From the
recent medical literature…
1. Top Stories of 2015
A. In Emergency Medicine NEJM Journal Watch by Richard D.
Zane, MD, FAAEM
Dear Readers,
Compiling our annual list of the most important studies
was especially challenging this year. From the elimination of vasopressin in
advanced cardiac life support guidelines to new definitions of sepsis to the
role of supplemental oxygen in ST-segment elevation myocardial infarction,
there were so many practice-changing studies that it seemed as though 10 just
wasn't enough. That said, we believe these 10 stories warrant revisiting and
that reading the original articles would add important context.
- Time for a New Definition of Severe Sepsis?
- Pediatric SIRS Vital Signs: Poor Predictor of Need for Critical Care
- AHA CPR and Emergency Cardiac Care Guidelines: Updates for 2015
- Updated International Guidelines for Post–Cardiac Arrest Care
- Supplemental Oxygen Is Not Needed for STEMI Patients with Normal Oxygen Saturations
- Ruling Out Subarachnoid Hemorrhage at Nonacademic Hospitals
- Patients with Negative ED Evaluations for Chest Pain Rarely Have In-Hospital Adverse Cardiac Events
- MRI Is Not Needed for Cervical Spine Clearance in Obtunded Blunt Trauma Patients
- Abscess Irrigation Does Not Improve Outcomes
- Starting Suboxone Therapy in the ED for Opioid Abusers
B. In General Medicine NEJM
Journal Watch by Allan S. Brett, MD, Editor-in-Chief
Each year, the editors of NEJM Journal Watch General
Medicine choose the year's most important thematic areas in clinical
research. We try to strike a balance among relevance to primary care,
recognition of landmark studies, and acknowledgment of media publicity and
public awareness. Some of our stories emerge from one important study, and
others come from several studies on a single topic. The order of these stories
is not intended to reflect their relative importance.
- A New Blood Pressure Target for High-Risk Patients?
- Spironolactone for Resistant Hypertension
- Endovascular Treatment of Stroke — A Dramatic Reversal
- Cholesterol Guidelines and Statin Therapy: Debate Continues
- Corticosteroids for Hospitalized Community-Acquired Pneumonia — Time to Change Practice?
- High-Flow Oxygen for Respiratory Support
- Functional or Anatomic Testing for Patients with Chest Pain?
- Managing Venous Thromboembolism
- Testosterone Supplementation in Older Men with Low Testosterone Levels?
- Increasing Calcium Intake Has Minimal Effects on Bone-Mineral Density and Fracture Risk
- ART for All
- Infant Exposure Might Limit Later Peanut Allergies
C. Three
Must-Read EM Articles of 2015 by Amal Mattu, MD
1. Cardiac Arrest: A Treatment
Algorithm for Emergent Invasive Cardiac Procedures in the Resuscitated Comatose
Patient
2. Evaluation of Patients With
Suspected Acute Pulmonary Embolism: Best Practice Advice From the Clinical
Guidelines Committee of the American College of Physicians
3. In-flight Medical Emergencies
During Commercial Travel
Full-text of Mattu’s discussion (free after
registration): http://www.medscape.com/viewarticle/856669
2. It Can be Safe to Forego Antibiotics in Women with
Uncomplicated UTIs.
DRV Note: Whoa! Really? First otitis
media, then simple diverticulitis, and now uncomplicated UTI. What’s next?
Gágyor I, et al. Ibuprofen versus fosfomycin for uncomplicated urinary tract infection in women: randomised controlled trial. BMJ 2015;351:h6544
Gágyor I, et al. Ibuprofen versus fosfomycin for uncomplicated urinary tract infection in women: randomised controlled trial. 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.
3. Outcomes of warfarinized patients with minor head injury and
normal initial CT scan.
Lim BL, et
al. Am J Emerg Med. 2016 Jan;34(1):75-8.
OBJECTIVES:
We investigated delayed outcomes of patients with minor head injury, warfarin,
and a normal initial head computer tomographic (CT) scan finding.
METHODS: We
conducted a single-center, retrospective study on such patients who were
admitted. A second CT was not mandatory. International normalized ratios were
classified into subtherapeutic, therapeutic, and supratherapeutic ranges. We
traced them 2 weeks after discharge for delayed intracranial hemorrhage (ICH).
Primary outcomes were proportions with ICH on second CT, fresh-frozen plasma
(FFP) and/or vitamin K administration, and neurosurgical intervention.
Secondary outcomes were hospital length of stay and the proportion with ICH 2
weeks after discharge. We explored differences in proportions of ICH during
hospital stay among different strata (age ≥65 years, antiplatelet therapy,
supratherapeutic international normalized ratio ranges, and FFP
administration). Data were analyzed using descriptive statistics. P values less
than .05 were considered statistically significant.
RESULTS: We
recruited 298 patients. Of admissions (N = 295), 11 (3.7%) had a second CT,
with one (0.3%) abnormality. There were 7 (2.4%) and 8 (2.7%) patients who
received FFP and vitamin K, respectively. One patient (0.3%) required
neurosurgical intervention. The median hospital length of stay was 3
(interquartile range, 2) days. No patients reattended 2 weeks after discharge.
There were no statistically significant differences in the proportions of ICH
during hospital stay among the 4 strata.
CONCLUSIONS:
Delayed ICH was rare with no predictive factors. Clinical monitoring before
deciding on second CT was safe. The optimal period and mode of observation had
yet to be determined.
4. Prothrombin complex concentrates in the treatment of
warfarin-associated bleeding
A. Risk
of Venous Thromboembolism after Receiving PCC for Warfarin-associated ICH.
Felton D, et
al. J Emerg Med. 2016 Jan;50(1):1-6.
BACKGROUND:
Prothrombin complex concentrates (PCCs) are commonly used to rapidly reverse
warfarin-associated coagulopathy; however, venous thromboembolism (VTE) is an
established adverse event.
OBJECTIVE: To
determine risk factors for VTE AFTER administration of a three-factor prothrombin
complex concentrate (3F-PCC) for warfarin-associated intracranial hemorrhage
(ICH).
METHODS:
Retrospective chart review of all patients with a warfarin-associated ICH who
received a 3F-PCC at a single tertiary care hospital between 2008 and 2013.
