1. A Little Satirical Levity
A. How Hospitalists and Emergency
Physicians Can Learn to Work Together
About: ZDoggMD
is a physician, off-white rapper, and the founder of Turntable Health. He’s not
a businessman. He’s a business, man. OK we stole that line from Jay-Z but you
get the idea. A hospitalist at Stanford for almost 10 years, Dr. Z currently
resides in Las Vegas—a city he finds simply adorable.
B. The Idiosyncrasies and Frustrations
of Conference Calls
2. Emergency Medicine Code Black Documentary Basis for CBS TV
Primetime Series
By ACEP Now,
November 17, 2015
When ACEP Now
last spoke with emergency physician and documentary filmmaker Ryan McGarry, MD,
his film, Code Black, which chronicled life in the emergency department at
University of Southern California Los Angeles County General Hospital, was
receiving high praise on the documentary film circuit. Now, a year later, Code
Black has made the jump from silver screen to television screens worldwide. CBS
is currently airing a fictional drama series based on Dr. McGarry’s documentary
Wednesdays at 10 p.m. Eastern/9 p.m. Central.
Dr. McGarry
recently spoke with ACEP Now Medical Editor-in-Chief Kevin Klauer, DO, EJD,
FACEP, about the process of bringing Code Black to TV and the show’s commitment
to an honest and accurate portrayal of emergency medicine. Here are some
highlights from their conversation.
The
interview: http://www.acepnow.com/article/emergency-medicine-code-black-documentary-basis-for-cbs-tv-primetime-series/
3. Brief Lit Reviews from Ann Emerg Med
A. Does Ultrasonographic Guidance
Reduce Failure Rates and Adverse Events for Subclavian Vein Catheterization
Compared With the Landmark Technique?
Bottom Line:
Yes! Compared with the landmark technique, dynamic 2-dimensional (2D)
(real-time) ultrasonographic guidance increases the success rate and reduces
adverse events in subclavian vein catheterization.
B. What Is the Risk of Symptomatic
Intracerebral Hemorrhage in Patients With Stroke Mimics Who Receive Intravenous
Thrombolytics?
Take-home: In
studies of thrombolysis for ischemic stroke, some subjects receiving the drug
for conditions mimicking stroke experienced intracranial hemorrhage, although
this was less frequent than in patients treated for true stroke.
C. Is Extracorporeal Membrane
Oxygenation More Effective Than Standard Measures in Critically Ill Adults?
Bottom Line: In
critically ill adults with respiratory failure or cardiac arrest, there is
currently insufficient evidence for the use of extracorporeal membrane
oxygenation (ECMO).
D. Can Vasopressors Safely Be
Administered Through Peripheral Intravenous Catheters Compared With Central
Venous Catheters?
Take-home: Although
the safety profile of peripheral administration of vasopressors remains
uncertain, most reported adverse events are associated with a distal peripheral
site or prolonged duration of administration.
E. Comparison of Early Goal-Directed
Therapy With Usual Care for Severe Sepsis and Septic Shock
Bottom Line: Compared
with unstructured usual care, early goal-directed therapy does not decrease
mortality in patients with severe sepsis or septic shock.
4. Finding the fifth intercostal space for chest drain
insertion: guidelines and ultrasound.
Bowness JS,
et al. Emerg Med J. 2015 Dec;32(12):951-4.
OBJECTIVES:
International guidelines exist for chest drain insertion and recommend
identifying the fifth intercostal space or above, around the midaxillary line.
In a recent study, applying these guidelines in cadavers risked insertion in
the 6th intercostal space or below in 80% of cases. However, there are
limitations of cadaveric studies and this investigation uses ultrasound to
determine the intercostal space identified when applying these guidelines in
healthy adult volunteers.
METHODS: On
each side of the chest wall in 31 volunteers, the position for drain insertion
was identified using the European Trauma Course method, Advanced Trauma Life
Support (ATLS) method, British Thoracic Society's 'safe triangle' and the
'traditional' method of palpation. Ultrasound imaging was used to determine the
relationship of the skin marks with the underlying intercostal spaces.
RESULTS: Five
methods were assessed on 60 sides. In contrast to the cadaveric study, 94% of
skin marks lay over a safe intercostal space. However, the range of intercostal
spaces found spanned the second to the seventh space. In 44% of women, the
inferior boundary of the 'safe triangle' and the ATLS guidelines located the
sixth intercostal space or below.
CONCLUSIONS:
Current guidelines often identify a safe site for chest drain insertion,
although the same site is not reproducibly found. In addition, women appear to
be at risk of subdiaphragmatic drain insertion when the nipple is used to
identify the fifth intercostal space. Real-time ultrasonography can be used to
confirm the intercostal space during this procedure, although a safe guideline
is still needed for circumstances in which ultrasound is not possible.
5. Written Informed Consent for CT of the Abdomen/Pelvis is
Associated with Decreased CT Utilization in Low-Risk ED Patients
Merck LH, et
al. West J Emerg Med 2015 Nov 16 [Epub ahead of print]
Objective:
The increasing rate of patient exposure to radiation from Computerized
Tomography (CT) raises questions about appropriateness of utilization. There is
no current standard to employ informed consent for CT (ICCT). Our study
assessed the relationship between informed consent and CT utilization in
Emergency Department patients.
Methods: An
observational multiphase before-after cohort study was completed from
4/2010-5/2011. CT utilization was assessed before and after (Time I/ Time II)
the implementation of an informed consent protocol. Adult patients were
included if they presented with symptoms of abdominal/pelvic pathology or
completed ED CT. Patients with pregnancy, trauma, or altered mental status were
excluded. Data on history, exam, diagnostics, and disposition were collected
via standard abstraction tool. A multivariate logistic model was generated via
stepwise regression (SAS software v9.3), to assess CT utilization across risk
groups. Logistic models, stratified by risk, were generated to include time
period and a propensity score that controlled for potential confounders of CT
utilization and time.
Results:
7,684 patients met inclusion criteria. At Time II, there was a 24% reduction in
CT utilization in the low-risk patient group (p less than 0.002). ICCT did not
affect CT utilization in the high-risk group (p=0.16). In low-risk patients,
the propensity score was significant (p less than 0.001). There were no adverse
events reported during the study period.
Conclusion:
The implementation of ICCT was associated with reduced CT utilization in
low-risk ED patients. ICCT has the potential to increase informed, shared
decision making with patients, as well as to reduce the risks and cost
associated with CT.
6. Expanded Testing for PE Leads CT Scan Overuse
Ryan Radecki.
ACEP Now. Nov 18, 2015
In the vast
ocean of medicine, few diagnostic dilemmas descend so quickly into madness as
does pulmonary embolism (PE). In the classical teaching, PE remains one of a
handful of life-threatening diagnoses considered in the context of chest pain
or shortness of breath. The proliferation of advanced imaging technology has
also dramatically eased evaluation for PE, leading to an explosion of testing.
Sadly, the cumulative effect of such expanded testing appears to be a pervasive
preponderance of negative studies and low-yield, but costly, utilization.
And, frankly,
it’s even worse than we’ve acknowledged.
