Friday, August 21, 2015

Lit Bits: August 21, 2015

From the recent medical literature...

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 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.

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.

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.

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…

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:

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.