Friday, April 22, 2016

Lit Bits: April 22, 2016

From the recent medical literature…

1. No SIRS; Quick SOFA Instead: SCCM Redefines Sepsis without EM Input

Faust JS. Ann Emerg Med. 2016;67(5):A15–A19.

It’s barely noon and already 5 patients have triggered a sepsis alert in triage. Once that happens, patients are expedited into the emergency department (ED), assessed, and treated urgently. Laboratory tests are ordered; fluids are given. Two systemic inflammatory response criteria and suspect infection is all it takes to sound the alarm, but this may be about to change.

Until February, the Society of Critical Care Medicine’s (SCCM’s) definitions for sepsis had remained largely unchanged since 1991, although some revisions were incorporated into a 2003 update. To reflect changes in the understanding of sepsis pathophysiology and to respond to the need for more precise definitions, a task force composed of intensivists and infectious disease, surgical, and pulmonary specialists (emergency medicine was notably absent) was convened from representatives of the SCCM and the European Society of Intensive Care Medicine (ESICM) in January 2014. The task force was given the mandate to determine the Third International Consensus Definitions for Sepsis and Septic Shock, which were unveiled at the 45th annual SCCM Critical Care Congress in Orlando, FL, on February 22, 2016, and published as a trio of articles in the Journal of the American Medical Association the same day.

According to Clifford S. Deutschman, MS, MD, of the Feinstein Institute for Medical Research, who, along with Mervyn Singer, MBBS, of University College London, cochaired the task force, the new definition states that sepsis is life-threatening organ dysfunction resulting from a dysregulated host response to infection (Figure 1). Septic shock is now defined as a subset of sepsis patients in whom “circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality.”1

In the creation of these definitions, the term “severe sepsis” was determined to be redundant with the new definition of sepsis and thus was eliminated from official nomenclature.

Dr. Deutschman highlighted an important departure from previous official statements on sepsis. “We didn’t just do definitions,” he said by telephone in February. “We did both definitions and clinical criteria.” The purpose was to create the most scientifically valid description of sepsis possible while providing a definition that would be clinically useful. Furthermore, the task force sought to distinguish patients with sepsis—in whom organ damage increased the risk of mortality to greater than 10%—from patients with septic shock, whose mortality exceeded 40%. The criteria, Dr. Deutschman said, are intended to help physicians identify and stratify septic patients by using “proxies for a likely sepsis-related outcome,” which was defined as death from sepsis or a course of 3 or more days in an ICU.2

The problem of quickly identifying patients who may have sepsis was also addressed. Systemic inflammatory response syndrome (SIRS) criteria—in use since 1991—were deemed “unhelpful” by the task force. In work led by Christopher W. Seymour, MD, MSc, of the University of Pittsburgh, SIRS was found to be reasonably sensitive, but extremely nonspecific.2

As an alternative, the use of the Sepsis-related/Sequential Organ Failure Assessment (SOFA) was discussed (Figure 2). However, because a SOFA score cannot be performed in out-of-hospital, triage, and some emergency settings, a new measure relying on 3 easily obtainable clinical features, termed quick SOFA, was derived and validated retrospectively (Figure 3)…

DRV Note: Q(uick)SOFA Score (1 point each; score range 0-3)
  • New or worsened AMS (GCS 13 or less)
  • RR ≥22/min
  • SBP ≤100mmHg 

If the sum is 0-1 points, patient not high risk by qSOFA. If sepsis is still suspected, continue to monitor, evaluate, and initiate treatment as appropriate, including serial qSOFA assessments.

If the sum is 2-3 points, patient high risk by qSOFA. Assess for evidence of organ dysfunction with blood testing including serum lactate and calculation of the full SOFA Score. Patients meeting these qSOFA criteria should have infection considered even if it was previously not.

“The qSOFA was tested in 4 external data sets comprising 706,399 patient encounters at 165 hospitals in out-of-hospital (n = 6508), non-ICU (n = 619,137), and ICU (80,595) settings...” Seymour CW, et al. Assessment of Clinical Criteria for Sepsis: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016 Feb 23;315(8):762-74. Abstract:

2. New Stroke Research

A. One-Year Risk of Stroke after Transient Ischemic Attack or Minor Stroke

Amarenco P, et al. N Engl J Med. 2016;374:1533-1542.

Previous studies conducted between 1997 and 2003 estimated that the risk of stroke or an acute coronary syndrome was 12 to 20% during the first 3 months after a transient ischemic attack (TIA) or minor stroke. The project was designed to describe the contemporary profile, etiologic factors, and outcomes in patients with a TIA or minor ischemic stroke who receive care in health systems that now offer urgent evaluation by stroke specialists.

We recruited patients who had had a TIA or minor stroke within the previous 7 days. Sites were selected if they had systems dedicated to urgent evaluation of patients with TIA. We estimated the 1-year risk of stroke and of the composite outcome of stroke, an acute coronary syndrome, or death from cardiovascular causes. We also examined the association of the ABCD2 score for the risk of stroke (range, 0 [lowest risk] to 7 [highest risk]), findings on brain imaging, and cause of TIA or minor stroke with the risk of recurrent stroke over a period of 1 year.

From 2009 through 2011, we enrolled 4789 patients at 61 sites in 21 countries. A total of 78.4% of the patients were evaluated by stroke specialists within 24 hours after symptom onset. A total of 33.4% of the patients had an acute brain infarction, 23.2% had at least one extracranial or intracranial stenosis of 50% or more, and 10.4% had atrial fibrillation. The Kaplan–Meier estimate of the 1-year event rate of the composite cardiovascular outcome was 6.2% (95% confidence interval, 5.5 to 7.0). Kaplan–Meier estimates of the stroke rate at days 2, 7, 30, 90, and 365 were 1.5%, 2.1%, 2.8%, 3.7%, and 5.1%, respectively. In multivariable analyses, multiple infarctions on brain imaging, large-artery atherosclerosis, and an ABCD2 score of 6 or 7 were each associated with more than a doubling of the risk of stroke.

We observed a lower risk of cardiovascular events after TIA than previously reported. The ABCD2 score, findings on brain imaging, and status with respect to large-artery atherosclerosis helped stratify the risk of recurrent stroke within 1 year after a TIA or minor stroke. (Funded by Sanofi and Bristol-Myers Squibb.)

B. The Value of Urgent Specialized Care for TIA and Minor Stroke

Sacco RL, et al. N Engl J Med 2016; 374:1577-1579.

Patients with minor stroke or transient ischemic attack (TIA), characterized as a brief episode of neurologic dysfunction caused by focal cerebral ischemia without infarction, have the least amount of disability and the most to lose should they have a stroke. Patients with vanishing symptoms may slip through our systems for detecting acute stroke owing either to patients’ delays in seeking medical attention or clinicians’ assessments that urgent treatment is not needed. This lost opportunity is even more worrisome given the tremendous improvements in the quality of primary and secondary stroke prevention that include evidence-based treatments with antiplatelet and oral anticoagulation therapy; better control of hypertension, dyslipidemia, and diabetes; more accurate and sensitive neuroimaging; increased use of thrombolytics and interventional treatments for acute stroke; and organized systems of stroke care that are designed for the rapid evaluation of symptomatic patients. Just as the rapid diagnosis and treatment of acute stroke has improved outcomes, the urgent evaluation of patients with a TIA or minor stroke and the use of preventive treatments can markedly reduce the risk of stroke.1 Demonstrations of these dramatic results in clinical trials, however, are not enough and require implementation and dissemination of successful community programs.

In this issue of the Journal, Amarenco and colleagues2 report a very low risk of stroke after a TIA or minor stroke in specialized TIA units in which urgent evidence-based care is delivered by stroke specialists. Using data from a large, international registry (the project), the authors report a risk of stroke of only 1.5% at 2 days, 2.1% at 7 days, and 3.7% at 90 days after symptom onset. Although this was not a randomized trial and there was no comparison group to assess whether specialized units performed better than nonspecialized units, these risks are substantially lower than expected. Outcomes in this study were at least 50% lower than those reported in previous studies in which the risk of stroke was between 8% and 20% at 30 and 90 days and as high as 10% within the first 2 days after symptom onset.3-5

The study is not the first to show that rates of stroke after TIA and minor stroke have declined…

C. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials.

Goyal M et al. Lancet 2016 Feb 18 [Epub ahead of print]

BACKGROUND: In 2015, five randomised trials showed efficacy of endovascular thrombectomy over standard medical care in patients with acute ischaemic stroke caused by occlusion of arteries of the proximal anterior circulation. In this meta-analysis we, the trial investigators, aimed to pool individual patient data from these trials to address remaining questions about whether the therapy is efficacious across the diverse populations included.

METHODS: We formed the HERMES collaboration to pool patient-level data from five trials (MR CLEAN, ESCAPE, REVASCAT, SWIFT PRIME, and EXTEND IA) done between December, 2010, and December, 2014. In these trials, patients with acute ischaemic stroke caused by occlusion of the proximal anterior artery circulation were randomly assigned to receive either endovascular thrombectomy within 12 h of symptom onset or standard care (control), with a primary outcome of reduced disability on the modified Rankin Scale (mRS) at 90 days. By direct access to the study databases, we extracted individual patient data that we used to assess the primary outcome of reduced disability on mRS at 90 days in the pooled population and examine heterogeneity of this treatment effect across prespecified subgroups. To account for between-trial variance we used mixed-effects modelling with random effects for parameters of interest. We then used mixed-effects ordinal logistic regression models to calculate common odds ratios (cOR) for the primary outcome in the whole population (shift analysis) and in subgroups after adjustment for age, sex, baseline stroke severity (National Institutes of Health Stroke Scale score), site of occlusion (internal carotid artery vs M1 segment of middle cerebral artery vs M2 segment of middle cerebral artery), intravenous alteplase (yes vs no), baseline Alberta Stroke Program Early CT score, and time from stroke onset to randomisation.

FINDINGS: We analysed individual data for 1287 patients (634 assigned to endovascular thrombectomy, 653 assigned to control). Endovascular thrombectomy led to significantly reduced disability at 90 days compared with control (adjusted cOR 2·49, 95% CI 1·76-3·53; p less than 0·0001). The number needed to treat with endovascular thrombectomy to reduce disability by at least one level on mRS for one patient was 2·6. Subgroup analysis of the primary endpoint showed no heterogeneity of treatment effect across prespecified subgroups for reduced disability (pinteraction=0·43). Effect sizes favouring endovascular thrombectomy over control were present in several strata of special interest, including in patients aged 80 years or older (cOR 3·68, 95% CI 1·95-6·92), those randomised more than 300 min after symptom onset (1·76, 1·05-2·97), and those not eligible for intravenous alteplase (2·43, 1·30-4·55). Mortality at 90 days and risk of parenchymal haematoma and symptomatic intracranial haemorrhage did not differ between populations.

