Sunday, July 10, 2016

Lit Bits: July 10, 2016

From the recent medical literature...

1. Empirical Anti-MRSA Therapy Not Supported for non-ICU patients with CAP

The low prevalence (0.1%) of MRSA CAP among patients not admitted to an ICU provides support for the current Infectious Diseases Society of America and American Thoracic Society CAP guidelines, which do not recommend routine anti-MRSA antibiotics for patients admitted to a general medical floor. Among patients admitted to an intensive care unit, MRSA CAP prevalence was 2.7%.

Self WH, et al. Clin Infect Dis. 2016 May 8 [Epub ahead of print].

Background. Prevalence of Staphylococcus aureus community-acquired pneumonia (CAP) and its clinical features remain incompletely understood, complicating empirical selection of antibiotics.

Methods. Using a multicenter, prospective surveillance study of adults hospitalized with CAP, we calculated the prevalence of methicillin-resistant S. aureus (MRSA) and methicillin-susceptible S. aureus (MSSA) among all CAP episodes. We compared the epidemiologic, radiographic, and clinical characteristics of S. aureus CAP (per respiratory or blood culture) with those of pneumococcal (per respiratory or blood culture or urine antigen) and all-cause non-S. aureus CAP using descriptive statistics.

Results. Among 2259 adults hospitalized for CAP, 37 (1.6%) had S. aureus identified, including 15 (0.7%) with MRSA and 22 (1.0%) with MSSA; 115 (5.1%) had Streptococcus pneumoniae. Vancomycin or linezolid was administered to 674 (29.8%) patients within the first 3 days of hospitalization. Chronic hemodialysis use was more common among patients with MRSA (20.0%) than pneumococcal (2.6%) and all-cause non-S. aureus (3.7%) CAP. Otherwise, clinical features at admission were similar, including concurrent influenza infection, hemoptysis, multilobar infiltrates, and prehospital antibiotics. Patients with MRSA CAP had more severe clinical outcomes than those with pneumococcal CAP, including intensive care unit admission (86.7% vs 34.8%) and in-patient mortality (13.3% vs 4.4%).

Conclusions. Despite very low prevalence of S. aureus and, specifically, MRSA, nearly one-third of adults hospitalized with CAP received anti-MRSA antibiotics. The clinical presentation of MRSA CAP overlapped substantially with pneumococcal CAP, highlighting the challenge of accurately targeting empirical anti-MRSA antibiotics with currently available clinical tools and the need for new diagnostic strategies.

2007 Guidelines: Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults

Moran GJ, et al. Emergency management of community-acquired bacterial pneumonia: what is new since the 2007 Infectious Diseases Society of America/American Thoracic Society guidelines.  Am J Emerg Med. 2013 Mar;31(3):602-12.

2. Intensive Blood-Pressure Lowering (to SBP 110-139) Ineffective in Patients with Acute Cerebral Hemorrhage.

Qureshi AI, et al; ATACH-2 Trial Investigators and the Neurological Emergency Treatment Trials Network. N Engl J Med. 2016 Jun 8 [Epub ahead of print]

Background Limited data are available to guide the choice of a target for the systolic blood-pressure level when treating acute hypertensive response in patients with intracerebral hemorrhage.

Methods We randomly assigned eligible participants with intracerebral hemorrhage (volume, below 60 cm3) and a Glasgow Coma Scale (GCS) score of 5 or more (on a scale from 3 to 15, with lower scores indicating worse condition) to a systolic blood-pressure target of 110 to 139 mm Hg (intensive treatment) or a target of 140 to 179 mm Hg (standard treatment) in order to test the superiority of intensive reduction of systolic blood pressure to standard reduction; intravenous nicardipine to lower blood pressure was administered within 4.5 hours after symptom onset. The primary outcome was death or disability (modified Rankin scale score of 4 to 6, on a scale ranging from 0 [no symptoms] to 6 [death]) at 3 months after randomization, as ascertained by an investigator who was unaware of the treatment assignments.

Results Among 1000 participants with a mean (±SD) systolic blood pressure of 200.6±27.0 mm Hg at baseline, 500 were assigned to intensive treatment and 500 to standard treatment. The mean age of the patients was 61.9 years, and 56.2% were Asian. Enrollment was stopped because of futility after a prespecified interim analysis. The primary outcome of death or disability was observed in 38.7% of the participants (186 of 481) in the intensive-treatment group and in 37.7% (181 of 480) in the standard-treatment group (relative risk, 1.04; 95% confidence interval, 0.85 to 1.27; analysis was adjusted for age, initial GCS score, and presence or absence of intraventricular hemorrhage). Serious adverse events occurring within 72 hours after randomization that were considered by the site investigator to be related to treatment were reported in 1.6% of the patients in the intensive-treatment group and in 1.2% of those in the standard-treatment group. The rate of renal adverse events within 7 days after randomization was significantly higher in the intensive-treatment group than in the standard-treatment group (9.0% vs. 4.0%, P=0.002).

Conclusions The treatment of participants with intracerebral hemorrhage to achieve a target systolic blood pressure of 110 to 139 mm Hg did not result in a lower rate of death or disability than standard reduction to a target of 140 to 179 mm Hg.

3. Routine Midazolam Administration Prior to Nasogastric Tube Insertion in the ED Decreases Patients' Pain

Manning CT, et al. Acad Emerg Med. 2016 Jul;23(7):766-71

OBJECTIVES: Patients report pain and discomfort with nasogastric tube (NGT) intubation. We tested the hypothesis that premedication with midazolam alleviates pain during NGT placement in the emergency department (ED) by greater than 13 on a 100-mm visual analog scale (VAS).

METHODS: We performed a double-blind randomized controlled pilot study, assigning ED patients requiring NGT placement to midazolam or placebo. All patients received intranasal cophenylcaine; additionally, they received an intravenous (IV) dose of the study drug, either 2 mg of IV midazolam or saline control. Nurses placed NGTs while observed by research staff, who then interviewed subjects to determine the primary outcome of pain using a VAS. Additional data collected from patients and their nurses included discomfort during the procedure, difficulty of tube insertion, and complications.

RESULTS: We enrolled 23 eligible patients and obtained complete data in all: 10 midazolam and 13 controls. We found a significant reduction in mean pain VAS score of -31 (95% confidence interval = -53 to -9 mm) with 2 mg of midazolam (mean ± SD = 52 ± 30 mm), compared to placebo (mean ± SD = 21 ± 18 mm), more than double the effect size considered clinically relevant. Treatment did not impact ease of placement and there were no serious adverse effects.

CONCLUSIONS: Premedication with 2 mg of IV midazolam reduces pain of NGT insertion in ED patients without the need for full procedural sedation.

4. Working up the ED CP Patient

A. Multicenter Evaluation of a 0-Hour/1-Hour Algorithm in the Diagnosis of MI With High-Sensitivity Cardiac Trop T

Mueller C, et al. Ann Emerg Med 2016;68(1):76–87.e4

STUDY OBJECTIVE: We aim to prospectively validate the diagnostic accuracy of the recently developed 0-h/1-h algorithm, using high-sensitivity cardiac troponin T (hs-cTnT) for the early rule-out and rule-in of acute myocardial infarction.

METHODS: We enrolled patients presenting with suspected acute myocardial infarction and recent (less than 6 hours) onset of symptoms to the emergency department in a global multicenter diagnostic study. Hs-cTnT (Roche Diagnostics) and sensitive cardiac troponin I (Siemens Healthcare) were measured at presentation and after 1 hour, 2 hours, and 4 to 14 hours in a central laboratory. Patient triage according to the predefined hs-cTnT 0-hour/1-hour algorithm (hs-cTnT below 12 ng/L and Δ1 hour below 3 ng/L to rule out; hs-cTnT at least 52 ng/L or Δ1 hour at least 5 ng/L to rule in; remaining patients to the "observational zone") was compared against a centrally adjudicated final diagnosis by 2 independent cardiologists (reference standard). The final diagnosis was based on all available information, including coronary angiography and echocardiography results, follow-up data, and serial measurements of sensitive cardiac troponin I, whereas adjudicators remained blinded to hs-cTnT.

