Wednesday, September 23, 2015

Lit Bits: Sept 23, 2015

From the recent medical literature...

1. Diagnostic prediction models for suspected PE: systematic review and independent external validation in primary care [Wells Wins]

Hendriksen JM, et al. BMJ. 2015 Sep 8;351:h4438.

OBJECTIVE: To validate all diagnostic prediction models for ruling out pulmonary embolism that are easily applicable in primary care.

DESIGN: Systematic review followed by independent external validation study to assess transportability of retrieved models to primary care medicine.

SETTING: 300 general practices in the Netherlands.

PARTICIPANTS: Individual patient dataset of 598 patients with suspected acute pulmonary embolism in primary care.

MAIN OUTCOME MEASURES: Discriminative ability of all models retrieved by systematic literature search, assessed by calculation and comparison of C statistics. After stratification into groups with high and low probability of pulmonary embolism according to pre-specified model cut-offs combined with qualitative D-dimer test, sensitivity, specificity, efficiency (overall proportion of patients with low probability of pulmonary embolism), and failure rate (proportion of pulmonary embolism cases in group of patients with low probability) were calculated for all models.

RESULTS: Ten published prediction models for the diagnosis of pulmonary embolism were found. Five of these models could be validated in the primary care dataset: the original Wells, modified Wells, simplified Wells, revised Geneva, and simplified revised Geneva models. Discriminative ability was comparable for all models (range of C statistic 0.75-0.80). Sensitivity ranged from 88% (simplified revised Geneva) to 96% (simplified Wells) and specificity from 48% (revised Geneva) to 53% (simplified revised Geneva). Efficiency of all models was between 43% and 48%. Differences were observed between failure rates, especially between the simplified Wells and the simplified revised Geneva models (failure rates 1.2% (95% confidence interval 0.2% to 3.3%) and 3.1% (1.4% to 5.9%), respectively; absolute difference -1.98% (-3.33% to -0.74%)). Irrespective of the diagnostic prediction model used, three patients were incorrectly classified as having low probability of pulmonary embolism; pulmonary embolism was diagnosed only after referral to secondary care.

CONCLUSIONS: Five diagnostic pulmonary embolism prediction models that are easily applicable in primary care were validated in this setting. Whereas efficiency was comparable for all rules, the Wells rules gave the best performance in terms of lower failure rates.


2. Derivation and validation of a clinical decision rule to identify young children with skull fracture following isolated head trauma

Gravel J, et al. CMAJ 2015 September 8 [Epub ahead of print]

Background: There is no clear consensus regarding radiologic evaluation of head trauma in young children without traumatic brain injury. We conducted a study to develop and validate a clinical decision rule to identify skull fracture in young children with head trauma and no immediate need for head tomography.

Methods: We performed a prospective cohort study in 3 tertiary care emergency departments in the province of Quebec. Participants were children less than 2 years old who had a head trauma and were not at high risk of clinically important traumatic brain injury (Glasgow Coma Scale score less than 15, altered level of consciousness or palpable skull fracture). The primary outcome was skull fracture. For each participant, the treating physician completed a standardized report form after physical examination and before radiologic evaluation. The decision to order skull radiography was at the physician's discretion. The clinical decision rule was derived using recursive partitioning.

Results: A total of 811 patients (49 with skull fracture) were recruited during the derivation phase. The 2 predictors identified through recursive partitioning were parietal or occipital swelling or hematoma and age less than 2 months. The rule had a sensitivity of 94% (95% confidence interval [CI] 83%–99%) and a specificity of 86% (95% CI 84%–89%) in the derivation phase. During the validation phase, 856 participants (44 with skull fracture) were recruited. The rule had a sensitivity of 89% and a specificity of 87% during this phase.

Interpretation: The clinical decision rule developed in this study identified about 90% of skull fractures among young children with mild head trauma who had no immediate indication for head tomography. Use of the rule would have reduced the number of radiologic evaluations by about 60%.

In an accompanying commentary, Peter Gill, MD, The Hospital for Sick Children (SickKids) and University of Toronto, Toronto, Ontario, and Terry Klassen, MD, University of Manitoba, Winnipeg, Manitoba, wrote: “The authors provide front-line clinicians with objective decision-making criteria, more helpful than 'observation versus CT. But perhaps most important, the rule is simple: in children aged less than 2 years with a minor head injury who do not meet the criteria for a CT scan, perform a skull radiograph if they are less than 2 months old or they have parietal or occipital swelling. If only all clinical decision rules could be this simple.”


3. Ketamine-Propofol Versus Propofol Alone for Procedural Sedation in the ED: A Systematic Review and Meta-analysis.

Yan JW, et al. Acad Emerg Med. 2015 Sep;22(9):1003-13.

OBJECTIVES: Propofol is an agent commonly used for procedural sedation and analgesia (PSA) in the emergency department (ED), but it can cause respiratory depression and hypotension. The combination of ketamine-propofol (K-P) is an alternative that theoretically provides a reduction in adverse events compared to propofol. The primary objective of this review was to determine if K-P has a lower frequency of adverse respiratory events in patients undergoing PSA in the ED than propofol alone. Secondary objectives were to compare the proportion of overall adverse events, sedation time, procedure time, and recovery time between K-P and propofol.

METHODS: Electronic searches of Medline, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL were conducted and reference lists were hand-searched. Randomized controlled trials (RCTs) published in English comparing the use of K-P to propofol alone for PSA in the ED were included.

RESULTS: Six RCTs were included with a combined total of 932 patients (K-P = 520, propofol = 412). Five RCTs reported the proportion of adverse respiratory events; the pooled estimate revealed fewer adverse respiratory events with K-P compared to propofol (29.0% vs. 35.4%; risk ratio [RR] = 0.82; 95% confidence interval [CI] = 0.68 to 0.99). There was no significant difference with respect to the proportion of overall adverse events (38.8% vs. 42.5%; RR = 0.88; 95% CI = 0.75 to 1.04). Procedure time was similar when the groups were compared.

CONCLUSIONS: The premise of combining ketamine with propofol is based on the many synergies that theoretically exist between these two agents. In this study, K-P had a lower frequency of adverse respiratory events in patients undergoing PSA in the ED compared to propofol alone.

4. Common Diagnoses and Outcomes in Elderly Patients Who Present to the ED with Non-Specific Complaints.

Quinn K, et al. CJEM. 2015 Sep;17(5):516-22.

OBJECTIVE: Elderly patients often present to the emergency department (ED) with non-specific complaints. Previous studies indicate that such patients are at greater risk for life-threatening illnesses than similarly aged patients with specific complaints. We evaluated the diagnoses and outcomes of elderly patients presenting with non-specific complaints.

METHODS: Two trained data abstractors independently reviewed all records of patients over 70 years old presenting (to two academic EDs) with non-specific complaints, as defined by the Canadian Emergency Department Information System (CEDIS). Outcomes of interest were ED discharge diagnosis, hospital admission, length of stay, and ED revisit within 30 days.

RESULTS: Of the 743 patients screened for the study, 265 were excluded because they had dizziness, vertigo, or a specific complaint recorded in the triage notes. 419 patients (87.7%) presented with weakness and 59 patients (12.3%) presented with general fatigue or unwellness. The most common diagnoses were urinary tract infection (UTI) (11.3%), transient ischemic attack (TIA) (10.0%), and dehydration (5.6%). There were 11 hospital admissions with median length of stay of five days. Eighty-one (16.9%) patients revisited the ED within 30 days of discharge. Regression analysis indicated that arrival to the ED by ambulance was independently associated with hospital admission.

CONCLUSIONS: Our results suggest that elderly patients presenting to the ED with non-specific complaints are not at high risk for life-threatening illnesses. The most common diagnoses are UTI, TIA, and dehydration. Most patients can be discharged safely, although a relatively high proportion revisit the ED within 30 days.

5. The effect of targeted temperature management on coagulation parameters and bleeding events after out-of-hospital cardiac arrest of presumed cardiac cause

Jacob M, et al. Resuscitation. 2015 Sep 8 [Epub ahead of print]

AIMS: Targeted temperature management (TTM) is part of the standard treatment of comatose patients after out-of-hospital cardiac arrest (OHCA) to attenuate neurological injury. In other clinical settings, hypothermia promotes coagulopathy leading to an increase in bleeding and thrombosis tendency. Thus, concern has been raised as to whether TTM can be applied safely, as acute myocardial infarction requiring primary percutaneous coronary intervention (PCI) with the need of effective antiplatelet therapy is frequent following OHCA. This study investigated the influence of TTM at 33 or 36°C on various laboratory and coagulation parameters.

METHODS AND RESULTS: In this single-center predefined substudy of the TTM trial, 171 patients were randomized to TTM at either 33 or 36°C in the postresuscitation phase. The two subgroups were compared regarding standard laboratory coagulation parameters, thrombelastography (TEG), bleeding, and stent thrombosis events. Platelet counts were lower in the TTM33-group compared to TTM36 (p=0.009), but neither standard coagulation nor TEG-parameters showed any difference between the groups. TEG revealed a normocoagulable state in the majority of patients, while approximately 20% of the population presented as hypercoagulable. Adverse events included 38 bleeding events, one stent thrombosis, and one reinfarction, with no significant difference between the groups.

CONCLUSIONS: There was no evidence supporting the assumption that TTM at 33°C was associated with impaired hemostasis or increased the frequency of adverse bleeding and thrombotic events compared to TTM at 36°C. We found that TTM at either temperature can safely be applied in the postresuscitation phase after acute myocardial infarction and primary PCI.

6. Complications Associated With Nitrate Use in Patients Presenting With Acute Pulmonary Edema and Concomitant Moderate or Severe Aortic Stenosis

Claveau D, et al. Ann Emerg Med. 2015;66: 355–362.e1

STUDY OBJECTIVE: We evaluate the incidence of complications associated with the use of nitrates in patients presenting with acute pulmonary edema and concomitant moderate or severe aortic stenosis compared with patients without aortic stenosis. Nitrates are contraindicated in severe aortic stenosis because of the theoretical yet unproven risk of precipitating profound hypotension.

METHODS: A cohort design with retrospective chart review study was conducted at two Canadian hospitals. Patients with aortic stenosis (moderate or severe) and without aortic stenosis were included if they presented with acute cardiogenic pulmonary edema, received intravenous or sublingual nitroglycerin, and had an echocardiography report available. The primary outcome was clinically relevant hypotension, defined as hypotension leading to any of the following predefined events: nitroglycerin discontinuation, intravenous fluid bolus, vasopressor use, or cardiac arrest. The secondary outcome was sustained hypotension, defined as a systolic blood pressure less than 90 mm Hg and lasting greater than or equal to 30 minutes.

RESULTS: The cohort consisted of 195 episodes of acute pulmonary edema, representing 65 episodes with severe aortic stenosis (N=65) and an equal number of matched episodes with moderate aortic stenosis (N=65) and no aortic stenosis (N=65). Nitroglycerin was administered intravenously only in 70% of cases, intravenously and sublingually in 25%, and sublingually only in the remaining 5%. After adjustment for sex, initial systolic blood pressure, furosemide dose, and use of noninvasive ventilation, moderate and severe aortic stenosis were not associated with clinically relevant hypotension after receipt of nitroglycerin (adjusted odds ratio [OR] 0.97, 95% confidence interval [CI] 0.40 to 2.37 for moderate aortic stenosis; adjusted OR 0.99, 95% CI 0.41 to 2.41 for severe aortic stenosis). The incidence of clinically relevant hypotension was 26.2% for moderate and severe aortic stenosis and 23.1% in the no aortic stenosis reference group. The secondary outcome of sustained hypotension occurred in 29.2% of patients with severe aortic stenosis, 16.9% with moderate aortic stenosis, and 13.8% in the no aortic stenosis group (adjusted OR for severe aortic stenosis 2.34; 95% CI 0.91 to 6.01).

CONCLUSION: In this retrospective study, neither moderate nor severe aortic stenosis was associated with a greater risk of clinically relevant hypotension requiring intervention when nitroglycerin was used for acute pulmonary edema. Future studies should investigate safety and efficacy of nitroglycerin for patients with aortic stenosis because this study was limited by a small sample size and design limitations. Cautious use of nitroglycerin in patients with moderate or severe aortic stenosis and presenting with acute pulmonary edema may be a safer strategy than traditionally thought.


7. Accuracy of WBC Count and CRP Levels Related to Duration of Sxs in Pts Suspected of Acute Appendicitis.

Atema JJ, et al. Acad Emerg Med. 2015 Sep;22(9):1015-24.

OBJECTIVES: Low levels of white blood cell (WBC) count and C-reactive protein (CRP) have been suggested to sufficiently rule out acute appendicitis. The diagnostic value of these tests is likely to depend on the duration of complaints. The aim of this study was to evaluate the accuracy of these inflammatory markers in relation to duration of symptoms in patients suspected of acute appendicitis.

METHODS: Patients suspected of having acute appendicitis were retrospectively selected from five prospective cohorts of patients with acute abdominal pain presenting at the emergency department (ED) in two European countries. Only adult patients with clinical suspicion of acute appendicitis based on medical history, physical examination, and laboratory studies at the time of registration in the original cohorts were included in this analysis. WBC count and CRP level were determined in all patients and a final diagnosis was assigned to every patient by an expert panel based on all available clinical data and follow-up. For categories based on symptom duration, the diagnostic accuracy of single and combined cutoff values was determined, and negative predictive values (NPV) and positive predictive values (PPV) were calculated. Subgroup analyses for age (less than 40 years or ≥40 years) and sex were performed.

