Saturday, March 19, 2016

Lit Bits: Mar 19, 2016

From the recent medical literature...

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.

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]

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.

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, number NCT02187614.

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.

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.

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.

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.

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.

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.

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).

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


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.              

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 ( as well as a website ( 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.


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):

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.

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).

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.

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.

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.

And it’s available for free at

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….

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.

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.

Article (subscription required):

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.