Tuesday, November 10, 2015

Lit Bits: Nov 10, 2015

From the recent medical literature...

1. Just Out: New 2015 AHA ACS Guidelines

The 2015 Guidelines Update marks a change in the scope of the AHA guidelines for the evaluation and management of ACS. Starting with this update, recommendations will be limited to the prehospital and ED phases of care. In-hospital care is addressed by guidelines for the management of myocardial infarction published jointly by the AHA and the American College of Cardiology Foundation.

Publication of the 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) marks 49 years since the first CPR guidelines were published in 1966 by an Ad Hoc Committee on Cardiopulmonary Resuscitation established by the National Academy of Sciences of the National Research Council.1 Since that time, periodic revisions to the Guidelines have been published by the AHA in 1974,2 1980,3 1986,4 1992,5 2000,6 2005,7 2010,8 and now 2015. The 2010 AHA Guidelines for CPR and ECC provided a comprehensive review of evidence-based recommendations for resuscitation, ECC, and first aid. The 2015 AHA Guidelines Update for CPR and ECC focuses on topics with significant new science or ongoing controversy, and so serves as an update to the 2010 AHA Guidelines for CPR and ECC rather than a complete revision of the Guidelines.

The formal guidelines (in 15 parts), published in Circulation 2015 October supplement:  http://circ.ahajournals.org/content/132/18_suppl_2.toc

Selected excerpts

A. Troponin to Identify Patients Who Can Be Safely Discharged from the ED

High-sensitivity cardiac troponin is now widely available. The 2015 CoSTR review examined whether a negative troponin test could reliably exclude a diagnosis of ACS in patients who did not have signs of STEMI on ECG. For emergency department patients with a presenting complaint consistent with ACS, high-sensitivity cardiac troponin T (hs-cTnT) and cardiac troponin I (cTnI) measured at 0 and 2 hours should not be interpreted in isolation (without performing clinical risk stratification) to exclude the diagnosis of ACS. In contrast, high-sensitivity cardiac troponin I (hs-cTnI), cTnI, or cardiac troponin T (cTnT) may be used in conjunction with a number of clinical scoring systems to identify patients at low risk for 30-day major adverse cardiac events (MACE) who may be safely discharged from the emergency department.

We recommend that hs-cTnI measurements that are less than the 99th percentile, measured at 0 and 2 hours, may be used together with low risk stratification (Thrombolysis in Myocardial Infarction [TIMI] score of 0 or 1) to predict a less-than-1% chance of 30-day MACE (Class IIa, LOE B-NR).

We recommend that negative cTnI or cTnT measurements at 0 and between 3 and 6 hours may be used together with very low risk stratification (Vancouver score of 0 or North American Chest Pain score of 0 and age less than 50 years) to predict a less-than-1% chance of 30-day MACE (Class IIa, LOE B-NR).

B. Withhold Oxygen in Normoxic Patients

Supplementary oxygen has been routinely administered to patients with suspected ACS for years. Despite this tradition, the usefulness of supplementary oxygen therapy has not been established in normoxemic patients.

The usefulness of supplementary oxygen therapy has not been established in normoxic patients. In the prehospital, emergency department, and hospital settings, the withholding of supplementary oxygen therapy in normoxemic patients with suspected or confirmed ACS may be considered (Class IIb, LOE C-LD).

C. Reperfusion Strategies

Timely restoration of blood flow to ischemic myocardium in acute STEMI remains the highest treatment priority. While the Class of Recommendation regarding reperfusion strategies remains unchanged from 2010, the choice between fibrinolysis and PCI has been reexamined to focus on clinical circumstances, system capabilities, and timing, and the recommendations have been updated accordingly. The anticipated time to PCI has been newly examined in 2015, and new time-dependent recommendations regarding the most effective reperfusion strategy are made. In STEMI patients, when long delays to primary PCI are anticipated (more than 120 minutes), a strategy of immediate fibrinolysis followed by routine early angiography (within 3 to 24 hours) and PCI, if indicated, is reasonable. It is acknowledged that fibrinolysis becomes significantly less effective at more than 6 hours after symptom onset, and thus a longer delay to primary PCI is acceptable in patients at more than 6 hours after symptom onset. To facilitate ideal treatment, systems of care must factor information about hospital capabilities into EMS destination decisions and interfaculty transfers.

In adult patients presenting with STEMI in the emergency department (ED) of a non–PCI-capable hospital, we recommend immediate transfer without fibrinolysis from the initial facility to a PCI center instead of immediate fibrinolysis at the initial hospital with transfer only for ischemia-driven PCI (Class I, LOE B-R).

When STEMI patients cannot be transferred to a PCI-capable hospital in a timely manner, fibrinolytic therapy with routine transfer for angiography may be an acceptable alternative to immediate transfer to primary PCI (Class IIb, LOE C-LD).

When fibrinolytic therapy is administered to STEMI patients in a non–PCI-capable hospital, it may be reasonable to transport all postfibrinolysis patients for early routine angiography in the first 3 to 6 hours and up to 24 hours rather than transport postfibrinolysis patients only when they require ischemia-guided angiography (Class IIb, LOE B-R).

2. Does This Patient with CP Have ACS? The Rational Clinical Examination Systematic Review

Fanaroff AC, et al. JAMA. 2015;314(18):1955-1965.

Importance  About 10% of patients with acute chest pain are ultimately diagnosed with acute coronary syndrome (ACS). Early, accurate estimation of the probability of ACS in these patients using the clinical examination could prevent many hospital admissions among low-risk patients and ensure that high-risk patients are promptly treated.

Objective  To review systematically the accuracy of the initial history, physical examination, electrocardiogram, and risk scores incorporating these elements with the first cardiac-specific troponin.

Study Selection  MEDLINE and EMBASE were searched (January 1, 1995-July 31, 2015), along with reference lists from retrieved articles, to identify prospective studies of diagnostic test accuracy among patients admitted to the emergency department with symptoms suggesting ACS.

Data Extraction and Synthesis  We identified 2992 unique articles; 58 met inclusion criteria.

Main Outcomes and Measures  Sensitivity, specificity, and likelihood ratio (LR) of findings for the diagnosis of ACS. The reference standard for ACS was either a final hospital diagnosis of ACS or occurrence of a cardiovascular event within 6 weeks.

Results  The clinical findings and risk factors most suggestive of ACS were prior abnormal stress test (specificity, 96%; LR, 3.1 [95% CI, 2.0-4.7]), peripheral arterial disease (specificity, 97%; LR, 2.7 [95% CI, 1.5-4.8]), and pain radiation to both arms (specificity, 96%; LR, 2.6 [95% CI, 1.8-3.7]). The most useful electrocardiogram findings were ST-segment depression (specificity, 95%; LR, 5.3 [95% CI, 2.1-8.6]) and any evidence of ischemia (specificity, 91%; LR, 3.6 [95% CI,1.6-5.7]). Both the History, Electrocardiogram, Age, Risk Factors, Troponin (HEART) and Thrombolysis in Myocardial Infarction (TIMI) risk scores performed well in diagnosing ACS: LR, 13 (95% CI, 7.0-24) for the high-risk range of the HEART score (7-10) and LR, 6.8 (95% CI, 5.2-8.9) for the high-risk range of the TIMI score (5-7). The most useful for identifying patients less likely to have ACS were the low-risk range HEART score (0-3) (LR, 0.20 [95% CI, 0.13-0.30]), low-risk range TIMI score (0-1) (LR, 0.31 [95% CI, 0.23-0.43]), or low to intermediate risk designation by the Heart Foundation of Australia and Cardiac Society of Australia and New Zealand risk algorithm (LR, 0.24 [95% CI, 0.19-0.31]).

Conclusions and Relevance  Among patients with suspected ACS presenting to emergency departments, the initial history, physical examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores, which incorporate the first cardiac troponin, provided more diagnostic information.

3. More on Troponins

A. The meaning of elevated troponin I levels: Not always ACS

Harvell B, et al. Amer J Emerg Med 2015 Oct 2 [Epub ahead of print]

Troponin elevation can be caused by etiologies other than acute coronary syndromes (ACS). Our hypothesis was that elevated troponins occur more frequently in non-ACS cases but that ACS cases (Type 1 STEMI and type 1 NSTEMI) have significantly higher troponin elevations.