Outcomes were VTE events (defined as deep vein thrombosis [DVT], pulmonary
embolism [PE], limb ischemia, transient ischemic attack, cerebrovascular
accident, non-ST-segment elevation myocardial infarction, ST-segment elevation
myocardial infarction, and unexplained sudden death) occurring within 30 days
of 3F-PCC administration. Risk factors in subjects with and without VTE
complications were compared via Fisher's exact test, Student's t-test,
Mann-Whitney U test, and univariate logistic regression as appropriate.
RESULTS: Two
hundred nine subjects received 3F-PCC for warfarin-associated ICH. There were
22 VTE events in 19 subjects (9.1%). Baseline characteristics of subjects with
and without VTE were similar. There was a significant increase in VTE events in
29 subjects who were taking warfarin for a previous PE or DVT (36.8% vs. 11.6%,
p = 0.007; logistic regression odds ratio 4.455, p = 0.005).
CONCLUSIONS:
Patients with a prior history of PE or DVT who were given 3F-PCC for
warfarin-associated ICH were 4.5 times more likely to sustain a VTE within 30
days. A careful analysis of risks and benefits of rapidly reversing
anticoagulation must be made prior to the administration of 3F-PCC in this
patient population.
B. Evaluation of Warfarin Reversal
with 4-Factor PCC Compared to 3-Factor PCC at a Tertiary Academic Medical
Center.
Al-Majzoub O,
et al. J Emerg Med. 2016 Jan;50(1):7-13.
BACKGROUND:
The U.S. Food and Drug Administration recently approved a four-factor
prothrombin complex concentrate (4-PCC) for warfarin reversal. The literature
supporting its use over three-factor prothrombin complex concentrate (3-PCC) is
limited.
OBJECTIVE:
Our objective was to retrospectively compare the efficacy of 3-PCC to 4-PCC in
reversing warfarin in patients who were actively bleeding.
METHODS: We
conducted a single-center, retrospective cohort analysis of adult patients who
received 3-PCC or 4-PCC for international normalized ratio (INR) reversal. Our
study excluded patients not actively bleeding and not on warfarin. The main
outcome was the percentage of patients who achieved warfarin reversal defined
as INR ≤ 1.3 at first INR check post factor administration. We recorded
baseline data including PCC dose, location of bleed, pre- and posttreatment
INR, and time to INR reversal.
RESULTS: We
included a total of 53 patients. Intracranial hemorrhage was the most common
site of bleeding (26 [74.3%] in 3-PCC vs. 12 [66.7%] in 4-PCC). The mean dose
of 3-PCC was 25.5 units/kg, compared to 27.9 units/kg of 4-PCC. The mean baseline
INR was 2.3 in the 3-PCC group and 3 in the 4-PCC group (p = 0.03), and the
first posttreatment INRs were 1.4 and 1.2, respectively (p less than 0.01).
Warfarin reversal was achieved in 15 (42.9%) patients who received 3-PCC and 15
(83.3%) patients who received 4-PCC (p less than 0.01). Faster time to INR
reversal was noted in the 4-PCC group vs. the 3-PCC group (3.7 vs. 5 h, p =
0.48).
CONCLUSION: A
higher percentage of patients achieved warfarin reversal with 4-PCC compared to
3-PCC treatment. A prospective randomized control trial is necessary to confirm
our results.
C. Limb-threatening DVT Complicating
Warfarin Reversal with Three-factor PCC: A Case Report.
Jablow LM, et
al. J Emerg Med. 2016 Jan;50(1):28-31.
BACKGROUND:
Three- and four-factor prothrombin complex concentrates (PCC) are gaining
popularity for acute reversal of vitamin K antagonist-associated bleeding.
Although acute thrombosis after PCC administration has been described, it seems
to be rare.
CASE REPORT:
An 83-year-old woman on warfarin for history of deep venous thrombosis (DVT)
presented to the Emergency Department with life-threatening gastrointestinal
bleeding, requiring urgent PCC administration. After stabilization, she
subsequently developed a new limb-threatening upper-extremity DVT. WHY SHOULD
AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: As PCC therapy gains popularity for
reversal of anticoagulant-induced bleeding in urgent bleeding scenarios, the
emergency physician must be aware of the complications of PCC administration,
including new limb-threatening DVT.
5. Azithromycin versus Doxycycline for Urogenital Chlamydia
trachomatis Infection.
Geisler WM,
et al. N Engl J Med. 2015 Dec 24;373(26):2512-21.
BACKGROUND:
Urogenital Chlamydia trachomatis infection remains prevalent and causes
substantial reproductive morbidity. Recent studies have raised concern about
the efficacy of azithromycin for the treatment of chlamydia infection.
METHODS: We
conducted a randomized trial comparing oral azithromycin with doxycycline for
the treatment of urogenital chlamydia infection among adolescents in youth
correctional facilities, to evaluate the noninferiority of azithromycin (1 g in
one dose) to doxycycline (100 mg twice daily for 7 days). The treatment was
directly observed. The primary end point was treatment failure at 28 days after
treatment initiation, with treatment failure determined on the basis of nucleic
acid amplification testing, sexual history, and outer membrane protein A (OmpA)
genotyping of C. trachomatis strains.
RESULTS:
Among the 567 participants enrolled, 284 were randomly assigned to receive
azithromycin, and 283 were randomly assigned to receive doxycycline. A total of
155 participants in each treatment group (65% male) made up the per-protocol
population. There were no treatment failures in the doxycycline group. In the
azithromycin group, treatment failure occurred in 5 participants (3.2%; 95%
confidence interval, 0.4 to 7.4%). The observed difference in failure rates
between the treatment groups was 3.2 percentage points, with an upper boundary
of the 90% confidence interval of 5.9 percentage points, which exceeded the
prespecified absolute 5-percentage-point cutoff for establishing the
noninferiority of azithromycin.
CONCLUSIONS:
In the context of a closed population receiving directly observed treatment for
urogenital chlamydia infection, the efficacy of azithromycin was 97%, and the
efficacy of doxycycline was 100%. The noninferiority of azithromycin was not
established in this setting.
6. Vital Signs Are Not Associated with Self-Reported Acute Pain
Intensity in the ED
Daousta R. et
al. CJEM 2016;18(1):19-27.
Objectives
This study aimed to ascertain the association between self-reported pain
intensity and vital signs in both emergency department (ED) patients and a
subgroup of patients with diagnosed conditions known to produce significant
pain.
