1. Safety of peripheral IV administration of vasoactive
medication.
Cardenas-Garcia
J, et al. J Hosp Med. 2015;10(9):581-5.
BACKGROUND:
Central venous access is commonly performed to administer vasoactive
medication. The administration of vasoactive medication via peripheral intravenous
access is a potential method of reducing the need for central venous access.
The aim of this study was to evaluate the safety of vasoactive medication
administered through peripheral intravenous access.
METHODS: Over
a 20-month period starting in September 2012, we monitored the use of
vasoactive medication via peripheral intravenous access in an 18-bed medical
intensive care unit. Norepinephrine, dopamine, and phenylephrine were all
approved for use through peripheral intravenous access.
RESULTS: A
total of 734 patients (age 72 ± 15 years, male/female 398/336, SAPS II score
75 ± 15) received vasoactive medication via peripheral intravenous access 783
times. Vasoactive medication used was norepinephrine (n = 506), dopamine
(n = 101), and phenylephrine (n = 176). The duration of vasoactive medication
via peripheral intravenous access was 49 ± 22 hours. Extravasation of the
peripheral intravenous access during administration of vasoactive medication
occurred in 19 patients (2%) without any tissue injury following treatment,
with local phentolamine injection and application of local nitroglycerin paste.
There were 95 patients (13%) receiving vasoactive medication through peripheral
intravenous access who eventually required central intravenous access.
CONCLUSIONS:
Administration of norepinephrine, dopamine, or phenylephrine by peripheral
intravenous access was feasible and safe in this single-center medical
intensive care unit. Extravasation from the peripheral intravenous line was
uncommon, and phentolamine with nitroglycerin paste were effective in
preventing local ischemic injury. Clinicians should not regard the use of
vasoactive medication is an automatic indication for central venous access.
2. Observation Units as Substitutes for Hospitalization or Home
Discharge? Both!
Blecker S, et
al. Ann Emerg Med. 2016;67(6):706–713.e2
STUDY
OBJECTIVE: Observation unit admissions have been increasing, a trend that will
likely continue because of recent changes in reimbursement policies. The
purpose of this study is to determine the effect of the availability of
observation units on hospitalizations and discharges to home for emergency
department (ED) patients.
METHODS: We
studied ED visits with a final diagnosis of chest pain in the National Hospital
Ambulatory Medical Care Survey from 2007 to 2010. ED visits that resulted in an
observation unit admission were propensity-score matched to visits at hospitals
without an observation unit. We used logistic regression to develop a
prediction model for hospitalization versus discharge home for matched patients
treated at nonobservation hospitals. The model was applied to matched
observation unit patients to determine the likely alternative disposition had
the observation unit not been available.
RESULTS:
There were 1,325 eligible visits that represented 5,079,154 visits in the
United States. Two hundred twenty-seven visits resulted in an observation unit
admission. The predictive model for hospitalization had a c statistic of 0.91;
variables significantly associated with subsequent hospitalization included
age, history of coronary atherosclerosis, systolic blood pressure less than 115
beats/min, and administration of antianginal medications. When the model was
applied to matched observation unit patients, 49.9% of them were categorized as
discharge home likely.
CONCLUSION:
In this study, we estimated that half of ED visits for chest pain that resulted
in an observation unit admission were made by patients who may have been
discharged home had the observation unit not been available. Increased
availability of observation units may result in both decreased hospitalizations
and decreased discharges to home.
3. ACE-I Angioedema: Accurate Clinical Diagnosis May Prevent
Epinephrine-Induced Harm
Curtis RM, et
al. West J Emerg Med. 2016 April 26 [Epub ahead of print]
Introduction:
Upper airway angioedema is a life-threatening emergency department (ED)
presentation with increasing incidence. Angiotensin-converting enzyme inhibitor
induced angioedema (AAE) is a non-mast cell mediated etiology of angioedema.
Accurate diagnosis by clinical examination can optimize patient management and
reduce morbidity from inappropriate treatment with epinephrine. The aim of this
study is to describe the incidence of angioedema subtypes and the management of
AAE. We evaluate the appropriateness of treatments and highlight preventable
iatrogenic morbidity.
Methods: We
conducted a retrospective chart review of consecutive angioedema patients
presenting to two tertiary care EDs between July 2007 and March 2012.
Results: Of
1,702 medical records screened, 527 were included. The cause of angioedema was
identified in 48.8% (n=257) of cases. The most common identifiable etiology was
AAE (33.1%, n=85), with a 60.0% male predominance. The most common AAE
management strategies included diphenhydramine (63.5%, n=54), corticosteroids
(50.6%, n=43) and ranitidine (31.8%, n=27). Epinephrine was administered in
21.2% (n=18) of AAE patients, five of whom received repeated doses. Four AAE
patients required admission (4.7%) and one required endotracheal intubation.
Epinephrine induced morbidity in two patients, causing myocardial ischemia or
dysrhythmia shortly after administration.
Conclusion:
AAE is the most common identifiable etiology of angioedema and can be
accurately diagnosed by physical examination. It is easily confused with
anaphylaxis and mismanaged with antihistamines, corticosteroids and
epinephrine. There is little physiologic rationale for epinephrine use in AAE
and much risk. Improved clinical differentiation of mast cell and non-mast cell
mediated angioedema can optimize patient management.
4. Comparison of IV Morphine Versus Paracetamol in Sciatica: A
Randomized Placebo Controlled Trial.
Serinken M,
et al. Acad Emerg Med. 2016 Jun;23(6):674-8.
OBJECTIVE:
The objective was to compare intravenous morphine and intravenous acetaminophen
(paracetamol) for pain treatment in patients presenting to the emergency
department with sciatica.
METHODS:
Patients, between the ages of 21 and 65 years, suffering from pain in the
sciatic nerve distribution and a positive straight leg-raise test composed the
study population. Study patients were assigned to one of three intravenous
interventions: morphine (0.1 mg/kg), acetaminophen (1 g), or placebo. Physicians,
nurses, and patients were blinded to the study drug. Changes in pain intensity
were measured at 15 and 30 minutes using a visual analog scale. Rescue drug
(fentanyl) use and adverse effects were also recorded.
RESULTS:
Three-hundred patients were randomized. The median change in pain intensity
between treatment arms at 30 minutes were as follows: morphine versus
acetaminophen 25 mm (95% confidence interval [CI] = 20 to 29 mm), morphine
versus placebo 41 mm (95% CI = 37 to 45 mm), and acetaminophen versus placebo
16 mm (95% CI = 12 to 20 mm). Eighty percent of the patients in the placebo
group (95% CI = 63.0% to 99%), 18% of the patients in the acetaminophen group
(95% CI = 10.7% to 28.5%), and 6% of those in the morphine group (95% CI = 2.0%
to 13.2%) required a rescue drug. Adverse effects were similar between the
morphine and acetaminophen groups.
CONCLUSION:
Morphine and acetaminophen are both effective for treating sciatica at 30
minutes. However, morphine is superior to acetaminophen.
5. Self-referrals in the ED: reasons why patients attend the ED
without consulting a general practitioner first—a questionnaire study.
Kraaijvanger
N, et al. Int J Emerg Med. 2015 Dec;8(1):46.
BACKGROUND:
To influence self-referral, it is crucial to know a patient's motives to
directly visit the emergency department (ED). The goal of this study is to
examine motives for self-referral to the ED and compare these motives in
relation to appropriateness.
METHODS: All
self-referred patients visiting the ED of a Dutch hospital over four separate
months in a 1-year period were included. Patients were handed questionnaires
that included questions on their reasons to visit the ED directly and where
they would seek medical help next time. Additionally, the motives of patients
that either appropriately or inappropriately visited the ED were compared. In a
previous study on the same patient cohort, the appropriateness of the ED visits
was determined using predefined criteria.