RESULTS: Among 1,282 patients enrolled, acute myocardial infarction was the final diagnosis for 213 (16.6%) patients. Applying the hs-cTnT 0-hour/1-hour algorithm, 813 (63.4%) patients were classified as rule out, 184 (14.4%) were classified as rule in, and 285 (22.2%) were triaged to the observational zone. This resulted in a negative predictive value and sensitivity for acute myocardial infarction of 99.1% (95% confidence interval [CI] 98.2% to 99.7%) and 96.7% (95% CI 93.4% to 98.7%) in the rule-out zone (7 patients with false-negative results), a positive predictive value and specificity for acute myocardial infarction of 77.2% (95% CI 70.4% to 83.0%) and 96.1% (95% CI 94.7% to 97.2%) in the rule-in zone, and a prevalence of acute myocardial infarction of 22.5% in the observational zone.
CONCLUSION: The hs-cTnT 0-hour/1-hour algorithm performs well for early rule-out and rule-in of acute myocardial infarction.

B. Effectiveness of EDACS vs ADAPT Accelerated Diagnostic Pathways for CP: A Pragmatic RCT Embedded Within Practice

Than MP, et al. Ann Emerg Med. 2016;68:93–102.e1

Study objective
A 2-hour accelerated diagnostic pathway based on the Thrombolysis in Myocardial Infarction score, ECG, and troponin measures (ADAPT-ADP) increased early discharge of patients with suspected acute myocardial infarction presenting to the emergency department compared with standard care (from 11% to 19.3%). Observational studies suggest that an accelerated diagnostic pathway using the Emergency Department Assessment of Chest Pain Score (EDACS-ADP) may further increase this proportion. This trial tests for the existence and size of any beneficial effect of using the EDACS-ADP in routine clinical care.

This was a pragmatic randomized controlled trial of adults with suspected acute myocardial infarction, comparing the ADAPT-ADP and the EDACS-ADP. The primary outcome was the proportion of patients discharged to outpatient care within 6 hours of attendance, without subsequent major adverse cardiac event within 30 days.

Five hundred fifty-eight patients were recruited, 279 in each arm. Sixty-six patients (11.8%) had a major adverse cardiac event within 30 days (ADAPT-ADP 29; EDACS-ADP 37); 11.1% more patients (95% confidence interval 2.8% to 19.4%) were identified as low risk in EDACS-ADP (41.6%) than in ADAPT-ADP (30.5%). No low-risk patients had a major adverse cardiac event within 30 days (0.0% [0.0% to 1.9%]). There was no difference in the primary outcome of proportion discharged within 6 hours (EDACS-ADP 32.3%; ADAPT-ADP 34.4%; difference −2.1% [−10.3% to 6.0%], P=.65).

There was no difference in the proportion of patients discharged early despite more patients being classified as low risk by the EDACS-ADP than the ADAPT-ADP. Both accelerated diagnostic pathways are effective strategies for chest pain assessment and resulted in an increased rate of early discharges compared with previously reported rates.

C. The (questionable) incremental value of stress testing in patients with acute CP beyond serial cardiac troponin testing

Aldous S, et al. Emerg Med J  2016;33:319-324  

Objective In patients with acute chest pain and normal range cardiac troponin (cTn), accurate risk stratification for acute coronary syndrome is challenging. This study assesses the incremental value of stress testing to identify patients for angiography with a view to revascularisation.

Methods A single-centre observational study recruited patients with acute chest pain in whom serial cTn tests were negative and stress testing (exercise tolerance testing/dobutamine stress echocardiography) was performed. Stress tests were reported as negative, non-diagnostic or positive. The primary outcomes were revascularisation on index admission, or cardiac death and myocardial infarction over 1 year follow-up.

Results Of 749 patients recruited, 709 underwent exercise tolerance testing and 40 dobutamine stress echo of which 548 (73.2%) were negative, 169 (22.6%) were non-diagnostic and 32 (4.3%) were positive. Patients with positive tests (n=19 (59.4%)) were more likely to undergo index admission revascularisation than patients with non-diagnostic (n=15 (8.9%)) (p less than 0.001) tests who in turn were more likely undergo index admission revascularisation than those with negative tests (n=2 (0.4%)) (p less than 0.001). The risks of adverse events including cardiovascular death/acute myocardial infarction were low and were similar across stress test outcomes.

Conclusions The incremental value of stress testing was the identification of an additional 34 (4.5% (95% CI 3.0% to 6.0%)) patients who underwent index admission revascularisation with a view to preventing future adverse events. Uncertainty in whether revascularisation prevents adverse events in patients with negative cTn means the choice to undertake stress testing depends on whether clinicians perceive value in identifying 4.5% of these patients for revascularisation.

5. Antiemetics for ED patients with undifferentiated abdominal pain or acute gastroenteritis

A. Parenteral antiemetics are as good as placebo or IV fluids—but costlier and with more side effects

Drugs for the treatment of nausea and vomiting in adults in the ED setting.

Furyk JS, et al. Cochrane Database Syst Rev. 2015 Sep 28;(9):CD010106.

BACKGROUND: Nausea and vomiting is a common and distressing presenting complaint in emergency departments (ED). The aetiology of nausea and vomiting in EDs is diverse and drugs are commonly prescribed. There is currently no consensus as to the optimum drug treatment of nausea and vomiting in the adult ED setting.

OBJECTIVES: To provide evidence of the efficacy and safety of antiemetic medications in the management of nausea and vomiting in the adult ED setting.

SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 8), MEDLINE (OvidSP) (January 1966 to August 2014), EMBASE (OvidSP) (January 1980 to August 2014) and ISI Web of Science (January 1955 to August 2014). We also searched relevant clinical trial registries and conference proceedings.

SELECTION CRITERIA: We included randomized controlled trials (RCTs) of any drug in the treatment of nausea and vomiting in the treatment of adults in the ED. Study eligibility was not restricted by language or publication status.

DATA COLLECTION AND ANALYSIS: Two review authors independently performed study selection, data extraction and assessment of risk of bias in included studies. We contacted authors of studies to obtain missing information if required.

MAIN RESULTS: We included eight trials, involving 952 participants, of which 64% were women. Included trials were generally of adequate quality, with six trials at low risk of bias, and two trials at high risk of bias. Three trials with 518 participants compared five different drugs with placebo; all reported the primary outcome as mean change in visual analogue scale (VAS) (0 to 100) for nausea severity from baseline to 30 minutes. Trials did not routinely report other primary outcomes of the change in nausea VAS at 60 minutes or number of vomiting episodes. Differences in mean VAS change from baseline to 30 minutes between placebo and the drugs evaluated were: metoclopramide (three trials, 301 participants; mean difference (MD) -5.27, 95% confidence interval (CI) -11.33 to 0.80), ondansetron (two trials, 250 participants; MD -4.32, 95% CI -11.20 to 2.56), prochlorperazine (one trial, 50 participants; MD -1.80, 95% CI -14.40 to 10.80), promethazine (one trial, 82 participants; MD -8.47, 95% CI -19.79 to 2.85) and droperidol (one trial, 48 participants; MD -15.8, 95% CI -26.98 to -4.62). The only statistically significant change in baseline VAS to 30 minutes was for droperidol, in a single trial of 48 participants. No other drug was statistically significantly superior to placebo. Other included trials evaluated a drug compared to "active controls" (alternative antiemetic). There was no convincing evidence of superiority of any particular drug compared to active control. All trials included in this review reported adverse events, but they were variably reported precluding meaningful pooling of results. Adverse events were generally mild, there were no reported serious adverse events. Overall, the quality of the evidence was low, mainly because there were not enough data.

