0. Light-hearted Studies from the 2016 BMJ Christmas Issue
A. Gotta catch’em all! Pokémon GO and
physical activity among young adults: difference in differences study
Conclusions:
Pokémon GO was associated with an increase in the daily number of steps after
installation of the game. The association was, however, moderate and no longer
observed after six weeks.
Full-text
(free): http://www.bmj.com/content/355/bmj.i6270
B. Do celebrity endorsements matter?
Observational study of BRCA gene testing and mastectomy rates after Angelina
Jolie’s New York Times editorial
Conclusions: Celebrity
endorsements can have a large and immediate effect on use of health services.
Such announcements can be a low cost means of reaching a broad audience
quickly, but they may not effectively target the subpopulations that are most
at risk for the relevant underlying condition.
Full-text
(free): http://www.bmj.com/content/355/bmj.i6357
C. Dispelling the nice or naughty
myth: retrospective observational study of Santa Claus
Conclusions: The
results of this study dispel the traditional belief that Santa Claus rewards
children based on how nice or naughty they have been in the previous year.
Santa Claus is less likely to visit children in hospitals in the most deprived
areas. Potential solutions include a review of Santa’s contract or employment
of local Santas in poorly represented regions.
Full-text
(free): http://www.bmj.com/content/355/bmj.i6355
D. Sniffing out significant “Pee
values”: genome wide association study of asparagus anosmia
Conclusion: A
large proportion of people have asparagus anosmia. Genetic variation near multiple
olfactory receptor genes is associated with the ability of an individual to
smell the metabolites of asparagus in urine. Future replication studies are
necessary before considering targeted therapies to help anosmic people discover
what they are missing.
Full-text
(free): http://www.bmj.com/content/355/bmj.i6071
1. Shared decision making in patients with low risk CP:
prospective randomized pragmatic trial.
Hess EP, et
al. BMJ. 2016 Dec 5;355:i6165.
OBJECTIVE: To compare the effectiveness of shared
decision making with usual care in choice of admission for observation and
further cardiac testing or for referral for outpatient evaluation in patients
with possible acute coronary syndrome.
DESIGN: Multicenter pragmatic parallel randomized
controlled trial.
SETTING: Six emergency departments in the United
States.
PARTICIPANTS: 898 adults (aged over 17 years) with a
primary complaint of chest pain who were being considered for admission to an
observation unit for cardiac testing (451 were allocated to the decision aid
and 447 to usual care), and 361 emergency clinicians (emergency physicians,
nurse practitioners, and physician assistants) caring for patients with chest
pain.
INTERVENTIONS: Patients were randomly assigned (1:1) by an
electronic, web based system to shared decision making facilitated by a
decision aid or to usual care. The primary outcome, selected by patient and
caregiver advisers, was patient knowledge of their risk for acute coronary
syndrome and options for care; secondary outcomes were involvement in the
decision to be admitted, proportion of patients admitted for cardiac testing,
and the 30 day rate of major adverse cardiac events.
RESULTS: Compared with the usual care arm, patients in
the decision aid arm had greater knowledge of their risk for acute coronary
syndrome and options for care (questions correct: decision aid, 4.2 v usual
care, 3.6; mean difference 0.66, 95% confidence interval 0.46 to 0.86), were
more involved in the decision (observing patient involvement scores: decision
aid, 18.3 v usual care, 7.9; 10.3, 9.1 to 11.5), and less frequently decided
with their clinician to be admitted for cardiac testing (decision aid, 37% v
usual care, 52%; absolute difference 15%; P less than 0.001). There were no
major adverse cardiac events due to the intervention.
CONCLUSIONS: Use of a decision aid in patients at low risk
for acute coronary syndrome increased patient knowledge about their risk,
increased engagement, and safely decreased the rate of admission to an
observation unit for cardiac testing.
Journal
Watch overview: thumbs up
Daniel M.
Lindberg, MD
Use of a
Web-based tool improved patient engagement and knowledge about risk and
treatment options and decreased observation-unit admissions.
For chest
pain patients with normal electrocardiogram and initial troponin results,
adverse events are rare but serious. Some emergency physicians, guidelines, and
clinical pathways recommend admission or observation for routine provocative
testing in patients with low-risk chest pain, which can result in additional testing
and significant cost.
Investigators
studied 898 patients from six U.S. emergency departments who had low-risk chest
pain and were being considered for admission for cardiac testing (stress test
or coronary computed tomography). Patients were randomized to usual care or
shared decision making facilitated by a decision aid. The Web-based decision
aid took into account patients' personalized risk factors and reported their
45-day risk for major adverse cardiac events. Patients in both groups were surveyed
immediately after the visit.
Patients
randomized to the decision aid had increased knowledge of their risk and
available options for their care and were more involved in decision making
compared with those randomized to usual care. Conversations between the patient
and physician took approximately 1 minute longer in the decision aid group.
Significantly fewer patients in the decision aid group decided (with their
clinician) to be admitted for further testing (37% vs. 52%). There were no
major adverse events related to the intervention.
Comment
Beyond the
concept of shared decision making, this study demonstrates the value of this
particular publicly available tool. I plan to use the tool with all my low-risk
chest pain patients, prior to observation-unit admission.
Resources: http://shareddecisions.mayoclinic.org/decision-aid-information/chest-pain-choice-decision-aid/
The
KP CREST Network responds (excerpt)
Vinson DR,
Ballard DW, Mark DG, Chettipally UK. Shared decision making in low risk chest
pain: looking ahead [letter]. BMJ. 2016;355:i6165/rr-1.
We commend
Hess et al for their well-designed and clinically useful pragmatic shared
decision making study (1). This is sure to serve as an example for shared
decision making research addressing other clinical scenarios, both in the
emergency department and beyond.
Shared
decision making is best suited for the fork in the road, a divergence of care
where neither course is clearly superior (2). Such a decision, though equivocal
from the clinician’s perspective, is “preference-sensitive” when seen in a
patient-centered light. The Centers for Medicare and Medicaid Services applies
shared decision making to conditions “for which the clinical evidence does not
clearly support one treatment option, and the appropriate course of treatment
depends on the values or preferences of the beneficiary regarding the benefits,
harms, and scientific evidence for each treatment option” (3). This appears to
be true at the moment regarding the site-of-care decision for many low-risk
chest pain patients: should they go home to follow-up with their primary care
provider or should they be admitted for short-term observation and provocative
testing? Let’s educate our patients and help them decide.
But the field
is rapidly changing: what is equivocal today may not be so in the coming years.
The advent of highly sensitive troponin assays, with or without the use of
refined risk stratification pathways, will help us identify emergency
department patients with short-term risks of acute coronary syndrome
sufficiently low to obviate the need for observation and advanced cardiac
testing prior to home discharge (4-6). As evidence continues to accumulate that
this practice is safe, clinicians will feel empowered to confidently shift the
site of care in an outpatient direction for a growing number of low-risk chest
pain patients. This shift in emergency department disposition is a familiar
transition, and when done safely can be associated with increased patient
convenience and satisfaction as well as a more responsible stewardship of
healthcare resources. We have learned to do this with low-risk pneumonia (7)
and are learning to do it with low-risk pulmonary embolism (8).
Even in this
projected future of increasing outpatient care for low-risk chest pain, the
best emergency department disposition will at times remain an open question.
Here the patient’s preference elicited during shared decision making can be
called upon to guide management, as Hess et al have shown (1). But absent the
equipoise of “preference-sensitive” conditions, when the clinician believes
that home management is the optimal disposition, we still need to do better at
educating our patients about their risks and explaining to them the rationale
of the recommendations we provide. The well-conceived, field-tested
patient-centered decision aid that Hess and colleagues used in this study is readily
adaptable for just this task. Whether we’re soliciting a patient’s tie-breaking
opinion on site of care (shared decision making) or we’re informing them why we
think a certain disposition is most appropriate (patient education), a clear,
accessible pictographic decision aid can help us more clearly communicate our
thoughts and leave the patient with a fuller understanding of their situation
(1)…
The remainder
of the essay (free): http://www.bmj.com/content/355/bmj.i6165/rr-1
Ryan
Radecki’s critique (excerpt)
…In short, it
seems to me the authors are not using their decision aid to help patients
choose between equally valued clinical pathways, but rather to try and convince
more patients to choose to be discharged.
In a sense,
it represents offering patients a menu of options where overtreatment is one of
them. If a dyspneic patient meets PERC,
we don’t offer them a visual aid where a CTPA is an option – and that shouldn’t
be our expectation here, either. These
authors have put in tremendous effort over many years to integrate many
important tools, but it feels like the end result is a demonstration of a
shared decision-making instrument intended to nudge patients into choosing the
disposition we think they ought, but are somehow afraid to outright tell them.
For
more on shared decision making in the ED:
See this
month’s issue of Acad Emerg Med. TOC here: http://onlinelibrary.wiley.com/doi/10.1111/acem.2016.23.issue-12/issuetoc
2. GCS Motor Component ("Patient Does Not Follow
Commands") Performs Similarly to Total GCS in Predicting Severe Injury in
Trauma Patients.
Better
for Field Triage
Kupas DF, et
al. Ann Emerg Med. 2016 Dec;68(6):744-750.e3.
STUDY
OBJECTIVE: Trauma victims are frequently triaged to a trauma center according
to the patient's calculated Glasgow Coma Scale (GCS) score despite its known
inconsistencies. The substitution of a simpler binary assessment of GCS-motor
(GCS-m) score less than 6 (ie, "patient does not follow commands")
would simplify field triage. We compare total GCS score to this binary
assessment for predicting trauma outcomes.