The vast
majority of PEs are diagnosed using one test, the computed tomography (CT)
pulmonary angiogram. This test gained widespread acceptance with the Prospective
Investigation of Pulmonary Embolism Diagnosis (PIOPED) studies, demonstrating
adequate sensitivity for PE compared with conventional angiography.1
Sensitivity is a valuable test attribute for a disease believed to have a high
case-fatality rate. However, as technology has improved, CT has begun detecting
smaller and smaller clots. By assigning the same clinical significance across
the disease severity spectrum, it becomes unclear whether this improved
sensitivity benefits our patients and whether our test specificity is adequate
for our current strategy.
The problem
is twofold, and two specialties are complicit in this predicament: radiology
and emergency medicine. In radiology, the subsegmental PE is the culprit. As
vessel size decreases, the quality of opacification and contrast capture
diminishes. This results in consistent ambiguity regarding the presence of a
flow-limiting lesion.
For example,
a group of authors in Pennsylvania reviewed 415 images from their institution
judged diagnostic for PE, focusing mostly on segmental and subsegmental PE.2
Using five radiologists, four of whom were subspecialty trained in thoracic
radiology, each image was individually re-reviewed. Based on their sample of
192 images read initially as segmental PE, a majority of authors could not
agree on a positive finding in 5.7 percent of cases. For subsegmental PE, at
least one reviewer dissented in 60 percent of cases. When compared with the
original community radiologist’s official read, the consensus was a false-positive
rate of 3.6 percent for segmental PE and 15 percent for subsegmental PE.
A second
radiology department, this time in Ireland, reviewed 174 CTs reported positive
for PE.3 Three subspecialty-trained thoracic radiologists subsequently reviewed
each of the studies read initially by one of 15 general radiologists. In this
study, 45 (25.9 percent) cases were judged erroneously reported positive,
including 26.8 percent segmental and 59.4 percent subsegmental. The authors
reported the most common causes of diagnostic error were technical
image-acquisition artifacts underappreciated by the general radiologists.
The authors
offer a few specific suggestions relevant to radiologists to improve image
quality and account for technical issues, but their primary complaint was
simply this: we scanned too many patients who did not have a PE. After
subtracting the patients with false-positives, yield in this study was 129 of
937, or 13.7 percent, falling at the low end of most published performance
characteristics. This prompted another recommendation: the best way to improve
yields is to refer patients for scan only when they have a higher pretest
likelihood of disease.
Referring
appropriate patients for CT is, unfortunately, something we do terribly in the
United States. A comparison of populations of patients evaluated for PE in
several observational studies, with 3,174 patients in Europe and 7,940 patients
in the United States, showed patients were reliably higher risk in European
populations.4 Interestingly, this was most exaggerated in the clinical gestalt
of treating clinicians: in Europe only a third of patients were thought to be
low risk, while in the United States these totaled nearly two-thirds. The net
effect in this study was an overall yield for PE of 28.1 percent in Europe
compared with 7.1 percent in the United States. The PEs diagnosed in the United
States were also generally less severe as stratified by the Pulmonary Embolism
Severity Index, and PE-related deaths were likewise lower. The concise summary:
we’re performing astounding numbers of negative CTs and finding less
significant disease, and it’s almost certain our already-low numbers of
positive results are further diluted by false-positives.
Using a
validated diagnostic strategy, grounded in sound risk assessment, can reduce
excessive testing. The fantastic Ali Raja, MD, leads a team that recently
published updated American College of Physicians clinical guidelines for the
evaluation of patients with suspected acute PE.5 These guidelines include most
of the same strategies espoused in ACEP’s prior guideline but now updated to
include age-adjusted D-dimer.6 The age-adjusted threshold, age × 10 ng/mL added
to the generic 500 ng/mL in patients older than age 50, has been validated in
multiple studies. Most recently, a review of a large cohort of Kaiser
Permanente patients revealed a small handful of additional missed PEs, but the
corresponding decrease in radiation exposure and contrast-induced nephropathy
provided a net benefit.7 These authors did not account for the likelihood of
false-positive CTs in patients with low pretest probability, and it is
reasonable to suggest their study overstates the excess misses while
understating the harm reduction.
Looking
further at how our emergency medicine experts view the evaluation for PE, Jeff
Kline offers a comprehensive summary of risk factors and diagnostic
considerations.8,9 In his view, nonspecific cardiopulmonary symptoms are not
sufficient in isolation to reasonably consider the possibility of PE. Patients
must have physiologic manifestations of PE absent an alternative cause, paired
with the presence of at least one known risk factor for PE. Risk-stratification
into low, intermediate, or high risk can be performed by gestalt, Wells score,
or revised Geneva score. Low-risk patients who meet the PE rule-out criteria
fulfill an unfavorable risk-to-benefit ratio, and testing should be avoided.
For otherwise low- and intermediate-risk patients, quantitative D-dimer testing
is recommended.
Better yet,
Kline has also proposed dynamically adjusting the D-dimer cutoff level based on
the pretest probability.10 In a review of 126 patients diagnosed with PE, there
were 11 patients for whom the pretest likelihood of PE was low and who had
D-dimer levels less than 1000 ng/mL. All but one was subsegmental, representing
less than 5 percent of the pulmonary vascular tree, and none had concomitant
deep venous thrombosis. Accounting for the risks of anticoagulation, the
increasing prevalence of false-positive CT pulmonary arteriography, and the
risks of contrast-induced nephropathy, it may yet prove reasonable to forgo CT
in this subset of patients. However, until better evidence becomes available,
such a strategy should be approached via shared decision making, balancing the
risks of small, undiagnosed PE against those associated with anticoagulation.
As vessel
size decreases, the quality of opacification and contrast capture diminishes.
This results in consistent ambiguity regarding the presence of a flow-limiting
lesion.
There is no
question that widespread use of CT has provided substantial benefit to patients
and the health care system. However, its ubiquity and ease of use is leading to
unintended consequences, particularly in overdiagnosis paired with substantial
risks of unnecessary treatment. Every effort should be made to reduce use of CT
in those with low pretest likelihood of PE, and small, subsegmental PE should
be viewed with suspicion in the context of individual patient factors. We must
continue to refine and reflect upon our routine evaluation of cardiopulmonary
complaints, lest our pursuit of this white whale slip into madness.
References: http://www.acepnow.com/article/expanded-testing-for-pulmonary-embolism-leads-ct-scan-overuse/
7. On the Prescribing of Oral
Antibiotics
A. Should antibiotics be
routinely used in patients with acute uncomplicated diverticulitis?
Isacson
D, et al. Outpatient, non-antibiotic management in acute uncomplicated
diverticulitis: a prospective study. Int J Colorectal Dis. 2015
Sep;30(9):1229-34.
PURPOSE:
The aim of this study was to evaluate outpatient, non-antibiotic management in
acute uncomplicated diverticulitis with regard to admissions, complications,
and recurrences, within a 3-month follow-up period.
METHODS:
A prospective, observational study in which patients with computer
tomography-verified acute uncomplicated diverticulitis were managed as
outpatients without antibiotics. The patients kept a personal journal, were
contacted daily by a nurse, and then followed up by a surgeon at 1 week and 3
months.
