centers.
Project
HOPE—The People-to-People Health Foundation, Inc.
19. Over-Diagnosis of UTI and Under-Diagnosis of STIs in Adult
Women Presenting to an ED
Tomas ME, et
al. J Clin Microbio 10 June 2015 [Epub
ahead of print]
Urinary tract
infections (UTI) and sexually transmitted infections (STI) are commonly
diagnosed in emergency departments (ED). Distinguishing between these syndromes
can be challenging due to overlapping symptomatology and both are associated
with abnormalities on urinalysis (UA).
We conducted
a 2-month observational cohort study to determine the accuracy of clinical
diagnoses of UTI and STI in adult women presenting with genitourinary (GU)
symptoms or diagnosed with GU infections at an urban academic ED. For all urine
specimens, UA, culture, and nucleic acid amplification testing for Neisseria
gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis were performed.
Of 264 women
studied, providers diagnosed 175 (66%) with UTI, 100 (57%) of whom were treated
without performing a urine culture during routine care. Combining routine care
and study-performed urine cultures, only 84 (48%) of these women had a positive
urine culture. Sixty (23%) of all 264 women studied had one or more positive
STI tests, 22 (37%) of whom did not receive STI treatment within 7 days of the
ED visit. Fourteen (64%) of these 22 women were diagnosed with a UTI instead of
an STI. Ninety-two percent of all women studied had an abnormal UA (leukocyte
esterase above trace, positive nitrite, or pyuria). Positive and negative
predictive values for an abnormal UA were 41% and 76% respectively.
In this
population, empiric therapy for UTI without urine culture testing and
over-diagnosis of UTI were common and associated with unnecessary antibiotic
exposure and missed STI diagnoses. Abnormal UAs were common and not predictive
of positive urine cultures.
20. Traumatic Brain Injuries and CT Use in Pediatric Sports
Participants
Glass T, et
al. Amer J Emerg Med. 2015 July 6 [Epub ahead of print]
Background: Childhood
sports-related head trauma is common, frequently leading to emergency
department (ED) visits. We describe the spectrum of these injuries and trends
in computed tomography (CT) use in the Pediatric Emergency Care Applied
Research Network (PECARN).
Methods: This
was a secondary analysis of a large prospective cohort of children with head
trauma in 25 PECARN EDs between 2004–6. We described and compared children 5–18
years by CT rate, TBI on CT and clinically-important TBI (ciTBI). We used
multivariable logistic regression to compare CT rates, adjusting for clinical
severity. Outcomes included frequency of CT, TBIs on CT, and ciTBIs (defined by
a) death, b) neurosurgery, c) intubation longer than 24 hours, or d)
hospitalization for ≥2 nights).
Findings: 3,289
/ 23,082 (14%) children had sports-related head trauma. 2% had Glasgow Coma
Scale scores below 14. 53% received ED CTs, 4% had TBIs on CT, and 1% had
ciTBIs. Equestrians had increased adjusted odds [1.8 (95% CI 1.0, 3.0)] of CTs;
the rate of TBI on CT was 4% (95% CI 3, 5%). Compared to team sports, snow [AOR
4.1 (95% CI 1.5, 11.4)] and non-motorized wheeled [AOR 12.8 (95% CI 5.5, 32.4)]
sports had increased adjusted odds of ciTBIs.
Conclusions: Children
with sports-related head trauma commonly undergo CT. Only 4% of those imaged
had TBIs on CT. ciTBIs occurred in 1%, with significant variation by sport.
There is an opportunity for injury prevention efforts in high-risk sports and
opportunities to reduce CT use in general by use of evidence-based prediction
rules.
What is known
about this subject – Pediatric sports-related head injuries are a common and
increasingly frequent emergency department (ED) presentation, as is the use of
computed tomography (CT) in their evaluation. Little is known about traumatic
brain injuries (TBIs) resulting from different types of sports activities in
children.
What this
study adds to existing knowledge – This study broadens the understanding of the
epidemiology of pediatric TBIs resulting from different sports activities
through a prospective assessment of frequency and severity of
clinically-important TBIs, and ED CT use in a large cohort of head-injured
children in a network of pediatric EDs.
21. Risk factors for 30-day readmission among patients with
culture-positive severe sepsis and septic shock: A retrospective cohort study.
Zilberberg MD,
et al. J Hosp Med. 2015 Jul 20 [Epub ahead of print]
BACKGROUND:
With decreasing mortality in sepsis, attention has shifted to longer-term
consequences associated with survivorship. Thirty-day readmission as a
component of healthcare utilization is an important outcome.