Methods We
performed a retrospective analysis of real-time, archived data from an
electronic medical record system at an urban teaching hospital and regional
community hospital. We included consecutive ED patients ≥16 years old who had a
self-reported pain intensity ≥1 as measured during triage, from March 2005 to
December 2012. The primary outcome was vital signs for self-reported pain
intensity levels (mild, moderate, severe) on an 11-point verbal numerical
scale. Changes in pain intensity levels were also compared to variations in
vital signs. Both analyses were repeated on a subgroup of patients with
diagnosed conditions recognized to produce significant pain: fracture, dislocation,
or renal colic.
Results We
included 153,567 patients (mean age of 48.4±19.3 years; 55.5% women) triaged
with pain (median intensity of 7/10±3). Of these, 8.9% of patients had
diagnosed conditions recognized to produce significant pain. From the total
sample, the difference between mild and severe pain categories was 2.7
beats/minutes (95% CI: 2.4−3.0) for heart rate and 0.13 mm Hg (95% CI:
-0.26−0.52) for systolic blood pressure. These differences generated small
effect sizes and were not clinically significant. Results were similar for
patients who experienced changes in pain categories and for those conditions
recognized to produce significant pain.
Conclusion
Health care professionals cannot use vital signs to estimate or substantiate
self-reported pain intensity levels or changes over time.
7. On ED Sepsis Management
A. A systematic review and
meta-analysis of EGDT for septic shock: the ARISE, ProCESS and ProMISe
Investigators.
Angus DC, et
al. Intensive Care Med. 2015;41(9):1549-60.
PURPOSE: To
determine whether early goal-directed therapy (EGDT) reduces mortality compared
with other resuscitation strategies for patients presenting to the emergency
department (ED) with septic shock.
METHODS:
Using a search strategy of PubMed, EmBase and CENTRAL, we selected all relevant
randomised clinical trials published from January 2000 to January 2015. We
translated non-English papers and contacted authors as necessary. Our primary
analysis generated a pooled odds ratio (OR) from a fixed-effect model.
Sensitivity analyses explored the effect of including non-ED studies, adjusting
for study quality, and conducting a random-effects model. Secondary outcomes
included organ support and hospital and ICU length of stay.
RESULTS: From
2395 initially eligible abstracts, five randomised clinical trials (n = 4735
patients) met all criteria and generally scored high for quality except for
lack of blinding. There was no effect on the primary mortality outcome (EGDT:
23.2% [495/2134] versus control: 22.4% [582/2601]; pooled OR 1.01 [95% CI 0.88-1.16],
P = 0.9, with heterogeneity [I(2) = 57%; P = 0.055]). The pooled estimate of
90-day mortality from the three recent multicentre studies (n = 4063) also
showed no difference [pooled OR 0.99 (95% CI 0.86-1.15), P = 0.93] with no
heterogeneity (I(2) = 0.0%; P = 0.97). EGDT increased vasopressor use (OR 1.25
[95% CI 1.10-1.41]; P less than 0.001) and ICU admission [OR 2.19 (95% CI
1.82-2.65); P less than 0.001]. Including six non-ED randomised trials
increased heterogeneity (I(2) = 71%; P less than 0.001) but did not change overall
results [pooled OR 0.94 (95% CI 0.82 to 1.07); P = 0.33].
CONCLUSION:
EGDT is not superior to usual care for ED patients with septic shock but is
associated with increased utilisation of ICU resources.
B. Triage sepsis alert and sepsis
protocol lower times to fluids and antibiotics in the ED.
Hayden GE, et
al. Am J Emerg Med. 2016 Jan;34(1):1-9.
BACKGROUND:
Early identification of sepsis in the emergency department (ED), followed by
adequate fluid hydration and appropriate antibiotics, improves patient
outcomes.
OBJECTIVES:
We sought to measure the impact of a sepsis workup and treatment protocol
(SWAT) that included an electronic health record (EHR)-based triage sepsis
alert, direct communication, mobilization of resources, and standardized order sets.
METHODS: We
conducted a retrospective, quasiexperimental study of adult ED patients
admitted with suspected sepsis, severe sepsis, or septic shock. We defined a
preimplementation (pre-SWAT) group and a postimplementation (post-SWAT) group
and further broke these down into SWAT A (septic shock) and SWAT B (sepsis with
normal systolic blood pressure). We performed extensive data comparisons in the
pre-SWAT and post-SWAT groups, including demographics, systemic inflammatory
response syndrome criteria, time to intravenous fluids bolus, time to
antibiotics, length-of-stay times, and mortality rates.
RESULTS:
There were 108 patients in the pre-SWAT group and 130 patients in the post-SWAT
group. The mean time to bolus was 31 minutes less in the postimplementation
group, 51 vs 82 minutes (95% confidence interval, 15-46; P value less than
.01). The mean time to antibiotics was 59 minutes less in the
postimplementation group, 81 vs 139 minutes (95% confidence interval, 44-74; P
value less than .01). Segmented regression modeling did not identify secular
trends in these outcomes. There was no significant difference in mortality
rates.
CONCLUSIONS:
An EHR-based triage sepsis alert and SWAT protocol led to a significant
reduction in the time to intravenous fluids and time to antibiotics in ED
patients admitted with suspected sepsis, severe sepsis, and septic shock.
8. Outcomes of Patients Requiring BP Control before Thrombolysis
with tPA for Acute Ischemic Stroke
Darger B, et
al. West J Emerg Med 2015;16(7):1002-1006.
Introduction:
The purpose of this study was to assess safety and efficacy of thrombolysis in
the setting of aggressive blood pressure (BP) control as it compares to
standard BP control or no BP control prior to thrombolysis.
Methods: We
performed a retrospective review of patients treated with tissue plasminogen
activator (tPA) for acute ischemic stroke (AIS) between 2004-2011. We compared
the outcomes of patients treated with tPA for AIS who required aggressive BP
control prior to thrombolysis to those requiring standard or no BP control
prior to thrombolysis. The primary outcome of interest was safety, defined by
all grades of hemorrhagic transformation and neurologic deterioration. The
secondary outcome was efficacy, determined by functional status at discharge,
and in-hospital deaths.
Results: Of
427 patients included in the analysis, 89 received aggressive BP control prior
to thrombolysis, 65 received standard BP control, and 273 required no BP
control prior to thrombolysis. Patients requiring BP control had more severe
strokes, with median arrival National Institutes of Health Stroke Scale of 10
(IQR [6-17]) in patients not requiring BP control versus 11 (IQR [5-16]) and 13
(IQR [7-20]) in patients requiring standard and aggressive BP lowering
therapies, respectively (p=0.048). In a multiple logistic regression model
adjusting for baseline differences, there were no statistically significant
differences in adverse events between the three groups (P greater than 0.10).
