From the recent medical literature…
1. Surveillance Recommended for Subsegmental PE with Low Risk of
Recurrence [Whoa!! Really?]
“For
subsegmental PE and no proximal DVT, we suggest clinical surveillance over
anticoagulation with a low risk of recurrent VTE (Grade 2C), and
anticoagulation over clinical surveillance with a high risk (Grade 2C).”
Kearon C, et
al. Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel
Report. CHEST 2016; 149(2):315-352 [referred to at AT10]
Summary of the (weak but suggestive) Evidence
Subsegmental
PE refers to PE that is confined to the subsegmental pulmonary arteries.
Whether these patients should be treated, a question that was not addressed in
AT9, has grown in importance because improvements in CT pulmonary angiography
have increased how often subsegmental PE is diagnosed (ie, from approximately
5% to more than 10% of PE). There is uncertainty whether these patients should
be anticoagulated for two reasons. First, because the abnormalities are small,
a diagnosis of subsegmental PE is more likely to be a false-positive finding
than a diagnosis of PE in the segmental or more proximal pulmonary arteries.
Second, because a true subsegmental PE is likely to have arisen from a small
DVT, the risk of progressive or recurrent VTE without anticoagulation is
expected to be lower than in patients with a larger PE.
Our
literature search did not identify any randomized trials in patients with
subsegmental PE. There is, however, high-quality evidence for the efficacy and
safety of anticoagulant therapy in patients with larger PE, and this is
expected to apply similarly to patients with subsegmental PE. Whether the risk
of progressive or recurrent VTE is high enough to justify anticoagulation in
patients with subsegmental PE is uncertain. There were no episodes of recurrent
VTE in retrospective reports that included about 60 patients with subsegmental
PE and no proximal DVT and who were not anticoagulated., However, in another
retrospective analysis, patients with subsegmental PE appeared to have a
similar risk of recurrent VTE during 3 months of anticoagulant therapy as
patients with larger PE, and a higher risk than in patients who were suspected
of having PE but had PE excluded.
The AT10
panel endorsed that, if no anticoagulant therapy is an option, patients with
subsegmental PE should have bilateral US examinations to exclude proximal DVT
of the legs., DVT should also be excluded in other high-risk locations, such as
in upper extremities with central venous catheters. If DVT is detected,
patients require anticoagulation. If DVT is not detected, there is uncertainty
whether patients should be anticoagulated. If a decision is made not to
anticoagulate, there is the option of doing one or more follow-up US
examinations of the legs to detect (and then treat) evolving proximal DVT.,
Serial testing for proximal DVT has been shown to be a safe management strategy
in patients with suspected PE who have nondiagnostic ventilation-perfusion
scans, many of whom are expected to have subsegmental PE.
We suggest
that a diagnosis of subsegmental PE is more likely to be correct (ie, a true
positive) if: (1) the CT pulmonary angiogram is of high quality with good
opacification of the distal pulmonary arteries; (2) there are multiple
intraluminal defects; (3) defects involve more proximal subsegmental arteries
(ie, are larger); (4) defects are seen on more than one image; (5) defects are
surrounded by contrast rather than appearing to be adherent to the pulmonary
artery walls; (6) defects are seen on more than one projection; (7) patients
are symptomatic, as opposed to PE being an incidental finding; (8) there is a
high clinical pretest probability for PE; and (9) D-dimer level is elevated,
particularly if the increase is marked and otherwise unexplained.
In addition
to whether or not patients truly have subsegmental PE, we consider the
following to be risk factors for recurrent or progressive VTE if patients are
not anticoagulated—patients who: are hospitalized or have reduced mobility for
another reason; have active cancer (particularly if metastatic or being treated
with chemotherapy); or have no reversible risk factor for VTE such as recent
surgery. Furthermore, a low cardiopulmonary reserve or marked symptoms that
cannot be attributed to another condition favor anticoagulant therapy, whereas
a high risk of bleeding favors no anticoagulant therapy. The decision to
anticoagulate or not is also expected to be sensitive to patient preferences.
Patients who are not anticoagulated should be told to return for reevaluation
if symptoms persist or worsen.
The evidence
supporting our recommendations is low quality because of indirectness and
because there is limited ability to predict which patients will have VTE
complications without anticoagulation.
Full-text
(free): http://journal.publications.chestnet.org/article.aspx?articleid=2479255
2. Sensitivity of Early Brain CT to Exclude Aneurysmal SAH: A
Systematic Review and Meta-Analysis.
Dubosh NM, et
al. Stroke. 2016 Jan 21 [Epub ahead of print]
BACKGROUND
AND PURPOSE: Emerging evidence demonstrating the high sensitivity of early
brain computed tomography (CT) brings into question the necessity of always
performing lumbar puncture after a negative CT in the diagnosis of spontaneous
subarachnoid hemorrhage (SAH). Our objective was to determine the sensitivity
of brain CT using modern scanners (16-slice technology or greater) when
performed within 6 hours of headache onset to exclude SAH in neurologically
intact patients.
METHODS:
After conducting a comprehensive literature search using Ovid MEDLINE, Ovid
EMBASE, Web of Science, and Scopus, we conducted a meta-analysis. We included
original research studies of adults presenting with a history concerning for
spontaneous SAH and who had noncontrast brain CT scan using a modern generation
multidetector CT scanner within 6 hours of symptom onset. Our study adheres to
the preferred reporting items for systematic reviews and meta-analyses
(PRISMA).
RESULTS: A
total of 882 titles were reviewed and 5 articles met inclusion criteria,
including an estimated 8907 patients. Thirteen had a missed SAH (incidence 1.46
per 1000) on brain CTs within 6 hours. Overall sensitivity of the CT was 0.987
(95% confidence intervals, 0.971-0.994) and specificity was 0.999 (95%
confidence intervals, 0.993-1.0). The pooled likelihood ratio of a negative CT
was 0.010 (95% confidence intervals, 0.003-0.034).
CONCLUSIONS:
In patients presenting with thunderclap headache and normal neurological
examination, normal brain CT within 6 hours of headache is extremely sensitive
in ruling out aneurysmal SAH.
3. Target-specific Oral Anticoagulants in the ED
Peacock WF,
et al. J Emerg Med. 2016 Feb;50(2):246-57.
BACKGROUND:
Emergency physicians make treatment decisions in patients who present to the
emergency department (ED) with acute venous thromboembolism (VTE). They also
encounter patients on target-specific oral anticoagulants (TSOACs) who require
urgent intervention. New approvals and increasing prescriptions for TSOACs
(e.g., apixaban, dabigatran, edoxaban, and rivaroxaban) for the management of
several thromboembolic disorders warrant an evaluation of the impact of these
agents in the ED setting.
OBJECTIVE OF
THE REVIEW: This review discusses the use of TSOACs in the ED for the treatment
of acute VTE, and highlights strategies for the management of patients on
TSOACs who present to the ED with other complications, such as bleeding
complications or requiring emergency surgery.
DISCUSSION:
Apixaban, dabigatran, edoxaban, and rivaroxaban have been approved for the
treatment of acute VTE. We discuss the impact of this on ED management of
TSOAC-naïve patients and highlight results with TSOACs in high-risk subgroups
including the elderly and those with prior VTE or active cancer. This review
also discusses management strategies for patients on TSOACs. For emergency
physicians, strategies for the management of bleeding, approaches to patient
care when emergency surgery is needed, laboratory assays for measuring plasma
concentrations of TSOACs, and drug-drug interactions are of special importance.
CONCLUSIONS:
Familiarity with TSOACs will better position emergency physicians to provide
state-of-the art care to their patients with VTE and help them manage
potentially complicated circumstances related to the chronic use of these
drugs.