METHODS: This
retrospective analysis of a statewide trauma registry includes records from
393,877 patients from 1999 to 2013. Patients with initial GCS score less than
or equal to 13 were compared with those with GCS-m score less than 6 for
outcomes of Injury Severity Score (ISS) greater than 15, ISS greater than 24,
death, ICU admission, need for surgery, or need for craniotomy. We judged a
priori that differences less than 5% lack clinical importance.
RESULTS: The
relative differences between GCS and GCS-m scores less than 6 were less than 5%
and thus clinically unimportant for all outcomes tested, even when
statistically significant. For the 6 outcomes, the differences in areas under
receiver operating characteristic curves ranged from 0.014 to 0.048. Total GCS
score less than or equal to 13 was slightly more sensitive (difference 3.3%;
95% confidence interval 3.2% to 3.4%) and slightly less specific (difference
-1.5%; 95% confidence interval -1.6% to -1.5%) than GCS-m score less than 6 for
predicting ISS greater than 15, with similar overall accuracy (74.1% versus
74.2%).
CONCLUSION:
Replacement of the total GCS score with a simple binary decision point of GCS-m
score less than 6, or a patient who "does not follow commands,"
predicts serious injury, as well as the total GCS score, and would simplify
out-of-hospital trauma triage.
3. Spontaneously resolved STEMI after a hymenoptera sting.
Yikes!
Kim SW, et
al. Amer J Emerg Med 2016 Nov 4 [Epub ahead of press].
Bee stings
can cause various clinical manifestations, especially symptoms and signs
similar to those of acute coronary syndrome.
We
experienced a case of 56-year-old male without a prior diagnosis of cardiologic
disease. The patient was found collapsed 10 min after he left a cafeteria for a
cigarette. He told the emergency medical service (EMS) team that he had been
stung by a hornet. During the transfer, he became pale and unconscious. The EMS
team could not obtain his blood pressure, and his heart rate was 40/min.
As he arrived
at the local hospital, he was intubated immediately. Bolus crystalloid fluids,
intravenous antihistamine, intravenous methylprednisolone and intramuscular
epinephrine were given to the patient. After his vital signs had been
stabilized, an electrocardiogram (ECG) of the patient was obtained. It showed
about 9 mm of ST-segment elevation in lead II, III, aVF with a reciprocal change
in lead I, aVL. He was diagnosed with inferior wall ST-segment elevation
myocardial infarction (STEMI) and transferred to the tertiary medical center.
When he arrived at our regional emergency center, he was alert then. His ECG
and blood sample was taken immediately. The ECG showed a regression of
ST-segment elevation, and all laboratory test results were normal. On portable
transthoracic echocardiography, the ejection fraction was well preserved
without regional wall motion abnormality.
The coronary
angiography revealed normal coronary arteries. Diagnosis of Kounis syndrome was
made. He was extubated on the day of admission and discharged 2 days later
without any complication.
The first
report associating cardiovascular symptoms and signs with anaphylaxis was
published in 1950[1]. However, the relationship between an allergic reaction
and acute coronary syndrome was not fully discovered until 1991 when Kounis et
al. described in detail about allergic angina syndrome, called Kounis syndrome
(KS), which could progress to acute allergic myocardial infarction[2].
KS is the
concurrence of acute coronary syndromes with conditions associated with mast
cell activation including allergic or hypersensitivity and anaphylactic or
anaphylactoid insults. It is caused by inflammatory mediators released through
mast cell activation[3] . It presents a variety of allergic reactions followed
by cardiac symptoms and signs including acute chest pain, chest discomfort,
dyspnea, faintness, nausea, pruritus, syncope, vomiting, urticaria,
palpitation, diaphoresis, pallor, tachycardia or bradycardia and hypotension.
It is also associated with ECG abnormalities such as arterial fibrillation,
ST-segment depression or elevation, T-wave inversion, QT segment prolongation
or ventricular ectopics/fibrillation[4] .
There are
several causes that have been reported to trigger KS, such as prior allergic
conditions, several drugs, contrast media, insect or jellyfish sting, latex
contact and viper venom poisoning[3]. When these factors induce mast cell
degranulation, several inflammatory mediators such as histamine, tryptase,
chymase and leukotrienes are released locally and within the systemic
circulation. Histamine induces coronary vasoconstriction and platelet
activation, while tryptase and chymase can induce plaque erosion and rupture.
Leukotrienes also play an important role on vasoconstriction[5].The first
report associating cardiovascular symptoms and signs with anaphylaxis was
published in 1950[1]. However, the relationship between an allergic reaction
and acute coronary syndrome was not fully discovered until 1991 when Kounis et
al. described in detail about allergic angina syndrome, called Kounis syndrome
(KS), which could progress to acute allergic myocardial infarction[2].
4. Annals Review: Is Nebulized Hypertonic Saline Solution
Effective for Acute Bronchiolitis? …Who Knows!
Summary
Both
systematic reviews (links below) emphasized that the majority of studies
demonstrating a larger effect for hypertonic saline solution compared with 0.9%
saline solution were of high or uncertain risk of biases. In summary, the
evidence for the use of hypertonic saline solution in bronchiolitis is
evolving, and there is a need for rigorously designed studies focused on ED–relevant
outcomes to provide guidance for emergency physicians.
Take-Home
Message
Hypertonic
saline solution is possibly effective in decreasing hospital admission and
length of stay for infants with bronchiolitis.
Full-text
(free): http://www.annemergmed.com/article/S0196-0644(16)30370-5/fulltext
Their Two Systematic Reviews
Everad et al.
Health Technol Assess. 2015. https://www.ncbi.nlm.nih.gov/pubmed/26295732
Zheng et al. https://www.ncbi.nlm.nih.gov/pubmed/23900970
See also Macguire
in BMC Pulm Med 2015: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4657365/
The 2014 AAP Bronchiolitis Guidelines Don’t
Want Nebbed Hypertonic Saline Given in the ED
4a. Nebulized hypertonic saline should not be administered to infants with a diagnosis of bronchiolitis in the ED (Evidence Quality: B; Recommendation Strength: Moderate Recommendation).
4a. Nebulized hypertonic saline should not be administered to infants with a diagnosis of bronchiolitis in the ED (Evidence Quality: B; Recommendation Strength: Moderate Recommendation).
4b.
Clinicians may administer nebulized hypertonic saline to infants and children
hospitalized for bronchiolitis (Evidence Quality: B; Recommendation Strength:
Weak Recommendation [based on randomized controlled trials with inconsistent
findings]).
Full-text
guideline (free): http://pediatrics.aappublications.org/content/134/5/e1474
5. Two Cases of Anti-NMDA Receptor Encephalitis
Baker J, et
al. West J Emerg Med. 2016; 17(5): 623–626.
Anti-N-methyl-D-aspartate
receptor (anti-NMDAR) encephalitis is a form of autoimmune encephalitis with
prominent neuropsychiatric features. Patients present with acute psychosis,
memory impairment, dyskinesias, seizures, and/or speech disorders. The clinical
course is often complicated by respiratory failure, requiring intubation.
Approximately half of patients are found to have an associated ovarian tumor,
which expresses NMDAR.
Recognition
of anti-NMDAR encephalitis by emergency physicians is essential in order to
initiate early treatment and avoid psychiatric misdiagnosis. The disease is
highly treatable with tumor removal and immunosuppression, and most patients
demonstrate a full recovery. In this case series, we report two cases of
anti-NMDAR encephalitis in adult women in the United States and provide a
review of the literature.
Full-text
(free): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5017850/
6. Alpha blockers for treatment of ureteric stones: systematic
review and meta-analysis.
Hollingsworth
JM, et al. BMJ. 2016 Dec 1;355:i6112.
OBJECTIVE: To investigate the efficacy and safety of
alpha blockers in the treatment of patients with ureteric stones.
DESIGN: Systematic review and meta-analysis.
DATA
SOURCES: Cochrane Central Register of
Controlled Trials, Web of Science, Embase, LILACS, and Medline databases and
scientific meeting abstracts to July 2016.
REVIEW
METHODS: Randomized controlled trials of
alpha blockers compared with placebo or control for treatment of ureteric
stones were eligible. : Two team members independently extracted data from each
included study. The primary outcome was the proportion of patients who passed their
stone. Secondary outcomes were the time to passage; the number of pain
episodes; and the proportions of patients who underwent surgery, required
admission to hospital, and experienced an adverse event. Pooled risk ratios and
95% confidence intervals were calculated for the primary outcome with profile
likelihood random effects models. Cochrane Collaboration's tool for assessing
risk of bias and the GRADE approach were used to evaluate the quality of
evidence and summarize conclusions.
RESULTS: 55 randomized controlled trials were
included. There was moderate quality evidence that alpha blockers facilitate
passage of ureteric stones (risk ratio 1.49, 95% confidence interval 1.39 to
1.61). Based on a priori subgroup analysis, there seemed to be no benefit to
treatment with alpha blocker among patients with smaller ureteric stones (1.19,
1.00 to 1.48). Patients with larger stones treated with an alpha blocker,
however, had a 57% higher risk of stone passage compared with controls (1.57,
1.17 to 2.27). The effect of alpha blockers was independent of stone location
(1.48 (1.05 to 2.10) for upper or middle stones; 1.49 (1.38 to 1.63) for lower
stones). Compared with controls, patients who received alpha blockers had
significantly shorter times to stone passage (mean difference -3.79 days, -4.45
to -3.14; moderate quality evidence), fewer episodes of pain (-0.74 episodes,
-1.28 to -0.21; low quality evidence), lower risks of surgical intervention
(risk ratio 0.44, 0.37 to 0.52; moderate quality evidence), and lower risks of
admission to hospital (0.37, 0.22 to 0.64; moderate quality evidence). The risk
of a serious adverse event was similar between treatment and control groups
(1.49, 0.24 to 9.35; low quality evidence).