INTERPRETATION: Endovascular thrombectomy is of benefit to most patients with acute ischaemic stroke caused by occlusion of the proximal anterior circulation, irrespective of patient characteristics or geographical location. These findings will have global implications on structuring systems of care to provide timely treatment to patients with acute ischaemic stroke due to large vessel occlusion.

D. Analysis of Workflow and Time to Treatment and the Effects on Outcome in Endovascular Treatment of Acute Ischemic Stroke: Results from the SWIFT PRIME RCT [Time Matters!]

Goyal M, et al. Radiology. 2016 Apr 19 [Epub ahead of print]

Purpose To study the relationship between functional independence and time to reperfusion in the Solitaire with the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke (SWIFT PRIME) trial in patients with disabling acute ischemic stroke who underwent endovascular therapy plus intravenous tissue plasminogen activator (tPA) administration versus tPA administration alone and to investigate variables that affect time spent during discrete steps.

Materials and Methods Data were analyzed from the SWIFT PRIME trial, a global, multicenter, prospective study in which outcomes were compared in patients treated with intravenous tPA alone or in combination with the Solitaire device (Covidien, Irvine, Calif). Between December 2012 and November 2014, 196 patients were enrolled. The relation between time from (a) symptom onset to reperfusion and (b) imaging to reperfusion and clinical outcome was analyzed, along with patient and health system characteristics that affect discrete steps in patient workflow. Multivariable logistic regression was used to assess relationships between time and outcome; negative binomial regression was used to evaluate effects on workflow. The institutional review board at each site approved the trial. Patients provided written informed consent, or, at select sites, there was an exception from having to acquire explicit informed consent in emergency circumstances.

Results In the stent retriever arm of the study, symptom onset to reperfusion time of 150 minutes led to 91% estimated probability of functional independence, which decreased by 10% over the next hour and by 20% with every subsequent hour of delay. Time from arrival at the emergency department to arterial access was 90 minutes (interquartile range, 69-120 minutes), and time to reperfusion was 129 minutes (interquartile range, 108-169 minutes). Patients who initially arrived at a referring facility had longer symptom onset to groin puncture times compared with patients who presented directly to the endovascular-capable center (275 vs 179.5 minutes, P less than .001).

Conclusion Fast reperfusion leads to improved functional outcome among patients with acute stroke treated with stent retrievers. Detailed attention to workflow with iterative feedback and aggressive time goals may have contributed to efficient workflow environments. © RSNA, 2016 Online supplemental material is available for this article.

3. Zika Virus: A NEJM Review

Petersen LR, et al. N Engl J Med 2016; 374:1552-1563.

In 1947, a study of yellow fever yielded the first isolation of a new virus, from the blood of a sentinel rhesus macaque that had been placed in the Zika Forest of Uganda.1 Zika virus remained in relative obscurity for nearly 70 years; then, within the span of just 1 year, Zika virus was introduced into Brazil from the Pacific Islands and spread rapidly throughout the Americas.2 It became the first major infectious disease linked to human birth defects to be discovered in more than half a century and created such global alarm that the World Health Organization (WHO) would declare a Public Health Emergency of International Concern.3 This review describes the current understanding of the epidemiology, transmission, clinical characteristics, and diagnosis of Zika virus infection, as well as the future outlook with regard to this disease…

4. Ketamine as Rescue Treatment for Difficult-to-Sedate Severe Acute Behavioral Disturbance in the ED

Isbister GK, et al. Ann Emerg Med. 2016;67(5):581–587.e1.

STUDY OBJECTIVE: We investigate the effectiveness and safety of ketamine to sedate patients with severe acute behavioral disturbance who have failed previous attempts at sedation.

METHODS: This was a prospective study of patients given ketamine for sedation who had failed previous sedation attempts. Patients with severe acute behavioral disturbance requiring parenteral sedation were treated with a standardized sedation protocol including droperidol. Demographics, drug dose, observations, and adverse effects were recorded. The primary outcome was the number of patients who failed to sedate within 120 minutes of ketamine administration or requiring further sedation within 1 hour.

RESULTS: Forty-nine patients from 2 hospitals were administered rescue ketamine during 27 months; median age was 37 years (range 20-82 years); 28 were men. Police were involved with 20 patients. Previous sedation included droperidol (10 mg; 1), droperidol (10+10 mg; 33), droperidol (10+10+5 mg; 1), droperidol (10+10+10 mg; 11), and combinations of droperidol and benzodiazepines (2) and midazolam alone (1). The median dose of ketamine was 300 mg (range 50 to 500 mg). Five patients (10%; 95% confidence interval 4% to 23%) were not sedated within 120 minutes or required additional sedation within 1 hour. Four of 5 patients received 200 mg or less. Median time to sedation postketamine was 20 minutes (interquartile range 10 to 30 minutes; 2 to 500 minutes). Three patients (6%) had adverse effects, 2 had vomiting, and a third had a transient oxygen desaturation to 90% after ketamine that responded to oxygen.

CONCLUSION: Ketamine appeared effective and did not cause obvious harm in this small sample and is a potential option for patients who have failed previous attempts at sedation. A dose of 4 to 5 mg/kg is suggested, and doses less than 200 mg are associated with treatment failure.

5. New Cardiac Arrest Research

A. Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest

Kudenchuk PJ, et al. Resuscitation Outcomes Consortium Investigators. N Engl J Med. 2016 Apr 4 [Epub ahead of print].

Background Antiarrhythmic drugs are used commonly in out-of-hospital cardiac arrest for shock-refractory ventricular fibrillation or pulseless ventricular tachycardia, but without proven survival benefit.

Methods In this randomized, double-blind trial, we compared parenteral amiodarone, lidocaine, and saline placebo, along with standard care, in adults who had nontraumatic out-of-hospital cardiac arrest, shock-refractory ventricular fibrillation or pulseless ventricular tachycardia after at least one shock, and vascular access. Paramedics enrolled patients at 10 North American sites. The primary outcome was survival to hospital discharge; the secondary outcome was favorable neurologic function at discharge. The per-protocol (primary analysis) population included all randomly assigned participants who met eligibility criteria and received any dose of a trial drug and whose initial cardiac-arrest rhythm of ventricular fibrillation or pulseless ventricular tachycardia was refractory to shock. Results In the per-protocol population, 3026 patients were randomly assigned to amiodarone (974), lidocaine (993), or placebo (1059); of those, 24.4%, 23.7%, and 21.0%, respectively, survived to hospital discharge. The difference in survival rate for amiodarone versus placebo was 3.2 percentage points (95% confidence interval [CI], -0.4 to 7.0; P=0.08); for lidocaine versus placebo, 2.6 percentage points (95% CI, -1.0 to 6.3; P=0.16); and for amiodarone versus lidocaine, 0.7 percentage points (95% CI, -3.2 to 4.7; P=0.70). Neurologic outcome at discharge was similar in the three groups. There was heterogeneity of treatment effect with respect to whether the arrest was witnessed (P=0.05); active drugs were associated with a survival rate that was significantly higher than the rate with placebo among patients with bystander-witnessed arrest but not among those with unwitnessed arrest. More amiodarone recipients required temporary cardiac pacing than did recipients of lidocaine or placebo.

Conclusions Overall, neither amiodarone nor lidocaine resulted in a significantly higher rate of survival or favorable neurologic outcome than the rate with placebo among patients with out-of-hospital cardiac arrest due to initial shock-refractory ventricular fibrillation or pulseless ventricular tachycardia.

B. Early administration of epinephrine (adrenaline) in patients with cardiac arrest with initial shockable rhythm in hospital: propensity score matched analysis.

Andersen LW, et al. American Heart Association’s Get With The Guidelines-Resuscitation Investigators. BMJ. 2016 Apr 6;353:i1577.

OBJECTIVES:  To evaluate whether patients who experience cardiac arrest in hospital receive epinephrine (adrenaline) within the two minutes after the first defibrillation (contrary to American Heart Association guidelines) and to evaluate the association between early administration of epinephrine and outcomes in this population.

DESIGN: Prospective observational cohort study.

SETTING: Analysis of data from the Get With The Guidelines-Resuscitation registry, which includes data from more than 300 hospitals in the United States.

PARTICIPANTS: Adults in hospital who experienced cardiac arrest with an initial shockable rhythm, including patients who had a first defibrillation within two minutes of the cardiac arrest and who remained in a shockable rhythm after defibrillation.

INTERVENTION: Epinephrine given within two minutes after the first defibrillation.

MAIN OUTCOME MEASURES: Survival to hospital discharge. Secondary outcomes included return of spontaneous circulation and survival to hospital discharge with a good functional outcome. A propensity score was calculated for the receipt of epinephrine within two minutes after the first defibrillation, based on multiple characteristics of patients, events, and hospitals. Patients who received epinephrine at either zero, one, or two minutes after the first defibrillation were then matched on the propensity score with patients who were "at risk" of receiving epinephrine within the same minute but who did not receive it.

RESULTS: 2978 patients were matched on the propensity score, and the groups were well balanced. 1510 (51%) patients received epinephrine within two minutes after the first defibrillation, which is contrary to current American Heart Association guidelines. Epinephrine given within the first two minutes after the first defibrillation was associated with decreased odds of survival in the propensity score matched analysis (odds ratio 0.70, 95% confidence interval 0.59 to 0.82; P less than 0.001). Early epinephrine administration was also associated with a decreased odds of return of spontaneous circulation (0.71, 0.60 to 0.83; P less than 0.001) and good functional outcome (0.69, 0.58 to 0.83; P less than 0.001).

CONCLUSION: Half of patients with a persistent shockable rhythm received epinephrine within two minutes after the first defibrillation, contrary to current American Heart Association guidelines. The receipt of epinephrine within two minutes after the first defibrillation was associated with decreased odds of survival to hospital discharge as well as decreased odds of return of spontaneous circulation and survival to hospital discharge with a good functional outcome.