4. On Procedural Sedation
A. Incidence of Adverse Events in
Adults Undergoing Procedural Sedation in the ED: A Systematic Review and
Meta-analysis.
Bellolio MF,
et al. Acad Emerg Med. 2016 Jan 22 [Epub ahead of print]
OBJECTIVES:
This was a systematic review and meta-analysis to evaluate the incidence of
adverse events in adults undergoing procedural sedation in the emergency
department (ED).
METHODS:
Eight electronic databases were searched, including MEDLINE, EMBASE, EBSCO,
CINAHL, CENTRAL, Cochrane Database of Systematic Reviews, Web of Science, and
Scopus, from January 2005 through 2015. Randomized controlled trials and
observational studies of adults undergoing procedural sedation in the ED that
reported a priori selected outcomes and adverse events were included.
Meta-analysis was performed using a random-effects model and reported as
incidence rates with 95% confidence intervals (CIs).
RESULTS: The
search yielded 2,046 titles for review. Fifty-five articles were eligible,
including 9,652 procedural sedations. The most common adverse event was
hypoxia, with an incidence of 40.2 per 1,000 sedations (95% CI = 32.5 to 47.9),
followed by vomiting with 16.4 per 1,000 sedations (95% CI = 9.7 to 23.0) and
hypotension with 15.2 per 1,000 sedations (95% CI = 10.7 to 19.7). Severe
adverse events requiring emergent medical intervention were rare, with one case
of aspiration in 2,370 sedations (1.2 per 1,000), one case of laryngospasm in
883 sedations (4.2 per 1,000), and two intubations in 3,636 sedations (1.6 per
1,000). The incidence of agitation and vomiting were higher with ketamine
(164.1 per 1,000 and 170.0 per 1,000, respectively). Apnea was more frequent
with midazolam (51.4 per 1,000), and hypoxia was less frequent in patients who
received ketamine/propofol compared to other combinations. The case of
laryngospasm was in a patient who received ketamine, and the aspiration and
intubations were in patients who received propofol. When propofol and ketamine
are combined, the incidences of agitation, apnea, hypoxia, bradycardia,
hypotension, and vomiting were lower compared to each medication separately.
CONCLUSIONS:
Serious adverse events during procedural sedation like laryngospasm,
aspiration, and intubation are exceedingly rare. Quantitative risk estimates
are provided to facilitate shared decision-making, risk communication, and
informed consent.
Full-text
(free): http://onlinelibrary.wiley.com/doi/10.1111/acem.12875/full
B. Meta-Analysis Suggests Ketofol Is
Safer Than Propofol Alone
Pooling of
data from several trials suggests fewer respiratory and cardiovascular adverse
events with ketofol.
Jalili M, et
al. Ketamine-propofol combination (ketofol) vs propofol for procedural sedation
and analgesia: systematic review and meta-analysis. Am J Emerg Med. 2015 Dec 29
[Epub ahead of print].
OBJECTIVE: This
meta-analysis of trials was conducted to evaluate the analgesic and side
effects of ketamine-propofol combination (ketofol) in comparison to propofol in
procedural sedation and analgesia (PSA).
METHODS: Medline,
EMBASE, Scopus, CINHAL, and Cochrane Central Register of Controlled Trials were
searched for clinical trial. The administration complications were the key
outcomes of interest.
RESULT: Eighteen
clinical trials that met our criteria were included in the analysis. Pooling of
data showed that ketofol is significantly effective for reduction of
respiratory complication and with relative risk (RR) of 0.31 in 14 trials (95%
confidence interval [CI], 0.47-0.7; P = .001). Ketofol was also effective in
reducing cardiovascular complications with hypotension RR of 0.11 in 9 trials
(95% CI, 0.17-0.97; P = .04) and bradycardia RR of 0.47 in 8 trials (95% CI,
0.28-0.72; P = .008). The present study also showed that the summary of RR for
psychomimetic complications was 1.95 in 13 trials were (95% CI, 0.79-4.81; P =
.15) and for muscle rigidity was 0.52 for 2 trials (95% CI, 0.06-4.67; P =
.56), and both were insignificant. In regard to nausea and vomiting, the RR was
1.23 in 12 trials (95% CI, 0.39-3.88; P = .72) and insignificant.
CONCLUSION: This
meta-analysis demonstrates good safety profile in cardiorespiratory problems
and comparable rate of other complications with propofol in adult procedural
sedation and analgesia.
5. Women experience different symptoms, causes of heart attack
than men
The American
Heart Association published a scientific statement in Circulation that said
when it comes to heart attacks, women are "understudied, underdiagnosed
and undertreated," which leads to poor outcomes, hospital readmissions,
repeat heart attacks and death after a heart attack.
The first
scientific statement from the AHA on heart attacks in women emphasizes the
differences in warning signs and causes of heart attack for women compared with
men. Either sex might experience chest pain, but women may also experience
nausea, back or neck pain and shortness of breath. Women tend to suffer heart
attacks nearly 10 years later in life than men and have a different type of
artery blockage, wherein smaller pieces of plaque that have broken off cause
smaller blood clots, according to the statement and other experts.
Mehta LS, et
al. AHA Scientific Statement: AMI in Women. A Scientific Statement from the American
Heart Association. Circulation. 25 Jan 2016 [Epub ahead of print].
Full-text
(free): http://circ.ahajournals.org/content/early/2016/01/25/CIR.0000000000000351.abstract
6. Lit Reviews in Ann Emerg Med
A. Do Systemic Corticosteroids Improve
Outcomes in Chronic Obstructive Pulmonary Disease Exacerbations?
Take-home: Systemic
corticosteroid treatment (oral or parenteral) in the setting of chronic obstructive
pulmonary disease exacerbations is effective in reducing the likelihood of
treatment failure and relapse at 1 month while shortening hospital length of
stay.
B. Do Clinical Prediction Rules for
Acute PE Have Sufficient Sensitivity to Identify Patients at Very Low Risk of
Death?
Take-home: Five
pulmonary embolism clinical prediction rules to predict early all-cause
mortality have sensitivities greater than 88%, but only 3 are supported by a
high level of evidence. The simplified Pulmonary Embolism Severity Index
appears to have the greatest potential, given its relatively higher sensitivity
and ease of use.
C. Managing Suicidal Patients in the
ED
…Conclusion
Through an
empathetic, evidence-based, and collaborative approach to managing suicidal
patients, ED providers can help prevent future injury and death. Focused
medical assessment and suicide risk assessment can help providers determine
whether a mental health consultation is required and whether the patient needs
hospitalization. Brief ED interventions—including counseling about reducing
access to firearms and toxic medications—may be both feasible and effective,
depending on the ED environment and resources. Suicide remains a leading cause
of death in the United States, but ED providers have an opportunity to ease
emotional pain and save lives.
7. Beta-blockers Best for AF during Sepsis: A Propensity-Matched
Cohort Study.
Walkey AJ, et
al. Chest. 2016 Jan;149(1):74-83.
BACKGROUND: Atrial
fibrillation (AF) during sepsis is associated with increased morbidity and
mortality, but practice patterns and outcomes associated with rate- and
rhythm-targeted treatments for AF during sepsis are unclear.
METHODS: This
was a retrospective cohort study using enhanced billing data from approximately
20% of United States hospitals. We identified factors associated with IV AF
treatments (beta-blockers [BBs], calcium channel blockers [CCBs], digoxin, or
amiodarone) during sepsis. We used propensity score matching and instrumental
variable approaches to compare mortality between AF treatments.