OBJECTIVE: To
examine the frequency of and risk factors for 30-day readmission among patients
surviving sepsis.
DESIGN:
Single-center retrospective cohort.
METHODS/SETTING:
We examined 30-day readmission risk among survivors of hospitalization with
culture-positive severe sepsis or septic shock. Extended spectrum β-lactamase
(ESBL) organisms were identified via molecular laboratory testing.
Healthcare-associated (HCA) was defined by 1 of the following: (1) recent
hospitalization, (2) immune suppression, (3) nursing home residence, (4)
hemodialysis, (5) prior antibiotics, and (6) index bacteremia hospital-acquired
(onset beyond 2 days following admission). Acute kidney injury (AKI) was
defined according to the RIFLE (Risk, Injury, Failure, Loss, End-stage)
criteria. Logistic regression modeled predictors of 30-day readmission.
RESULTS:
Among 1697 sepsis survivors, 543 (32.0%) required 30-day readmission.
Readmitted patients had a higher chronic (median Charlson score 5 vs 4, P less
than 0.001) but not acute (median APACHE [Acute Physiology and Chronic Health
Evaluation] II score 15 and 15, P = 0.275) illness burden, and higher
prevalence of HCA sepsis (94.2% vs 90.2%, P = 0.014) than nonreadmitted
survivors. In logistic regression, 3 factors increased (Organism: ESBL [odds
ratio {OR}: 4.50, 95% confidence interval {CI}: 1.43-14.19], RIFLE: Injury or
RIFLE: Failure [OR: 1.95, 95% CI: 1.300-2.93], and Organism: Bacteroides spp [OR:
2.04, 95% CI: 1.06-3.95]) and 2 reduced (Source: Urine [OR: 0.58, 95% CI:
0.35-0.98], Organism: Escherichia coli [OR: 0.49, 95% CI: 0.27-0.90]) the odds
of 30-day readmission.
CONCLUSIONS:
One-third of survivors of severe sepsis/septic shock required 30-day
readmission. Mild-to-moderate AKI nearly doubled its risk.
22. Micro Bits
A. Therapeutic Hypothermia in Deceased
Organ Donors and Kidney-Graft Function
Conclusion: Mild
hypothermia, as compared with normothermia, in organ donors after declaration
of death according to neurologic criteria significantly reduced the rate of
delayed graft function among recipients.
B. What causes the more severe cases
of pneumonia?
Results: Among
2259 patients who had radiographic evidence of pneumonia and specimens
available for both bacterial and viral testing, a pathogen was detected in 853
(38%): one or more viruses in 530 (23%), bacteria in 247 (11%), bacterial and
viral pathogens in 59 (3%), and a fungal or mycobacterial pathogen in 17 (1%).
The most common pathogens were human rhinovirus (in 9% of patients), influenza
virus (in 6%), and Streptococcus pneumoniae (in 5%).
C. More blacks than whites experience
sudden cardiac arrest
A study in
the journal Circulation found that over the past 10 years, twice as many black
patients had a sudden cardiac arrest as same-gender white patients. Black
patients with sudden cardiac arrest were about six years younger than white
patients and were more likely to have comorbidities such as hypertension,
diabetes and congestive heart failure, researchers said.
D. Standing Better than Sitting for CV
Risk Factors
Sitting was
associated with higher fasting plasma glucose, triglycerides, and cholesterol
compared with standing, researchers have found.
Investigators
attached a monitor to nearly 700 participants over 7 days and found that each
additional 2 hours per day spent sitting was significantly associated with
higher body mass index (risk ratio 1.03, 95% CI 1.01-1.05; P less than 0.001),
waist circumference (Beta=2.12, 95% CI 0.83-3.41, or around 2 centimeters; P less
than 0.001), fasting plasma glucose (about 1%), total/high-density lipoprotein
(HDL) cholesterol ratio (5%), triglycerides (12%), 2-hour plasma glucose (4%),
and with lower HDL cholesterol (0.07 mmol/L).
E. Heart failure length of hospital
stay as proxy for severity
In this
study, longer length of stay during the index heart failure hospitalization was
associated with readmission and mortality within 30 days and one year
independent of comorbidities and cardiovascular risk factors. These results
suggest that length of stay may be a proxy for the severity of heart failure
during the index hospitalization.
F. Hospital seeks to reduce emotional
harm, emphasize patient respect
A Beth Israel
Deaconess Medical Center initiative aims to reduce the risk of emotional harm
to patients and emphasize respect and dignity. The hospital uses a Web-based
portal in its ICU to help families track a loved one's care plan and to upload
photos or details that help physicians get to know their patients better.