C. Defibrillation time intervals and outcomes of cardiac arrest in hospital: retrospective cohort study from Get With The Guidelines-Resuscitation registry.

Bradley SM, et al. American Heart Association’s Get With The Guidelines-Resuscitation Investigators. BMJ. 2016 Apr 6;353:i1653.

OBJECTIVE: To describe temporal trends in the time interval between first and second attempts at defibrillation and the association between this time interval and outcomes in patients with persistent ventricular tachycardia or ventricular fibrillation (VT/VF) arrest in hospital.

DESIGN: Retrospective cohort study

SETTING: 172 hospitals in the United States participating in the Get With The Guidelines-Resuscitation registry, 2004-12.

PARTICIPANTS: Adults who received a second defibrillation attempt for persistent VT/VF arrest within three minutes of a first attempt.

INTERVENTIONS: Second defibrillation attempts categorized as early (time interval of up to and including one minute between first and second defibrillation attempts) or deferred (time interval of more than one minute between first and second defibrillation attempts).

MAIN OUTCOME MEASURE: Survival to hospital discharge.

RESULTS: Among 2733 patients with persistent VT/VF after the first defibrillation attempt, 1121 (41%) received a deferred second attempt. Deferred second defibrillation for persistent VT/VF increased from 26% in 2004 to 57% in 2012 (P less than 0.001 for trend). Compared with early second defibrillation, unadjusted patient outcomes were significantly worse with deferred second defibrillation (57.4%v62.5% for return of spontaneous circulation, 38.4%v43.6% for survival to 24 hours, and 24.7%v30.8% for survival to hospital discharge; P less than 0.01 for all comparisons). After risk adjustment, deferred second defibrillation was not associated with survival to hospital discharge (propensity weighting adjusted risk ratio 0.89, 95% confidence interval 0.78 to 1.01; P=0.08; hierarchical regression adjusted 0.92, 0.83 to 1.02; P=0.1).

CONCLUSIONS: Since 2004, the use of deferred second defibrillation for persistent VT/VF in hospital has doubled. Deferred second defibrillation was not associated with improved survival.

6. How to read a scientific paper

By Adam Ruben. Science. Jan. 20, 2016, 3:15 PM

Nothing makes you feel stupid quite like reading a scientific journal article.

I remember my first experience with these ultra-congested and aggressively bland manuscripts so dense that scientists are sometimes caught eating them to stay regular. I was in college taking a seminar course in which we had to read and discuss a new paper each week. And something just wasn’t working for me.

Every week I would sit with the article, read every single sentence, and then discover that I hadn’t learned a single thing. I’d attend class armed with exactly one piece of knowledge: I knew I had read the paper. The instructor would ask a question; I’d have no idea what she was asking. She’d ask a simpler question—still no idea. But I’d read the damn paper!

It reminded me of kindergarten, when I would feel proud after reading a book above my grade level. But if you had asked me a simple question about the book’s contents—What kind of animal is Wilbur? How did Encyclopedia Brown know that Bugs Meany wasn’t really birdwatching?—I couldn’t have answered it.

A few weeks into the seminar, I decided enough was enough. I wasn’t going to read another paper without understanding it. So I took that week’s journal article to the library. Not just the regular library, but the obscure little biology library, one of those dusty academic hidey-holes only populated by the most wretched forms of life, which are, of course, insects and postdocs.

I placed the paper on a large empty desk. I eliminated all other distractions. To avoid interruptions from friends encouraging alcohol consumption, as friends do in college, I sat in an obscure anteroom with no foot traffic. To avoid interruptions from cellphone calls, I made sure it was 1999.

Most importantly, if I didn’t understand a word in a sentence, I forbade myself from proceeding to the next sentence until I looked it up in a textbook and then reread the sentence until it made sense.

I specifically remember this happening with the word “exogenous.” Somehow I had always glossed over this word, as though it was probably unimportant to its sentence. Wrong.

It took me more than 2 hours to read a three-page paper. But this time, I actually understood it.

And I thought, “Wow. I get it. I really get it.”

And I thought, “Oh crap. I’m going to have to do this again, aren’t I?”

If you’re at the beginning of your career in science, you may be struggling with the same problem. It may help you to familiarize yourself with the 10 Stages of Reading a Scientific Paper:

1. Optimism. “This can’t be too difficult,” you tell yourself with a smile—in the same way you tell yourself, “It’s not damaging to drink eight cups of coffee a day” or “There are plenty of tenure-track jobs.” After all, you’ve been reading words for decades. And that’s all a scientific paper is, right? Words?

2. Fear. This is the stage when you realize, “Uh … I don’t think all of these are words.” So you slow down a little. Sound out the syllables, parse the jargon, look up the acronyms, and review your work several times. Congratulations: You have now read the title.

3. Regret. You begin to realize that you should have budgeted much more time for this whole undertaking. Why, oh why, did you think you could read the article in a single bus ride? If only you had more time. If only you had one of those buzzer buttons from workplaces in the 1960s, and you could just press it and say, “Phoebe, cancel my January.” If only there was a compact version of the same article, something on the order of 250 or fewer words, printed in bold at the beginning of the paper…

4. Corner-cutting. Why, what’s this? An abstract, all for me? Blessed be the editors of scientific journals who knew that no article is comprehensible, so they asked their writers to provide, à la Spaceballs, “the short, short version.” Okay. Let’s do this.

5. Bafflement. What the hell? Was that abstract supposed to explain something? Why was the average sentence 40 words long? Why were there so many acronyms? Why did the authors use the word “characterize” five times?

6. Distraction. What if there was, like, a smartphone for ducks? How would that work? What would they use it for? And what was that Paul Simon lyric, the one from “You Can Call Me Al,” that’s been in your head all day? How would your life change if you owned a bread maker? You’d have to buy yeast. Is yeast expensive? You could make your own bread every few days, but then it might go stale. It’s not the same as store-bought bread; it’s just not. Oh, right! “Don’t want to end up a cartoon in a cartoon graveyard.” Is Paul Simon still alive? You should check Wikipedia. Sometimes you confuse him with Paul McCartney or Paul Shaffer. Shame about David Bowie. Can you put coffee in a humidifier?

7. Realization that 15 minutes have gone by and you haven’t progressed to the next sentence.

8. Determination. All righty. Really gonna read this time. Really gonna do it. Yup, yuppers, yup-a-roo, readin’ words is what you do. Let’s just point those pupils at the dried ink on the page, and …


10. Genuine contemplation of a career in the humanities. Academic papers written on nonscientific subjects are easy to understand, right? Right?

What a strange document a scientific journal article is. We work on them for months or even years. We write them in a highly specialized vernacular that even most other scientists don’t share. We place them behind a paywall and charge something ridiculous, like $34.95, for the privilege of reading them. We so readily accept their inaccessibility that we have to start “journal clubs” in the hopes that our friends might understand them and summarize them for us.

Can you imagine if mainstream magazine articles were like science papers? Picture a Time cover story with 48 authors. Or a piece in The Economist that required, after every object described, a parenthetical listing of the company that produced the object and the city where that company is based. Or a People editorial about Jimmy Kimmel that could only be published following a rigorous review process by experts in the field of Jimmy Kimmel.

Do you know what you’d call a magazine article that required intellectual scrutiny and uninterrupted neural commitment to figure out what it’s even trying to say? You’d call it a badly written article.

So for those new to reading journals, welcome. Good luck. And we’re sorry. We’re trying to write articles comprehensibly, but sometimes our subdiscipline is so hyperspecific that we need a million acronyms. And sometimes we’re attempting to sound like good scientists by copying the tone of every article we’ve read. And sometimes we’re just writing badly.

Quackberry. That’s what you’d call the smartphone for ducks.

7. Ultrasound in Emergency Medicine

A. Mistakes and Pitfalls Associated with Two-Point Compression Ultrasound for DVT

Zitek T, et al. West J Emerg Med. 2016;17(2):201-208.

Introduction: Two-point compression ultrasound is purportedly a simple and accurate means to diagnose proximal lower extremity deep vein thrombosis (DVT), but the pitfalls of this technique have not been fully elucidated. The objective of this study is to determine the accuracy of emergency medicine resident-performed two-point compression ultrasound, and to determine what technical errors are commonly made by novice ultrasonographers using this technique.

Methods: This was a prospective diagnostic test assessment of a convenience sample of adult emergency department (ED) patients suspected of having a lower extremity DVT. After brief training on the technique, residents performed two-point compression ultrasounds on enrolled patients. Subsequently a radiology department ultrasound was performed and used as the gold standard. Residents were instructed to save videos of their ultrasounds for technical analysis.

Results: Overall, 288 two-point compression ultrasound studies were performed. There were 28 cases that were deemed to be positive for DVT by radiology ultrasound. Among these 28, 16 were identified by the residents with two-point compression. Among the 260 cases deemed to be negative for DVT by radiology ultrasound, 10 were thought to be positive by the residents using two-point compression. This led to a sensitivity of 57.1% (95% CI [38.8-75.5]) and a specificity of 96.1% (95% CI [93.8-98.5]) for resident-performed two-point compression ultrasound. This corresponds to a positive predictive value of 61.5% (95% CI 42.8% to 80.2%) and a negative predictive value of 95.4% (95% CI 92.9% to 98.0%).  The positive likelihood ratio is 14.9 (95% CI 7.5 to 29.5) and the negative likelihood ratio is 0.45 (95% CI 0.29 to 0.68). Video analysis revealed that in four cases the resident did not identify a DVT because the thrombus was isolated to the superior femoral vein (SFV), which is not evaluated by two-point compression. Moreover, the video analysis revealed that the most common mistake made by the residents was inadequate visualization of the popliteal vein.

Conclusion: Two-point compression ultrasound does not identify isolated SFV thrombi, which reduces its sensitivity. Moreover, this technique may be more difficult than previously reported, in part because novice ultrasonographers have difficulty properly assessing the popliteal vein.

B. US-Guided Cannulation: Time to Bring Subclavian Central Lines Back

Despite multiple advantages, subclavian vein (SCV) cannulation via the traditional landmark approach has become less used in comparison to ultrasound (US) guided internal jugular catheterization due to a higher rate of mechanical complications. A growing body of evidence indicates that SCV catheterization with real-time US guidance can be accomplished safely and efficiently. While several cannulation approaches with real-time US guidance have been described, available literature suggests that the infraclavicular, longitudinal “in-plane” technique may be preferred. This approach allows for direct visualization of needle advancement, which reduces risk of complications and improves successful placement. Infraclavicular SCV cannulation requires simultaneous use of US during needle advancement, but for an inexperienced operator, it is more easily learned compared to the traditional landmark approach. In this article, we review the evidence supporting the use of US guidance for SCV catheterization and discuss technical aspects of the procedure itself.