RESULTS: A
total of 3196 self-referred patients were included, and 48.9 % completed the
questionnaires. The majority of patients (28.0 %) attended the ED without a
referral because they thought they would get help faster; the next reason was
the easier access to radiologic and laboratory investigations (answered by 23.8
%); and the third was the symptoms were considered too severe to visit a
general practitioner (GP) (answered by 22.7 %). The majority (78.5 %) would
attend the ED the next time they are faced with similar symptoms. Appropriate
visits were significantly more seen in females, elderly, and patients in higher
triage categories. Patients who expect investigations are necessary, think
their symptoms are too severe to visit a GP, or would return to the ED next
time were more often appropriately visiting the ED.
CONCLUSIONS:
The choice of patients to self-refer to an ED is often an explicate decision.
Patients are looking for specialist help and want fast and easy access to
radiologic and laboratory investigations. Even though the primary care network
is well developed in the Netherlands, the reasons for self-referral are similar
to the reasons found in previous literature based in other countries. Patients
who visit the ED because of health concerns visit the ED more often
appropriately than patients visiting for practical reasons.
6. The Influence of Patient Age on the Diagnostic Performance of
WBC Count and Absolute Neutrophil Count in Suspected Pediatric Appendicitis
Bachur RG, et
al. Acad Emerg Med. 2016 Jun 2 [Epub ahead of print].
Objective:
White blood cell (WBC) count and absolute neutrophil count (ANC) are a standard
part of the evaluation of suspected appendicitis. Specific threshold values are
utilized in clinical pathways, but the discriminatory value of WBC and ANC may
vary by age. The objective of this study was to investigate whether the
diagnostic value of WBC and ANC varies across age groups and whether diagnostic
thresholds should be age-adjusted.
Methods: This
is a multicenter prospective observational study of patients aged 3-18 years
who were evaluated for appendicitis. Receiver operator characteristic curves
were developed to assess overall discriminative power of WBC and ANC across 3
age groups: less than 5 years, 5-11 years, 12-18 years of age. Diagnostic
performance of WBC and ANC was then assessed at specific cut-points.
Results:
2,133 patients with a median age of 10.9 years (IQR, 8-13.9) were studied. 41%
had appendicitis. The area under-the-curve (AUC) for WBC was 0.69 [95% CI,
0.61-0.77] for patients less than 5 years of age, 0.76 [95% CI, 0.73-0.79] for
5-11 years of age, and 0.83 [95% CI, 0.81, 0.86] for 12-18 years of age. The
AUC's for ANC across age groups mirrored WBC performance. At a
commonly-utilized WBC cut-point of 10,000/mm(3) , the sensitivity decreased
with increasing age: 95% (less than 5 years), 91% (5-11 years), and 89% (12-18
years) whereas specificity increased by age: 36% (less than 5 years), 49% (5-12
years), 64% (12-18 years).
Conclusion:
WBC and ANC had better diagnostic performance with increasing age. Age-adjusted
values of WBC or ANC should be considered in diagnostic strategies for
suspected pediatric appendicitis.
7. A Randomized Controlled Noninferiority Trial of Single Dose
of Oral Dex Vs 5 Days of Oral Prednisone in Acute Adult Asthma.
Rehrer MW, et
al. Ann Emerg Med. 2016 Apr 14 [Epub ahead of print].
STUDY
OBJECTIVE: Oral dexamethasone demonstrates bioavailability similar to that of
oral prednisone but has a longer half-life. We evaluate whether a single dose
of oral dexamethasone plus 4 days of placebo is not inferior to 5 days of oral
prednisone in treatment of adults with mild to moderate asthma exacerbations to
prevent relapse defined as an unscheduled return visit for additional treatment
for persistent or worsening asthma within 14 days.
METHODS:
Adult emergency department patients (aged 18 to 55 years) were randomized to
receive either a single dose of 12 mg of oral dexamethasone with 4 days of
placebo or a 5-day course of oral prednisone 60 mg a day. Outcomes including
relapse were assessed by a follow-up telephone interview at 2 weeks.
RESULTS: One
hundred seventy-three dexamethasone and 203 prednisone subjects completed the
study regimen and telephone follow-up. The dexamethasone group by a small
margin surpassed the preset 8% difference between groups for noninferiority in
relapse rates within 14 days (12.1% versus 9.8%; difference 2.3%; 95%
confidence interval -4.1% to 8.6%). Subjects in the 2 groups had similar rates
of hospitalization for their relapse visit (dexamethasone 3.4% versus
prednisone 2.9%; difference 0.5%; 95% confidence interval -4.1% to 3.1%).
Adverse effect rates were generally the same in the 2 groups.
CONCLUSION: A
single dose of oral dexamethasone did not demonstrate noninferiority to
prednisone for 5 days by a very small margin for treatment of adults with mild
to moderate asthma exacerbations. Enhanced compliance and convenience may
support the use of dexamethasone regardless.
8. High-frequency linear transducer improves (transabdominal) detection
of an IUP in first-tri US
Tabbut M, et
al. Am J Emerg Med. 2016;34(2):288-91.
OBJECTIVE:
The objective was to determine if the need for transvaginal ultrasonographic
examination can be decreased by the addition of the transabdominal
high-frequency, 12-4-MHz linear transducer after a failed examination with the
6-2-mHz curvilinear transducer when evaluating for an intrauterine pregnancy
(IUP).
METHODS: This
is a prospective pilot study of women in their first trimester of pregnancy
presenting to the emergency department with abdominal pain and/or vaginal
bleeding. If no IUP was identified using the curvilinear transducer via the
transabdominal approach, they were subsequently scanned using the linear
transducer. Patients without evidence of an IUP transabdominally were scanned
via the transvaginal approach.
RESULTS:
Eighty-one patients were evaluated; no IUP was visualized in 27 using the
standard curvilinear transducer approach, and these then had an ultrasonography
performed with the linear transducer. Of these, 9 patients (33.3%; 0.95
confidence interval [CO], 15.5%-51.1%) were found to have an IUP with the
linear transducer. For the 18 patients who received a transvaginal scan, 15
patients (83.3%; 0.95 CI, 66.1%-100%) had no IUP identified with the
transvaginal transducer, and 3 (16.7%; 0.95 CI, 0%-33.9%) had an IUP
identified.
CONCLUSIONS:
The transabdominal use of a high-frequency linear transducer in the evaluation
of patients in the first trimester after failed curvilinear transducer results
in a clinically significant reduction in the need for transvaginal
ultrasonography to confirm the presence of an IUP.
9. Physician in Triage vs Rotational Patient Assignment
Traub SJ, et
al. J Emerg Med. 2016 May;50(5):784-90.
BACKGROUND:
Physician in triage and rotational patient assignment are different front-end
processes that are designed to improve patient flow, but there are little or no
data comparing them.
OBJECTIVE: To
compare physician in triage with rotational patient assignment with respect to
multiple emergency department (ED) operational metrics.
METHODS:
Design-Retrospective cohort review. Patients-Patients seen on 23 days on which
we utilized a physician in triage with those patients seen on 23 matched days
when we utilized rotational patient assignment.
RESULTS:
There were 1,869 visits during physician in triage and 1,906 visits during
rotational patient assignment. In a simple comparison, rotational patient
assignment was associated with a lower median length of stay (LOS) than
physician in triage (219 min vs. 233 min; difference of 14 min; 95% confidence
interval [CI] 5-27 min). In a multivariate linear regression incorporating
multiple confounders, there was a nonsignificant reduction in the geometric
mean LOS in rotational patient assignment vs. physician in triage (204 min vs.