CONCLUSIONS: Alpha blockers seem efficacious in the
treatment of patients with ureteric stones who are amenable to conservative
management. The greatest benefit might be among those with larger stones. These
results support current guideline recommendations advocating a role for alpha
blockers in patients with ureteric stones.
Ryan
Radecki: Not So Fast!
7. Some New DVT/PE Research
A. Test
Characteristics of EP-Performed Limited Compression US for Lower-Extremity DVT
Kim DJ, et
al. J Emerg Med. 2016 Dec;51(6):684-690.
BACKGROUND:
The current literature suggests that emergency physician (EP)-performed limited
compression ultrasound (LCUS) is a rapid and accurate test for deep vein
thrombosis (DVT).
OBJECTIVE:
Our primary objective was to determine the sensitivity and specificity of LCUS
for the diagnosis of DVT when performed by a large heterogeneous group of EPs.
METHODS: This
was a prospective diagnostic test assessment of LCUS conducted at two urban
academic emergency departments. The scanning protocol involved compression at
the common femoral, superficial femoral, and popliteal veins. Patients were
eligible if undergoing radiology department ultrasound of the lower extremity
with moderate or high pretest probability for DVT, or low pretest probability
for DVT with a positive d-dimer. The enrolling EP performed LCUS before
radiology department ultrasound of the same lower extremity. Sensitivity,
specificity, and associated 95% confidence intervals (CIs) were calculated with
the radiologist interpretation of the radiology department ultrasound as the
criterion standard.
RESULTS: A
total of 56 EPs enrolled 296 patients for LCUS, with a median age of 50 years
and 50% female. Fifty (17%) DVTs were identified by radiology department
ultrasound, and another five (2%) cases were deemed indeterminate. The
sensitivity and specificity of EP-performed LCUS was 86% (95% CI 73-94%) and
93% (95% CI 89-96%), respectively.
CONCLUSIONS:
A large heterogeneous group of EPs with limited training can perform LCUS with
intermediate diagnostic accuracy. Unfortunately, LCUS performed by EPs with
limited ultrasound training is not sufficiently sensitive or specific to rule
out or diagnose DVT as a single testing modality.
B.
Age-adjusted D-dimer excludes PE and reduces unnecessary radiation exposure in
older adults: retrospective study
Nobes J, et
al. Postgrad Med J 2016 Dec 9 [Epub ahead of print]
Background
Patients in whom a diagnosis of pulmonary embolism (PE) is suspected and whose
D-dimers are elevated frequently require CT pulmonary angiogram (CTPA) for
diagnosis. Because D-dimer rises with age, an age-adjusted D-dimer threshold
may prevent unnecessary radiation exposure from CTPA in older patients.
Objective To
determine the efficacy and safety of implementing an age-adjusted D-dimer
threshold to exclude PE.
Design,
settings and patients Retrospective comparison of conventional and age-adjusted
D-dimer thresholds in 1000 consecutive patients who had both D-dimer and CTPA.
Main outcome
measures Conventional and age-adjusted D-dimer thresholds for excluding PE were
less than 250 ng/mL and 5× age for patients older than 50 years, respectively.
We defined patients as unlikely to have PE using the revised Geneva score (RGS)
and two different categories of clinical risk: RGS ≤5 and RGS ≤10.
Results We
diagnosed PE by CTPA in 244 (24.4%) patients. 3/86 patients (3.5%) whose
D-dimer was below the conventional threshold of 250 ng/mL had PE (RGS 3, 9 and
14), all of which were judged to be light clot load (group 1). 3/108 patients
(2.8%) whose D-dimer lay between 250 ng/mL and the age-adjusted threshold had
PE (RGS 6, 8 and 9), all of which were again judged to be light clot load
(group 2). 62/108 group 2 patients with RGS ≤5 were considered unlikely to have
PE as were 102/108 using the RGS clinical risk category ≤10. None of the 62
patients with RGS ≤5 had PE while 3/102 patients with RGS ≤10 had PE. 236/806
patients (29.3%) whose D-dimer was above the age-adjusted threshold had PE
(group 3).
Conclusions
In a consecutive series of 1000 patients, an RGS ≤5 and an age-adjusted D-dimer
would have led to 62 fewer CTPA at a cost of no missed PEs.
C. RESPECT-ED:
Rates of PE and Sub-Segmental PE with Modern CTPAs in EDs: A Multi-Center
Observational Study Finds Significant Yield Variation, Uncorrelated with Use or
Small PE Rates.
Mountain D, et al. PLoS One. 2016
Dec 5;11(12):e0166483.
INTRODUCTION: Overuse of CT
Pulmonary Angiograms (CTPA) for diagnosing pulmonary embolism (PE),
particularly in Emergency Departments (ED), is considered problematic. Marked
variations in positive CTPA rates are reported, with American 4-10% yields
driving most concerns. Higher resolution CTPA may increase sub-segmental PE
(SSPE) diagnoses, which may be up to 40% false positive. Excessive use and
false positives could increase harm vs. benefit. These issues have not been
systematically examined outside America.
AIMS: To describe current yield
variation and CTPA utilisation in Australasian ED, exploring potential factors
correlated with variation.
METHODS: A retrospective
multi-centre review of consecutive ED-ordered CTPA using standard radiology
reports. ED CTPA report data were inputted onto preformatted data-sheets. The
primary outcome was site level yield, analysed both intra-site and against a
nominated 15.3% yield. Factors potentially associated with yield were assessed
for correlation.
RESULTS: Fourteen radiology
departments (15 ED) provided 7077 CTPA data (94% ≥64-slice CT); PE were
reported in 1028 (yield 14.6% (95%CI 13.8-15.4%; range 9.3-25.3%; site
variation p less than 0.0001) with four sites significantly below
and one above the 15.3% target. Admissions, CTPA usage, PE diagnosis rates and
size of PE were uncorrelated with yield. Large PE (≥lobar) were 55% (CI:
52.1-58.2%) and SSPE 8.8% (CI: 7.1-10.5%) of positive scans. CTPA usage
(0.2-1.5% adult attendances) was correlated (p less than 0.006) with
PE diagnosis but not SSPE: large PE proportions.
DISCUSSION/ CONCLUSIONS: We found
significant intra-site CTPA yield variation within Australasia. Yield was not
clearly correlated with CTPA usage or increased small PE rates. Both SSPE and
large PE rates were similar to higher yield historical cohorts. CTPA use was
considerably below USA 2.5-3% rates. Higher CTPA utilisation was positively
correlated with PE diagnoses, but without evidence of increased proportions of
small PE. This suggests that increased diagnoses seem to be of clinically
relevant sized PE.
8. ED Use: Two Studies of a Changing Dynamic
A.
Insurance Expansion and Hospital ED Access: Evidence from the Affordable Care
Act.
Garthwaite C,
et al. Ann Intern Med. 2016 Dec 20 [Epub ahead of print]
BACKGROUND: Little
is known about whether insurance expansion affects the location and type of
emergency department (ED) use. Understanding these changes can inform
state-level decisions about the Medicaid expansion under the Patient Protection
and Affordable Care Act (ACA).
OBJECTIVE: To
investigate the effect of the 2014 ACA Medicaid expansion on the location,
insurance status, and type of ED visits.
DESIGN: Quasi-experimental
observational study from 2012 to 2014.
SETTING: 126
investor-owned, hospital-based EDs.
PARTICIPANTS:
Uninsured and Medicaid-insured adults aged 18 to 64 years.
INTERVENTION:
ACA expansion of Medicaid in January 2014.
MEASUREMENTS:
Number of ED visits overall, type of visit (for example, nondiscretionary or
nonemergency), and average travel time to the ED. Interrupted time-series
analyses comparing changes from the end of 2013 to end of 2014 for patients
from Medicaid expansion versus nonexpansion states were done.
RESULTS: There
were 1.06 million ED visits among patients from 17 Medicaid expansion states,
and 7.87 million ED visits among patients from 19 nonexpansion states. The EDs
treating patients from Medicaid expansion states saw an overall 47.1% decrease
in uninsured visits (95% CI, -65.0% to -29.3%) and a 125.7% (CI, 89.2% to
162.6%) increase in Medicaid visits after 12 months of ACA expansion. Average
travel time for nondiscretionary conditions requiring immediate medical care
decreased by 0.9 minutes (-6.2% [CI, -8.9% to -3.5%]) among all Medicaid
patients from expansion states. We found little evidence of similar changes
among patients from nonexpansion states.
LIMITATION: Results
reflect shifts in ED care at investor-owned facilities, which limits
generalizability to other hospital types.
CONCLUSION: Meaningful
changes in insurance status and location and type of ED visits in the first
year of ACA Medicaid expansion were found, suggesting that expansion provides
patients with a greater choice of hospital facilities.
B.
Retail clinics fail to curb non-emergency ER use, study says
Patient use
of hospital emergency departments for non-emergency care has not decreased
despite the growth of retail clinics. RAND Corp. researcher Grant Martsolf
noted retail clinics increased in number when off-hours care was not readily
available, but now many primary care offices have same-day visits and extended
hours to expand options for patients.
9. Adult epiglottitis: a case series.
Lindquist B,
Zachariah S, Kulkarni A. Perm J. 2017;21:16-089.
