1. Clinical Risk Score for Persistent Postconcussion Symptoms among
Children with Acute Concussion in the ED.
Zemek R, et
al. JAMA. 2016 Mar 8;315(10):1014-25. doi: 10.1001/jama.2016.1203.
IMPORTANCE:
Approximately one-third of children experiencing acute concussion experience
ongoing somatic, cognitive, and psychological or behavioral symptoms, referred
to as persistent postconcussion symptoms (PPCS). However, validated and
pragmatic tools enabling clinicians to identify patients at risk for PPCS do
not exist.
OBJECTIVE: To
derive and validate a clinical risk score for PPCS among children presenting to
the emergency department.
DESIGN,
SETTING, AND PARTICIPANTS: Prospective, multicenter cohort study (Predicting
and Preventing Postconcussive Problems in Pediatrics [5P]) enrolled young
patients (aged 5 to 18 years) who presented within 48 hours of an acute head
injury at 1 of 9 pediatric emergency departments within the Pediatric Emergency
Research Canada (PERC) network from August 2013 through September 2014
(derivation cohort) and from October 2014 through June 2015 (validation
cohort). Participants completed follow-up 28 days after the injury.
EXPOSURES:
All eligible patients had concussions consistent with the Zurich consensus
diagnostic criteria.
MAIN OUTCOMES
AND MEASURES: The primary outcome was PPCS risk score at 28 days, which was
defined as 3 or more new or worsening symptoms using the patient-reported
Postconcussion Symptom Inventory compared with recalled state of being prior to
the injury.
RESULTS: In
total, 3063 patients (median age, 12.0 years [interquartile range, 9.2-14.6
years]; 1205 [39.3%] girls) were enrolled (n = 2006 in the derivation cohort;
n = 1057 in the validation cohort) and 2584 of whom (n = 1701 [85%] in the
derivation cohort; n = 883 [84%] in the validation cohort) completed follow-up
at 28 days after the injury. Persistent postconcussion symptoms were present in
801 patients (31.0%) (n = 510 [30.0%] in the derivation cohort and n = 291
[33.0%] in the validation cohort). The 12-point PPCS risk score model for the
derivation cohort included the variables of female sex, age of 13 years or
older, physician-diagnosed migraine history, prior concussion with symptoms lasting
longer than 1 week, headache, sensitivity to noise, fatigue, answering
questions slowly, and 4 or more errors on the Balance Error Scoring System
tandem stance. The area under the curve was 0.71 (95% CI, 0.69-0.74) for the
derivation cohort and 0.68 (95% CI, 0.65-0.72) for the validation cohort.
CONCLUSIONS
AND RELEVANCE: A clinical risk score developed among children presenting to the
emergency department with concussion and head injury within the previous 48
hours had modest discrimination to stratify PPCS risk at 28 days. Before this
score is adopted in clinical practice, further research is needed for external
validation, assessment of accuracy in an office setting, and determination of
clinical utility.
Journal Watch
editorial: http://www.jwatch.org/na40745/2016/03/08/can-we-predict-which-children-are-risk-persistent
2. Skin Abscess: Management Options
A.
NEJM Case Vignette: A Woman with an Abscess
Wilbur MB, et
al. N Engl J Med 2016; 374:882-884.
A 22-year-old
woman presents to the ED with a 3-day history of increasing redness, swelling,
and pain in her left thigh. She tells you that she otherwise feels well. She
reports no recent trauma and no fevers, chills, nausea, or vomiting. She has no
relevant medical history. She is not currently taking any medications and has
no known drug allergies. On physical examination, her body-mass index (the
weight in kilograms divided by the square of the height in meters) is 26, she
is afebrile, and her vital signs are within normal limits. Clinically, she
appears well. Her examination is notable only for an area of fluctuance,
approximately 2 cm in diameter, with associated tenderness, on the left
anterior thigh approximately 12 cm above the patella and not involving the
knee. Erythema extends approximately 2 cm beyond the edges of the fluctuance.
There is no spontaneous drainage and no associated lymphadenopathy.
Treatment Options
Which of the
following initial treatment options is most appropriate for this patient?
1. Incision
and drainage alone.
2. Incision
and drainage followed by trimethoprim–sulfamethoxazole therapy.
To aid in
your decision making, each of these approaches is defended in a short essay by
an expert in the field. Given your knowledge of the patient and the points made
by the experts, which option would you choose?
B.
Trimethoprim–Sulfamethoxazole Better than Placebo for Uncomplicated Skin
Abscess in an MRSA-prevalent Population
Talan TA, et
al. N Engl J Med 2016; 374:823-832.
Background: U.S.
emergency department visits for cutaneous abscess have increased with the
emergence of methicillin-resistant Staphylococcus aureus (MRSA). The role of
antibiotics for patients with a drained abscess is unclear.
Methods: We
conducted a randomized trial at five U.S. emergency departments to determine
whether trimethoprim–sulfamethoxazole (at doses of 320 mg and 1600 mg,
respectively, twice daily, for 7 days) would be superior to placebo in
outpatients older than 12 years of age who had an uncomplicated abscess that
was being treated with drainage. The primary outcome was clinical cure of the
abscess, assessed 7 to 14 days after the end of the treatment period.
Results: The
median age of the participants was 35 years (range, 14 to 73); 45.3% of the
participants had wound cultures that were positive for MRSA. In the modified
intention-to-treat population, clinical cure of the abscess occurred in 507 of
630 participants (80.5%) in the trimethoprim–sulfamethoxazole group versus 454
of 617 participants (73.6%) in the placebo group (difference, 6.9 percentage
points; 95% confidence interval [CI], 2.1 to 11.7; P=0.005). In the
per-protocol population, clinical cure occurred in 487 of 524 participants
(92.9%) in the trimethoprim–sulfamethoxazole group versus 457 of 533
participants (85.7%) in the placebo group (difference, 7.2 percentage points;
95% CI, 3.2 to 11.2; P less than 0.001). Trimethoprim–sulfamethoxazole was
superior to placebo with respect to most secondary outcomes in the per-protocol
population, resulting in lower rates of subsequent surgical drainage procedures
(3.4% vs. 8.6%; difference, −5.2 percentage points; 95% CI, −8.2 to −2.2), skin
infections at new sites (3.1% vs. 10.3%; difference, −7.2 percentage points;
95% CI, −10.4 to −4.1), and infections in household members (1.7% vs. 4.1%;
difference, −2.4 percentage points; 95% CI, −4.6 to −0.2) 7 to 14 days after the
treatment period. Trimethoprim–sulfamethoxazole was associated with slightly
more gastrointestinal side effects (mostly mild) than placebo. At 7 to 14 days
after the treatment period, invasive infections had developed in 2 of 524
participants (0.4%) in the trimethoprim–sulfamethoxazole group and in 2 of 533
participants (0.4%) in the placebo group; at 42 to 56 days after the treatment
period, an invasive infection had developed in 1 participant (0.2%) in the
trimethoprim–sulfamethoxazole group.
Conclusions: In
settings in which MRSA was prevalent, trimethoprim–sulfamethoxazole treatment
resulted in a higher cure rate among patients with a drained cutaneous abscess
than placebo.