Conclusion:
We observed no association between BP control and adverse outcomes in ischemic
stroke patients undergoing thrombolysis. However, additional study is necessary
to confirm or refute the safety of aggressive BP control prior to thrombolysis.
9. Comfort Care for Patients Dying in the Hospital
Blinderman
CD, et al. N Engl J Med 2015; 373:2549-2561.
For
hospitalized patients whose death is imminent, palliative care can alleviate
distressing symptoms that are common during the last few days or weeks of life.
The essentials of such care that are presented in this review are intended to
provide both generalists and specialists in fields other than palliative care with
a practical, evidence-based approach to alleviating these symptoms in patients
who are dying in a hospital. Communication skills that are essential to
personalized care and goal setting are described briefly; the alleviation of
the psychosocial and spiritual suffering that is often faced by terminally ill
patients and their families is addressed only incidentally.
The term
“comfort care” is used here to describe a set of the most basic palliative care
interventions that provide immediate relief of symptoms in a patient who is
very close to death. Typically, these measures are used to achieve comfort for
the patient rapidly; diagnostic or therapeutic maneuvers that might be
appropriate for palliation in earlier stages of the illness are usually not considered
in this context. Many elements of this approach can be used to ease patients’
distress in other phases of a life-threatening illness and in nonhospital
settings, and they can also be applied to relieve symptoms in patients with
less grave conditions.
The Need for
Comfort-Care Skills in Hospital Practice
Although a
growing proportion of deaths in the United States now occur at home or in
nursing homes, hospitals remain a major site for end-of-life care; in 2010, 29%
of deaths occurred in the hospital, and the average terminal admission lasted
7.9 days.1
Multiple
distressing symptoms affect hospitalized patients who have advanced,
life-threatening illnesses,2,3 and some of these symptoms worsen as the patient
approaches death.4 Poorly controlled symptoms have been documented in patients
with advanced cancer, congestive heart failure, chronic obstructive pulmonary
disease (COPD), and many other life-threatening conditions.5,6 The meticulous
management of distressing symptoms is important in any phase of illness, but it
becomes a primary focus near the end of life.7
Palliative
care services can reduce the distress caused by symptoms and improve the
quality of life of patients near the end of life.8 However, the current
scarcity of board-certified palliative care specialists — a workforce shortage
that is projected to continue far into the future — means that the
responsibility for ensuring excellent end-of-life care for dying patients will
continue to fall primarily on generalists and on specialists in areas other
than palliative care.9,10 Thus, familiarity with basic comfort measures is an
essential skill for all clinicians who are caring for patients whose death is
imminent.7,11
Setting Goals
at the End of Life: The Importance of Communication…
10. Images in Clinical Practice
Polychondritis
with Auricular and Ocular Involvement
A Lousy
Diagnosis
Percutaneous
Rotational Pulmonary Thrombectomy
Air
Bronchogram
Phthiriasis
Palpebrarum in a Child
Lancisi’s
Sign
Primary
Epiploic Appendagitis
Chilaiditi
Sign (pseudopneumoperitoneum) on CXR
Dig toxicity:
mistaken STEMI
Mal-positioned
Gastrojejunostomy Tube (whoops!)
Adult Female
with Abd Pain: TOA
Necrotizing
Gingivitis
11. Von Willebrand disease in the ED.
Livesey K, et
al. Haemophilia. 2015 Nov 11 [Epub ahead of print].
BACKGROUND:
The emergency department (ED) is often the first medical contact point for von
Willebrand disease (VWD) patients experiencing acute conditions, notably
bleeding. However, knowledge of VWD disease types and management options by ED
providers is uncertain.
AIM: To
determine the scope of VWD bleeding and treatment in the ED.
METHODS: We
evaluated medical record data in an IRB-approved study from 922 notes
accounting for 385 ER visits by 183 VWD patients from a single large institution's
emergency department.
RESULTS: Over
half the ED visits were for an active or suspected bleed, the majority of which
were associated with trauma, surgery, epistaxis, gastrointestinal bleeding or
gynaecologic bleeding. By treatment, only 25% of all bleeds, including 77.8% of
those with menorrhagia and 50.0% of those with epistaxis, received DDAVP or von
Willebrand factor concentrate (VWF). The likelihood of receiving treatment was
related to referral source, with the highest rates of treatment in patients
referred by a haematologist.
CONCLUSIONS:
These data suggest more patient and physician education are needed in managing
patients with VWD, preferably at the time of diagnosis, including confirmation
of the diagnosis, response to DDAVP testing, indication for DDAVP testing and
formulation of a plan for suspected or actual bleeding.
12. Skin Glue Reduces the Failure Rate of ED–Inserted Peripheral
IV Catheters: A RCT
Bugden S, et
al. Ann Emerg Med. 2015 Dec 31 [Epub ahead of print].
Study objective
Peripheral
intravenous catheters are the most common invasive device in health care yet
have very high failure rates. We investigate whether the failure rate could be
reduced by the addition of skin glue to standard peripheral intravenous catheter
care.
Methods
We conducted
a single-site, 2-arm, nonblinded, randomized, controlled trial of 380
peripheral intravenous catheters inserted into 360 adult patients. The standard
care group received standard securement. The skin glue group received standard
securement plus cyanoacrylate skin glue applied to the skin insertion site. The
primary outcome was peripheral intravenous catheter failure at 48 hours,
regardless of cause. Secondary outcomes were the individual modes of peripheral
intravenous catheter failure: infection, phlebitis, occlusion, or dislodgement.
Results
Peripheral
intravenous catheter failure was 10% lower (95% confidence interval –18% to
–2%; P=.02) with skin glue (17%) than standard care (27%), and dislodgement was
7% lower (95% confidence interval –13% to 0%; P=.04). Phlebitis and occlusion
were less with skin glue but were not statistically significant. There were no
infections.
Conclusion
This study
supports the use of skin glue in addition to standard care to reduce peripheral
intravenous catheter failure rates for adult emergency department patients
admitted to the hospital.
13. Many Hospitals Neglect Practices To Combat ED Overcrowding
By Michelle
Andrews. Kaiser Health News. December 11, 2015.
Crowded
emergency departments have been vexing patients and hospital staff for years as
consumers have increasingly sought care there. But a new study finds that many
of the busiest facilities have yet to adopt several well regarded measures to
reduce the wait and minimize delays.