RESULTS:
In total, 155 patients were included, of which 54 were men; the mean age of the
patients was 57.4 years. At the time of diagnosis, the mean C-reactive protein
and white blood cell count were 73 mg/l and 10.5 × 10(9), respectively, and
normalized in the vast majority of patients within the first week. The majority
of the patients (97.4%) were managed successfully as outpatients without
antibiotics, admissions, or complications. In only four (2.6%) patients, the
management failed because of complications in three and deterioration in one.
These patients were all treated successfully as inpatients without surgery.
Five patients had recurrences and were treated as outpatients without
antibiotics. Follow-up colonic investigations revealed cancer in two patients
and polyps in 13 patients.
CONCLUSION:
Previous results of low complication rates with the non-antibiotic policy were
confirmed. The new policy of outpatient management without antibiotics in acute
uncomplicated diverticulitis is now shown to be feasible, well functioning, and
safe.
In
support of this approach:
i. Chabok A, et al. AVOD
Study Group. Randomized clinical trial of antibiotics in acute uncomplicated
diverticulitis. Br J Surg. 2012 Apr;99(4):532-9.
ii. The new American Gastroenterological
Association Institute Guideline on the Management of Acute Diverticulitis.
Stollman
N, et al. Gastroenterol 2015 Oct 7 [Epub ahead of print]
Excerpt
In
patients with CT-documented acute uncomplicated diverticulitis, the use of
antibiotics does not seem to improve symptoms or decrease the need for surgery,
and may not decrease the development of complications or recurrence rates. The
AGA suggests that antibiotics should be used selectively, rather than
routinely, in patients with uncomplicated disease. Conditional recommendation,
low quality of evidence.
Until
recently, antibiotics have been the unquestioned cornerstone of treatment of
acute diverticulitis, consistently recommended in prior guidelines, textbooks
and expert reviews. An emerging conception that acute diverticulitis may be
more inflammatory than infectious, and increasing concerns about the overuse of
antibiotics, have led to preliminary investigations into the necessity of
antibiotics. Two recent randomized trials and two systematic reviews have
reported no clear benefit and questioned their routine use, as does this
guideline, suggesting selective and individualized use. It is important to
emphasize that the current data are of low quality, and recommendations could
change as further studies are performed. Further the patients studied were
inpatients with CT-confirmed uncomplicated disease; therefore, the results
should not be generalized to complicated patients (i.e., those with abscesses
or fistulas), those with signs of severe infection or sepsis, the
immunosuppressed, or patients with other significant comorbidities. This
recommendation is conditional due to the low quality of current evidence.
Additionally, outpatient management without antibiotics has not been studied,
although we would expect these patients to have generally milder disease and
logically equal or better outcomes.
AGA’s
“A Patient Guide: Managing Diverticulitis” http://www.gastro.org/info_for_patients/2015/10/29/a-patient-guide-managing-diverticulitis
B. Doctor-patient discussions may cut
antibiotic overprescribing
Shared
decision-making between primary care physicians and patients helps reduce
prescriptions for antibiotics to treat respiratory infections, according to a
Cochrane Library report. When patients and doctors discuss the issue, 29% are
prescribed antibiotics, compared with nearly 50% of clinical encounters that
did not involve shared decision-making. The findings were based on over 1,000
doctors and hundreds of thousands of patients who participated in 10 randomized
controlled trials in the UK and Europe.
C. Inappropriate
Antibiotic Therapy in a Patient with Heart Failure and Prolonged QT Interval: A
Teachable Moment of Torsades
Gupta A, et
al. JAMA Intern Med. 2015;175(11):1748-1749.
This case
illustrates how unnecessary antibiotic use might cause life-threatening adverse
events in the context of certain types of heart disease.
8. FDA moves quickly to approve easy-to-use nasal spray to treat
opioid overdose
Naloxone in nasal spray form provides
important new alternative for family members, first responders
November 18,
2015
Today the
U.S. Food and Drug Administration approved Narcan nasal spray, the first
FDA-approved nasal spray version of naloxone hydrochloride, a life-saving
medication that can stop or reverse the effects of an opioid overdose. Opioids
are a class of drugs that include prescription medications such as oxycodone,
hydrocodone, and morphine, as well as the illegal drug heroin.
Drug overdose
deaths, driven largely by prescription drug overdoses, are now the leading
cause of injury death in the United States – surpassing motor vehicle crashes.
In 2013, the Centers for Disease Control and Prevention reported the number of
drug overdose deaths had steadily increased for more than a decade. When
someone overdoses on an opioid, it can be difficult to awaken the person, and
breathing may become shallow or stop – leading to death if there is no medical
intervention. If naloxone is administered quickly, it can counter the overdose
effects, usually within two minutes.
“Combating
the opioid abuse epidemic is a top priority for the FDA,” said Stephen Ostroff,
M.D., acting commissioner, Food and Drug Administration. “We cannot stand by
while Americans are dying. While naloxone will not solve the underlying
problems of the opioid epidemic, we are speeding to review new formulations
that will ultimately save lives that might otherwise be lost to drug addiction
and overdose.”
Until this
approval, naloxone was only approved in injectable forms, most commonly
delivered by syringe or auto-injector. Many first responders and primary
caregivers, however, feel a nasal spray formulation of naloxone is easier to
deliver, and eliminates the risk of a contaminated needle stick. As a result,
there has been widespread use of unapproved naloxone kits that combine an injectable
formulation of naloxone with an atomizer that can deliver naloxone nasally.
Now, people have access to an FDA-approved product for which the drug and its
delivery device have met the FDA’s high standards for safety, efficacy and
quality.
Narcan nasal
spray does not require assembly and delivers a consistent, measured dose when
used as directed. This prescription product can be used on adults or children
and is easily administered by anyone, even those without medical training. The
drug is sprayed into one nostril while the patient is lying on his or her back,
and can be repeated if necessary. However, it is important to note that it is
not a substitute for immediate medical care, and the person administering
Narcan nasal spray should seek further immediate medical attention on the
patient’s behalf.
The FDA
granted fast-track designation and priority review for Narcan nasal spray. Fast
track is a process designed to facilitate development and expedite review of
drugs intended to treat serious conditions and that demonstrate the potential
to address an unmet medical need. The agency’s priority review program provides
for an expedited review of drugs that offer a significant improvement in the
safety or effectiveness of the treatment, prevention, or diagnosis of a serious
condition. Narcan nasal spray is being approved in less than four months,
significantly ahead of the product’s prescription drug user fee goal date of
January 20, 2016.
In clinical
trials conducted to support the approval of Narcan nasal spray, administering
the drug in one nostril delivered approximately the same levels or higher of
naloxone as a single dose of an FDA-approved naloxone intramuscular injection,
and achieved these levels in approximately the same time frame.
“We heard the
public call for this new route of administration, and we are happy to have been
able to move so quickly on a product we are confident will deliver consistently
adequate levels of the medication – a critical attribute for this emergency
life-saving drug,” said Janet Woodcock, M.D., director of the FDA’s Center for
Drug Evaluation and Research.