C.
Proportion of S. aureus infections due to MRSA declines in US children
Researchers
found that susceptibility of methicillin-susceptible Staphylococcus aureus to
clindamycin dropped from 90% to 83% over the 10-year study period, while more
than 60% of isolates had an increased susceptibility to oxacillin in 2014. The
findings in Pediatrics, based on 41,745 S. aureus isolates collected from
39,207 children from 2005 to 2014, showed that the proportion of S. aureus
infections due to methycillin-resistant S. aureus appear to be decreasing among
children.
3. The long spine board does not reduce lateral motion during
transport—a randomized healthy volunteer crossover trial
Wampler DA,
et al. Amer J Emerg Med. 2016;34(4):717-721.
OBJECTIVE:
For thirty years, emergency medical services agencies have emphasized limiting
spinal motion during transport of the trauma patient to the emergency department.
The long spine board (LSB) has been the mainstay of spinal motion restriction
practices, despite the paucity of data to support its use. The purpose of this
study was to determine reduction in lateral motion afforded by the LSB in
comparison to the stretcher mattress alone.
METHODS: This
was a randomized controlled crossover trial where healthy volunteer subjects
were randomly assigned to either LSB or stretcher mattress only. All subjects
were fitted with a rigid cervical collar, secured to the assigned device
(including foam head blocks), and driven on a closed course with prescribed
turns at a low speed (less than 20 mph). Upon completion, the subjects were
then secured to the other device and the course was repeated. Each subject was
fitted with 3 graduated-paper disks (head, chest, hip). Lasers were affixed to
a scaffold attached to the stretcher bridging over the patient and aimed at the
center of the concentric graduations on the disks. During transport, the degree
of lateral movement was recorded during each turn. Significance was determined
by t test.
RESULTS: In
both groups, the head demonstrated the least motion with 0.46±0.4-cm mattress
and 0.97±0.7-cm LSB (P≤ .0001). The chest and hip had lateral movement with
chest 1.22±0.9-cm mattress and 2.22±1.4-cm LSB (P≤ .0001), and the hip
1.20±0.9-cm mattress and 1.88±1.2-cm LSB (P≤ .0001), respectively. In addition,
lateral movement had a significant direct correlation with body mass index.
CONCLUSION:
The stretcher mattress significantly reduced lateral movement during transport.
4. Delivering safe and effective analgesia for management of
renal colic in the ED: a double-blind, multigroup, randomised controlled trial
Pathan SA, et
al. Lancet 2016 March 15 [Epub ahead of print]
Background
The
excruciating pain of patients with renal colic on presentation to the emergency
department requires effective analgesia to be administered in the shortest
possible time. Trials comparing intramuscular non-steroidal anti-inflammatory
drugs with intravenous opioids or paracetamol have been inconclusive because of
the challenges associated with concealment of randomisation, small sample size,
differences in outcome measures, and inadequate masking of participants and
assessors. We did this trial to develop definitive evidence regarding the
choice of initial analgesia and route of administration in participants
presenting with renal colic to the emergency department.
Methods
In this
three-treatment group, double-blind, randomised controlled trial, adult
participants (aged 18–65 years) presenting to the emergency department of an
academic, tertiary care hospital in Qatar, with moderate to severe renal colic
(Numerical pain Rating Scale ≥4) were recruited. With the use of computer-generated
block randomisation (block sizes of six and nine), participants were assigned
(1:1:1) to receive diclofenac (75 mg/3 mL intramuscular), morphine (0·1 mg/kg
intravenous), or paracetamol (1 g/100 mL intravenous). Participants,
clinicians, and trial personnel were masked to treatment assignment. The
primary outcome was the proportion of participants achieving at least a 50%
reduction in initial pain score at 30 min after analgesia, assessed by
intention-to-treat analysis and per-protocol analysis, which included patients
where a calculus in the urinary tract was detected with imaging. This trial is
registered with ClinicalTrials.gov, number NCT02187614.
Findings
Between Aug
5, 2014, and March 15, 2015, we randomly assigned 1645 participants, of whom 1644
were included in the intention-to-treat analysis (547 in the diclofenac group,
548 in the paracetemol group, and 549 in the morphine group). Ureteric calculi
were detected in 1316 patients, who were analysed as the per-protocol
population (438 in the diclofenac group, 435 in the paracetemol group, and 443
in the morphine group). The primary outcome was achieved in 371 (68%) patients
in the diclofenac group, 364 (66%) in the paracetamol group, and 335 (61%) in
the morphine group in the intention-to-treat population. Compared to morphine,
diclofenac was significantly more effective in achieving the primary outcome
(odds ratio [OR] 1·35, 95% CI 1·05–1·73, p=0·0187), whereas no difference was
detected in the effectiveness of morphine compared with intravenous paracetamol
(1·26, 0·99–1·62, p=0·0629). In the per-protocol population, diclofenac (OR
1·49, 95% CI 1·13–1·97, p=0·0046) and paracetamol (1·40, 1·06–1·85, p=0·0166)
were more effective than morphine in achieving the primary outcome. Acute
adverse events in the morphine group occurred in 19 (3%) participants.
Significantly lower numbers of adverse events were recorded in the diclofenac
group (7 [1%] participants, OR 0·31, 95% CI 0·12–0·78, p=0·0088) and
paracetamol group (7 [1%] participants, 0·36, 0·15–0·87, p=0·0175) than in the
morphine group. During the 2 week follow-up, no additional adverse events were
noted in any group.
Interpretation
Intramuscular
non-steroidal anti-inflammatory drugs offer the most effective sustained
analgesia for renal colic in the emergency department and seem to have fewer
side-effects.
Journal Watch
editorial: http://www.jwatch.org/na40833/2016/03/16/pain-control-renal-colic-emergency-department
5. Effectiveness of EDACS vs ADAPT Accelerated Diagnostic
Pathways for CP: A Pragmatic RCT Embedded within Practice.
Than MP, et
al. Ann Emerg Med. 2016 Mar 2 [Epub ahead of print]
STUDY OBJECTIVE:
A 2-hour accelerated diagnostic pathway based on the Thrombolysis in Myocardial
Infarction score, ECG, and troponin measures (ADAPT-ADP) increased early
discharge of patients with suspected acute myocardial infarction presenting to
the emergency department compared with standard care (from 11% to 19.3%).
Observational studies suggest that an accelerated diagnostic pathway using the
Emergency Department Assessment of Chest Pain Score (EDACS-ADP) may further
increase this proportion. This trial tests for the existence and size of any
beneficial effect of using the EDACS-ADP in routine clinical care.
METHODS: This
was a pragmatic randomized controlled trial of adults with suspected acute
myocardial infarction, comparing the ADAPT-ADP and the EDACS-ADP. The primary
outcome was the proportion of patients discharged to outpatient care within 6
hours of attendance, without subsequent major adverse cardiac event within 30
days.