Related article: Kim EH, et al. Influence of caudal traction of ipsilateral arm on ultrasound image for supraclavicular central venous catheterization. Am J Emerg Med. 2016 Feb 12 [Epub ahead of print]

C. Routine CXR Is Not Necessary After US-Guided Right IJ Vein Catheterization.

Hourmozdi JJ, et al. Crit Care Med. 2016 Mar 31 [Epub ahead of print]

OBJECTIVES: Central venous catheter placement is a common procedure performed on critically ill patients. Routine postprocedure chest radiographs are considered standard practice. We hypothesize that the rate of clinically relevant complications detected on chest radiographs following ultrasound-guided right internal jugular vein catheterization is exceedingly low.

DESIGN: Retrospective chart review.

SETTING: Adult ICUs, emergency departments, and general practice units at an academic tertiary care hospital system.

PATIENTS: All 1,322 ultrasound-guided right internal jugular vein central venous catheter attempts at an academic tertiary care hospital system over a 1-year period.


MEASUREMENTS AND MAIN RESULTS: Data from standardized procedure notes and postprocedure chest radiographs were extracted and individually reviewed to verify the presence of pneumothorax or misplacement, and any intervention performed for either complication. The overall success rate of ultrasound-guided right internal jugular vein central venous catheter placement was 96.9% with an average of 1.3 attempts. There was only one pneumothorax (0.1% [95% CI, 0-0.4%]), and the rate of catheter misplacement requiring repositioning or replacement was 1.0% (95% CI, 0.6-1.7%). There were no arterial placements found on chest radiographs. Multivariate regression analysis showed no correlation between high-risk patient characteristics and composite complication rate.

CONCLUSIONS: In a large teaching hospital system, the overall rate of clinically relevant complications detected on chest radiographs following ultrasound-guided right internal jugular vein catheterization is exceedingly low. Routine chest radiograph after this common procedure is an unnecessary use of resources and may delay resuscitation of critically ill patients.

8. Pediatric Corner

A. Lung US may be alternative for pediatric pneumonia diagnosis

Feasibility and Safety of Substituting Lung Ultrasound for Chest X-ray When Diagnosing Pneumonia in Children: A RCT

Jones BP, et al. Chest. 2016 Feb 25 [Epub ahead of print].

BACKGROUND: Chest x-ray (CXR) is the test of choice for diagnosing pneumonia. Lung ultrasound (LUS) has been shown to be accurate for diagnosing pneumonia in children and may be an alternative to CXR. Our objective was to determine the feasibility and safety of substituting LUS for CXR when evaluating children with suspected pneumonia.

METHODS: We conducted a randomized control trial comparing LUS to CXR in 191 children from birth to 21 years of age with suspected pneumonia in an emergency department. Patients in the investigational arm received a LUS. If there was clinical uncertainty after ultrasound, clinicians had the option to obtain CXR. Patients in the control arm underwent sequential imaging with CXR followed by LUS. Primary outcome was the rate of CXR reduction; secondary outcomes were missed pneumonia, subsequent unscheduled healthcare visits, and adverse events between investigational and control arms.

RESULTS: There was a 38.8% reduction (95% CI, 30.0 to 48.9%) in CXR among investigational subjects compared to no reduction (95% CI, 0.0 to 3.6%) in the control group. Novice and experienced clinician-sonologists achieved 30.0% and 60.6% reduction in CXR use, respectively. There were no cases of missed pneumonia among all study participants (investigational arm 0%; 95% CI: 0.0-2.9%; control arm 0%; 95% CI 0.0-3%) or differences in adverse events, or subsequent unscheduled healthcare visits between arms.

CONCLUSIONS: It may be feasible and safe to substitute LUS for CXR when evaluating children with suspected pneumonia with no missed cases of pneumonia or increase in rates of adverse events.

B. Implementation of Electronic Clinical Decision Support for Pediatric Appendicitis

Kharbanda AB, et al. Pediatic 2016 April [Epub ahead of print]

BACKGROUND AND OBJECTIVE: Computed tomography (CT) and ultrasound (US) are commonly used in patients with acute abdominal pain. We sought to standardize care and reduce CT use while maintaining patient safety through implementation of a multicomponent electronic clinical decision support tool for pediatric patients with possible appendicitis.

METHODS: We conducted a quasi-experimental study of children 3 to 18 years old who presented with possible appendicitis to the pediatric emergency department (ED) between January 2011 and December 2013. Outcomes were use of CT and US. Balancing measures included missed appendicitis, ED revisits within 30 days, appendiceal perforation, and ED length of stay.

RESULTS: Of 2803 patients with acute abdominal pain over the 3-year study period, 794 (28%) had appendicitis and 207 (26.1% of those with appendicitis) had a perforation. CT use during the 10-month preimplementation period was 38.8% and declined to 17.7% by the end of the study (54% relative decrease). For CT, segmented regression analysis revealed that there was a significant change in trend from the preimplementation period to implementation (monthly decrease –3.5%; 95% confidence interval: –5.9% to –0.9%; P = .007). US use was 45.7% preimplementation and 59.7% during implementation. However, there was no significant change in US or total imaging trends. There were also no statistically significant differences in rates of missed appendicitis, ED revisits within 30 days, appendiceal perforation, or ED length of stay between time periods.

CONCLUSIONS: Our electronic clinical decision support tool was associated with a decrease in CT use while maintaining safety and high quality care for patients with possible appendicitis.

C. Observation for isolated traumatic skull fractures in the pediatric population: unnecessary and costly

Blackwood BP, et al. J Pediatr Surg. 2015 Sep 24. [Epub ahead of print]

BACKGROUND: Blunt head trauma accounts for a majority of pediatric trauma admissions. There is a growing subset of these patients with isolated skull fractures, but little evidence guiding their management. We hypothesized that inpatient neurological observation for pediatric patients with isolated skull fractures and normal neurological examinations is unnecessary and costly.

METHODS: We performed a single center 10year retrospective review of all head traumas with isolated traumatic skull fractures and normal neurological examination. Exclusion criteria included: penetrating head trauma, depressed fractures, intracranial hemorrhage, skull base fracture, pneumocephalus, and poly-trauma. In each patient, we analyzed: age, fracture location, loss of consciousness, injury mechanism, Emergency Department (ED) disposition, need for repeat imaging, hospital costs, intracranial hemorrhage, and surgical intervention.

RESULTS: Seventy-one patients presented to our ED with acute isolated skull fractures, 56% were male and 44% were female. Their ages ranged from 1week to 12.4years old. The minority (22.5%) of patients were discharged from the ED following evaluation, whereas 77.5% were admitted for neurological observation. None of the patients required neurosurgical intervention. Age was not associated with repeat imaging or inpatient observation (p=0.7474, p=0.9670). No patients underwent repeat head imaging during their index admission. Repeat imaging was obtained in three previously admitted patients who returned to the ED. Cost analysis revealed a significant difference in total hospital costs between the groups, with an average increase in charges of $4,291.50 for admitted patients (p less than 0.0001).

CONCLUSION: Pediatric isolated skull fractures are low risk conditions with a low likelihood of complications. Further studies are necessary to change clinical practice, but our research indicates that these patients can be discharged safely from the ED without inpatient observation. This change in practice, additionally, would allow for huge health care dollar savings.

D. Techniques and Trends, Success Rates, and Adverse Events in ED Pediatric Intubations: A Report from the National Emergency Airway Registry.

Pallin DJ, et al. Ann Emerg Med. 2016;67(5):610–615.e1.

STUDY OBJECTIVE: We describe emergency department (ED) intubation practices for children younger than 16 years through multicenter prospective surveillance.

METHODS: Academic and community EDs in the United States, Canada, and Australia recorded data electronically, from 2002 to 2012, with verified greater than or equal to 90% reporting.

RESULTS: Ten of 18 participating centers provided qualifying data, reporting 1,053 encounters. Emergency physicians initiated 85% of intubations. Trainees initiated 83% (95% confidence interval [CI] 81% to 85%). Premedication became uncommon, reaching less than 30% by the last year. Etomidate was used in 78% of rapid sequence intubations. Rocuronium use increased during the period of study, whereas succinylcholine use declined. Video laryngoscopy increased, whereas direct laryngoscopy declined. The first attempt was successful in 83% of patients (95% CI 81% to 85%) overall. The risk of first-attempt failure was highest for infants (relative risk versus all others 2.3; 95% CI 1.8 to 3.0). Odds of first-attempt success for girls relative to boys were 0.57. The odds were 3.4 times greater for rapid sequence intubation than sedation without paralysis. The ultimate success rate was 99.5%.

CONCLUSION: Because we sampled only 10 centers and most of the intubations were by trainees, our results may not be generalizable to the typical ED setting. We found that premedication is now uncommon, etomidate is the predominant induction agent, and rocuronium and video laryngoscopy are used increasingly. First-attempt failure is most common in infants.

E. Clinical Policy for Well-Appearing Infants and Children less than 2 Years of Age Presenting to the ED with Fever

Mace SE, et al. Ann Emerg Med. 2016;67(5):625–639.e13.

This clinical policy from the American College of Emergency Physicians addresses key issues for well-appearing infants and children younger than 2 years presenting to the emergency department with fever. A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions:

(1) For well-appearing immunocompetent infants and children aged 2 months to 2 years presenting with fever (≥38.0°C [100.4°F]), are there clinical predictors that identify patients at risk for urinary tract infection?

(2) For well-appearing febrile infants and children aged 2 months to 2 years undergoing urine testing, which laboratory testing method(s) should be used to diagnose a urinary tract infection?

(3) For well-appearing immunocompetent infants and children aged 2 months to 2 years presenting with fever (≥38.0°C [100.4°F]), are there clinical predictors that identify patients at risk for pneumonia for whom a chest radiograph should be obtained?

(4) For well-appearing immunocompetent full-term infants aged 1 month to 3 months (29 days to 90 days) presenting with fever (≥38.0°C [100.4°F]), are there predictors that identify patients at risk for meningitis from whom cerebrospinal fluid should be obtained? Evidence was graded and recommendations were made based on the strength of the available data.