RESULTS: A total of 1,024 patients with clinically suspected acute appendicitis were included, of whom 580 (57%) were assigned a final diagnosis of appendicitis. No value of WBC count, CRP level, or their combination resulted in a NPV of more than 90%, regardless of the duration of symptoms. A WBC count of over 20 × 10(9) /L in combination with symptoms for more than 48 hours was associated with a PPV of 100%. However, only eight of the 1,024 patients (1%) fulfilled these criteria, limiting the clinical applicability. No other cutoff level of WBC count, CRP level, or their combination resulted in a PPV of more than 80%, regardless of the duration of symptoms. In female patients, normal levels of CRP and WBC count more accurately excluded the diagnosis of appendicitis than normal levels did in male patients.

CONCLUSIONS: No WBC count or CRP level can safely and sufficiently confirm or exclude the suspected diagnosis of acute appendicitis in patients who present with abdominal pain of 5 days or less in duration.

8. ‘Landmark’ Study Supports New, More Aggressive BP Targets

Gina Kolata. New York Times. September 11, 2015

Declaring they had “potentially lifesaving information,” federal health officials said on Friday that they were ending a major study early because it has already conclusively answered a question cardiologists have puzzled over for decades: how low should blood pressure go?

The answer: way lower than the current guidelines.

For years doctors have been uncertain what the optimal goal should be for patients with high blood pressure. The aim of course is to bring it down, but how far and how aggressively remained a mystery. There are trade-offs — risks and side effects from drugs — and there were lingering questions about whether older patients needed somewhat higher blood pressure to push blood to the brain.

The study found that patients who were assigned to reach a systolic blood pressure goal below 120 — far lower than current guidelines of 140, or 150 for people over 60 — had their risk of heart attacks, heart failure and strokes reduced by a third and their risk of death reduced by nearly a quarter.

The study, called Sprint, randomly assigned more than 9,300 men and women ages 50 and over who were at high risk of heart disease or had kidney disease to of two systolic blood pressure targets: less than 120 millimeters of mercury, which is lower than any guideline ever suggested, or less than 140. (Systolic pressure is the higher of the two blood pressure numbers and represents pressure on blood vessels when the heart contracts.)

The study was expected to conclude in 2017, but considering the results of great importance to public health, the National Heart, Lung and Blood Institute announced them Friday morning, saying a paper with the data would be published within a few months.


9. ED Corticosteroid Use for Allergy or Anaphylaxis Is Not Associated With Decreased Relapses

Grunau BE, et al. Ann Emerg Med 2015;66:381–389

STUDY OBJECTIVE: Corticosteroids (steroids) are often used to mitigate symptoms and prevent subsequent reactions in emergency department (ED) patients with allergic reactions, despite a lack of evidence to support their use. We sought to determine the association of steroid administration with improved clinical outcomes.

METHODS: Adult allergy-related encounters to 2 urban EDs during a 5-year period were identified and classified as "anaphylaxis" or "allergic reaction." Regional and provincial databases identified subsequent ED visits or deaths within a 7-day period. The primary outcome was allergy-related ED revisits in the steroid- and nonsteroid-exposed groups, adjusting for potential confounders with a propensity score analysis; secondary outcomes included the number of clinically important biphasic reactions and deaths.

RESULTS: Two thousand seven hundred one encounters (473 anaphylactic) were included; 48% were treated with steroids. Allergy-related ED revisits occurred in 5.8% and 6.7% of patients treated with and without steroids, respectively (adjusted odds ratio [OR] 0.91; 95% confidence interval [CI] 0.64 to 1.28), with a number needed to treat (NNT) to benefit of 176 (95% CI NNT to benefit 39 to ∞ to NNT to harm 65). The adjusted OR in the anaphylaxis subgroup was 1.12 (95% CI 0.41 to 3.27). In the allergic reaction group, the adjusted OR was 0.91 (95% CI 0.63 to 1.31), with an NNT to benefit of 173 (95% CI NNT to benefit 38 to ∞ to NNT to harm 58). In the steroid and nonsteroid groups, there were 4 and 1 clinically important biphasic reactions, respectively. There were no deaths.

CONCLUSION: Among ED patients with allergic reactions or anaphylaxis, corticosteroid use was not associated with decreased relapses to additional care within 7 days.

10. Images in Clinical Practice

A Viper Bite

Arachnoid Cyst

Ptosis after Swimming in the Red Sea

Young Girl with Nasal Congestion and Pain

Elderly Man with Dark Urine

Discussion: Catheter-Associated Urinary Tract Infections: If You Hear Hoofbeats…

11. A Systematic Review and Meta-analysis of D-dimer as a Rule-out Test for Suspected Acute Aortic Dissection.

Asha SE, et al. Ann Emerg Med. 2015;66:368-78.

STUDY OBJECTIVE: The aim of this systematic review and meta-analysis is to determine the diagnostic accuracy of D-dimer as a rule-out test for acute aortic dissection. Previous meta-analyses have had methodological problems with conflicting conclusions, and new diagnostic accuracy studies have been published since.

METHODS: All prospective cross-sectional analytic studies of D-dimer as a diagnostic test for acute aortic dissection were included where diagnosis was confirmed by an accepted reference standard. Studies were identified with MEDLINE, EMBASE, Medion, Google Scholar, Web of Science, and bibliographies of relevant articles and previous systematic reviews. Two reviewers independently screened articles for inclusion, assessed study quality, and extracted data.

RESULTS: Abstracts from 800 articles were reviewed, yielding 30 potentially relevant studies that were reviewed in full text. Five studies met all eligibility criteria. Data from 4 studies (1,557 participants) that used a D-dimer cutoff of 0.50 μg/mL were pooled to estimate sensitivity, specificity, and positive and negative likelihood ratios. Overall, sensitivity and negative likelihood ratio were 98.0% (95% confidence interval [CI] 96.3% to 99.1%) and 0.05 (95% CI 0.03 to 0.09), respectively. These measurements had little statistical heterogeneity. Specificity (41.9%; 95% CI 39.0% to 44.9%) and positive likelihood ratio (2.11; 95% CI 1.46 to 3.05) showed significant statistical heterogeneity. When applied to a low-risk population as defined by the American Heart Association (prevalence 6%), the posttest probability for acute aortic dissection was 0.3%.

CONCLUSION: This meta-analysis suggests that a negative D-dimer result may be useful to help rule out acute aortic dissection in low-risk patients.


12. Burnout in ED healthcare professionals is associated with coping style: a cross-sectional survey.

Howlett M, et al. Emerg Med J. 2015 Sep;32(9):722-7.

INTRODUCTION: Ineffective coping may lead to impaired job performance and burnout, with adverse consequences to staff well-being and patient outcomes. We examined the relationship between coping styles and burnout in emergency physicians, nurses and support staff at seven small, medium and large emergency departments (ED) in a Canadian health region (population 500 000).

METHODS: Linear regression with the Coping Inventory for Stressful Situations (CISS) and Maslach Burnout Inventory (MBI) was used to evaluate the effect of coping style on levels of burnout in a cross-sectional survey of 616 ED staff members. CISS measures coping style in three categories: task-oriented, emotion-oriented and avoidance-oriented coping; MBI, in use for 30 years, assesses the level of burnout in healthcare workers.

RESULTS: Task-oriented coping was associated with decreased risk of burnout, while emotion-oriented coping was associated with increased risk of burnout.

DISCUSSION: Specific coping styles are associated with varied risk of burnout in ED staff across several different types of hospitals in a regional network. Coping style intervention may reduce burnout, while leading to improvement in staff well-being and patient outcomes. Further studies should focus on building and sustaining task-oriented coping, along with alternatives to emotion-oriented coping.

What are these different coping styles?

Task-oriented coping: a primary control style that is adaptive when situations are appraised as changeable. Focus is maintained and emotions are controlled. This can be maladaptive for complex changing social problems.

Emotion-oriented coping: a secondary control style adaptive when situations are appraised as unchangeable. The aim is to reduce stress, but over the long term it can increase stress and produce negative outcomes like anxiety and depression.

Avoidant-distracted coping: This is adaptive in the short-term for uncontrollable problems. You just don’t let the problem bother you and focus on something more interesting. If problems are controllable, this strategy will be maladaptive over the long run.

Avoidant-social coping: Recourse to others is sought in the face of threat, for diversion or for assistance. This strategy is also adaptive for short-term, but over time it is more effective to develop the skills needed to address the threat as an instrumental problem.

13. The Frequency of Postreduction Interventions After Successful Enema Reduction of Intussusception.

Lessenich EM, et al. Acad Emerg Med. 2015 Sep;22(9):1042-7.

OBJECTIVES: The objective was to determine the frequency of postreduction, hospital-level interventions among children with successful reduction of ileocolic intussusception and identify factors that predict the need for such interventions.

METHODS: This was a retrospective cross-sectional study of children who underwent successful enema reduction for ileocolic intussusception at a single emergency department. Hospital-level interventions were included if they occurred within 24 hours of reduction and were further classified as either major (recurrence or possible perforation) or minor (imaging for suspected recurrence or administration of parenteral narcotics or antiemetics). Binary logistic regression was used to identify predictors for hospital-level interventions.

RESULTS: A total of 464 children underwent enema reduction. The median age was 1.7 years (interquartile range [IQR] = 0.8 to 2.5 years), and 66% were male. A total of 435 (94%) were hospitalized with a median hospital stay of 25 hours (IQR = 19 to 34 hours). Nineteen percent (95% confidence interval [CI] = 15% to 22%) needed postreduction interventions, including 6% (95% CI = 4% to 9%) who required major interventions. The median time to any hospital intervention was 9.9 hours (IQR = 6.3 to 16.4 hours). We identified two independent predictors for hospital-level interventions: duration of symptoms over 24 hours (adjusted odds ratio [OR] = 2.1, 95% CI = 1.3 to 3.4) and location of the intussusception tip at (or proximal to) the hepatic flexure (adjusted OR = 1.9, 95% CI = 1.1 to 3.3); the latter factor was also a predictor of a major intervention. None of the children (95% CI = 0 to 1.0%) had an acute decompensation after an initially successful enema reduction.

CONCLUSIONS: Clinical decompensation is rare and recurrence is relatively low after an uncomplicated reduction of ileocolic intussusception. However, one in five children required hospital-level interventions after reduction. Children with the intussusception tip at (or proximal to) the hepatic flexure, and those with symptoms for longer than 24 hours, are more likely to require subsequent interventions. Although outpatient management appears safe after a period of observation, caregivers should be counseled about the risk of ongoing symptoms and recurrence.

14. Marketers should at least be required to try to communicate risk information as effectively as they do their promotional messages.

Amen!

The Vernacular of Risk — Rethinking Direct-to-Consumer Advertising of Pharmaceuticals

Greene JA , et al. N Engl J Med 2015; 373:1087-1089.

Aside from New Zealand, the United States is the only country with a strong pharmaceutical regulatory infrastructure that allows direct-to-consumer advertising (DTCA) of prescription drugs in print, broadcast, and electronic media. U.S. consumers are accustomed to full-page ads in newspapers and magazines detailing a drug's benefits — followed by another page of fine print in which its contraindications, risks, and side effects are spelled out in minute detail and equally minute print.

That may soon change, however, as the Food and Drug Administration (FDA) moves to enact new regulations regarding risk communication in DTCA. Earlier this year, the FDA sought public comments on new guidance for pharmaceutical marketers on communicating risks to consumers in print advertisements. This proposal, which the FDA has kicked around in one form or another since 2004, responds to mounting research showing that reprinting highly technical package inserts in print ads does very little to communicate risks to consumers. The goal is to communicate those risks in a new vernacular.

Instead of reproducing the fine print meant for physicians and pharmacists, the FDA proposes that drug marketers use a new “consumer brief summary” focused “on the most important risk information . . . in a way most likely to be understood by consumers.” A summary written in everyday language might take the form of a Q&A list, for example, or a Drug Facts box like those on packaging for over-the-counter medicines. Drug marketers are being asked to use popular idiom to communicate with people with a wide range of literacy levels; to use larger fonts and more readable formats; and to use visual elements such as white space, logos, and color schemes to highlight the most relevant risks.1…


15. If It's in the News, It Won't Happen to You

Cook T. Emergency Medicine News. 2015;37(8):23

A few years back, the news was all about flesh-eating bacteria. Stories surfaced about a small number of people who died from necrotizing fasciitis, and one happened to be a young guy living in my hometown of Columbia, SC. Soon after, everyone with a rash came to the ED to make sure it wasn't that flesh-eating stuff. Parents lined up to ignore our opinion that it was not serious and to demand antibiotics (not realizing antibiotics caused these rare flesh-eaters in the first place).

Recently on an evening shift, we were taking care of a teenage girl with pleuritic chest pain. It was her second visit that week, and her mother was demanding and anxious. We eventually did x-rays, blood and urine tests, an ECG, and even an echocardiogram and chest CT. All normal.

This still did not make the mother comfortable. “The previous doctor we saw here told us that if she did not get better, we should come back so she could be admitted.” Of course, the previous doctor was one of my interns. Even though she had come for our opinion and received an extensive workup, she clung to the idea that we were overlooking something. She wagged her finger in our faces. “What if something terrible happens to her tonight? Are you sure you know what you are doing?”

How do you talk someone off this cliff of anxiety? Despite our best efforts to inject reality into the discussion, she clung to her fear and the interaction ended tensely. Situations such as these are common in our job, and learning how to manage and deal with the frustration they cause is a part of becoming an emergency physician.

Every day, the media tell us about incredibly rare ways people have been maimed or killed. Last year it was Ebola. The United States has seen four cases with one death. Preventing the spread of the disease is necessary, but you would think thousands of Americans were going to die if you watched the news at that time. My hospital spent millions to provide quarantine areas in the ED, buy special equipment and protective gear, and train personnel on proper decontamination techniques. None of it has been used.