RESULTS: Five
hundred fifty-eight patients were recruited, 279 in each arm. Sixty-six
patients (11.8%) had a major adverse cardiac event within 30 days (ADAPT-ADP
29; EDACS-ADP 37); 11.1% more patients (95% confidence interval 2.8% to 19.4%)
were identified as low risk in EDACS-ADP (41.6%) than in ADAPT-ADP (30.5%). No
low-risk patients had a major adverse cardiac event within 30 days (0.0% [0.0%
to 1.9%]). There was no difference in the primary outcome of proportion
discharged within 6 hours (EDACS-ADP 32.3%; ADAPT-ADP 34.4%; difference -2.1%
[-10.3% to 6.0%], P=.65).
CONCLUSION: There
was no difference in the proportion of patients discharged early despite more
patients being classified as low risk by the EDACS-ADP than the ADAPT-ADP. Both
accelerated diagnostic pathways are effective strategies for chest pain
assessment and resulted in an increased rate of early discharges compared with
previously reported rates.
6. Standardized Asthma Admission Criteria Reduce Length of Stay
in a Pediatric ED.
Rutman L, et
al. Acad Emerg Med. 2016;23(3):289-296.
OBJECTIVES:
Asthma is the most common chronic illness in children and accounts for over 600,000
emergency department (ED) visits each year. Reducing ED length of stay for
moderate to severe asthmatics improves ED throughput and patient care for this
high risk population. The objective of this study was to determine the impact
of adding standardized, respiratory score based admission criteria to an asthma
pathway on: ED length of stay for admitted patients; time to bed request;
overall percent admitted asthmatics; inpatient length of stay; and percent of
PICU admissions.
METHODS: This
was a retrospective study of a quality improvement intervention. Statistical
process control methodologies were used to analyze measures 15 months before
and after implementation of a modified asthma pathway (6/2010 to 12/2012;
pathway modification 9/2011).
RESULTS:
Three thousand six hundred eighty-eight patients aged 1 through 18 years who
presented to an ED with an asthma exacerbation during the study period were
included. Patients were excluded if they were not eligible for the asthma
pathway. Patient characteristics were similar before and after the
intervention. Mean ED length of stay and time to bed request for admitted
asthmatics both decreased by 30 minutes. There was no change in percent of
asthma admissions (34%), mean inpatient length of stay (1.4 days), or percent
PICU admissions (2%).
CONCLUSIONS:
Standardizing care for asthma patients to include objective admission criteria
early in the ED course may optimize patient care and improve ED flow. This
article is protected by copyright. All rights reserved.
7. IV fluids for migraine: a post hoc analysis of clinical trial
data.
Balbin JE, et
al. Am J Emerg Med. 2016;34(4):713–716.
BACKGROUND: A
total of 1.2 million patients present to US emergency departments (EDs)
annually with migraine headache. Intravenous fluid (IVF) hydration is used to
treat acute migraine commonly. We were unable to identify published data to
support or refute this practice. The goal of this analysis was to determine if
administration of IVF is associated with improved short-term (1 hour) or
sustained (24hours) migraine outcomes.
METHODS: This
was a post hoc analysis of data collected from 4 ED-based migraine clinical
trials in which patients were randomized to treatment with intravenous
metoclopramide. In each of these studies, patients were administered IVF at the
discretion of the treating physician. Our primary short-term outcome was
improvement in 0 to 10 pain scale between baseline and 1hour later. Our primary
sustained outcome was the attainment of sustained headache freedom, defined as
achieving a headache level of "none" in the ED and maintaining a
level of "none" without headache recurrence throughout the 24- to
48-hour follow-up period. We compared mean improvement in pain scores between
baseline and 1hour later between those patients who received IVF and those who
did not. We also compared the frequency of sustained headache freedom between
both groups. We then used regression models to elucidate how nausea at baseline
and the baseline pain score modified the relationship between IVF and the 2
outcomes.
RESULTS: A
total of 570 patients were included in the analysis. Of these, 112 (20%) were
treated with IVF. Patients who received IVF improved by 4.5 (95% confidence
interval [CI], 4.0-5.0) on the 0 to 10 scale, whereas patients who did not
receive IVF improved by 5.1 (95% CI, 4.8-5.3) (95% CI for difference of 0.6,
0-1.1). Of patients who received IVF, 14% (95% CI, 9-22%) enjoyed sustained
headache freedom vs 18% (95% CI, 15%-22%) of patients who did not (95% CI for difference
of 4%, -4% to 11%). In the linear regression model, IVF was associated with
less improvement in 0 to 10 pain score between baseline and 1 hour (B
coefficient, -0.6; 95% CI, -1.1 to 0; P=.05). In the logistic regression model,
IVF administration was not associated with sustained headache freedom (odds
ratio, 0.8; 95% CI, 0.4-1.5; P=.52).
CONCLUSION:
Intravenous fluid did not improve pain outcomes among patients with acute
migraine who were treated with intravenous metoclopramide.
8. Heart Failure in the ED
A.
Diagnosing Acute HF in the ED: A Systematic Review and Meta-analysis
Martindale
JL, et al. Acad Emerg Med. 2016;23(3):223–242.
Background
Acute heart
failure (AHF) is one of the most common diagnoses assigned to emergency
department (ED) patients who are hospitalized. Despite its high prevalence in
the emergency setting, the diagnosis of AHF in ED patients with
undifferentiated dyspnea can be challenging.
Objectives
The primary
objective of this study was to perform a systematic review and meta-analysis of
the operating characteristics of diagnostic elements available to the emergency
physician for diagnosing AHF. Secondary objectives were to develop a
test–treatment threshold model and to calculate interval likelihood ratios
(LRs) for natriuretic peptides (NPs) by pooling patient-level results.
Methods
PubMed,
EMBASE, and selected bibliographies were searched from January 1965 to March
2015 using MeSH terms to address the ability of the following index tests to
predict AHF as a cause of dyspnea in adult patients in the ED: history and
physical examination, electrocardiogram, chest radiograph (CXR), B-type
natriuretic peptide (BNP), N-terminal proB-type natriuretic peptide
(NT-proBNP), lung ultrasound (US), bedside echocardiography, and bioimpedance.
A diagnosis of AHF based on clinical data combined with objective test results
served as the criterion standard diagnosis. Data were analyzed using Meta-DiSc
software. Authors of all NP studies were contacted to obtain patient-level
data. The Quality Assessment Tool for Diagnostic Accuracy Studies-2 (QUADAS-2)
for systematic reviews was utilized to evaluate the quality and applicability
of the studies included.
Results
Based on the
included studies, the prevalence of AHF ranged from 29% to 79%. Index tests
with pooled positive LRs ≥ 4 were the auscultation of S3 on physical
examination (4.0, 95% confidence interval [CI] = 2.7 to 5.9), pulmonary edema
on both CXR (4.8, 95% CI = 3.6 to 6.4) and lung US (7.4, 95% CI = 4.2 to 12.8),
and reduced ejection fraction observed on bedside echocardiogram (4.1, 95% CI =
2.4 to 7.2). Tests with low negative LRs were BNP less than 100 pg/mL (0.11,
95% CI = 0.07 to 0.16), NT-proBNP less than 300 pg/mL (0.09, 95% CI = 0.03 to
0.34), and B-line pattern on lung US LR (0.16, 95% CI = 0.05 to 0.51). Interval
LRs of BNP concentrations at the low end of “positive” results as defined by a
cutoff of 100 pg/mL were substantially lower (100 to 200 pg/mL; 0.29, 95% CI =
0.23 to 0.38) than those associated with higher BNP concentrations (1000 to
1500 pg/mL; 7.12, 95% CI = 4.53 to 11.18). The interval LR of NT-proBNP
concentrations even at very high values (30,000 to 200,000 pg/mL) was 3.30 (95%
CI = 2.05 to 5.31).