AUTHORS' CONCLUSIONS: In an ED population, there is no definite evidence to support the superiority of any one drug over any other drug, or the superiority of any drug over placebo. Participants receiving placebo often reported clinically significant improvement in nausea, implying general supportive treatment such as intravenous fluids may be sufficient for the majority of people. If a drug is considered necessary, choice of drug may be dictated by other considerations such as a person's preference, adverse-effect profile and cost. The review was limited by the paucity of clinical trials in this setting. Future research should include the use of placebo and consider focusing on specific diagnostic groups and controlling for factors such as intravenous fluid administered.

B. Isopropyl Alcohol Nasal Inhalation Improves Nausea in ED Patients at 10 minutes

Beadle KL, et al. Ann Emerg Med. 2016;68(1):1-9.e1.

Study objective: We compare nasal inhalation of isopropyl alcohol versus placebo in treating nausea among emergency department (ED) patients.

Methods: A convenience sample of adults with chief complaints of nausea or vomiting was enrolled in a randomized, double-blind, placebo-controlled trial conducted in an urban tertiary care ED. Patients were randomized to nasally inhaled isopropyl alcohol versus nasally inhaled normal saline solution. Patient nausea and pain were measured with previously published 11-point verbal numeric response scale scores; patient satisfaction was measured by a 5-point Likert scale. The primary outcome was reduction in nausea 10 minutes poststart. Secondary outcomes included patient satisfaction and pain reduction measured at 10 minutes poststart.

Results: Of 84 recruited patients, 80 (95.2%) completed the study. Thirty-seven (46.3%) received nasally inhaled isopropyl alcohol and 43 (53.8%) received nasally inhaled normal saline solution. At 10 minutes postintervention, median nausea verbal numeric response scale score was 3 in the isopropyl alcohol arm versus 6 in the placebo arm, for an effect size of 3 (95% confidence interval 2 to 4). Median satisfaction score was 4 in the isopropyl alcohol arm versus 2 in the placebo arm, for an effect size of 2 (95% confidence interval 2 to 2). There were no significant differences between the 2 arms in median pain verbal numeric response scale scores or subsequent receipt of rescue antiemetics.

Conclusion: We found that nasally inhaled isopropyl alcohol achieves increased nausea relief compared with placebo during a 10-minute period.

How the investigators describe the intervention: "Study investigators instructed subjects to nasally inhale from their assigned pad at study start, 2 minutes, and 4 minutes. At each of these 3 points, subjects were instructed to take deep inhalations for no more than 60 seconds through their nose. During these deep inhalations, subjects were instructed to hold their pad 2.5 cm from their nose. If at any time subjects’ nausea became completely relieved, they were instructed not to take further deep inhalations. No subjects were permitted any inhalation therapy after the 4-minute period."

6. Isolated Calf Vein Thrombosis

A. Should we be looking for and treating isolated calf vein thrombosis?

Horner D, et al. Emerg Med J  2016;33:431-437  

Management of isolated calf deep vein thrombosis is an area of significant international debate and variable clinical practice. Both therapeutic anticoagulation and conservative management carry risk. As clinical care of suspected and confirmed venous thromboembolic disease increasingly becomes the remit of emergency medicine, complex decisions are left to practising clinicians at the front door. We aim to provide a contemporary overview of recent evidence on this topic and associated challenges facing clinicians. Given the lack of high-level evidence, we present this work as a narrative review, based on structured literature review and expert opinion.

A decision to manage calf thrombosis is principally dependent on the risk of complications without treatment balanced against the risks of therapeutic anticoagulation. Estimates of the former risks taken from systematic review, meta-analysis, observational cohort and recent pilot trial evidence include proximal propagation 7%–10%, pulmonary embolism 2%–3% and death less than 1%. Fatal bleeding with therapeutic anticoagulation stands at less than 0.5%, and major bleeding at approximately 2%. Estimates of haemorrhagic risk are based on robust data from large prospective management studies of venous thromboembolic disease; the risks of untreated calf deep vein thrombosis are based on small cohorts and therefore less exact.

Pending further trial evidence, these risks should be discussed with patients openly, in the context of personal preference and shared decision-making. Anticoagulation may maximally benefit those patients with extensive and/or symptomatic disease or those with higher risk for complication (unprovoked, cancer-associated or pregnancy).

B. ED Management of Suspected Calf-Vein DVT: A Diagnostic Algorithm

Kitchen L, et al. West J Emerg Med 2016;17(4):384

Introduction: Unilateral leg swelling with suspicion of deep venous thrombosis (DVT) is a common emergency department (ED) presentation. Proximal DVT (thrombus in the popliteal or femoral veins) can usually be diagnosed and treated at the initial ED encounter. When proximal DVT has been ruled out, isolated calf-vein deep venous thrombosis (IC-DVT) often remains a consideration. The current standard for the diagnosis of IC-DVT is whole-leg vascular duplex ultrasonography (WLUS), a test that is unavailable in many hospitals outside normal business hours. When WLUS is not available from the ED, recommendations for managing suspected IC-DVT vary. The objective is to use current evidence and recommendations to (1) propose a diagnostic algorithm for ICDVTwhen definitive testing (WLUS) is unavailable; and (2) summarize the controversy surrounding IC-DVTtreatment.

Discussion: The Figure combines D-dimer testing with serial CUS or a single deferred FLUS for the diagnosis of IC-DVT. Such an algorithm has the potential to safely direct the management of suspected IC-DVT when definitive testing is unavailable. Whether or not to treat diagnosed IC-DVT remains widely debated and awaiting further evidence.

Conclusion: When IC-DVT is not ruled out in the ED, the suggested algorithm, although not prospectively validated by a controlled study, offers an approach to diagnosis that is consistent with current data and recommendations. When IC-DVT is diagnosed, current references suggest that a decision between anticoagulation and continued follow-up outpatient testing can be based on shared decision-making. The risks of proximal progression and life-threatening embolization should be balanced against the generally more benign natural history of such thrombi, and an individual patient’s risk factors for both thrombus propagation and complications of anticoagulation.

7. Quick Lit Reviews from Ann Emerg Med

A. What Is the Most Effective Treatment of Herpes Simplex Keratitis?

Take-Home Message
Treatment of herpes simplex virus keratitis can be accomplished with either topical trifluridine or ganciclovir, which have similar efficacy. Oral acyclovir is an acceptable treatment option in cases for which compliance with a topical ophthalmic regimen may be of concern.

B. Is Passive Leg Raise an Accurate Diagnostic Method for Assessing Fluid Responsiveness in Adults?

Take-Home Message
Transthoracic echocardiography and passive leg-raise maneuvers can be used to assess preload responsiveness in the critically ill.

C. Utility of Central Venous Pressure as a Predictor of Fluid Responsiveness

Take-Home Message
Existing evidence suggests that central venous pressure poorly predicts fluid responsiveness in acute and critically ill patients.

D. What Is the Significance of Elevated Troponin in Patients With Suspected Acute Coronary Syndrome and Chronic Kidney Disease?

Take-Home Message
Patients with suspected acute coronary syndrome with elevated troponin level in the setting of chronic kidney disease have a worse prognosis than patients with normal troponin levels.