This was a cross sectional cohort analysis of a random subset of all patients with elevated troponins (defined as ≥ 0.06 ng/mL) over a 1 year period from July 2013-June 2014. The first positive troponin I and the peak were used in this study. All included patients had chart reviews looking for whether our Cardiologists or Hospitalists attributed the elevated troponin to an ACS (NSTEMI or STEMI) or non-ACS cause. Non-ACS causes were categorized as infection, cancer, renal diseases, cardiovascular disease, pulmonary disease, trauma, cardiac arrest, neurological disease, hypertension or other. Data were extracted by two investigators on the cause of the elevated troponin. Three sessions to educate data extractors were arranged and methods of data extraction discussed, then a 5% sample was re-evaluated by the other extractor to determine inter-rater agreement measures. Parametric data were evaluated with t-test and ANOVA. Dichotomous variables were compared using chi-square. Troponin data were evaluated using non-parametric Kruskal Wallis or Mann Whitney U. A logistic regression model was created with variables selected a priori to evaluate the predictive ability of these variables in differentiating ACS vs. non-ACS causes of elevated troponin.

We evaluated 458 randomly-selected patients from 1317 unique cases of all patients with initial elevated troponins ≥ 0.06 mg/mL during the study period. There was 84% inter-rater agreement in the 5% sampling. Seventy-nine percent had a non-ACS cause of elevated troponin and the average initial positive troponin I level was significantly lower in the non-ACS cases (0.14, 95%CI=0.08, 0.37) than those with documented STEMI (10.2, 95%CI=0.75, 20.1) or NSTEMIs (0.4, 95%CI= 0.13, 1.7). In the non-ACS group the median initial troponin was 0.14 ng/mL (0.08,0.37). Peak troponin levels were highest in STEMI, next NSTEMI, lowest in non ACS causes. The most frequent subgroups in the non-ACS group were non-ACS cardiovascular, infectious, renal or hypertensive causes. In a linear regression model adjusting for age and gender, higher troponin levels had higher odds of being related to ACS causes (aOR=1.4,95%CI=1.2, 1.6) than non-ACS causes.

The etiology for the majority of initial elevated troponin I levels in a randomly selected population are the result of non-ACS causes. As initial+ troponin levels increased, they were more likely associated with ACS causes than with non-ACS causes. Average initial + and peak troponin values were highest in STEMIs, next highest in NSTEMIs and lowest overall in non-ACS causes.

B. Does undetectable troponin I at presentation using a contemporary sensitive assay rule out MI? A cohort study

Kelly AM, et al. Emerg Med J  2015;32:760-763  

Aim Recent evidence suggests that an undetectable troponin level at emergency department (ED) presentation can rule out the presence of myocardial infarction (MI) in low-risk patients. The aim of this study was to investigate whether an undetectable troponin I (TnI) level at presentation using a contemporary troponin assay can accurately rule out MI at various front-door thrombolysis in myocardial infarction (fTIMI) score cut-offs.

Methods Planned substudy of a prospective observational cohort study of patients presenting to ED with chest pain without ECG evidence of ischaemia who underwent a ‘rule out’ acute coronary syndrome process. Clinical, investigational and outcome data were collected. A contemporary TnI assay (Siemens TnI Ultra) was used. Primary outcome of interest was diagnostic accuracy for MI of undetectable initial TnI at presentation at various fTIMI scores (sensitivity, specificity, positive predictive value and negative predictive value (NPV)).

Results 1076 patients were studied, of whom 156 had a final diagnosis of MI (14.5%). For patients with undetectable TnI and fTIMI scores 0, 0–1, 0–2 and 0–6, sensitivities were 98.7%, 98.1%, 97.4% and 97.4%, respectively, specificities were 22.6%, 41.7%, 53.8% and 69.9%, respectively, and NPV were 99%, 99.2%, 99.2% and 99.4%, respectively. If early presenters (less than 2 h of symptoms) were excluded, undetectable initial troponin had 100% sensitivity (95% CI 95.2% to 100%) and NPV (95% CI 98.8% to 100%).

Conclusions Using a contemporary TnI assay, undetectable initial TnI has high but not perfect sensitivity and NPV, unless early presenters are excluded.

4. Emergency physician attitudes, preferences, and risk tolerance for stroke as a potential cause of dizziness symptoms

Kene MV, et al. Emergency physician attitudes, preferences, and risk tolerance for stroke as a potential cause of dizziness symptoms. West J Emerg Med. 2015;16(5):768-776.

Dizziness is a common presenting symptom in the emergency department (ED) that is usually benign, but rarely the harbinger of stroke, particularly in the posterior circulation. Nationally, dizziness and vertigo symptoms accounted for 4% of ED visits overall in 2011.1 The total cost for these visits was estimated at $4 billion, which reflects the often substantial resources involved in evaluating these patients in the ED with neuroimaging, specialty consultation, and hospital admission.1,2 Although dizziness-related ED visits and use of imaging studies during these visits increased from 1995-2004, there was no corresponding increase in the diagnosis of cerebrovascular disease among these patients.3 The prevalence of stroke was low in patients with dizziness as well: 3.2% of all ED patients with undifferentiated dizziness and only 0.7% of patients with isolated dizziness (dizziness, vertigo or imbalance without motor, sensory or language findings) were diagnosed with stroke or transient ischemic attack (TIA).4

Within this context, a clinical prediction rule to risk-stratify patients with dizziness could be useful in decision making and resource utilization. Clinical prediction rules rely on readily obtainable historical, physical examination and clinical data to provide a standardized risk assessment for bedside decision making. For example, the PECARN (Pediatric Emergency Care Applied Research Network) head injury clinical decision rule helps clinicians identify children at risk of clinically important brain injury after head trauma, in order to target the use of CT imaging.5

As part of the process for developing a useful clinical prediction rule for dizziness in the ED, a better understanding of emergency physicians’ (EPs) perceptions of their current practice and attitudes towards currently available diagnostic aids is crucial. Recently, a three-step bedside evaluation developed and tested by expert neuro-otologists (head-thrust test, gaze-evoked nystagmus, and skew deviation [HINTS]) has been proposed to clinically differentiate central from peripheral etiologies of vertigo, but its actual use in current emergency practice is unknown.6 Similarly, the required performance of a clinical prediction rule for dizziness evaluation to be clinically useful for EPs is also unknown. Therefore, we conducted a survey of EPs to assess their current practice, their attitudes and preferences for decision support, and to determine the specific risk thresholds that would make a clinical prediction rule useful in evaluating dizziness in the ED.

Introduction: We evaluated emergency physicians’ (EP) current perceptions, practice, and attitudes towards evaluating stroke as a cause of dizziness among emergency department patients.

Methods: We administered a survey to all EPs in a large integrated healthcare delivery system. The survey included clinical vignettes, perceived utility of historical and exam elements, attitudes about the value of and requisite post-test probability of a clinical prediction rule for dizziness. We calculated descriptive statistics and post-test probabilities for such a clinical prediction rule.

Results: The response rate was 68% (366/535). Respondents’ median practice tenure was eight years (37% female, 92% emergency medicine board certified). Symptom quality and typical vascular risk factors increased suspicion for stroke as a cause of dizziness. Most respondents reported obtaining head computed tomography (CT) (74%). Nearly all respondents used and felt confident using cranial nerve and limb strength testing. A substantial minority of EPs used the Epley maneuver (49%) and HINTS (head-thrust test, gaze-evoked nystagmus, and skew deviation) testing (30%); however, few EPs reported confidence in these tests’ bedside application (35% and 16%, respectively). Respondents favorably viewed applying a properly validated clinical prediction rule for assessment of immediate and 30-day stroke risk, but indicated it would have to reduce stroke risk to less than 0.5% to be clinically useful.

Conclusion: EPs report relying on symptom quality, vascular risk factors, simple physical exam elements, and head CT to diagnose stroke as the cause of dizziness, but would find a validated clinical prediction rule for dizziness helpful. A clinical prediction rule would have to achieve a 0.5% post-test stroke probability for acceptability.