The study,
published in the journal Health Affairs this week, measured crowding based on
patients’ length of stay in the emergency department and then divided hospitals
into quartiles from least to most crowded. In 2010, half of patients in the
least crowded quartile of emergency departments spent less than 93 minutes
there, while in the most crowded quartile of EDs half of patients had a length
of stay of more than 160 minutes.
Overcrowding
in the emergency department can lead to worse outcomes for patients, including
more complications — especially for cardiovascular patients — and higher
mortality rates.
The study
examined hospital implementation of 17 practices to reduce crowding in
emergency departments and counted how many of them hospitals adopted from 2007
to 2010.
The data came
from the National Hospital Ambulatory Medical Care Survey, an annual survey
that includes approximately 36,000 hospital-based emergency department visits.
The
interventions included separating patients with minor problems from those more
seriously harmed to improve workflow, computer-assisted triage systems and
hospital protocols to move admitted patients out of the emergency department to
inpatient areas to await room assignment rather than “boarding” them in the
emergency department.
During the
study period, the number of measures that hospitals put in place to reduce
crowding grew by 25 percent, on average. In addition, more crowded emergency
departments generally adopted more interventions than did less crowded ones.
But among the emergency departments in the most crowded grouping, significant
numbers didn’t adopt effective interventions, the study found.
Hospitals
might balk at some of the measures that require an investment in technology,
such as radio frequency identification that tags patients so they can be
tracked through the emergency department, says Dr. Leah Honigman Warner, the
study’s lead author and an attending emergency physician at Long Island Jewish
Medical Center in New Hyde Park, N.Y. Another intervention—scheduling elective
surgeries every day, including weekends, that can ease emergency department
access to inpatient beds when necessary—requires a change in hospital
operations, Warner says.
But those
details don’t explain why the most crowded emergency departments adopted fewer
than half of the interventions studied, Warner says. For example, in 2010 just
38 percent of the emergency departments in the most crowded quartile adopted
“full-capacity protocols” in which admitted patients are boarded in inpatient
areas rather than the emergency department. Overall, 46 percent of all
hospitals had those practices in place in 2010.
“It’s much
easier to implement [full-capacity protocols] than changing the surgical
schedule,” she says.
It can be
easy to overlook crowding in the emergency department, in part because it’s so
common, Warner says. The study shows there’s a lot of work to be done.
“It is
reassuring that a lot of these hospitals have a rise in adopting these
interventions. But in the most crowded hospitals, they’re not even doing half
of the things they could do to reduce overcrowding.”
14. Inpt Readmissions and ED Visits within 30 Days of a Hospital
Admission
Brennan JJ,
et al. West J Emerg Med. 2015;16(7):1025-1029.
Introduction:
Inpatient hospital readmissions have become a focus for healthcare reform and
cost-containment efforts. Initiatives targeting unanticipated readmissions have
included care coordination for specific high readmission diseases and patients
and health coaching during the post-discharge transition period. However,
little research has focused on emergency department (ED) visits following an
inpatient admission. The objective of this study was to assess 30-day ED
utilization and all-cause readmissions following a hospital admission.
Methods: This
was a retrospective study using inpatient and ED utilization data from two
hospitals with a shared patient population in 2011. We assessed the 30-day ED
visit rate and 30-day readmission rate and compared patient characteristics
among individuals with 30-day inpatient readmissions, 30-day ED discharges, and
no 30-day visits.
Results: There
were 13,449 patients who met the criteria of an index visit. Overall, 2,453
(18.2%) patients had an ED visit within 30 days of an inpatient stay. However,
only 55.6% (n=1,363) of these patients were admitted at one of these 30-day
visits, resulting in a 30-day all-cause readmission rate of 10.1%.
Conclusion:
Approximately one in five patients presented to the ED within 30 days of an
inpatient hospitalization and over half of these patients were readmitted.
Readmission measures that incorporate ED visits following an inpatient stay
might better inform interventions to reduce avoidable readmissions.
15. On Ureteral Colic
A. PLUS: Evaluation of ED Pts with
Suspected Renal Colic, Using a Clinical Prediction Tool Combined With
Point-of-Care Limited Ultrasonography
Daniels B, et
al. Ann Emerg Med 2015 Dec 31 [Epub ahead of print].
Study
objective
We determine
whether renal point-of-care limited ultrasonography (PLUS) used in conjunction
with the Sex, Timing, Origin, Nausea, Erythrocytes (STONE) clinical prediction
score can aid identification of emergency department (ED) patients with
uncomplicated ureteral stone or need for urologic intervention.
Methods
This was a
prospective observational study of adult ED patients undergoing computed
tomography (CT) scan for suspected ureteral stone. The previously validated
STONE score classifies patients into risk categories of low (≈10%), moderate (≈50%),
or high (≈90%) for symptomatic stone. Renal PLUS assessed for presence of
hydronephrosis before CT scanning. The primary outcomes of symptomatic ureteral
stone or acutely important alternative finding were abstracted from CT reports.
The secondary outcome, urologic intervention, was assessed by 90-day follow-up
interview and record review.
Results
Of 835
enrolled patients, ureteral stone was identified in 53%, whereas 6.5% had an
acutely important alternative finding on CT. Renal PLUS modestly increased
sensitivity for symptomatic stone among low and moderate STONE score
categories. Moderate or greater hydronephrosis improved specificity from 67%
(62% to 72%) to 98% (93% to 99%) and 42% (37% to 47%) to 92% (86% to 95%) in
low- and moderate-risk patients, with likelihood ratios of 22 (95% CI, 4.2-111)
and 4.9 (95% CI, 2.9-8.3), respectively. Test characteristics among high-risk
patients were unchanged by renal PLUS. For urologic intervention, any
hydronephrosis was 66% sensitive (57% to 74%), whereas moderate or greater
hydronephrosis was 86% specific overall (83% to 89%) and 81% (69% to 90%)
sensitive and 79% 95% CI, (73-84) specific among patients with the highest
likelihood of symptomatic stone.
Conclusion
Hydronephrosis
on renal PLUS modestly improved risk stratification in low- and moderate-risk
STONE score patients. The presence or absence of hydronephrosis among high-risk
patients did not significantly alter likelihood of symptomatic stone but may
aid in identifying patients more likely to require urologic intervention.