RESULTS: Among
39,693 patients with AF during sepsis, mean age was 77 ± 11 years, 49% were
women, and 76% were white. CCBs were the most commonly selected initial AF
treatment during sepsis (14,202 patients [36%]), followed by BBs (11,290
[28%]), digoxin (7,937 [20%]), and amiodarone (6,264 [16%]). Initial AF
treatment selection differed according to geographic location, hospital
teaching status, and physician specialty. In propensity-matched analyses, BBs
were associated with lower hospital mortality when compared with CCBs (n =
18,720; relative risk [RR], 0.92; 95% CI, 0.86-0.97), digoxin (n = 13,994; RR,
0.79; 95% CI, 0.75-0.85), and amiodarone (n = 5,378; RR, 0.64; 95% CI,
0.61-0.69). Instrumental variable analysis showed similar results (adjusted RR
fifth quintile vs first quintile of hospital BB use rate, 0.67; 95% CI,
0.58-0.79). Results were similar among subgroups with new-onset or preexisting
AF, heart failure, vasopressor-dependent shock, or hypertension.
CONCLUSIONS: Although
CCBs were the most frequently used IV medications for AF during sepsis, BBs
were associated with superior clinical outcomes in all subgroups analyzed. Our
findings provide rationale for clinical trials comparing the effectiveness of
AF rate- and rhythm-targeted treatments during sepsis.
8. Two Reviews on Contrast-induced Nephropathy in Ann Intern Med
A. Effectiveness of Prevention
Strategies for Contrast-Induced Nephropathy: A Systematic Review and
Meta-analysis
Subramaniam
RM, et al. Ann Intern Med. 2016 February 2 [Epub ahead of print]
Background:
N-acetylcysteine, sodium bicarbonate, statins, and ascorbic acid have been
studied for reducing contrast-induced nephropathy (CIN).
Purpose: To
evaluate the comparative effectiveness of interventions to reduce CIN in adults
receiving contrast media.
Data Sources:
MEDLINE, EMBASE, Cochrane Library, ClinicalTrials.gov, and Scopus databases
through June 2015. Risk of bias of studies and overall strength of evidence
(SOE) were assessed.
Study
Selection: Randomized, controlled trials of N-acetylcysteine, sodium
bicarbonate, statins, or ascorbic acid that used intravenous (IV) or
intra-arterial contrast media and defined CIN with enough data for
meta-analysis.
Data Extraction:
Two reviewers independently extracted data and assessed study quality.
Data
Synthesis: Low-dose N-acetylcysteine compared with IV saline (risk ratio [RR],
0.75 [95% CI, 0.63 to 0.89]; low SOE), N-acetylcysteine compared with IV saline
in patients receiving low-osmolar contrast media (RR, 0.69 [CI, 0.58 to 0.84];
moderate SOE), and statins plus N-acetylcysteine versus N-acetylcysteine (RR,
0.52 [CI, 0.29 to 0.93]; low SOE) had clinically important and statistically
significant benefits. The following 3 comparisons suggested a clinically
important difference that was not statistically significant: sodium bicarbonate
versus IV saline in patients receiving low-osmolar contrast media (RR, 0.65
[CI, 0.33 to 1.25]; low SOE), statins plus IV saline versus IV saline (RR, 0.68
[CI, 0.39 to 1.20]; low SOE), and ascorbic acid versus IV saline (RR, 0.72 [CI,
0.48 to 1.01]; low SOE). Strength of evidence was generally insufficient for
comparisons of the need for renal replacement, cardiac events, and mortality.
Limitation:
Too few studies were done in patients receiving IV contrast media.
Conclusion:
The greatest reduction in CIN was seen with N-acetylcysteine in patients
receiving LOCM and with statins plus N-acetylcysteine.
B. Comparative Effect of Contrast
Media Type on the Incidence of Contrast-Induced Nephropathy: A Systematic
Review and Meta-analysis
Ann Intern
Med. 2016 February 2 [Epub ahead of print]
Background:
Iodinated contrast media are essential components of many imaging procedures.
An important potential side effect is contrast-induced nephropathy (CIN).
Purpose: To
compare CIN risk for contrast media within and between osmolality classes in
patients receiving diagnostic or therapeutic imaging procedures.
Data Sources:
PubMed, EMBASE, Cochrane Library, Clinical Trials.gov, and Scopus through June
2015.
Study
Selection: Randomized, controlled trials that reported CIN-related outcomes in
patients receiving low-osmolar contrast media (LOCM) or iso-osmolar contrast
media for imaging.
Data
Extraction: Independent study selection and quality assessment by 2 reviewers
and dual extraction of study characteristics and results.
Data
Synthesis: None of the 5 studies that compared types of LOCM reported a
statistically significant or clinically important difference among study
groups, but the strength of evidence was low. Twenty-five randomized,
controlled trials found a slight reduction in CIN risk with the iso-osmolar
contrast media agent iodixanol compared with a diverse group of LOCM that just
reached statistical significance in a meta-analysis (pooled relative risk, 0.80
[95% CI, 0.65 to 0.99]; P = 0.045). This comparison's strength of evidence was
moderate. In a meta regression of randomized, controlled trials of iodixanol,
no relationship was found between route of administration and comparative CIN
risk.
Limitations:
Few studies compared LOCM. Procedural details about contrast administration
were not uniformly reported. Few studies specified clinical indications or
severity of baseline renal impairment.
Conclusion:
No differences were found in CIN risk among types of LOCM. Iodixanol had a
slightly lower risk for CIN than LOCM, but the lower risk did not exceed a
criterion for clinical importance.
9. Lowering levels of bed occupancy is associated with decreased
inhospital mortality and improved performance on the 4-hour target in a UK
District General Hospital
Boden DG, et
al. Emerg Med J 2016;33:85-90.
OBJECTIVE: To
evaluate whether there is an association between an intervention to reduce
medical bed occupancy and performance on the 4-hour target and hospital
mortality.
METHODS: This
before-and-after study was undertaken in a large UK District General Hospital
over a 32 month period. A range of interventions were undertaken to reduce
medical bed occupancy within the Trust. Performance on the 4-hour target and
hospital mortality (hospital standardised mortality ratio (HSMR), summary
hospital-level mortality indicator (SHMI) and crude mortality) were compared
before, and after, intervention. Daily data on medical bed occupancy and
percentage of patients meeting the 4-hour target was collected from hospital
records. Segmented regression analysis of interrupted time-series method was
used to estimate the changes in levels and trends in average medical bed
occupancy, monthly performance on the target and monthly mortality measures
(HSMR, SHMI and crude mortality) that followed the intervention.
RESULTS: Mean
medical bed occupancy decreased significantly from 93.7% to 90.2% (p=0.02). The
trend change in target performance, when comparing preintervention and
postintervention, revealed a significant improvement (p=0.019). The
intervention was associated with a mean reduction in all markers of mortality
(range 4.5-4.8%). SHMI (p=0.02) and crude mortality (p=0.018) showed
significant trend changes after intervention.
CONCLUSIONS:
Lowering medical bed occupancy is associated with reduced patient mortality and
improved ability of the acute Trust to achieve the 95% 4-hour target. Whole
system transformation is required to create lower average medical bed
occupancy.
In a linked editorial, Professor Steve Goodacre and Mike
Campbell of the University of Sheffield sound a note of caution.
For example,
they suggest that increased bed availability might have led to less seriously
ill patients being admitted who might otherwise have been cared for at home,
and although the death rate data were adjusted to take account of influential
factors, illness severity was not one of them. They conclude: “Measures that
reduce bed occupancy (increasing bed and senior doctor availability) use up
precious health service resources. If this saves lives, then it may be
worthwhile, but if it just increases admissions then resources would be better
spent elsewhere.”
