Saturday, February 06, 2016

Lit Bits: Feb 6, 2016

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.

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.

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].

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

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,, 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, 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:

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.

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:  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”

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…

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

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…

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

The remainder of the essay (free):

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.


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.