Sunday, January 17, 2016

Lit Bits: Jan 17, 2016

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. 

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. 

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):

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

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…

The remainder of the essay (full-text free):

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.

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.

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.

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.

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.

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.

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]

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…

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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.

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.

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.

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…

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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

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.