8. The Use of ED Holding (ED Transition) Orders to Reduce ED Length of Stay.

Haydar SA, et al. Acad Emerg Med. 2016 Jul;23(7):776-85.

OBJECTIVE: The objective was to evaluate the effect of an emergency clinician-initiated "ED admission holding order set" on emergency department (ED) treatment times and length of stay (LOS). We further describe the impact of a performance improvement strategy with sequential plan-do-study-act (PDSA) cycles used to influence the primary outcome measures, ED LOS, and disposition decision to patient gone (DDTPG) time, for admitted patients.

METHODS: We developed and implemented an expedited, emergency physician-facilitated admission protocol that bypassed typical inpatient workflows requiring inpatient evaluations prior to the placement of admission orders. During the 48-month study period, ED flow metrics generated during the care of 27,580 admissions from the 24-month period prior to the intervention were compared to the 29,978 admissions that occurred during the 24-month period following the intervention. The intervention was the result of an in-depth, five-phase PDSA cycle quality improvement intervention evaluating ED flow, which identified the requirement of bedside inpatient evaluations prior admission order placement as being a "non-value-added" activity. ED output flow metrics evaluating the admission process were tracked for 24 months following the intervention and were compared to the 24 months prior.

RESULTS: The use of an emergency physician-initiated admission holding order protocol resulted in sustainable reductions in ED LOS when comparing the 2 years prior to the intervention, with median LOS of 410 (interquartile range [IQR] = 295 to 543) and 395 (IQR = 283 to 527) minutes, to the 2 calendar years following the intervention, with the median LOS of 313 (IQR = 21 to 431) and 316 (IQR = 224 to 438) minutes, respectively. This overall reduction in ED LOS of nearly 90 minutes was found to be primarily the result of a decrease in the time from the emergency physician's admitting DDTPG times with median times of 219 (IQR = 150 to 306) and 200 (IQR = 136 to 286) minutes for the 2 years prior to the intervention compared to 89 (IQR = 58 to 138) and 92 (IQR = 60 to 147) minutes for the 2 years following the intervention. It is notable that there was a modest increase in the door to disposition decision of admission times during this same study period with annual medians of 176 (IQR = 112 to 261) and 178 (IQR = 129 to 316) minutes, respectively, for the 2 years prior to 207 (IQR = 129 to 316) and 202 (IQR = 127 to 305) minutes following the intervention.

CONCLUSIONS: We conclude that the use of emergency physician-initiated holding orders can lead to marked reductions in ED LOS for admitted patients. Continued improvement can be demonstrated with an effective performance improvement initiative designed to continuously optimize the process change.

9. Addressing Social Determinants of Health from the ED through Social Emergency Medicine

Anderson ES, et al. West J Emerg Med 2016;17(4):487-9.

Dialogue and policy surrounding healthcare reform have drawn increasing interest to the social factors, accountable for nearly one-third of annual deaths in the United States,1 that affect the health of populations. The Affordable Care Act (ACA) includes provisions for health systems to address social determinants of health, but how this is to be accomplished remains uncertain. If we are to make progress as a health system in addressing social determinants of health, we must open a dialogue and practice that reaches patients at the front lines of the medical system and population health – including in the emergency department (ED). The fact that emergency physicians care for patients who are complicated both medically and socially is no surprise, but the idea that we have an important role to play in the social determinants of health of our patients is, while controversial, gaining increasing attention among emergency physicians across the country. This interest comes largely from necessity, as we face a daunting task of providing care to the large volume of vulnerable patients who seek refuge in our EDs.

The ED is a window into the community, which starkly frames the contributions of the social determinants underlying the trauma resuscitations, repeat child visits for asthma exacerbation, or sepsis due to delay in seeking care. In the ED, we diagnose and treat the medical problem – but in order to improve the health of our patients we need to expand our role to diagnose and treat their social determinants of health as well. We urge our colleagues to not only consider the social determinants underlying health and illness, but to also develop systematic interventions, measure their effects, collaborate with others, and advocate for policies that will improve the health of our patients. We advocate physicians to address the social determinants of health from the ED, in other words, to practice Social Emergency Medicine…

For the remainder of the essay, full-text (free):

10. Images in Clinical Practice

Male With Pain in Right Calf

Woman With Pain in Left Shoulder

Woman With Abdominal Pain

Man With Abdominal Pain

Pregnant Woman With Vaginal Pressure

Child With Acute Neck Pain

Discussion: Neck Spasms in Children

Woman With Abdominal Pain

Elderly Woman With Dizziness

Hypopyon and Klebsiella Sepsis

Oral HPV-Associated Papillomatosis in AIDS

Image Diagnosis: Pott Puffy Tumor

Eyelid Melanoma

Tachyarrhythmia in Wolff-Parkinson-White Syndrome

A Woman with Vaginal Bleeding and an Intrauterine Device

11. Characteristics and Outcomes of Adult Outpatients with Heart Failure and Improved or Recovered Ejection Fraction

Kalogeropoulos AP, et al. JAMA Cardiol. 2016 July 06 [Epub ahead of print]

Importance  Heart failure (HF) guidelines recognize that a subset of patients with HF and preserved left ventricular ejection fraction (LVEF) previously had reduced LVEF but experienced improvement or recovery in LVEF. However, data on these patients are limited.

Objective  To investigate the characteristics and outcomes of adult outpatients with HF and improved or recovered ejection fraction (HFrecEF).

Design, Setting, and Participants  Retrospective cohort study (inception period, January 1, 2012, to April 30, 2012) with 3-year follow-up at cardiology clinics (including HF subspecialty) in an academic institution. The dates of the analysis were May 21, 2015, to August 10, 2015. Participants were all outpatients 18 years or older who received care for a verified diagnosis of HF not attributed to specific cardiomyopathies or other special causes during the inception period.

Exposures  Type of HF at baseline, classified as HF with reduced ejection fraction (HFrEF) (defined as current LVEF ≤40%), HF with preserved ejection fraction (HFpEF) (defined as current and all previous LVEF reports over 40%), and HF with recovered ejection fraction (HFrecEF) (defined as current LVEF over 40% but any previously documented LVEF ≤40%).

Main Outcomes and Measures  Mortality, hospitalization rates, and composite end points.

Results  The study cohort comprised 2166 participants. Their median age was 65 years, 41.4% (896 of 2166) were female, 48.7% (1055 of 2166) were white and 45.2% (1368 of 2166) black, and 63.2% (1368 of 2166) had coronary artery disease. Preserved (over 40%) LVEF at inception was present in 816 of 2166 (37.7%) patients. Of these patients, 350 of 2166 (16.2%) had previously reduced (≤40%) LVEF and were classified as having HFrecEF, whereas 466 of 2166 (21.5%) had no previous reduced LVEF and were classified as having HFpEF. The remaining 1350 (62.3%) patients were classified as having HFrEF. After 3 years, age and sex–adjusted mortality was 16.3% in patients with HFrEF, 13.2% in patients with HFpEF, and 4.8% in patients with HFrecEF (P  less than .001 vs HFrEF or HFpEF). Compared with patients with HFpEF and patients with HFrEF, patients with HFrecEF had fewer all-cause (adjusted rate ratio [RR] vs HFpEF, 0.71; 95% CI, 0.55-0.91; P = .007), cardiovascular (RR, 0.50; 95% CI, 0.35-0.71; P less than  .001), and HF-related (RR, 0.48; 95% CI, 0.30-0.76; P = .002) hospitalizations and were less likely to experience composite end points commonly used in clinical trials (death or cardiovascular hospitalization and death or HF hospitalization).

Conclusions and Relevance  Outpatients with HFrecEF have a different clinical course than patients with HFpEF and HFrEF, with lower mortality, less frequent hospitalizations, and fewer composite end points. These patients may need to be investigated separately in outcomes studies and clinical trials.