Use of Nasal Naloxone in the Community
Walley AY, et
al. Opioid overdose rates and implementation of overdose education and nasal
naloxone distribution in Massachusetts: interrupted time series analysis. BMJ.
2013;346:f174.
CONCLUSIONS: Opioid
overdose death rates were reduced in communities where OEND was implemented.
This study provides observational evidence that by training potential
bystanders to prevent, recognize, and respond to opioid overdoses, OEND is an
effective intervention.
9. High-frequency linear transducer improves transabdominal detection
of an IUP in first trimester ultrasound.
Tabbut M et
al. Am J Emerg Med 2015 Nov 3 [Epub ahead of print]
A third of
transvaginal ultrasound exams were avoided by use of the high-frequency probe.
Objective
To determine
if the need for transvaginal ultrasound examination can be decreased by the
addition of the transabdominal high-frequency, 12–4 MHz linear transducer after
a failed examination with the 6–2 mHz curvilinear transducer when evaluating
for an intrauterine pregnancy (IUP).
Methods
This is a
prospective pilot study of women in their first trimester of pregnancy
presenting to the Emergency Department with abdominal pain and/or vaginal
bleeding. If no IUP was identified using the curvilinear transducer via the
transabdominal approach, they were subsequently scanned using the linear
transducer. Patients without evidence of an IUP transabdominally were scanned
via the transvaginal approach.
Results
81 patients
were evaluated and, no IUP was visualized in 27 using the standard curvilinear
transducer approach and these then had an ultrasound performed with the linear
transducer. Of these, 9 patients (33.3%, 0.95 CI 15.5-51.1%) were found to have
an IUP with the linear transducer. For the 18 patients who received a
transvaginal scan, 15 patients (83.3%, 0.95 CI 66.1-100%) had no IUP identified
with the transvaginal transducer and 3 (16.7%, 0.95 CI 0–33.9%) had an IUP
identified.
Conclusions
The
transabdominal use of a high-frequency linear transducer in the evaluation of
patients in the first trimester after failed curvilinear transducer results in
a clinically significant reduction in the need for transvaginal ultrasonography
to confirm the presence of an IUP.
10. Risk of Bacterial Meningitis in Children 6 to 11 Months of
Age with a First Simple Febrile Seizure: A Retrospective, Cross-sectional,
Observational Study.
Guedj R, et
al. Acad Emerg Med. 2015 Nov;22(11):1290-7.
OBJECTIVES:
National and international guidelines are very heterogeneous about the
necessity to perform a lumbar puncture (LP) in children under 12 months of age
with a first simple febrile seizure. We estimated the risk of bacterial
meningitis in children aged 6 to 11 months with a first simple febrile seizure.
METHODS: This
multicenter retrospective study was conducted in seven pediatric emergency
departments (EDs) in the region of Paris, France. Visits of patients aged 6 to
11 months for a first simple febrile seizure from January 2007 to December 2011
were analyzed. Bacterial meningitis was sequentially sought for by 1) analyzing
bacteriologic data at the time of the visit, 2) looking for data from a second
visit to the hospital after the index visit, and 3) phone calling the child's
parents to determine the symptom evolution after the index visit. Infants lost
to this follow-up were searched for in a national bacterial meningitis database.
RESULTS: From
a total of 1,183,487 visits in the seven pediatric EDs, 116,503 were for
children 6 to 11 months of age. From these, 205 visits were for a first simple
febrile seizure. An LP was performed in 61 patients (29.8%). The outcome
bacterial meningitis was ascertainable for 168 (82%) visits. No bacterial
meningitis was found among these patients (95% confidence interval = 0% to
2.2%). None of the 37 infants lost to our follow-up were registered in the
national database as having bacterial meningitis.
CONCLUSIONS:
Among children between 6 and 11 months of age with a first simple febrile
seizure, the risk of bacterial meningitis is extremely low. These results
should encourage national and international societies to either develop or
endorse guidelines limiting routine LP in these infants and contribute to
widely homogenized management practices.
11. Trial of Continuous or Interrupted Chest Compressions during
CPR.
Nichol G, et
al. N Engl J Med. 2015 Nov 9. [Epub ahead of print]
Background
During cardiopulmonary resuscitation (CPR) in patients with out-of-hospital
cardiac arrest, the interruption of manual chest compressions for rescue
breathing reduces blood flow and possibly survival. We assessed whether
outcomes after continuous compressions with positive-pressure ventilation
differed from those after compressions that were interrupted for ventilations
at a ratio of 30 compressions to two ventilations.
Methods This
cluster-randomized trial with crossover included 114 emergency medical service
(EMS) agencies. Adults with non-trauma-related cardiac arrest who were treated
by EMS providers received continuous chest compressions (intervention group) or
interrupted chest compressions (control group). The primary outcome was the
rate of survival to hospital discharge. Secondary outcomes included the
modified Rankin scale score (on a scale from 0 to 6, with a score of ≤3
indicating favorable neurologic function). CPR process was measured to assess
compliance.
Results Of
23,711 patients included in the primary analysis, 12,653 were assigned to the
intervention group and 11,058 to the control group. A total of 1129 of 12,613
patients with available data (9.0%) in the intervention group and 1072 of
11,035 with available data (9.7%) in the control group survived until discharge
(difference, -0.7 percentage points; 95% confidence interval [CI], -1.5 to 0.1;
P=0.07); 7.0% of the patients in the intervention group and 7.7% of those in
the control group survived with favorable neurologic function at discharge (difference,
-0.6 percentage points; 95% CI, -1.4 to 0.1, P=0.09). Hospital-free survival
was significantly shorter in the intervention group than in the control group
(mean difference, -0.2 days; 95% CI, -0.3 to -0.1; P=0.004).
Conclusions
In patients with out-of-hospital cardiac arrest, continuous chest compressions
during CPR performed by EMS providers did not result in significantly higher
rates of survival or favorable neurologic function than did interrupted chest
compressions. (Funded by the National Heart, Lung, and Blood Institute and
others; ROC CCC ClinicalTrials.gov number, NCT01372748 .).
12. Images in Clinical Practice
Left Main
Coronary Artery Stent Migration
Central
Retinal-Vein Occlusion
Treponema
pallidum — The Great Imitator
Tension
Pneumoperitoneum
Man with
Chest Pain
Young Boy with
Shedding Nails
Discussion:
That’s Some Weird Nail Polish You Got There!
Woman with
Mass on Her Back
Woman with
Abdominal Pain and Diarrhea
Amaurosis
Fugax Caused by a Branch Retinal Artery Embolus
Mistaken STEMI
13. Andexanet Alfa for the Reversal of Factor Xa Inhibitor
Activity
Siegal DM, et
al. N Engl J Med 2015 Nov 11 [Epub ahead of print]
Background
Bleeding is a complication of treatment with factor Xa inhibitors, but there
are no specific agents for the reversal of the effects of these drugs.
Andexanet is designed to reverse the anticoagulant effects of factor Xa
inhibitors.