Common Causes

But what choice did anyone have? If you were the unlucky hospital (or emergency physician) taking care of the first Ebola patient, you were skewered by the press for missing the diagnosis of a disease that had never been seen on the continent. I'm surprised they did not hang the emergency physician, but you can be sure he will be in court. (Seriously, I would have missed the diagnosis, too.)

All of this overlooks the most common causes of unexpected death in the United States, however. Every day, 110 people die in car accidents, 57 from self-inflicted gunshot wounds, and a whopping 44 from prescription drug overdose. But you can be sure you will not see anyone stop driving their cars (while texting, no less) or asking for pain meds. If I could tell the mother of the young girl with chest pain what to worry about, it would be to teach her to drive safely, secure their firearms, and lock up their pain meds. These are way more likely to cause the tragedy she intensely fears.

The bottom line is human beings are irrational and natural worriers, and our unique gift of communication fans the flames of panic. If the story involves sharks, large snakes, lightning, terrorist attacks, tornados, child abductions, or any other number of incredible events that are almost entirely viewed in movie theaters, we cannot wait to worry about it. But if we are advised to alter the activities in our day-to-day lives of convenience so that we may safeguard our future existence, it will be a hard sell to get us to change.

16. Commonly Dispensed Medications During Pregnancy: Think Twice Before You Prescribe

Antibiotics topped the list of prescription medications among pregnant women on Medicaid, and 42% received category D or X medications

Palmsten K, et al. The Most Commonly Dispensed Prescription Medications Among Pregnant Women Enrolled in the U.S. Medicaid Program. Obstet Gynecol. 2015 Sep;126(3):465-73.

OBJECTIVE: To characterize the 20 most common prescription medications and the 10 most common prescription medications classified in the former U.S. Food and Drug Administration categories D or X dispensed to pregnant women enrolled in the U.S. Medicaid program.

METHODS: We conducted a cohort study of 1,106,757 pregnant women with live births using 2000-2007 Medicaid Analytic eXtract data. We used outpatient pharmacy records to identify medication dispensings and reported the proportion of pregnancies that were dispensed at least one prescription medication. Maternal age and race and ethnicity-stratified estimates were compared using prevalence ratios and 95% confidence intervals (CIs).

RESULTS: During pregnancy, 82.5% of the cohort had a dispensing for one or more prescription medication. The most commonly dispensed medications during pregnancy included nitrofurantoin (21.6%), metronidazole (19.4%), amoxicillin (18.0%), azithromycin (16.9%), and promethazine (13.5%). Proportions were highest among younger women for several medications; eg, nitrofurantoin (23.9% compared with 15.4%; prevalence ratio 1.55, CI 1.52-1.58), metronidazole (20.7% compared with 12.0%; prevalence ratio 1.73, CI 1.69-1.77), and azithromycin (21.1% compared with 11.0%; prevalence ratio 1.93, CI 1.89-1.97) were more common among women younger than 20 years than among women aged 35 years or older. Proportions were highest among white women with some exceptions; eg, compared with white women, metronidazole was more common among black women (29.8% compared with 14.4%; prevalence ratio 2.07, CI 2.05-2.09). Excluding fertility treatments, 42.0% had at least one dispensing for a D or X medication during pregnancy. Codeine (11.9%) and hydrocodone (10.2%) were the most common D medications.

CONCLUSION: Medications used to treat infections were the most commonly dispensed prescription medications. Dispensing of commonly used prescription medications during pregnancy varied by maternal age and race-ethnicity.

17. Brief Lit Reviews

A. Can Transtracheal Ultrasonography Be Used to Verify Endotracheal Tube Placement?

Answer: Yup!


B. Do patients with a clinically suspected subsegmental PE need anticoagulation therapy?

Answer: Who knows?

Choi H, et al. Emerg Med J 2015;32:744-747

A short cut review was carried out to establish whether the incidence of recurrent venous thromboembolism and mortality is lower among patients with isolated subsegmental pulmonary embolism who are treated with anticoagulant therapy compared with those who are not treated with anticoagulant therapy.

We identified six studies that were directly relevant to the question. All of these studies were observational in nature and included only a small number of patients with isolated subsegmental pulmonary embolism who were not treated with anticoagulants. Of those studies, only two included patients with confirmed isolated subsegmental pulmonary embolism that were not treated with anticoagulation. Among the 47 patients meeting those criteria, no recurrent venous thromboembolism was noted within 3 months. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated.

The clinical bottom line is that the limited available evidence suggests that the incident of recurrent venous thromboembolism is very low in patients with isolated subsegmental pulmonary embolism. However, this is based on limited data from small observational studies. Further evidence from larger trials is necessary before a recommendation can be made to withhold anticoagulation in this situation.

18. Using baby oil to remove asphalt from burn.

Nawrocki PS, Thompson H. CJEM. 2015 Aug 3 [Epub ahead of print]

Intro (excerpt)
Hot mix asphalt concrete is a composite material composed of asphalt mixed with sand, gravel, or stone aggregate. Informally known as blacktop, tarmac, or just asphalt, it is most commonly used in the construction of road surfaces and roofing after being mixed and heated to between 150°C (302°F) and 190°C (374°F). The hot mix asphalt concrete is either heated at a plant away from the construction site or by a mobile mixer on-site, transported to the desired location, offloaded onto the road surface, compacted with a roller, and allowed to dry. Each step in this process represents a risk to workers as the asphalt remains at a high temperature during the entire process. Not surprisingly, hot asphalt burns affect primarily those in the road construction and roofing industries. A review of the Occupational Safety and Health Administration (OSHA) Accident Investigation Summaries yielded 43 reported “hot asphalt” burns and 41 reported “hot tar” burns since 2003, including several fatalities, although injuries are likely underreported…

Case
A 39-year-old male presented to the emergency department with asphalt burns to both upper extremities following a construction site accident. He had been carrying a bucket of hot asphalt when he tripped and dropped the bucket, splashing the asphalt over him. He presented within 30 minutes of the accident and reported that he could still feel the tar burning him. Both upper extremities were immediately immersed in cold water to cool the asphalt and prevent further thermal injury. Upon surveying the extent of the burn, it was noted that both anterior forearms were affected, and several areas of his face, neck, and shoulders were spattered with asphalt. The burns encompassed approximately 6% of the total body surface area.

Baby oil was directly applied to both upper extremities and the areas of his face, neck, and shoulders that had been splashed. Gauze was then soaked in baby oil and applied to the affected areas. After gently pressing the gauze into the skin and allowing the asphalt to emulsify for several minutes, the gauze was peeled off. This process was then repeated every 5 to 10 minutes, and, at 1 hour, nearly all of the asphalt had been removed. Rubbing of the gauze on skin was avoided to prevent mechanical injury to the damaged skin. Partial thickness (second degree) burns were noted over the anterior right forearm and wrist (Figure 1), where the majority of asphalt was spilled. The areas that had been spattered showed signs of superficial (first degree) burns. Following the removal of all asphalt, the affected areas were covered with a nonadherent dressing. The patient was then referred to a designated burn care facility for further management…

Full-text, link to journal from here (subscription required): http://www.ncbi.nlm.nih.gov/pubmed/26235727

19. Endotracheal intubation versus supraglottic airway placement in out-of-hospital cardiac arrest: A meta-analysis.

Benoit JL, et al. Resuscitation. 2015 Aug;93:20-6.

Objective: Overall survival from out-of-hospital cardiac arrest (OHCA) is less than 10%. After initial bag-valve mask ventilation, 80% of patients receive an advanced airway, either by endotracheal intubation (ETI) or placement of a supraglottic airway (SGA). The objective of this meta-analysis was to compare patient outcomes for these two advanced airway methods in OHCA patients treated by Emergency Medical Services (EMS).

Methods: A dual-reviewer search was conducted in PubMed, Scopus, and the Cochrane Database to identify all relevant peer-reviewed articles for inclusion in the meta-analysis. Exclusion criteria were traumatic arrests, pediatric patients, physician/nurse intubators, rapid sequence intubation, video devices, and older airway devices. Outcomes were (1) return of spontaneous circulation (ROSC), (2) survival to hospital admission, (3) survival to hospital discharge, and (4) neurologically intact survival to hospital discharge. Results were adjusted for covariates when available and combined using the random effects model.

Results: From 3,454 titles, 10 observational studies fulfilled all criteria, representing 34,533 ETI patients and 41,116 SGA patients. Important covariates were similar between groups. Patients who received ETI had statistically significant higher odds of ROSC (odds ratio [OR] 1.28, 95% confidence interval [CI] 1.05–1.55), survival to hospital admission (OR 1.34, CI 1.03–1.75), and neurologically intact survival (OR 1.33, CI 1.09–1.61) compared to SGA. Survival to hospital discharge was not statistically different (OR 1.15, CI 0.97–1.37).

Conclusions: Patients with OHCA who receive ETI by EMS are more likely to obtain ROSC, survive to hospital admission, and survive neurologically intact when compared to SGA.

20. Improving Care for Lesbian, Gay, Bisexual, and Transgender Patients in the ED

Jalali S, et al. Ann Emerg Med. 2015;66: 417–423

Introduction

Providing quality care in the emergency department (ED) has become more challenging as the patient census becomes increasingly diverse.1  Studies have shown that marginalized populations face greater social inequalities and health disparities, placing them at higher risk for disease burden and death.2  The lesbian, gay, bisexual, and transgender (LGBT) community is no exception.

An estimated 9 million people in the United States identify themselves as LGBT.3 Although the abbreviation “LGBT” serves as a commonly accepted inclusive term, there is significant diversity of sexuality and gender identity within this community. Figure 1 outlines the commonly used LGBT terms, but these are not meant to define a person’s sexual practices or orientation.4, 5 Despite what popular stereotypes tell us, one’s sexual orientation or gender identity is not always evident, and patients often hide this information from providers for fear of discrimination.5, 6

Medical education has proven to be effective in improving providers’ comfort level, attitude, and communication for the care of LGBT patients.7, 8, 9 However, without standards for LGBT health education, providers are often poorly prepared to care for this at-risk population, resulting in patients’ distrust and avoidance in seeking prompt medical care.5 Until recently, there have been no educational guidelines that teach providers how to effectively care for LGBT patients. The ED is a place where all people should feel safe seeking medical care, so having a better understanding of the disparities and health care risks the LGBT patients face may help emergency providers communicate more effectively with these at-risk patients…


21. Have you heard this one?

A doctor walks into the room and says to his patient, “I’m sorry Mrs Smith, but your test results are back. I have some bad news and some more bad news.”

“Oh, ok. So what’s the bad news?”

“Well, the bad news is that you have cancer.”

“And the more bad news?”

“You also have Alzheimer’s disease.”

Long pause . . .

Then Mrs Smith says, “Well, at least I don’t have cancer.”

I know, I know. It’s …

Source: Mukadam N. BMJ 2015;351:h4592

22. Micro Bits

0. Cave divers uncover new humanlike species in South Africa



A. More research needed on when to deprescribe heart drugs

Few, if any, clinical studies have focused on when aspirin, statins, beta-blockers and angiotensin-converting enzyme inhibitors -- and many other drugs -- should be discontinued, according to a review in the Journal of the American College of Cardiology. Long-term prescribing is based on the assumption that benefits persist, but the theory has not been tested and interactions are more likely as patients age and receive more drugs, the authors wrote.


B. Sleep quality, duration tied to cardiovascular risk, study finds

Adults who sleep for five hours or less a night have 50% more coronary artery calcification than those who sleep for seven hours, and those who sleep nine hours or more have 70% more coronary calcium than intermediate sleepers, according to new research. The authors, whose work was published in the journal Arteriosclerosis, Thrombosis and Vascular Biology, found the lowest levels of cardiovascular disease in people who slept seven hours a night and said their sleep quality was good.


C. Surgeon general seeks to make walking a national campaign

The federal government, under a call to action by US Surgeon General Vivek Murthy, is expected to work with schools, nonprofits and the private sector to promote walking. "We've really lost touch with physical activity. It has slowly vanished from the workplace. More and more kids in school don't have time to exercise," Murthy said.


D. Acceptability of Uncoated Mini-Tablets in Neonates-A Randomized Controlled Trial.

The administration of uncoated mini-tablets proved to be a valuable alternative to syrup for term neonates. Our data on neonates close the age gap of prior findings in toddlers and infants: uncoated mini-tablets offer the potential of a single formulation for all age groups. These findings further shift the paradigm from liquid toward small-sized solid drug formulations for children of all age groups, as the World Health Organization proposes.


E. CDC Commits $20 Million to Combat Prescription Drug Overdose


F. Medicine's Wild West — Unlicensed Stem-Cell Clinics in the United States

… Stem-cell clinics in the United States and abroad have capitalized on this confusion by selling treatments that are not approved by the Food and Drug Administration (FDA), supported by clinical studies, or covered by insurers.

The FDA has approved few treatments involving stem cells. The approved therapies use hematopoietic stem cells to treat diseases of the blood and immune system. But the majority of therapies offered by stem-cell clinics use adipose-derived stem cells packaged as a product called stromal vascular fraction (SVF). Procedures using SVF have become increasingly popular because of the relative ease of acquiring the cells. To produce SVF, clinics collect liposuction aspirate from a patient, separate the cells from the surrounding fat tissue, and administer the isolated cells back to the patient intravenously or by injection into the tissue to be treated. The stem cells found in SVF are multipotent, and proponents postulate that they may regenerate injured tissue or alter the immune system's inflammatory response. Although the FDA has not determined that SVF is safe or effective in treating any disease, U.S. clinics sell SVF-based procedures to patients with myriad conditions — from benign conditions such as hair loss to chronic and life-threatening diseases such as heart failure, muscular dystrophy, and Parkinson's disease.