Introduction:
Emergency Departments are inundated by patients with respiratory illness during
the winter months. Emergency physicians are required to quickly identify
critically ill patients among the large volume of patients with mild upper
respiratory illness. Among these life-threatening conditions is acute
epiglottitis.
Case
Presentation: We report a rare series of four adult patients who presented to
our Emergency Department during a period of only one week in April 2015 and
were ultimately diagnosed with acute epiglottitis. Three of the patients
improved with conservative measures and were observed in the intensive care
unit. One patient required an emergent tracheostomy.
Discussion:
This series of patients is unique in that all four patients presented to a
single Emergency Department within a few days of each other and, despite a
myriad of presenting chief complaints, the patients were eventually found to
have the same potentially life-threatening diagnosis. These cases reinforce the
variability of presenting symptoms and physical examination findings that can
occur in patients with epiglottitis. They also highlight clinical findings and
adjunctive testing that can help identify patients who would most benefit from
intervention.
Full-text (free): http://www.thepermanentejournal.org/issues/2017/6279-adult-epiglottitis-a-case-series.html
10. Tons of Images in Clinical Practice
Tinea Imbricata
Tongue Fasciculations in
Organophosphate Poisoning
Skin Mottling
Neurogenic Megacolon in Spinal
Cord Injury
Patellar Fracture with Sleeve
Avulsion
African Trypanosomiasis
Woman With Lower Back Pain
Young Woman With Rash on Left
Thigh
Elderly Woman With Altered Mental
Status and Hypoxia
Adolescent Male With Knee Pain
and Swelling
Young Child With Abdominal and
Back Pain
Young Male With Neck Pain
Young Woman With Paraplegia
Following a Motor Vehicle Crash
EM-RAP Commentary: “A Clinical
Decision Rule for Thoracolumbar Spine Imaging in Blunt Trauma?” http://www.annemergmed.com/article/S0196-0644(16)31249-5/fulltext
Newborn With Scalp Swelling
Postpartum Woman With Seizures
EM:RAP
Commentary on Postpartum Headaches
Elderly Man With Abdominal
Discomfort and Circulatory Failure
Young Man With Scrotal Swelling
and Pain
Elderly Man with Syncope
Wrist Pain after a Fall
Elderly Man With Headache and
Neck Pain
Young Man With Abdominal Pain
11. Are reductions in ED LOS associated with improvements in
quality of care? A difference-in-differences analysis.
Vermeulen MJ, et al. BMJ Qual
Saf. 2016;25(7):489-98.
BACKGROUND: We sought to
determine whether patients seen in hospitals who had reduced overall emergency
department (ED) length of stay (LOS) in the 2 years following the introduction
of the Ontario Emergency Room Wait Time Strategy were more likely to experience
improvements in other measures of ED quality of care for three important
conditions.
METHODS: Retrospective medical
record review using difference-in-differences analysis to compare changes in
performance on quality indicators over the 3-year period between 11 Ontario
hospitals where the median ED LOS had improved from fiscal year 2008 to 2010
and 13 matched sites where ED LOS was unchanged or worsened. Patients with
acute myocardial infarction (AMI), asthma and paediatric and adult upper limb
fractures in these hospitals in 2008 and 2010 were evaluated with respect to 18
quality indicators reflecting timeliness and safety/effectiveness of care in
the ED. In a secondary analysis, we examined shift-level ED crowding at the
time of the patient visit and performance on the quality indicators.
RESULTS: Median ED LOS improved
by up to 26% (63 min) from 2008 to 2010 in the improved hospitals, and worsened
by up to 47% (91 min) in the unimproved sites. We abstracted 4319 and 4498
charts from improved and unimproved hospitals, respectively. Improvement in a
hospital's overall median ED LOS from 2008 to 2010 was not associated with a
change in any of the other ED quality indicators over the same time period. In
our secondary analysis, shift-level crowding was associated only with
indicators that reflected timeliness of care. During less crowded shifts,
patients with AMI were more likely to be reperfused within target intervals
(rate ratio 1.59, 95% CI 1.03 to 2.45), patients with asthma more often
received timely administration of steroids (rate ratio 1.88, 95% CI 1.59 to
2.24) and beta-agonists (rate ratio 1.47, 95% CI 1.25 to 1.74), and adult (but
not paediatric) patients with fracture were more likely to receive analgesia or
splinting within an hour (rate ratio 1.66, 95% CI 1.22 to 2.26).
CONCLUSIONS: These results
suggest that a policy approach that targets only reductions in ED LOS is not
associated with broader improvements in selected quality measures. At the same
time, there is no evidence that efforts to address crowding have a detrimental
effect on quality of care.
12. Burn Out: What Is It and How Can We Address It?
A.
Controlled Interventions to Reduce Burnout in Physicians: A Systematic Review
and Meta-analysis
Question: Are
interventions for reducing burnout in physicians effective?
Findings:
This meta-analysis of 20 controlled interventions on 1550 physicians found that
existing interventions were associated with small and significant reductions in
burnout. The strongest evidence for effectiveness was found for
organization-directed interventions, but these interventions were rare.
Meaning: More effective models of interventions are
needed to mitigate risk for burnout in physicians. Such models could be
organization-directed approaches that promote healthy individual-organization
relationships.
Abstract in
JAMA Intern Med: http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2588814
B.
Burnout Research on Emergency Providers?
a. Compassion Fatigue (CF) among
Healthcare, Emergency and Community Service Workers: A Systematic Review.
Cocker F, et
al. Int J Environ Res Public Health. 2016;13(6).
Conclusion: This
review revealed that evidence of the effectiveness of CF interventions in
at-risk health and social care professions is relatively recent. Therefore, we
recommend more research to determine how best to protect vulnerable workers at
work to prevent not only CF, but also the health and economic consequences
related to the ensuing, and more disabling, physical and mental health
outcomes.
b. Comparing Burnout across Emergency
Physicians, Nurses, Technicians, and Health Information Technicians Working for
the Same Organization.
Schooley B,
et al. Medicine (Baltimore). 2016 Mar;95(10):e2856
Studies on
the topic of burnout measure the effects of emotional exhaustion (EE),
depersonalization (DP) (negative or cynical attitudes toward work), and reduced
sense of personal accomplishment (PA). While the prevalence of burnout in
practicing emergency medicine (EM) professionals has been studied, little is
known of the prevalence and factors across physicians, nurses, technicians, and
health information technicians working for the same institution. The aim of
this study was to assess burnout differences across EM professional types.
The total
population of 250 EM professionals at 2 public urban hospitals in Turkey were
surveyed using the Maslach Burnout Inventory and basic social- and work-related
demographics. Descriptive statistics, ANOVA, and additional post hoc tests were
computed.
Findings show
that EE and DP scores were high across all occupational groups, while scores on
PA were low. There was a statistically significant difference between nurses
and medical technicians (P less than 0.05) for EE; and between physicians and
both nurses and medical technicians (P less than 0.05) for PA; while no group
differences were found for DP. Age, gender, economic well-being, and income
level were all significant; while patient load and marital status showed no
significance.
Burnout can
be high across occupational groups in the emergency department. Burnout is
important for EM administrators to assess across human resources. Statistically
significant differences across socio-demographic groups vary across
occupational groups. However, differences between occupational groups may not
be explained effectively by the demographic factors assessed in this or other
prior studies. Rather, the factors associated with burnout are incomplete and
require further institutional, cultural, and organizational analyses including
differentiating between job tasks carried out by each EM job type.
C.
Why Some People Get Burned Out and Others Don’t
Kandi Wiens, Annie
McKee. Harvard Business Review · November 23, 2016
Stress and
burnout are not the same thing. And while we know that stress often leads to
burnout, it’s possible to handle the onslaught of long hours, high pressure,
and work crises in a way that safeguards you from the emotional exhaustion,
cynicism, and a lack of confidence in one’s abilities that characterizes
burnout. The key is tapping into your emotional intelligence.
This is what
one of us (Kandi) discovered in a recent study (“Leading Through Burnout”)
where we assessed 35 chief medical officers (CMOs) at 35 large hospitals for
their level of stress and tried to determine what, if anything, they do to deal
with burnout. The findings surprised us: despite the fact that an overwhelming
69% of the CMOs described their current stress level as severe, very severe, or
worst possible, the majority were not burned out according to the Maslach
Burnout Inventory. In our interviews with these CMOs, we found…
Full-text
(free): https://hbr.org/2016/11/why-some-people-get-burned-out-and-others-dont
D.
Burnout and the Brain
Burnout is
not just a state of mind. Psychological research that draws on neuroscience and
endocrinology shows it to be a condition that leads to distinctive changes in
the anatomy and functioning of the brain.
[DRV: Scary!
I posted this in the Jan 2016 issue of Lit Bits. Given the importance of the
topic and the scientific insights of the article, it deserves a re-posting.]
By Alexandra
Michel. Observer. 2016;29(2):26-31. (a publication of the Association for
Psychological Science)
One of the
greatest threats to workplace safety may be from an unexpected source: stress…
It’s a
mistake to assume that burnout is merely an emotional response to long hours or
a challenging job. Rather, mounting scientific evidence shows that burnout
takes a profound physical toll that cascades well beyond our professional
lives. Using cutting-edge techniques, integrative research teams are
demonstrating that burnout is not just a state of mind, but a condition that
leaves its mark on the brain as well as the body.
Just as the
impact of burnout stifles healthy professional growth, emerging research shows
that the chronic psychosocial stress that characterizes burnout not only
impairs people’s personal and social functioning, it also can overwhelm their
cognitive skills and neuroendocrine systems — eventually leading to distinctive
changes in the anatomy and functioning of the brain.