Methods Healthy
older volunteers were given 5 mg of apixaban twice daily or 20 mg of
rivaroxaban daily. For each factor Xa inhibitor, a two-part randomized
placebo-controlled study was conducted to evaluate andexanet administered as a
bolus or as a bolus plus a 2-hour infusion. The primary outcome was the mean
percent change in anti-factor Xa activity, which is a measure of factor Xa
inhibition by the anticoagulant.
Results Among
the apixaban-treated participants, anti-factor Xa activity was reduced by 94%
among those who received an andexanet bolus (24 participants), as compared with
21% among those who received placebo (9 participants) (P less than 0.001), and
unbound apixaban concentration was reduced by 9.3 ng per milliliter versus 1.9
ng per milliliter (P less than 0.001); thrombin generation was fully restored
in 100% versus 11% of the participants (P less than 0.001) within 2 to 5
minutes. Among the rivaroxaban-treated participants, anti-factor Xa activity
was reduced by 92% among those who received an andexanet bolus (27
participants), as compared with 18% among those who received placebo (14
participants) (P less than 0.001), and unbound rivaroxaban concentration was
reduced by 23.4 ng per milliliter versus 4.2 ng per milliliter (P less than 0.001);
thrombin generation was fully restored in 96% versus 7% of the participants (P less
than 0.001). These effects were sustained when andexanet was administered as a
bolus plus an infusion. In a subgroup of participants, transient increases in
levels of d-dimer and prothrombin fragments 1 and 2 were observed, which
resolved within 24 to 72 hours. No serious adverse or thrombotic events were
reported.
Conclusions
Andexanet reversed the anticoagulant activity of apixaban and rivaroxaban in
older healthy participants within minutes after administration and for the
duration of infusion, without evidence of clinical toxic effects.
Editorial: Antidote for Factor Xa
Anticoagulants
14. Can You Multitask? Evidence and Limitations of Task
Switching and Multitasking in Emergency Medicine
Skaugset LM,
et al. Ann Emerg Med 2015 Nov 13 [Epub ahead of print]
Emergency
physicians work in a fast-paced environment that is characterized by frequent
interruptions and the expectation that they will perform multiple tasks
efficiently and without error while maintaining oversight of the entire
emergency department. However, there is a lack of definition and understanding
of the behaviors that constitute effective task switching and multitasking, as
well as how to improve these skills. This article reviews the literature on
task switching and multitasking in a variety of disciplines—including cognitive
science, human factors engineering, business, and medicine—to define and
describe the successful performance of task switching and multitasking in emergency
medicine. Multitasking, defined as the performance of two tasks simultaneously,
is not possible except when behaviors become completely automatic; instead,
physicians rapidly switch between small tasks. This task switching causes
disruption in the primary task and may contribute to error. A framework is
described to enhance the understanding and practice of these behaviors.
Full-text
(subscription required): http://www.annemergmed.com/article/S0196-0644(15)01364-5/fulltext
15. Stroke risk stratification in acute dizziness presentations:
A prospective imaging-based study.
Kerber KA, et
al. Neurology. 2015 Oct 28 [Epub ahead of print]
OBJECTIVE: To
estimate the ability of bedside information to risk stratify stroke in acute
dizziness presentations.
METHODS:
Surveillance methods were used to identify patients with acute dizziness and
nystagmus or imbalance, excluding those with benign paroxysmal positional
vertigo, medical causes, or moderate to severe neurologic deficits. Stroke was
defined as acute infarction or intracerebral hemorrhage on a clinical or
research MRI performed within 14 days of dizziness onset. Bedside information
comprised history of stroke, the ABCD2 score (age, blood pressure, clinical
features, duration, and diabetes), an ocular motor (OM)-based assessment (head
impulse test, nystagmus pattern [central vs other], test of skew), and a
general neurologic examination for other CNS features. Multivariable logistic
regression was used to determine the association of the bedside information
with stroke. Model calibration was assessed using low (less than 5%),
intermediate (5% to less than 10%), and high (≥10%) predicted probability risk
categories.
RESULTS:
Acute stroke was identified in 29 of 272 patients (10.7%). Associations with
stroke were as follows: ABCD2 score (continuous) (odds ratio [OR] 1.74; 95%
confidence interval [CI] 1.20-2.51), any other CNS features (OR 2.54; 95% CI
1.06-6.08), OM assessment (OR 2.82; 95% CI 0.96-8.30), and prior stroke (OR
0.48; 95% CI 0.05-4.57). No stroke cases were in the model's low-risk
probability category (0/86, 0%), whereas 9 were in the moderate-risk category
(9/94, 9.6%) and 20 were in the high-risk category (20/92, 21.7%).
CONCLUSION:
In acute dizziness presentations, the combination of ABCD2 score, general
neurologic examination, and a specialized OM examination has the capacity to
risk-stratify acute stroke on MRI.
16. Lidocaine with morphine for ED patients with acute renal
colic improves nausea control: a double-blind, RCT
Firouzian A,
et al. Amer J Emerg Med. 2015 November 18 [Epub ahead of print]
Objective
Renal colic
(RC) is a common clinical presentation in the emergency department (ED). Prompt
and effective pain control is one of the first responsibilities of emergency
physicians. The aim of this study was to evaluate the analgesic effect of
adding lidocaine to morphine compared to morphine alone in patients presenting
to the ED with RC.
Methods
In a
double-blind, randomized controlled trial a total of 110 adults’ patients of
both sexes, aged 18-50 years, who presented to the ED with signs and symptoms
suggestive of RC were randomly assigned into 1 of 2 groups. Patients in group A
received morphine (0.1 mg/kg) plus lidocaine (1.5 mg/kg), while those in group
B received morphine (0.1 mg/kg) plus normal saline 0.9% as placebo. All
patients were asked to rate the intensity of their pain and nausea on a 0-10
point Visual Analogue Scale (VAS) at before and 5, 10, 30, 60, and 120 minutes
after intervention.
Results
There was a
statistically significant time trend decline in both groups for both pain and
nausea scores (P less than 0.01). Repeated measures analysis showed a significant
effect for the interaction between group and time of persistent pain
(P = 0.034), but there was no significant group effect in this regard
(P = 0.146). Median times to being pain-free in the group receiving morphine
plus lidocaine and in the group taking morphine alone were 87.02 minutes (95%
CI: 74.23-94.82) and 100.12 minutes (95%CI: 89.95-110.23), respectively
(P = 0.071). Repeated-measures analysis also showed a significant group effect
for nausea (P = 0.038), but there was no interaction between group and time in
this regard (P = 0.243). The median nausea-free times in the group receiving
morphine plus lidocaine and the group receiving morphine alone were
26.6 minutes (95% CI: 14.16-39.03) and 58.33 minutes (95% CI: 41.85-74.82),
respectively. This time difference was statistically significant (P less than 0.001).
Conclusions
Using
lidocaine may be recommended as an effective, safe, and inexpensive adjuvant to
morphine in improving nausea and reducing the time needed to achieve pain and
nausea relief in patients visiting the ED with acute RC.