12. You Are Not Alone: Ten Strategies for Surviving a Malpractice Lawsuit

Sheridan A. Perm J 2016;20(3):16-004.

I wasn’t even scheduled to work that morning; I had just gone into the office for a meeting. Chatting with coworkers on my way out the door, I was told there was someone asking for me at the reception desk. So it was there, in front of a waiting room full of patients, that I received the papers notifying me of the lawsuit. “Have a nice day,” the woman called out to me as she left.

Over the next months, as the legalities played out, I struggled to keep moving. My confidence evaporated. I’d been taught that physicians who build good relationships are less likely to be sued, so I had obviously failed. I didn’t know how I could face my patients—I felt like a fraud. I couldn’t sleep. I lost my appetite. Sometimes my experience felt surreal, especially when my attorney told me: “This case will not affect your life in any way.”

I wondered if I would lose my job, my license, my home. Even worse, I wondered if I had lost the trust of my colleagues.

I met a coworker who had survived a lawsuit; she had been as stressed as I was, and knowing that my reaction was not abnormal reassured me. I began to practice strategies to help myself cope, and life slowly improved.

As much as we hate to think about it, most physicians, about 60%, will be sued at some point in their career.1 Not everyone will be as unnerved as I was, but physicians typically do feel intense strain when faced with a lawsuit. Our trust in ourselves and in our patients is shaken. We practice more defensively. We are more likely to suffer depression and burnout. We may feel anxious, depressed, angry, and afraid. Here I offer ten techniques for coping that really work…

1. Resist Isolation

Asking for help can be tough for physicians; we’re used to being the ones people come to for help, not the ones who need help. You will be advised not to talk with anyone about the case, but you’ve got to know that you’re not alone. Conversations with certain people are protected from discovery. Ask your attorney for advice here, but typically it is acceptable to talk to family members, counselors, and your personal physician. And you can generally feel safe discussing your emotions while avoiding the medical details of the case.

Some liability insurance providers cover psychological counseling costs, so make sure to ask about this option. If you think you might benefit from talking to someone who has had a similar experience, check to see if your organization or insurance provider offers a peer support team.

It’s common for physicians undergoing litigation to contemplate suicide.2 If you’re having thoughts of suicide, pick up the phone and call someone immediately: 911, your physician, a counselor, your spiritual advisor, or a friend or family member. Don’t do anything until you’ve spoken with someone. Keep a list in your phone of people you can call for support.

If you are so depressed or anxious that you can’t stop the negative thoughts, if you’re not eating or not sleeping, or if you feel overwhelmed, medication may be helpful. Do not prescribe for yourself; talk to a physician you can trust. It could save your life.

2. Use Your Strengths

We all developed skills for managing stress as we made our way through college, medical school, and residency. Remind yourself that you have these tools, and turn to them now. Focus, persistence, preparation, not taking things personally—we know how to do these things.

3. Retrain Your Brain

We all have habitual thought patterns, places our minds go when under stress. But you can create new patterns for yourself. Use your rational mind to respond to the sometimes overwhelming fears that come up; this is a technique that clinicians tend to practice a lot. When the ugly thoughts begin to spiral, and you start thinking that you’re obviously a fraud, and no one should trust you to care for them, stop and remind yourself of the patients you’ve helped, the procedures that went well, and the successes you’ve had. These new neural pathways will become more ingrained as you continue to practice them.

Research by Martin Seligman, MD, shows that a simple gratitude exercise increases happiness and resilience (read his book Flourish3 or go to Take a few moments each evening to consider what went well and write it down. At first all you may be able to come up with is that you have clean sheets, or that you had a really great piece of chocolate for dessert. But as you begin to look for the good, you see it more, even when life seems bleak. I look forward to this “what went well” exercise at the end of my day.

4. Take Care of Yourself

It’s important to make room in your hectic schedule for some downtime. Staying busy can make you feel more in control. It can distract you and keep you from fixating on the case. But you need all your strength right now, so you’ve got to preserve that. Sleep is crucial, to give your brain time to recover from the stress of each day. Exercise helps release stress. Eating well fuels your body and brain (but give yourself enough slack to turn to comfort food when you most need it—I might not have survived without mint Newman-O’s). Take some relaxation time, whether it’s for a massage, bedtime reading to your kids, a hot bath, yoga, or meditation (research has shown the effectiveness of Jon Kabat-Zinn, MD’s mindfulness-based stress-reduction program, for example). Just be careful about using alcohol or drugs to check out—they can quickly cause more problems than they solve when used to self-medicate.

5. Give Yourself a Break

Physicians tend to be perfectionists, and being sued seems only to reinforce the expectation to be perfect. Much of the time we are our own worst critics, and we say things to ourselves that we’d never say to a colleague. Show yourself the same compassion you’d show your child, patient, or best friend. Read Kristin Neff, MD’s work for more information on self-compassion (

13. Can transcutaneous carbon dioxide pressure be a surrogate of blood gas samples for spontaneously breathing emergency patients?


Peschanski N, et al. Emerg Med J  2016;33:325-328

Background It is known that the arterial carbon dioxide pressure (PaCO2) is useful for emergency physicians to assess the severity of dyspnoeic spontaneously breathing patients. Transcutaneous carbon dioxide pressure (PtcCO2) measurements could be a non-invasive alternative to PaCO2 measurements obtained by blood gas samples, as suggested in previous studies. This study evaluates the reliability of a new device in the emergency department (ED).

Methods We prospectively included patients presenting to the ED with respiratory distress who were breathing spontaneously or under non-invasive ventilation. We simultaneously performed arterial blood gas measurements and measurement of PtcCO2 using a sensor placed either on the forearm or the side of the chest and connected to the TCM4 CombiM device. The agreement between PaCO2 and PtcCO2 was assessed using the Bland–Altman method.

Results Sixty-seven spontaneously breathing patients were prospectively included (mean age 70 years, 52% men) and 64 first measurements of PtcCO2 (out of 67) were analysed out of the 97 performed. Nineteen patients (28%) had pneumonia, 19 (28%) had acute heart failure and 19 (28%) had an exacerbation of chronic obstructive pulmonary disease. Mean PaCO2 was 49 mm Hg (range 22–103). The mean difference between PaCO2 and PtcCO2 was 9 mm Hg (range −47 to +54) with 95% limits of agreement of −21.8 mm Hg and 39.7 mm Hg. Only 36.3% of the measurement differences were within 5 mm Hg.

Conclusions Our results show that PtcCO2 measured by the TCM4 device could not replace PaCO2 obtained by arterial blood gas analysis.

14. Body Mass Index is a Poor Predictor of Bedside Appendix Ultrasound Success or Accuracy

Lam HSF, et al. West J Emerg Med. 2016;17(4):454

Objectives: To determine whether there is a relationship between body mass index (BMI) and success or accuracy rate of BUS for the diagnosis of appendicitis.

Methods: Patients 4 years of age and older presenting to the emergency department with suspected appendicitis were eligible. Enrollment was by convenience sampling. After informed consent, BUS was performed by trained emergency physicians who had undergone a minimum of 1-hour didactic training on the use of BUS to diagnose appendicitis. Subject outcomes were ascertained by a combination of medical record review and telephone follow-up.  Calculated BMI for adults and children were divided into 4 categories (underweight, normal, overweight, obese) according to Centers for Disease Control and Prevention classifications.