10. Images in Clinical Practice
Primary and
Secondary Syphilis
Cannon A
Waves
Taenia
saginata Infestation
Spontaneous
Retropharyngeal Hematoma
Male with
Severe Abdominal Pain
Child with
Dinner Fork Deformity
Man with
Acute Respiratory Distress
An Unusual
Cause of Limp in a Toddler
Expanded
Discussion: Limping Child? Think LIMPSS
Young Woman with
Vaginal Bleeding
Knee
Dislocation
11. Ryan Radecki on Inappropriate Testing/Imaging of ED CP Pts
Stolen from
his Blog: http://www.emlitofnote.com/
A. Let’s Get Inappropriate With AHA
Guidelines
Thursday,
February 4, 2016
How do you
hide bad science? With meta-analyses,
systematic reviews, and, the granddaddy of them all, guidelines. Guidelines have become so twisted over the
recent history of medicine the Institute of Medicine had to release a statement
on how to properly create them, and a handful of folks have even gone so far as
to imply guidelines have become so untrustworthy a checklist is required for evaluation
in order to protect patients.
Regardless,
despite this new modern era, we have yet another guideline – this time from the
American Heart Association – that deviates from our dignified ideals. This guideline is meant to rate appropriate
use of advanced imaging in all patients presenting to the Emergency Department
with chest pain. This includes, for
their purposes, imaging to evaluate nSTEMI/ACS, suspected PE, suspected
syndromes of the aorta, and “patients for whom a leading diagnosis is problematic
or not possible”.
My
irritation, as you might expect, comes at the expense of ACS and “leading
diagnosis is problematic or not possible”.
The guidelines weighing the pros and cons of the various options for
imaging PE and the aorta are inoffensive.
However, their evaluation of chest pain has one big winner: coronary CT
angiograms. The only time this test is
not appropriate in a patient with potential ACS is when the patient has a
STEMI. They provide a wide range of
broad clinical scenarios to assist the dutiful reader – all of which are CCTA
territory – including as every low/intermediate risk nonischemic EKG and
troponin-negative syndrome, explicitly even TIMI 0 patients.
Their
justification of such includes citation of the big three – ACRIN-PA, ROMICAT
II, and CT-STAT – showing the excellent negative predictive value of the
test. Indeed, the issues with the test –
middling specificity inflicted upon low disease prevalence, increased
downstream invasive angiography and revascularization of questionable value –
are basically muttered under the breath of the authors. Such dismissive treatment of the downsides of
the test are of no surprise, considering Harold Litt, of ACRIN-PA and Siemens,
is part of the writing panel for the guideline.
I will, again, point you to Rita Redberg’s excellent editorial in the
New England Journal of Medicine, refuting the foundation of such wanton use of
CCTA in the emergency evaluation of low-risk chest pain.
The “leading
diagnosis is problematic or not possible” category is just baffling. Are we really trying to enable clinicians to
be so helpless as to say, “I don’t know!
Why think when I can scan?” The
so-called “triple rule-out” is endorsed in this document for this exact
scenario – so you can use a test whose characteristics for detection of each
entity under consideration are just as degraded as your clinical acumen.
Fantastically,
both the Society of Academic Emergency Medicine and the American College of
Emergency Physicians are somehow co-signatories to this document. How can we possibly endorse such fragrant
literature?
See also: 2015
ACR/ACC/AHA/AATS/ACEP/ ASNC/NASCI/SAEM/SCCT/SCMR/ SCPC/SNMMI/STR/STS
Appropriate Utilization of Cardiovascular Imaging in Emergency Department
Patients with Chest Pain. http://www.ncbi.nlm.nih.gov/pubmed/26809772
B. What Did We Find On Stress Testing?
Wednesday,
November 4, 2015
The so-called
“provocative” testing advocated by the American Heart Association for every
patient with chest pain of possible ischemic origin has been the thistle in our
salad for many years. They are the nidus
for the crystallization of countless chest-pain observation units in our
Emergency Departments.
And, they are
one of lowest-yield venues in medicine.
Last year, I
reported on a set of 1,754 biomarker-negative patients undergoing stress
testing in Rhode Island, only 20 of which were true positives: http://www.emlitofnote.com/2014/05/burn-accaha-low-risk-chest-pain.html.
This latest report follows-up the stress
testing outcomes from the ASPECT and ADAPT cohorts in New Zealand. Of the 1,483 patients enrolled with negative
biomarkers, 749 ultimately underwent exercise tolerance testing – 32 of which
were positive, 22 of such had stenosis of greater than 70%. Including index admission and 1-year
follow-up of the study cohort, 20 of these received some form of
revascularization (PCI or CABG). In
addition, there were 66 equivocal and 103 submaximal stress tests contributing
to a total of 70 episodes of invasive coronary angiography, 32 of which
identified stenosis over 70%.
This is
slightly higher yield, overall, than the previously reported U.S. cohort. Most likely, this is due to patients in this
study being almost a decade older – almost 60 years on average – and having
median TIMI score of 2, compared with the U.S. stress test population having a
TIMI of 0. But, clearly, a cohort
referred for stress testing resulting in only a 4.8% initial revascularization,
including just 36 of 93 referred for coronary angiography, is not an effective
use of healthcare resources. And, this
presumes the interventions performed as a result of stress testing provide some
incremental morbidity or mortality benefit.
There are
certainly patients for whom the various types of stress testing, non-invasive
coronary angiography, and invasive angiography are each appropriate – but
clearly we need to dramatically improve the specificity of our selection
criteria.
“The
incremental value of stress testing in patients with acute chest pain beyond
serial cardiac troponin testing” http://emj.bmj.com/content/early/2015/10/28/emermed-2015-204823.abstract
11. Drug shortages affect hospital, physician decision-making
Shortages of
drugs from antibiotics to cancer treatments have become a new norm in medicine,
and physicians and government and hospital officials say it has led to ad hoc
policies, contradictory conclusions and questionable ethical decisions and
medical practices. Physicians can see the effects of cutting back drug dosages
or making drug substitutions, but the industry is not tracking outcomes of
patients getting substitute medications or delayed treatment.
12. Delays to initial reduction attempt are associated with
higher failure rates in anterior shoulder dislocation: a retrospective analysis
of factors affecting reduction failure.
Kanji A, et
al. Emerg Med J. 2016 Feb;33(2):130-3.
INTRODUCTION:
Little is understood about the relationship between delay to treatment and
initial reduction success for anterior shoulder dislocation. Our study examines
whether delays to initial treatment, from injury and hospital presentation, are
associated with higher reduction failure rates for anterior shoulder
dislocation.
METHODS: A
retrospective database and chart review was performed for patients undergoing
intravenous sedation for attempted reduction of anterior shoulder dislocation
in the emergency department (ED). Stepwise regression analysis was performed to
identify predictors of reduction failure. Key variables analysed were the
duration of the wait in the ED, the interval between the time of injury and
first intervention and the interval from time of injury to arrival at the ED.
Possible confounding variables analysed included age, gender, dose of sedative
agent, qualifications of the reducing physician and whether the dislocated
shoulder was recurrent.
RESULTS: The
duration of the intervals from injury to first reduction attempt and from arrival
at the ED to first reduction attempt were both independent predictors of a
higher reduction failure rate (OR=1.07, 95% CI 1.02 to 1.13; OR=1.19, 95% CI
1.05 to 1.34). Every interval of 10 min increased the odds of a failed
reduction attempt by 7% and 19%, respectively. Overall, shoulder reduction was
successful during the initial sedation event in 97 cases (92%) and unsuccessful
in nine cases (8%).
CONCLUSIONS:
Delays to first reduction attempt either from the time of injury or within the
ED are associated with a lower reduction success rate for anterior shoulder
dislocations.