Burnout
Begins
The
psychologist Herbert Freudenberger is credited with bringing the term “burnout”
into the research lexicon in 1974, defining it as the loss of motivation,
growing sense of emotional depletion, and cynicism he observed among volunteers
working at a free clinic in New York City. Formerly idealistic mental health
workers were finding themselves depleted and weary, resenting patients and the
clinic.
Burnout is
now recognized as a legitimate medical disorder by much of mainstream medicine
and has even been given its own ICD-10 code (Z73.0 – Burn-out state of vital
exhaustion). Many of the symptoms of burnout overlap with the hallmarks of
depression, including extreme fatigue, loss of passion, and intensifying
cynicism and negativity.
APS Fellow
Christina Maslach, professor emerita at the University of California, Berkeley,
and one of the foremost researchers on burnout, began studying this emerging
phenomenon in the 1970s through a series of extensive interviews with employees
in service organizations. In analyzing the interviews, Maslach and colleagues
noticed a trend: Workers often reported feelings of profound emotional
exhaustion, negativity directed at clients and patients, and a crisis in
feelings of professional competence. Much like symptoms of depression, burnout
was asphyxiating people’s ambitions, idealism, and sense of worth.
The 1976
publication of Maslach’s article “Burned-Out,” published in the magazine Human
Behavior, generated a huge public response — popularizing the concept of
burnout within the popular press. Maslach received an incredible outpouring of
letters and phone calls from people who were grateful to find out that they
were not alone in their experience of burnout.
“I had not
expected at all that kind of reaction,” Maslach said. “The impact of that
article was just huge.” The article led to more research, more books, and more
attention from academic journals.
Maslach and
APS Fellow Susan E. Jackson (Rutgers University) collaborated on what would
become the most influential framework for defining and assessing burnout.
Published in 1981, the original paper describing the Maslach Burnout Inventory
has been cited well over 6,000 times to date, according to Google Scholar. The
scale evaluates burnout based on three key stress responses: an overwhelming
sense of exhaustion, feelings of cynicism and detachment, and a sense of
professional ineffectiveness and lack of accomplishment.
At its core,
burnout emerges when the demands of a job outstrip a person’s ability to cope
with the stress. People in careers focused on caregiving — teachers, nurses,
social workers, and physicians — report the most prevalent rates of burnout,
but the condition ultimately doesn’t discriminate among call center
representatives, professional athletes, or CEOs. Over time, jobs that require
too much of employees will cultivate feelings of negativity and hopelessness as
people struggle to meet impossible deadlines, deal with rude customers, or cope
with the emotional toll of professional caretaking.
It’s a common
misconception that the culprit behind burnout is simply working too long or too
hard — research indicates that other factors, both individual and
organizational, can be just as detrimental. For example, a comprehensive report
on psychosocial stress in the workplace published by the World Health Organization
identified consistent evidence that “high job demands, low control, and
effort–reward imbalance are risk factors for mental and physical health
problems.” Ultimately, burnout results when the balance of deadlines, demands,
working hours, and other stressors outstrips rewards, recognition, and
relaxation.
Over the past
20 years, Maslach and her collaborators have developed a comprehensive model
identifying six key components of the workplace environment that contribute to
burnout: workload, control, reward,
community, fairness, and values. Burnout emerges when one or more of these
six areas is chronically mismatched between an individual and his job. Over
time, Maslach explained, passion erodes not only because people have too much
to do, but because of these other factors…
The rest of
the article (free): http://www.psychologicalscience.org/index.php/publications/observer/2016/february-16/burnout-and-the-brain.html
13. Flush Rate Oxygen for Emergency Airway Preoxygenation.
Driver BE, et al. Ann Emerg Med.
2017 Jan;69(1):1-6.
STUDY OBJECTIVE: Recent data
suggest that emergency airway preoxygenation with a bag-valve-mask (BVM) device
(held with a tight mask seal but without squeezing the bag) is superior to a
nonrebreather (NRB) mask at standard oxygen flow rates. We seek to determine
whether preoxygenation with an NRB mask with flush rate oxygen (over 40 L/min
by fully opening a standard oxygen flowmeter) is noninferior to BVM device with
standard-flow oxygen (15 L/min). We also seek to compare the efficacy of
preoxygenation with NRB mask at flush rate oxygen with both NRB mask with
oxygen at 15 L/min and simple mask at flush rate oxygen.
METHODS: We performed a crossover
trial using healthy volunteers. In random sequence, subjects underwent 3-minute
trials of preoxygenation with nonrebreather mask with oxygen at 15 L/min
(NRB-15), nonrebreather mask with flush rate oxygen (NRB-Flush), BVM device
with oxygen at 15 L/min (BVM-15), and simple mask with flush rate oxygen. The
primary outcome measure was the FeO2 in a single exhaled breath. We compared
the FeO2 of NRB-Flush to other study groups, using a prespecified
noninferiority margin of 10%.
RESULTS: We enrolled 26 subjects.
Mean FeO2 values for NRB-15, NRB-Flush, BVM-15, and simple mask with flush rate
oxygen were 54% (95% confidence interval [CI] 50% to 57%), 86% (95% CI 84% to
88%), 77% (95% CI 74% to 81%), and 72% (95% CI 69% to 76%), respectively. FeO2
for NRB-Flush was noninferior to BVM-15 (difference 8%; 95% CI 5% to 11%). FeO2
for NRB-Flush was higher than both NRB-15 (FeO2 difference 32%; 95% CI 29% to
35%) and simple mask with flush rate oxygen (FeO2 difference 13%; 95% CI 10% to
17%).
CONCLUSION: Preoxygenation with
NRB-Flush was noninferior to BVM-15. NRB with flush rate oxygen may be a
reasonable preoxygenation method for spontaneously breathing patients
undergoing emergency airway management.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(16)30296-7/fulltext
14. Pneumonia and UTI Often Resolve without Antibiotics
A. Disease
Course of Lower Respiratory Tract Infection with a Bacterial Cause Untreated
with Antibiotics
Teepe J, et al. Ann Fam Med. 2016;14:534-539.
PURPOSE Bacterial pathogens are
assumed to cause an illness course different from that of nonbacterial causes
of acute cough, but evidence is lacking. We evaluated the disease course of
lower respiratory tract infection (LRTI) with a bacterial cause in adults with
acute cough.
METHODS We conducted a secondary
analysis of a multicenter European trial in which 2,061 adults with acute cough
(28 days’ duration or less) were recruited from primary care and randomized to
amoxicillin or placebo. For this analysis only patients in the placebo group (n
= 1,021) were included, reflecting the natural course of disease. Standardized
microbiological and serological analyses were performed at baseline to define a
bacterial cause. All patients recorded symptoms in a diary for 4 weeks. The
disease course between those with and without a bacterial cause was compared by
symptom severity in days 2 to 4, duration of symptoms rated moderately bad or
worse, and a return consultation.
RESULTS Of 1,021 eligible
patients, 187 were excluded for missing diary records, leaving 834 patients, of
whom 162 had bacterial LRTI. Patients with bacterial LRTI (and no antibiotic
treatment) had worse symptoms at day 2 to 4 after the first office visit (P =
.014) and returned more often for a second consultation, 27% vs 17%, than those
without bacterial LRTI (P = .004). Resolution of symptoms rated moderately bad
or worse did not differ (P = .375).
CONCLUSIONS Patients with acute
bacterial LRTI (and no antibiotic treatment) have a slightly worse course of
disease when compared with those without an identified bacterial cause, but the
relevance of this difference is not meaningful.
Full-text (free): http://www.annfammed.org/content/14/6/534.full
B. Ibuprofen
versus fosfomycin for uncomplicated UTI in women: randomised controlled trial
Gágyor I, et al. BMJ 2015;351:h6544
Study question Can treatment of
the symptoms of uncomplicated urinary tract infection (UTI) with ibuprofen
reduce the rate of antibiotic prescriptions without a significant increase in
symptoms, recurrences, or complications?
Methods Women aged 18-65 with
typical symptoms of UTI and without risk factors or complications were
recruited in 42 German general practices and randomly assigned to treatment
with a single dose of fosfomycin 3 g (n=246; 243 analysed) or ibuprofen 3×400
mg (n=248; 241 analysed) for three days (and the respective placebo dummies in
both groups). In both groups additional antibiotic treatment was subsequently
prescribed as necessary for persistent, worsening, or recurrent symptoms. The
primary endpoints were the number of all courses of antibiotic treatment on
days 0-28 (for UTI or other conditions) and burden of symptoms on days 0-7. The
symptom score included dysuria, frequency/urgency, and low abdominal pain.
Study answer and limitations The
248 women in the ibuprofen group received significantly fewer course of
antibiotics, had a significantly higher total burden of symptoms, and more had
pyelonephritis. Four serious adverse events occurred that lead to hospital
referrals; one of these was potentially related to the trial drug. Results have
to be interpreted carefully as they might apply to women with mild to moderate
symptoms rather than to all those with an uncomplicated UTI.
What this paper adds Two thirds
of women with uncomplicated UTI treated symptomatically with ibuprofen
recovered without any antibiotics. Initial symptomatic treatment is a possible
approach to be discussed with women willing to avoid immediate antibiotics and
to accept a somewhat higher burden of symptoms.
15. Antiemetics May Be No Better than IV Fluids for Adults in
the ED
A.
For Adults With Nausea and Vomiting in the ED, What Medications Provide Rapid
Relief?
Meltzer AC,
et al. Ann Emerg Med 2016;68:6:717-718.