9. Ondansetron good second-line treatment for nausea in pregnancy

Ondansetron may be a good option for relieving nausea and vomiting in pregnant women when other treatments do not work, researchers reported in Obstetrics & Gynecology. Study data showed using the drug in the first trimester was tied to a low risk of birth defects and a small potential increase in cardiac malformations in newborns.

Carstairs SD. Ondansetron Use in Pregnancy and Birth Defects: A Systematic Review. Obstet Gynecol. 2016 May;127(5):878-883.

OBJECTIVE: To examine the risk of birth defects in children born to women who used ondansetron early in pregnancy for nausea and vomiting of pregnancy or hyperemesis gravidarum.

DATA SOURCES: PubMed, EMBASE, Cochrane, Scopus, Web of Science, Journals@Ovid Fulltext,, and Google Scholar databases.

METHODS OF STUDY SELECTION: Studies were included for review if they were written in English, included a comparison population of patients not exposed to ondansetron, and reported human data, original research, exposure to ondansetron during the first trimester, and structural birth defects as an outcome.

TABULATION, INTEGRATION, AND RESULTS: A total of 423 records were identified. After accounting for duplicate records and including only relevant articles, a total of eight records met criteria for review. Data from the various studies were conflicting: whereas the three largest studies showed no increased risk of birth defects as a whole (36 malformations, 1,233 exposed compared with 141 malformations and 4,932 unexposed; 58/1,248 exposed compared with 31,357/895,770 unexposed; and 38/1,349 exposed compared with 43,620/1,500,085 unexposed; with odds ratios [ORs] of 1.12 (95% confidence interval [CI] 0.69–1.82), 1.3 [95% CI 1.0–1.7], and 0.95 [95% CI 0.72–1.26], respectively), two of these studies demonstrated a slightly increased risk of cardiac defects specifically (OR 2.0 [95% CI 1.3–3.1] and 1.62 [95% CI 1.04–2.14]), a finding that was not replicated in other studies. The most consistent association (if any) appears to be a small increase in the incidence of cardiac abnormalities, the bulk of which are septal defects.

CONCLUSION: The overall risk of birth defects associated with ondansetron exposure appears to be low. There may be a small increase in the incidence of cardiac abnormalities in ondansetron-exposed neonates. Therefore, ondansetron use for nausea and vomiting of pregnancy should be reserved for those women whose symptoms have not been adequately controlled by other methods.

10. What the ED can do to address the rising rates of opioid addiction?

A. ED motivational interview might lower opioid misuse risk

A pilot randomized clinical trial of an intervention to reduce overdose risk behaviors among ED patients at risk for prescription opioid overdose.

Bohnert AS, et al. Drug Alcohol Depend. 2016 Mar 26 [Epub ahead of print]

BACKGROUND AND AIMS: Prescription opioid overdose is a significant public health problem. Interventions to prevent overdose risk behaviors among high-risk patients are lacking. This study examined the impact of a motivational intervention to reduce opioid misuse and overdose risk behaviors.

METHODS: This study was a pilot randomized controlled trial set in a single emergency department (ED) in which, 204 adult, English-speaking patients seeking care who reported prescription opioid misuse during the prior 3 months were recruited. Patients were randomized to either the intervention, a 30-minute motivational interviewing-based session delivered by a therapist plus educational enhanced usual care (EUC), or EUC alone. Participants completed self-reported surveys at baseline and 6 months post-baseline (87% retention rate) to measure the primary outcomes of overdose risk behaviors and the secondary outcome of non-medical opioid use.

FINDINGS: Participants in the intervention condition reported significantly lower levels of overdose risk behaviors (incidence rate ratio [IRR]=0.72, 95% CI: 0.59-0.87; 40.5% reduction in mean vs. 14.7%) and lower levels of non-medical opioid use (IRR=0.81, 95% CI: 0.70-0.92; 50.0% reduction in mean vs. 39.5%) at follow-up compared to the EUC condition.

CONCLUSIONS: This study represents the first clinical trial of a behavioral intervention to reduce overdose risk. Results indicate that this single motivational enhancement session reduced prescription opioid overdose risk behaviors, including opioid misuse, among adult patients in the ED.

B. RCT of Electronic Care Plan Alerts and Resource Utilization by High Frequency ED Users with Opioid Use Disorder

Rathlev N, et al. West J Emerg Med. 2016;17(1):28-34.

INTRODUCTION: There is a paucity of literature supporting the use of electronic alerts for patients with high frequency emergency department (ED) use. We sought to measure changes in opioid prescribing and administration practices, total charges and other resource utilization using electronic alerts to notify providers of an opioid-use care plan for high frequency ED patients.

METHODS: This was a randomized, non-blinded, two-group parallel design study of patients who had 1) opioid use disorder and 2) high frequency ED use. Three affiliated hospitals with identical electronic health records participated. Patients were randomized into "Care Plan" versus "Usual Care groups". Between the years before and after randomization, we compared as primary outcomes the following: 1) opioids (morphine mg equivalents) prescribed to patients upon discharge and administered to ED and inpatients; 2) total medical charges, and the numbers of; 3) ED visits, 4) ED visits with advanced radiologic imaging (computed tomography [CT] or magnetic resonance imaging [MRI]) studies, and 5) inpatient admissions.

RESULTS: A total of 40 patients were enrolled. For ED and inpatients in the "Usual Care" group, the proportion of morphine mg equivalents received in the post-period compared with the pre-period was 15.7%, while in the "Care Plan" group the proportion received in the post-period compared with the pre-period was 4.5% (ratio=0.29, 95% CI [0.07-1.12]; p=0.07). For discharged patients in the "Usual Care" group, the proportion of morphine mg equivalents prescribed in the post-period compared with the pre-period was 25.7% while in the "Care Plan" group, the proportion prescribed in the post-period compared to the pre-period was 2.9%. The "Care Plan" group showed an 89% greater proportional change over the periods compared with the "Usual Care" group (ratio=0.11, 95% CI [0.01-0.092]; p=0.04). Care plans did not change the total charges, or, the numbers of ED visits, ED visits with CT or MRI or inpatient admissions.

CONCLUSION: Electronic care plans were associated with an incremental decrease in opioids (in morphine mg equivalents) prescribed to patients with opioid use disorder and high frequency ED use.

11. Present and future of cardiac troponin in clinical practice

Sandoval Y, et al. Am J Med. 2016 Apr;129(4):354-65.

Despite its wide use and central role in the evaluation of patients with potential ischemic symptoms, misconceptions and confusion about cardiac troponin (cTn) prevail. The implementation of high-sensitivity (hs) cTn assays in clinical practice has multiple potential advantages provided there is an education process tied to the introduction of these assays that emphasizes appropriate use.

Several diagnostic strategies have been explored with hs-cTn assays, including the use of undetectable values, accelerated serial hs-cTn sampling, hs-cTn measurements in combination with a clinical-risk score, and a single hs-cTn measurement with a concentration threshold tailored to meet a clinical need. The authors discuss basic concepts to facilitate integration of hs-cTn assays into clinical care.

12. Images in Clinical Practice

Man With Sharp Periumbilical Pain

Elderly Man With Dyspnea

Man With Right Hand Bullae

Discussion: Phytophotodermatitis: The Other “Lime” Disease

Young Woman With Syncope

Adult Female With Abdominal Pain

Elderly Woman With Pain and Numbness in Left Hand

Electronic Vapor Cigarette Battery Explosion Causing Shotgun-like Superficial Wounds and Contusion

Traumatic Arthrotomy with Pneumarthrosis on Plain Radiograph of the Knee

Young Woman with a Fever and Chest Pain

Bullosis Diabeticorum

Turbid Peritoneal Fluid

Diffuse Melanosis Cutis


Paget’s Disease of Bone

Carotid–Cavernous Sinus Fistula

Reversible Loss of Vision in Malignant Hypertension

Creeping Eruption — Cutaneous Larva Migrans

Metronidazole-Associated Encephalopathy

“Frog Sign” in Atrioventricular Nodal Reentrant Tachycardia

Resolution of Lumbar Disk Herniation without Surgery

Young Woman With Diffuse Pustular Rash

Young Girl With Shoulder and Chest Pain

Discussion: Penetrating Neck Injury: What’s In and What’s Out?

Ulcerations on the Neck and Forearm

Child With Swollen Face

Man With Thrill in Neck

Female With Severe Shock

Video on Managing Procedural Anxiety in Children

For those with access to NEJM, you’ll appreciate this.

Krauss BS, et al. N Engl J Med 2016; 374:e19.

When children need medical care, the situation can be stressful for both the parents and the child. This video describes the signs of acute anxiety in children and demonstrates approaches to interacting with children that minimize anxiety and maximize cooperation.

13. Community Paramedicine — Addressing Questions as Programs Expand

Iezzoni LI, et al. N Engl J Med 2016; 374:1107-1109.

Growing increasingly short of breath late one night, Ms. E. called her health care provider’s urgent care line, anticipating that the on-call nurse practitioner would have her transported to the emergency department (ED). Over the past 6 months, Ms. E. had made many ED visits. She is 83 years old and poor, lives alone, and has multiple health problems, including heart failure, advanced kidney disease, hepatitis C with liver cirrhosis, diabetes, and hypertension. In the ED, she generally endures long waits, must repeatedly recite her lengthy medical history, and feels vulnerable and helpless. She was therefore relieved when, instead of dialing 911, the nurse practitioner dispatched a specially trained and equipped paramedic to her home. As part of a pilot program overseen by the Massachusetts Department of Public Health, the paramedic retrieved Ms. E.’s electronic health record, performed a physical examination, and conducted blood tests while communicating with her provider’s on-call physician. As instructed, the paramedic administered intravenous diuretics and ensured that Ms. E. was clinically stable before leaving her home, where her primary care team followed up with her the next morning.

The Massachusetts acute community care program is one of numerous new initiatives in the United States using emergency medical services (EMS) personnel. These mobile integrated health care and community paramedicine programs aim to address critical problems in local delivery systems, such as insufficient primary and chronic care resources, overburdened EDs, and costly, fragmented emergency and urgent care networks.1 Despite growing enthusiasm for these programs,2 however, their performance has rarely been rigorously evaluated, and they raise important questions about training, oversight, care coordination, and value.

