1. Opioids and the Emergency Physician: Ducking Between Pendulum
Swings
Yealy DM, et
al. Ann Emerg Med. 2016;68:209-212.
In the late
1980s, undertreated pain became a focus of many clinicians, investigators, and
industry. We coined a term, oligoanalgesia, to embolden earlier, titrated
opioids and other analgesic use. Regulators mandated pain assessments and
actions as a part of health care facility credentialing, and the prescribing of
opioids increased yearly from 1990 to 2010.
We now sit
amid another opioid epidemic with death and disability. Many know of the
patterns of use and abuse near the turn of the 20th century when opium was a
new agent; this triggered opioid regulations and control, notably, the US
Harrison Narcotics Tax Act of 1914 criminalizing nonmedical use. Despite
regulation of opioids, swings upward in medical and nonmedical use exist in
recent modern times. For example, a 1959 Readers Digest article noted a current opioid addiction
crisis, reminding us that the cycles reappear often, with varying frequency,
responses, and consequences.
The current
opioid upswing is rooted in prescribed and illicit use, the latter including
heroin (or other “street” opioids) and diversion of another’s or factitious
gain of a prescribed opioid. The widespread increase in opioid use correlates
with increased overdose deaths and deaths in all segments, including more
affluent and suburban or rural groups, not just in an inner-city or isolated
population. Although the peak of the current wave crested in approximately
2010, we retain a large group with this affliction. This triggered calls for regulation
and control in many facets of opioid deployment, including emergency care,
despite few data suggesting a clear link between emergency department (ED)
opioid use and later harm. Some seek governmental ED dose restrictions, and
others call for “an opioid-free ED.” The goal of these calls to action is good:
to avoid opioid harm, notably, death. At the same time, we seek to provide
relief of pain and wonder how our acute care episode affects the broader
epidemic.
With all the
dialogue, emergency physicians seek the answer to the question, “What am I
supposed to do: skip the pain relief that an opioid delivers or risk addiction
and overdose in some fraction of patients?”…
…More
important in assessing the risk is knowing how often ED opioid analgesia turns
patients into addicts. The data from Butler et al may help us estimate this
risk. Our crude estimate indicates that 1 new heroin abuser might result from
the administration of opioids to approximately 7,864 ED patients. An emergency
physician administering opioids in the usual fashion could “prime” a new heroin
addict once every 3 to 4 years of full-time practice. The number of total new
heroin abusers attributable to first ED exposures appears to approximate 3,179
annually, a 1.1% contribution to the total US heroin addiction burden. Although
the precise numbers we calculated could be inaccurate, we doubt these are
differences of orders of magnitude, retaining the basic relationship. On top of
this calculation, we posit that a much smaller unknown fraction will experience
overdose or death, the group driving calls for action...
Chen et al report
an opioid prescription analysis that includes 68% of the roughly 50 million US
residents with Medicare insurance, finding that emergency physicians were ninth
of the 25 specialties represented when the total number of opioid schedule II
prescriptions were ranked. Indeed, physicians in the 8 higher-ranking
specialties—most primary care or pain management—collectively wrote more than
25 times as many opioid prescriptions as emergency physicians did. In terms of
opioid prescriptions per individual physician, emergency physicians ranked very
low—18th of the 25 specialties. Although Medicare data sets do not include all
US residents, it is unlikely that another analysis could assign a more
prominent role in the opioid crisis to emergency physicians, tempering the need
for aggressive ED reduction efforts. When the number and type of ED discharge
opioid doses were examined, recent observations showed that prudence is common,
with a regimen of usually 20 doses or fewer of a moderate-potency, short-acting
agent. Not surprising is that efforts that have succeeded in cutting overdoses
and deaths targeted the high-frequency prescribers and dispensers rather than
ED prescribing.
Despite these
observations, some EDs are implementing policies to decrease all opioid
prescribing. One such approach withholds opioids for patients with migraine or
preexisting back pain, those unable to obtain timely refills from their primary
care provider, and those with any
previous opioid therapy from another physician. Many ED patients,
particularly the poor, lack short-notice access to their primary care
physicians. Are the sharp reductions in opioid use observed improving overall
ED patient health or are they mostly symbolic? How many patients should have
less relief to avoid the very small chance of downstream potential opioid
abuse? We can only estimate, but the numbers are high, depending on the
reduction in opioid prescribing sought.