G. Emphasize dangers of not
vaccinating to change people's minds
A survey of
315 people revealed that even the most skeptical about vaccination changed
their attitudes when told about the risks that children could face if they
aren't vaccinated.
Abstract: Three
times as many cases of measles were reported in the United States in 2014 as in
2013. The reemergence of measles has been linked to a dangerous trend: parents
refusing vaccinations for their children. Efforts have been made to counter
people's antivaccination attitudes by providing scientific evidence refuting
vaccination myths, but these interventions have proven ineffective. This study
shows that highlighting factual information about the dangers of communicable
diseases can positively impact people's attitudes to vaccination. This method
outperformed alternative interventions aimed at undercutting vaccination myths.
H. WHO: Ebola vaccine shows 100%
success rate in trial
A trial of an
Ebola vaccine in Guinea scored a 100% success rate, says the World Health
Organization. "If proven effective, this is going to be a game changer,
and it will change the management of the current Ebola outbreak and future
outbreaks," says Margaret Chan, WHO director-general.
I. Yelp Adds ER Wait Times to Its
Hospital Review Pages
The new data
comes from patient surveys conducted by the Centers for Medicare and Medicaid
Services.
In addition
to reviews written by users, the Yelp pages for many hospitals now include
government information about doctors’ communication skills, room noise levels,
and emergency room wait times.
Yelp lists
the data in the upper-right corner of each profile and has added a similar box
to nursing home and dialysis center pages, with stats on numbers of beds and
patient survivorship…
The Yelp page
for KP Roseville: http://www.yelp.com/biz/kaiser-permanente-roseville-medical-center-roseville-9?osq=kaiser+roseville+medical+center
J. ER nurses are leaving. Patient
satisfaction is a major reason why.
K. Get Informed About the New CA
Immunization Law
In June,
Governor Jerry Brown signed SB 277 (Pan) to eliminate the personal belief and
religious exemptions to the state’s childhood vaccination requirements. This
was a huge success for California, now one of three states to only allow a
medical exemption. Despite fervent opposition from a vocal minority of
individuals, our family physician members stood strongly on the side of science
and public health to convince legislators to support this important bill. The
new law stipulates that after January 1, 2016 all parents who choose not to
vaccinate their children will have to choose between either a private
home-schooling program or an independent study program.
It is
important to note that opponents of the law are currently gathering signatures
to place a referendum to SB 277 on the November 2016 Ballot. Should they
succeed in qualifying the referendum, the law’s implementation would be put on
hold until after the vote takes place. It is also important to note that
opponents are attempting to recall Senator Richard Pan, MD, pediatrician and
author of SB 277. If you would like to help fight against both the referendum
and the recall, we encourage you to contribute to the Family Physicians
Political Action Committee, which has been a stalwart supporter of Dr. Pan and
is currently battling both of these misguided efforts.
California
Department of Public Health’s Shots for School website: http://www.shotsforschool.org/laws/sb277faq/
L. Again, Silver-containing topicals
are no longer the standard treatment for second-degree burns
M. Study finds drug-resistant head
lice in 25 U.S. states
Head lice
populations in 25 U.S. states are now immune to over-the-counter permethrin
treatments, while head lice in four more states have developed partial
resistance to such treatments, according to a study presented at the annual
meeting of the American Chemical Society. Researchers also found that
prescription medications without permethrin are still effective against head
lice, which affects 6 million to 12 million U.S. children each year.
N. On Being a Doctor: Shining a Light
on the Dark Side
O. Modern management of irritable bowel
syndrome
P. Study identifies predictors of
readmission
Belgian
researchers found that patients with chronic cardiovascular and pulmonary
disease were most likely to be readmitted to the hospital. Predictors of
readmission included at least four emergency department visits over six months,
Friday discharge and longer length of hospitalization. The researchers, whose
work was published in the Journal of Evaluation in Clinical Practice, suggest
improving continuity of care following discharge and carefully monitoring
patients who exhibit risk factors for readmission.
Q. Hospitals aim to reduce sleep
interruptions to improve patient satisfaction
Hospitals
that want better patient satisfaction ratings are trying to ensure patients get
a better night's sleep by reducing the number of times they are awakened
unnecessarily for vital signs checks or medication administration. Hospitals
are also trying to reduce noise levels at night and are creating quiet hours to
help patients sleep better.
Kaiser Health
News: http://khn.org/news/for-hospitals-sleep-and-patient-satisfaction-may-go-hand-in-hand/