Conclusions
Bedside lung
US and echocardiography appear to the most useful tests for affirming the
presence of AHF while NPs are valuable in excluding the diagnosis.
B.
European Society of Cardiology – Acute Cardiovascular Care Association position
paper on safe discharge of acute HF patients from the ED
Miró Ò, et
al. Eur Heart J Acute Cardiovasc Care. 2016 Feb 21 [Epub ahead of print]
Heart failure
is a global public health challenge frequently presenting to the emergency
department. After initial stabilization and management, one of the most
important decisions is to determine which patients can be safely discharged and
which require hospitalization. This is a complex decision that depends on
numerous subjective factors, including both the severity of the patient's
underlying condition and an estimate of the acuity of the presentation. An
emergency department observation period may help select the correct option.
Ideally, during an observation period, risk stratification should be carried
out using parameters specifically designed for use in the emergency department.
Unfortunately, there is little objective literature to guide this disposition
decision. An objective and reliable definition of low-risk characteristics to
identify early discharge candidates is needed. Benchmarking outcomes in
patients discharged from the emergency department without hospitalization could
aid this process. Biomarker determinations, although undoubtedly useful in
establishing diagnosis and predicting longer-term prognosis, require
prospective validation for emergency department disposition guidance. The
challenge of identifying emergency department acute heart failure discharge
candidates will only be overcome by future multidisciplinary research defining
the current knowledge gaps and identifying potential solutions.
Full-text
(free):
9. Oral fluoroquinolone use and serious arrhythmia: bi-national
cohort study.
Inghammar M,
et al. BMJ. 2016 Feb 26;352:i843.
OBJECTIVE: To evaluate if oral fluoroquinolone use is
associated with an increased risk of serious arrhythmia.
DESIGN: Bi-national cohort study, linking register
data on filled prescriptions, cases of serious arrhythmia, and patient
characteristics.
SETTING: Denmark, 1997-2011; Sweden, 2006-13.
PARTICIPANTS: The study cohort was derived from a source
population of all Danish and Swedish adults, aged 40 to 79 years. 909 656
courses of fluoroquinolone use (ciprofloxacin 82.6%, norfloxacin 12.1%,
ofloxacin 3.2%, moxifloxacin 1.2%, and other fluoroquinolones 0.9%) and 909 656
courses of penicillin V use, matched 1:1 on propensity score, were included.
MAIN OUTCOME
MEASURE: The main outcome was risk of
serious arrhythmia (fatal and non-fatal), comparing courses of fluoroquinolone
use with courses of penicillin V use (an antibiotic with no pro-arrhythmic
effect). The risk period of interest was current use, defined as days 0-7 of
treatment. Subgroup analyses were conducted according to country, sex, age,
underlying cardiovascular disease, concomitant use of drugs known to increase
the risk of torsades de pointes, fluoroquinolone type, and levels of arrhythmia
risk score.
RESULTS: 144 cases of serious arrhythmia occurred
during follow-up, 66 among current fluoroquinolone users (incidence rate 3.4
per 1000 person years) and 78 among current penicillin users (4.0 per 1000
person years); comparing oral fluoroquinolone treatment with penicillin V, the
rate ratio was 0.85 (95% confidence interval 0.61 to 1.18). Compared with
penicillin V, the absolute risk difference was -13 (95% confidence interval -35
to 16) cases of serious arrhythmia per 1 000 000 courses of fluoroquinolones.
The risk of serious arrhythmia was not statistically significantly increased in
any of the subgroups, including analyses by fluoroquinolone type.
CONCLUSIONS: Contrary to previous reports, oral
fluoroquinolone treatment was not associated with an increased risk of serious
arrhythmia in the general adult populations of Denmark and Sweden. Given the
statistical power of the study, even small increases in relative and absolute
risk could be ruled out. Since ciprofloxacin was the most commonly used
fluoroquinolone in our study, we cannot exclude that intraclass differences
influence the risk of serious arrhythmia associated with other less frequently
used fluoroquinolones.
10. Images in Clinical Practice
Right
Ventricular Infarction
Vertebral-Body
Erosion in Thoracic Aortic Aneurysm
Midline Destructive
Lesions in a Cocaine User
Tinea
Versicolor
Capitellar
Fracture
Scabies
Froin’s
Syndrome
11. The meaning of elevated troponin I levels: not always ACS.
Harvell B, et
al. Am J Emerg Med. 2016 Feb;34(2):145-8.
BACKGROUND:
Troponin elevation can be caused by etiologies other than acute coronary
syndromes (ACS). Our hypothesis was that elevated troponins occur more
frequently in non-ACS cases but that ACS cases (type 1 ST-elevation myocardial
infarction [STEMI] and type 1 non-STEMI [NSTEMI]) have significantly higher
troponin elevations.
METHODS: This
was a cross-sectional cohort analysis of a random subset of all patients with
elevated troponins (defined as ≥0.06 ng/mL) over a 1-year period from July 2013
to June 2014. The first positive troponin I and the peak were used in this
study. All included patients had medical record reviews looking for whether our
cardiologists or hospitalists attributed the elevated troponin to an ACS
(NSTEMI or STEMI) or non-ACS cause. Non-ACS causes were categorized as
infection, cancer, renal diseases, cardiovascular disease, pulmonary disease,
trauma, cardiac arrest, neurologic disease, hypertension, or other. Data were
extracted by 2 investigators on the cause of the elevated troponin. Three
sessions to educate data extractors were arranged and methods of data extraction
discussed, then a 5% sample was reevaluated by the other extractor to determine
interrater agreement measures. Parametric data were evaluated with t test and
analysis of variance. Dichotomous variables were compared using χ(2) test.
Troponin data were evaluated using nonparametric Kruskal-Wallis or Mann-Whitney
U. A logistic regression model was created with variables selected a priori to
evaluate the predictive ability of these variables in differentiating ACS vs
non-ACS causes of elevated troponin.
RESULTS: We
evaluated 458 randomly selected patients from 1317 unique cases of all patients
with initial elevated troponins at least 0.06 mg/mL during the study period.
There was 84% interrater agreement in the 5% sampling. Seventy-nine percent had
a non-ACS cause of elevated troponin, and the average initial positive troponin
I level was significantly lower in the non-ACS cases (0.14; 95% confidence
interval [CI], 0.08-0.37) than those with documented STEMI (10.2; 95% CI,
0.75-20.1) or NSTEMIs (0.4; 95% CI, 0.13-1.7). In the non-ACS group, the median
initial troponin was 0.14 ng/mL (0.08-0.37 ng/mL). Peak troponin levels were
highest in STEMI, next NSTEMI, and lowest in non ACS causes. The most frequent
subgroups in the non-ACS group were non-ACS cardiovascular, infectious, renal,
or hypertensive causes. In a linear regression model adjusting for age and sex,
higher troponin levels had higher odds of being related to ACS causes (adjusted
odds ratio, 1.4; 95% CI, 1.2-1.6) than non-ACS causes.