These clinics neither claim their treatments are effective nor explicitly state that they're unfounded. Their websites frame their work as experimental — although none of the clinics are conducting FDA-approved clinical trials — and emphasize the potential regenerative capabilities of stem cells. Their language is intentionally imprecise and exploits the vulnerability of patients with debilitating diseases…


G. Survey shows physician concerns over increased use of quality metrics

A survey found about half of primary care physicians said increased emphasis on quality metrics has had a negative impact on quality of care. The report from the Commonwealth Fund and the Kaiser Family Foundation found half of physicians said health IT has a positive effect on patient care, and 47% said new trends in health care have made them consider an earlier retirement.


H. Voluntary Stopping of Eating and Drinking (VSED), Physician-Assisted Death (PAD), or Neither in the Last Stage of Life? Both Should be Available as a Last Resort


Physician experience with the practice: http://www.annfammed.org/content/13/5/421.full

I. Efficacy of common hypertension treatment varies among racial groups

Angiotensin-converting-enzyme inhibitors, widely used in treating hypertension, are less effective in black patients than white patients, according to a study in the Journal of the American College of Cardiology. Black patients treated with ACE inhibitors experienced an 8.7% rate of poor cardiovascular outcomes, compared with 6.4% of white patients. The study follows Joint National Committee recommendations that clinicians choose an alternative to ACE inhibitors for black patients with hypertension.


J. Socioeconomic factors may affect readmission risk, study shows

Patients who have limited incomes, are covered by Medicaid or who did not graduate from high school may be at higher risk for hospital readmission within 30 days, researchers reported in JAMA Internal Medicine. Researchers said the data suggest Medicare readmission penalties may punish hospitals for patient outcomes that are beyond a physician's ability to control.


Tuesday, September 08, 2015

Lit Bits: Sept 8, 2015

From the recent medical literature...

1. Three Pubs on Acute Stroke Treatment

A. ACEP Clinical Policy: Use of IV tPA for the Management of Acute Ischemic Stroke in the ED

Brown MD and the Clinical Policies Subcommittee on Use of Intravenous tPA for Ischemic Stroke. Ann Emerg Med. 2015;66:322-333.e31

Summary
This clinical policy from the American College of Emergency Physicians is the revision of a clinical policy approved in 2012 addressing critical questions in the evaluation and management of patients with acute ischemic stroke.1 A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions:

(1) Is intravenous tissue plasminogen activator safe and effective for patients with acute ischemic stroke if given within 3 hours of symptom onset?

Level A recommendations: None specified.

Level B recommendations
With a goal to improve functional outcomes, IV tPA should be offered and may be given to selected patients with acute ischemic stroke within 3 hours after symptom onset at institutions where systems are in place to safely administer the medication. The increased risk of symptomatic intracerebral hemorrhage (sICH) should be considered when deciding whether to administer IV tPA to patients with acute ischemic stroke.

Level C recommendations
When feasible, shared decisionmaking between the patient (and/or his or her surrogate) and a member of the health care team should include a discussion of potential benefits and harms prior to the decision whether to administer IV tPA for acute ischemic stroke. (Consensus recommendation)

(2) Is intravenous tissue plasminogen activator safe and effective for patients with acute ischemic stroke treated between 3 to 4.5 hours after symptom onset?

Level A recommendations: None specified.

Level B recommendations
Despite the known risk of sICH and the variability in the degree of benefit in functional outcomes, IV tPA may be offered and may be given to carefully selected patients with acute ischemic stroke within 3 to 4.5 hours after symptom onset at institutions where systems are in place to safely administer the medication.

Level C recommendations
When feasible, shared decisionmaking between the patient (and/or his or her surrogate) and a member of the health care team should include a discussion of potential benefits and harms prior to the decision whether to administer IV tPA for acute ischemic stroke. (Consensus recommendation)


B. Implementation of an inpatient EHR with computerized physician order entry is associated with improved outcomes for patients admitted with ischemic stroke.

Ballard DW, and the KP CREST Network. Ann Emerg Med. 2015 8 Sept [Epub ahead of print].

Study objective: Electronic health record systems with computerized physician order entry and condition-specific order sets are intended to standardize patient management and minimize errors of omission. However, the effect of these systems on disease-specific process measures and patient outcomes is not well established. We seek to evaluate the effect of computerized physician order entry electronic health record implementation on process measures and short-term health outcomes for patients hospitalized with acute ischemic stroke.

Methods: We conducted a quasi-experimental cohort study of patients hospitalized for acute ischemic stroke with concurrent controls that took advantage of the staggered implementation of a comprehensive computerized physician order entry electronic health record across 16 medical centers within an integrated health care delivery system from 2007 to 2012. The study population included all patients admitted to the hospital from the emergency department (ED) for acute ischemic stroke, with an initial neuroimaging study within 2.5 hours of ED arrival. We evaluated the association between the availability of a computerized physician order entry electronic health record and the rates of ED intravenous tissue plasminogen activator administration, hospital-acquired pneumonia, and inhospital and 90-day mortality, using doubly robust estimation models to adjust for demographics, comorbidities, secular trends, and concurrent primary stroke center certification status at each center.

Results: Of 10,081 eligible patients, 6,686 (66.3%) were treated in centers after the computerized physician order entry electronic health record had been implemented. Computerized physician order entry was associated with significantly higher rates of intravenous tissue plasminogen activator administration (rate difference 3.4%; 95% confidence interval 0.8% to 6.0%) but not with significant rate differences in pneumonia or mortality.

Conclusion: For patients hospitalized for acute ischemic stroke, computerized physician order entry use was associated with increased use of intravenous tissue plasminogen activator.

Associated editorials
1. PR Newswire: Electronic Health Records with Decision Support Help Optimize ED Care for Ischemic Stroke Patients: KP study shows patients received recommended and proven therapy safely and more consistently


2. EHRIntelligence: How CPOE Adoption Helps Clinicians Treat Stroke Effectively


C. Low-Versus Standard-Dose Alteplase for Ischemic Strokes within 4.5 Hours: A Comparative Effectiveness and Safety Study.

Kim BJ, et al. Stroke. 2015 Sep;46(9):2541-8.

BACKGROUND AND PURPOSE: The low-dose (0.6 mg/kg) alteplase strategy to treat acute ischemic stroke patients became widespread in East Asian countries, without rigorous testing against standard-dose (0.9 mg/kg) alteplase treatment. Our aim was to investigate the comparative effectiveness and safety of the low-dose versus standard-dose intravenous alteplase strategy.

METHODS: A total of 1526 acute ischemic stroke patients who qualified for intravenous alteplase and treated within 4.5 hours were identified from a prospective, multicenter, and nationwide stroke registry database. Primary outcomes were a modified Rankin scale score of 0 to 1 at 3 months after stroke and occurrence of symptomatic hemorrhagic transformation. Inverse probability of low-dose alteplase weighting by propensity scores was used to remove baseline imbalances between the 2 groups, and variation among centers were also accounted using generalized linear mixed models with a random intercept.

RESULTS: Low-dose intravenous alteplase was given to 450 patients (29.5%) and standard-dose intravenous alteplase to 1076 patients (70.5%). Low-dose alteplase treatment was comparable to standard-dose therapy according to the following adjusted outcomes and odds ratios (95% confidence intervals): modified Rankin scale score 0 to 1 at 3 months and 0.95 (0.68-1.32); modified Rankin scale 0 to 2 at 3 months and 0.84 (0.62-1.15); symptomatic hemorrhagic transformation and 1.05 (0.65-1.70); and 3-month mortality and 0.54 (0.35-0.83). The associations were unchanged when the analysis was limited to those without endovascular recanalization.

CONCLUSIONS: The low-dose alteplase strategy was comparable to the standard-dose treatment in terms of the effectiveness and safety. 

2. Time to Epinephrine and Survival after Pediatric In-Hospital Cardiac Arrest

Andersen LW, et al; for the American Heart Association Get With the Guidelines–Resuscitation Investigators. JAMA 2015;314(8):802-810.

Importance  Delay in administration of the first epinephrine dose is associated with decreased survival among adults after in-hospital, nonshockable cardiac arrest. Whether this association is true in the pediatric in-hospital cardiac arrest population remains unknown.

Objective  To determine whether time to first epinephrine dose is associated with outcomes in pediatric in-hospital cardiac arrest.

Design, Setting. and Participants  We performed an analysis of data from the Get With the Guidelines–Resuscitation registry. We included US pediatric patients (age less than 18 years) with an in-hospital cardiac arrest and an initial nonshockable rhythm who received at least 1 dose of epinephrine. A total of 1558 patients (median age, 9 months [interquartile range [IQR], 13 days–5 years]) were included in the final cohort.

Exposure  Time to epinephrine, defined as time in minutes from recognition of loss of pulse to the first dose of epinephrine.

Main Outcomes and Measures  The primary outcome was survival to hospital discharge. Secondary outcomes included return of spontaneous circulation (ROSC), survival at 24 hours, and neurological outcome. A favorable neurological outcome was defined as a score of 1 to 2 on the Pediatric Cerebral Performance Category scale.

Results  Among the 1558 patients, 487 (31.3%) survived to hospital discharge. The median time to first epinephrine dose was 1 minute (IQR, 0-4; range, 0-20; mean [SD], 2.6 [3.4] minutes). Longer time to epinephrine administration was associated with lower risk of survival to discharge in multivariable analysis (multivariable-adjusted risk ratio [RR] per minute delay, 0.95 [95% CI, 0.93-0.98]). Longer time to epinephrine administration was also associated with decreased risk of ROSC (multivariable-adjusted RR per minute delay, 0.97 [95% CI, 0.96-0.99]), decreased risk of survival at 24 hours (multivariable-adjusted RR per minute delay, 0.97 [95% CI, 0.95-0.99]), and decreased risk of survival with favorable neurological outcome (multivariable-adjusted RR per minute delay, 0.95 [95% CI, 0.91-0.99]). Patients with time to epinephrine administration of longer than 5 minutes (233/1558) compared with those with time to epinephrine of 5 minutes or less (1325/1558) had lower risk of in-hospital survival to discharge (21.0% [49/233] vs 33.1% [438/1325]; multivariable-adjusted RR, 0.75 [95% CI, 0.60-0.93]; P = .01).

Conclusions and Relevance  Among children with in-hospital cardiac arrest with an initial nonshockable rhythm who received epinephrine, delay in administration of epinephrine was associated with decreased chance of survival to hospital discharge, ROSC, 24-hour survival, and survival to hospital discharge with a favorable neurological outcome.

3. Postural modification to the standard Valsalva manoeuvre for emergency treatment of SVT (REVERT): a RCT

Appelboam A, et al. on behalf of the REVERT trial collaborators. Lancet 2015 August 24 [Epub ahead of print]

Background
The Valsalva manoeuvre is an internationally recommended treatment for supraventricular tachycardia, but cardioversion is rare in practice (5–20%), necessitating the use of other treatments including adenosine, which patients often find unpleasant. We assessed whether a postural modification to the Valsalva manoeuvre could improve its effectiveness.

Methods
We did a randomised controlled, parallel-group trial at emergency departments in England. We randomly allocated adults presenting with supraventricular tachycardia (excluding atrial fibrillation and flutter) in a 1:1 ratio to undergo a modified Valsalva manoeuvre (done semi-recumbent with supine repositioning and passive leg raise immediately after the Valsalva strain), or a standard semi-recumbent Valsalva manoeuvre. A 40 mm Hg pressure, 15 s standardised strain was used in both groups. Randomisation, stratified by centre, was done centrally and independently, with allocation with serially numbered, opaque, sealed, tamper-evident envelopes. Patients and treating clinicians were not masked to allocation. The primary outcome was return to sinus rhythm at 1 min after intervention, determined by the treating clinician and electrocardiogram and confirmed by an investigator masked to treatment allocation. This study is registered with Current Controlled Trials (ISRCTN67937027).

Findings
We enrolled 433 participants between Jan 11, 2013, and Dec 29, 2014. Excluding second attendance by five participants, 214 participants in each group were included in the intention-to-treat analysis. 37 (17%) of 214 participants assigned to standard Valsalva manoeuvre achieved sinus rhythm compared with 93 (43%) of 214 in the modified Valsalva manoeuvre group (adjusted odds ratio 3·7 (95% CI 2·3–5·8; p less than 0·0001). We recorded no serious adverse events.

Interpretation
In patients with supraventricular tachycardia, a modified Valsalva manoeuvre with leg elevation and supine positioning at the end of the strain should be considered as a routine first treatment, and can be taught to patients.


4. Concussion is confusing us all

Sharp DJ, et al. Pract Neurol  2015;15:172-186.

It is time to stop using the term concussion as it has no clear definition and no pathological meaning. This confusion is increasingly problematic as the management of ‘concussed’ individuals is a pressing concern. Historically, it has been used to describe patients briefly disabled following a head injury, with the assumption that this was due to a transient disorder of brain function without long-term sequelae. However, the symptoms of concussion are highly variable in duration, and can persist for many years with no reliable early predictors of outcome. Using vague terminology for post-traumatic problems leads to misconceptions and biases in the diagnostic process, producing uninterpretable science, poor clinical guidelines and confused policy. We propose that the term concussion should be avoided. Instead neurologists and other healthcare professionals should classify the severity of traumatic brain injury and then attempt to precisely diagnose the underlying cause of post-traumatic symptoms.


5. Training the Mind, and the FDA, on Droperidol

Newman D. Ann Emerg Med. 2015;66:243-245.