Take-Home
Message
Although a
number of medications are often used to treat nausea and vomiting in the
emergency department (ED), only droperidol has been demonstrated to decrease
nausea at 30 minutes.
B.
The Cochrane Review on Treatment of n/v in the ED Setting
Furyk JS,
Meek RA, Egerton-Warburton D. Drugs for the treatment of nausea and vomiting in
adults in the emergency department setting. Cochrane Database Syst Rev
2015;CD010106.
Full-text of
the Cochrane review (free): http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010106.pub2/full
C.
Antiemetic use for nausea and vomiting in adult ED patients: RCT comparing
ondansetron, metoclopramide, and placebo.
Egerton-Warburton
D, et al. Ann Emerg Med. 2014;64(5):526-532.e1.
CONCLUSION:
Reductions in nausea severity for this adult ED nausea and vomiting population
were similar for 4 mg intravenous ondansetron, 20 mg intravenous
metoclopramide, and placebo. There was a trend toward greater reductions in VAS
ratings and a lesser requirement for rescue medication in the antiemetic drug
groups, but differences from the placebo group did not reach significance. The
majority of patients in all groups were satisfied with treatment.
D.
Oligoantiemesis or Inadequate Prescription of Antiemetics in the ED: A Local
and National Perspective (also see letter below)
Singer AJ, et
al. J Emerg Med. 2016;50(6):818-24.
BACKGROUND:
Nausea and vomiting are common, but prevalence of antiemetic use in ED patients
is unknown.
OBJECTIVES:
We determined the use of antiemetics in emergency department (ED) patients
presenting with nausea and vomiting (NV).
METHODS: We
conducted a retrospective chart review of ED patients presenting to a local ED
with NV and analyzed data from the National Hospital Ambulatory Care Survey for
similar patients to determine the frequency of administration of antiemetics in
the ED.
RESULTS: Of
3876 patients presenting to a local ED with NV in 2014, 2637 (68% [95%
confidence interval (CI) 67-69%]) received an antiemetic. Of an estimated 11.3
million U.S. ED visits for NV in 2011 (the latest year available), antiemetics
were prescribed in 56% (95% CI 53-59%). Females, older patients, and those with
vomiting were more likely to receive antiemetics. Use of antiemetics was
associated with reduced admissions in the single institution (odds ratio [OR]
0.62, 95% CI 0.52-0.74), but not in the national database (OR 1.08, 95% CI
0.74-1.60).
CONCLUSIONS:
Many patients presenting with NV do not receive antiemetics while in the ED.
Effort should be made to further study and reduce the phenomenon of
undertreatment of nausea or vomiting, coined "oligoantiemesis."
E.
Oligoantiemesis: A Premature Neologism for an Intervention Insufficiently
Substantiated in the Emergency Setting (response to the study above).
Vinson DR,
Nagam MR, Lugovskaya N, Nasrollahi FS, Egerton-Warburton D, Furyk JS, Meek RA. J
Emerg Med. 2016 Oct 6 [Epub ahead of print].
We commend
Drs. Singer et al for their excellent description of the prevalence and
patterns of antiemetic use in emergency medicine in the U.S. (1). Their
intriguing finding that a sizable proportion of patients with nausea or
vomiting did not receive an antiemetic agent in their academic emergency
department (ED) is validated by the similar results they report from the U.S.
National Hospital Ambulatory Care Survey. They also observed that antiemetics
were administered twice as often for ED patients with vomiting than for those
with isolated nausea, which is consistent with physician survey data from
Australia (2).
The authors
believe the failure to provide antiemetics to a large proportion of ED patients
with nausea or vomiting is a shortcoming of patient care, akin to the
inadequate treatment of pain. To evoke this association with oligoanalgesia,
they coin a similar word “oligoantiemesis,” around which the emergency care
community can rally its efforts to increase the administration of antiemetics.
In exploring
possible reasons for the “inadequate” use of antiemetics, Singer et al suggest
that some practitioners may not be convinced of the efficacy of antiemetic
agents in the ED. We are among the unconvinced. Why? Evidence strongly supports
the use of antiemetics in the management of nausea and vomiting in other
populations and settings, for example, chemotherapy-induced nausea and vomiting
(3). But efficacy in one population doesn’t guarantee efficacy in another. In
fact, in the ED, where people with undifferentiated nausea and vomiting most
often receive diagnoses of non-specific abdominal pain or presumed
gastroenteritis, evidence to support antiemetic efficacy is lacking.
One recent
randomized trial found that ondansetron and metoclopramide were no better than
placebo in emergency patients with a chief complaint of nausea or vomiting (4).
Singer et al cite this study, but then minimize it and the concurring
literature with the following disclaimer: “many of the previous studies may
have used suboptimal drug doses, and many of the effects of the antiemetics may
have been masked by the simultaneous administration of intravenous fluids. Yet
other studies failed to include placebo as a control” (1). If that is the case,
rather than push for more antiemetic use at this time, the authors should
encourage more research, designed to meet their quality standards. If positive,
claims of ED antiemetic efficacy, and calls for increased drug usage, would
then be on more solid footing.
The evidence,
however, that questions the efficacy of antiemetics in treatment of
undifferentiated ED nausea and vomiting may not be as tenuous as these authors
suggest. Several of us have co-authored a recent systematic review with the
Cochrane database identifying eight randomized trials of drugs in the treatment
of nausea and vomiting among adults in the ED (5). After describing the studies’
methods and results, we concluded that “there is no definite evidence to
support the superiority of any one drug over any other drug, or the superiority
of any drug over placebo.” In light of this, we suggested that “general
supportive treatment such as intravenous fluids may be sufficient for the
majority of people” (5). Forgoing ineffective medications has the additional
benefits of avoiding drug toxicities and side-effects and better stewarding our
healthcare resources.
We do agree
with Singer et al that nausea and vomiting are serious complaints and that they
should not be dismissed. But we are hesitant to rally around the concept of
“oligoantiemesis” until evidence is forthcoming that “antiemetics” (the
pharmaceutical category) live up to their name as true anti-emetics (the
functional category) among ED patients with undifferentiated nausea or
vomiting. For now, at least, we think “oligoantiemesis” is a premature
neologism for an intervention that in this population is insufficiently substantiated.
16. Inaccuracy in ECG lead placement among technicians, nurses,
general physicians and cardiologists.
Rajaganeshan R, et al. Int J Clin
Pract. 2008;62(1):65-70.
[DRV: An older article, but worth
resurrecting]
The objective of the study was to
determine the reliability of ECG precordial electrode placement by doctors and
nurses involved in the emergency care of patients admitted with suspected
cardiac diseases.
A total of 120 subjects were
recruited within 2 days from six hospitals. They comprised physicians, nurses
and cardiac technicians involved in the clinical assessment and care of
patients with suspected cardiac disease. Subjects were asked to complete a
questionnaire and marked on two diagrams of the chest wall the positions they
would place precordial electrodes V1-V6.
This study showed wide
inter-individual and inter-group variations in the placement of electrodes.
Notably, V1 and V2 were frequently incorrectly positioned in the second
intercostal space, especially by physicians. The correct position of V1 in the
fourth right intercostal space was identified by 90% of cardiac technicians,
49% of nurses, 31% of physicians (excluding cardiologists) and--most
disappointing of all--only 16% of cardiologists (p less than 0.001 for inter-group differences). V5 and V6
were also often mispositioned, too high on the lateral chest wall.
Nurses and doctors (especially
cardiologists) do not know the correct positions for ECG electrodes. Because
incorrect positioning of the precordial electrodes changes the ECG
significantly, patients are at risk of potentially harmful therapeutic
procedures. Equally, doctors who are aware of the possibility of lead
misplacement may be inclined to ignore some ECG changes that may be genuine
evidence of ischaemia. The only safe solution is proper precordial electrode
placement, which requires training and an environment supporting precision.
17. Fatal Fentanyl: One Pill Can Kill.
Sutter ME, et al. Acad Emerg Med.
2016 Jun 20 [Epub ahead of print]
OBJECTIVE: The current national
opioid epidemic is a public health emergency. We have identified an outbreak of
exaggerated opioid toxicity caused by fentanyl adulterated tablets purchased on
the street as hydrocodone/acetaminophen.
METHODS: Over an 8-day period in
late March 2016, a total of 18 patients presented to our institution with
exaggerated opioid toxicity. The patients provided a similar history: ingesting
their "normal dose" of hydrocodone/acetaminophen tablets but with
more pronounced symptoms. Toxicology testing and analysis was performed on
serum, urine, and surrendered pills.
RESULTS: One of the 18 patients
died in hospital. Five patients underwent cardiopulmonary resuscitation, one
required extracorporeal life support, three required intubation, and two
received bag-valve-mask ventilation. One patient had recurrence of toxicity
after 8 hours after naloxone discontinuation. Seventeen of 18 patients required
boluses of naloxone, and four required prolonged naloxone infusions (26-39
hours). All 18 patients tested positive for fentanyl in the serum. Quantitative
assays conducted in 13 of the sera revealed fentanyl concentrations of 7.9 to
162 ng/mL (mean = 52.9 ng/mL). Pill analysis revealed fentanyl amounts of
600-6,900 μg/pill. The pills are virtually indistinguishable from authentic
hydrocodone/acetaminophen tablets and are similar in weight. To date, our
county has reported 56 cases of fentanyl opioid toxicity, with 15 fatalities.
In our institution, the outbreak has stressed the capabilities and resources of
the emergency department and intensive care units.
