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

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]

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.

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).

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.

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 grĂ¢ce.

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.

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.

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.

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.

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

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.

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.

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.

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.

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

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.

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.

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.

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.

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.

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%).

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.

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.

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.

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.

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.

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.