In 1956, George Pickering,1  an eminent British physician, picked a fight with the medical establishment. He criticized the enormous content of “so-called facts” in medical curricula and singled out the true purpose of medical education: “training the student's mind to collect and assess data.”

Pickering's admonitions were broadly appreciated and have been, for 60 years, largely ignored. Today, despite bedside resources including the Internet, pocket guides, smartphones, and more, students are still asked to memorize an insurmountable quantity of factoids. Meanwhile, their minds remain untrained to collect and assess the published data that define and continually redefine their science.2 3 4 5  

In this issue of Annals , Calver et al6  present a rigorous prospective examination of droperidol, labeled in 2001 by the Food and Drug Administration (FDA) with a black box warning (the agency's strictest caution) despite 3 quiet decades of safety data. The warning was apparently based on 2 studies showing QT prolongation, 1 case of arrhythmia, and 65 events from the FDA’s MedWatch system, representing 30 years, multiple countries, and countless millions of administrations.7 8 9 10  Since 2001, however, this motley collection has been handily trumped by a slew of published reviews and original investigations.11 12 13 14 15 16 17 18 19 20 21 22  The Calver report, a study of droperidol for agitation in which no arrhythmia events occurred in 1,781 patients, is a coup de grâce.

It seems, however, that data supporting the safety of droperidol were, even before 2001, greater in quantity, quality, and source credibility than reports that led to the warning. This should be unsurprising. The FDA’s MedWatch system, a good-faith effort to ensure dangerous event reporting, undergoes no peer review, includes no auditing for scientific veracity, can be used anonymously without restriction, and demands no supporting evidence or contextual data for evaluation of a causal link. It is the uncontrolled nature of these reports that led to close outside scrutiny of the source data for the droperidol warning. The findings, including irregular reporting (eg, 71 cases submitted on a single day), duplication of many reports,11 13 19  and nonstandard dosing (up to 600 mg intravenously),19  have done little to relieve concerns about the propriety and origins of the warning.10  In comparison, published, peer-reviewed literature in the years leading up to 2001 appears to have produced neither a single case report nor a prospectively documented event of ventricular arrhythmia or sudden death with the drug,23 24 25 26 27  despite 1 review of 74 droperidol trials with more than 13,000 subjects,25  another of 67,000 droperidol uses,26  and multiple comprehensive literature reviews including case reports and observational data.23 24 27  Meanwhile, the MedWatch reports have spawned at least 5 external reviews by 4 independent research groups, all of whom challenge the black box warning as unwarranted.7 9 11 13 14  

This leaves the evidence-informed practitioner in an awkward spot—between a reasoned approach to droperidol based on best evidence, and an alarming FDA warning—and it is worth asking, how did it come to this? The answer of course is complex, with acts of both commission and omission across the spectrum of stakeholders. But first and foremost, the key players in this saga, practitioners and regulators, have lacked Pickering’s training of the mind.

There are few, if any, medical professionals who would not describe themselves as “evidence based.” The same is true for most published data reviews, virtually all guidelines, and, it seems, every grand rounds lecture. Indeed, the term’s bastardization and empty deployment are major drivers of the evidence-based medicine crisis,28  originating in medicine’s triumvirate of influence: professional societies, journal editorial boards, and government advisory committees. Despite the controlling presence of prominent, highly educated medical professionals in these venues, all 3 commonly fail as stewards of integrity for medical science.

In perhaps the most brazen dereliction, professional medical societies, the very face of physician-scientist leadership, have broadly failed to ensure the validity and credibility of clinical guidelines. The result of this failure is the crux of Pickering’s “so-called facts”—a nod to the chameleon of accepted medical practice. From one iteration to the next, guidelines often reverse even their strongest (class 1) recommendations, suggesting an absence of scientific methodology and consistency.

Peer-reviewed journals, the defining source for medical science, also miscarry as a filter for valid data and interpretation.33 34 35  The influence of this breakdown is concentrated, ironically, among medicine's most prestigious and thus most cited publications.36 37  Yet the entropic force of this failure has remained less visible, hidden behind a closely guarded peer review process that operates on the peculiar and circular authority of its own criterion standard.

Finally, government committees are failing. The credibility of FDA recommendations has recently been questioned in a report identifying decades of drug approvals based on surrogate endpoints, few to none of which translated into patient-oriented benefits.38  Similar problems39 40 41 42  have only compounded a general sense that, despite the presence of respected physicians and scientists working with and on government panels, the fruit of such work is neither free of industry and political influence nor scientifically dependable. The droperidol episode, a complicated misunderstanding of evidence hierarchies, causal inference, and comparative validity, may not be isolated.

What Can Be Done?
In the case of droperidol, medical science is defined, in the most practical sense, by common practice. The standard-of-care concept rests on this foundation, scientifically bereft as it may be…

The remainder of the editorial (requires subscription): http://www.annemergmed.com/article/S0196-0644(15)00477-1/abstract

This is an editorial in relation to Calver’s droperidol study (presented in Lit Bits, June 19, 2015). Full-text (free): http://www.annemergmed.com/article/S0196-0644(15)00222-X/fulltext 

6. D-dimer Thresholds: Tailor for the Elderly and for the Pregnant

A. An age-adjusted d-dimer threshold for ED patients with suspected PE: accuracy and clinical implications.

Sharp AL, et al. Ann Emerg Med. 2015 Aug 27 [Epub ahead of print].

Study objective
We determine the accuracy of an age-adjusted D-dimer threshold to detect pulmonary embolism in emergency department (ED) patients older than 50 years and describe current ED practices when evaluating possible pulmonary embolism.

Methods
This was a retrospective study of ED encounters for suspected pulmonary embolism from 2008 to 2013. We used structured data to calculate the sensitivity, specificity, negative predictive value, and positive predictive value of different D-dimer thresholds. We describe the incidence of pulmonary embolism, the proportion of patients receiving imaging concordant with D-dimer levels, and the number of “missed” pulmonary embolisms. These findings were used to estimate patient outcomes based on different D-dimer thresholds.

Results
Among 31,094 encounters for suspected pulmonary embolism, there were 507 pulmonary embolism diagnoses. The age-adjusted D-dimer threshold was more specific (64% versus 54%) but less sensitive (93% versus 98%) than the standard threshold of 500 ng/dL; 11,999 imaging studies identified 507 pulmonary embolisms (4.2%); of these, 1,323 (10.6%) were performed with a D-dimer result below the standard threshold. Among patient encounters without imaging, 17.6% had D-dimer values above the threshold, including 5 missed pulmonary embolisms. Among patients who received imaging, 10.6% had a negative D-dimer result. Applying an age-adjusted D-dimer threshold to our sample would avert 2,924 low-value imaging tests while resulting in 26 additional cases of missed pulmonary embolism.

Conclusion
An age-adjusted D-dimer limit has the potential to reduce chest imaging among older ED patients and is more accurate than a standard threshold of 500 ng/dL. Our findings support the adoption of an age-adjusted D-dimer cutoff in community EDs.

B. Gestation-specific D-dimer reference ranges: a cross-sectional study.

Murphy N, et al. BJOG. 2015 Feb;122(3):395-400.

OBJECTIVE: To establish a gestation-specific reference range for D-dimer in healthy pregnant women with a singleton pregnancy using the Auto-Dimer assay.

DESIGN: Cross-sectional study

SETTING: Cork University Maternity Hospital, Ireland.

POPULATION: Healthy pregnant women attending for routine antenatal care.

METHODS: Simultaneous-quantile regression was performed to construct a median, 5th percentile, and 95th percentile, model of normal pregnancy D-dimer concentration versus gestational week, ranging from week 6 to 42. Additionally, pair-wise Mann-Whitney U-tests were performed to compare distributions of D-dimer concentrations for each of the four discrete gestational sampling windows with the distribution of D-dimer concentrations 48 hours postpartum.

MAIN OUTCOME MEASURES: D-dimer concentrations (ng/ml) during normal gestation (approximately week 6 to week 42).

RESULTS: Seven hundred and sixty healthy pregnant women were investigated between gestational age week 5 and 48 hours postpartum. There was a clear steady increase in median D-dimer concentrations over the complete gestational period. Additionally, the 95th centile estimates for all gestational time-points were above the accepted non-pregnancy normal cut-off concentration (224 ng/ml). The results of the Mann-Whitney U-tests suggested that the long-term postnatal return to normal D-dimer concentrations begins in the immediate postpartum period.

CONCLUSIONS: We found that there is a continuous increase in D-dimer concentrations across all gestations. This research is potentially beneficial to future diagnosis of venous thromboembolism (VTE) in pregnancy using the new recommended 95th centile potential cut-offs. Possible further investigation involves an observational study comparing D-dimer concentrations in women with proven DVT with those that don't, generating likelihood ratios.

7. Clinical Features and Outcomes of Takotsubo (Stress) Cardiomyopathy

Templin C, et al. N Engl J Med 2015; 373:929-938.

Background
The natural history, management, and outcome of takotsubo (stress) cardiomyopathy are incompletely understood.

Methods
The International Takotsubo Registry, a consortium of 26 centers in Europe and the United States, was established to investigate clinical features, prognostic predictors, and outcome of takotsubo cardiomyopathy. Patients were compared with age- and sex-matched patients who had an acute coronary syndrome.

Results
Of 1750 patients with takotsubo cardiomyopathy, 89.8% were women (mean age, 66.8 years). Emotional triggers were not as common as physical triggers (27.7% vs. 36.0%), and 28.5% of patients had no evident trigger. Among patients with takotsubo cardiomyopathy, as compared with an acute coronary syndrome, rates of neurologic or psychiatric disorders were higher (55.8% vs. 25.7%) and the mean left ventricular ejection fraction was markedly lower (40.7±11.2% vs. 51.5±12.3%) (P less than 0.001 for both comparisons). Rates of severe in-hospital complications including shock and death were similar in the two groups (P=0.93). Physical triggers, acute neurologic or psychiatric diseases, high troponin levels, and a low ejection fraction on admission were independent predictors for in-hospital complications. During long-term follow-up, the rate of major adverse cardiac and cerebrovascular events was 9.9% per patient-year, and the rate of death was 5.6% per patient-year.

Conclusions
Patients with takotsubo cardiomyopathy had a higher prevalence of neurologic or psychiatric disorders than did those with an acute coronary syndrome. This condition represents an acute heart failure syndrome with substantial morbidity and mortality.

8. Falls and Implementation of NEXUS in the Elderly (The FINE Study)

Denver D, et al. J Emerg Med. 2015;49:294-300.

Background
The incidence of cervical spine injuries (CSI) in people over 65 years of age from low-energy mechanisms is far greater than in younger populations. Algorithms and decision rules exist for selection of trauma patients requiring cervical spine imaging.

Objectives
To determine the validity of the NEXUS criteria in the elderly population with low-mechanism injuries.

Methods
We prospectively conducted computed tomography (CT) imaging in patients over 65 years of age presenting with fall from standing height or less to rule out predefined clinically significant CSI. Eligible patients were prospectively categorized into NEXUS positive or negative.

Results
There were 169 patients included in the final analyses. One hundred twenty (71%) patients in the cohort were classified as “NEXUS positive.” Eleven patients (6.5% of the cohort) had CSI detected on CT imaging of the cervical spine. Nine patients had clinically significant CSI. The NEXUS decision instrument demonstrated 88.9% sensitivity (50.7–99.4%) and 98% negative predictive value (NPV) (87.8–99.9%) in detecting clinically significant CSI. The NEXUS decision instrument demonstrated 81.8% sensitivity (47.8–96.8%) and 95.9% NPV (84.9–99.3%) in detecting any CSI.

Conclusion
In our study, the NEXUS decision instrument was not a valid tool to rule out imaging for patients over 65 years of age presenting after a fall from standing height or less. We advocate the liberal use of CT imaging of the cervical spine in this cohort of patients to rule out cervical spine injury.

9. On the nature of work

A. Rethinking Work

By BARRY SCHWARTZ. New York Times. AUG. 28, 2015

HOW satisfied are we with our jobs?

Gallup regularly polls workers around the world to find out. Its survey last year found that almost 90 percent of workers were either “not engaged” with or “actively disengaged” from their jobs. Think about that: Nine out of 10 workers spend half their waking lives doing things they don’t really want to do in places they don’t particularly want to be.

Why? One possibility is that it’s just human nature to dislike work. This was the view of Adam Smith, the father of industrial capitalism, who felt that people were naturally lazy and would work only for pay. “It is the interest of every man,” he wrote in 1776 in “The Wealth of Nations,” “to live as much at his ease as he can.”

This idea has been enormously influential. About a century later, it helped shape the scientific management movement, which created systems of manufacture that minimized the need for skill and close attention — things that lazy, pay-driven workers could not be expected to have.

Today, in factories, offices and other workplaces, the details may be different but the overall situation is the same: Work is structured on the assumption that we do it only because we have to. The call center employee is monitored to ensure that he ends each call quickly. The office worker’s keystrokes are overseen to guarantee productivity.

I think that this cynical and pessimistic approach to work is entirely backward. It is making us dissatisfied with our jobs — and it is also making us worse at them. For our sakes, and for the sakes of those who employ us, things need to change.

To start with, I don’t think most people recognize themselves in Adam Smith’s description of wage-driven idlers. Of course, we care about our wages, and we wouldn’t work without them. But we care about more than money. We want work that is challenging and engaging, that enables us to exercise some discretion and control over what we do, and that provides us opportunities to learn and grow. We want to work with colleagues we respect and with supervisors who respect us. Most of all, we want work that is meaningful — that makes a difference to other people and thus ennobles us in at least some small way.