The data from
Butler et al make it clear that we don’t
need to take a blanket approach to refusing opioids because patients who linked
an ED opioid exposure to heroin use are often men, young (average age of 18
years at first exposure), and with previous drug abuse, known commonalities for
heroin abuse. The real value in meaningful ED opioid-prescribing reduction
efforts is in focusing, especially on the addiction prone and those with opioid
abuse or a diversion history. Said more clearly, we doubt providing
short-course hydrocodone for Grandma’s flare of diverticulitis will drive her
into the streets for heroin; writing an opioid prescription for those who
“lost” their opioid is much more likely to trigger or enhance abuse and harm.
The zeal to
avoid oligoanalgesia encouraged opioid prescribing for some patients when
alternatives were a better choice; we wonder whether the backlash calling for
“opioid-free EDs” or marked restrictions such as “only give 2 to 3 days” may
create a different version of suboptimal care. We are uncertain what exactly “2
to 3 days” of analgesia entails, given the variability of need; can we
accurately estimate how many doses are needed to ease pain with an acute
fracture (opioids have a wide titration response range) and
then ensure follow-up by the fourth day after the ED visit?
We think a
better ED approach to limiting opioid addiction entails avoiding frequent ED
opioid refills, placing prescription monitoring data at emergency providers’
fingertips during care, recognizing abuse patterns during an ED visit, and
addressing and regularly considering alternative analgesic options—but not
broad opioid restrictions. Let’s avoid a pendulum swing toward castigation or
shackling of emergency providers seeking to responsibly relieve acute pain. ED
opioids are a minor contributor to the current scourge of opioid addiction,
with a likely far greater influence on this epidemic coming through the
targeting of high-volume prescribers and illicit heroin sources.
Full-text
(subscription needed): http://www.annemergmed.com/article/S0196-0644(16)00036-6/fulltext
The Butler
study: http://www.annemergmed.com/article/S0196-0644(15)01567-X/abstract
2. Improving the Diagnosis and Treatment of UTI in Young
Children in Primary Care: Results from the DUTY Prospective Diagnostic Cohort
Study
Hay AD, et
al. Ann Fam Med 2016;14:325-336
PURPOSE Up to
50% of urinary tract infections (UTIs) in young children are missed in primary
care. Urine culture is essential for diagnosis, but urine collection is often
difficult. Our aim was to derive and internally validate a 2-step clinical rule
using (1) symptoms and signs to select children for urine collection; and (2)
symptoms, signs, and dipstick testing to guide antibiotic treatment.
METHODS We
recruited acutely unwell children aged under 5 years from 233 primary care
sites across England and Wales. Index tests were parent-reported symptoms,
clinician-reported signs, urine dipstick results, and clinician opinion of UTI
likelihood (clinical diagnosis before dipstick and culture). The reference
standard was microbiologically confirmed UTI cultured from a clean-catch urine
sample. We calculated sensitivity, specificity, and area under the receiver
operator characteristic (AUROC) curve of coefficient-based (graded severity)
and points-based (dichotomized) symptom/sign logistic regression models, and we
then internally validated the AUROC using bootstrapping.
RESULTS Three
thousand thirty-six children provided urine samples, and culture results were
available for 2,740 (90%). Of these results, 60 (2.2%) were positive: the
clinical diagnosis was 46.6% sensitive, with an AUROC of 0.77. Previous UTI,
increasing pain/crying on passing urine, increasingly smelly urine, absence of
severe cough, increasing clinician impression of severe illness, abdominal
tenderness on examination, and normal findings on ear examination were
associated with UTI. The validated coefficient- and points-based model AUROCs
were 0.87 and 0.86, respectively, increasing to 0.90 and 0.90, respectively, by
adding dipstick nitrites, leukocytes, and blood.
CONCLUSIONS A
clinical rule based on symptoms and signs is superior to clinician diagnosis
and performs well for identifying young children for noninvasive urine
sampling. Dipstick results add further diagnostic value for empiric antibiotic
treatment.
The clinical
rule: http://www.annfammed.org/content/14/4/325/F2.expansion.html
Full-text
(free): http://www.annfammed.org/content/14/4/325.full
3. Skin Glue Reduces the Failure Rate of ED-Inserted Peripheral IV
Catheters: A RCT
Bugden S, et
al. Ann Emerg Med. 2016 Aug;68(2):196-201.