CONCLUSION:
The etiology for most initial elevated troponin I levels in a randomly selected
population is the result of non-ACS causes. As initial + troponin levels
increased, they were more likely associated with ACS causes than with non-ACS
causes. Average initial + and peak troponin values were highest in STEMIs, next
highest in NSTEMIs, and lowest overall in non-ACS causes.
12. The Impact of Cognitive Stressors in the ED on Physician
Implicit Racial Bias.
Johnson TJ,
et al. Acad Emerg Med. 2016;23(3):297-305.
OBJECTIVES:
The emergency department (ED) is characterized by stressors (e.g. fatigue,
stress, time-pressure, and complex decision-making) that can pose challenges to
delivering high quality, equitable care. Although it has been suggested that
characteristics of the ED may exacerbate reliance on cognitive heuristics, no
research has directly investigated whether stressors in the ED impact physician
racial bias, a common heuristic. We seek to determine if physicians have
different levels of implicit racial bias post-ED shift versus pre-shift, and to
examine associations between demographics and cognitive stressors with bias.
METHODS: This
repeated measures study of resident physicians in a pediatric ED used
electronic pre- and post-shift assessments of implicit racial bias,
demographics, and cognitive stressors. Implicit bias was measured using the
Race Implicit Association Test (IAT). Linear regression models compared
differences in IAT scores pre- to post-shift, and determined associations
between participant demographics and cognitive stressors with post-shift IAT
and pre- to post-shift difference scores.
RESULTS:
Participants (n=91) displayed moderate pro-white/anti-black bias on pre-shift
(M=0.50, SD=0.34, d=1.48) and post-shift (M=0.55, SD=0.39, d=1.40) IAT scores.
Overall, IAT scores did not differ pre-shift to post-shift (mean increase=0.05,
95% CI -0.02,0.14, d=0.13). Sub-analyses revealed increased pre- to post-shift
bias among participants working when the ED was more overcrowded (mean
increase=0.09, 95% CI 0.01,0.17, d=0.24) and among those caring for more than 10
patients (mean increase=0.17, 95% CI 0.05,0.27, d=0.47). Residents'
demographics (including specialty), fatigue, busyness, stressfulness, and
number of shifts were not associated with post-shift IAT or difference scores.
In multivariable models, ED overcrowding was associated with greater post-shift
bias (coefficient=0.11 per 1 unit of NEDOCS score, SE=0.05, 95% CI 0.00,0.21).
CONCLUSIONS:
While resident implicit bias remained stable overall pre-shift to post-shift,
cognitive stressors (overcrowding and patient load) were associated with
increased implicit bias. Physicians in the ED should be aware of how cognitive
stressors may exacerbate implicit racial bias.
13. Top 10 facts about "Spice"
In April and
May 2015, the state of Mississippi experienced an unprecedented outbreak of
severe reactions to the drug commonly referred to as "Spice." After
numerous calls to the Poison Control Center, it became clear that health care
providers were largely unfamiliar with the category of synthetic cannabinoids.
This review article briefly highlights cannabinoid effects, chemical
characteristics, and treatment for this often dangerous category of drugs of
abuse.
Synthetic
Cannabinoids Are Not Marijuana/Cannabis
Synthetic
Cannabinoids Are Often More Potent Than Marijuana/Cannabis
Synthetic
Cannabinoids Are Ever-changing
Synthetic
Cannabinoid Research Was “High Jacked”
Synthetic
Cannabinoids Are Dangerous Chemicals with Unpredictable Composition and Human
Toxicity
Synthetic
Cannabinoids Have Many Street Names
Synthetic
Cannabinoids Usage Is Not Limited to Young People
Synthetic
Cannabinoids Are Easily Obtained
Synthetic
Cannabinoids Can Be Addicting, with Unknown Long-term Consequences
Provider
Education Is Key
14. TIA: management in the ED and impact of an outpatient
neurovascular clinic
Hosiera GW,
et al. CJEM 2016 Feb 16 [Epub ahead of print]
Objectives 1)
To evaluate whether transient ischemic attack (TIA) management in emergency
departments (EDs) of the Nova Scotia Capital District Health Authority followed
Canadian Best Practice Recommendations, and 2) to assess the impact of being
followed up in a dedicated outpatient neurovascular clinic.
Methods
Retrospective chart review of all patients discharged from EDs in our district
from January 1, 2011 to December 31, 2012 with a diagnosis of TIA. Cox
proportional hazards models, Kaplan-Meier survival curve, and propensity
matched analyses were used to evaluate 90-day mortality and readmission.
Results Of
the 686 patients seen in the ED for TIA, 88.3% received computed tomography
(CT) scanning, 86.3% received an electrocardiogram (ECG), 35% received vascular
imaging within 24 hours of triage, 36% were seen in a neurovascular clinic, and
4.2% experienced stroke, myocardial infarction, or vascular death within 90
days. Rates of antithrombotic use were increased in patients seen in a
neurovascular clinic compared to those who were not (94% v. 86.3%, p less than 0.0001).
After adjustment for age, sex, vascular disease risk factors, and stroke
symptoms, the risk of readmission for stroke, myocardial infarction, or
vascular death was lower for those seen in a neurovascular clinic compared to
those who were not (adjusted hazard ratio 0.28; 95% confidence interval
0.08–0.99, p=0.048).
Conclusion
The majority of patients in our study were treated with antithrombotic agents
in the ED and investigated with CT and ECG within 24 hours; however, vascular
imaging and neurovascular clinic follow-up were underutilized. For those with
neurovascular clinic follow-up, there was an association with reduced risk of
subsequent stroke, myocardial infarction, or vascular death.
15. Utility of CT in Elbow Trauma Patients with Normal X-Ray
Study and Positive Elbow Extension Test.
Acar K, et
al. J Emerg Med. 2016 Mar;50(3):444-8.
BACKGROUND:
Elbow fractures are a common injury seen among emergency department trauma
patients. Despite its high frequency, there is no standardized method of
diagnosis using conventional x-ray imaging for trauma patients presenting with
elbow pain and restricted elbow movement.
OBJECTIVE: We
aimed to assess trauma patients, using computed tomography (CT), who present
with a positive elbow extension test and have no evident fracture on x-ray
study.
METHODS:
Patients presented to our emergency department with elbow trauma and were
evaluated between April 2010 and March 2011. A CT scan of the injured elbow was
ordered for patients with pain on elbow extension (a positive elbow extension
test) and no evidence of fracture on x-ray study. All CT and x-ray images were
evaluated by a designated radiologist.