We want these things so much that we may even be willing to take home a thinner pay envelope to get them. Lawyers leave white-shoe firms to work with the underclass and underserved. Doctors abandon cushy practices to work in clinics that serve poorer areas. Wall Street analysts move to Washington to work as economic advisers in government.

You might object that those are examples of professionals — people who have the financial security to care about more than just their paychecks and the privilege of working in fields in which it is possible to find meaning and personal satisfaction. What about the janitor? The phone solicitor? The hairdresser? The fast-food worker?

I submit that they, too, are looking for something more than wages. About 15 years ago, the Yale organizational behavior professor Amy Wrzesniewski and colleagues studied custodians in a major academic hospital. Though the custodians’ official job duties never even mentioned other human beings, many of them viewed their work as including doing whatever they could to comfort patients and their families and to assist the professional staff members with patient care. They would joke with patients, calm them down so that nurses could insert IVs, even dance for them. They would help family members of patients find their way around the hospital…


B. Time in the bank: A Stanford plan to save doctors from burnout

By Brigid Schulte, Washington Post. 2015 August 20

PALO ALTO, Calif. — It was just before noon on a recent Friday when Greg Gilbert, an emergency room physician at Stanford Hospital, made it home from another of what would be six overnight shifts in a row. Bleary-eyed and hungry, the divorced single dad was thinking about how to squeeze in a nap before it was time to pick up his three kids from his ex later that afternoon.

He spied a cardboard box from Blue Apron, which delivers all the makings of a home-cooked meal, and a black bag from the Munchery, with gourmet ready-made meals, waiting for him on his front porch and cracked a weary smile. They meant he’d have grilled flat iron steak salad for lunch, instead of his usual fast-food burger. And for dinner, he wouldn’t have to think of what to make or go to the grocery store but could just cook what was in the box and have time to play with the kids.

All of it is courtesy of the Stanford Department of Emergency Medicine. As was Gilbert’s freshly cleaned condo, the gift cards he’d given his assistant to thank her for her work, and the life coach he’s worked with to find better balance in his life.

“This gives me more bandwidth at work,” Gilbert said. “And because I can hang out with my kids and not be exhausted all the time, I’m able to be the kind of parent I’d always hoped to be.”

The meals, housecleaning and a host of other services — babysitting, elder care, movie tickets, grant writing help, handyman services, dry cleaning pickup, speech training, Web support and more — are part of a groundbreaking new “time banking” program aimed to ease work-life conflicts for the emergency medicine faculty.

Doctors can “bank” the time they spend doing the often-unappreciated work of mentoring, serving on committees, covering colleagues’ shifts on short notice or deploying in emergencies, and earn credits to use for work or home-related services.

The simple idea is aimed at addressing a complex challenge: Doctors, on average, work 10 hours more a week than other professionals, with nearly 40 percent working 60 hours or more, according to a 2012 study published in the Archives of Internal Medicine.

It found that “an alarming” 1 in 2 physicians report at least one symptom of burnout and that they’re twice as dissatisfied with their work-life balance than those in other professions. Within 10 years of joining an academic medical faculty, 5 of every 10 doctors leave, and four leave academic medicine entirely.

And that is just as concerns about a coming physician shortage are reaching a fever pitch. The Association of American Medical Colleges projects a shortfall of as many as 90,000 physicians by 2025 as doctors retire, aging baby boomers need more care and mandates of the Affordable Care Act kick in.

Stanford’s time bank, part of a two-year, $250,000 pilot funded largely by the Sloan Foundation, showed big increases in job satisfaction, work-life balance and collegiality, in addition to a greater number of research grants applied for and a higher approval rate than Stanford faculty not in the pilot…


10. Images in Clinical Practice

Man with History of Multiple Abscesses

Related discussion: Probing the Utility of the Rectal Examination

Elderly Woman Presenting After a Collapse

A Child with Gross Hematuria

Single Bubble — Pyloric Atresia

Gastric Pneumatosis

11. A RCT of IV Haloperidol vs. IV Metoclopramide for Acute Migraine Therapy in the ED

Gaffigan ME, et al. J Emerg Med 2015;49:326-334.

Background
Emergency Department (ED) headache patients are commonly treated with neuroleptic antiemetics like metoclopramide. Haloperidol has been shown to be effective for migraine treatment.

Study Objective
Our study compared the use of metoclopramide vs. haloperidol to treat ED migraine patients.

Methods
A prospective, double-blinded, randomized control trial of 64 adults aged 18–50 years with migraine headache and no recognized risks for QT-prolongation. Haloperidol 5 mg or metoclopramide 10 mg was given intravenously after 25 mg diphenhydramine. Pain, nausea, restlessness (akathisia), and sedation were assessed with 100-mm visual analog scales (VAS) at baseline and every 20 min, to a maximum of 80 min. The need for rescue medications, side effects, and subject satisfaction were recorded. QTc intervals were measured prior to and after treatment. Follow-up calls after 48 h assessed satisfaction and recurrent or persistent symptoms.

Results
Thirty-one subjects received haloperidol, 33 metoclopramide. The groups were similar on all VAS measurements, side effects, and in their satisfaction with therapy. Pain relief averaged 53 mm VAS over both groups, with equal times to maximum improvement. Subjects receiving haloperidol required rescue medication significantly less often (3% vs. 24%, p less than 0.02). Mean QTcs were equal and normal in the two groups and did not change after treatment. In telephone follow-up, 90% of subjects contacted were “happy with the medication” they had received, with haloperidol-treated subjects experiencing more restlessness (43% vs. 10%).

Conclusions
Intravenous haloperidol is as safe and effective as metoclopramide for the ED treatment of migraine headaches, with less frequent need for rescue medications.

12. Perioperative Bridging Anticoagulation in Patients with AF

Background It is uncertain whether bridging anticoagulation is necessary for patients with atrial fibrillation who need an interruption in warfarin treatment for an elective operation or other elective invasive procedure. We hypothesized that forgoing bridging anticoagulation would be noninferior to bridging with low-molecular-weight heparin for the prevention of perioperative arterial thromboembolism and would be superior to bridging with respect to major bleeding.

Methods We performed a randomized, double-blind, placebo-controlled trial in which, after perioperative interruption of warfarin therapy, patients were randomly assigned to receive bridging anticoagulation therapy with low-molecular-weight heparin (100 IU of dalteparin per kilogram of body weight) or matching placebo administered subcutaneously twice daily, from 3 days before the procedure until 24 hours before the procedure and then for 5 to 10 days after the procedure. Warfarin treatment was stopped 5 days before the procedure and was resumed within 24 hours after the procedure. Follow-up of patients continued for 30 days after the procedure. The primary outcomes were arterial thromboembolism (stroke, systemic embolism, or transient ischemic attack) and major bleeding.

Results In total, 1884 patients were enrolled, with 950 assigned to receive no bridging therapy and 934 assigned to receive bridging therapy. The incidence of arterial thromboembolism was 0.4% in the no-bridging group and 0.3% in the bridging group (risk difference, 0.1 percentage points; 95% confidence interval [CI], -0.6 to 0.8; P=0.01 for noninferiority). The incidence of major bleeding was 1.3% in the no-bridging group and 3.2% in the bridging group (relative risk, 0.41; 95% CI, 0.20 to 0.78; P=0.005 for superiority).

Conclusions In patients with atrial fibrillation who had warfarin treatment interrupted for an elective operation or other elective invasive procedure, forgoing bridging anticoagulation was noninferior to perioperative bridging with low-molecular-weight heparin for the prevention of arterial thromboembolism and decreased the risk of major bleeding.


13. Ann Emerg Med Reviews

A. What Is the Clinical Utility of Bedside US in the Diagnosis of Acute Cardiogenic Pulmonary Edema in the Undifferentiated Dyspneic Patient?

Summary: In patients with a moderate to high pretest probability of acute cardiogenic pulmonary edema, sonographic B-lines help to confirm the diagnosis. In patients with a low pretest probability, a normal lung ultrasonographic result nearly excludes cardiogenic pulmonary edema.


B. Does Colchicine Improve Pain in an Acute Gout Flare?

Summary: Low-quality evidence suggests that both high- and low-dose colchicine decreases pain in acute gout flares; however, high-dose regimens are associated with more frequent adverse effects.


14. Wound Care of Pretibial Thin-skin Lacerations with the Combined Use of Sterile Adhesive Strips and Sutures

Andreana L, et al. J Emerg Med 2015;49:345-346.

Elderly patients and patients chronically treated with corticosteroids often have thin and inelastic skin. Traumatic skin lacerations, especially of the pretibial area, are particularly difficult to treat in these patients, due to skin retraction and fragility.

In a recent publication, Davis et al. described a technique combining the use of the Steri-strip™ (3M, St. Paul, MN) and simple suture ( Figure 1A) for wound care on thin skin, providing an acceptable opposition of skin edges and reducing the risk of suture cutting through the tissue (1).

We aim to describe a different technique that may be more appropriate for managing pretibial lacerations and that has potential advantages compared to the one by Davis et al (1).

This specific technique was proposed for the first time in a prospective observational study published in 2001 (2). The study included 147 patients with pretibial lacerations and showed an average healing time of 26 days for flap lacerations and of only 16 days for linear lacerations(2).

After wound disinfection and debridement, sterile adhesive tape is applied parallel with both sides of the wound margins. Better opposition of wound edges may be obtained using a simple suture carefully applied through the adhesive strip.

The most important and difficult part of the procedure is the careful manual layout of the skin, eventually helped by sterile gauze. This technique will enable maximal tissue stretching prior to sterile adhesive application, as well as prevention of blistering and folding of the skin. Wound edges are then stretched with the application of a suture across the laceration through the adhesive strip, applying additional tension on the skin, while the strip protects the skin from the suture cutting (Figure 1B, interrupted).


To have additional tension relief, the same procedure can be performed on a large flap itself, this time by inserting the suture through the adhesive strip deeply to the fascia or muscle (Figure 1B, immobilizing).

The discussed technique tries to overcome the two main elements causing problems that arise during attempted closure of pretibial thin-skin lacerations: suture cutting through the skin and optimal wound-edge opposition.

Compared to the technique described by Davis et al., where suture is just reinforcing the adhesive strip, the above-mentioned technique results in additional skin-margin opposition (1, 2). The parallel application of the strips offers more tension and better adhesion of the wound edge. It is a quick and easy technique that also can be used in other body areas when difficult skin-edge opposition is expected.

References:  
1. Davis M, et al. J Emerg Med 2011;40:322-323. http://www.ncbi.nlm.nih.gov/pubmed/20880653  
2. Silk J. Injury 2001;32:373-376.

15. Outcomes of Daytime Procedures Performed by Attending Surgeons after Night Work

Govindarajan A, et al. N Engl J Med 2015; 373:845-853.

BACKGROUND
Sleep loss in attending physicians has an unclear effect on patient outcomes. In this study, we examined the effect of medical care provided by physicians after midnight on the outcomes of their scheduled elective procedures performed during the day.

METHODS
We conducted a population-based, retrospective, matched-cohort study in Ontario, Canada. Patients undergoing 1 of 12 elective daytime procedures performed by a physician who had treated patients from midnight to 7 a.m. were matched in a 1:1 ratio to patients undergoing the same procedure by the same physician on a day when the physician had not treated patients after midnight. Outcomes included death, readmission, complications, length of stay, and procedure duration. We used generalized estimating equations to compare outcomes between patient groups.

RESULTS
We included 38,978 patients, treated by 1448 physicians, in the study, of whom 40.6% were treated at an academic center. We found no significant difference in the primary outcome (death, readmission, or complication) between patients who underwent a daytime procedure performed by a physician who had provided patient care after midnight and those who underwent a procedure performed by a physician who had not treated patients after midnight (22.2% and 22.4%, respectively; P=0.66; adjusted odds ratio, 0.99; 95% confidence interval, 0.95 to 1.03). We also found no significant difference in outcomes after stratification for academic versus nonacademic center, physician’s age, or type of procedure. Secondary analyses revealed no significant difference between patient groups in length of stay or procedure duration.

CONCLUSIONS
Overall, the risks of adverse outcomes of elective daytime procedures were similar whether or not the physician had provided medical services the previous night. (Funded by the University of Toronto Dean’s Fund and others.)

16. Comparison of Clinician Suspicion vs a Clinical Prediction Rule in Identifying Children at Risk for Intra-abdominal Injuries after Blunt Torso Trauma.

Mahajan P, et al. for PECARN. Acad Emerg Med. 2015 Aug 20 [Epub ahead of print].

OBJECTIVES: Emergency department (ED) identification and radiographic evaluation of children with intra-abdominal injuries who need acute intervention can be challenging. To date, it is unclear if a clinical prediction rule is superior to unstructured clinician judgment in identifying these children. The objective of this study was to compare the test characteristics of clinician suspicion with a derived clinical prediction rule to identify children at risk of intra-abdominal injuries undergoing acute intervention following blunt torso trauma.

METHODS: This was a planned subanalysis of a prospective, multicenter observational study of children (less than 18 years old) with blunt torso trauma conducted in 20 EDs in the Pediatric Emergency Care Applied Research Network (PECARN). Clinicians documented their suspicion for the presence of intra-abdominal injuries needing acute intervention as less than 1, 1 to 5, 6 to 10, 11 to 50, or over 50% prior to knowledge of abdominal computed tomography (CT) scanning (if performed). Intra-abdominal injuries undergoing acute intervention were defined by a therapeutic laparotomy, angiographic embolization, blood transfusion for abdominal hemorrhage, or intravenous fluid administration for 2 or more days in those with pancreatic or gastrointestinal injuries. Patients were considered to be positive for clinician suspicion if suspicion was documented as ≥1%. Suspicion ≥ 1% was compared to the presence of any variable in the prediction rule for identifying children with intra-abdominal injuries undergoing acute intervention.