17. Identifying Patients Suitable for DC after a Single-Presentation
High-Sensitivity Trop Result: A Comparison of Five Established Risk Scores and
Two High-Sensitivity Assays.
Carlton EW,
et al. Ann Emerg Med. 2015;66(6):635–645.e1
STUDY
OBJECTIVE: We compare the ability of 5 established risk scores to identify
patients with suspected acute coronary syndromes who are suitable for discharge
after a modified single-presentation high-sensitivity troponin result.
METHODS: This
was a prospective observational study conducted in a UK district general
hospital emergency department. Consecutive adults recruited with suspected
acute coronary syndrome for whom attending physicians determined evaluation
with serial troponin testing was required. Index tests were definitions of low
risk applied to modified Goldman, Thrombolysis in Myocardial Infarction (TIMI),
Global Registry of Acute Cardiac Events (GRACE), History, ECG, Age, Risk
Factors, Troponin (HEART), and Vancouver Chest Pain Rule risk scores,
incorporating either high-sensitivity troponin T or I results. The endpoint was
acute myocardial infarction within 30 days. A test sensitivity threshold for
acute myocardial infarction of 98% was chosen. Clinical utility was defined as
a negative predictive value greater than or equal to 99.5% and identification
of greater than 30% suitable for discharge.
RESULTS: Nine
hundred fifty-nine patients underwent high-sensitivity troponin T analysis and
867 underwent high-sensitivity troponin I analysis. In the high-sensitivity
troponin T group, 79 of 959 (8.2%) had an acute myocardial infarction and 66 of
867 (7.6%) in the high-sensitivity troponin I group. Two risk scores (GRACE less
than 80 and HEART ≤3) did not have the potential to achieve a sensitivity of
98% with high-sensitivity troponin T, and 3 scores (Goldman ≤1, TIMI ≤1, and
GRACE less than 80) with high-sensitivity troponin I. A TIMI score of 0 or less
than or equal to 1 and modified Goldman score less than or equal to 1 with
high-sensitivity troponin T, and TIMI score of 0 and HEART score of less than
or equal to 3 with high-sensitivity troponin I had the potential to achieve a
negative predictive value greater than or equal to 99.5% while identifying
greater than 30% of patients as suitable for immediate discharge.
CONCLUSION:
With established risk scores, it may be possible to identify greater than 30%
of patients suitable for discharge, with a negative predictive value greater
than or equal to 99.5% for the diagnosis of acute myocardial infarction, using
a single high-sensitivity troponin test result at presentation. There is
variation in high-sensitivity troponin assays, which may have implications in
introducing rapid rule-out protocols.
18. Accuracy of Peripheral Thermometers for Estimating
Temperature: A Systematic Review and Meta-analysis.
Niven DJ, et
al. Ann Intern Med. 2015 Nov 17;163(10):768-77.
BACKGROUND:
Body temperature is commonly used to screen patients for infectious diseases,
establish diagnoses, monitor therapy, and guide management decisions.
PURPOSE: To
determine the accuracy of peripheral thermometers for estimating core body
temperature in adults and children.
DATA SOURCES:
MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL
Plus from inception to July 2015.
STUDY
SELECTION: Prospective studies comparing the accuracy of peripheral (tympanic
membrane, temporal artery, axillary, or oral) thermometers with central
(pulmonary artery catheter, urinary bladder, esophageal, or rectal) thermometers.
DATA
EXTRACTION: 2 reviewers extracted data on study characteristics, methods, and
outcomes and assessed the quality of individual studies.
DATA
SYNTHESIS: 75 studies (8682 patients) were included. Most studies were at high
or unclear risk of patient selection bias (74%) or index test bias (67%).
Compared with central thermometers, peripheral thermometers had pooled 95%
limits of agreement (random-effects meta-analysis) outside the predefined
clinically acceptable range (± 0.5 °C), especially among patients with fever
(-1.44 °C to 1.46 °C for adults; -1.49 °C to 0.43 °C for children) and
hypothermia (-2.07 °C to 1.90 °C for adults; no data for children). For
detection of fever (bivariate random-effects meta-analysis), sensitivity was
low (64% [95% CI, 55% to 72%]; I2 = 95.7%; P less than 0.001) but specificity
was high (96% [CI, 93% to 97%]; I2 = 96.3%; P less than 0.001). Only 1 study
reported sensitivity and specificity for the detection of hypothermia.
LIMITATIONS:
High-quality data for some temperature measurement techniques are limited.
Pooled data are associated with interstudy heterogeneity that is not fully
explained by stratified and metaregression analyses.
CONCLUSION:
Peripheral thermometers do not have clinically acceptable accuracy and should
not be used when accurate measurement of body temperature will influence
clinical decisions.
19. Comparison of Two Sepsis Recognition Methods in a Pediatric ED.
Balamuth F,
et al. Acad Emerg Med. 2015 Nov;22(11):1298-306.
OBJECTIVES:
The objective was to compare the effectiveness of physician judgment and an
electronic algorithmic alert to identify pediatric patients with severe
sepsis/septic shock in a pediatric emergency department (ED).
METHODS: This
was an observational cohort study of patients older than 56 days with fever or
hypothermia. All patients were evaluated for potential sepsis in real time by
the ED clinical team. An electronic algorithmic alert was retrospectively
applied to identify patients with potential sepsis independent of physician judgment.
The primary outcome was the proportion of patients correctly identified with
severe sepsis/septic shock defined by consensus criteria. Test characteristics
were determined and receiver operating characteristic (ROC) curves were
compared.
RESULTS: Of
19,524 eligible patient visits, 88 patients developed consensus-confirmed
severe sepsis or septic shock. Physician judgment identified 159 and the
algorithmic alert identified 3,301 patients with potential sepsis. Physician
judgment had sensitivity of 72.7% (95% confidence interval [CI] = 72.1% to
73.4%) and specificity of 99.5% (95% CI = 99.4% to 99.6%); the algorithmic
alert had sensitivity of 92.1% (95% CI = 91.7% to 92.4%) and specificity of
83.4% (95% CI = 82.9% to 83.9%) for severe sepsis/septic shock. There was no
significant difference in the area under the ROC curve for physician judgment
(0.86, 95% CI = 0.81 to 0.91) or the algorithm (0.88, 95% CI = 0.85 to 0.91; p
= 0.54). A combination method using either positive physician judgment or an algorithmic
alert improved sensitivity to 96.6% and specificity to 83.3%. A sequential
approach, in which positive identification by the algorithmic alert was then
confirmed by physician judgment, achieved 68.2% sensitivity and 99.6%
specificity. Positive and negative predictive values for physician judgment
versus algorithmic alert were 40.3% versus 2.5% and 99.88% versus 99.96%,
respectively.
CONCLUSIONS:
The electronic algorithmic alert was more sensitive but less specific than
physician judgment for recognition of pediatric severe sepsis and septic shock.
These findings can help to guide institutions in selecting pediatric sepsis
recognition methods based on institutional needs and priorities.
20. Prevalence and Clinical Import of Thoracic Injury Identified
by Chest CT but Not CXR in Blunt Trauma: Multicenter Prospective Cohort Study.