5. A Randomized Trial of Single-Dose Oral Dex Vs Multidose Prednisolone for Acute Exacerbations of Asthma in Children who Attend the ED

Cronin JJ, et al. Ann Emerg Med 2015 Oct 10 [Epub ahead of print]

Study objective
In acute exacerbations of asthma in children, corticosteroids reduce relapses, subsequent hospital admission, and the need for ß2-agonist bronchodilators. Prednisolone is the most commonly used corticosteroid, but prolonged treatment course, vomiting, and a bitter taste may reduce patient compliance. Dexamethasone has a longer half-life and has been used safely in other acute pediatric conditions. We examine whether a single dose of oral dexamethasone is noninferior to prednisolone in the emergency department (ED) treatment of asthma exacerbations in children, as measured by the Pediatric Respiratory Assessment Measure (PRAM) at day 4.

We conducted a randomized, open-label, noninferiority trial comparing oral dexamethasone (single dose of 0.3 mg/kg) with prednisolone (1 mg/kg per day for 3 days) in patients aged 2 to 16 years and with a known diagnosis of asthma or at least 1 previous episode of ß2-agonist–responsive wheeze who presented to a tertiary pediatric ED. The primary outcome measure was the mean PRAM score (range of 0 to 12 points) performed on day 4. Secondary outcome measures included requirement for further steroids, vomiting of study medication, hospital admission, and unscheduled return visits to a health care practitioner within 14 days.

There were 245 enrollments involving 226 patients. There was no difference in mean PRAM scores at day 4 between the dexamethasone and prednisolone groups (0.91 versus 0.91; absolute difference 0.005; 95% CI –0.35 to 0.34). Fourteen patients vomited at least 1 dose of prednisolone compared with no patients in the dexamethasone group. Sixteen children (13.1%) in the dexamethasone group received further systemic steroids within 14 days after trial enrollment compared with 5 (4.2%) in the prednisolone group (absolute difference 8.9%; 95% CI 1.9% to 16.0%). There was no significant difference between the groups in hospital admission rates or the number of unscheduled return visits to a health care practitioner.

In children with acute exacerbations of asthma, a single dose of oral dexamethasone (0.3 mg/kg) is noninferior to a 3-day course of oral prednisolone (1 mg/kg per day) as measured by the mean PRAM score on day 4.

6. Predictors of infection from dog bite wounds: which patients may benefit from prophylactic antibiotics?

Tabaka ME, et al. Emerg Med J. 2015 Nov;32(11):860-3.

OBJECTIVES: To determine a current infection rate of dog bite wounds and predictors of wounds at risk for infection that may benefit from prophylactic antibiotics.

METHODS: A prospective multicentre observational study was conducted over 4.5 years. At the time of treatment Emergency Physicians completed a structured data form evaluating patient, wound and treatment characteristics of patients with dog bite wounds. Patients were followed up at 30 days to assess for infection. Predictor variables were analysed with univariate analysis, using either χ(2), parametric or nonparametric methods where appropriate. Significant variables and those with important interactions on univariate analysis were considered in a logistic regression (LR) analysis.

RESULTS: 495 patients with dog bites were enrolled and 345 had complete follow-up. Eighteen patients (5.2%, 95% CI 3.1% to 8.1%) had bites that became infected. On univariate analysis, only puncture wounds were found to be significantly associated with infection RR 2.8 (95% CI 1.2 to 6.9). However, location and wound closure met criteria for entry into the model having important interactions; facial wounds had a higher risk of infection than anticipated but were also more likely to be closed (p less than 0.0001). A LR model considering puncture wounds, wound closure and wound location found that puncture wounds (OR 4.1 [95% CI 1.4 to 11.7]) and wound closure (OR 3.1 [95% CI 1.03 to 9.0]) were independent predictors of infection. The incidence of infection in wounds that were not punctured or closed during treatment was only 2.6% (95% CI 0.7% to 6.5%).

CONCLUSIONS: Puncture wounds or wounds closed during treatment are dog bite wounds at a high risk of infection and should be considered for treatment with prophylactic antibiotics.

7. PECARN undertaking large study of RNA transcriptional biosignature analysis for identifying febrile infants with SBI

Introduction from the recent publication of their methods
There is a large degree of variability in the evaluation and management of febrile infants younger than 60 days of age in the setting of the emergency department (ED).1 Approximately 6% to 10% of these infants have serious bacterial infections (SBIs) that require prompt antimicrobial therapy,1,2 and many other infants without bacterial infections are hospitalized unnecessarily until culture results are available. Microbiologic culture for identification of bacteria in the relevant body fluids (e.g., blood, urine, cerebrospinal fluid [CSF]) remains the reference standard for diagnosis of SBIs, as it has been for decades.3–6 However, using cultures, and more specifically blood culture, as the gold standard for diagnosis of SBI has important limitations, including a noninconsequential number of false-positive and false-negative results, and lengthy duration (up to 48 to 72 hours) to determine or exclude a positive result.6–8 In great part because of these limitations, many febrile infants are subjected to excessive evaluation procedures, receive empiric antibiotic therapy, and are hospitalized, exposing them to iatrogenic risks.9 Therefore, there is a clear need for developing less invasive, highly accurate, and more timely diagnostic strategies for the evaluation of young febrile infants.

Advances in genomic techniques now allow us to distinguish the types of infections by assessing the host response to infection caused by different microbes. Previous research has shown that host responses can reliably be measured with distinct transcriptional biosignatures in the RNA of host blood leukocytes.6,10,11 Studies in hospitalized children have demonstrated that RNA biosignatures can distinguish patients with bacterial and viral infections with 95% accuracy.10 This transition from bench to clinical research suggests the potential application of transcriptional biosignatures for the evaluation of febrile infants in the ED.

The Pediatric Emergency Care Applied Research Network (PECARN) annually evaluates more than 4000 febrile infants 60 days of age or younger. PECARN, thus, offers an ideal setting to evaluate the application of RNA expression analysis for diagnosis and management of febrile infants in a prospective manner.12 Because there is limited experience in conducting large multi-center studies with this new technology, especially with a young infant population in the setting of the ED, it was necessary to develop an infrastructure to identify and recruit eligible patients in a consistent and reliable fashion. We also sought obtain high-quality blood RNA samples for expression analysis from these patients across multiple sites. Finally, it was important to demonstrate that the RNA samples collected from multiple sites do not substantially degrade during transport, storage, and processing.

We are currently conducting a prospective cross-sectional study of a convenience sample of more than 4000 febrile infants younger than 60 days of age in the PECARN. The objective of the present article is to describe the development of the necessary infrastructure and methods for conducting genomic studies in this population. We also aim to demonstrate the ability to obtain samples in 21 PECARN EDs that yield adequate quantities of high-quality RNA for transcriptional profiles which would be required for identifying the diagnostic bacterial (SBI) and nonbacterial (non-SBI) biosignatures in febrile infants…

Mahajan P, et al. RNA Transcriptional Biosignature Analysis for Identifying Febrile Infants With Serious Bacterial Infections in the ED: A Feasibility Study. Pediatr Emerg Care. 2015; 31(1): 1–5.

The results of this fascinating study are under peer-review and should be published in early 2016.

8. Two New Studies on SAH Diagnostics

A. An Observational Study of 2,248 Patients Presenting With Headache, Suggestive of Subarachnoid Hemorrhage, who Received LPs Following Normal CT of the Head

Sayer D, et al. Acad Emerg Med. 2015 Oct 19 [Epub ahead of print]

OBJECTIVES: The objective was to determine the incidence of subarachnoid hemorrhage (SAH) diagnosed by lumbar puncture (LP) when the head computed tomography (CT) was reported as demonstrating no subarachnoid blood.

METHODS: Data were obtained on patients who received LP to diagnose or exclude SAH attending six hospitals over 5 years. Subsequent investigations and outcomes were reviewed in all patients with LPs that did not exclude SAH.

RESULTS: A total of 2,248 patients were included. A total of 1,898 LPs were suitable for biochemical analysis, of which 92 (4.8%) were positive for blood, suggesting SAH; 1,507 (79.4%) were negative; and 299 (15.6%) were inconclusive. Of the 92 patients with positive cerebrospinal fluid analysis, eight patients (0.4%) had aneurysms on further imaging, and one had a carotid cavernous fistula.

CONCLUSIONS: In patients presenting to the emergency department with acute severe headache, LP to diagnose or exclude SAH after negative head CT has a very low diagnostic yield, due to low prevalence of the disease and uninterpretable or inconclusive samples. A clinical decision rule may improve diagnostic yield by selecting patients requiring further evaluation with LP following nondiagnostic or normal noncontrast CT brain imaging.