217 min; reduction of 6.25%; 95% CI -3.6% to 15.2%). There were no significant
differences between groups for left before being seen, left subsequent to being
seen, early (within 72 h) returns, early returns with admission, or complaint
ratio.
CONCLUSIONS:
In a single-site study, there were no statistically significant differences in
important ED operational metrics between a physician in triage model and a
rotational patient assignment model after adjusting for confounders.
10. Images in Clinical Practice
Man With
Pigmentation on Left Flank
Persistent
Fever and Ankle Pain in a Child
Female Infant
With Toe Swelling
Young Male
With Oral Swelling
Woman With
Facial Trauma
Young Man
With Bilateral Arm Pain
Sickle
Cell Crisis and You: A How-to Guide
Man With
Acute Eye Lesion
Elderly
Female With Swelling of the Right Breast
The Rash
Worth A Midnight Phone Call
Salmonella
enterica Aortitis
Hyperkalemia
after Missed Hemodialysis
Ventricular
Septal Defect after Acute Myocardial Infarction
11. Effect of Noninvasive Ventilation Delivered by Helmet vs
Face Mask on the Rate of Endotracheal Intubation in Patients With ARDS: A RCT.
Patel BK, et
al. JAMA. 2016 Jun 14;315(22):2435-41.
IMPORTANCE: Noninvasive
ventilation (NIV) with a face mask is relatively ineffective at preventing
endotracheal intubation in patients with acute respiratory distress syndrome (ARDS).
Delivery of NIV with a helmet may be a superior strategy for these patients.
OBJECTIVE: To
determine whether NIV delivered by helmet improves intubation rate among
patients with ARDS.
DESIGN,
SETTING, AND PARTICIPANTS: Single-center randomized clinical trial of 83
patients with ARDS requiring NIV delivered by face mask for at least 8 hours
while in the medical intensive care unit at the University of Chicago between
October 3, 2012, through September 21, 2015.
INTERVENTIONS:
Patients were randomly assigned to continue face mask NIV or switch to a helmet
for NIV support for a planned enrollment of 206 patients (103 patients per
group). The helmet is a transparent hood that covers the entire head of the
patient and has a rubber collar neck seal. Early trial termination resulted in
44 patients randomized to the helmet group and 39 to the face mask group.
MAIN OUTCOMES
AND MEASURES: The primary outcome was the proportion of patients who required
endotracheal intubation. Secondary outcomes included 28-day invasive
ventilator-free days (ie, days alive without mechanical ventilation), duration
of ICU and hospital length of stay, and hospital and 90-day mortality.
RESULTS: Eighty-three
patients (45% women; median age, 59 years; median Acute Physiology and Chronic
Health Evaluation [APACHE] II score, 26) were included in the analysis after
the trial was stopped early based on predefined criteria for efficacy. The
intubation rate was 61.5% (n = 24) for the face mask group and 18.2% (n = 8)
for the helmet group (absolute difference, -43.3%; 95% CI, -62.4% to -24.3%; P less
than .001). The number of ventilator-free days was significantly higher in the
helmet group (28 vs 12.5, P less than .001). At 90 days, 15 patients (34.1%)
in the helmet group died compared with 22 patients (56.4%) in the face mask
group (absolute difference, -22.3%; 95% CI, -43.3 to -1.4; P = .02). Adverse
events included 3 interface-related skin ulcers for each group (ie, 7.6% in the
face mask group had nose ulcers and 6.8% in the helmet group had neck ulcers).
CONCLUSIONS
AND RELEVANCE: Among patients with ARDS, treatment with helmet NIV resulted in
a significant reduction of intubation rates. There was also a statistically
significant reduction in 90-day mortality with helmet NIV. Multicenter studies
are needed to replicate these findings.
12. Ann Emerg Med Lit Reviews
A. Do β-2 Agonists for Acute
Bronchitis Provide Any Benefit?
Although
there is no evidence to support the use of β-2 agonists in children with acute
cough without airflow restriction, limited evidence suggests that they may
benefit adults with an acute cough and wheezing but their use must be weighed
against any adverse effects.
B. The Impact of Clinical Decision
Rules on CT Use and Yield for PE: A Systematic Review and Meta-analysis
Conclusion: Among
participants with suspected pulmonary embolism, implementation of the Wells
criteria was associated with a modest increase in CT angiography yield. There
is a lack of cluster-randomized trials to confirm the efficacy of clinical
decision rules for the diagnosis of pulmonary embolism.
13. Reducing the dose of tPA for CVA?
Ryan Radecki on ENCHANTED – Positive
or Negative?
Monday, June
6, 2016.
I am probably
the last person to comment on ENCHANTED, the trial testing low-dose vs.
standard-dose tPA in “Asians”. When it was released, to some fanfare in
the New England Journal of Medicine, I had little to say – it is, frankly, a
rather bland contribution to the science. What has been fascinating, however,
is the unusually divergent interpretation of the results. To wit,
the accompanying editorial in the NEJM states:
“ENCHANTED
provides no compelling evidence for using low-dose alteplase for acute ischemic
stroke in Asian or other populations on the basis of safety considerations or
clinical outcomes.”
This
is a relatively reasonable interpretation of the results – hinging on the word
“compelling”. No one’s hearts are to be set a-flutter over these results,
but that does a disservice to the ultimate clinical question of which dose is
appropriate. The lay press, however, is here to clear things up – or is
it?
“ENCHANTED: Low-Dose tPA Now a Viable
Option in Stroke?”
“ENCHANTED results challenge reduced alteplase dose in Asian stroke patients”
“Low-Dose tPA Not as Effective, Even for Asians”
“Lower Dose of Clot-Busting Drug Reduces Brain Bleeding”
“Low-dose alteplase fails to prove noninferiority to standard dose, shows some benefit in stroke”
“Low-Dose Alteplase Not as Effective as Standard-Dose in Acute Ischemic Stroke”
The question, simply, comes down to how easily one interprets “non-inferiority” – a point made nicely by Rory Spiegel in his post – and, further, how one interprets these findings in a Bayesian sense. The prevailing opinion going into this trial was that low-dose tPA was safer and similarly efficacious in certain ethnic subpopulations on the Asian continent. The nonsignificant difference (OR 1.09; 95% CI 0.95 to 1.25) in patients having excellent outcomes (mRS 0-1) and the even smaller difference (OR 1.03; 95% CI 0.89 to 1.19) in those having good outcomes (mRS 0-2) does nothing to move the needle on the prevailing clinical hypothesis. If there is unlikely to be a profound difference in clinical outcomes, what of the safety outcomes? Here, low-dose alteplase is obviously a winner – significant reductions in hemorrhage and a corresponding decrease in 90-day mortality (p=0.07).
If ECASS failed gloriously due to adverse effects at 1.1 mg/kg, subsequent trials found some favorable risk/benefit at 0.9 mg/kg, and the (supposed) clinical efficacy seems preserved with even greater safety at 0.6 mg/kg, it seems logical to expand interest in lower doses of tPA. I disagree with those who would dismiss this trial as an unimportant “failure”.