RESULTS: One
hundred and forty-eight patients presented to our emergency department with
elbow trauma. Two patients were excluded from the study, one with former motion
disability and another with an open fracture. In the remaining patients, there
were 32 fractures in total. Forty-three of 114 patients without fracture signs
had a positive elbow extension test and 4 of these patients refused CT imaging.
Fractures were found in 5 (12.8%) of the 39 patients assessed with CT. CT
imaging found that two of these patients had a radial head fracture, two others
had an olecranon fracture, and one patient had a coronoid fracture.
CONCLUSIONS:
We recommend CT as an additional evaluation imaging study for trauma patients
who have a positive elbow extension test and who present with no apparent
fracture on x-ray imaging.
16. CDC Guideline for Prescribing
Opioids for Chronic Pain — United States, 2016: Recommendations and Reports
Dowell
D, et al. MMWR. 2016;65(1);1–49.
Summary
This guideline provides recommendations for primary
care clinicians who are prescribing opioids for chronic pain outside of active
cancer treatment, palliative care, and end-of-life care. The guideline
addresses 1) when to initiate or continue opioids for chronic pain; 2) opioid
selection, dosage, duration, follow-up, and discontinuation; and 3) assessing
risk and addressing harms of opioid use. CDC developed the guideline using the
Grading of Recommendations Assessment, Development, and Evaluation (GRADE)
framework, and recommendations are made on the basis of a systematic review of
the scientific evidence while considering benefits and harms, values and
preferences, and resource allocation. CDC obtained input from experts, stakeholders,
the public, peer reviewers, and a federally chartered advisory committee. It is
important that patients receive appropriate pain treatment with careful
consideration of the benefits and risks of treatment options.
This guideline is intended to improve communication
between clinicians and patients about the risks and benefits of opioid therapy
for chronic pain, improve the safety and effectiveness of pain treatment, and
reduce the risks associated with long-term opioid therapy, including opioid use
disorder, overdose, and death. CDC has provided a checklist for prescribing
opioids for chronic pain (http://stacks.cdc.gov/view/cdc/38025) as well
as a website (http://www.cdc.gov/drugoverdose/prescribingresources.html) with
additional tools to guide clinicians in implementing the recommendations.
17. Do doctors treat difficult patients as well as nice ones?
By RANDY
DOTINGA. HEALTHDAY. March 16, 2016, 9:34 AM
What happens to medical care when the
patient is a jerk?
Dutch
researchers asked the question in two new studies, and the answer should make
grumps think the better of their bad behavior: "Disruptive" patients
may get worse care from physicians.
The findings
aren't definitive because the researchers tested how physicians responded in
fictional vignettes, instead of real-life encounters. Still, the results
suggest that patients who make a scene distract physicians from doing their
jobs.
"Patients
who behave disruptively by displaying disrespect or aggressiveness may induce
their doctors to make diagnostic mistakes," said Dr. Silvia Mamede, who
worked on both studies. She is an associate professor with the Institute of
Medical Education Research Rotterdam at Erasmus Medical Center in the
Netherlands.
An estimated
15 percent of patients treated in doctors' offices are aggressive,
disrespectful, overly demanding or distrustful, Mamede said.
"As
might be expected, these behaviors provoke emotional reactions in
doctors," she said.
But do these
patients actually get worse care? Physicians have long talked about this
question, but researchers haven't investigated that issue, according to Mamede.
The study
authors could have monitored actual doctors' visits to find an answer, but Mamede
said that approach would have been "virtually impossible" because
each case is so different.
Instead, the
researchers created vignettes about "neutral" patients and disruptive
patients who do things such as make frequent demands, ignore the doctor's advice
and act helpless. Then they asked physicians to diagnose the patients.
This approach
is "feasible, ethical and reasonable," said Dr. Donald Redelmeier,
senior core scientist with the Institute for Clinical Evaluative Sciences in
Toronto. Redelmeier co-wrote a commentary accompanying the study.
In one study
of 63 family medicine physicians from Rotterdam, "doctors made 42 percent
more mistakes in disruptive than in non-disruptive patients when the cases were
complex, and 6 percent more mistakes when the cases were simple," Mamede
said. (The physicians did a better job when they had more time to think about
their diagnoses; experts determined the correct diagnoses.)
The other
study, which included 74 internal medicine residents, produced similar findings:
In cases considered to be moderately complex, "doctors made 20 percent
more mistakes in difficult compared to neutral patients," she added.
The studies
don't provide information about how often the physicians got a diagnosis
completely correct or missed it entirely. Instead, the researchers scored the
diagnoses based on whether they were correct, partially correct or wrong.
What's going
on? Mamede said disruptive patients distract physicians by
"capturing" their attention, preventing them from focusing more on
actual medical conditions.
It's not
clear, she said, if poorer care will make disruptive patients even more
frustrating to deal with over time, creating a vicious cycle of increasing
disruption and more inaccurate diagnoses.
But
Redelmeier said such a "negative feedback loop" is possible.
What can be
done?
"Physicians
should be trained to deal with these disruptive behaviors explicitly and
effectively," Mamede said. "An aggressive patient can be calmed. A
patient who displays lack of trust in his doctor can be referred to another
doctor," she suggested.
As for
patients, Redelmeier referred to the points he and a co-author make in the
commentary. Patients, they explained, can try to channel their emotion into
polite comments; for example, "Thank you for seeing me. I am frightened by
what I am experiencing and that is why I am here looking for something that
might help."
Still, the
editorialists added, "real people . . . cannot always control their temper
when suffering or in pain." More research is needed to figure out the best
approaches, Redelmeier suggested.
Abstracts:
18. Effect of phenylephrine and terbutaline on ischemic
priapism: a retrospective review.
Martin C, et
al. Am J Emerg Med. 2016 Feb;34(2):222-4.
BACKGROUND:
Ischemic priapism is the most common cause of priapism due to low blood flow.
Current guidelines recommend penile aspiration and the use of intracavernous
injection of vasoactive agents. The data to support these recommendations are
limited and rely on expert consensus.
OBJECTIVE:
The objective was to determine the effectiveness of terbutaline and
phenylephrine on detumescence of ischemic priapism.
METHODS: This
was a retrospective review of patients presenting to the emergency department
with a chief concern of priapism who received oral or subcutaneous terbutaline
or intracavernous phenylephrine. The primary outcome is successful
detumescence. The secondary outcome is drug-related adverse drug events.
RESULTS: A
total of 31 cases of ischemic priapism were included, with 8 patients receiving
terbutaline and 23 receiving phenylephrine. Of the cases treated with
terbutaline, 25% had successful detumescence compared with phenylephrine with a
74% success rate. No drug-related adverse events were reported or identified.
CONCLUSIONS:
Patients receiving intracavernous irrigation with phenylephrine were more
likely to achieve successful detumescence than those treated with oral or
subcutaneous terbutaline.
19. The Impact of Personalized Preventive Care on Health Care
Quality, Utilization, and Expenditures
Musich S, et
al. Popul Health Manage. 2016 Feb [Epub ahead of print]
The objective
of this study was to evaluate the impact on health care utilization and
expenditure trends over time of a personalized preventive medicine program
delivering individualized care focused on lifestyle behavior modification,
disease prevention, and compliance with quality-related metrics.