Comments by Ryan Radecki: How Many LPs Does It Take to Find SAH?

In this observational series: 204.

This study describes the findings of 2,248 patients with “headache, suggestive of subarachnoid hemorrhage” who underwent computed tomography, followed by lumbar puncture.  CT is quite sensitive for aneurysmal hemorrhage in the few hours following onset, but fades with time.  Spectrophotometric analysis of CSF is the gold standard for diagnosis in the United Kingdom, and was used by these facilities to describe positive, negative, and indeterminate results on LP.

Of these 2,248 patients, LP were negative in 1,507, uninterpretable in 350, indeterminate in 299, and positive in 92.  All patients with positive LP had follow-up CTA or MRA, and there were 9 vascular abnormalities.  Then, a subset of the uninterpretable and indeterminate patients underwent CTA or MRA, as well, resulting in an additional two vascular abnormalities.

Thus, 204.

There are a few surprising bits regarding these data.  The ~4% rate of “SAH” detected in this study is lower than most other observation series.  Some of these were neurosurgical referral centers, with much higher rates.  Then, of course, the incidence will further depend on various definitions of positivity and the rate at which patients with lower pre-test likelihood are evaluated for SAH.  Additionally, the rate of vascular abnormality in those with “SAH” was also quite low.  In such a small sample, the confidence intervals are quite wide, so it’s hard to estimate the generalizability of these findings.

Regardless of the precise numbers, their overall conclusion is reasonable: CT + LP is extremely low yield for true pathology.  There is a definite need for decision instruments with improved specificity to prevent such extensive resource utilization.

B. Sensitivity of a SAH decision rule and early CT in patients with aneurysmal SAH: a retrospective cohort study.

Mark DG, et al. West J Emerg Med. 2015;16(5):671-676.

Approximately 80% of non-traumatic cases of subarachnoid hemorrhage are attributable to ruptured cerebral aneurysms, for which delays in definitive aneurysm treatment can increase the risk of disability or death.1,2 While the vast majority of aneurysmal SAH (aSAH) cases are identified by cranial CT, the sensitivity of CT diminishes with time such that lumbar puncture is recommended as the definitive test to exclude a diagnosis of “CT-negative” SAH. While two large studies have reported that early cranial CT (i.e. performed within six hours of headache onset) may be up to 100% sensitive for SAH among patients presenting with a normal mental status,3-6 a prior study by our research group demonstrated imperfect sensitivity of this definition of early cranial CT in the non-academic emergency department (ED) setting.7 Accordingly we proposed that sequential application of a validated SAH clinical decision rule (age over 40, presence of neck pain or stiffness, headache onset with exertion, loss of consciousness at headache onset) in such a clinical scenario might further reduce the posterior probability of CT-negative SAH to an acceptable level of risk. 8,9

Introduction: Application of a clinical decision rule for subarachnoid hemorrhage, in combination with cranial computed tomography (CT) performed within six hours of ictus (early cranial CT), may be able to reasonably exclude a diagnosis of aneurysmal subarachnoid hemorrhage (aSAH). This study’s objective was to examine the sensitivity of both early cranial CT and a previously validated clinical decision rule among emergency department (ED) patients with aSAH and a normal mental status.

Methods: Patients were evaluated in the 21 EDs of an integrated health delivery system between January 2007 and June 2013. We identified by chart review a retrospective cohort of patients diagnosed with aSAH in the setting of a normal mental status and performance of early cranial CT. Variables comprising the SAH clinical decision rule (age over 40, presence of neck pain or stiffness, headache onset with exertion, loss of consciousness at headache onset) were abstracted from the chart and assessed for inter-rater reliability.

Results: One hundred fifty-five patients with aSAH met study inclusion criteria. The sensitivity of early cranial CT was 95.5% (95% CI [90.9-98.2]). The sensitivity of the SAH clinical decision rule was also 95.5% (95% CI [90.9-98.2]). Since all false negative cases for each diagnostic modality were mutually independent, the combined use of both early cranial CT and the clinical decision rule improved sensitivity to 100% (95% CI [97.6-100.0]).

Conclusion: Neither early cranial CT nor the SAH clinical decision rule demonstrated ideal sensitivity for aSAH in this retrospective cohort. However, the combination of both strategies might optimize sensitivity for this life-threatening disease.

9. Lit Reviews

A. Which form of aspirin is the fastest to inhibit platelet aggregation in ED patients with non-STEMI?

Morris N, et al. Emerg Med J 2015;32:823-826  

A short cut review was carried out to establish whether, in patients with suspected acute coronary syndromes presenting to the emergency department, what form of aspirin has the most rapid onset of action. Papers comparing the speed of onset of chewable aspirin, or soluble aspirin or solid aspirin were included. This summarises all three parts of a combined best evidence topic report (BET). The clinical bottom line is that chewable aspirin may be faster than soluble aspirin at decreasing the amount of time to achieve platelet inhibition in a patient. Soluble aspirin is faster than whole solid aspirin, which is faster than enteric-coated aspirin.

B. Safety of Epinephrine in Digital Nerve Blocks: A Literature Review

Ilicki J, et al. J Emerg Med 2015;49:799-809.

Digital nerve blocks are commonly performed in emergency departments. Health care practitioners are often taught to avoid performing blocks with epinephrine due to a risk of digital necrosis.

To review the literature on the safety of epinephrine 1:100,000–200,000 (5–10 μg/mL) with local anesthetics in digital nerve blocks in healthy patients and in patients with risk for poor peripheral circulation.

PubMed, Web of Science, and the Cochrane Library were searched in June 2014 using the query “digital block AND epinephrine OR digital block AND adrenaline”. The searches were performed without any limits.

Sixty-three articles were identified, and 39 of these were found to be relevant. These include nine reviews, 12 randomized control trials, and 18 other articles. Most studies excluded patients with risk for poor peripheral circulation. Two studies described using epinephrine on patients with vascular comorbidities. No study reported digital necrosis or gangrene attributable to epinephrine, either in healthy patients or in patients with risk for poor peripheral circulation. In total, at least 2797 digital nerve blocks with epinephrine have been performed without any complications.

Epinephrine 1:100,000–200,000 (5–10 μg/mL) is safe to use in digital nerve blocks in healthy patients. Physiological studies show epinephrine-induced vasoconstriction to be transient. There are no reported cases of epinephrine-induced harm to patients with risk for poor peripheral circulation despite a theoretical risk of harmful epinephrine-induced vasoconstriction. A lack of reported complications suggests that the risk of epinephrine-induced vasoconstriction to digits may be overstated.

C. The Safety of Topical Anesthetics in the Treatment of Corneal Abrasions: A Review

Swaminathan A, et al. J Emerg Med. 2015;49:810-815.

Despite the fact that topical anesthetics provide superb analgesia to the painful eye, they are not prescribed routinely to patients when they are discharged from the emergency department because of concerns for delayed healing and corneal erosion.

To summarize the evidence for the safety of topical proparacaine and tetracaine for pain relief in patients with corneal abrasions.

This is a systematic review looking at the use of topical anesthetic agents in the treatment of corneal abrasions in the emergency department.

Our literature search produced two emergency department−based, randomized, double blind, placebo-controlled studies on human patients with corneal abrasions. Additionally, we found four studies that investigated the application of topical anesthetics in patients who underwent photorefractive keratectomy. All six studies demonstrated that a short course of dilute topical anesthetic provided efficacious analgesia without adverse effects or delayed epithelial healing.

Limited available data suggests that the use of dilute topical ophthalmologic proparacaine or tetracaine for a short duration of time is effective, though their safety for outpatient use is inconclusive.

10. Comparative Analgesic Efficacy of Oxycodone/APAP Vs Hydrocodone/APAP for Short-term Pain Management in Adults Following ED Discharge

Chang AK, et al. Acad Emerg Med 2015 Oct 19 [Epub ahead of print]

The objective was to test the hypothesis that oxycodone/acetaminophen provides superior analgesia to hydrocodone/acetaminophen for the treatment of acute extremity pain following emergency department (ED) discharge.