RESULTS: Clinicians recorded their suspicion in 11,919 (99%) of 12,044 patients enrolled in the parent study. Intra-abdominal injuries undergoing acute intervention were diagnosed in 203 (2%) patients. Abdominal CT scans were obtained in the ED in 2,302 of the 2,667 (86%, 95% confidence interval [CI] = 85% to 88%) enrolled patients with clinician suspicion ≥1% and in 3,016 of the 9,252 (33%, 95% CI = 32% to 34%) patients with clinician suspicion less than 1%. Sensitivity of the prediction rule for intra-abdominal injuries undergoing acute intervention (197 of 203; 97.0%, 95% CI = 93.7% to 98.9%) was higher than that of clinician suspicion ≥1% (168 of 203; 82.8%, 95% CI = 76.9% to 87.7%; difference = 14.2%, 95% CI = 8.6% to 20.0%). Specificity of the prediction rule (4,979 of the 11,716; 42.5%, 95% CI = 41.6% to 43.4%), however, was lower than that of clinician suspicion (9,217 of the 11,716, 78.7%, 95% CI = 77.9% to 79.4%; difference = -36.2%, 95% CI = -37.3% to -35.0%). Thirty-five (0.4%, 95% CI = 0.3% to 0.5%) patients with clinician suspicion less than 1% had intra-abdominal injuries that underwent acute intervention.

CONCLUSIONS: The derived clinical prediction rule had a significantly higher sensitivity, but lower specificity, than clinician suspicion for identifying children with intra-abdominal injuries undergoing acute intervention. The higher specificity of clinician suspicion, however, did not translate into clinical practice, as clinicians frequently obtained abdominal CT scans in patients they considered very low risk. If validated, this prediction rule can assist in clinical decision-making around abdominal CT use in children with blunt torso trauma.

17. Can your state’s ED nurses administer deep sedation meds? They can now in New Mexico. Here’s how it came about.

Controversy Surrounds Nurse-Administered Emerg Physician– Supervised Sedation in the ED: New Mexico Registered Nurse Board Issues New Policy

Jan Greene. Ann Emerg Med 2015;66:A18-20.

Registered nurses (RNs) in New Mexico now have clear authorization from the state nursing board to administer sedating drugs such as propofol and ketamine under the supervision of emergency physicians, as long as they have appropriate training.

The change in state policy was championed by emergency physician Eric Ketcham, MD, working in close concert with emergency nurse organizations. They advocated for more than 2 years against strong opposition from anesthesiology representatives who argued that only those with training in anesthesiology should be giving sedation.

Emergency nurses in New Mexico say that the rule change simply codifies actual practice in emergency departments (EDs), where nurses not only have the expertise to administer sedation but also the training to recognize and deal with a patient’s adverse reaction to the drug.

“Imagine if the physician was there setting a broken leg and the patient had the need for more sedative,” said Kevin McFarlane, RN, MSN, president of the New Mexico Emergency Nurses Association. “The physician would have to stop what he is doing to administer the sedative. Typically, it is the nurse who gives the medications.”

Advocates of the change argue that it’s safer to use sedatives such as propofol for procedural sedation in the ED because it is better tolerated and wears off more quickly than other drugs.

“The alternative is old-school sedation with morphine or Versed, which is not the optimal combination and leads to a longer recovery period for the patient,” Mr. McFarlane said.

But anesthesiologists also cite patient safety in their opposition to giving RNs easier access to sedatives. For more than a decade, anesthesiologists have watched propofol gain wider use in outpatient settings such as gastroenterology clinics. The American Society of Anesthesiologists (ASA) has drawn a clear line against nonanesthesiologists administering intravenous sedation in any setting, ED or outpatient clinic, says ASA President J.P. Abenstein, MD. He is not swayed by the argument that the ED, unlike a physician’s office or clinic, is well versed in quick rescue of patients with an airway emergency.

“Every procedural suite that wants to go off on its own has started out saying, ‘You don’t understand; we’re different,’” Dr. Abenstein said. “They all think they are uniquely competent to do what they do. We stick by the science and our experience.”

The profession of anesthesiology has worked hard to reduce adverse reactions to sedatives and as a result may have left the impression “that anesthesia and deep sedation is so easy anyone can do it,” Dr. Abenstein said. “We’re very leery of these trends. Propofol and ketamine are particularly potent, and how individual patients react to even small doses of the medication can be unpredictable. You can be doing a procedure with sedation, and it can easily get out of control.”

The anesthesiology group stands by its contention that even in an ED setting, procedural sedation should be managed by an anesthesiologist or a certified registered nurse anesthetist (CRNA).

“We get called to the emergency room to rescue airways” in procedures managed by other specialties, Dr. Abenstein said. He questions the efforts of emergency physicians to allow RNs to use sedatives. “The emergency physicians do a fabulous job, but in my opinion they are pushing the envelope [seeking RN access], and I would recommend against it.”

Dr. Ketcham, who is medical director of emergency medicine at San Juan Regional Medical Center in Farmington, NM, argues that there is no safety concern with the 1 physician, 1 nurse model used in many EDs.

“We wanted to get policies written to support modern practice,” he said. “This is just about good practice, and good patient safety.”

Dr. Ketcham compiled an exhaustive literature review to bolster the case for regulatory change; it is summarized in an article in the October 2013 Emergency Nurse.1

In the article, Dr. Ketcham—along with Frances Lopez Bushnell, RN, a nursing professor at the University of New Mexico, and Cindy Ketcham, EdD, CCHP-RN, clinical director of patient care services at San Juan Regional Medical Center—offers evidence largely from research on the use of specific sedatives by emergency nurse/physician combos.

The article argues there is no evidence in the literature of poor patient outcomes in these scenarios. “The availability of [physician-directed nurse-administered procedural sedation] dramatically reduces the anxiety and pain of patients undergoing a range of procedures including abscess drainage, bronchoscopy, cardiac instrumentation, cardioversion, chest tube placement endoscopy, and fracture and dislocation reduction.”

Ms. Bushnell said emergency nurses, working with emergency physicians, are capable of administering sedatives and recognizing adverse patient reactions. But there’s also the practical issue of staffing EDs with anesthesiologists or CRNAs.

“That would be ideal, but they don’t exist, and they don’t want to work [those hours],” Ms. Bushnell said. “Sure, we’d use them if we could find them, and we could afford them.”

Mr. McFarlane argues it’s just not realistic to have anesthesiology coverage of EDs, and particularly not in rural areas.

“They just don’t have an anesthesiologist on site 24/7, if at all,” he said.

The rest of the article (full-text free): http://www.annemergmed.com/article/S0196-0644(15)00421-7/fulltext

Related study: Vinson DR, et al. The safety of one doc/one nurse sedation (full-text free): http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3582522/

18. Here’s How Doctors Get through Their Day

Sanaz Majd, MD, Business Insider. August 14, 2015

I will never forget a particularly unsettling incident in the operating room while I was a young and impressionable medical student on my first surgery rotation:

Attending Surgeon: "Intern, what’s the story on this patient?”

Resident Intern (replies sheepishly): "This patient is a 51-year-old with a left breast lump, and 17 out of 20 lymph nodes positive for cancer, returning to the operating room.”

Attending Surgeon (in a very matter-of-fact tone): “Oh, she’s F-----.”

It felt as though the room temperature fell below zero for a moment — not because the OR is preserved like a freezer, but because the surgeon’s response seemed so cold. The intern fought hard not to appear uncomfortable in light of that deadened, crude response. But because medical school and residency have constructed a strict hierarchy, not unlike the military, there was no way that this intern was going to speak up in return — despite having a parent that also suffered from breast cancer.

At the time, being so low on the totem pole, I found myself peering over the sterile field in the corner and thinking:

A. I’m so glad surgery is not my field of interest. (Sorry, surgeons, but some of you can be pretty uninviting.)

B. How in the world do physicians reach this surprising level of stoicism?

Last week, I discussed how challenging it can be to say goodbye to patients, despite this unnerving feeling that we as physicians are not supposed to allow ourselves to feel for them. Why is that? Why do we seemingly model our behavior after vampires? And how can we effectively treat patients if we don’t display compassion?

Primary care doctors are stereotypically more of the warm and fuzzy kind (relatively speaking), although I have met some very down-to-earth and compassionate specialists. However, there is still an underlying, unspoken culture among physicians across all specialties, including primary care, that frowns upon the expression of emotions in the medical field.

In some circles of health professionals, showing emotion is simply a big no-no

As a patient, you may be curious about how this trend of stoicism evolved. When were physicians first taught of this unspoken ideology, which encouraged them not to feel?

I can recall as far back as my Gross Anatomy class while in medical school. In the early stages of the course, I was part of a small group of three or four eager medical students forced to confront our first real deceased human.

There was no denying how real he initially felt to us. He had a tattoo on his arm of someone's name, and it was clear he cared for that person. He had numerous surgical scars, more than we could count. Who was this man? How did he come to leave this world? Who did he leave behind? My peers and I contemplated the answers to these mysterious questions, even though we'd never discover their answers, while respectfully dissecting our mysterious cadaver.

When the course initially began, the medical school required its students to attend a “support group” of sorts. They understood the potentially emotional transition that may occur for us students as we likely faced death for the first time in the flesh.

I remember the support group instructor seeking our candor as he asked, “How are you all emotionally dealing with dissecting a cadaver?” I was relieved to hear this question. And asking it was appropriate and very professional on the faculty’s part, a way of addressing our internal struggles head-on. I have always been grateful for my education at Drexel University, and this is one of the numerous reasons why.

In my conversations with other medical students, a few did reveal their emotional struggles (whether it was spiritual, religious, or personal) with encountering a corpse face to face. However, when the instructor asked for our personal perspectives, I was surprised to find that no one voiced their thoughts, their unsettling feelings about working with cadavers for the first time.

My classmates were afraid to discuss their emotions in an atmosphere where “sharing your feelings” is typically discouraged, despite how much our instructor prodded. How can you blame them?

Finally, there was one student who spoke up, and whose words I will never forget. He said that he sought to view the cadaver as an “object,” so that he could complete the dissection tasks. But it was only when he viewed the cadaver’s hands that this person became "real" to him. “You do a lot with your hands,” I remember him saying.

He, too, was struggling to resist those emotions…


19. Opioid Prescribing in a Cross Section of US EDs.

Hoppe JA, et al, and the Prescribing Opioids Safely in the Emergency Department (POSED) Study Investigators. Ann Emerg Med. 2015;66(3): 253–259.e1 

STUDY OBJECTIVE: Opioid pain reliever prescribing at emergency department (ED) discharge has increased in the past decade but specific prescription details are lacking. Previous ED opioid pain reliever prescribing estimates relied on national survey extrapolation or prescription databases. The main goal of this study is to use a research consortium to analyze the characteristics of patients and opioid prescriptions, using a national sample of ED patients. We also aim to examine the indications for opioid pain reliever prescribing, characteristics of opioids prescribed both in the ED and at discharge, and characteristics of patients who received opioid pain relievers compared with those who did not.

METHODS: This observational, multicenter, retrospective, cohort study assessed opioid pain reliever prescribing to consecutive patients presenting to the consortium EDs during 1 week in October 2012. The consortium study sites consisted of 19 EDs representing 1.4 million annual visits, varied geographically, and were predominantly academic centers. Medical records of all patients aged 18 to 90 years and discharged with an opioid pain reliever (excluding tramadol) were individually abstracted by standardized chart review by investigators for detailed analysis. Descriptive statistics were generated.

RESULTS: During the study week, 27,516 patient visits were evaluated in the consortium EDs; 19,321 patients (70.2%) were discharged and 3,284 (11.9% of all patients and 17.0% of discharged patients) received an opioid pain reliever prescription. For patients prescribed an opioid pain reliever, mean age was 41 years (SD 14 years) and 1,694 (51.6%) were women. Mean initial pain score was 7.7 (SD 2.4). The most common diagnoses associated with opioid pain reliever prescribing were back pain (10.2%), abdominal pain (10.1%), and extremity fracture (7.1%) or sprain (6.5%). The most common opioid pain relievers prescribed were oxycodone (52.3%), hydrocodone (40.9%), and codeine (4.8%). Greater than 99% of pain relievers were immediate release and 90.0% were combination preparations, and the mean and median number of pills was 16.6 (SD 7.6) and 15 (interquartile range 12 to 20), respectively.

CONCLUSION: In a study of ED patients treated during a single week across the country, 17% of discharged patients were prescribed opioid pain relievers. The majority of the prescriptions had small pill counts and almost exclusively immediate-release formulations.

20. Time to Adopt High-Flow Oxygen Delivery Systems for Emergency AW Procedures

High-flow oxygen delivery via nasal cannula improved oxygen saturations and prevented desaturation in patients with difficult airways undergoing flexible bronchoscopic intubation.

Badiger S et al. Br J Anaesth 2015 Aug 7 [Epub ahead of print].

BACKGROUND: Awake fibre-optic intubation is a widely practised technique for anticipated difficult airway management. Despite the administration of supplemental oxygen during the procedure, patients are still at risk of hypoxia because of the effects of sedation, local anaesthesia, procedural complications, and the presence of co-morbidities. Traditionally used oxygen-delivery devices are low flow, and most do not have a sufficient reservoir or allow adequate fresh gas flow to meet the patient's peak inspiratory flow rate, nor provide an adequate fractional inspired oxygen concentration to prevent desaturation should complications arise.