13. Opioids and Abuse
A. Relationship between Nonmedical
Prescription-Opioid Use and Heroin Use
Compton WM,
et al. N Engl J Med 2016; 374:154-16
The
nonmedical use of prescription opioids is a major public health issue in the
United States, both because of the overall high prevalence and because of
marked increases in associated morbidity and mortality.1 In 2014, a total of
10.3 million persons reported using prescription opioids nonmedically (i.e.,
using medications that were not prescribed for them or were taken only for the
experience or feeling that they caused).2 Emergency department visits involving
misuse or abuse of prescription opioids increased 153% between 2004 and 2011,
and admissions to substance-abuse treatment programs linked to prescription
opioids more than quadrupled between 2002 and 2012.3,4 Most troubling, between
2000 and 2014 the rates of death from prescription-opioid overdose nearly
quadrupled (from 1.5 to 5.9 deaths per 100,000 persons).
The pattern
of nonmedical use of prescription opioids varies, from infrequent use once or
twice per year to daily or compulsive heavy use and addiction. A key underlying
characteristic of the epidemic is the association between the increasing rate
of opioid prescribing and increasing opioid-related morbidity and mortality.6-9
Pain has also been identified as a poorly addressed clinical and public health
problem for which treatment with prescription opioids may play an important
role.10 Taken together, these trends suggest the need for balanced prevention
responses that aim to reduce the rates of nonmedical use and overdose while
maintaining access to prescription opioids when indicated.
In response
to these interrelated public health problems, federal, state, and other vested
interests are implementing a variety of policies and programs aimed at curbing
inappropriate prescribing.1,6,11-16 These efforts include educating health
professionals and the public about appropriate use, implementing
prescription-drug monitoring programs, taking enforcement and regulatory
actions to address egregious prescribing (e.g., eliminating “pill mills”), and
developing prescription opioids that incorporate abuse-deterrent technologies.
Although more
rigorous evaluation is needed, there are some indications that these
initiatives are beginning to show some success. A recent study showed that the
rate of opioid prescribing in the United States stabilized between 2010 and
2012, with some medical specialties showing declines in the rate of opioid
prescribing after consistent increases for a number of years.17 States and
localities that took the most decisive action are seeing a decrease in the
availability of prescription opioids coupled with a decline in the rate of
deaths from overdose.13-15 Using national data, the Centers for Disease Control
and Prevention reported that there were 16,007 and 16,235 overdose-related
deaths in 2012 and 2013, respectively, involving opioid analgesic agents, down
from a peak of 16,917 deaths in 2011; however, the 18,893 deaths reported in
2014 suggest continued concerns.5 Another study showed that abuse of
prescription opioids increased between 2002 and 2010 and then plateaued between
2011 and 2013.18
Coinciding
with these efforts to reduce nonmedical prescription-opioid use and overdose
are reports of increases in the rates of heroin use (including both injection
and noninjection routes of administration) and deaths from heroin overdose.
According to national surveillance data, 914,000 people reported heroin use in
2014, a 145% increase since 2007,2 and mortality due to heroin overdose more
than quintupled, from 1842 deaths in 2000 to 10,574 deaths in 2014.5 Some
researchers suggest that the very policies and practices that have been
designed to address inappropriate prescribing are now fueling the increases in
rates of heroin use and death.16,18 This is the key question addressed in this
review…
B. Opioid risk reduction initiatives
for chronic therapy patients
Avoiding high
opioid doses may reduce chronic opioid therapy (COT) risks, but the feasibility
of reducing opioid doses in community practice is unknown. Washington state and
a health plan's group practice implemented initiatives to reduce high-dose COT
prescribing. The group practice physicians were exposed to both initiatives,
while its contracted physicians were exposed only to statewide changes. The
authors assessed whether these initiatives reduced opioid doses among COT
patients. The proportion receiving excess opioid days supplied declined from
24.0% to 10.4% among group practice COT patients and from 20.1% to 14.7% among
COT patients of contracted physicians.
14. Laparoscopic Lavage for Perforated Diverticulitis with
Purulent Peritonitis: A Randomized Trial
Thornell A,
et al. Ann Intern Med. 2016;164(3):137-145.
Background:
Perforated diverticulitis with purulent peritonitis has traditionally been
treated with open colon resection and stoma formation with risk for
reoperations, morbidity, and mortality. Laparoscopic lavage alone has been
suggested as definitive treatment.
Objective: To
compare laparoscopic lavage with open colon resection and colostomy (Hartmann
procedure) for perforated diverticulitis with purulent peritonitis.
Design:
Randomized, controlled, multicenter, open-label trial. (ISRCTN registry number:
ISRCTN82208287)
Setting: 9
hospitals in Sweden and Denmark.
Patients:
Patients who have confirmed Hinchey grade III perforated diverticulitis with
purulent peritonitis at diagnostic laparoscopy.
Intervention:
Randomization between laparoscopic lavage and the Hartmann procedure.
Measurements:
Primary outcome was the percentage of patients having 1 or more reoperations
within 12 months. Key secondary outcomes were number of reoperations, hospital
readmissions, total length of hospital stay during 12 months, and adverse
events.
Results: A
total of 43 and 40 patients were randomly assigned to laparoscopic lavage and
the Hartmann procedure with a median (first, third quartiles) follow-up of 372
days (336, 394) and 378 days (226, 396), respectively. Fewer patients in the
laparoscopic group (12 of 43; 27.9%) than in the Hartmann group (25 of 40;
62.5%) had at least 1 reoperation within 12 months (relative risk reduction,
59%; relative risk, 0.41 [95% CI, 0.23 to 0.72]; P = 0.004). Mortality and
severe adverse events did not differ between groups. Total length of hospital
stay (days) within 12 months was shorter for the laparoscopic group than the
Hartmann group, with a reduction of 35% (relative risk, 0.65 [CI, 0.45 to
0.94]; P = 0.047). After 12 months, 3 patients in the laparoscopic group and 11
in the Hartmann group had a stoma.
Limitation:
Not all patients presenting with suspected diverticulitis were enrolled.
Conclusion:
Laparoscopic lavage reduced the need for reoperations, had a similar safety
profile to the Hartmann procedure, and may be an appropriate treatment of
choice for acute perforated diverticulitis with purulent peritonitis.
15. Inadequacies of Physical Examination as a Cause of Medical
Errors and Adverse Events: A Collection of Vignettes.
Verghese A,
et al. Am J Med. 2015 Dec;128(12):1322-1324.e3
BACKGROUND:
Oversights in the physical examination are a type of medical error not easily
studied by chart review. They may be a major contributor to missed or delayed
diagnosis, unnecessary exposure to contrast and radiation, incorrect treatment,
and other adverse consequences. Our purpose was to collect vignettes of
physical examination oversights and to capture the diversity of their
characteristics and consequences.
METHODS: A
cross-sectional study using an 11-question qualitative survey for physicians
was distributed electronically, with data collected from February to June of
2011. The participants were all physicians responding to e-mail or social media
invitations to complete the survey. There were no limitations on geography,
specialty, or practice setting.
RESULTS: Of
the 208 reported vignettes that met inclusion criteria, the oversight was
caused by a failure to perform the physical examination in 63%; 14% reported
that the correct physical examination sign was elicited but misinterpreted,
whereas 11% reported that the relevant sign was missed or not sought.
Consequence of the physical examination inadequacy included missed or delayed
diagnosis in 76% of cases, incorrect diagnosis in 27%, unnecessary treatment in
18%, no or delayed treatment in 42%, unnecessary diagnostic cost in 25%, unnecessary
exposure to radiation or contrast in 17%, and complications caused by
treatments in 4%. The mode of the number of physicians missing the finding was
2, but many oversights were missed by many physicians. Most oversights took up
to 5 days to identify, but 66 took longer. Special attention and skill in
examining the skin and its appendages, as well as the abdomen, groin, and
genitourinary area could reduce the reported oversights by half.