This was a prospective, randomized, double-blind clinical trial of nonelderly adult ED patients with acute musculoskeletal extremity pain, randomly allocated at discharge to receive oxycodone/acetaminophen (5 mg/325 mg) or hydrocodone/acetaminophen (5 mg/325 mg). The primary outcome was the between-group difference in improvement in numerical rating scale (NRS) pain scores over a 2-hour period following the most recent ingestion of study drug, obtained during telephone contact 24 hours after ED discharge. Secondary outcomes included proportionate decrease in pain, comparative side-effect profiles, and patient satisfaction.

A total of 240 patients were enrolled. The final sample consisted of 220 patients, 107 randomly allocated to oxycodone/acetaminophen and 113 to hydrocodone/acetaminophen. At 24 hours after ED discharge, the mean NRS pain scores prior to the most recent dose of outpatient pain medication were 7.8 and 7.9 in the oxycodone/acetaminophen and hydrocodone/acetaminophen groups, respectively. The mean decreases in pain scores over 2 hours were 4.4 NRS units in the oxycodone/acetaminophen group versus 4.0 NRS units in the hydrocodone/acetaminophen group, for a difference of 0.4 NRS units (95% confidence interval = −0.2 to 1.1 NRS units). Satisfaction with the analgesics was similar.

This study design could not detect a clinically or statistically significant difference in analgesic efficacy between oxycodone/acetaminophen (5 mg/325 mg) and hydrocodone/acetaminophen (5 mg/325 mg) for treatment of acute musculoskeletal extremity pain in adults following ED discharge. Both opioids reduced pain scores by approximately 50%.

11. Images in Clinical Practice

Bullous Pemphigoid

Megaduodenum in Systemic Sclerosis

Septic Cerebral Venous Thrombosis

Bursitis and Tenosynovitis Due to Mycobacterium avium Complex

Young Woman with Chest Pain After Fall

Discussion: Chest Pain Bounce-Back: Posterior Sternoclavicular Dislocation

Young Adult with Abdominal Pain

Isolated Posterior Wall Myocardial Infarction.

Erucism Due to Lepidoptera Caterpillar Envenomation

12. Assessing the association between occupancy and outcome in critically Ill hospitalized patients with sepsis

Yergens DW, et al. BMC Emergency Medicine 2015, 15:31 

Sepsis has a high prevalence, mortality-rate and cost. Sepsis patients usually enter the hospital through the Emergency Department (ED). Process or structural issues related to care may affect outcome.

Multi-centered retrospective observational cohort study using administrative databases to identify adult patients (18 years or greater) with sepsis and severe sepsis admitted to Alberta Health Services Calgary zone adult multisystem intensive care units (ICU) through the ED between January 1, 2006 and September 30, 2009. We examined the association between ICU occupancy and hospital outcome. We explored other associations of hospital outcome including the effect of ED wait time, admission from ED during weekdays versus weekends and ED admission during the day versus at night.

One thousand and seven hundred seventy patients were admitted to hospital via ED, 1036 (58.5%) with sepsis and 734 (41.5 %) with severe sepsis. In patients with sepsis, ICU occupancy over 90% was associated with an increase in hospital mortality even after adjusting for age, sex, triage level, Charlson index, time of first ED physician assessment and ICU admission. No differences in hospital mortality were found for patients who waited more than 7 h, were admitted during the day versus night or weekdays versus weekends.

In patients with sepsis admitted via the ED, increased ICU occupancy was associated with higher in-hospital mortality.

13. Acute Medical Diagnoses Are Common in "Found Down" Adult Patients Presenting to the ED as Trauma.

Jacobs BG, et al. J Emerg Med. 2015 Jun 2 [Epub ahead of print]

BACKGROUND: Patients often present to the emergency department (ED) as "found down," with limited history to suggest a primary traumatic or medical etiology.

OBJECTIVE: The study objective was to describe the characteristics of "found down" adult patients presenting to the ED as trauma, specifically the incidence of acute medical diagnoses and major trauma.

METHODS: Using an institutional trauma registry, we reviewed trauma activations with the cause of injury "found down" between January 2008 and December 2012. We excluded patients with cardiac arrest, transfers from other hospitals, and patients with a more than likely (above 50%) traumatic or medical etiology on initial ED presentation. Inclusion and exclusion criteria were reviewed by two independent abstractors. We abstracted demographic, clinical, injury severity, and outcomes variables. Major trauma was defined as Injury Severity Score ≥ 16.

RESULTS: There were 659 patients identified with the cause of injury "found down." A total of 207 (31%) patients met inclusion criteria; median age was 67 years (interquartile range 50-82 years), and 110 (53%) were male. Among the included patients, 137 (66%, 95% confidence interval [Cl] 59-73%) had a discharge diagnosis of an acute medical condition, 14 (7%, 95% Cl 4-11%) with major trauma alone, 21 (10%, 95% Cl 6-15) with both an acute medical condition and major trauma, and 35 (17%, 95% Cl 12-23%) with minor trauma. The most common acute medical diagnoses were toxicological (56 patients, 35%; 95% Cl 28-43%) and infectious (32 patients, 20%; 95% Cl 14-27%).

CONCLUSION: Acute medical diagnoses were common in undifferentiated ED patients "found down" in an institutional trauma registry. Clinicians should maintain a broad differential diagnosis in the workup of the undifferentiated "found down" patient.

14. Endovascular Thrombectomy for Acute Ischemic Stroke: A Meta-analysis.

Badhiwala JH, et al. JAMA. 2015 Nov 3;314(17):1832-43.

IMPORTANCE: Endovascular intervention for acute ischemic stroke improves revascularization. But trials examining endovascular therapy yielded variable functional outcomes, and the effect of endovascular intervention among subgroups needs better definition.

OBJECTIVE: To examine the association between endovascular mechanical thrombectomy and clinical outcomes among patients with acute ischemic stroke.

DATA SOURCES: We systematically searched MEDLINE, EMBASE, CINAHL, Google Scholar, and the Cochrane Library without language restriction through August 2015.

STUDY SELECTION: Eligible studies were randomized clinical trials of endovascular therapy with mechanical thrombectomy vs standard medical care, which includes the use of intravenous tissue plasminogen activator (tPA).

DATA EXTRACTION AND SYNTHESIS: Independent reviewers evaluated the quality of studies and abstracted the data. We calculated odds ratios (ORs) and 95% CIs for all outcomes using random-effects meta-analyses and performed subgroup and sensitivity analyses to examine whether certain imaging, patient, treatment, or study characteristics were associated with improved functional outcome. The strength of the evidence was examined for all outcomes using the GRADE method.

MAIN OUTCOMES AND MEASURES: Ordinal improvement across modified Rankin scale (mRS) scores at 90 days, functional independence (mRS score, 0-2), angiographic revascularization at 24 hours, symptomatic intracranial hemorrhage within 90 days, and all-cause mortality at 90 days.

RESULTS: Data were included from 8 trials involving 2423 patients (mean [SD] age, 67.4 [14.4] years; 1131 [46.7%] women), including 1313 who underwent endovascular thrombectomy and 1110 who received standard medical care with tPA. In a meta-analysis of these trials, endovascular therapy was associated with a significant proportional treatment benefit across mRS scores (OR, 1.56; 95% CI, 1.14-2.13; P = .005). Functional independence at 90 days (mRS score, 0-2) occurred among 557 of 1293 patients (44.6%; 95% CI, 36.6%-52.8%) in the endovascular therapy group vs 351 of 1094 patients (31.8%; 95% CI, 24.6%-40.0%) in the standard medical care group (risk difference, 12%; 95% CI, 3.8%-20.3%; OR, 1.71; 95% CI, 1.18-2.49; P = .005). Compared with standard medical care, endovascular thrombectomy was associated with significantly higher rates of angiographic revascularization at 24 hours (75.8% vs 34.1%; OR, 6.49; 95% CI, 4.79-8.79; P  less than  .001) but no significant difference in rates of symptomatic intracranial hemorrhage within 90 days (70 events [5.7%] vs 53 events [5.1%]; OR, 1.12; 95% CI, 0.77-1.63; P = .56) or all-cause mortality at 90 days (218 deaths [15.8%] vs 201 deaths [17.8%]; OR, 0.87; 95% CI, 0.68-1.12; P = .27).

CONCLUSIONS AND RELEVANCE: Among patients with acute ischemic stroke, endovascular therapy with mechanical thrombectomy vs standard medical care with tPA was associated with improved functional outcomes and higher rates of angiographic revascularization, but no significant difference in symptomatic intracranial hemorrhage or all-cause mortality at 90 days.