“ENCHANTED results challenge reduced alteplase dose in Asian stroke patients”
“Low-Dose tPA Not as Effective, Even for Asians”
“Lower Dose of Clot-Busting Drug Reduces Brain Bleeding”
“Low-dose alteplase fails to prove noninferiority to standard dose, shows some benefit in stroke”
“Low-Dose Alteplase Not as Effective as Standard-Dose in Acute Ischemic Stroke”
The question, simply, comes down to how easily one interprets “non-inferiority” – a point made nicely by Rory Spiegel in his post – and, further, how one interprets these findings in a Bayesian sense. The prevailing opinion going into this trial was that low-dose tPA was safer and similarly efficacious in certain ethnic subpopulations on the Asian continent. The nonsignificant difference (OR 1.09; 95% CI 0.95 to 1.25) in patients having excellent outcomes (mRS 0-1) and the even smaller difference (OR 1.03; 95% CI 0.89 to 1.19) in those having good outcomes (mRS 0-2) does nothing to move the needle on the prevailing clinical hypothesis. If there is unlikely to be a profound difference in clinical outcomes, what of the safety outcomes? Here, low-dose alteplase is obviously a winner – significant reductions in hemorrhage and a corresponding decrease in 90-day mortality (p=0.07).
If ECASS failed gloriously due to adverse effects at 1.1 mg/kg, subsequent trials found some favorable risk/benefit at 0.9 mg/kg, and the (supposed) clinical efficacy seems preserved with even greater safety at 0.6 mg/kg, it seems logical to expand interest in lower doses of tPA. I disagree with those who would dismiss this trial as an unimportant “failure”.
14. Treatment of Alcohol Withdrawal Syndrome with and without
Dexmedetomidine
Beg M, et al.
Perm J 2016;20(2):49-53.
Context:
Studies suggest that dexmedetomidine—an intravenous central-acting
a2-adrenergic agonist that effectively reduces anxiety among critically ill
patients—is being used in patients with severe alcohol withdrawal. However,
evidence supporting its use is limited, and it is not approved for this
indication.
Objective: To
assess the effect of dexmedetomidine on severe alcohol withdrawal symptoms and
to compare its use with benzodiazepines alone.
Design: A
retrospective, cohort study of 77 patients admitted to the adult medical
intensive care unit with severe alcohol withdrawal between January 1, 2009, and
October 31, 2013.
Main Outcome
Measures: The difference in lorazepam equivalents and Clinical Institute
Withdrawal Assessment for Alcohol scores in the 24 hours before and after
initiation of dexmedetomidine therapy.
Results: The
frequency of dexmedetomidine use increased dramatically between 2009 and 2013
(16.7% vs 82.4%; p = 0.01). Initiation of dexmedetomidine therapy was
associated with significant improvements in Clinical Institute Withdrawal
Assessment for Alcohol scores over corresponding 24-hour intervals (14.5 vs
8.5; p less than 0.01). Benzodiazepine use also decreased, but the difference
was not statistically significant at 24 hours (p = 0.10). Dexmedetomidine was
well tolerated, requiring discontinuation of therapy in only 4 patients
(10.5%). Dexmedetomidine use was also associated with significantly longer
hospitalizations (p less than 0.01).
Conclusion:
Dexmedetomidine initiation was associated with a reduction in short-term
alcohol withdrawal symptoms in patients in the intensive care unit, with only a
few patients experiencing adverse events. However, its use was also associated
with longer hospitalizations. Further research is necessary to evaluate whether
dexmedetomidine is efficacious or cost-effective in severe alcohol withdrawal.
Full-text
(free): http://www.thepermanentejournal.org/issues/2016/spring/6163-alcohol-withdrawal-syndrome.html
15. First Pass Success Without Hypoxemia Is Increased With the
Use of Apneic Oxygenation During Rapid Sequence Intubation in the ED.
Sakles JC, et
al. Acad Emerg Med. 2016 Jun;23(6):703-10.
OBJECTIVES:
The objective was to determine the effect of apneic oxygenation (AP OX) on
first pass success without hypoxemia (FPS-H) in adult patients undergoing rapid
sequence intubation (RSI) in the emergency department (ED).
METHODS:
Continuous quality improvement data were prospectively collected on all
patients intubated in an academic ED from July 1, 2013, to June 30, 2015.
During this period the use of AP OX was introduced and encouraged for all
patients undergoing RSI in the ED. Following each intubation, the operator
completed a standardized data form that included information on patient,
operator, and intubation characteristics. Adult patients 18 years of age or
greater who underwent RSI in the ED by emergency medicine residents were
included in the analysis. The primary outcome was FPS-H, which was defined as
successful tracheal intubation on a single laryngoscope insertion without
oxygen saturation falling below 90%. A multivariate logistic regression
analysis was performed to determine the effect of AP OX on FPS-H.
RESULTS:
During the 2-year study period, 635 patients met inclusion criteria. Of these,
380 (59.8%) had AP OX utilized and 255 (40.2%) had no AP OX utilized. In the AP
OX cohort the FPS-H was 312/380 (82.1%) and in the no AP OX cohort the FPS-H
was 176/255 (69.0%) (difference = 13.1%, 95% confidence interval [CI] = 6.2% to
19.9%). In the multivariate logistic regression analysis, the use of AP OX was
associated with an increased odds of FPS-H (adjusted odds ratio = 2.2, 95% CI =
1.5 to 3.3).
CONCLUSIONS:
The use of AP OX during the RSI of adult patients in the ED was associated with
a significant increase in FPS-H. These results suggest that the use of AP OX
has the potential to increase the safety of RSI in the ED by reducing the
number of intubation attempts and the incidence of hypoxemia.
16. Effect of Nebulized Albuterol on Serum Lactate and Potassium
in Healthy Subjects.
Zitek T, et
al. Acad Emerg Med. 2016 Jun;23(6):718-21.
OBJECTIVES:
The objectives were to determine if nebulized albuterol causes an increase in
the serum lactate level compared to placebo and, secondarily, to confirm that
albuterol decreases serum potassium levels compared to placebo in patients with
normokalemia.
METHODS: This
was a randomized, double-blind, placebo-controlled trial. Twenty-eight healthy
adult volunteers were assigned to receive either 10 mg of nebulized albuterol
or placebo (nebulized saline) over 1 hour. Serum lactate was measured prior to
treatment and at 30 and 70 minutes after the start of treatment. Serum
potassium level was measured prior to treatment and at 70 minutes. The primary
outcome was the degree of change in lactate level. The secondary outcome was
the degree of change in potassium level.
RESULTS: In
the 14 subjects who received albuterol, the mean increase in lactate was 0.77
mmol/L (95% confidence interval [CI] = 0.52 to 1.02 mmol/L), and the mean
decrease in potassium level was 0.5 mEq/L (95% CI = -0.72 to -0.28 mEq/L).
Among the subjects who received placebo, the lactate level decreased by 0.15
mmol/L (95% CI = -0.39 to 0.09 mmol/L) and there was no change in potassium
level at (0.0 mEq/L [95% CI = -0.21 to 0.21 mEq/L]). These differences are
statistically significant (p less than 0.0001 and p = 0.003, respectively).
CONCLUSION:
Nebulized albuterol increases lactate levels and decreases potassium levels in
healthy adults.
17. Relationship of Affordable Care Act Implementation to ED
Utilization Among Young Adults.
Hernandez-Boussard
T, et al. Ann Emerg Med. 2016;67(6):714–720.e1
STUDY
OBJECTIVE: The 2010 provision of the Patient Protection and Affordable Care Act
(ACA) extended eligibility for health insurance for young adults aged 19 to 25
years. It is unclear, however, how expanded coverage changes health care
behavior and promotes efficient use of emergency department (ED) services. Our
objective was to use population-level emergency department data to characterize
any changes in diagnoses seen in ED among young adults since the implementation
of the ACA dependent coverage expansion.
METHODS: We
performed a difference-in-differences analysis of 2009 to 2011 ED visits from
California, Florida, and New York, using all-capture administrative data to
determine how the use of ED services changed for clinical categories after the
ACA provision among young adults aged 19 to 25 years compared with slightly
older adults unaffected by the provision, aged 26 to 31 years.