CONCLUSIONS:
Physical examination inadequacies are a preventable source of medical error,
and adverse events are caused mostly by failure to perform the relevant
examination.
16. Can VBG analysis replace ABG analysis in emergency care?
Anne-Maree
Kelly. Emerg Med J 2016;33:152-154
Blood gas
analysis is an integral part of the assessment of emergency department (ED)
patients with acute respiratory or metabolic disease. Traditionally ABG
analyses have been used, but increasingly, emergency clinicians are using
venous blood gas (VBG) analyses. This has been challenged, especially by
respiratory physicians, as being too inaccurate.
This clinical
review, using case examples, summarises the evidence supporting use of VBG to
guide management decisions. Arteriovenous agreement for pH is such that values
are clinically interchangeable and agreement for bicarbonate is also close.
Agreement for pCO2 is poor with 95% limits of agreement of the order of
20 mm Hg (2.67 kPa); however, there is solid evidence that a venous pCO2
≤45 mm Hg (6 kPa) reliably excludes clinically significant hypercarbia.
Evidence regarding arteriovenous agreement for base excess is unclear. Given
knowledge of the performance characteristics of VBG analyses, integration of
the clinical findings with VBG results is often sufficient to safely guide
treatment decision making.
17. Burnout and the Brain
Burnout is
not just a state of mind. Psychological research that draws on neuroscience and
endocrinology shows it to be a condition that leads to distinctive changes in
the anatomy and functioning of the brain. [Scary!]
By Alexandra
Michel. Observer. 2016;29(2):26-31.
(a publication of the Association for Psychological Science)
One of the
greatest threats to workplace safety may be from an unexpected source: stress…
It’s a
mistake to assume that burnout is merely an emotional response to long hours or
a challenging job. Rather, mounting scientific evidence shows that burnout
takes a profound physical toll that cascades well beyond our professional
lives. Using cutting-edge techniques, integrative research teams are
demonstrating that burnout is not just a state of mind, but a condition that
leaves its mark on the brain as well as the body.
Just as the
impact of burnout stifles healthy professional growth, emerging research shows
that the chronic psychosocial stress that characterizes burnout not only
impairs people’s personal and social functioning, it also can overwhelm their
cognitive skills and neuroendocrine systems — eventually leading to distinctive
changes in the anatomy and functioning of the brain.
Burnout Begins
The
psychologist Herbert Freudenberger is credited with bringing the term “burnout”
into the research lexicon in 1974, defining it as the loss of motivation,
growing sense of emotional depletion, and cynicism he observed among volunteers
working at a free clinic in New York City. Formerly idealistic mental health
workers were finding themselves depleted and weary, resenting patients and the
clinic.
Burnout is
now recognized as a legitimate medical disorder by much of mainstream medicine
and has even been given its own ICD-10 code (Z73.0 – Burn-out state of vital
exhaustion). Many of the symptoms of burnout overlap with the hallmarks of
depression, including extreme fatigue, loss of passion, and intensifying cynicism
and negativity.
APS Fellow
Christina Maslach, professor emerita at the University of California, Berkeley,
and one of the foremost researchers on burnout, began studying this emerging
phenomenon in the 1970s through a series of extensive interviews with employees
in service organizations. In analyzing the interviews, Maslach and colleagues
noticed a trend: Workers often reported feelings of profound emotional
exhaustion, negativity directed at clients and patients, and a crisis in
feelings of professional competence. Much like symptoms of depression, burnout
was asphyxiating people’s ambitions, idealism, and sense of worth.
The 1976
publication of Maslach’s article “Burned-Out,” published in the magazine Human
Behavior, generated a huge public response — popularizing the concept of
burnout within the popular press. Maslach received an incredible outpouring of
letters and phone calls from people who were grateful to find out that they
were not alone in their experience of burnout.
“I had not
expected at all that kind of reaction,” Maslach said. “The impact of that
article was just huge.” The article led to more research, more books, and more
attention from academic journals.
Maslach and
APS Fellow Susan E. Jackson (Rutgers University) collaborated on what would
become the most influential framework for defining and assessing burnout.
Published in 1981, the original paper describing the Maslach Burnout Inventory
has been cited well over 6,000 times to date, according to Google Scholar. The
scale evaluates burnout based on three key stress responses: an overwhelming
sense of exhaustion, feelings of cynicism and detachment, and a sense of
professional ineffectiveness and lack of accomplishment.
At its core,
burnout emerges when the demands of a job outstrip a person’s ability to cope
with the stress. People in careers focused on caregiving — teachers, nurses,
social workers, and physicians — report the most prevalent rates of burnout,
but the condition ultimately doesn’t discriminate among call center
representatives, professional athletes, or CEOs. Over time, jobs that require
too much of employees will cultivate feelings of negativity and hopelessness as
people struggle to meet impossible deadlines, deal with rude customers, or cope
with the emotional toll of professional caretaking.
It’s a common
misconception that the culprit behind burnout is simply working too long or too
hard — research indicates that other factors, both individual and
organizational, can be just as detrimental. For example, a comprehensive report
on psychosocial stress in the workplace published by the World Health
Organization identified consistent evidence that “high job demands, low
control, and effort–reward imbalance are risk factors for mental and physical
health problems.” Ultimately, burnout results when the balance of deadlines,
demands, working hours, and other stressors outstrips rewards, recognition, and
relaxation.
Over the past
20 years, Maslach and her collaborators have developed a comprehensive model
identifying six key components of the workplace environment that contribute to
burnout: workload, control, reward, community, fairness, and values. Burnout
emerges when one or more of these six areas is chronically mismatched between
an individual and his job. Over time, Maslach explained, passion erodes not
only because people have too much to do, but because of these other factors…
The rest of
the article (free): http://www.psychologicalscience.org/index.php/publications/observer/2016/february-16/burnout-and-the-brain.html
18. Influence of EMS-physician presence on survival after
out-of-hospital CPR: systematic review and meta-analysis.
Böttiger BW,
et al. Crit Care. 2016 Jan 9;20(1):4.
BACKGROUND: Evidence
suggests that EMS-physician-guided cardiopulmonary resuscitation (CPR) in
out-of-hospital cardiac arrest (OOHCA) may be associated with improved
outcomes, yet randomized controlled trials are not available. The goal of this
meta-analysis was to determine the association between EMS-physician- versus
paramedic-guided CPR and survival after OOHCA.
METHODS AND
RESULTS: Studies that compared EMS-physician- versus paramedic-guided CPR in
OOHCA published until June 2014 were systematically searched in MEDLINE, EMBASE
and Cochrane databases. All studies were required to contain survival data.
Data on study characteristics, methods, and as well as survival outcomes were
extracted. A random-effects model was used for the meta-analysis due to a high
degree of heterogeneity among the studies (I (2) = 44 %). Return of
spontaneous circulation [ROSC], survival to hospital admission, and survival to
hospital discharge were the outcome measures. Out of 3,385 potentially eligible
studies, 14 met the inclusion criteria. In the pooled analysis (n = 126,829),
EMS-physician-guided CPR was associated with significantly improved outcomes
compared to paramedic-guided CPR: ROSC 36.2 % (95 % confidence interval [CI]
31.0 - 41.7 %) vs. 23.4 % (95 % CI 18.5 - 29.2 %) (pooled odds ratio [OR] 1.89,
95 % CI 1.36 - 2.63, p less than 0.001); survival to hospital admission 30.1 %
(95 % CI 24.2 - 36.7 %) vs. 19.2 % (95 % CI 12.7 - 28.1 %) (pooled OR 1.78, 95
% CI 0.97 - 3.28, p = 0.06); and survival to discharge 15.1 % (95 % CI 14.6 -
15.7 %) vs. 8.4 % (95 % CI 8.2 - 8.5 %) (pooled OR 2.03, 95 % CI 1.48 - 2.79,
p less than 0.001).