15. Outcomes of Basic vs Advanced Life Support for Out-of-Hospital Medical Emergencies

Sanghavi P, et al. Ann Intern Med.  2015 Oct 13 [Epub ahead of print]

Ann Intern Med. 2015 Oct 13. doi: 10.7326/M15-0557. [Epub ahead of print]

Background: Most Medicare patients seeking emergency medical transport are treated by ambulance providers trained in advanced life support (ALS). Evidence supporting the superiority of ALS over basic life support (BLS) is limited, but some studies suggest ALS may harm patients.

Objective: To compare outcomes after ALS and BLS in out-of-hospital medical emergencies.

Design: Observational study with adjustment for propensity score weights and instrumental variable analyses based on county-level variations in ALS use.

Setting: Traditional Medicare.

Patients: 20% random sample of Medicare beneficiaries from nonrural counties between 2006 and 2011 with major trauma, stroke, acute myocardial infarction (AMI), or respiratory failure.

Measurements: Neurologic functioning and survival to 30 days, 90 days, 1 year, and 2 years.

Results: Except in cases of AMI, patients showed superior unadjusted outcomes with BLS despite being older and having more comorbidities. In propensity score analyses, survival to 90 days among patients with trauma, stroke, and respiratory failure was higher with BLS than ALS (6.1 percentage points [95% CI, 5.4 to 6.8 percentage points] for trauma; 7.0 percentage points [CI, 6.2 to 7.7 percentage points] for stroke; and 3.7 percentage points [CI, 2.5 to 4.8 percentage points] for respiratory failure). Patients with AMI did not exhibit differences in survival at 30 days but had better survival at 90 days with ALS (1.0 percentage point [CI, 0.1 to 1.9 percentage points]). Neurologic functioning favored BLS for all diagnoses. Results from instrumental variable analyses were broadly consistent with propensity score analyses for trauma and stroke, showed no survival differences between BLS and ALS for respiratory failure, and showed better survival at all time points with BLS than ALS for patients with AMI.

Limitation: Only Medicare beneficiaries from nonrural counties were studied.

Conclusion: Advanced life support is associated with substantially higher mortality for several acute medical emergencies than BLS.

16. Synthetic Cannabinoid Abuse in Adolescents: A Case Series

Besli GE, et al. J Emerg Med 2015;49:644-50.

Synthetic cannabinoids, referred to as “Bonzai” in Turkey, are relatively new recreational drugs of abuse. Although the use of synthetic cannabinoids has been dramatically increasing in young populations in many countries, their adverse effects are not well known.

To report on the clinical features and social history of pediatric patients with a diagnosis of synthetic cannabinoid intoxication and to highlight the dangers of these drugs to public health.

We retrospectively reviewed 16 cases presenting to our Emergency Department (ED) with synthetic cannabinoid intoxication in the last 10 months. Usage characteristics and the psychoactive, physical, and metabolic effects of synthetic cannabinoids were analyzed.

The mean age of the 16 patients with a diagnosis of synthetic cannabinoid intoxication was 15.4 ± 1.7 years (15 males, 1 female). The most common physical symptoms were eye redness, nausea/vomiting, sweating, and altered mental status; the main psychoactive findings were agitation, anxiety, hallucinations, and perceptual changes. We observed hypotension and bradycardia in 8 (50%) and 5 (31.3%) of the patients, respectively. Although most patients were discharged from the ED, 25% were transferred to an intensive care unit. They all had reduced school attendance and performance. The rates of cigarette smoking and alcohol drinking were also significantly higher.

Synthetic cannabinoids are unsafe and potentially harmful drugs of abuse; they may even cause life-threatening effects. It is important for pediatricians to be familiar with the signs and symptoms of consumption of synthetic cannabinoid products. Education of parents, teachers, and adolescents about the potential health risks of using these products is essential.

17. ED Rotational Patient Assignment Improves Operational Metrics

Traub SJ, et al. Ann Emerg Med. 2015 Oct 6 [Epub ahead of print].

STUDY OBJECTIVE: We compare emergency department (ED) operational metrics obtained in the first year of a rotational patient assignment system (in which patients are assigned to physicians automatically according to an algorithm) with those obtained in the last year of a traditional physician self-assignment system (in which physicians assigned themselves to patients at physician discretion).

METHODS: This was a pre-post retrospective study of patients at a single ED with no financial incentives for physician productivity. Metrics of interest were length of stay; arrival-to-provider time; rates of left before being seen, left subsequent to being seen, early returns (within 72 hours), and early returns with admission; and complaint ratio.

RESULTS: We analyzed 23,514 visits in the last year of physician self-assignment and 24,112 visits in the first year of rotational patient assignment. Rotational patient assignment was associated with the following improvements (percentage change): median length of stay 232 to 207 minutes (11%), median arrival to provider time 39 to 22 minutes (44%), left before being seen 0.73% to 0.36% (51%), and complaint ratio 9.0/1,000 to 5.4/1,000 (40%). There were no changes in left subsequent to being seen, early returns, or early returns with admission.

CONCLUSION: In a single facility, the transition from physician self-assignment to rotational patient assignment was associated with improvement in a broad array of ED operational metrics. Rotational patient assignment may be a useful strategy in ED front-end process redesign.

DRV: These results validates those from Kaiser Permanente.
Patel PB, et al. Team assignment system: expediting emergency department care. Ann Emerg Med. 2005;46(6):499-506. Abstract: http://www.ncbi.nlm.nih.gov/pubmed/16308063

Song H, Tucker AL, Murrell KL. The diseconomies of queue pooling: an empirical investigation of Emergency Department length of stay. Man Sci. 2015 May 28 [Epub ahead of print].

18. Accuracy of ‘My Gut Feeling:’ Comparing System 1 to System 2 Decision-Making for Acuity Prediction, Disposition and Diagnosis in an Academic ED

Cabrera D, et al. West J Emerg Med 2015;16(5):653-657.

Introduction: Current cognitive sciences describe decision-making using the dual-process theory, where a System 1 is intuitive and a System 2 decision is hypothetico-deductive. We aim to compare the performance of these systems in determining patient acuity, disposition and diagnosis.

Methods: Prospective observational study of emergency physicians assessing patients in the emergency department of an academic center. Physicians were provided the patient’s chief complaint and vital signs and allowed to observe the patient briefly. They were then asked to predict acuity, final disposition (home, intensive care unit (ICU), non-ICU bed) and diagnosis. A patient was classified as sick by the investigators using previously published objective criteria.

Results: We obtained 662 observations from 289 patients. For acuity, the observers had a sensitivity of 73.9% (95% CI [67.7-79.5%]), specificity 83.3% (95% CI [79.5-86.7%]), positive predictive value 70.3% (95% CI [64.1-75.9%]) and negative predictive value 85.7% (95% CI [82.0-88.9%]). For final disposition, the observers made a correct prediction in 80.8% (95% CI [76.1-85.0%]) of the cases. For ICU admission, emergency physicians had a sensitivity of 33.9% (95% CI [22.1-47.4%]) and a specificity of 96.9% (95% CI [94.0-98.7%]). The correct diagnosis was made 54% of the time with the limited data available.

Conclusion: System 1 decision-making based on limited information had a sensitivity close to 80% for acuity and disposition prediction, but the performance was lower for predicting ICU admission and diagnosis. System 1 decision-making appears insufficient for final decisions in these domains but likely provides a cognitive framework for System 2 decision-making.

19. Association of a Guardian's Report of a Child Acting Abnormally With TBI after Minor Blunt Head Trauma.

Nishijima DK, et al. JAMA Pediatr. 2015 Oct 19 [Epub ahead of print]

Importance: Increased use of computed tomography (CT) in children is concerning owing to the cancer risk from ionizing radiation, particularly in children younger than 2 years. A guardian report that a child is acting abnormally is a risk factor for clinically important traumatic brain injury (ciTBI) and may be a driving factor for CT use in the emergency department.

Objective: To determine the prevalence of ciTBIs and TBIs in children younger than 2 years with minor blunt head trauma and a guardian report of acting abnormally with (1) no other findings or (2) other concerning findings for TBI.

Design, Setting, and Participants: Secondary analysis of a large, prospective, multicenter cohort study that included 43 399 children younger than 18 years with minor blunt head trauma evaluated in 25 emergency departments. The study was conducted on data obtained between June 2004 and September 2006. Data analysis was performed between August 21, 2014, and March 9, 2015.