EMS systems were established in the United States in the 1950s and expanded, using federal funding, in the 1970s to create 911 response networks nationwide. Operating EMS systems around the clock requires trained workers with diverse skills. In 1975, the American Medical Association recognized emergency medical technicians (EMTs), paramedics, and other EMS staff as allied health workers. The federal government specifies educational standards for the various EMS occupations. As entry-level EMS providers, for example, EMTs undergo about 6 months of training and must pass state certification exams. In contrast, paramedics must have substantial prior EMT experience and then complete at least 2 years of didactic and field training before passing rigorous state licensing exams assessing knowledge and psychomotor skills.

Since the 1980s, reduced federal funding has contributed to EMS fragmentation. Local fire departments provide roughly half of today’s emergency medical services. Almost all 911 calls result in transportation to an ED because of state regulations and payment policies: insurers, including Medicare, typically reimburse EMS providers only for transporting patients. At the receiving end, many EDs face escalating demand and soaring costs, as more people seek attention for nonurgent acute and chronic conditions — in part because they lack regular sources of primary and chronic disease care. One estimate suggests that about 15% of persons transported by ambulance to EDs could safely receive care in non–urgent care settings, potentially saving the system hundreds of millions of dollars each year.2

Other countries have faced similar health care delivery challenges, and some have enlisted EMS personnel as part of their solutions. For example, in Australia and Canada, specially trained paramedics provide preventive and nonurgent primary care in rural regions, which benefits both patients and the paramedics, who can use their clinical skills to maximum advantage in regions with low emergency call volumes. In England, Wales, Canada, Australia, and New Zealand, EMS personnel provide urgent care on scene, averting unnecessary trips to the ED. The United Kingdom spent more than £4 million ($5.7 million) investigating new approaches that would allow EMS personnel to safely care for people who called 999 — the U.K. equivalent of 911 — in their homes or communities.3 It implemented the successful approaches to substantially change how EMS providers respond to 999 calls, reducing ED transport rates from 90% in 2000 to 58% in 2012.3 These changes have not affected patient safety.

Community paramedicine has come to the United States only recently, but initiatives are already under way in nearly 20 states. These programs vary widely…

14. Dual-targeted therapy with trastuzumab and lapatinib in treatment-refractory, KRAS codon 12/13 wild-type, HER2-positive metastatic colorectal cancer (HERACLES): a proof-of-concept, multicentre, open-label, phase 2 trial

Sartore-Bianchi A, et al. Lancet Oncology 2016 April 20 [Epub ahead of print].

Whoa! Where did that come from?

I thought it was one cool title. And you gotta love the acronym.

15. Ineffectiveness of glucagon in relieving esophageal foreign body impaction: a multicenter study

Bodkin RP, et al. Am J Emerg Med. 2016 Mar 9 [Epub ahead of print].

PURPOSE: Glucagon is thought to decrease lower esophageal sphincter tone and is used as an alternative to invasive endoscopy for esophageal foreign body impaction (EFBI). The purpose of this study was to evaluate efficacy and safety of glucagon and identify characteristics associated with success.

METHODS: A multicenter, retrospective study of patients receiving glucagon for EFBI at 2 academic emergency departments was conducted between 2006 and 2010. A control group of patients that did not receive glucagon was evaluated. Data collection included demographics, type of foreign body, glucagon dose, resolution of impaction, incidence of vomiting, additional medication, and endoscopy required. Descriptive and univariate analysis was performed as appropriate.

RESULTS: A total of 133 doses of glucagon were administered in 127 patients. Glucagon-related resolution of EFBI occurred in 18 patients (14.2%) and vomiting in 16 patients (12.6%). No statistical differences between successful and unsuccessful groups were seen with the exception of concomitant medication administration (benzodiazepine or nitroglycerin) being associated with less glucagon success, 33.3% vs 59.6%, respectively (P = .04). Eighty-four percent of patients in the unsuccessful group underwent endoscopy. Comparing those that received glucagon (n = 127) and the control group (n = 29), there was no significant difference in resolution of EFBI, 14.2% vs 10.3%, respectively (P = .586).

CONCLUSIONS: Glucagon-related resolution occurred in 14.2% of patients and was not significantly different compared with those that did not receive glucagon (10.3%). Concomitant medication administration was associated with lower success. Overall, glucagon had a low success rate, was related to adverse effects, and does not offer advantages for treatment.

16. Quick Reviews from Ann Emerg Med

A. Are New Oral Anticoagulants Safer Than Vitamin K Antagonists in the Treatment of Venous Thromboembolism?

Take-home: Patients with acute venous thromboembolism treated with new oral anticoagulants have similar rates of recurrent venous thromboembolism and death as those treated with warfarin. Although new oral anticoagulants are associated with a lower incidence of major bleeding, there may be an increased incidence of myocardial infarction.

B. Does Albumin Infusion Reduce Renal Impairment and Mortality in Patients With Spontaneous Bacterial Peritonitis?

Take-home: Albumin administration within 6 hours of diagnosis has been shown to decrease the risk of both renal impairment and mortality in patients with spontaneous bacterial peritonitis.

American Association for the Study of Liver Diseases Guidelines:

C. Do Nonopioid Medications Provide Effective Analgesia in Adult Patients With Acute Renal Colic?

Take-home: Nonsteroidal anti-inflammatory drugs are effective in the treatment of acute renal colic and may be more effective than other nonopioid medication.

Associated Cochrane review:

D. Do Corticosteroids Provide Benefit to Patients With Community-Acquired Pneumonia?

Take-home: For adult patients with community-acquired pneumonia requiring hospitalization, data suggest that corticosteroid therapy may reduce mortality, need for mechanical ventilation, and hospital length of stay.

E. What Is the Prognostic Value of Intermediate Lactate Level Elevations in ED Patients With Suspected Infection?

Take-home: Patients with a suspected infection in the emergency department (ED) who have intermediate lactate level elevations (2.0 to 3.9 mmol/L) carry a moderate to high risk of mortality, even without hypotension.

F. Should Patients Who Receive a Diagnosis of Acute PE and Have Evidence of Right Ventricular Strain Be Treated With Thrombolytic Therapy?

Take-home: There is evidence to suggest a small mortality benefit with the administration of thrombolytics for hemodynamically stable pulmonary embolism patients with right ventricular strain, but this benefit must be weighed against the significantly increased risk of major bleeding.

G. Does Using a Low Threshold for Venous Thromboembolism Testing in Pregnant Patients Lead to Low Diagnostic Yield?

Take-home: In the emergency department (ED) setting, clinicians have a low threshold for testing pregnant patients for pulmonary embolism, which leads to lower rates of positive diagnostic test results for venous thromboembolism than in nonpregnant patients.

H. What Is the Most Effective Treatment of Superficial Thrombophlebitis?

Take-home: Although there is insufficient evidence to support or refute the utility of systemic or topical therapies for superficial thrombophlebitis, the use of nonsteroidal anti-inflammatory drugs, heat, and anticoagulants (for low-risk thromboses) is reasonable.

17. The effect of nebulized magnesium sulfate in the treatment of moderate to severe asthma attacks: a RCT

Hossein S, et al. Amer J Emerg Med. 2016 Jan 16 [Epub ahead of print]

Thirty percent of people with asthma do not respond to standard treatment, and complementary therapies are needed. The objective of this study was to investigate the impact of inhaled magnesium sulfate on the treatment response in emergency department (ED) patients with moderate to severe attacks of asthma.

This study is a randomized controlled trial, enrolling patients with moderate to severe asthma in the ED. Subjects allocated to the study group were treated with the standard, plus 3 ml of 260 mmol/L solution of magnesium sulfate every 20 to 60 minutes. The control group was treated with nebulized saline as a placebo in addition to standard protocol. The study results included admission rate and changes in peak expiratory flow rate (PEFR) (primary outcomes) as well as dyspnea severity score, respiratory rate and peripheral oxygen saturation.

A total of 50 patients were enrolled (25 allocated to the study group and 25 to the control group). The study group as compared to the control group had significantly more improvement in the intensity of dyspnea, PEFR and Spo2 20, 40 and 60 minutes after intervention. In the control group, 11 patients (44%) required admission as compared to 18 (72%) in the control group (P = .02).

Adding nebulized magnesium sulfate to standard therapy in patients with moderate to severe asthma attacks leads to greater and faster improvement in PEFR, respiratory rate, oxygen saturation and respiratory rate. It also reduces hospitalization rates in this patient population.

18. Eye of the Beholder: N Engl J Med Interactive Case

A 47-year-old man presented to an urgent care ambulatory clinic with a 3-day history of swelling around his left eye and a sensation of tightness in his throat. It had become difficult for him to swallow solids, and he felt as if food was sticking in his throat. The patient had no shortness of breath or wheezing, but 1 day before presentation he felt his voice was becoming hoarse. He . . .

19. Outcomes in a Warfarin-Treated Population with Atrial Fibrillation

Björck F, et al. JAMA Cardiol. 2016 April 20 [Epub ahead of print]

Importance  Vitamin K antagonist (eg, warfarin) use is nowadays challenged by the non–vitamin K antagonist oral anticoagulants (NOACs) for stroke prevention in atrial fibrillation (AF). NOAC studies were based on comparisons with warfarin arms with times in therapeutic range (TTRs) of 55.2% to 64.9%, making the results less credible in health care systems with higher TTRs.

Objectives  To evaluate the efficacy and safety of well-managed warfarin therapy in patients with nonvalvular AF, the risk of complications, especially intracranial bleeding, in patients with concomitant use of aspirin, and the impact of international normalized ratio (INR) control.

Design, Setting, and Participants  A retrospective, multicenter cohort study based on Swedish registries, especially AuriculA, a quality register for AF and oral anticoagulation, was conducted. The register contains nationwide data, including that from specialized anticoagulation clinics and primary health care centers. A total of 40 449 patients starting warfarin therapy owing to nonvalvular AF during the study period were monitored until treatment cessation, death, or the end of the study. The study was conducted from January 1, 2006, to December 31, 2011, and data were analyzed between February 1 and November 15, 2015. Associating complications with risk factors and individual INR control, we evaluated the efficacy and safety of warfarin treatment in patients with concomitant aspirin therapy and those with no additional antiplatelet medications.

Exposures  Use of warfarin with and without concomitant therapy with aspirin.

Main Outcomes and Measures  Annual incidence of complications in association with individual TTR (iTTR), INR variability, and aspirin use and identification of factors indicating the probability of intracranial bleeding.