STUDY
OBJECTIVE: Peripheral intravenous catheters are the most common invasive device
in health care yet have very high failure rates. We investigate whether the
failure rate could be reduced by the addition of skin glue to standard
peripheral intravenous catheter care.
METHODS: We
conducted a single-site, 2-arm, nonblinded, randomized, controlled trial of 380
peripheral intravenous catheters inserted into 360 adult patients. The standard
care group received standard securement. The skin glue group received standard
securement plus cyanoacrylate skin glue applied to the skin insertion site. The
primary outcome was peripheral intravenous catheter failure at 48 hours,
regardless of cause. Secondary outcomes were the individual modes of peripheral
intravenous catheter failure: infection, phlebitis, occlusion, or dislodgement.
RESULTS:
Peripheral intravenous catheter failure was 10% lower (95% confidence interval
-18% to -2%; P=.02) with skin glue (17%) than standard care (27%), and
dislodgement was 7% lower (95% confidence interval -13% to 0%; P=.04).
Phlebitis and occlusion were less with skin glue but were not statistically
significant. There were no infections.
CONCLUSION:
This study supports the use of skin glue in addition to standard care to reduce
peripheral intravenous catheter failure rates for adult emergency department patients
admitted to the hospital.
4. Immediate total-body CT scanning versus conventional imaging
and selective CT scanning in patients with severe trauma (REACT-2): a RCT
Sierink JC,
et al. Lancet. 2016 Jun 28 [Epub ahead of print]
BACKGROUND:
Published work suggests a survival benefit for patients with trauma who undergo
total-body CT scanning during the initial trauma assessment; however, level 1
evidence is absent. We aimed to assess the effect of total-body CT scanning
compared with the standard work-up on in-hospital mortality in patients with
trauma.
METHODS: We
undertook an international, multicentre, randomised controlled trial at four
hospitals in the Netherlands and one in Switzerland. Patients aged 18 years or
older with trauma with compromised vital parameters, clinical suspicion of
life-threatening injuries, or severe injury were randomly assigned (1:1) by
ALEA randomisation to immediate total-body CT scanning or to a standard work-up
with conventional imaging supplemented with selective CT scanning. Neither
doctors nor patients were masked to treatment allocation. The primary endpoint
was in-hospital mortality, analysed in the intention-to-treat population and in
subgroups of patients with polytrauma and those with traumatic brain injury.
The χ2 test was used to assess differences in mortality. This trial is
registered with ClinicalTrials.gov, number NCT01523626.
FINDINGS:
Between April 22, 2011, and Jan 1, 2014, 5475 patients were assessed for
eligibility, 1403 of whom were randomly assigned: 702 to immediate total-body
CT scanning and 701 to the standard work-up. 541 patients in the immediate
total-body CT scanning group and 542 in the standard work-up group were
included in the primary analysis. In-hospital mortality did not differ between
groups (total-body CT 86 [16%] of 541 vs standard work-up 85 [16%] of 542;
p=0·92). In-hospital mortality also did not differ between groups in subgroup
analyses in patients with polytrauma (total-body CT 81 [22%] of 362 vs standard
work-up 82 [25%] of 331; p=0·46) and traumatic brain injury (68 [38%] of 178 vs
66 [44%] of 151; p=0·31). Three serious adverse events were reported in
patients in the total-body CT group (1%), one in the standard work-up group
(less than 1%), and one in a patient who was excluded after random allocation. All
five patients died.
INTERPRETATION:
Diagnosing patients with an immediate total-body CT scan does not reduce
in-hospital mortality compared with the standard radiological work-up. Because
of the increased radiation dose, future research should focus on the selection
of patients who will benefit from immediate total-body CT.
5. CT use for adults with head injury: describing likely
avoidable ED imaging based on the Canadian CT Head Rule.
Sharp AL, et
al. Acad Emerg Med. 2016 Jul 30 [Epub ahead of print].
BACKGROUND:
Millions of head computed tomography (CT) scans are ordered annually, but the
extent of avoidable imaging is poorly defined.
OBJECTIVE: To
determine the prevalence of likely avoidable CT imaging among adults evaluated
for head injury in 14 community emergency departments (ED) in Southern
California from 2008-2013.