B. Ureteral Stone Management: A Review
Wang RC. Ann
Emerg Med. 2015 Nov 23 [Epub ahead of print]
Introduction
Urolithiasis
is a common disease, estimated to affect 11% of men and 7% of women in their
lifetime.1 Ureteral stones can cause acute unilateral flank pain radiating to
the groin, often accompanied by nausea, vomiting, and urinary symptoms.2 More
than 1 million patients with suspected urolithiasis present to an emergency
department (ED) each year in the United States.3
This review
will describe ED evaluation, therapies, and the identification of patients who
require urgent urologic intervention, with recommendations based on clinical
trials; on guidelines from the American College of Emergency Physicians (ACEP),
American College of Radiology, and American Urologic Association; and on
anecdotal experience.
Goals of the
Evaluation
- Risk Assessment for Clinically Important Diagnoses
- Selection of Appropriate Imaging
- Moderate to High Risk of a Clinically Important Diagnosis
- Low Risk of a Clinically Important Diagnosis
- Very Low Risk of a Clinically Important Diagnosis
- Treatment of Ureteral Stone
- Patient Disposition
- Expectant Management for Stone Passage
16. Shared Decision Making — Finding the Sweet Spot
Fried TR. N
Engl J Med 2016; 374:104-106
The
importance of shared decision making in health care has been increasingly
recognized over the past several decades. Consensus has emerged that of the
various types of decisions we make, those that involve choosing among more than
one reasonable treatment option should be made through a process in which
patients participate: clinicians provide patients with information about all
the options and help them to identify their preferences in the context of their
values.
But there are
many ways in which decision making can be shared between clinicians and
patients. Physicians describe processes that range from explaining the clinical
situation and making a recommendation that the patient can accept or reject to
outlining the treatment options and leaving the final decision to the patient.1
In other words, the leeway and responsibility given to the patient for making
the decision can vary widely.
Unfortunately,
the role the patient is asked to play in the process is frequently not
appropriately matched to the clinical circumstances underlying the decision. The
greater the uncertainty surrounding the options and the greater the clinician’s
ambivalence about the “right” choice, the greater the likelihood that the
patient will be asked to make the decision. Conversely, the greater the precision
with which a decision’s outcomes can be predicted, the greater the likelihood
that the physician will make a strong recommendation. This approach is
supported by the language found in many guidelines and, at first blush, may
appear to make good sense. A deeper examination of some common decisions,
however, reveals, in my opinion, that just the opposite must occur if we are to
optimize shared decision making…
17. Regional Nerve Blocks for Hip and Femoral Neck Fractures in
the ED: A Systematic Review
Ritcey B, et
al. CJEM 2016;18(1):37-47.
Objectives
Hip and femoral neck fractures are common in elderly patients, who are at an
increased risk of complications if their pain is suboptimally managed. This
systematic review seeks to determine if regional nerve blocks reduce pain,
reduce the need for parenteral opiates, and reduce complications, compared to
standard pain management with opiates, acetaminophen, or NSAIDs.
Data sources
Systematic review of MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register
of Controlled Trials found 401 articles, of which nine were selected for
inclusion.
Study
selection Randomized controlled trials including adult patients with a hip or
femoral neck fracture (Population) who had a 3-in-1 femoral nerve block,
traditional femoral nerve block, or fascia iliaca compartment block performed
preoperatively (Intervention). Comparison must have been made with standard
pain management with opiates, acetaminophen, or NSAIDs (Comparison) and
outcomes must have included pain score reduction (Outcome).
Data
synthesis Eight out of nine studies concluded pain scores were improved with
the regional nerve block compared to standard pain management. A significant
reduction in parenteral opiate use was seen in five out of six studies. No
patients suffered life-threatening complications related to the nerve block;
however, more minor complications were under-reported. Most of the studies were
at a moderate to high risk of bias.
Conclusions
Regional nerve blocks for hip and femoral neck fractures have a benefit in
reducing pain and the need for IV opiates. The use of these blocks can be
recommended for these patients. Further high-quality randomized controlled
trials are required.
18. Lidocaine-Induced Cardiac Arrest in the ED: Effectiveness of
Lipid Therapy.
Tierney KJ,
et al. J Emerg Med. 2016 Jan;50(1):47-50.
BACKGROUND:
Local anesthetics are commonly used in the emergency department (ED). Overdoses
can lead to disastrous complications including cardiac toxicity and arrest.
Recognition of local anesthetic systemic toxicity (LAST) is important; however,
prevention is even more critical. Knowledge of proper lidocaine dosage can
prevent LAST. LAST may be effectively treated with lipid emulsion therapy.
Although the mechanism is not well understood, its use may have a profound impact
on morbidity and mortality.
CASE REPORT:
Fifty milliliters of 2% lidocaine was infiltrated for local anesthesia in a
35-year-old woman during the incision and drainage of a labial abscess.
Following the procedure, the patient complained of vomiting, with rapid
progression to an altered mental state and seizure requiring endotracheal
intubation for airway protection. Suspecting lidocaine toxicity, intralipids
were ordered. While waiting for the intralipids, the patient decompensated and
suffered pulseless electrical activity (PEA) cardiac arrest. A 100-mL bolus of
20% intralipids was administered 3 minutes into the resuscitation, after which
return of spontaneous circulation occurred. The intralipid bolus was then
followed by a continuous infusion of 0.25 mL/kg/minute, for an infusion dose of
930 mL. Despite a complicated hospital course, the patient was discharged home
neurologically intact. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We
believe this patient's cardiovascular collapse was secondary to an iatrogenic
overdose of lidocaine. This is one of the first cases to support the efficacy
of intravenous lipids in the treatment of LAST in humans in the ED.
19. About 8% of patients with paroxysmal A Fib are thrown into
the rhythm by drinking icy cold drinks. Who knew?
Paroxysmal
Atrial Fibrillation and Brain Freeze: A Case of Recurrent Co-Incident
Precipitation from a Frozen Beverage.
Lugovskaya N,
et al. Am J Case Rep. 2016;17:23-6.
BACKGROUND:
Episodes of paroxysmal atrial fibrillation may be precipitated by the rapid
ingestion of ice-cold foods and beverages. This condition has received little
research attention, and its true prevalence is poorly described. Treating
physicians may not identify cold ingestion as a causal factor of paroxysmal
atrial fibrillation, thus compromising both history taking and patient
education.