Langdorf MI,
et al. Ann Emerg Med 2015;66(6):589–600.
STUDY
OBJECTIVE: Chest computed tomography (CT) diagnoses more injuries than chest
radiography, so-called occult injuries. Wide availability of chest CT has
driven substantial increase in emergency department use, although the incidence
and clinical significance of chest CT findings have not been fully described.
We determine the frequency, severity, and clinical import of occult injury, as
determined by changes in management. These data will better inform clinical
decisions, need for chest CT, and odds of intervention.
METHODS: Our
sample included prospective data (2009 to 2013) on 5,912 patients at 10 Level I
trauma center EDs with both chest radiography and chest CT at physician
discretion. These patients were 40.6% of 14,553 enrolled in the parent study
who had either chest radiography or chest CT. Occult injuries were
pneumothorax, hemothorax, sternal or greater than 2 rib fractures, pulmonary
contusion, thoracic spine or scapula fracture, and diaphragm or great vessel
injury found on chest CT but not on preceding chest radiography. A priori, we
categorized thoracic injuries as major (having invasive procedures), minor
(observation or inpatient pain control over 24 hours), or of no clinical
significance. Primary outcome was prevalence and proportion of occult injury
with major interventions of chest tube, mechanical ventilation, or surgery.
Secondary outcome was minor interventions of admission rate or observation
hours because of occult injury.
RESULTS: Two
thousand forty-eight patients (34.6%) had chest injury on chest radiography or
chest CT, whereas 1,454 of these patients (71.0%, 24.6% of all patients) had
occult injury. Of these, in 954 patients (46.6% of injured, 16.1% of total),
chest CT found injuries not observed on immediately preceding chest
radiography. In 500 more patients (24.4% of injured patients, 8.5% of all
patients), chest radiography found some injury, but chest CT found occult
injury. Chest radiography found all injuries in only 29.0% of injured patients.
Two hundred and two patients with occult injury (of 1,454, 13.9%) had major
interventions, 343 of 1,454 (23.6%) had minor interventions, and 909 (62.5%)
had no intervention. Patients with occult injury included 514 with pulmonary
contusions (of 682 total, 75.4% occult), 405 with pneumothorax (of 597 total,
67.8% occult), 184 with hemothorax (of 230 total, 80.0% occult), those with
greater than 2 rib fractures (n=672/1,120, 60.0% occult) or sternal fracture
(n=269/281, 95.7% occult), 12 with great vessel injury (of 18 total, 66.7%
occult), 5 with diaphragm injury (of 6, 83.3% occult), and 537 with multiple
occult injuries. Interventions for patients with occult injury included
mechanical ventilation for 31 of 514 patients with pulmonary contusion (6.0%),
chest tube for 118 of 405 patients with pneumothorax (29.1%), and 75 of 184
patients with hemothorax (40.8%). Inpatient pain control or observation greater
than 24 hours was conducted for 183 of 672 patients with rib fractures (27.2%)
and 79 of 269 with sternal fractures (29.4%). Three of 12 (25%) patients with
occult great vessel injuries had surgery. Repeated imaging was conducted for
50.6% of patients with occult injury (88.1% chest radiography, 11.9% chest CT,
7.5% both). For patients with occult injury, 90.9% (1,321/1,454) were admitted,
with 9.1% observed in the ED for median 6.9 hours. Forty-four percent of
observed patients were then admitted (4.0% of patients with occult injury).
CONCLUSION:
In a more seriously injured subset of patients with blunt trauma who had both
chest radiography and chest CT, occult injuries were found by chest CT in 71%
of those with thoracic injuries and one fourth of all those with blunt chest
trauma. More than one third of occult injury had intervention (37.5%). Chest
tubes composed 76.2% of occult injury major interventions, with observation or
inpatient pain control greater than 24 hours in 32.4% of occult fractures. Only
1 in 20 patients with occult injury was discharged home from the ED. For these
patients with blunt trauma, chest CT is useful to identify otherwise occult
injuries.
21. Malpractice Litigation and Testicular Torsion: A Legal
Database Review.
Colaco M, et
al. J Emerg Med. 2015;49(6):849–854.
BACKGROUND:
The litigious nature of the American medical environment is a major concern for
physicians, with an estimated annual cost of $10 billion.
OBJECTIVE:
The purpose of this study is to identify causes of litigation in cases of
testicular torsion and what factors contribute to verdicts or settlements
resulting in indemnity payments.
METHODS:
Publicly available jury verdict reports were retrieved from the Westlaw legal
database (Thomson Reuters, New York, NY). In order to identify pertinent cases,
we used the search terms "medical malpractice" and "testicular
torsion" with date ranging from 2000 to 2013. Jury verdicts, depositions,
and narrative summaries were evaluated for their medical basis, alleged malpractice,
findings, and indemnity payment(s) (if any).
RESULTS:
Fifty-two cases were identified that were relevant to this study. Fifty-one
percent of relevant cases were found in favor of the defendant physician, with
the remaining 49% involving an indemnity payment (13% of which were settled).
The most commonly sued medical providers were emergency physicians (48% of
defendants), with urologists being second most common and making up 23% of the
defendant pool. Emergency physicians were significantly more likely to make
indemnity payments than urologists.
CONCLUSION:
Testicular torsion is a delicate condition and requires expertise in evaluation
and treatment. When emergency physicians choose not to consult an urologist for
possible torsion, they leave themselves open to litigation risk. When an
urologist is involved in torsion litigation, they are rarely unsuccessful in
their defense. Finally, ultrasound is no guarantee for success against
litigation.
22. Choose to Be Grateful. It Will Make You Happier.
Arthur C
Brooks. New York Times. Nov 21, 2015
TWENTY-FOUR
years ago this month, my wife and I married in Barcelona, Spain. Two weeks
after our wedding, flush with international idealism, I had the bright idea of
sharing a bit of American culture with my Spanish in-laws by cooking a full
Thanksgiving dinner.
Easier said
than done. Turkeys are not common in Barcelona. The local butcher shop had to
order the bird from a specialty farm in France, and it came only partially
plucked. Our tiny oven was too small for the turkey. No one had ever heard of
cranberries.
Over dinner,
my new family had many queries. Some were practical, such as, “What does this
beast eat to be so filled with bread?” But others were philosophical: “Should
you celebrate this holiday even if you don’t feel grateful?”
I stumbled
over this last question. At the time, I believed one should feel grateful in
order to give thanks. To do anything else seemed somehow dishonest or fake — a
kind of bourgeois, saccharine insincerity that one should reject. It’s best to
be emotionally authentic, right? Wrong. Building the best life does not require
fealty to feelings in the name of authenticity, but rather rebelling against
negative impulses and acting right even when we don’t feel like it. In a nutshell,
acting grateful can actually make you grateful.
For many
people, gratitude is difficult, because life is difficult. Even beyond
deprivation and depression, there are many ordinary circumstances in which
gratitude doesn’t come easily. This point will elicit a knowing, mirthless
chuckle from readers whose Thanksgiving dinners are usually ruined by a drunk
uncle who always needs to share his political views. Thanks for nothing.