CONCLUSIONS: This
systematic review suggests that EMS-physician-guided CPR in out-of-hospital
cardiac arrest is associated with improved survival outcomes.
19. Focused TEE by Emergency Physicians is Feasible and
Clinically Influential: Observational Results from a Novel US Program.
Arntfield R,
et al. J Emerg Med. 2016 Feb;50(2):286-94.
BACKGROUND:
Emergency physicians frequently employ transthoracic echocardiography (TTE) to
assist in diagnosis and therapy for patients with circulatory failure or
arrest. In critically ill patients, transesophageal echocardiography (TEE)
offers several advantages over TTE, including reliable, continuous image
acquisition and superior image quality. Despite these advantages, TEE is not
widely used by emergency physicians.
OBJECTIVE:
Report the feasibility, findings, and clinical influence observed from the
first described TEE program implemented in an emergency department (ED)
point-of-care ultrasound program.
METHODS: This
was a retrospective review of all ED TEE examinations carried out between
February 1, 2013 and January 30, 2015. TEE images and report details (including
operator, indication, findings, and clinical recommendation[s]) were exported
from the institutional ultrasound archive and analyzed. The electronic chart of
each patient was subsequently reviewed for the presence of any complications
related to the examination and their clinical course in the hospital.
RESULTS: A
total of 54 TEE examinations were performed by 12 different emergency
physicians. All patients were intubated, and 98% of the examinations were
determinate. The most common indications for TEE were intracardiac arrest care
in 23 (43%), postarrest management in 14 (26%), and undifferentiated
hypotension in 16 (40%). Probe insertion was successful in all cases. TEE
imparted a diagnostic influence in 78% of cases and impacted therapeutic
decisions in 67% of cases.
CONCLUSION:
From our analysis of a single-center experience, ED-based TEE showed a high
degree of feasibility and clinical utility, with a diagnostic and therapeutic
influence seen in the majority of cases. Focused TEE demonstrated strongest
uptake among intubated patients with either undifferentiated shock or cardiac
arrest.
20. Poor Historians: Some Notes on the Medical Memoir
By Suzanne
Koven. VQR, Winter 2016.
Suzanne Koven
is a primary-care physician and writer-in-residence in the Division of General
Internal Medicine at Massachusetts General Hospital. Her work has appeared in
the Boston Globe, the New England Journal of Medicine, and the Los Angeles
Review of Books. She contributes the interview column “The Big Idea” to the
Rumpus.
[DRV’s subtitle: Writing makes people
feel better]
I’m not
superstitious, but when I go for my mammogram every year, I perform a private
ritual. As I wait in the dark for the tech to return and tell me that the
radiologist has said all is well, I force myself to imagine that all is not
well. I imagine the request for additional images, the biopsy, the consultation
with the oncologist and the surgeon, the sessions in the reclining chemotherapy
chair, my head bald. I try on various cancer personalities: brave and dignified
versus whining and cowardly. In my mind I wear jaunty baseball caps and Hermès
scarves. I feel the plastic lump of the catheter in my upper chest. I believe
that the more clearly I imagine these things, the less real they are likely to
become. I believe, against all reason and everything I know as a physician,
that misfortune always surprises, and that I can prevent cancer simply by
expecting it.
For many
years, my ritual worked. Then, one year, a glitch. The tech returned and said
“additional images.” She said there was an area of concern in my right breast
and that the radiologist wanted to get a better look. Barely had she uttered
these phrases when they italicized in my mind, angling deep into the fear
center of my brain. Then the tech took another round of pictures and excused
herself, leaving me in the cool, dimly lit room, half naked, the shadow of my
doom glowing on a computer screen.
Imagining the
worst as I stood and waited did nothing to assuage my fear. But imagining how I
might write about imagining the worst did. I began composing an essay—or the
first chapter of a memoir, I decided, if things turned out really badly. With
each sentence I grew less anxious. A couple of hours later, when a needle
aspiration proved the “area of concern” to be a benign cyst, I was already
quite calm.
Writing makes people feel better. This may sound strange to anyone
who’s struggled with a class assignment, or to many professional writers. But
research begun in the 1970s, much of it done by James W. Pennebaker, a
psychologist at the University of Texas at Austin, has shown that writing as
little as thirty minutes a day for four days in a row can ease anxiety and
depression and help people recover from illness and trauma. In one study of
what Pennebaker named “expressive writing,” participants who wrote about
stressful experiences were less likely to require urgent medical care than
students who wrote about more mundane subjects, like their dorm rooms or their
shoes. In another study, people with asthma or rheumatoid arthritis who wrote
about the most traumatic events of their lives had fewer flare-ups of their
diseases. Writing can boost immunity, relieve pain, improve liver and lung
function, and lower blood pressure.
No one is
really sure how this works, but it may be similar to how psychotherapy does. In
ways which elude our full understanding, putting emotions into words changes
brain chemistry and brain architecture, which, in turn, affects the rest of the
body. Writing rather than speaking or thinking those words seems to have a
particularly profound influence on the brain. If I’d had a way to jot down my
thoughts in the mammography room that day, I might have felt even calmer. And
there’s some evidence that putting pen or pencil to paper is even more helpful
than typing.
In explaining
his findings, Pennebaker emphasizes the toxicity of keeping secrets. One of his
early studies showed that people who wrote about their traumas were less likely
to have physical symptoms than those who didn’t articulate them, a validation
and amplification of Freud’s work on conversion disorders and hysteria a
century earlier. In thinking about my medical practice and my own experiences
as a patient, I’ve wondered if writing restores, even if briefly, a sense of
control. To be ill or injured is to lack control, and the humiliations of the
hospital routine compound a patient’s feeling of helplessness. (My mother once
commented, upon having her clothes, eyeglasses, jewelry, cell phone, and wallet
confiscated before surgery: “This is how they treat prisoners.”) Writing can
transform what feels like a shapeless, endless, and meaningless experience into
something with structure, finitude, and implication.
Just recently
a patient of mine told me through tears that she was having a tough time after
a major illness and the death of several family members. She rebuffed my offers
of counseling and medication and said, “I don’t need any of that. I have my
journal.” As she said this, the woman pantomimed hugging her journal, as if she
could limit her pain to the notebook-sized space between her own hands—which,
in fact, she felt she had.
Writing also
offers a chance to reengage the person you used to be before you got sick, to
reassert what doctors sometimes call—awful phrase—your “premorbid personality.”
A medical student once told me that when he arrived in an emergency room
hallucinating, a psychiatrist quizzed him about what his diagnosis might be. He
told me he didn’t find the psychiatrist’s grilling insensitive but, rather, a
helpful acknowledgment that he wasn’t only mentally ill—he was also a medical
student…
21. CDC, ACP recommend limited antibiotic use for common
respiratory infections
The CDC and
the American College of Physicians have released guidelines advising physicians
to avoid prescribing antibiotics to adults with acute respiratory tract
infections, such as sore throat and sinus infection, unless a test confirms
streptococcal pharyngitis or sinus symptoms persist or worsen. The guidelines
also recommend against prescribing antibiotics for bronchitis unless signs of
pneumonia are present. The guidelines were published in the Annals of Internal
Medicine.
Appropriate Antibiotic Use for Acute
Respiratory Tract Infection in Adults: Advice for High-Value Care From the
American College of Physicians and the Centers for Disease Control and
Prevention
22. Medical Taylorism (and Toyota’s Lean Practices)
Hartzband P,
et al. N Engl J Med 2016; 374:106-108.