MD-Value in
Prevention (MDVIP) is a network of affiliated primary care physicians who
utilize a model of health care delivery based on an augmented physician-patient
relationship and focused on personalized preventive health care. Multivariate
modeling was used to control for demographics, socioeconomics, supply of health
care services, and health status among 10,186 MDVIP members and randomly
selected, matched nonmembers. Health care utilization and expenditure trends
were tracked from the pre period prior to member enrollment for a period of up
to 3 years post enrollment.
MDVIP members
experienced reduced utilization of emergency room and urgent care services
compared to nonmembers. Program savings ranges indicated that, over time,
increasing percentages of members achieved cost savings compared to nonmembers.
Older age groups were more likely to realize savings in the early years with
preventive activities indicating condition management, and younger age groups
were most likely to achieve savings by the third year after enrollment.
These results
indicate that a primary care model based on an enhanced physician-patient
relationship and focused on quality and personalized preventive care within a
time frame of 3 years can achieve positive health care expenditure outcomes and
improved health management.
20. Octreotide in the ED
By CHRISTINA
SHENVI, MD, PHD. Emergency Physicians Monthly, MARCH 3, 2016
This
somatostatin analog is used “off-label” in the ED for variceal bleeds and
sulfonylurea overdoses.
Octreotide is
an octapeptide that mimics endogenous somatostatin. Somatostatin is released by
cells in the pyloric antrum, the pancreas, and the duodenum. It has an overall
inhibitory effect on secretion of multiple hormones, reducing gut motility and
gastric emptying, and decreasing splanchnic blood flow. Octreotide contains the
active moiety of somatostatin, and is several times more active than the
endogenous hormone.
Major Indications
The major
indications for octreotide use are not things we would treat in the ED. For
example, it is used for chronic treatment of acromegaly, carcinoid tumor, and
VIPomas. Its two major uses in the ED are, in fact, “off-label.”
Octreotide is
frequently used in the ED for patients with a history of cirrhosis who present
with a moderate or severe upper GI bleed presumed to be from a variceal source.
Octreotide inhibits the release of glucagon, which is a splanchnic vasodilator.
It therefore reduces splanchnic blood flow and portal venous pressure. The
effect on portal pressure, however, is transient, lasting about five minutes
even when used as an infusion [1], though it may continue to reduce intestinal
blood flow for longer through other mechanisms [2]. The current therapy for
acute variceal bleed typically involves octreotide in combination with
sclerotherapy or band ligation, along with antibiotic prophylaxis [3].
Treatment with octreotide and sclerotherapy results in lower rates of
re-bleeding than use of either therapy alone, though there was no improvement
in mortality with the addition of octreotide [4]. A Cochrane review in 2008
systematically reviewed 21 trials with a total of 2,588 patients. They found no
reduction in mortality with octreotide. They found the treatment group did
have, on average, 0.7 fewer units of PRBCs transfused compared with patients
who did not receive octreotide [5]. The authors of the Cochrane review conclude
that: “It is doubtful whether this effect is worthwhile.” However, the risk of
octreotide use is low, and it may provide a small benefit in reducing early
re-bleeding. The treatment dose for variceal bleeds is with a 50 mcg IV bolus
(range 25-100mcg), followed by 25-50 mcg/hr drip [6].
The other ED
use for octreotide is in sulfonylurea overdose with hypoglycemia. Patients who
present with sulfonylurea-induced hypoglycemia may initially respond to
treatment with IV dextrose. However, the increase in blood sugar can then
trigger insulin release, and cause worse rebound hypoglycemia from the
increased insulin along with continued activity of the sulfonylurea, which both
stimulates insulin release and also increases peripheral sensitivity to
insulin. Octreotide inhibits the secretion of insulin, and can help prevent this
recurrent hypoglycemia [7]. Treatment for this use is typically with 50-75 mcg
SQ, which can be repeated every 6 hours if needed, and 1-2 mcg/kg SQ in
children [8]…
The rest of
the essay (free): http://epmonthly.com/article/octreotide-in-the-ed/
21. CURB-65 Performance among admitted and discharged ED patients with community acquired pneumonia.
Sharp AL, et
al. CURB-65 Acad Emerg Med. 2016 Jan 30 [Epub ahead of print].
OBJECTIVES: Pneumonia
severity tools were primarily developed in cohorts of hospitalized patients,
limiting their applicability to the emergency department (ED). We describe
current community ED admission practices and examine the accuracy of the CURB-65
to predict 30-day mortality for patients, either discharged or admitted with,
community acquired pneumonia (CAP).
METHODS: A
retrospective, observational study of adult CAP encounters in 14 community EDs
within an integrated health care system. We calculated CURB-65 scores for all
encounters and described the use of hospitalization, stratified by each score
(0-5). We then used each score as a cut-off to calculate sensitivity,
specificity, positive predictive value, negative predictive value (NPV),
positive likelihood ratios and negative likelihood ratios for predicting 30-day
mortality.
RESULTS: The
sample included 21,183 ED encounters for CAP (7,952 discharged and 13,231
admitted). The C-statistic describing the accuracy of CURB-65 for predicting
30-day mortality in the full sample was 0.761 (95% CI, 0.747-0.774). The
C-statistic was 0.864 (95% CI, 0.821-0.906) among patients discharged from the
ED compared with 0.689 (95% CI, 0.672-0.705) among patients who were admitted.
Among all ED encounters a CURB-65 threshold ≥1 was 92.8% sensitive and 38.0%
specific for predicting mortality, with a 99.9% NPV. Among all encounters,
62.5% were admitted, including 36.2% of those at lowest risk (CURB-65=0).
CONCLUSION: CURB-65
had very good accuracy for predicting 30-day mortality among patients
discharged from the ED. This severity tool may help ED providers risk stratify
patients to assist with disposition decisions and identify unwarranted
variation in patient care.
22. Cost-effectiveness Analysis of Follow-up Strategies for
Thunderclap HA Patients with Negative Noncontrast CT
Malhotra A,
et al. Acad Emerg Med. 2016;23(3):243-50.
Objectives
Accurate
diagnosis of acute subarachnoid hemorrhage (SAH) is critical in thunderclap
headache patients due to high morbidity and mortality associated with missed
aneurysmal bleeds. The objective of this study was to determine the utility of
computed tomography angiography (CTA) in managing patients with acute, severe
headaches and negative noncontrast CT and assess the cost-effectiveness of
three different screening strategies—no follow up, CTA, and lumbar puncture
(LP).
Methods
A
modeling-based economic evaluation was performed with a time horizon of 1 year
for thunderclap headache patients in the emergency department with negative
noncontrast CT for SAH. Sensitivity analyses were performed to determine the
effect of sensitivity of CT and the prevalence of SAH on cost-effectiveness.
Results
Lumbar
puncture follow-up has the lowest cost and the highest utility in the
mathematical model. The Monte Carlo simulation shows noncontrast CT with LP
follow-up to be the most cost-effective strategy in 85.3% of all cases even at
a $1 million/quality-adjusted life-years willingness-to-pay. Sensitivity
analyses demonstrate that LP follow-up should be performed, except for when CT
sensitivity exceeds 99.2% and the SAH prevalence is below 3.2%, where no
follow-up may be considered.