Results  Of the 40 449 patients included in the study, 16 201 (40.0%) were women; mean (SD) age of the cohort was 72.5 (10.1) years, and the mean CHA2DS2-VASc (cardiac failure or dysfunction, hypertension, age ≥75 years [doubled], diabetes mellitus, stroke [doubled]–vascular disease, age 65-74 years, and sex category [female]) score was 3.3 at baseline. The annual incidence, reported as percentage (95% CI) of all-cause mortality was 2.19% (2.07-2.31) and, for intracranial bleeding, 0.44% (0.39-0.49). Patients receiving concomitant aspirin had annual rates of any major bleeding of 3.07% (2.70-3.44) and thromboembolism of 4.90% (4.43-5.37), and those with renal failure were at higher risk of intracranial bleeding (hazard ratio, 2.25; 95% CI, 1.32-3.82). Annual rates of any major bleeding and any thromboembolism in iTTR less than 70% were 3.81% (3.51-4.11) and 4.41% (4.09-4.73), respectively, and, in high INR variability, were 3.04% (2.85-3.24) and 3.48% (3.27-3.69), respectively. For patients with iTTR 70% or greater, the level of INR variability did not alter event rates.

Conclusions and Relevance  Well-managed warfarin therapy is associated with a low risk of complications and is still a valid alternative for prophylaxis of AF-associated stroke. Therapy should be closely monitored for patients with renal failure, concomitant aspirin use, and poor INR control.

20. College Admissions Shocker!

Frank Bruni, New York Times, March 30, 2016
PALO ALTO, California — Cementing its standing as the most selective institution of higher education in the country, Stanford University announced this week that it had once again received a record-setting number of applications and that its acceptance rate — which had dropped to a previously uncharted low of 5 percent last year — plummeted all the way to its inevitable conclusion of 0 percent.

With no one admitted to the class of 2020, Stanford is assured that no other school can match its desirability in the near future.

“We had exceptional applicants, yes, but not a single student we couldn’t live without,” said a Stanford administrator who requested anonymity. “In the stack of applications that I reviewed, I didn’t see any gold medalists from the last Olympics — Summer or Winter Games — and while there was a 17-year-old who’d performed surgery, it wasn’t open-heart or a transplant or anything like that. She’ll thrive at Yale.”

News of Stanford’s unprecedented selectiveness sent shock waves through the Ivy League, along with Amherst, Northwestern and at least a dozen other elite schools where, as a consequence, there could be substantial turnover among underperforming deans of admission.

Administrators at several of these institutions, mortified by acceptance rates still north of 6 percent, chided themselves for insufficient international outreach. Carnegie Mellon vowed that over the next five years, it would quadruple the number of applicants from Greenland. The University of Chicago announced plans to host a college fair in Ulan Bator.

Officials at the University of Pennsylvania, meanwhile, realized that sweatshirts, T-shirts and glossy print and web catalogs weren’t doing nearly enough to advertise its charms, and that the university wasn’t fully leveraging the mystique of its world-renowned business school. So early next fall, every high school senior in America who scored in the top 4 percent nationally on the SAT will receive, in the mail, a complimentary spray bottle of Wharton: The Fragrance, which has a top note of sandalwood and a bottom note of crisp, freshly minted $100 bills.

Seniors who scored in the top 2 percent will get the scented shower gel and reed diffuser set as well.

On campuses from coast to coast, there was soul searching about ways in which colleges might be unintentionally deterring prospective applicants.

Were the applications themselves too laborious? Brown may give next year’s aspirants the option of submitting, in lieu of several essays, one haiku and one original recipe using organic kale…

21. A Clinical Decision Rule to Identify ED Patients at Low Risk for ACS who Do Not Need Objective CAD Testing: The No Objective Testing Rule.

Greenslade JH, et al. Ann Emerg Med. 2016;67(4): 478–489.e2.

STUDY OBJECTIVE: We derive a clinical decision rule for ongoing investigation of patients who present to the emergency department (ED) with chest pain. The rule identifies patients who are at low risk of acute coronary syndrome and could be discharged without further cardiac testing.

METHODS: This was a prospective observational study of 2,396 patients who presented to 2 EDs with chest pain suggestive of acute coronary syndrome and had normal troponin and ECG results 2 hours after presentation. Research nurses collected clinical data on presentation, and the primary endpoint was diagnosis of acute coronary syndrome within 30 days of presentation to the ED. Logistic regression analyses were conducted on 50 bootstrapped samples to identify predictors of acute coronary syndrome. A rule was derived and diagnostic accuracy statistics were computed.

RESULTS: Acute coronary syndrome was diagnosed in 126 (5.3%) patients. Regression analyses identified the following predictors of acute coronary syndrome: cardiac risk factors, age, sex, previous myocardial infarction, or coronary artery disease and nitrate use. A rule was derived that identified 753 low-risk patients (31.4%), with sensitivity 97.6% (95% confidence interval [CI] 93.2% to 99.5%), negative predictive value 99.6% (95% CI 98.8% to 99.9%), specificity 33.0% (95% CI 31.1% to 35.0%), and positive predictive value 7.5% (95% CI 6.3% to 8.9%) for acute coronary syndrome. This was referred to as the no objective testing rule.

CONCLUSION: We have derived a clinical decision rule for chest pain patients with negative early cardiac biomarker and ECG testing results that identifies 31% at low risk and who may not require objective testing for coronary artery disease. A prospective trial is required to confirm these findings.

22. Health Wearables

A. Counting Steps: Fit or Fad?

Ballard DB. Emerg Med News 2016;38(3B).  

My brother recently gave me the gift of friendly competition. Sibling rivalry is nothing new with just an 18-month age difference between us. Not that long ago we competed on the basketball court, but these days, due to the ravages of middle-aged arthritis, we're better suited to more pedestrian exploits such as counting steps!

He introduced me about a month ago to the 20-million-strong Fitbit nation. I've been rocking a Fitbit Zip since then, and have earned buzzy 10,000 steps-in-a-day “badges” and one “Penguin March” award for my first 70 miles. I have tried my bit in my pocket, on my shoe, in my gym bag, and even in the dryer. I have read up on Fitbit and other step counters in the press and scientific literature. I have even committed the Fitbit jingle to memory:

Should You Count?

Is counting steps a worthwhile endeavor? If you are an uber-active athlete, the type who does yoga in the morning, jogs at midday, and rides a bike in the evening (that sounds fantastic, by the way), then I suspect that counting steps is probably not worth your time. You can measure your activity level in many other ways, and you're not really missing out. In fact, some evidence suggests that it is not just the volume of steps that improves health but the combination of volume and intensity.

Pillay, et al., compared several metrics of physical health (waist circumference, body fat percentage, and V02max) among study participants with low and high numbers of steps as well as “aerobic” steps (greater than 60 steps/minute for at least a minute). (J Phys Act Health 2014;11[1]:10.) They found that those in the high-high group (those active at a high volume of steps and aerobic steps) had significantly better metrics of physical health than those in other groups. Counting steps alone may not be of maximal benefit if you are young and active, unless, of course, you think knowing your steps (and perhaps bragging about them) is fun, in which case, go for it.

On the other hand, if you have fewer athletic outlets or higher intensity exercise isn't practical, then counting steps could have a significant impact on your health, particularly if you tend to gravitate to couches, elevators, and valet parking. You may even find that you really enjoy that little dopamine squirt the buzz-buzz of your phone gives you when you hit your daily step goal.

How Should You Count?

Is the Fitbit the best choice? The answer depends on how much you value accuracy. The traditional gold standard is an old-fashioned pedometer, like the Yamax SW-200, which uses a coil spring mechanism to keep count. The downside to these devices is that they lack the technical and social features of step-counters that link to or work on your smartphone. Smartphone step-counting applications use GPS data plus or minus an accelerometer. A recent study in Bio Medical Central Research Notes compared these technologies in accuracy during five different scenarios and found widely divergent values.

On the other hand, a recent Journal of the American Medical Association study noted that the apps on your smartphone are perhaps even better than the Fitbit, at least in measuring steps and calories. (2015;313[6]:625.) University of Pennsylvania researchers compared 10 of the top-selling smartphone fitness applications and pedometers with wearable devices, tracking 14 healthy adults as they walked on the treadmill, and found that wearable devices had significantly more variation (22%) than smartphones (6%).

My own informal experiments with two Fitbits (mine and my wife's) supported these findings. A Fitbit in my pocket during a 12-hour ED shift counted 800 fewer steps than one on my shoe. The next day, the Fitbit on my wife's shoe registered 2,000 more steps than the one in her pocket! And I registered 883 steps purely by storing my Fitbit in my gym bag in the back of the car and 6,000 or so by giving it a prolonged spin in the dryer. Bottom line: Buyer bewareFIT if you are a stickler for accuracy.

You can mitigate discrepancies with a Fitbit by being consistent with how and where you apply your device: Use the same physical location each day, and recognize that your pocket may not be as accurate as your wrist or waist.

What About a Daily Goal?

The most widely published goal by far is 10,000 steps a day (the pre-set goal for Fitbit customers). Interestingly, this step target, admittedly a nice round number, does not have its origin in evidence. Apparently, the 10,000-step mantra originated around the time of the 1964 Tokyo Olympics with a pedometer named the Manpo Meter and a popular Japanese “Let's walk 10,000 steps a day” tagline.

Hitting 10,000 steps with the Fitbit provides a properly configured phone to give you a buzz-buzz of approval, but is there any magic in this number? New evidence suggests that there might be, and in a surprising way.

Vallance and colleagues examined the association in people 55 or older between steps per day in three categories (less than 7,000, 7,000-10,000, and more than 10,000) and scores on a phone-administered quality of life survey. (J Aging Health 2015; Oct 20 [ePub Ahead of Print].) Participants in the high-step group had significantly better scores on mental, physical, and global health scores independent of obesity markers (such as waist circumference and body mass index) than those in the low-step group. This was a rather skewed sample of wealthy Caucasians, and it is difficult to know if the steps themselves rather than the ability to take steps (e.g., freedom from severe joint pain, time, and wherewithal to walk) contributed to the improvement in quality of life.

Nonetheless, it would seem that the makers of Fitbit and other step-trackers may be onto something. Research shows that people over 55 who take more steps may be happier and healthier than those who do not. There may be other equally valid means of achieving these benefits, but steps are so easy to count and to take! Want more of them? Don't circle three times to find the closest parking spot, just park and amble; march up the stairs; promenade the dog rather than letting it promenade itself; don't send the tech to grab a warm blanket for Trauma A, grab it yourself! Game on!