Exposures: A guardian report that the child was acting abnormally after minor blunt head trauma.

Main Outcomes and Measures: The prevalence of ciTBI (defined as death, neurosurgery, intubation for more than 24 hours, or hospitalization for ≥2 nights in association with TBI on CT imaging) and TBI on CT imaging in children with a guardian report of acting abnormally with (1) no other findings and (2) other concerning findings for TBI.

Results: Of 43 399 children in the cohort study, a total of 1297 children had reports of acting abnormally, of whom 411 (31.7%) had this report as their only finding. Reported as percentage (95% CI), 1 of 411 (0.2% [0-1.3%]) had a ciTBI, and 4 TBIs were noted on the CT scans in 185 children who underwent imaging (2.2% [0.6%-5.4%]). In children with reports of acting abnormally and other concerning findings for TBI, 29 of 886 (3.3% [2.2%-4.7%]) had ciTBIs and 66 of 674 (9.8% [7.7%-12.3%]) had TBIs on CT.

Conclusions and Relevance: Clinically important TBIs are very uncommon, and TBIs noted on CT are uncommon in children younger than 2 years with minor blunt head trauma and guardian reports of the child acting abnormally with no other clinical findings suspicious for TBI. Computed tomographic scans are generally not indicated in these children although observation in the emergency department may be warranted.

20. Three Studies on the Acute Management of Low Back Pain

A. Naproxen with Cyclobenzaprine, Oxycodone/Acetaminophen, or Placebo for Treating Acute LBP: A RCT

Neither cyclobenzaprine nor opioids are helpful as adjuncts to naproxen therapy for LBP.

Friedman BW, et al. JAMA. 2015 Oct 20;314(15):1572-80.

IMPORTANCE: Low back pain (LBP) is responsible for more than 2.5 million visits to US emergency departments (EDs) annually. These patients are usually treated with nonsteroidal anti-inflammatory drugs, acetaminophen, opioids, or skeletal muscle relaxants, often in combination.

OBJECTIVE: To compare functional outcomes and pain at 1 week and 3 months after an ED visit for acute LBP among patients randomized to a 10-day course of (1) naproxen + placebo; (2) naproxen + cyclobenzaprine; or (3) naproxen + oxycodone/acetaminophen.

DESIGN, SETTING, AND PARTICIPANTS: This randomized, double-blind, 3-group study was conducted at one urban ED in the Bronx, New York City. Patients who presented with nontraumatic, nonradicular LBP of 2 weeks' duration or less were eligible for enrollment upon ED discharge if they had a score greater than 5 on the Roland-Morris Disability Questionnaire (RMDQ). The RMDQ is a 24-item questionnaire commonly used to measure LBP and related functional impairment on which 0 indicates no functional impairment and 24 indicates maximum impairment. Beginning in April 2012, a total of 2588 patients were approached for enrollment. Of the 323 deemed eligible for participation, 107 were randomized to receive placebo and 108 each to cyclobenzaprine and to oxycodone/acetaminophen. Follow-up was completed in December 2014.

INTERVENTIONS: All participants were given 20 tablets of naproxen, 500 mg, to be taken twice a day. They were randomized to receive either 60 tablets of placebo; cyclobenzaprine, 5 mg; or oxycodone, 5 mg/acetaminophen, 325 mg. Participants were instructed to take 1 or 2 of these tablets every 8 hours, as needed for LBP. They also received a standardized 10-minute LBP educational session prior to discharge.

MAIN OUTCOMES AND MEASURES: The primary outcome was improvement in RMDQ between ED discharge and 1 week later.

RESULTS: Demographic characteristics were comparable among the 3 groups. At baseline, median RMDQ score in the placebo group was 20 (interquartile range [IQR],17-21), in the cyclobenzaprine group 19 (IQR,17-21), and in the oxycodone/acetaminophen group 20 (IQR,17-22). At 1-week follow-up, the mean RMDQ improvement was 9.8 in the placebo group, 10.1 in the cyclobenzaprine group, and 11.1 in the oxycodone/acetaminophen group. Between-group difference in mean RMDQ improvement for cyclobenzaprine vs placebo was 0.3 (98.3% CI, -2.6 to 3.2; P = .77), for oxycodone/acetaminophen vs placebo, 1.3 (98.3% CI, -1.5 to 4.1; P = .28), and for oxycodone/acetaminophen vs cyclobenzaprine, 0.9 (98.3% CI, -2.1 to 3.9; P = .45).

CONCLUSIONS AND RELEVANCE: Among patients with acute, nontraumatic, nonradicular LBP presenting to the ED, adding cyclobenzaprine or oxycodone/acetaminophen to naproxen alone did not improve functional outcomes or pain at 1-week follow-up. These findings do not support use of these additional medications in this setting.

Reviewed by Daniel J. Pallin, MD, MPH, Journal Watch Emerg Med 2015 Oct 20.

Comment: Back pain is vexing for providers and patients alike. Opioids and so-called muscle relaxants appear to add little to nonsteroidal anti-inflammatory medications. Cyclobenzaprine has sedative and anticholinergic side effects, and prescribing opioids for a condition that evidence-based consensus guidelines warn against can lead to abuse and addiction.

B. Does a Single Dose of IV Dex Reduce Symptoms in ED Patients With LBP and RAdiculopathy (SEBRA)? A Double-Blind RCT

Balakrishnamoorthy R, et al. Emerg Med J. 2015;32(7):525-530.

OBJECTIVE: To assess the effect of a single dose of intravenous dexamethasone in addition to routine treatment on visual analogue scale (VAS) pain scores at 24 h in emergency department (ED) patients with low back pain with radiculopathy (LBPR).

METHODS: Double-blind randomised controlled trial of 58 adult ED patients with LBPR, conducted in one tertiary and one urban ED. The intervention was 8 mg of intravenous dexamethasone (or placebo) in addition to current routine care. The primary outcome was the change in VAS pain scores between presentation and 24 h. Secondary outcomes included VAS pain scores at 6 weeks, ED length of stay (EDLOS), straight leg raise (SLR) angles and Oswestry functional scores.

RESULTS: Patients treated with dexamethasone had a 1.86 point (95% CI 0.31 to 3.42, p=0.019) greater reduction in VAS pain scores at 24 h than placebo (dexamethasone: -2.63 (95% CI -3.63 to -1.63) versus placebo: -0.77 (95% CI -2.04 to 0.51)). At 6 weeks, both groups had similar significant and sustained decrease in VAS scores compared with baseline. Patients receiving dexamethasone had a significantly shorter EDLOS (median: 3.5 h vs 18.8 h, p=0.049) and improved SLR angle at discharge (14.7°, p=0.040). There was no difference in functional scores.

CONCLUSIONS: In patients with LBPR, a single dose of intravenous dexamethasone in addition to routine management improved VAS pain scores at 24 h, but this effect was not statistically significant at 6 weeks. Dexamethasone may reduce EDLOS and can be considered as a safe adjunct to standard treatment.

C. Early Physical Therapy vs Usual Care in Patients with Recent-Onset LBP: A RCT

Fritz JM, et al. JAMA. 2015;314(14):1459-1467.

Importance  Low back pain (LBP) is common in primary care. Guidelines recommend delaying referrals for physical therapy.

Objective  To evaluate whether early physical therapy (manipulation and exercise) is more effective than usual care in improving disability for patients with LBP fitting a decision rule.

Design, Setting, and Participants  Randomized clinical trial with 220 participants recruited between March 2011 and November 2013. Participants with no LBP treatment in the past 6 months, aged 18 through 60 years (mean age, 37.4 years [SD, 10.3]), an Oswestry Disability Index (ODI) score of 20 or higher, symptom duration less than 16 days, and no symptoms distal to the knee in the past 72 hours were enrolled following a primary care visit.

Interventions  All participants received education. Early physical therapy (n = 108) consisted of 4 physical therapy sessions. Usual care (n = 112) involved no additional interventions during the first 4 weeks.

Main Outcomes and Measures  Primary outcome was change in the ODI score (range: 0-100; higher scores indicate greater disability; minimum clinically important difference, 6 points) at 3 months. Secondary outcomes included changes in the ODI score at 4-week and 1-year follow-up, and change in pain intensity, Pain Catastrophizing Scale (PCS) score, fear-avoidance beliefs, quality of life, patient-reported success, and health care utilization at 4-week, 3-month, and 1-year follow-up.