Beyond rotten
circumstances, some people are just naturally more grateful than others. A 2014
article in the journal Social Cognitive and Affective Neuroscience identified a
variation in a gene (CD38) associated with gratitude. Some people simply have a
heightened genetic tendency to experience, in the researchers’ words, “global
relationship satisfaction, perceived partner responsiveness and positive
emotions (particularly love).” That is, those relentlessly positive people you
know who seem grateful all the time may simply be mutants.
But we are
more than slaves to our feelings, circumstances and genes. Evidence suggests
that we can actively choose to practice gratitude — and that doing so raises
our happiness…
The remainder
of the essay: http://www.nytimes.com/2015/11/22/opinion/sunday/choose-to-be-grateful-it-will-make-you-happier.html
23. Book Recommendation
Sherry Turkle
(MIT), Reclaiming
Conversation: The Power of Talk in a Digital Age (New York: Penguin
Press, 2015).
Renowned
media scholar Sherry Turkle investigates how a flight from conversation
undermines our relationships, creativity, and productivity—and why reclaiming
face-to-face conversation can help us regain lost ground.
Sherry Turkle
is Abby Rockefeller Mauzé Professor of the Social Studies of Science and
Technology in the Program in Science, Technology, and Society at MIT and the
founder (2001) and current director of the MIT Initiative on Technology and
Self. Professor Turkle received a joint doctorate in sociology and personality
psychology from Harvard University and is a licensed clinical psychologist.
Book review
in the New York Times: http://www.nytimes.com/2015/10/04/books/review/jonathan-franzen-reviews-sherry-turkle-reclaiming-conversation.html
24. Micro Bits
A. IT in the ED: Emergency Physicians
Explore Their Inner Geeks
Emergency
physicians tend to be the MacGyvers of the medical world. They must think
quickly and decisively, maintain a wide variety of medical skills, and under
stressful conditions find creative solutions to problems. So it seems natural
that an emergency physician would not simply accept using a clunky information
system that slows things down.
A new breed
of emergency informaticists has emerged, and they’re educating themselves about
what’s under the hood of their electronic medical record systems so they can be
tweaked to do good instead of evil: to access key information about new
patients, get tips on the best care, and document the visit, rather than
introducing time-wasting and potentially dangerous steps into providers’ work
flow.
Thus, we have
the field of emergency informatics. Emergency physicians interested in a basic
grounding in the topic have been taking the online 10×10 course in Biomedical
and Health Informatics for Emergency Physicians, sponsored by Oregon Health
& Science University. The 10×10 informatics course is designed for physicians
and nurses of all backgrounds; an emergency medicine–specific version has been
available for the past 5 years, in partnership with the American College of
Emergency Physicians (ACEP) (which publishes this journal). The course
culminates in an in-person session at the fall ACEP Scientific Assembly…
B. Lower BP targets may reduce risk of
cardiac events, study finds
Data from the
SPRINT trial showed a target systolic blood pressure of 120 reduced mortality,
heart attack, heart failure and stroke rates, compared with the current
recommendations of 140 for people younger than 60 and 150 for elderly patients.
The study was presented at the American Heart Association annual meeting and
published in the New England Journal of Medicine. A related report in the
Journal of the American College of Cardiology estimates that at least 16.8
million Americans could benefit from therapy to reduce BP to the lower levels
studied in the SPRINT trial.
C. Angioplasty does not improve stable
heart disease outcomes, study finds
People with
stable heart disease and chest pain should try medications and lifestyle
modification before turning to angioplasty, according to findings published in
the New England Journal of Medicine. The study followed patients for 15 years
and found that patients who undergo angioplasty and stenting fare no better
than those who make lifestyle changes and take a regimen of statins,
hypertension drugs and aspirin. Researcher William Boden, M.D., said it's
important that patients getting angioplasty understand it will not help them
live longer or avoid a heart attack.
D. Exercise and Health: Dose and
Response, Considering Both Ends of the Curve
Regular
exercise is the most effective way to prevent disease; exercise also can help
treat many of the chronic illnesses that plague America.47 Exercise is
necessary for optimal health, and for health, moderate exercise is sufficient.
We know much
more about the minimum daily requirement for exercise than about the maximum
safe limit. But we do know that each individual does have a limit, which
increases with proper training but decreases with age and when illness or
injury intervenes. Individuals who choose to push toward their limit should do
so with informed consent, knowing that some experts worry they may risk cardiac
damage, while others believe intense exercise may attenuate the health benefits
of more moderate exercise.
Walking,
jogging, and running will all promote good health, but no one should mistake
health as the reason to run a marathon. Still, there are valid personal reasons
for high-level exercise; if marathon running seems right for you, just be sure
to do it right.
Edward
Stanley, the Earl of Derby, got it right in 1873 when he said that those who
think they have not time for bodily exercise will sooner or later have to find
time for illness.
E. Inpatient PPI use tied to
infection, death risk
A study in
the Journal of General Internal Medicine found that proton-pump inhibitors,
frequently prescribed in hospital settings to prevent stomach bleeding, may be
linked to greater mortality from hospital-acquired infections. The study used a
simulation based on inpatient data to explore risk, finding that those who
start PPIs while hospitalized have a 90% higher risk of death, while patients
who previously took PPIs and continue during a hospital stay have 79% increased
risk. Patients taking PPIs may develop pneumonia or Clostridium difficile
infection.
F. CDC: Uninsured rate continues to
decline
The
proportion of Americans without health insurance was about 9% in the first half
of this year, compared with 16% in 2010, according to the CDC's National Center
for Health Statistics. About 28.5 million US residents were still without
health insurance this year, the survey found.
G. Study links moderate coffee
consumption to lower risk of death
Researchers
found people who drank one to five cups of coffee daily, whether caffeinated,
decaffeinated or both, were less likely to die from type 2 diabetes, heart
disease, neurological diseases or suicide, but not cancer, compared with those
who didn't drink coffee. The findings in Circulation were based on data from
more than 200,000 participant.
H. Patients may benefit when surgical
residents scrub in
There is no
danger and it might even be beneficial to have surgical residents join senior
physicians in the operating room, data show. Rates of complications were
similar in cases that included residents, compared with those involving only
senior physicians, and 30-day mortality risk was 7% lower, according to a study
published in the Journal of the American College of Surgeons. Surgical
residents may help attending surgeons to improve proper preoperative
decision-making and act as an additional safety checkpoint, said senior study
author Faek Jamali.
I. Early Administration of
Azithromycin and Prevention of Severe Lower Respiratory Tract Illnesses in
Preschool Children with a History of Such Illnesses: A RCT
J. Study highlights risks of off-label
prescribing
About 12% of
prescriptions written are off-label, and about 80% of those off-label
prescriptions are not supported by strong scientific evidence, researchers
report in JAMA Internal Medicine. Although no difference was seen in the side
effect rates for on-label and off-label prescriptions backed by strong
scientific evidence, the risk of adverse effects associated with off-label
prescriptions not backed by strong scientific evidence was 54% higher than for
on-label prescriptions supported by such evidence, the study found.