RESULTS: We
analyzed a total of 10,158,254 ED visits made by 4,734,409 patients. After the
implementation of the 2010 ACA provision, young adults had a relative decrease
of 0.5% ED visits per 1,000 people compared with the older group. For the
majority of diagnostic categories, young adults' rates and risk of visit did
not change relative to that of slightly older adults after the implementation
of the ACA. However, although young adults' ED visits significantly increased
for mental illnesses (2.6%) and diseases of the circulatory system (eg,
nonspecific chest pain) (4.8%), visits decreased for pregnancy-related
diagnoses and diseases of the skin (eg, cellulitis, abscess) compared with that
of the older group (3.7% and 3.1%, respectively).
CONCLUSION:
Our results indicate that increased coverage has kept young adults out of the
ED for specific conditions that can be cared for through access to other
channels. As EDs face capacity challenges, these results are encouraging and
offer insight into what could be expected under further insurance expansions
from health care reform.
18. Management of Adults With Acute Migraine in the ED: The
American Headache Society Evidence Assessment of Parenteral Pharmacotherapies.
Orr SL, et
al. Headache. 2016 Jun;56(6):911-40.
OBJECTIVE: To
provide evidence-based treatment recommendations for adults with acute migraine
who require treatment with injectable medication in an emergency department
(ED). We addressed two clinically relevant questions: (1) Which injectable
medications should be considered first-line treatment for adults who present to
an ED with acute migraine? (2) Do parenteral corticosteroids prevent recurrence
of migraine in adults discharged from an ED?
METHODS: The
American Headache Society convened an expert panel of authors who defined a
search strategy and then performed a search of Medline, Embase, the Cochrane
database and clinical trial registries from inception through 2015. Identified
articles were rated using the American Academy of Neurology's risk of bias
tool. For each medication, the expert panel determined likelihood of efficacy.
Recommendations were created accounting for efficacy, adverse events,
availability of alternate therapies, and principles of medication action.
RESULTS/CONCLUSIONS:
The search identified 68 unique randomized controlled trials utilizing 28
injectable medications. Of these, 19 were rated class 1 (low risk of bias), 21
were rated class 2 (higher risk of bias), and 28 were rated class 3 (highest
risk of bias). Metoclopramide, prochlorperazine, and sumatriptan each had
multiple class 1 studies supporting acute efficacy, as did dexamethasone for
prevention of headache recurrence. All other medications had lower levels of
evidence.
RECOMMENDATIONS:
Intravenous metoclopramide and prochlorperazine, and subcutaneous sumatriptan
should be offered to eligible adults who present to an ED with acute migraine
(Should offer-Level B). Dexamethasone should be offered to these patients to
prevent recurrence of headache (Should offer-Level B). Because of lack of
evidence demonstrating efficacy and concern about sub-acute or long-term
sequelae, injectable morphine and hydromorphone are best avoided as first-line
therapy (May avoid-Level C).
19. The Mistrust of Science
By Atul
Gawande , The New Yorker, June 10, 2016
The following
was delivered as the commencement address at the California Institute of
Technology, on Friday, June 10th.
If this place
has done its job—and I suspect it has—you’re all scientists now. Sorry, English
and history graduates, even you are, too. Science is not a major or a career.
It is a commitment to a systematic way of thinking, an allegiance to a way of
building knowledge and explaining the universe through testing and factual
observation. The thing is, that isn’t a normal way of thinking. It is unnatural
and counterintuitive. It has to be learned. Scientific explanation stands in
contrast to the wisdom of divinity and experience and common sense. Common
sense once told us that the sun moves across the sky and that being out in the
cold produced colds. But a scientific mind recognized that these intuitions
were only hypotheses. They had to be tested.
When I came
to college from my Ohio home town, the most intellectually unnerving thing I
discovered was how wrong many of my assumptions were about how the world works—whether
the natural or the human-made world. I looked to my professors and
fellow-students to supply my replacement ideas. Then I returned home with some
of those ideas and told my parents everything they’d got wrong (which they just
loved). But, even then, I was just replacing one set of received beliefs for
another. It took me a long time to recognize the particular mind-set that
scientists have. The great physicist Edwin Hubble, speaking at Caltech’s
commencement in 1938, said a scientist has “a healthy skepticism, suspended
judgement, and disciplined imagination”—not only about other people’s ideas but
also about his or her own. The scientist has an experimental mind, not a
litigious one.
As a student,
this seemed to me more than a way of thinking. It was a way of being—a weird
way of being. You are supposed to have skepticism and imagination, but not too
much. You are supposed to suspend judgment, yet exercise it. Ultimately, you
hope to observe the world with an open mind, gathering facts and testing your
predictions and expectations against them. Then you make up your mind and
either affirm or reject the ideas at hand. But you also hope to accept that
nothing is ever completely settled, that all knowledge is just probable
knowledge. A contradictory piece of evidence can always emerge. Hubble said it
best when he said, “The scientist explains the world by successive
approximations.”
The
scientific orientation has proved immensely powerful. It has allowed us to
nearly double our lifespan during the past century, to increase our global
abundance, and to deepen our understanding of the nature of the universe. Yet
scientific knowledge is not necessarily trusted. Partly, that’s because it is
incomplete. But even where the knowledge provided by science is overwhelming,
people often resist it—sometimes outright deny it. Many people continue to
believe, for instance, despite massive evidence to the contrary, that childhood
vaccines cause autism (they do not); that people are safer owning a gun (they
are not); that genetically modified crops are harmful (on balance, they have
been beneficial); that climate change is not happening (it is)…
20. Medical Students: False Beliefs about Blacks' Biology Common
Tara Haelle. Medscape
Medical News. April 04, 2016
Half of white
medical students held at least one false belief about biological differences
between black and white patients, a trend that affected both their perception
of the patient's pain and the accuracy of their treatment recommendations,
according to a study published online April 4 in the Proceedings of the
National Academy of Sciences.
The more
false beliefs the students held, the more likely they were to rate a black
patient as experiencing less pain than a white patient in the same scenario,
and the less likely they were to make an appropriate medical recommendation.
"The present
work sheds light on a heretofore unexplored source of racial bias in pain
assessment and treatment recommendations within a relevant population (i.e.,
medical students and residents), in a context where racial disparities are well
documented (i.e., pain management)," write Kelly M. Hoffman, from the
Department of Psychology, University of Virginia, Charlottesville, and
colleagues. "It demonstrates that beliefs about biological differences
between blacks and whites — beliefs dating back to slavery — are associated
with the perception that black people feel less pain than do white people and
with inadequate treatment recommendations for black patients' pain."
The
researchers collected survey results from 222 white medical students, all
native English speakers born in the United States, including 63 first-year
students, 72 second-year students, 59 third-year students, and 28 residents.
The students read two hypothetical medical cases about a black patient and a
white patient and rated the pain they expected the patients felt on a scale of
0 (no pain) to 10 (worst possible pain). They also made medical recommendations
based on the cases, which the researchers then coded as accurate or inaccurate.
The medical
students also rated the accuracy of 15 statements (11 false and 4 true) about
biological differences between blacks and whites on a scale of 1 to 6, from
definitely untrue (1) to probably untrue, possibly untrue, possibly true,
probably true, or definitely true (6).
Among the
false statements they were asked to rate were that blacks age more slowly than
whites, blacks' nerve endings are less sensitive than whites', whites have
larger brains than blacks, blacks' skin is thicker than whites', and blacks
have stronger immune systems than whites. True statements included that blacks
have denser, stronger bones than whites and that whites are less likely to have
a stroke than blacks.