CONCLUSIONS: A serious outbreak
of exaggerated opioid toxicity caused by fentanyl-adulterated tablets purchased
on the street as hydrocodone/acetaminophen is under way in California. These
patients required higher dosing and prolonged infusions of naloxone.
Additionally, observation periods off naloxone were extended due to delayed,
recurrent toxicity. The outbreak has serious ramifications for public health
and safety, law enforcement, and healthcare facilities and resources.
18. Adverse Drug Events in the ED: What are the leading
offenders?
Shehab N, et
al. JAMA. 2016;316(20):2115-2125.
Key Points
Question:
What are the characteristics of adverse drug events that lead to US emergency
department (ED) visits?
Findings: Based on 2013-2014 nationally representative
surveillance data, an estimated 4 ED visits for adverse drug events occurred
per 1000 individuals annually. Among children (aged ≤5 years), antibiotics were
most commonly implicated; among older children and adolescents (aged 6-19
years), antibiotics were most commonly implicated, followed by antipsychotics;
and among older adults (aged ≥65 years), anticoagulants, diabetes agents, and
opioid analgesics were implicated in approximately 60% of ED visits for adverse
drug events.
Meaning:
Adverse drug events from anticoagulants, antibiotics, diabetes agents, opioid
analgesics, and antipsychotics are a common reason for ED visits and may
benefit from patient safety initiatives.
19. Carbon Monoxide Corner (three CO articles—amazing)
A.
Treatment in CO poisoning patients with HA: a prospective, multicenter,
double-blind, controlled clinical trial.
Ocak T, et
al. Am J Emerg Med. 2016 Nov;34(11):2140-2145.
BACKGROUND:
There is a lack of specificity of the analgesic agents used to treat headache
and underlying acute carbon monoxide poisoning.
OBJECTIVE: To
compare effectiveness of "oxygen alone" vs "metoclopramide plus
oxygen" vs "metamizole plus oxygen" therapy in treating carbon
monoxide-induced headache.
DESIGN: A
prospective, multicenter, double-blind, controlled trial.
SETTING:
Three emergency departments in Turkey.
POPULATION:
Adult carbon monoxide poisoning patients with headache.
METHODS: A
total of 117 carbon monoxide-intoxicated patients with headache were randomized
into 3 groups and assessed at baseline, 30 minutes, 90 minutes, and 4 hours.
MAIN OUTCOME
MEASURE: The primary outcome was patient-reported improvement rates for
headache. Secondary end points included nausea, need for rescue medication
during treatment, and reduction in carboxyhemoglobin levels.
RESULTS:
During observation, there was no statistical difference between drug type and
visual analog scale score change at 30 minutes, 90 minutes, or 4 hours, for
either headache or nausea. No rescue medication was needed during the study
period. The reduction in COHgb levels did not differ among the 3 groups.
CONCLUSION:
The use of "oxygen alone" is as efficacious as "oxygen plus
metoclopramide" or "oxygen plus metamizole sodium" in the
treatment of carbon monoxide-induced headache.
B.
ACEP Clinical Policy: Critical Issues in the Evaluation and Management of Adult
Pts Presenting to the ED with Acute CO Poisoning
This clinical
policy from the American College of Emergency Physicians addresses key issues
in the evaluation and management of adult patients presenting to the emergency
department with acute carbon monoxide poisoning. A writing subcommittee
conducted a systematic review of the literature to derive evidence-based
recommendations to answer the following clinical questions: 1) In emergency
department patients with suspected acute carbon monoxide poisoning, can
noninvasive carboxyhemoglobin measurement be used to accurately diagnose carbon
monoxide toxicity? 2) In emergency department patients diagnosed with acute
carbon monoxide poisoning, does hyperbaric oxygen therapy as compared with
normobaric oxygen therapy improve long-term neurocognitive outcomes? 3) In
emergency department patients diagnosed with acute carbon monoxide poisoning,
can cardiac testing be used to predict morbidity or mortality? Evidence was
graded and recommendations were made based on the strength of the available
data.
Full-text
(free): http://www.annemergmed.com/article/S0196-0644(16)31345-2/fulltext
C.
An antidote for CO poisoning?
Wudan Yan.
Science. Dec. 7, 2016
On 26
January, Ling Wang and Qinzi Xu, two biomedical scientists at the University of
Pittsburgh in Pennsylvania, placed a mouse under a chemical hood, anesthetized
it, and hooked it up to monitors. Wang closed the hood and Xu turned on a
switch to deliver 3% carbon monoxide (CO)—a concentration so high that it would
kill most humans almost immediately—for 4.5 minutes. The mouse’s blood pressure
dropped precipitously and its heart rate turned irregular. Then, through an
intravenous tube, they delivered a molecule their lab had developed. Moments
later, the animal’s blood pressure began to rise and it recovered. This was a
first: There are no known antidotes for CO poisoning.
Given off by
engines, heaters, and fireplaces, the tasteless, odorless gas sends more than
50,000 Americans to the emergency room—and kills approximately 500—every year.
CO poisons in at least two ways. First, it binds tightly to the hemoglobin in
blood and prevents it from delivering oxygen throughout the body. Second, it
inhibits the process of respiration in mitochondria, cells’ powerhouses. About
the best physicians can now offer in cases of poisoning is a treatment
developed more than 50 years ago: high-pressure oxygen.
“People have
attempted some biochemical tricks to free carbon monoxide from hemoglobin, but
they don’t really work. That’s why we literally have a therapy that’s as old as
oxygen,” says Lance Becker, a physician at the Hofstra Northwell School of
Medicine in Manhasset, New York. “So the idea of finding something that might
work better, faster, and stronger is very appealing.”
That
something, described in this week’s issue of Science Translational Medicine, is
neuroglobin—a protein typically found in the brain and retina that protects
cells from injury by binding oxygen and nitric oxide—repurposed into a CO
scavenger. The Pittsburgh research team, led by critical care physician Mark
Gladwin, was originally studying its function when they noticed that isolated
neuroglobin molecules almost always had CO, a natural byproduct of hemoglobin
breakdown, bound to them. “I thought this was bad news at the time, because we
needed to get the CO off the neuroglobin in an extra experimental step,”
Gladwin said. But when a colleague asked in 2012 whether there was any antidote
for CO poisoning, he realized that his lab might already have an answer.
In the mouse
study, the group engineered a mutated version of neuroglobin that binds CO 500
times more tightly than it binds hemoglobin. The CO-laden molecules are
excreted through the kidneys. When given within 5 minutes of a lethal dose of
CO, the neuroglobin saved 87% of mice, the group reports. “This agent is
phenomenal: It can rip carbon monoxide right off the hemoglobin,” says Lindell
Weaver, a doctor who treats patients with high-pressure oxygen at Intermountain
Healthcare in Salt Lake City.
Weaver notes,
however, that CO poisoning also activates a series of immunological pathways
that cause lingering damage to the nervous and cardiovascular systems. “The
long-term effects of carbon monoxide are complicated, so just removing [it]
might not be enough,” he says. “But this agent could be life-saving if it’s
administered immediately.”
Gladwin’s
team now plans to further explore the efficacy and safety of the neuroglobin in
rats, larger mammals, and, eventually, patients. One challenge will be making
the neuroglobin scavenger in the amounts needed for use in the field and
clinic. The U.S. Food and Drug Administration, Gladwin says, has already
promised an expedited review of the treatment given that CO poisoning is a
“serious unmet need.”
21. The Good-Enough Physician-Parent
Gilsdorf JR. JAMA.
2016;316(20):2089.
The venue was
a career development session for pediatric infectious diseases physicians, and
mine was the voice of experience. Tension sizzled in the conference room air.
“How do I do this?” someone asked. “I’m a constant wreck.” The comments
continued. “My spouse travels a lot.” “My spouse is also a physician.” “Will it
ever get better?” “I don’t see how I can keep this up much longer.” “My kids
are so important to me, but so are my patients. And my research.”
“Life/Work
Balance” was the title of the session. Balancing personal life and medical
life? I thought. That’s a Sisyphean challenge, one doomed to failure, and to
try to push that rock uphill will only feed into the problem: yet more anxiety,
a greater sense of inadequacy, more internal torture. “Let’s be honest here,” I
told the group. “There is no balance in personal life and medical life. It’s a
matter of lurching from one crisis to the next.” But glorious islands of joy
wedge themselves between the calamities.
My husband (a
surgeon) and I (a pediatric infectious diseases physician-scientist) spent the
years of our children’s youth straddling this imbalance. We had our own
equation for success as physician-parents, or, rather, we had an equation that
we invented, we applied to the issue, and we hoped for success: No television
set. Cook together. Eat together. Read together. No long commutes to work. An
army of helpers: babysitters, alternative babysitters, emergency babysitters,
drivers, cleaning people; all of our relatives were many hundreds of miles away
from our home, and we were on our own. We kept materials around the house for
creative play. In truth, the kids found materials for clandestine play, such as
boards and nails and hammers to a construct a skateboard ramp in the bedroom
and a tree fort in the back yard. They secretly found laundry detergents and
bathroom cleansers to concoct magic potions, blankets to make tents over the
living room furniture, and rope and a shoe box for an elevator to ferry the
guinea pig from the second-floor balcony to the first-floor carpet….
The world is
a complex, imperfect place, and our children must learn to live in it and to
weather the imperfections, their own, our own, and those of others. As with
everything else important, they will learn that best from us, their good-enough
physician-parents.
22. Diagnostic Accuracy of Pediatric Abdominal Ultrasound: Do
You Need a Full Bladder?
Daniel M.
Lindberg, MD. Journal Watch Emerg Med. November 21, 2016
Reviewing Ross M et al. CJEM 2016 Nov.