Results: A total of 125 subjects consented for the study, and 116 of them had adequate image data for final analysis.  Seventy (60%) of the subjects were children.  Prevalence of appendicitis was 39%.  Fifty-two (45%) of the BUS studies were diagnostic (successful). Overall accuracy rate was 75%.  Analysis by Chi-square test or Mann Whitney U did not find any significant correlation between BMI category and BUS success. Similarly, there was no significant correlation between BMI category and BUS accuracy.  Same conclusion was reached when children and adults were analyzed separately, or when subjects were dichotomized into underweight/ normal and overweight/ obese categories. 

Conclusion: BMI category alone is a poor predictor of appendix BUS success or accuracy.

15. Diagnosis and Treatment of Methanol Intoxication

Methanol intoxication is an uncommon but serious poisoning that can cause severe cellular dysfunction and death, and delayed treatment can increase mortality to as high as 44%. Definitive diagnosis requires measurement with gas or liquid chromatography, which are difficult and costly tests, and clinical abnormalities can take 96 hours to appear, further complicating diagnosis. In this month's AJKD, Kraut presents a case involving a 22-year-old woman with acute methanol intoxication to investigate the value and limitations of new diagnostic approaches and treatments.

16. Is there a role for humidified heated high-flow nasal cannula therapy in paediatric emergency departments?

Long E, et al. Emerg Med J.  2016;33:386-389  

Background Humidified heated high-flow nasal cannula (HFNC) therapy is a potentially useful form of non-invasive respiratory support for children with moderate respiratory distress and/or hypoxaemia. No prospective data support its use in the paediatric emergency department (ED). We introduced HFNC therapy into a paediatric ED and evaluated its use and failure rates.

Methods Prospective observational study of all patients presenting to the Royal Children's Hospital, Australia, who received HFNC therapy between April 2013 and September 2013 (one southern hemisphere winter season). We assessed demographics, indications, failure rate, predictors of failure and adverse events.

Results 71 patients commenced HFNC therapy in ED over the study period. The median age was 9 months. The most common indication was bronchiolitis (49/71; 69%). Five (7%) of the patients failed HFNC and were escalated to other forms of respiratory support in ED, four to nasal continuous positive airway pressure and one required intubation. A further 21 (32%) failed HFNC therapy after intensive care unit (ICU) admission, giving a total failure of 28 (39%). There were no serious adverse events in ED, and one child with asthma developed air leak syndrome after transfer to the ICU.

Conclusions HFNC therapy may have a role in the paediatric ED as an easily administered and well tolerated form of non-invasive respiratory support, but about one-third of patients required escalation to a higher level of respiratory support. Further studies should assess the safety profile of HFNC in larger series, and define the role of HFNC in key respiratory conditions compared with other possible interventions.

17. Spontaneous SAH: A Systematic Review and Meta-Analysis Describing the Diagnostic Accuracy of History, Physical Exam, Imaging, and LP with an Exploration of Test Thresholds.

Carpenter CR, et al. Acad Emerg Med. 2016 Jun 16 [Epub ahead of print]

BACKGROUND: Spontaneous subarachnoid hemorrhage (SAH) is a rare, but serious etiology of headache. The diagnosis of SAH is especially challenging in alert, neurologically intact patients, as missed or delayed diagnosis can be catastrophic.

The objective was to perform a diagnostic accuracy systematic review and meta-analysis of history, physical examination, cerebrospinal fluid (CSF) tests, computed tomography (CT), and clinical decision rules for spontaneous SAH. A secondary objective was to delineate probability of disease thresholds for imaging and lumbar puncture (LP).

METHODS: PubMed, Embase, Scopus, and research meeting abstracts were searched up to June 2015 for studies of emergency department patients with acute headache clinically concerning for spontaneous SAH. QUADAS-2 was used to assess study quality and, when appropriate, meta-analysis was conducted using random effects models. Outcomes were sensitivity, specificity, and positive (LR+) and negative (LR-) likelihood ratios. To identify test and treatment thresholds, we employed the Pauker-Kassirer method with Bernstein test indication curves using the summary estimates of diagnostic accuracy.

RESULTS: A total of 5,022 publications were identified, of which 122 underwent full-text review; 22 studies were included (average SAH prevalence = 7.5%). Diagnostic studies differed in assessment of history and physical examination findings, CT technology, analytical techniques used to identify xanthochromia, and criterion standards for SAH. Study quality by QUADAS-2 was variable; however, most had a relatively low risk of biases. A history of neck pain (LR+ = 4.1; 95% confidence interval [CI] = 2.2 to 7.6) and neck stiffness on physical examination (LR+ = 6.6; 95% CI = 4.0 to 11.0) were the individual findings most strongly associated with SAH. Combinations of findings may rule out SAH, yet promising clinical decision rules await external validation. Noncontrast cranial CT within 6 hours of headache onset accurately ruled in (LR+ = 230; 95% CI = 6 to 8,700) and ruled out SAH (LR- = 0.01; 95% CI = 0 to 0.04); CT beyond 6 hours had a LR- of 0.07 (95% CI = 0.01 to 0.61). CSF analyses had lower diagnostic accuracy, whether using red blood cell (RBC) count or xanthochromia. At a threshold RBC count of 1,000 × 106 /L, the LR+ was 5.7 (95% CI = 1.4 to 23) and LR- was 0.21 (95% CI = 0.03 to 1.7). Using the pooled estimates of diagnostic accuracy and testing risks and benefits, we estimate that LP only benefits CT-negative patients when the pre-LP probability of SAH is on the order of 5%, which corresponds to a pre-CT probability greater than 20%.

CONCLUSIONS: Less than one in 10 headache patients concerning for SAH are ultimately diagnosed with SAH in recent studies. While certain symptoms and signs increase or decrease the likelihood of SAH, no single characteristic is sufficient to rule in or rule out SAH. Within 6 hours of symptom onset, noncontrast cranial CT is highly accurate, while a negative CT beyond 6 hours substantially reduces the likelihood of SAH. LP appears to benefit relatively few patients within a narrow pretest probability range. With improvements in CT technology and an expanding body of evidence, test thresholds for LP may become more precise, obviating the need for a post-CT LP in more acute headache patients. Existing SAH clinical decision rules await external validation, but offer the potential to identify subsets most likely to benefit from post-CT LP, angiography, or no further testing.

18. Characteristics and Outcomes of Patients Presenting With Hypertensive Urgency in the Office Setting.

Patel KK, et al. JAMA Intern Med. 2016 Jun 13. doi: 10.1001/jamainternmed.2016.1509. [Epub ahead of print]

Importance: The prevalence and short-term outcomes of hypertensive urgency (systolic blood pressure ≥180 mm Hg and/or diastolic blood pressure ≥110 mm Hg) are unknown. Guidelines recommend achieving blood pressure control within 24 to 48 hours. However, some patients are referred to the emergency department (ED) or directly admitted to the hospital, and whether hospital management is associated with better outcomes is unknown.

Objectives: To describe the prevalence of hypertensive urgency and the characteristics and short-term outcomes of these patients, and to determine whether referral to the hospital is associated with better outcomes than outpatient management.

Design, Setting, and Participants: This retrospective cohort study with propensity matching included all patients presenting with hypertensive urgency to an office in the Cleveland Clinic Healthcare system from January 1, 2008, to December 31, 2013. Pregnant women and patients referred to the hospital for symptoms or treatment of other conditions were excluded. Final follow-up was completed on June 30, 2014, and data were assessed from October 31, 2014, to May 31, 2015.

Exposures: Hospital vs ambulatory blood pressure management.

Main Outcomes and Measures: Major adverse cardiovascular events (MACE) consisting of acute coronary syndrome and stroke or transient ischemic attack, uncontrolled hypertension (≥140/90 mm Hg), and hospital admissions.