Half the
students rated at least one of the false statements as possibly, probably, or
definitely true. On average, the students said 11.55% (standard deviation [SD]
= 17.38) of the false beliefs were possibly, likely or definitely true.
Moreover, the
authors found that medical students who endorsed more false believes also rated
the black patient in the case as having less pain than the white patient.
Similarly,
medical students "who endorsed more false beliefs (+1 SD) were less
accurate in their treatment recommendations for the black target compared with
the white target," whereas "participants who endorsed fewer false
beliefs (−1 SD) did not differ in their treatment recommendation accuracy"
between black and white patients. An additional analysis showed that rating
black patients' pain as lower also correlated with making less accurate
treatment recommendations, even after controlling for the students' belief in
false statements about differences between blacks and whites.
"Although
the effect sizes for these findings were not large...the practical importance
is significant: those endorsing more false beliefs rated the pain of a black
(vs. white) patient half a scale point lower and were less accurate in their
treatment recommendations 15% of the time," the authors write.
In a separate
portion of their study, Hoffman and colleagues investigated the beliefs of
white laypeople, resulting in similar, but more pronounced, findings. The 92
white native English speakers born in the United States rated how painful they
expected various scenarios to be for themselves and for a black or white person
of the same sex on a scale of 1 to 4, from not painful to somewhat painful,
moderately painful, or extremely painful. They also rated how much they
believed the same statements about biological differences between blacks and
whites.
The
participants rated an average of 22.43% of the false beliefs as true, and about
73% of them believed at least one of the false statements was likely true. The
white participants also tended to rate pain experiences as lower for black
individuals than for white individuals, a perception that correlated with the
number of false beliefs they endorsed. Meanwhile, "participants who
endorsed fewer false beliefs (−1 SD) did not differ in their pain estimates for
a black vs. a white target."
This study of
white adults without medical training therefore showed that most of them held
"at least some beliefs about biological differences between blacks and
whites, many of which are false and fantastical in nature (e.g., black people's
blood coagulates more quickly than white people's blood)." These beliefs, as
among the medical students, correlated with a racial bias regarding pain
perception for black and white individuals.
Despite the
passage of 30 years since the 1985 Report of the Secretary's Task Force on
Black and Minority Health, known as the Heckler Report, "[r]acial
disparities in health and health care continue to be a problem in the United
States," the authors conclude.
21. Inadequate Sensitivity of the Laboratory Risk Indicator to
Rule Out Necrotizing Fasciitis in ED Patients
Burner E, et
al. West J Emerg Med. 2016 April 26 [Epub ahead of print]
Introduction:
Necrotizing fasciitis (NF) is a life-threatening illness, particularly when
surgical debridement is delayed. The Laboratory Risk Indicator for Necrotizing
Fasciitis (LRINEC) score was developed to identify patients at higher risk for
NF. Despite limited information in this regard, the LRINEC score is often used
to “rule out” NF if negative. We describe the sensitivity of the LRINEC score
in emergency department (ED) patients for the diagnosis of NF.
Methods: We
conducted a chart review of ED patients in whom coding of hospital discharge
diagnoses included NF. We employed standard methods to minimize bias. We used
laboratory data to calculate the LRINEC score, and confirmed the diagnosis of
NF via explicit chart review. We then calculated the sensitivity of a positive
LRINEC score (standardly defined as six or greater) in our cohort. We examined
the role of patient characteristics in the performance of the LRINEC score.
Finally, we performed sensitivity analyses to estimate whether missing data for
c-reactive protein (CRP) results were likely to impact our results.
Results: Of
266 ED patients coded as having a discharge diagnosis of NF, we were able to
confirm the diagnosis, by chart review, in 167. We were able to calculate a
LRINEC score in only 80 patients (due to absence of an initial CRP value); an
LRINEC score of 6 or greater had a sensitivity of 77%. Sensitivity analyses of
missing data supported our finding of inadequate sensitivity to rule out NF. In
sub-analysis, NF patients with concurrent diabetes were more likely to be
accurately categorized by the LRINEC score.
Conclusion:
Used in isolation, the LRINEC score is not sufficiently sensitive to rule out
NF in a general ED population.
22. The Effect of ED Boarding on Order Completion
Coil CJ, et
al. Ann Emerg Med. 2016;67(6):730–736.e2
STUDY
OBJECTIVE: We identify differences in the process of care for admitted patients
who board in the emergency department (ED) compared with admitted patients who
are transferred to an inpatient care area.
METHODS: This
is a retrospective study of a random sample of adult patients admitted through
the ED at one urban teaching hospital. Patients who boarded in the ED for at
least 6 hours after the decision to admit were matched to similar control
patients. Data were collected by 2 trained medical students using a
standardized data abstraction tool. All physician orders placed in the first 24
hours after admission orders were signed were identified. The medical record
was searched for documentation of order completion. Each order was classified
as being executed on time, delayed, or missed.
RESULTS: Of
848 patients screened for inclusion in the study, a total of 145 matched
case-control pairs were included, making a total of 290 patients. A total of
9,260 distinct orders were identified. Use of a generalized estimating equation
that controlled for correlation within subjects showed that orders were less
likely to be completed on time for boarders than for controls (odds ratio [OR]
0.46; 95% confidence interval [CI] 0.38 to 0.55). Among boarders, orders were
more likely to be either delayed (OR 1.84; 95% CI 1.46 to 2.30) or missed
entirely (OR 2.58; 95% CI 1.94 to 3.42). Boarders missed a median of 11 orders
during their first 24 hours of admission compared with 6 orders for control
patients.
CONCLUSION:
This study detected an important process difference between boarded patients
compared with control patients, which could explain previously suggested
outcome differences between these 2 groups. This provides additional support
for efforts to move patients to inpatient care areas in a timely fashion rather
than board in the ED.
23. Sprays Reduce Venipuncture Pain
A.
Prospective, randomized, double-blind controlled trial comparing vapocoolant
spray vs placebo spray in adults undergoing venipuncture.
Mace SE. Am J
Emerg Med. 2016 May;34(5):798-804.
INTRODUCTION:
Topical anesthetics are used to decrease procedural pain such as venipuncture.
Advantages of vapocoolants include rapid onset, ease of application, low cost,
and lack of associated pain of injection and other needlestick-related risks.
We hypothesized that the pain of venipuncture would be reduced by at least 1.8
points on a 10-point numerical rating scale after application of a vapocoolant
compared with placebo.
METHODS: We
conducted a prospective, randomized, double-blind controlled trial of
vapocoolant vs placebo spray in 100 adults (ages 18-80) requiring venipuncture
in a hospital emergency department or observation unit. The primary efficacy
outcome was the difference in pain scores immediately after venipuncture,
measured on a 10-point verbal numeric rating scale from 0 (none) to worst (10).
Safety outcomes included local adverse effects (edema, erythema, blanching) and
changes in vital signs (VS).
RESULTS:
Patient characteristics and venipuncture procedure were not significantly
different for the 2 groups. The median (interquartile range) pain of
venipuncture was 3 (1.2-5) in the placebo group and 1 (0-3) in the vapocoolant
group, P less than .001. Skin checklist revealed the following:
vapocoolant-minimal blanching 4%, minimal erythema 18% which resolved within 5
minutes; placebo-no visible skin changes. Photographs at 5 to 10 minutes
revealed no visible skin changes in any patient. There were 2 complaints:
"very wet and cold on skin" (placebo) and "felt burning on
skin" (vapocoolant).
CONCLUSION:
The vapocoolant significantly decreased venipuncture pain in adults compared
with placebo and was well tolerated with minor adverse effects that resolved
quickly. There were no significant differences in VS and no visible skin
changes documented at the site by photographs taken within 5 to 10 minutes
postspray/venipuncture.