B. EKG on a Wristband: Novel mobile health device could simplify frequent rhythm checks

by Satish Misra MD. iMedicalApps. March 17, 2016

AliveCor this week introduced the Kardia Band for the Apple Watch, which will let users capture a single-lead EKG by just touching the watch's band.

AliveCor is best known for its smartphone EKG device, the AliveCor Heart Monitor,which the company has now rebranded Kardia Mobile. That device uses a small smartphone attachment with two embedded electrodes to let users capture a single-lead EKG by just touching both of the electrodes with their hands or to their chest. Perhaps the most interesting feature of that device is how the data is transmitted to the smartphone - using an inaudible ultrasonic signal that's picked up by the smartphone's microphone and converted back to an EKG signal.

The Kardia Band is basically a band for the Apple Watch that has one electrode facing inwards and the other facing outwards. By touching the outer electrode, users can capture a single-lead EKG. Using previously validated and FDA-cleared algorithms, the companion Apple Watch app tells users whether the tracing was normal. It can also tell users if atrial fibrillation was identified.

Devices like Kardia Mobile and Kardia Band are generally most useful for patients with symptomatic paroxysmal arrhythmias. In addition, there has been some promising data in using the Kardia Mobile for atrial fibrillation (AF) screening. A large study in Australia using the Kardia Mobile device for opportunistic, one-time screening of elderly patients in community pharmacies showed a detection rate of around 2% for AF in elderly patients picking up medications at their pharmacy. Devices like Kardia Band may offer a strategy for monitoring that makes wearers more amenable to frequent rhythm checks that could improve screening sensitivity.

The Kardia Band could also have interesting applications for research, letting users capture frequent EKG tracings along with activity, heart rate, and other metrics already captured by the watch. AliveCor also recently announced integration with HealthKit, which could help integrate these devices into ResearchKit-based studies.

What is more interesting, though, is where AliveCor takes things from here. When I spoke to AliveCor founder and chief medical officer Dave Albert, MD, last fall, it was clear that his vision was to make these devices as accessible as possible. He was particularly proud of the fact that the Kardia Mobile had dropped in price by more than 50% within 2 years of release, and was redesigned to basically work with any smartphone. I'd guess the same vision will follow here with Kardia Band, and that over time we'll see it become available for a broader range of smartwatches, including low-cost devices, and at a lower price point.

The Kardia Band is anticipated to receive FDA clearance later this spring and become available for purchase soon after. This post originally appeared on iMedic

23. The Science of Choosing Wisely — Overcoming the Therapeutic Illusion

Casarett D. N Engl J Med 2016;374:1203-1205.

In recent years, the United States has seen increasing efforts to reduce inappropriate use of medical treatments and tests. Perhaps the most visible has been the Choosing Wisely campaign, in which medical societies have identified many tests, medications, and treatments that are used inappropriately. The result is recommendations advising against using these interventions or suggesting that they be considered more carefully and discussed with patients.

The success of such efforts, however, may be limited by the tendency of human beings to overestimate the effects of their actions. Psychologists call this phenomenon, which is based on our tendency to infer causality where none exists, the “illusion of control.”1 In medicine, it may be called the “therapeutic illusion” (a label first applied in 1978 to “the unjustified enthusiasm for treatment on the part of both patients and doctors”2). When physicians believe that their actions or tools are more effective than they actually are, the results can be unnecessary and costly care. Therefore, I think that efforts to promote more rational decision making will need to address this illusion directly.

The best illustration of the illusion of control comes from studies in which volunteers were asked to figure out how to press a button in order to cause a panel to light up.3 The volunteers searched enthusiastically for strategies and were generally confident that they’d succeeded. They didn’t know, however, that their success was determined entirely by chance.

The phenomenon has since been described in widely varied settings. Gamblers, for example, consistently overestimate the control they have over outcomes, both in gambling and in everyday life. Their belief leads them to engage in seemingly bizarre or ritualistic behaviors such as throwing dice in a certain way or wearing specific colors. But the illusion of control is widespread, and its effects may be enhanced when people are placed in positions of authority or subjected to time pressure or competition.

The decisions that physicians make at the bedside are both more complicated and more evidence-based than the choices of volunteers in a laboratory. Nevertheless, physicians also overestimate the benefits of everything from interventions for back pain to cancer chemotherapy.4,5 And their therapeutic illusion facilitates continued use of inappropriate tests and treatments.

The outcome of virtually all medical decisions is at least partly outside the physician’s control, and random chance can encourage physicians to embrace mistaken beliefs about causality. For instance, joint lavage is overused for relief of osteoarthritis-related knee pain, despite a recommendation against it from the American Academy of Orthopedic Surgery. Knee pain tends to wax and wane, so many patients report improvement in symptoms after lavage, and it’s natural to conclude that the intervention was effective.

Moreover, the therapeutic illusion is reinforced by a tendency to look selectively for evidence of impact — one manifestation of the “confirmation bias” that leads us to seek only evidence that supports what we already believe to be true. Physicians may be particularly susceptible to that bias when caring for a patient with a complex illness. When a patient has multiple medical problems, it’s often possible to find some evidence of improvement after an intervention, particularly if the patient is being intensively monitored. For instance, the Critical Care Collaborative advises against administering total parenteral nutrition during a patient’s first 7 days in an intensive care unit. However, if it is used, available tests are likely to provide at least a few indications of improvement in the patient’s electrolytes, volume status, or prealbumin level.

The illusion of control is deeply ingrained in human psychology in the form of a heuristic, or rule of thumb, that we rely on to interpret events and make decisions. Many heuristics are subconscious and therefore difficult to avoid or eradicate, but we can ameliorate their effects by using countervailing, conscious heuristics. Indeed, physicians already use this strategy to improve diagnostic decisions. For instance, we tend to ignore the pretest probability of an illness when making a diagnosis, which can cause us to overdiagnose rare conditions and underdiagnose common ones; medical students are therefore taught the rule “When you hear hoofbeats, look for horses, not zebras.” ….

For the rest of the essay (free):

24. Academic Life in Emerg Med (ALiEM) Resources

25. Micro Bits

A. Suicide screening in the emergency department

The Emergency Department Safety Assessment and Follow-up Evaluation Screening Outcome Evaluation examined whether universal suicide risk screening is feasible and effective in the emergency department. A three-phase interrupted time series design was used: Treatment as Usual (phase 1), Universal Screening (phase 2), and Universal Screening + Intervention (phase 3). Across the three phases, documented screenings rose from 26% (phase 1) to 84% (phase 3). Detection rose from 2.9% to 5.7%, with the majority of detected intentional self-harm confirmed as recent suicidal ideation or behavior by patient interview.

B. 67% of US seniors take 5 or more meds or supplements, study finds

A study published in JAMA Internal Medicine found that 67% of people ages 62 to 85 took at least five medications or supplements in 2010-2011, compared with 53% five years earlier. As polypharmacy rose over the study period, risk of major drug interactions increased from 8% to 15%. Gerontologist Michael Steinman, who wrote an editorial published with the study, said rising rates of polypharmacy are a sign more seniors are getting treatment they need, but he said the trend underscores the need for care coordination and clear physician-patient communication.

C. CDC reports on increase in US suicide rate

The rate of suicide in the US rose 24% from 1999 to 2014, resulting in 42,773 deaths in 2014, according to a report from the CDC. Researchers found major increases in suicide rates for white women and Native Americans.

D. The Effects of Azithromycin in Treatment-Resistant Cough: A Randomized, Double-Blind, Placebo-Controlled Trial

Conclusion: Treatment with low-dose azithromycin for 8 weeks did not significantly improve LCQ score compared with placebo. The use of macrolides for treatment-resistant cough cannot be recommended from this study.

E. Task force recommends low-dose aspirin therapy for some adults

The US Preventive Services Task Force reviewed the evidence on low-dose aspirin for primary prevention of cardiovascular disease and colorectal cancer and recommended the therapy for adults ages 50 to 59 with a 10% or higher risk of CVD and no increased risk for bleeding. The task said use of the drug among patients ages 60 to 69 should be considered on an individual basis. Similar recommendations were released by the AAFP.

F. Direct oral anticoagulants not recommended for obese patients

Patients whose body mass index is greater than 40 kg/m² or whose weight is more than 120 kg are not advised to take direct oral anticoagulants to prevent and treat venous thromboembolism or to prevent systemic arterial embolism and ischemic stroke in nonvalvular atrial fibrillation, according to a guideline published in the Journal of Thrombosis and Haemostasis. The authors noted that based on evidence, lower drug exposure, decreased peak concentration and shorter half-lives occur as weight increases.

G. Too little sleep might raise risk of colds, study finds

Nineteen percent of US adults who slept for five or fewer hours each night had experienced a head or chest cold in the past month, compared with 16% of those who got six hours of sleep and 15% of those who slept for seven hours or more, according to a study in JAMA Internal Medicine that included more than 22,000 adults. Those with a diagnosed sleep disorder were also at increased risk of such illness.

H. Antibiotics by age 3 may increase prediabetes risk in adolescents, study finds

Youths with prediabetes were 8.5 times as likely to have received antibiotics by age 3, compared with those who were healthy, according to a Greek study presented at the Endocrine Society meeting. The findings, based on stool samples of 24 youths with and without prediabetes, ages 12 to 17, also showed that those with prediabetes had fewer colonies of Ruminococcus, which feeds beneficial gut bacteria, compared with those without the condition.

I. Study suggests women have twice the risk of death from a heart attack

A study presented at a meeting of the American College of Cardiology found that women have up to twice the likelihood of in-hospital death from ST-segment elevation myocardial infarction than men. Researchers attribute the disparity to an average delay of 5.3 minutes in time to appropriate treatment in women. The findings, based on analyses of over 700,000 STEMI patients across 29 countries, also show that women have a 70% higher mortality risk than men within a month, six months and one year of suffering a heart attack.

J. Most Kidney Transplant Recipients Visit the Emergency Department After Discharge

More than half of kidney transplant recipients will visit an emergency department in the first 2 years after transplantation, according to a study appearing in an upcoming issue of the Clinical Journal of the American Society of Nephrology. The findings indicate that efforts are needed to coordinate care for this vulnerable patient population.