METHODS: A prospective observational study was conducted using a high-flow humidified transnasal oxygen-delivery system during awake fibre-optic intubation in 50 patients with anticipated difficult airways.

RESULTS: There were no episodes of desaturation or hypercapnia using the high-flow system, and in all patients the oxygen saturation improved above baseline values, despite one instance of apnoea resulting from over-sedation. All patients reported a comfortable experience using the device.

CONCLUSIONS: The high-flow nasal oxygen-delivery system improves oxygenation saturation, decreases the risk of desaturation during the procedure, and potentially, optimizes conditions for awake fibre-optic intubation. The soft nasal cannulae uniquely allow continuous oxygenation and simultaneous passage of the fibrescope and tracheal tube. The safety of the procedure may be increased, because any obstruction, hypoventilation, or periods of apnoea that may arise may be tolerated for longer, allowing more time to achieve ventilation in an optimally oxygenated patient.

21. Regional Nerve Blocks for Hip and Femoral Neck Fractures in the ED: A Systematic Review.

Ritcey B, et al. CJEM. 2015 Sep 2 [Epub ahead of print].

OBJECTIVES: Hip and femoral neck fractures are common in elderly patients, who are at an increased risk of complications if their pain is suboptimally managed. This systematic review seeks to determine if regional nerve blocks reduce pain, reduce the need for parenteral opiates, and reduce complications, compared to standard pain management with opiates, acetaminophen, or NSAIDs. Data sources Systematic review of MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials found 401 articles, of which nine were selected for inclusion. Study selection Randomized controlled trials including adult patients with a hip or femoral neck fracture (Population) who had a 3-in-1 femoral nerve block, traditional femoral nerve block, or fascia iliaca compartment block performed preoperatively (Intervention). Comparison must have been made with standard pain management with opiates, acetaminophen, or NSAIDs (Comparison) and outcomes must have included pain score reduction (Outcome). Data synthesis Eight out of nine studies concluded pain scores were improved with the regional nerve block compared to standard pain management. A significant reduction in parenteral opiate use was seen in five out of six studies. No patients suffered life-threatening complications related to the nerve block; however, more minor complications were under-reported. Most of the studies were at a moderate to high risk of bias.

CONCLUSIONS: Regional nerve blocks for hip and femoral neck fractures have a benefit in reducing pain and the need for IV opiates. The use of these blocks can be recommended for these patients. Further high-quality randomized controlled trials are required.

22. Radiology's Overdiagnosis Problem

Saurabh Jha, MBBS, MRCS; Tricia Ward. Medscape Radiology. August 21, 2015

Journal Editor's Note: Saurabh Jha, MBBS, MRCS, guest-edited the August 2015 print issue of Academic Radiology devoted to overdiagnosis in radiology. Below is our interview with Dr Jha about his goals in compiling this special edition of the journal.

Medscape: Why did you want to devote an entire issue of a radiology journal to the topic of overdiagnosis?

Dr Jha: My intention was to get the issue to the forefront in radiology. One of the pioneers who drew attention to this problem was the radiologist William Black, in a famous essay with Welch published in the New England Journal of Medicine.[1] But since then, much of the discussion on this topic has come from outside radiology.

I spoke to the editor of Academic Radiology, Sam Baum, who has had personal experience with the healthcare system and feels that this is a topic that needs to be highlighted by radiologists primarily. The important thing for radiologists to do is to acknowledge that we are in the thick of overdiagnosis, whether we like it or not. If we are involved in diagnosing, we are involved in overdiagnosing as well.

To get the broader radiology community to acknowledge this, it was important for a peer-reviewed publication to come out on the topic, and Academic Radiology delivered.

Medscape: You contributed some perspective articles[2,3] to the journal in which you discuss over diagnosis vs false-positives; can you expand on this for our audience?

Dr Jha: With overdiagnosis, we are lowering the bar for what is considered disease. A false-positive is when you call something a disease that is not really a disease. A false-positive is a limitation of the test, whereas overdiagnosis is "exuberance" of the test, so to speak.

The best example is with pulmonary embolism (PE). As we go from the main pulmonary artery to the subsegmental pulmonary arteries, which are very small, you could diagnose a false-positive subsegmental PE—you called it, but it wasn't really there. Or you could have a true subsegmental PE, but that is an overdiagnosis because what you are calling disease is of such little significance that it is equivalent to cracking a small nut with a sledgehammer. The sledgehammer can do more harm to the nut itself. It can be an overreaction to a problem that is quiescent. In this case, the true-positive is in fact an overdiagnosis.

False-positives are a different entity, but the two are linked. They both lead to over-medicalization. If you have a very big PE in the main pulmonary artery (a submassive PE) that is catastrophic, it can lead to death, whereas with a smaller subsegmental PE, you could cause more problems by treating it with anticoagulation vs leaving it alone. The specificity of the test is a lot lower for these smaller arteries compared with the bigger ones, so as the tendency toward overdiagnosing increases, so too does the number of false-positives.

Medscape: Do you think the problems is that radiologists are looking for more disease (the more you look, the more you find), or is it that better technologies allow you to see things than you could not see before (such as a very small subsegmental PE)?

Dr Jha: It's a combination of both. We certainly are looking for more. With PE or example, many people who come into the emergency department or other places have a blood test for D-dimer, and when the blood test is positive, they are categorized as having suspected PE. Patients who have cancer undergo more follow-up imaging, and technologies have improved.

Problems occur when we find something that we don't know anything about. Why don't we just ignore it? Why do we feel compelled to overtreat? That bias is the biggest driver of overdiagnosis and overtreatment. Just because a new technology enables me to see something new, it doesn't mean that I should start jumping off the building every time I encounter something I'm uncertain about. Why don't I just ignore it?

I think the best analogy comes from the legal system. They asked, "Is it better that 10 guilty men go free or that one innocent man is sent to the gallows?" In effect, they have said, "We know that information isn't perfect; we know there is a chance we are going to err. So we are going to err toward letting the guilty men go free rather than letting the innocent get strung up." The burden of proof is to prove that someone is guilty, not to prove that one is innocent.

In medicine, we have to prove that somebody is healthy rather than prove that they are diseased. In effect, we have said, "It is better that 10 people who are not going to be harmed by subsegmental PE get overtreated with anticoagulation (and possibly bleed) than it is that one person gets undertreated and harmed by the PE." That is a medical/ethical issue that isn't really explained by the incentive system. I think it goes beyond that.

Medscape: Do you think part of it is a fear of litigation? That is, missing a diagnosis is seen as a mistake, whereas overtreating wouldn't be seen as an error if it's well intentioned?

Dr Jha: The key phrase is "well intentioned." We think "well-intentioned" means erring toward, "This subsegmental PE could harm you," as opposed to erring toward the fact that I am going to put you on anticoagulation, which could harm you.

I certainly think the litigation culture is a large part of it. I sometimes wonder whether our medical culture drives the litigation culture. I'm sure they are both recursive, but if I were to identify what came first, the chicken or the egg, I would say it's the medical culture.

There is so much power in hindsight. We feel there is good intention in overtreating. It means, "I care for you." Whereas if I ignore the subsegmental PE, I sound flippant. The care and the intervention are so interlinked psychologically that it is hard to disassociate one from the other. Subtractive medicine is very hard to propagate culturally; it's very much a can-do culture.

I trained in the National Health Service in the United Kingdom. I heard surgeons say to the family that we are not going to intervene, we think it would be useless, a waste of your time and our time. That is not the culture in the United States.

Mind you, overdiagnosis is not entirely an American phenomenon. It is predominant in the United Kingdom. It is predominant in South Korea, where they started screening ultrasonography for thyroid cancer and found all of these small papillary carcinomas of the thyroid, which aren't going to do anything.[4] All of these patients had hemi-thyroidectomies, and so on and so forth.

It's an incredible waste of money, but also an incredible imposition of morbidity on people for no good whatsoever. It's like scoring an "own goal" in soccer, and we keep scoring it.

Medscape: How do you propose reducing the problem of overdiagnosis and overtreatment? Is this something the professional societies and academic groups should address?

Dr Jha: We need to have honesty. Using the subsegmental PE example, we need to stand up and say that we are overtreating subsegmental PE, because we are overdiagnosing it. To reduce the overtreatment, we are going to have to stop calling subsegmental PE and accept that there will be somebody who will be harmed as a result of that. That is the trade-off.

23. Micro Bits

A. Dustin & Angela Ballard Podcasts: Tips to a Healthier and Happier Life

1. Is Coffee Good for You?

Dustin & Angela Ballard provide some insight from the medical literature in this latest podcast: http://dballard30.podbean.com/ (Episode #10; 24min)

2. A Delicious New Gateway Drug (e-cigs)

Dustin & Angela explore the growing concern about e-cig use by youngsters. Parents be warned! http://dballard30.podbean.com/ (Episode #11; 24min)

Cf. case report: Gill N, et al. E-Cigarette Liquid Nicotine Ingestion in a Child: Case Report and Discussion. CJEM. 2015 Apr 20:1-5. [Epub ahead of print]. http://www.ncbi.nlm.nih.gov/pubmed/25892642

B. Study: Cough and throat clearing often do not indicate GERD

Study data from the Medical University of South Carolina showed 8% of patients with both cough and throat clearing had a positive symptom index for gastroesophageal reflux disease, compared with 26% of those who had just a cough and 22% of those with only throat clearing. First author Mustafa Abdul-Hussein said testing can eliminate patients who do not have GERD before beginning what would be unneeded therapy. The study was published in the Journal of Clinical Gastroenterology.


C. Epidural Corticosteroid Injections for Radiculopathy and Spinal Stenosis: A Systematic Review and Meta-analysis

Conclusion: Epidural corticosteroid injections for radiculopathy were associated with immediate reductions in pain and function. However, benefits were small and not sustained, and there was no effect on long-term surgery risk. Limited evidence suggested no effectiveness for spinal stenosis.


D. Studies: Longer work hours may increase heart disease, stroke risk

Two reports in The Lancet that analyzed multiple studies linked working 55 hours a week or more to a higher risk of heart disease and stroke, compared with a standard schedule of 35 to 40 hours a week. Paul Wright, M.D., at North Shore University Hospital in New York said data showed people who work long hours were less likely to see a physician for a medical evaluation.


E. Group calls for giving foods containing peanuts to infants at risk of allergy

Infants 4 to 11 months old at high risk of peanut allergies should be given foods that contain peanuts before they reach age 1, but they should first undergo allergy tests before being given such foods, according to a recommendation from the American Academy of Pediatrics. The guidance is in response to a British study, which showed that at-risk children who ate peanut products as infants experienced 81% fewer peanut allergies after five years than those who didn't. The recommendation will be published online in Pediatrics.


F. Study links cardiorespiratory fitness to risk of AF

A study found 84% of overweight or obese people with atrial fibrillation who had high levels of cardiorespiratory fitness over four years no longer experienced the potentially dangerous heartbeat, compared with 76% of those who maintained adequate fitness levels and 17% in a low fitness group. People who also lost weight reduced their risk of recurring atrial fibrillation even more, researchers wrote in the Journal of the American College of Cardiology.


G. Why doctors are prescribing legal aid for patients in need

PBS Newshour. September 2

Though lawyers are often the last people doctors want to see involved in patient care, across the country many medical systems have begun establishing special legal partnerships. Lawyers become allies for disadvantaged patients who need help navigating problems with landlords and insurers. Special correspondent Jackie Judd reports from Omaha, Nebraska.


H. Physician Prevention of Acute Kidney Injury

In a retrospective analysis of 170 hospitalized patients who developed acute kidney injury during admission, 30% of episodes could have been avoided if physicians had taken appropriate preventive actions.


I. Study: Ambulance diversion may increase mortality risk

When ambulances were diverted to a hospital emergency department farther away, heart attack patients were almost 10% more likely to die within one year compared with when ambulances were not diverted, researchers reported in the journal Health Affairs. The study, which included almost 30,000 Medicare patients in 26 California counties, found patients also were slightly less likely to get treatments such as angioplasty or coronary artery bypass graft to restore blood flow, mainly because they were taken to hospitals that had less advanced heart care technology.



J. 75% of US adults' hearts are aging faster than they should, CDC study finds

A CDC study published in Vital Signs found that 75% of Americans have functional heart age that is older than their chronological age. Functional age is calculated based on lifestyle and risk information including blood pressure, smoking status, BMI and diabetes. The heart age of the average man is eight years older than his chronological age, while for women heart age exceeds chronological age by five years. The authors say people should learn their functional heart age so they can then take steps to lower cardiovascular risks.


K. Safety and efficacy of digoxin: systematic review and meta-analysis of observational and controlled trial data

Digoxin is associated with a neutral effect on mortality in randomised trials and a lower rate of admissions to hospital across all study types. Regardless of statistical analysis, prescription biases limit the value of observational data.


L. TV viewing increases PE risk

People who spend at least five hours watching TV daily had a twofold greater risk of suffering a fatal pulmonary embolism compared with those who spend less than 2.5 hours watching TV daily, according to a study presented at the European Society of Cardiology meeting. Findings also show that adults under age 60 who watched five hours a day had up to six times greater risk of a pulmonary embolism, compared with those who watched less than 2.5 hours, while those who spent less than five hours but over 2.5 hours watching TV daily had three times the risk.


M. More parents seek antibiotics to treat pink eye despite ineffectiveness

A study in Clinical Pediatrics revealed that parents whose children were given a diagnosis of "pink eye" were more likely to intend to use antibiotics despite being told of the drugs' ineffectiveness to treat the symptoms, compared with those who received a diagnosis of "eye infection." Parents also thought symptoms of pink eye were more contagious than eye infection and were less inclined to believe their children could go to child care.