Results: Of 2 199 019 unique patient office visits, 59 836 (4.6%) met the definition of hypertensive urgency. After excluding 851 patients, 58 535 were included. Mean (SD) age was 63.1 (15.4) years; 57.7% were women; and 76.0% were white. Mean (SD) body mass index (calculated as weight in kilograms divided by height in meters squared) was 31.1 (7.6); mean (SD) systolic blood pressure, 182.5 (16.6) mm Hg; and mean (SD) diastolic blood pressure, 96.4 (15.8) mm Hg. In the propensity-matched analysis, the 852 patients sent home were compared with the 426 patients referred to the hospital, with no significant difference in MACE at 7 days (0 vs 2 [0.5%]; P = .11), 8 to 30 days (0 vs 2 [0.5%]; P = .11), or 6 months (8 [0.9%] vs 4 [0.9%]; P greater than .99). Patients sent home were more likely to have uncontrolled hypertension at 1 month (735 of 852 [86.3%] vs 349 of 426 [81.9%]; P = .04) but not at 6 months (393 of 608 [64.6%] vs 213 of 320 [66.6%]; P = .56). Patients sent home had lower hospital admission rates at 7 days (40 [4.7%] vs 35 [8.2%]; P = .01) and at 8 to 30 days (59 [6.9%] vs 48 [11.3%]; P = .009).

Conclusions and Relevance: Hypertensive urgency is common, but the rate of MACE in asymptomatic patients is very low. Visits to the ED were associated with more hospitalizations, but not improved outcomes. Most patients still had uncontrolled hypertension 6 months later.

19. The impact of senior doctor assessment at triage on ED performance measures: systematic review and meta-analysis of comparative studies

Abdulwahid MA, et al. Emerg Med J  2016;33:504-513

STUDY QUESTION: To determine if placing a senior doctor at triage versus standard single nurse in a hospital emergency department (ED) improves ED performance by reviewing evidence from comparative design studies using several quality indicators.

DESIGN: Systematic review.

DATA SOURCES: Cochrane Library, MEDLINE, EMBASE, CINAHL, Cochrane Effective Practice and Organisation of Care (EPOC), Web of Science, Clinical Trials Registry website. In addition, references from included studies and citation searches were used to identify relevant studies.

REVIEW METHODS: Databases were searched for comparative studies examining the role of senior doctor triage (SDT), published from 1994 to 2014. Senior doctor was defined as a qualified medical doctor who completed high specialty training in emergency medicine. Articles with a primary aim to investigate the effect of SDT on ED quality indicators such as waiting time (WT), length of stay (LOS), left without being seen (LWBS) and left without treatment complete (LWTC) were included. Articles examining the adverse events and cost associated with SDT were also included. Only studies with a control group, either in a randomised controlled trial (RCT) or in an observational study with historical controls, were included. The systematic literature search was followed by assessment of relevance and risk of bias in each individual study fulfilling the inclusion criteria using the Effective Public Health Practice Project (EPHPP) bias tool. Data extraction was based on a form designed and piloted by the authors for dichotomous and continuous data.

DATA SYNTHESIS: Narrative synthesis and meta-analysis of homogenous data were performed.

RESULTS: Of 4506 articles identified, 25 relevant studies were retrieved; 12 were of the weak pre-post study design, 9 were of moderate quality and 4 were of strong quality. The majority of the studies revealed improvements in ED performance measures favouring SDT. Pooled results from two Canadian RCTs showed a significant reduction in LOS of medium acuity patients (weighted means difference (WMD) -26.26 min, 95% CI -38.50 to -14.01). Another two RCTs revealed a significant reduction in WT (WMD -26.17 min, 95% CI -31.68 to -20.65). LWBS was reduced in two Canadian RCTs (risk ratio (RR)=0.79, 95% CI 0.66 to 0.94). This was echoed by the majority of pre-post study designs. SDT did not change the occurrence of adverse events. No clear benefit of SDT in terms of patient satisfaction or cost effectiveness could be identified.

CONCLUSIONS: This review demonstrates that SDT can be an effective measure to enhance ED performance, although cost versus benefit analysis is needed. The potential high risk of bias in the evidence identified, however, mandates more robust multicentred studies to confirm these findings. 

20. Tobacco Smoking as a Risk Factor for Increased Antibiotic Prescription.

Steinberg MB, et al. Am J Prev Med. 2016 Jun;50(6):692-8.

INTRODUCTION: Antibiotic resistance is rapidly spreading, affecting millions of people and costing billions of dollars. Potential factors affecting antibiotic prescription, such as tobacco use, could dramatically influence this public health crisis. The study determined the magnitude of impact that tobacco use has on antibiotic prescribing patterns.

METHODS: Pooled data were analyzed in 2015 from the 2006-2010 National Ambulatory Medical Care Survey, a cross-sectional survey describing use of ambulatory medical services in the U.S. via healthcare provider-patient encounters. Patients aged over 18 years with documented tobacco use status diagnosed with an infection were included (i.e., all encounters in the analysis included an infectious diagnosis of interest). The analytic sample included 8,307 visits, representing 294 million visits nationally.

RESULTS: Half (49.9%) of encounters that included any infection had an antibiotic prescribed. Adjusted odds of receiving antibiotics among current tobacco users was 1.20 (95% CI=1.02, 1.42), and even higher for encounters of respiratory infections (AOR=1.31, 95% CI=1.05, 1.62). Antibiotic prescription rates were lower among patients aged over 65 years, those with comorbid asthma or cancer, non-whites, and those covered by Medicaid and higher for primary care physicians.

CONCLUSIONS: Despite lack of evidence-based rationale, among a national sample of patients with an infectious diagnosis, tobacco users had 20%-30% higher odds of receiving antibiotics than non-tobacco users. This is the first U.S. study to quantify the magnitude of this unsubstantiated practice. Prescribers should understand that tobacco use could be associated with higher antibiotic prescription, which may subsequently increase antimicrobial resistance in the community.

21. Can paediatric early warning scores (PEWS) be used to guide the need for hospital admission and predict significant illness in children presenting to the ED? An assessment of PEWS diagnostic accuracy using sensitivity and specificity

Lillitos PJ, et al. Emerg Med J  2016;33:329-337

Objectives Designed to detect early deterioration of the hospitalised child, paediatric early warning scores (PEWS) validity in the emergency department (ED) is less validated. We aimed to evaluate sensitivity and specificity of two commonly used PEWS (Brighton and COAST) in predicting hospital admission and, for the first time, significant illness.

Methods Retrospective analysis of PEWS data for paediatric ED attendances at St Mary's Hospital, London, UK, in November 2012. Patients with missing data were excluded. Diagnoses were grouped: medical and surgical. To classify diagnoses as significant, established guidelines were used and, where not available, common agreement between three acute paediatricians.

Results 1921 patients were analysed. There were 211 admissions (11%). 1630 attendances were medical (86%) and 273 (14%) surgical. Brighton and COAST PEWS performed similarly. hospital admission: PEWS of ≥3 was specific (93%) but poorly sensitive (32%). The area under the receiver operating curve (AUC) was low at 0.690. Significant illness: for medical illness, PEWS ≥3 was highly specific (96%) but poorly sensitive (44%). The AUC was 0.754 and 0.755 for Brighton and COAST PEWS, respectively. Both scores performed poorly for predicting significant surgical illness (AUC 0.642). PEWS ≥3 performed well in predicting significant respiratory illness: sensitivity 75%, specificity 91%.

Conclusions Both Brighton and COAST PEWS scores performed similarly. A score of ≥3 has good specificity but poor sensitivity for predicting hospital admission and significant illness. Therefore, a high PEWS should be taken seriously but a low score is poor at ruling out the requirement for admission or serious underlying illness. PEWS was better at detecting significant medical illness compared with detecting the need for admission. PEWS performed poorly in detecting significant surgical illness. PEWS may be particularly useful in evaluating respiratory illness in a paediatric ED.