Results  One-year follow-up was completed by 207 participants (94.1%). Using analysis of covariance, early physical therapy showed improvement relative to usual care in disability after 3 months (mean ODI score: early physical therapy group, 41.3 [95% CI, 38.7 to 44.0] at baseline to 6.6 [95% CI, 4.7 to 8.5] at 3 months; usual care group, 40.9 [95% CI, 38.6 to 43.1] at baseline to 9.8 [95% CI, 7.9 to 11.7] at 3 months; between-group difference, −3.2 [95% CI, −5.9 to −0.47], P = .02). A significant difference was found between groups for the ODI score after 4 weeks (between-group difference, −3.5 [95% CI, −6.8 to −0.08], P = .045]), but not at 1-year follow-up (between-group difference, −2.0 [95% CI, −5.0 to 1.0], P = .19). There was no improvement in pain intensity at 4-week, 3-month, or 1-year follow-up (between-group difference, −0.42 [95% CI, −0.90 to 0.02] at 4-week follow-up; −0.38 [95% CI, −0.84 to 0.09] at 3-month follow-up; and −0.17 [95% CI, −0.62 to 0.27] at 1-year follow-up). The PCS scores improved at 4 weeks and 3 months but not at 1-year follow-up (between-group difference, −2.7 [95% CI, −4.6 to −0.85] at 4-week follow-up; −2.2 [95% CI, −3.9 to −0.49] at 3-month follow-up; and −0.92 [95% CI, −2.7 to 0.61] at 1-year follow-up). There were no differences in health care utilization at any point.

Conclusions and Relevance  Among adults with recent-onset LBP, early physical therapy resulted in statistically significant improvement in disability, but the improvement was modest and did not achieve the minimum clinically important difference compared with usual care.

21. Relief: Scientists Harness the Power of Perception to Fade Out Chronic Pain

By Rachel Adelson, The Observer, Nov 2015

Whether it’s from an unrelenting backache, a persistently stiff neck, or arthritis in the knee, chronic pain — pain that lasts more than 12 weeks — is considered a disease by the US government’s National Institutes of Health.

Chronic pain from any source affects mood along with physical and mental functioning, making it the most common cause of long-term disability in the United States. As baby boomers everywhere get older, “chronic pain is arguably the biggest health burden our species faces at the moment in terms of years lived with disability and economic load,” says Lorimer Moseley, a clinical neuroscientist at the University of South Australia.

Because pain is unique to every person, it’s difficult to quantify and treat, making it a major ongoing focus of study for psychological science. Clinicians already deliver a range of mind-based treatments, from guided relaxation, stress management, and self-hypnosis to cognitive-behavioral therapy (CBT), which helps patients challenge catastrophic thoughts about their pain. Increasingly, scientists are using new insights into the brain to devise new forms of pain relief. In pilot studies that involve interventions ranging from placebos to virtual-reality technology, they’re building a solid body of evidence on the power of perception to muffle pain…

22. Talking to a car or smartphone impairs driving for longer than you think

Drivers remain distracted for up to 27 seconds after giving voice commands to cellphones or infotainment systems, The Washington Post reports. Past research has shown that hands-free systems, including ones built into cars, are not safe to use while a car is moving. Now, an American Automobile Association-funded study has found that people need between 15 and 27 seconds to refocus afterward, suggesting that that drivers should refrain from using hands-free technology even while stopped at a stoplight.

JAMA Patient Page on Distracted Driving: http://jama.jamanetwork.com/article.aspx?articleid=2466150

23. Book Recommendation: The Marshmallow Test: Lessons for personal development, parenting, education, and public policy

Walter Mischel, The Marshmallow Test: Mastering Self-Control (New York: Little, Brown and Co, 2014).

Renowned psychologist Walter Mischel, designer of the famous Marshmallow Test, explains what self-control is and how to master it.

A child is presented with a marshmallow and given a choice: Eat this one now, or wait and enjoy two later. What will she do? And what are the implications for her behavior later in life?

The world's leading expert on self-control, Walter Mischel has proven that the ability to delay gratification is critical for a successful life, predicting higher SAT scores, better social and cognitive functioning, a healthier lifestyle and a greater sense of self-worth. But is willpower prewired, or can it be taught?

In The Marshmallow Test, Mischel explains how self-control can be mastered and applied to challenges in everyday life--from weight control to quitting smoking, overcoming heartbreak, making major decisions, and planning for retirement. With profound implications for the choices we make in parenting, education, public policy and self-care, The Marshmallow Test will change the way you think about who we are and what we can be.

24. Micro Bits

A. ED Visits for Adverse Events Related to Dietary Supplements

An estimated 23,000 emergency department visits in the United States every year are attributed to adverse events related to dietary supplements. Such visits commonly involve cardiovascular manifestations from weight-loss or energy products among young adults and swallowing problems, often associated with micronutrients, among older adults.

B. Nonmedical Prescription Opioid Use and Use Disorders Among Adults Aged 18 Through 64 Years in the United States, 2003-2013

During the 2003-2013 years, among adults aged 18 through 64 years, the percentage of nonmedical use of prescription opioids decreased. In contrast, the prevalence of prescription opioid use disorders, frequency of use, and related mortality increased.

C. Allergic sensitization tied to secondhand smoke exposure

Secondhand smoke exposure in infancy, but not while inside the womb, was associated with an increased risk of food sensitization in children who were tested at ages 4, 8 and 16, Swedish researchers reported in the journal Allergy. The findings, based on 3,316 children who were followed from birth up to age 16, also showed an association between secondhand smoke exposure in infancy and an overall increased risk of eczema in combination with sensitization.

D. American Cancer Society, in a Shift, Recommends Fewer Mammograms

One of the most respected and influential groups in the continuing breast-cancer screening debate said on Tuesday that women should begin mammograms later and have them less frequently than it had long advocated.

The American Cancer Society, which has for years taken the most aggressive approach to screening, issued new guidelines on Tuesday, recommending that women with an average risk of breast cancer start having mammograms at 45 and continue once a year until 54, then every other year for as long as they are healthy and likely to live another 10 years.

E. Dalai Lama’s American doctor wants more compassion in medicine

PBS Newshour, October 27, 2015

Before he was a personal physician to the Dalai Lama, Dr. Barry Kerzin never imagined that a professional trip to Tibet would lead him down a decades-long path studying Buddhism and meditation. Special correspondent Fred de Sam Lazaro talks to Kerzin in India about his feeling that compassion and empathy are essential to medical training.

F. Breast Cancer Screening for Women at Average Risk: 2015 Guideline Update From the American Cancer Society

G. Temporal Trends in Mortality in the United States, 1969-2013

H. How Can a Mother's Childhood Experiences Be Transmitted to Her Children?

Maternal trauma in childhood may affect placental function.

I. Got allergies? Blame parasites

Why are millions of people allergic to peanuts or pollen, but hardly anyone seems to have a reaction to rice or raisins? Because some of these foods have proteins that mimic those of nasty parasites that send our immune systems into hyperdrive. The new findings could help researchers predict what other foods might cause allergies and give doctors a more accurate way to dose allergy shots.

J. Scarlet Fever is Making a Comeback with Antibiotic Resistance

After nearly 100 years, scarlet fever may be making a comeback. Scientists have used genome sequencing techniques to investigate a rise in the incidence of this childhood disease and its increasing resistance to antibiotics.

K. All-cause mortality down 43% over more than 4 decades

Death rates related to five of six major diseases or conditions -- heart disease, stroke, cancer, diabetes and injuries -- dropped from 1969 to 2013, according to a report in the Journal of the American Medical Association. The all-cause mortality rate has dropped 43% overall, but mortality for chronic obstructive pulmonary disease has surged 101%. Mortality for heart disease and stroke declined 68% and 77%, respectively, while death rates dropped 40% for injuries, 18% for cancer and 17% for diabetes.

L. Hospitals strain to accommodate climbing ER visits

Emergency department visits to Washington hospitals have risen more than 16 percent in two years, according to data from the state Department of Health.

That’s in line with a national trend since implementation of the Affordable Care Act in late 2013, which brought insurance coverage to millions of people who may have little experience using the health care system in general.