Sunday, June 19, 2016

Lit Bits: June 19, 2016

From the recent medical literature...

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?

The ENCHANTED Trial in the NEJM:

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”.

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.

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…

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…

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.

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