22. Text messages on healthy habits could reduce risk of repeat heart attacks

Australian researchers have found that patients recovering from a heart attack who received four text messages per week asking about their health and giving health suggestions were more likely to have slower heart rates, lower cholesterol levels and less body fat and maintain lower blood pressure than the control group. The findings, based on 700 coronary heart disease patients, also showed that those who received text messages had smaller waist sizes and were more likely to be active and quit smoking than the control group.

23. Micro Bits

A. The CMS Sepsis Mandate: Right Disease, Wrong Measure

Michael Klompas, MD, MPH; and Chanu Rhee, MD, MPH

In 2015, the Centers for Medicare & Medicaid Services began requiring hospitals to report their adherence to treatment bundles for patients with sepsis. The reporting rules are rigid and onerous and may not always reflect best clinical care for all patients. The authors of this article describe what they think might be done about the situation…

B. Psychological factors contribute to delayed symptom resolution after concussion

Although postconcussive symptoms for most children resolve in one to two weeks, 15% to 30% of children with a concussion experience symptoms that last at least three months. Psychological components such as pre-existing anxiety and depression influence symptomatology after concussion. In this study, noninjury factors, especially somatization and anxiety, contributed significantly to delayed symptom resolution. Primary care providers should consider referring patients with persistent symptoms to providers with expertise in pediatric behavioral health.

C. Researchers find Tdap vaccine is safe in pregnant women

A study in Human Vaccines & Immunotherapeutics found that Tdap vaccine is safe for pregnant women and can help protect their newborns from whooping cough in the short term. The findings, based on data involving nearly 1,800 births to women who received and did not receive the shot, showed the only difference in health outcomes was in cesarean-section rates, which researchers said was not likely tied to the vaccine.

D. How to Nap

Malia Wollan. New York Times. June 19, 2016

“Duration is very important,” says Damien Léger, a doctor who runs the sleep-research center at the Hôtel-Dieu hospital in Paris. Aim to sleep for 20 minutes. Anything longer, and you risk drifting into what scientists call slow-wave sleep, a state of languid brain-wave activity considered important for consolidating memories. Set an alarm clock. A slow-wave encounter is likely to leave you with what Léger calls “sleep drunkenness” instead of a feeling of rejuvenation…

E. Serum S100B as a Surrogate Biomarker in the Diagnoses of Burnout and Depression in Emergency Medicine Residents

Conclusion: S100B levels correlate with depression scores and emotional exhaustion in burnout syndrome. The findings suggest that S100B can be used as a marker to screen emergency medicine residents and detect individuals with high risk for depression and burnout syndrome.

F. Diastolic Hypotension, Troponin Elevation, and Electrocardiographic Changes Associated With the Management of Moderate to Severe Asthma in Children

Conclusion: In a subset of children with moderate to severe asthma, diastolic hypotension, troponin elevation, and ECG ST-segment change occur during administration of continuous albuterol. Future studies are necessary to determine the clinical significance of these findings.

G. Ticagrelor no better than Aspirin in Acute Stroke or Transient Ischemic Attack

H. Attitudes and Practices of Euthanasia and Physician-Assisted Suicide in the United States, Canada, and Europe

Conclusions and Relevance:  Euthanasia and physician-assisted suicide are increasingly being legalized, remain relatively rare, and primarily involve patients with cancer. Existing data do not indicate widespread abuse of these practices.

I. Intensive Beats Standard Blood Pressure Control and Cardiovascular Disease Outcomes in Adults Aged ≥75 Years

Conclusion: Among ambulatory adults aged 75 years or older, treating to an SBP target of less than 120 mm Hg compared with an SBP target of less than 140 mm Hg resulted in significantly lower rates of fatal and nonfatal major cardiovascular events and death from any cause.

JAMA article:

JAMA editorial excerpt: “Because of the trial exclusion criteria, the current results may not be applicable to individuals with diabetes, heart failure, prior stroke, or postural decreases in BP. Also, despite the impressive benefits observed in the intensive group that had an SBP target of less than 120 mm Hg, the mean SBP actually achieved in this group was 123 mm Hg, indicating that not all patients in the study attained the preset SBP goal of less than 120 mm Hg. Furthermore, only ambulatory, community-based persons were recruited into the study, so the results may not be relevant to frail individuals and others restricted to their homes or to institutions…

“What should clinicians now recommend for the management of hypertension in most patients 75 years or older? Although the story is incomplete, the available evidence supports a stepwise approach to treatment beginning with an initial SBP goal of less than 140 mm Hg. If lowering SBP to that level is tolerated well, further titration with careful monitoring should be considered to achieve an SBP goal of less than 130 mm Hg. The choice of antihypertensive medications can vary depending on clinician and patient preference, considering that several studies have shown that the major benefit of treatment depends on BP lowering rather than type of antihypertensive medication used.11 In general, however, the preferred first-line drugs should be diuretics, calcium antagonists, angiotensin receptor antagonists, and angiotensin-converting enzyme inhibitors. β Receptor antagonists are also valuable as first-line agents in patients with coronary heart disease, arrhythmias, and heart failure. Combination drug preparations are useful because therapy often will involve multiple drugs. Since older persons with SBP less than 110 mm Hg while standing were excluded in SPRINT, the risk of syncope and falls may have been underestimated, and particular attention should be given to avoidance of orthostatic hypotension with treatment…”

J. Brain Training Does Not Improve Academic Outcomes in Kids

Conclusion: On balance, we cannot recommend this intervention as a population-level selective prevention strategy.

K. Effect of Pictorial Cigarette Pack Warnings on Changes in Smoking Behavior: A Randomized Clinical Trial

Conclusion: Pictorial warnings effectively increased intentions to quit, forgoing cigarettes, quit attempts, and successfully quitting smoking over 4 weeks. Our trial findings suggest that implementing pictorial warnings on cigarette packs in the United States would discourage smoking.

L. Aspirin Use for the Primary Prevention of Cardiovascular Disease and Colorectal Cancer: U.S. Preventive Services Task Force Recommendation Statement

Recommendations: The USPSTF recommends initiating low-dose aspirin use for the primary prevention of CVD and CRC in adults aged 50 to 59 years who have a 10% or greater 10-year CVD risk, are not at increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years. (B recommendation)The decision to initiate low-dose aspirin use for the primary prevention of CVD and CRC in adults aged 60 to 69 years who have a 10% or greater 10-year CVD risk should be an individual one. Persons who are not at increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years are more likely to benefit. Persons who place a higher value on the potential benefits than the potential harms may choose to initiate low-dose aspirin. (C recommendation)The current evidence is insufficient to assess the balance of benefits and harms of initiating aspirin use for the primary prevention of CVD and CRC in adults younger than 50 years. (I statement)The current evidence is insufficient to assess the balance of benefits and harms of initiating aspirin use for the primary prevention of CVD and CRC in adults aged 70 years or older. (I statement)

Baseline CVD Risk

The magnitude of the cardiovascular risk reduction with aspirin use depends on an individual's initial risk for CVD events. Risk assessment for CVD should include ascertainment of the following risk factors: age, sex, race/ethnicity, total cholesterol level, high-density lipoprotein cholesterol level, systolic blood pressure, hypertension treatment, diabetes, and smoking. An online version of the ACC/AHA risk calculator can be found at

M. Contrast CT Scans in the ED Do Not Increase Risk of Adverse Renal Outcomes.


Heller M, et al. West J Emerg Med. 2016;17(4):404

N. Giving Your Cell Phone Number to Patients

Verner CF. West J Emerg Med. 2016;17(4):477.