Conclusions
Although CTA
is frequently used for evaluation of thunderclap headache patients, its utility
is not clearly defined. LP follow-up is shown to be the most cost-effective
strategy for evaluation of thunderclap headache patients in most clinical
settings.
23. From ACEP Now, February 2016
A.
ACEP Toxicology Section App Named Top of 2015
An ACEP
mobile app that provides emergency physicians with quick toxicology information
has been named one of the top medical apps of 2015. The ACEP Toxicology
Section’s Antidote app was named one of the best new apps for iPhone and Android
by the physician editors at
iMedicalApps.
The app was deemed “fantastic,” providing easy access to important information.
B.
Antibiotics & Admission May Be Out The Door: New treatment trends for
uncomplicated diverticulitis
Ryan Radecki,
ACEP Now, February 2016
There is a
bit of an axiom that circulates in medical school: “Half of what you’re
learning is wrong, but we don’t yet know which half.” This has borne out
observationally simply by examining the frequency of reversed medical practices
in the major medical journals.1 There is also an entire school of academic
inquiry into the likelihood of research arriving at erroneous conclusions, and
it can be statistically demonstrated that most published findings are false.2
The treatment
of diverticulitis seems poised to be the next domino to fall in reversal of
dogmatic medical practice. Some patients with diverticulitis progress to
perforation, abscess, sepsis, and death, and the advent of antibiotic therapy
substantially reduced morbidity and mortality associated with diverticulitis.
The classic teaching, then, has required hospitalization and intravenous
antibiotic therapy while monitoring for deterioration. However, with better
understanding of the disease process, it was proposed that diverticulitis is
primarily an inflammatory rather than an infectious state, and only those with
a complicated disease course may benefit from antibiotic therapy.3
Given the
increasing challenges of antimicrobial resistance paired with the rise of
disabling Clostridium difficile infection, such a hypothesis did not go
unnoticed. The first bits of evidence testing the disutility of antibiotics in
acute, uncomplicated diverticulitis have been trickling out over the past three
years. The first, the AVOD randomized trial, was an open, multicenter study in
Sweden published in 2012.4 In this study, 669 patients with a CT-confirmed
diagnosis of acute, uncomplicated diverticulitis were hospitalized and
randomized to either intravenous fluids only or intravenous fluids and
intravenous antibiotics in combination with fluids. Patients were evaluated
daily while hospitalized, then followed for up to six months following
enrollment.
The quick
results summary: no difference. Patients in each group had nearly identical
hospital courses, with similar rates of resolution of pain and fever, and
median in-hospital length of stay of fewer than three days. The number of
patients progressing to complicated disease was in the single digits in both
cohorts. Ten patients randomized to no antibiotics were started on antibiotics
due to suspicion of clinical worsening, while three patients on antibiotics
terminated therapy due to allergic side effects. Recurrent episodes of
diverticulitis during follow-up were likewise identical at six months….
The rest of
the essay here (free): http://www.acepnow.com/article/antibiotics-hospital-admission-may-not-help-uncomplicated-diverticulitis/
24. Stop Trying to Find Balance
All our
talk and worry about "work-life balance" is such a bunch of
baloney.
Christine
Carter, PhD. Raising Happiness, March 10, 2016
I don't mean
to be depressing, but you will never find "balance" between your work
and your personal life. That very idea hinges on an implicit belief that there
is some perfect ratio between time spent on work (and work-like activities,
like checking your email) and time spent on everything else (like sleeping, or
eating your lunch away from your desk, or helping your kids with their
homework).
Your work and
your personal life do not amount to a zero-sum game, where more of one means
you're compromising the other. In fact, the quality of your work and your
productivity
--your
ability to create something of value and meaning for yourself and for
others--is utterly dependent on the quality of your personal life.
How happy you are profoundly influences how
well you do your job. Reams of research shows beyond a shadow of a doubt that
what we do outside of work thoroughly influences the energy, motivation, focus,
creativity, persistence, insight, and raw intellectual power we bring to a
given project or task at work.
The better
your personal life is, the higher your potential to do great work.
I can hear
the war cries from Silicon Valley and Wall Street now. "But no one in
tech or at a start-up or who is brokering a billion dollar deal has a life!!!
And THOSE people are rich and successful!!" you protest.
Hah. While
those professions are certainly rigged so that the [mostly male] people at the
top take home more money, their success is deeply subjective. Are they wealthy
in the things that matter to you? Brigid Shulte
reminds us to "remember
that the wolves of Wall Street bragging about those long hours at the office
got us into a global financial crisis, and that 95 percent of
startups fail."
Our sense
that the most successful and productive people--"ideal workers"--put in an insane number of
hours is just wrong. But what does the real "ideal
worker" ACTUALLY look like?
I've been
pondering this question for five or six years now, and I've come to see that
the real "ideal worker" has seven core qualities or skills.
The rest of
the essay here: https://medium.com/@raisinghappines/you-will-never-find-work-life-balance-ecb30f31183f#.lwcgtvxia
25. Micro Bits
A. Diagnosis and Management of
Diabetes: Synopsis of the 2016 American Diabetes Association Standards of
Medical Care in Diabetes
B. Nonpharmacologic Versus
Pharmacologic Treatment of Adult Patients With Major Depressive Disorder: A
Clinical Practice Guideline From the American College of Physicians
D. CDC lists top US public health
issues
The top
public health issues in the US include food safety, heart disease and stroke,
alcohol-related harm, and prescription drug overdose, according to the CDC's
National Center for Injury Prevention and Control. The report, which includes
all 50 states and Washington, D.C., also lists health care-associated
infections; HIV; motor vehicle injuries; nutrition, physical activity and
obesity; teen pregnancy; and tobacco use as top concerns nationwide.
E. Mesenteric Ischemia: Clinical
Review
Clair DG, et
al. N Engl J Med 2016; 374:959-968.
Although
mesenteric ischemia is uncommon, it can be life-threatening, and its
recognition is therefore crucial. This review article explains the
pathophysiology, diagnosis, and treatment of intestinal ischemic syndromes.
F. Clinical Practice Guideline: Otitis
Media with Effusion Executive Summary (Update)
The American
Academy of Otolaryngology—Head and Neck Surgery Foundation has published a
supplement to this issue of Otolaryngology—Head and Neck Surgery featuring the
updated “Clinical Practice Guideline: Otitis Media with Effusion.” To assist in
implementing the guideline recommendations, this article summarizes the
rationale, purpose, and key action statements. The 18 recommendations developed
emphasize diagnostic accuracy, identification of children who are most
susceptible to developmental sequelae from otitis media with effusion, and
education of clinicians and patients regarding the favorable natural history of
most otitis media with effusion and the lack of efficacy for medical therapy
(eg, steroids, antihistamines, decongestants). An updated guideline is needed
due to new clinical trials, new systematic reviews, and the lack of consumer
participation in the initial guideline development group.
Full-text
(free): http://oto.sagepub.com/content/154/2/201.full