METHODS: We
conducted an electronic health record (EHR) data-base and chart review of adult
ED trauma encounters receiving a head CT from 2008-2013. The primary outcome
was discordance with the Canadian CT Head Rule (CCHR) high-risk criteria; the
secondary outcome was use of a neurosurgical intervention in the discordant
cohort. We queried system-wide EHRs to identify CCHR discordance using criteria
identifiable in discrete data fields. Explicit chart review of a subset of
discordant CTs provided estimates of misclassification bias, and assessed the
low-risk cases who actually received an intervention.
RESULTS:
Among 27,240 adult trauma head CTs, EHR data classified 11,432 (42.0%)
discordant with CCHR recommendation. Subsequent chart review showed that the
designation of discordance based on the EHR was inaccurate in 12.2% (95% CI
5.6-18.8%). Inter-rater reliability for attributing CCHR concordance was 95%
(kappa=0.86). Thus we estimate that 36.8% of trauma head CTs were truly likely
avoidable (95% CI 34.1-39.6%). Among the likely avoidable CT group identified
by EHR, only 0.1% (n=13) received a neurosurgical intervention. Chart review
showed none of these were actually "missed" by the CCHR, as all 13
were misclassified.
CONCLUSION:
About 1/3 of head CTs currently performed on adults with head injury may be
avoidable by applying the CCHR. Avoidance of CT in such patients is unlikely to
miss any important injuries.
6. Prevalence of Chest Injury with the Presence of NEXUS Chest
Criteria: Data to Inform Shared Decision-making About Imaging Use
Raja AS, et
al. Ann Emerg Med. 2016;68:222-6.
Study
objective: The NEXUS chest decision instrument identifies a very-low-risk
population of patients with blunt trauma for whom chest imaging can be avoided.
However, it requires that all 7 National Emergency X-Ray Utilization Study
(NEXUS) chest criteria be absent. To inform patient and physician shared
decisionmaking about imaging, we describe the test characteristics of
individual criteria of the NEXUS chest decision instrument and provide the
prevalence of injuries when 1, 2, or 3 of the 7 criteria are present.
Methods: We
conducted this secondary analysis of 2 prospectively collected cohorts of
patients with blunt trauma who were older than 14 years and enrolled in NEXUS
chest studies between December 2009 and January 2012. Physicians at 9 US Level
I trauma centers recorded the presence or absence of the 7 NEXUS chest
criteria. We calculated test characteristics of each criterion and combinations
of criteria for the outcome measures of major clinical injuries and thoracic
injury observed on chest imaging.
Results: We
enrolled 21,382 patients, of whom 992 (4.6%) had major clinical injuries and
3,135 (14.7%) had thoracic injuries observed on chest imaging. Sensitivities of
individual test characteristics ranged from 15% to 56% for major clinical
injury and 14% to 53% for thoracic injury observed on chest imaging, with
specificities varying from 71% to 84% for major clinical injury and 67% to 84%
for thoracic injury observed on chest imaging. Individual criteria were
associated with a prevalence of major clinical injury between 1.9% and 3.8% and
of thoracic injury observed on chest imaging between 5.3% and 11.5%.
Conclusion: Patients
with isolated NEXUS chest criteria have low rates of major clinical injury. The
risk of major clinical injury for patients with 2 or 3 factors range from 1.7%
to 16.6%, depending on the combination of criteria. Criteria-specific risks
could be used to inform shared decisionmaking about the need for imaging by
patients and their physicians.
Full-text
(free): http://www.annemergmed.com/article/S0196-0644(15)01312-8/fulltext
7. Interference of New Drugs with Compatibility Testing for
Blood Transfusion
Murphy MF, et
al. N Engl J Med 2016; 375:295-296
New drugs may
have important yet underappreciated clinical consequences in patients requiring
blood transfusion. Interference with routine methods for compatibility testing
for blood transfusion puts patients at risk for delays in receiving compatible
blood. Even if laboratory methods are developed to circumvent the drug-related
artifacts, it takes time to establish them in general laboratories.
Daratumumab
(a monoclonal antibody that binds with high affinity to the CD38 molecule;
manufactured by Janssen), which was recently approved by the Food and Drug
Administration as a therapy for multiple myeloma, provides an illustrative
case. Once enrollment in the phase 1–2 trial began, staff at the trial site
quickly observed that daratumumab consistently interfered with routine
blood-compatibility testing. Standard serologic methods to eliminate
panreactive antibodies failed to resolve the interference, at times delaying
needed blood transfusions for patients treated with daratumumab.