B.
Topical ethyl chloride to reduce pain associated with venous catheterization: a
randomized crossover trial
Fossum K, et
al. Am J Emerg Med. 2016 May;34(5):845-50.
OBJECTIVE: To
compare pain associated with venous catheterization after administration of
topical ethyl chloride vs placebo among emergency department health care
providers.
METHODS: We
conducted a randomized, double-blind, placebo-controlled, crossover trial among
a convenience sample of health care provider volunteers in a tertiary care
urban emergency department. We randomly allocated subjects to initial treatment
(ethyl chloride vs sterile water aerosol spray) and catheterization site (left
or right antecubital fossa). After venous catheterization placement and discontinuation,
subjects underwent a 5-minute washout period. All subjects then underwent
venous catheterization in the contralateral antecubital fossa after
administration of the alternative agent. We measured all outcomes after
discontinuation of the second catheter. The primary outcome was difference in
pain verbal numeric rating scale score (0-10) between the 2 agents. Secondary
outcomes included preferred agent (binary) and future willingness to use agent
on patients (5-point Likert scale).
RESULTS: Thirty-eight
health care providers were recruited; all completed the study. Median pain
verbal numeric rating scale scores were 4 (interquartile range, 2-5) for
placebo vs 2 (1-4) for ethyl chloride. The effect size for pain reduction with
ethyl chloride compared with placebo was 2 (95% confidence interval, 0.5-2; P =
.001). Most subjects (68.4%) preferred ethyl chloride to placebo. Five-point
Likert scale scores measuring willingness to use preferred product on future
patients were higher by 2 (95% confidence interval, 1-3) among subjects
preferring ethyl chloride vs placebo.
CONCLUSIONS:
We found that topical ethyl chloride yields a greater reduction in pain
associated with venous catheterization compared with topical placebo.
24. It’s No Accident: Advocates Want to Speak of Car ‘Crashes’
Instead
Matt
Richtelmay, New York Times. May 22, 2016
Roadway
fatalities are soaring at a rate not seen in 50 years, resulting from crashes,
collisions and other incidents caused by drivers.
Just don’t
call them accidents anymore.
That is the
position of a growing number of safety advocates, including grass-roots groups,
federal officials and state and local leaders across the country. They are
campaigning to change a 100-year-old mentality that they say trivializes the
single most common cause of traffic incidents: human error.
“When you use
the word ‘accident,’ it’s like, ‘God made it happen,’ ” Mark Rosekind, the head
of the National Highway Traffic Safety Administration, said at a driver safety
conference this month at the Harvard School of Public Health.
“In our
society,” he added, “language can be everything.”
Almost all
crashes stem from driver behavior like drinking, distracted driving and other
risky activity. About 6 percent are caused by vehicle malfunctions, weather and
other factors.
Preliminary
estimates by the nonprofit National Safety Council show deadly crashes rose by
nearly 8 percent in 2015 over the previous year, killing about 38,000 people.
Dr. Rosekind
has added his voice to a growing chorus of advocates who say that the
persistence of crashes — driving is the most dangerous activity for most people
— can be explained in part by widespread apathy toward the issue.
Changing
semantics is meant to shake people, particularly policy makers out of the
implicit nobody’s-fault attitude that the word “accident” conveys, they said.
On Jan. 1,
the state of Nevada enacted a law, passed almost unanimously in the
Legislature, to change “accident” to “crash” in dozens of instances where the
word is mentioned in state laws, like those covering police and insurance
reports.
New York City
adopted a policy in 2014 to reduce fatalities that states the city “must no
longer regard traffic crashes as mere ‘accidents,’ ” and other cities,
including San Francisco, have taken the same step.
At least 28
state departments of transportation have moved away from the term “accident”
when referring to roadway incidents, according to Jeff Larason, director of
highway safety for Massachusetts. The traffic safety administration changed its
own policy in 1997, but has recently become more vocal about the issue.
Mr. Larason,
a former television traffic reporter, started a blog called “Drop The A Word”
and has led a campaign to get major media outlets to stop using the term…
The remainder
of the essay: http://www.nytimes.com/2016/05/23/science/its-no-accident-advocates-want-to-speak-of-car-crashes-instead.html
25. California in the News
A.
California to fund first public research center on gun violence in the United
States
By Emily
Underwood. Science. Jun. 17, 2016 , 9:45 AM
Four days
after a mass shooting at a gay nightclub in Orlando, Florida, left 49 people
dead and 53 injured, California’s state legislature voted yesterday to
establish a $5-million firearm violence research center within the University
of California (UC)—the first such publicly charted center in the country.
“Acts of
firearm violence like Sunday’s horrific mass shooting in Orlando leave us
searching for answers. California made finding those answers a priority, taking
leadership once again where Congress has failed,” said state Democratic Senator
Lois Wolk, who had proposed separate legislation earlier this year that was
folded into a $170-billion budget bill approved this week by the legislature.
The vote
follows Wednesday’s 15-hour filibuster in the U.S. Senate, in which Democrats
demanded tighter regulations on gun purchases. That move has set the stage for
votes Monday on four gun-related amendments to a spending bill that funds the
Justice Department and several other federal agencies, including the National
Science Foundation and NASA. The deep partisan split over the gun measures
could doom the bill, say some observers, and raise new obstacles to
congressional approval of any 2017 spending bills.
Epidemiologist
Garen Wintemute, who studies firearm violence at UC Davis, says it is
“coincidental” that the state legislature vote occurred so soon after the
massacre in Orlando. The center grew out of conversations he had last fall with
Wolk, he explained, and the timetable for approving a state budget—not the
deadly shootings—determined when the vote took place. Still, he says the new
research center provides “a very stark example” for Congress, which has balked
at President Barack Obama’s repeated requests for a $10-million investment into
gun violence research.
In 2013 Obama
directed the U.S. Centers for Disease Control and Prevention (CDC) and other
federal agencies to study the causes and prevention of gun violence. That work
had ground to a halt in 1996 after Congress banned the agency from any activity
that would “advocate or promote gun control” and took away a tiny pot of money
devoted to research on firearms. Former Representative Jay Dickey (R–AR), who
championed the 1996 amendment, has publicly reversed his position and now
lobbies for more research on gun violence.
Historically,
funding for gun-related research has been so difficult to obtain that Wintemute
has spent more than $1 million of his own funds to sustain his research. A
budget of $1 million per year for 5 years precludes a large-scale study or
extensive data collection, he says. But it could pay for a handful of
researchers to examine California’s unique data set on statewide gun transfers
and other firearm-related activities, he says. While the location of the new
center is not “locked in” yet, Wintemute believes UC Davis is the most likely
candidate.
One pressing
question that even a small team could address is why California’s annual death
rate from gun violence has dropped by roughly 20% since 2000 while the
nationwide rate has not changed. “We don’t know why that is,” Wintemute says.
“Are we doing something right? Or are we not doing something wrong that other
[states] are?”
He hopes the
$5 million will attract additional private and public funding and spur other
states to take action. In the meantime, he says, this week’s vote means
“California can say, well, we’re doing it.”
B.
Who May Die? California Patients and Doctors Wrestle With Assisted Suicide
Jennifer
Medina, New York Times. June 9, 2016
LOS ANGELES —
On Thursday, California became the fourth state in the country to put in effect
a law allowing assisted suicide for the terminally ill, what has come to be
known as aid in dying. Lawmakers here approved the legislation last year, after
Brittany Maynard, a 29-year-old schoolteacher who had brain cancer, received
international attention for her decision to move to Oregon, where terminally
ill patients have been allowed to take drugs to die since 1997.