This study suggests
the answer is no.
Ultrasound
has replaced computed tomography (CT) as the initial imaging study for most
children with suspected appendicitis. Some institutions require bladder filling
to facilitate ultrasound examinations, but this can be uncomfortable and delay
care. These authors evaluated the diagnostic accuracy of transabdominal
ultrasound with and without filled bladders in a retrospective cohort of 678
children with suspected appendicitis at a single center.
Ultrasound
images were reviewed to determine the percent of expected bladder capacity;
bladders filled to less than 75% capacity were considered suboptimally filled.
Ultrasound reports were considered to be “diagnostic” if they demonstrated a
fully visualized normal appendix, appendicitis, or an alternative diagnosis for
the patient's symptoms. Investigators also determined whether ovaries were
fully visualized in girls.
Among 678
children aged 2 to 17 years, 283 had full bladders and 395 had suboptimally
filled bladders. Ultrasound exams were diagnostic in 47% of children with full
bladders and 52% of those with suboptimally filled bladders (difference not
significant). This finding held in both sexes. Ovaries were visualized
significantly more often in girls with full bladders (96%) than in those with
suboptimally filled bladders (81%).
Comment
Routinely
making patients wait for urine to accumulate or endure catheterization is not
patient-centered and appears unwarranted based on the high rate of diagnostic
studies obtained in patients with unfilled bladders. In order to decrease risk
of perforation and to improve throughput and comfort, ultrasound should be
attempted early in children with suspected appendicitis. Nondiagnostic studies
in children with unfilled bladders can be repeated.
23. Anxiety Dreams
Do you have
one? Examples include “lost passport, naked in public, spitting out teeth,
forgotten exam, accidentally making out with cousin, smoking a cigarette after
quitting, pregnant, missing flights, bad outfit, exposure of self as fraud.”
Read on…
By Rosa
Lyster, NY Times. Dec. 7, 2016
It is
incredible to me how little I remember of what I was taught in high school.
Whole subjects, entire years, have just dissolved. I need a calculator to do
any kind of multiplication now. I recently tried to explain how electricity
worked to a small child, and even she could tell I was making it up. But there
are two things I recall with exceptional clarity: Napoleon’s retreat from
Moscow (the hunger, the cold, the sleeping bags made of horse carcasses), and
the opening soliloquy of “Richard III,” which I was required to memorize for
English class at 16. I took this request very seriously, because I was not
cool, and I spent many days slinking up and down the corridors hissing, “I am
determined to prove a villain” to myself and narrowing my eyes. Though my
ability to recite it remains useful as a party trick, that is not the reason it
has remained lodged in my mind.
In the years
since high school, that monologue has become the centerpiece of my most savage
and recurring anxiety dream. I have it about once a month: I will be standing
backstage under gloomy lighting, with people scampering around clutching wigs
and swords, and I will realize with a sickening suddenness that soon, very
soon, I will have to walk onstage and start reciting that speech, and everyone
will realize that I am the worst Richard III in the history of the theater. Not
even just the worst Richard III — the worst person, the biggest impostor, the
No.1 catastrophe in this land. I always wake up just before the curtain opens.
I almost look
forward to the dream whenever it descends. It is not fun, exactly, but it is
interesting, and intense: a familiar thing that manages to knock me out afresh
each time. It’s like being on a ride. And for this reason, anxiety dreams are
the only sort that I permit myself to recount to those around me.
Other
people’s dreams are mostly rubbish. They are dense and generally inconclusive
and involve too many bits like, “I was in my house, but like, it wasn’t my
house, you know?” For instance, my dream in which I become best friends with
the rapper Danny Brown (probably my favorite dream I’ve ever had) and my friend’s
dream in which she drives a Jetta up the stairs at a house party have far too
much going on, way too many variables to be revealing.
Anxiety
dreams, by contrast, are short in the telling — a rare commodity in the world
of dream-relaying. Ask people about them, and they will usually offer a
sentence at most, or even just a few key words: lost passport, naked in public,
spitting out teeth, forgotten exam, accidentally making out with cousin,
smoking a cigarette after quitting, pregnant, missing flights, bad outfit,
exposure of self as fraud. This limited scope enables easy comparison; anxiety
dreams can be held up to one another and scrutinized for what they say about
the dreamer’s orientation toward the world…
The remainder
of the essay:
24. Micro Bits
A. Testosterone treatment increases risk of
venous thromboembolism
According to this observational
study there is an increased risk of venous thromboembolism soon after the start
of testosterone use, which peaks in the first six months.
B. Acute kidney injury 2016: diagnosis and
diagnostic workup
C. New aspects in the management of pneumonia
D. Infants, mothers may benefit from immediate
skin-to-skin contact after birth
Babies and mothers who
immediately received skin-to-skin contact after birth had nearly 24% increased
odds of breast-feeding after one to four months, compared with those who
received various forms of usual care, according to a review in the Cochrane
Library. The findings, based on 46 randomized controlled trials from 21
countries, also showed increased heart and lung function scores and blood
glucose levels among newborns who received immediate skin-to-skin contact.
E. Improving Hypertension Control and Patient
Engagement Using Digital Tools
F. Predictive performance of a Fall Risk
Assessment Tool (FRAT-up)
Can a Fall Risk Tool (FRAT-up)
accurately predict future falls? Data about fall risk factors from four
European studies -- from Germany, England, Italy, and Ireland -- that used
other fall risk tools were compared to the FRAT-up tool for each of those
cohorts. It was found that FRAT-up was a valid tool for measuring future risk
of falls. More studies should be done to try to understand the reasons for
similarities across studies and to refine the tool.
G. Daily nut consumption tied to lower
disease risk
An analysis of 29 studies found
eating a handful of nuts each day may reduce the risk of heart disease, cancer,
respiratory conditions, diabetes and infections, researchers reported in BMC
Medicine. "We found a consistent reduction in risk across many different
diseases, which is a strong indication that there is a real underlying
relationship between nut consumption and different health outcomes," said
researcher Dagfinn Aune of Imperial College London.
H. Older adults have higher levels of
well-being, survey says
Survey data from Gallup-Healthways
showed people ages 55 and older had higher levels of well-being than younger
adults across five measures: financial well-being, community, purpose, social
and health.
I. Everolimus-Eluting Stents or Bypass
Surgery for Left Main Coronary Artery Disease
CONCLUSIONS
In patients with left main
coronary artery disease and low or intermediate SYNTAX scores by site
assessment, PCI with everolimus-eluting stents was noninferior to CABG with
respect to the rate of the composite end point of death, stroke, or myocardial
infarction at 3 years.
J. Linemen in Football Face Higher Cardiac
Risks
K. Relationship Between Stress Rankings and the
Overall Hospital Star Ratings: An Analysis of 150 Cities in the United States
L. Study quantifies benefits of widespread
low-dose aspirin use
A study published in the journal
PLOS ONE found that widespread daily intake of low-dose aspirin among older
Americans could ensure 900,000 more Americans are alive by 2036 and deliver
almost $692 billion in net health care benefits during the same period. Just
40% of Americans who the authors say should be taking aspirin are doing so,
despite evidence that utilization is associated with lower heart disease and
cancer risk and improved life expectancy.
M. Surgeon General releases first-ever report
on substance misuse
The US Surgeon General's office
released its first report covering alcohol and drug misuse, treatment and
prevention, which examines the science behind addiction and substance use
disorders and aims to address the stigma associated with substance misuse. AAFP
President John Meigs, M.D., commented on the report, saying, "I am hopeful
this report will help create new opportunities for increased access to
effective treatment and prevention strategies, as well as help dispel the shame
and misunderstanding that surrounds substance abuse disorders."
N. Pessimism may be a marker of heart disease
An 11-year Finnish study in BMC
Public Health found those who were more pessimistic were twice as likely to die
of heart disease, compared with those who were the least pessimistic. Pessimism
could be used as a factor to determine an individual's risk of dying from heart
disease, researcher Mikko Pankalainen, M.D., said.
O. Dispelling food safety myths
The Partnership for Food Safety
Education says that contrary to common belief, cross-contamination can occur in
the refrigerator, fruits and vegetables carry a risk for foodborne illness, and
leftovers can harbor dangerous bacteria even if they smell OK. The Partnership
and the US Food and Drug Administration discuss several other food safety myths
and actions you can take to protect yourself and your family from foodborne
illness.
P. Tetrahydrocannabinol Does Not Reduce Pain
in Patients With Chronic Abdominal Pain in a Phase 2 Placebo-controlled Study
Q. In and out surgery for appendicitis
BMJ 2016;355:i6485
Go home, your appendix is out
Southern Californians who are
covered by care consortium Kaiser Permanente and who have laparoscopic surgery
for simple appendicitis are likely to be home within 24 hours. And if that
happens, they are less likely to be readmitted within 30 days than similar patients
who are kept in longer. These are the findings of a retrospective review that
compared the records of 6710 patients who were discharged on the same day as
their procedure with 5993 patients who were admitted overnight. Within the
Kaiser system, 60% of patients who have laparoscopic surgery for non-perforated
appendicitis are now discharged straight from the recovery room.
R. Screen time tied to increased obesity risk
in adolescents
Teens who used screen devices
such as smartphones and tablets for five or more hours daily had a twofold
higher likelihood of getting too little physical activity and were 43% more
likely to become obese than those who didn't use such devices. The findings in
the Journal of Pediatrics also showed a 74% increased risk of poor sleep among
those who used screen devices for at least five hours daily.
S. EpiPen Controversy Reveals Complexity
Behind Drug Price Tags