Frederick
Taylor, a son of Philadelphia aristocrats who lived at the turn of the last
century, became known as the “father of scientific management” — the original
“efficiency expert.” He believed that the components of every job could and
should be scientifically studied, measured, timed, and standardized to maximize
efficiency and profit. Central to Taylor’s system is the notion that there is
one best way to do every task and that it is the manager’s responsibility to
ensure that no worker deviates from it. “In the past, the man has been first;
in the future, the system must be first,” Taylor asserted.1
Toyota,
inspired by these principles of “Taylorism,” successfully applied them to the
manufacture of cars, thereby improving quality, eliminating waste, and cutting
costs. As health care comes under increasing economic pressure to achieve these
same goals, Taylorism has begun permeating the culture of medicine.
Advocates
lecture clinicians about Toyota’s “Lean” practices, arguing that patient care
should follow standardized systems like those deployed in manufacturing
automobiles. Colleagues have told us, for example, that managers with
stopwatches have been placed in their clinics and emergency departments to
measure the duration of patient visits. Their aim is to determine the optimal
time for patient–doctor interactions so that they can be standardized.
Meanwhile,
the electronic health record (EHR) — introduced with the laudable goals of
making patient information readily available and improving safety by
identifying dangerous drug–drug interactions — has become a key instrument for
measuring the duration and standardizing the content of patient–doctor
interactions in pursuit of “the one best way.” Encounters have been
restructured around the demands of the EHR: specific questions must be asked,
and answer boxes filled in, to demonstrate to payers the “value” of care.
Open-ended interviews, vital for obtaining accurate clinical information and
understanding patients’ mindsets, have become almost impossible, given the
limited time allotted for visits — often only 15 to 20 minutes. Instead,
patients are frequently given checklists in an effort to streamline the
interaction and save precious minutes. The EHR was supposed to save time, but
surveys of nurses and doctors show that it has increased the clinical workload
and, more important, taken time and attention away from patients.
Physicians
sense that the clock is always ticking, and patients are feeling the effect.
One of our patients recently told us that when she came in for a yearly
“wellness visit,” she had jotted down a few questions so she wouldn’t forget to
ask them. She was upset and frustrated when she didn’t get the chance: her
physician told her there was no time for her questions because a standardized
list had to be addressed — she’d need to schedule a separate visit to discuss
her concerns.
We believe
that the standardization integral to Taylorism and the Toyota manufacturing
process cannot be applied to many vital aspects of medicine. If patients were
cars, we would all be used cars of different years and models, with different
and often multiple problems, many of which had previously been repaired by
various mechanics. Moreover, those cars would all communicate in different
languages and express individual preferences regarding when, how, and even
whether they wanted to be fixed. The inescapable truth of medicine is that
patients are genetically, physiologically, psychologically, and culturally
diverse. It’s no wonder that experts disagree about the best ways to diagnose
and treat many medical conditions, including hypertension, hyperlipidemia, and
cancer, among others.
To be sure,
certain aspects of medicine have benefited from Taylor’s principles. Strict
adherence to standardized protocols has reduced hospital-acquired infections,
and timely care of patients with stroke or myocardial infarction has saved
lives. It may be possible to find one best way in such areas. But this aim
cannot be generalized to all of medicine, least of all to such cognitive tasks
as eliciting an accurate history, synthesizing clinical and laboratory data to
make a diagnosis, and weighing the risks and benefits of a given treatment for
an individual patient. Good thinking takes time, and the time pressure of
Taylorism creates a fertile field for the sorts of cognitive errors that result
in medical mistakes. Moreover, rushed clinicians are likely to take actions
that ignore patients’ preferences.
Part of the
original promise of scientific management was that increased efficiency and
standardization would not only result in a better product at lower cost, but
would also give workers more free time to enjoy life. Lillian Gilbreth, who
with her husband Frank championed motion studies of workers to boost their
efficiency, called this outcome saving time for “happiness minutes”2 (see
Perspective article by Gainty, pages xxx–xx). Similarly, some prominent
policymakers have claimed that implementing scientific management in medicine
would free doctors, nurses, and other members of the clinical team to spend
more time with their patients.3 In fact, the opposite seems to be happening.
Yet some of the greatest rewards of working in medicine come from spending
unstructured time with our patients, sharing their joys and sorrows.
Instead of
gaining happiness minutes, clinicians are increasingly experiencing dissatisfaction
and burnout as they’re subjected to the time pressures of Taylorism and
scientific management in the name of efficiency. We have watched colleagues
fleeing to concierge practices, where they have control over their schedules.
Others have taken early retirement, unwilling to compromise on what they
believe is the time needed to deliver compassionate care. Some have moved into
management or consulting positions, where they tell others how to practice
while unburdening themselves of their clinical load. Just as Taylor enriched
himself by consulting for companies, a growing and lucrative industry has
emerged to generate and enforce metrics in medicine. By 2014, the Centers for
Medicare and Medicaid Services alone had mandated the use of more than 1000
performance measures. As the Institute of Medicine recently reported, such
metrics have proliferated, though many of them have little proven value….4
23. Micro Bits
A. Prevalence and Characteristics of
Physicians Prone to Malpractice Claims
In an
analysis of U.S. malpractice data, 1% of physicians accounted for 32% of all
paid claims. The risk of future malpractice claims increased with the number of
previous claims; physicians with three previous paid claims had a 24% chance of
having another claim within 2 years.
B. 43% of patients with chronic pain
have taken too much OTC pain medication
A survey
commissioned by the American Gastroenterological Association found that 43% of
1,000 survey respondents said they had knowingly taken a
higher-than-recommended dose of over-the-counter pain medication, such as
acetaminophen or ibuprofen. In addition, 38% indicated they were unaware that
combining at least two nonsteroidal anti-inflammatory drugs or two or more
acetaminophen pain pills could be dangerous. The organization warns that
overuse of pain medicine increases likelihood of ulcers, stomach bleeding,
liver damage and death.
C. USPSTF calls for all adults to be
screened for depression
The US
Preventive Services Task Force recommended all US adults be screened for
depression, especially pregnant or postpartum women, in a final statement that
updates 2009 guidance. The recommendations, published in the Journal of the
American Medical Association, carry a B rating.
D. ED Management of a Myasthenia
Gravis Patient with Community-Acquired Pneumonia: Does Initial Antibiotic
Choice Lead to Cure or Crisis?
E. AFib presents greater heart, stroke
risks in women than men
Researchers
analyzed data from 30 studies and found that women with atrial fibrillation had
twice the risk of stroke and a 55% higher risk of heart attack, compared with
men who had the condition. Data showed women with AFib also had a 93% higher
risk of dying from a heart condition, a 16% greater risk of heart failure and a
12% higher all-cause mortality risk, compared with men. The findings were
published in The BMJ.
F. Eating Breakfast Regularly may
Reduce Stroke Risk
G. Doctors need to learn to say no.
Here’s how to do it.
STARLA FITCH,
MD | PHYSICIAN | JANUARY 30, 2016
If you have a
life where you never, ever say yes when you mean no, then you can stop reading
right now. But I guess that you’re a lot like me. Now and then, you get caught
off guard. And before you know it, you’re staying late to see that emergency
patient. Bringing cupcakes for the second-grade class. Volunteering for the
coffee meet-and-greet at church next Sunday. What’s up with that? We’re smart. ...
H. Single Ingestions of Factor Xa
Inhibitors Don't Appear to Cause Bleeding
Data from 8
poison control centers show no bleeding in cases of single ingestions of
apixaban or rivaroxaban.