Oregon was
the first state to pass an assisted suicide law, and was followed by Washington
and Vermont. Under a Montana court ruling, doctors cannot be prosecuted for
helping terminally ill patients die, as long as the patient makes a written
request. With the California law, 16 percent of the country’s population has a
legal option for terminally ill patients to determine the moment of their death,
up from 4 percent.
In the states
with assisted suicide laws, the number of people who request and take
medication to hasten dying has steadily increased. In Oregon, for example, 16
people ended their lives under the law in 1998, and by 2015, that number had
grown to 132.
The
California legislation is strict, intended to ensure that patients have thought
through the decision and are making it voluntarily. Patients must make multiple
requests for the medication and have a prognosis of less than six months to
live.
Many
hospitals have not yet released policies for dealing with the law. And no
doctor, health system or pharmacy will be required to comply with a patient’s
request. Doctors who object to the practice are not even required to refer
patients who request the medication to another physician.
Roman
Catholic and other religious health systems have said they will not
participate. “We are crossing a line — from being a society that cares for
those who are aging and sick to a society that kills those whose suffering we
can no longer tolerate,” José H. Gomez, the Catholic archbishop of Los Angeles,
said in a statement Wednesday.
Here is how
two patients and two doctors are preparing for the new order…
The remainder
of the essay: http://www.nytimes.com/2016/06/10/us/assisted-suicide-california-patients-and-doctors.html
C.
New report shows Medi-Cal expansion threatened by low reimbursement rates
CMA Report.
June 2016
A new report
shows that while California’s Medi-Cal program has dramatically expanded its
reach—now covering about one-third of the state's population—these gains are
threatened by Medi-Cal’s low payments to physicians and other providers.
According to
the study, published by the Bay Area Council Economic Institute, California's
Medi-Cal reimbursement is near the bottom for all state Medicaid programs. In
2014, California ranked 47th in the nation in reimbursement rates for traditional
fee-for-service Medi-Cal.
In 2011,
Medi-Cal payment rates to physicians, hospitals, dentists and other providers
were cut by 10 percent as a way to balance the state’s budget. Even before the
cuts, California's Medi-Cal rates were abysmally low. Unfortunately, despite a
much better fiscal outlook, physician payment rates have not been restored.
Medi-Cal has
long been underfunded, resulting in decreased access to health care for
patients and dangerously low reimbursement rates for participating physicians.
Currently, payments to doctors for a typical office visit under Medi-Cal are
roughly $16—far less than the cost of providing care.
“No
physician, no care giver, should ever have to choose between providing care to
those who need it and staying in business,” said Dustin Corcoran, CEO of the
California Medical Association (CMA).
More than
13.3 million Californians—about one-third of the state’s population—are now
covered by Medi-Cal. More than 5 million have gained coverage since the
Affordable Care Act took effect, expanding eligibility for the program.
Currently,
Medi-Cal serves 4.7 million people who hold full-time jobs. An additional 2.8
million children and teens enrolled in Medi-Cal live in households where at
least one parent is working.
“People think
this is a safety net program for people who aren’t working, but that just isn’t
true anymore,” said Micah Weinberg, president of the San Francisco-based think
tank.
26. Micro Bits
A. On being a good listener
A 5-min video on the art and
value of being a good listener
B. Take Low-Salt Advice With a Grain of You
Know What
There seems to be pretty good
evidence that people with high blood pressure who consume an excessive amount
of salt should cut back. That’s where doctors started back in the day, and that
concept holds up. But the evidence doesn’t support the idea that increased salt
consumption by people with normal blood pressure makes that much of a difference.
NY Times Essay: http://www.nytimes.com/2016/05/27/upshot/take-low-salt-advice-with-a-grain-of-you-know-what.html
Conclusion of Lancet study: “These
data suggest that lowering sodium intake is best targeted at populations with
hypertension who consume high sodium diets.”
C. Loperamide
1. Emergency Physicians Warn of Increasing
Loperamide Abuse, Fatal Consequences
WASHINGTON, DC -- May 5, 2016 --
The over-the-counter anti-diarrhoea medication Imodium, or its key ingredient
loperamide, is increasingly being abused by people attempting to self-treat
their opioid addiction, with sometimes fatal results. Two case studies
outlining the phenomenon were published online in Annals of Emergency Medicine.
“Loperamide’s accessibility, low
cost, over-the-counter legal status and lack of social stigma all contribute to
its potential for abuse,” said lead author William Eggleston, PharmD, Upstate
New York Poison Center, Syracuse, New York. “People looking for either
self-treatment of withdrawal symptoms or euphoria are overdosing on loperamide
with sometimes deadly consequences. Loperamide is safe in therapeutic doses but
extremely dangerous in high doses.”
The paper outlines 2 case studies
of patients with histories of substance abuse who attempted to self-treat
opioid addictions with massive doses of loperamide. Both patients overdosed and
emergency medical services were called. The patients were treated with
cardiopulmonary resuscitation, naloxone and standard Advanced Cardiac Life
Support. Both patients died.
Oral loperamide abuse postings to
web-based forums increased 10-fold between 2010 and 2011. A majority of
user-generated content pertaining to loperamide discussed using the medication
to self-treat opioid withdrawal (70%). Users also cited abusing the medication
for its euphoric properties (25%).
The Upstate New York Poison
Center experienced a 7-fold increase in calls related to loperamide abuse or
misuse from 2011 through 2015, which is consistent with national poison data,
which reported a 71% increase in calls related to intentional loperamide
exposure from 2011 through 2014.
“Our nation's growing population
of opioid-addicted patients is seeking alternative drug sources with prescription
opioid medication abuse being limited by new legislation and regulations,” said
Dr. Eggleston.
“Healthcare providers must be
aware of increasing loperamide abuse and its under-recognised cardiac
toxicity,” he added. “This is another reminder that all drugs, including those
sold without a prescription, can be dangerous when not used as directed.”
2. FDA Drug Safety Communication: FDA warns
about serious heart problems with high doses of the antidiarrheal medicine
loperamide (Imodium), including from abuse and misuse
D. 30% of prescribed antibiotics are
unnecessary
Researchers who looked at 184,000
outpatient visits in 2010-2011 found that about 30% of prescriptions for
antibiotics were unnecessary overall, and about half of those written for acute
respiratory conditions were not needed. Experts said doctors should focus less
on what patients expect and more on what they need. "If we know that an
antibiotic is really not likely to make people feel better, we still can
provide alternatives for symptom relief that will help people feel
better," said Dr. Sara Cosgrove, who wrote an editorial that accompanied
the study in the Journal of the American Medical Association.
E. Hospitalist is fastest-growing specialty,
physician says
Hospital medicine is 20 years old
and the number of hospitalists has reached 52,000, making it "the
fastest-growing specialty of all time," said Lawrence Wellikson, M.D.,
chief executive of the Society of Hospital Medicine. Robert Wachter, M.D., who
first used the term "hospitalist," said the job is similar to an
orchestra conductor because it manages patients, specialists and staff in a
team-based setting.
F. FDA recommends cautious oral fluconazole
prescribing for pregnant women
The FDA has issued a safety alert
advising clinicians to take caution in prescribing oral fluconazole for
treating yeast infections in pregnant women. The notice is in light of a Danish
study that showed an association between the use of oral fluconazole during
pregnancy and an elevated risk for miscarriages. The agency is reviewing the
study, as well as other data, as it plans to make recommendations on the use of
the drug.
G. Lactate Clearance in Septic Shock Is Not a
Surrogate for Improved Microcirculatory Flow
H. As Opioid Prescribing Guidelines Tighten,
Mindfulness Meditation Holds Promise for Pain Relief
I. How Depressed Mood May Develop After Viral
Infection