CASE REPORT:
We report a case of a healthy young-adult man who drank a slushed ice beverage
that immediately induced atrial fibrillation and a brain freeze headache
simultaneously. This occurred on two separate occasions, years apart. During
both episodes, the acute brain freeze self-resolved quickly, but the new-onset
palpitations occasioned a visit to the emergency department for diagnosis and
treatment. The emergency physicians failed to make the causal link between the
cold drink and the atrial dysrhythmia. Though the brain freeze headache and
paroxysmal atrial fibrillation were both precipitated by rapid ingestion of an
ice-cold beverage, the mediating mechanisms are distinct. We review these two
cold-induced conditions, their prevalence, and their probable mechanisms.
CONCLUSIONS:
The recurrent simultaneous occurrence of brain-freeze headache with paroxysmal
atrial fibrillation identifies the ingestion of a frozen beverage as the
precipitant of the atrial dysrhythmia. Increasing physician awareness of cold
ingestion as a cause of paroxysmal atrial fibrillation will improve history
taking and patient education.
20. On Pulmonary Emboli
A. The Impact of Clinical Decision
Rules on CT Use and Yield for PE: A Systematic Review and Meta-analysis
Wang RC, et
al. Ann Emerg Med. 2015 Dec 31 [Epub ahead of print].
Study
objective
Validation
studies have confirmed the accuracy of clinical decision rules for the
evaluation of pretest probability of pulmonary embolism. It has been assumed
that clinical decision rules will also decrease testing in actual practice, but
the evidence for this is unclear. We perform a systematic review of impact
analyses on clinical decision rules for pulmonary embolism.
Methods
MEDLINE,
EMBASE, and the Cochrane Library were searched without language restriction for
studies assessing the effect of clinical decision rules on efficiency (computed
tomography [CT] angiography use and yield) and safety (missed pulmonary
embolism) through October 2014. Two reviewers independently extracted data on
study characteristics, methods, risk of bias, and outcomes.
Results
Eight studies
(n=6,677) contained sufficient information, including 1 randomized trial and 7
observational studies. Because of heterogeneity, the results of 4 studies of
moderate to high quality assessing the Wells criteria were pooled. The pooled
CT angiography yield was 9% (95% confidence interval [CI] 6% to 12%) in the
control group and 12% (95% CI 11% to 14%) in the intervention group, for a 3% increase
in yield (95% CI 1% to 5%), relative risk 1.3 (95% CI 1.1 to 1.6). We were
unable to report a pooled estimate of CT angiography use. Of 2 studies with
sufficient information, there was no difference in the rate of missed pulmonary
embolism between intervention and control groups. No studies used a
cluster-randomized design.
Conclusion
Among
participants with suspected pulmonary embolism, implementation of the Wells
criteria was associated with a modest increase in CT angiography yield. There
is a lack of cluster-randomized trials to confirm the efficacy of clinical
decision rules for the diagnosis of pulmonary embolism.
B. Use of CT and mechanical CPR in
cardiac arrest to confirm PE: a case study
Schuberta EC,
et al. CJEM 2016;18(1):66-69.
Precise therapeutic
decision-making is vital in managing out-of-hospital cardiac arrest. We present
an interesting approach where suspected pulmonary embolism could be confirmed
by early computed tomography in cardiac arrest. Chest compressions were
performed automatically by mechanical devices also during the acquisition of
computed tomography data and subsequent thrombolysis.
21. Evidence-based Comprehensive Approach to Forearm Arterial
Laceration
Thai JN, et
al. West J Emerg Med. 2015;16(7):1127-1134.
Introduction:
Penetrating injury to the forearm may cause an isolated radial or ulnar artery
injury, or a complex injury involving other structures including veins, tendons
and nerves. The management of forearm laceration with arterial injury involves
both operative and nonoperative strategies. An evolution in management has
emerged especially at urban trauma centers, where the multidisciplinary
resource of trauma and hand subspecialties may invoke controversy pertaining to
the optimal management of such injuries. The objective of this review was to
provide an evidence-based, systematic, operative and nonoperative approach to
the management of isolated and complex forearm lacerations. A comprehensive
search of MedLine, Cochrane Library, Embase and the National Guideline
Clearinghouse did not yield evidence-based management guidelines for forearm
arterial laceration injury. No professional or societal consensus guidelines or
best practice guidelines exist to our knowledge.
Discussion:
The optimal methods for achieving hemostasis are by a combination approach
utilizing direct digital pressure, temporary tourniquet pressure, compressive
dressings followed by wound closure. While surgical hemostasis may provide an
expedited route for control of hemorrhage, this aggressive approach is often
not needed (with a few exceptions) to achieve hemostasis for most forearm
lacerations. Conservative methods mentioned above will attain the same result.
Further, routine emergent or urgent operative exploration of forearm laceration
injuries are not warranted and not cost-beneficial. It has been widely accepted
with ample evidence in the literature that neither injury to forearm artery,
nerve or tendon requires immediate surgical repair. Attention should be
directed instead to control of bleeding, and perform a complete physical
examination of the hand to document the presence or absence of other associated
injuries. Critical ischemia will require expeditious surgical restoration of
arterial perfusion. In a well-perfused hand, however, the presence of one
intact artery is adequate to sustain viability without long-term functional
disability, provided the palmar arch circulation is intact. Early consultation
with a hand specialist should be pursued, and follow-up arrangement made for delayed
primary repair in cases of complex injury.
Conclusion:
Management in accordance with well-established clinical principles will
maximize treatment efficacy and functional outcome while minimizing the cost of
medical care.
22. Injectable Epinephrine: An Epidemic of Misuse
Gary J.
Stadtmauer, MD, Medscape News, 2015
An
Introduction to Epinephrine Misuse and Misinformation
It's time to
face the fact that there is an epidemic of miscommunication about the use of
epinephrine for allergic emergencies. This is a problem among both healthcare
professionals and patients. As highlighted in December by Medscape Medical
News, injectable epinephrine is often not used correctly by patients during
allergic emergencies. Studies have even found that most parents were afraid to
use the device in their children with peanut allergy.[1]
And doctors
don't get it right, either. In my own experience, epinephrine is often omitted
from the emergency care of the anaphylactic patient. R.S.H. Pumphrey
reported,[2] in a study, that epinephrine was administered in just 62% of the
fatal anaphylactic reactions that he reviewed, with only a small minority (14%)
receiving the drug before cardiac arrest.
My partner in
practice once had a patient in the emergency department for hours getting
fluids for hypotension (blood pressure, 80/50 mm Hg), along with antihistamines
and corticosteroids as anaphylaxis management. The patient was concerned and
called my partner in the middle of the night. The treating emergency physician
refused to give epinephrine and challenged my partner to come in if he wanted
to manage the case—which he in fact did, and the patient promptly responded to
a single intramuscular dose of 0.3 mg (1:1000) epinephrine.
Injectable
Epinephrine: Safe and Effective When Used Correctly
What is this
reluctance to use epinephrine, and from where does it arise? In my opinion, it
is out of ignorance—not just of the guidelines for anaphylaxis, but also of the
physiology of epinephrine.
At-rest
plasma epinephrine levels are 0.035 ng/mL.[3] Levels over 10 times that amount
have been measured in persons exercising,[4] and even higher than that in
people under mental stress.[5]
Incredibly,
it's not uncommon for doses of epinephrine to be administered intravenously
during routine dental procedures, and this is usually tolerated.[6] We need to
worry much less about the potential for epinephrine side effects.
It is
epinephrine underuse that has consistently been shown to be the issue in
anaphylactic emergencies,[2] and overdose is actually quite rare. The standard
adult dose of self-injecting epinephrine (0.3 mg of 1:1000 epinephrine) raises
the level of epinephrine in the body from an average of 0.035 ng/mL to about 10
times that amount.[7] It would require more about 20 such injections to reach a
toxic level.
It's also
important to note that a delay in use of epinephrine is linked to fatal food
anaphylaxis.[8] The other risk factor for fatal food reactions is poorly
controlled asthma, a point I always make to asthmatic patients with food
allergy.
Finally,
patients need to understand that allergic reactions are not all alike and that
the severity may be influenced by many endogenous and exogenous factors.
Factors that might accentuate an immediate hypersensitivity reaction include
hormones, viral infections, nonsteroidal anti-inflammatory drugs, alcohol, and
overheating/exercise.
To explain
much of this to patients takes time. So I have developed a patient handout,
which can be printed here, to help with your practice of medicine…
23. Micro Bits
A. Survey: Some patients say e-mail
with physicians improved their health
A Kaiser
Permanente survey in the Journal of Managed Care found 32% of patients with
chronic conditions said exchanging secure e-mails with physicians benefited
their health. The survey included 1,041 participants who had access to an
online patient portal with e-mail capability. The e-mail tool was used by 56%
of respondents. Among e-mail users, 42% said it led to fewer phone calls and
36% said it led to fewer visits.
B. Key Guidelines in Emergency
Medicine You Need to Know
Medscape
Editors. December 24, 2015
Full-text
(with free registration): http://reference.medscape.com/features/slideshow/guidelines-review/2015/year-in-review/emergency-medicine
C. Beverage purchases from stores in
Mexico under the excise tax on sugar sweetened beverages: observational study
The tax on
sugar sweetened beverages was associated with reductions in purchases of taxed
beverages and increases in purchases of untaxed beverages. Continued monitoring
is needed to understand purchases longer term, potential substitutions, and
health implications.
D. Almost all patients continue to
receive prescription opioids after an overdose.
E. The Institute of Medicine Says Time
to Act to Improve Cardiac Arrest Survival: Here’s How
F. Regulators seek to tame brain
training's 'Wild West'
If you watch
cable TV news or listen to NPR, you've likely been barraged with ads for
Lumosity, a set of digital "brain-training" games that purportedly
sharpens the mind based on the "science of neuroplasticity." Last
week, Lumosity hit the news for a different reason, as the Federal Trade
Commission (FTC) made it the latest target in a crackdown on companies selling
products that purportedly enhance memory, provide some other cognitive benefit,
or reduce the serious side effects of dementia. It fined the games' maker,
Lumos Labs, Inc., $2 million for false advertising and required it to create a
pop-up screen that alerts players to FTC's order and allows them to avoid
future billing. It's the third FTC complaint against the industry in 4 months,
and many neuroscientists and psychologists say action is long overdue. Still,
some worry that games based on solid science may be unfairly tarnished, and
that the agency may be imposing a standard of evidence that game developers
can't meet.
G. New dietary guidelines recommend
limits on sugar, fats, sodium
US officials
released the 2015-2020 Dietary Guidelines for Americans last week, which
recommend eating an overall healthy diet, limiting added sugars and saturated
fats, and reducing sodium intake. The AAFP, however, found scientific evidence
was lacking to support the recommendation to reduce daily sodium intake to less
than 2,300 milligrams for those 14 years and older. "It's not that we
think it's too low," said Jennifer Frost, M.D., medical director for the
AAFP Health of the Public and Science Division. "We just don't know what
the right amount is."
H. Smartphone apps to improve health
and fitness
Healthcare
providers often look for ways to monitor and improve their patients' health and
fitness objectively, especially between patient visits. Some insurance
companies use applications data as incentives to improve health and lower
premiums. As their use becomes more prevalent, smartphones may provide a tool
to improve patients' health and fitness. Fitness applications are programs that
use data collected from the smartphone's built-in tools, such as the Global
Positioning System, accelerometer, microphone, speaker, and camera, to measure
health and fitness parameters. The apps then analyze these data and summarize
them, as well as devise individualized plans based on users' goals and provide
frequent feedback, personalized coaching, and additional motivation by sharing
milestones on social media. This article introduces evidence that apps can
better help patients reach their health and fitness goals. It then discusses
what features to look for in an app, followed by an overview of popular health
and fitness apps. Last, patient scenarios with app recommendations, limitations
of apps, and future research are discussed
I. Screening for Breast Cancer: Recommendations
From the U.S. Preventive Services Task Force
J. Many patients may not understand
hospital discharge instructions
Researchers
found that just one-fourth of 500 trauma patients had the appropriate level of
reading skills to understand follow-up instructions given to them upon hospital
discharge. The study, published in the American Journal of Surgery, found that
40% of the 314 patients with education data available had sixth- to
eighth-grade reading level skills and were considered marginally literate, and
4% were functionally illiterate with fifth-grade skills or lower. Experts
recommend that patient discharge be written at a sixth-grade level, but the
study found that discharge notes are generally written at a level requiring
high-school-level reading skills
K. U.S. News & World Report's 2016
Best Diets list
L. Prophylactic blood thinners safe to
start before major cancer operation
Researchers
followed about 2,000 patients who started blood thinners before major cancer
surgery and almost 5,000 patients who did not, and found that a dose of the
drug resulted in a decreased risk of blood clots. There was no increase in the
risk of major bleeding or blood transfusion, according to the study published
in the Journal of the American College of Surgeons.