It was
eventually shown that daratumumab in patients’ plasma directly binds to CD38 on
reagent red cells used in the blood bank, causing the false positive antibody
screens. A dithiothreitol-based method to eliminate the interference was
discovered in an investigator-initiated study1 and was later shown to be both
effective and widely generalizable in a multicenter international study
performed by the Biomedical Excellence for Safer Transfusion (BEST)
Collaborative (data not shown); both studies were sponsored by Janssen. A
neutralization method with the use of an anti-daratumumab idiotype has shown
promise2; however, the antiidiotype method is not readily available. A third
approach is to issue phenotypically or genotypically matched red-cell units.3,4
In the
specific case of the interference of daratumumab, a practical solution for
blood banks has been developed. However, establishing this solution as a
routine method in hospital blood banks will be a major challenge.
High-dose
intravenous immune globulin is another example of antibodies that interfere
with routine immunohematologic assays. We are concerned that other drugs,
particularly monoclonal antibodies, that are under development may similarly
interfere with compatibility testing at blood banks, putting patients who
require transfusion at risk for delays in receiving compatible blood. Blood
products are essential and sometimes lifesaving treatments, and interference by
a new drug can result in unanticipated delays in the delivery of care to
patients.
We believe
that there is a pressing need for active investigation of whether a new drug
may interfere with routine testing at blood banks. We recommend that
investigations be performed early during drug development, certainly during
phase 1 studies involving healthy volunteers. If interference with
compatibility tests is found, we recommend that it be clearly drawn to the
attention of clinicians and blood banks with advice about how to overcome the
interference.
8. Discussion of the JAMA Sepsis Papers from The Third
International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)
Original
articles (Feb 23): http://jama.jamanetwork.com/Issue.aspx?journalid=67&issueID=935012
Letters to
the editor (July 26):
- Clinical Criteria to Identify Patients With Sepsis
- Defining Septic Shock
- Definitions for Sepsis and Septic Shock
- Composition of the Sepsis Definitions Task Force
Links to
full-texts here (scroll down to “Comment & Response”): http://jama.jamanetwork.com/issue.aspx#14352
9. Validation of the Pittsburgh Infant Brain Injury Score for
Abusive Head Trauma.
Berger RP, et
al. Pediatrics. 2016 Jul;138(1).
BACKGROUND: Abusive
head trauma is the leading cause of death from physical abuse. Misdiagnosis of
abusive head trauma as well as other types of brain abnormalities in infants is
common and contributes to increased morbidity and mortality. We previously
derived the Pittsburgh Infant Brain Injury Score (PIBIS), a clinical prediction
rule to assist physicians deciding which high-risk infants should undergo
computed tomography of the head.
METHODS: Well-appearing
infants 30 to 364 days of age with temperature below 38.3°C, no history of
trauma, and a symptom associated with an increased risk of having a brain
abnormality were eligible for enrollment in this prospective, multicenter
clinical prediction rule validation. By using a predefined neuroimaging
paradigm, subjects were classified as cases or controls. The sensitivity,
specificity, and negative and positive predictive values of the rule for
prediction of brain injury were calculated.
RESULTS: A
total of 1040 infants were enrolled: 214 cases and 826 controls. The 5-point
PIBIS included abnormality on dermatologic examination (2 points), age ≥3.0
months (1 point), head circumference over 85th percentile (1 point), and serum
hemoglobin less than 11.2g/dL (1 point). At a score of 2, the sensitivity and
specificity for abnormal neuroimaging was 93.3% (95% confidence interval
89.0%-96.3%) and 53% (95% confidence interval 49.3%-57.1%), respectively.
CONCLUSIONS: Our
data suggest that the PIBIS accurately identifies infants who would benefit
from neuroimaging to evaluate for brain injury. An implementation analysis is
needed before the PIBIS can be integrated into clinical practice.
10. Images in Clinical Practice
Elderly
Female With Perianal Rash
Man With
Abdominal Swelling
Man With
Necrotizing Ulcers on the Leg
Young Man
With Painful Mass on the Palm
Woman With
Dyspnea and Abdominal Rash
Worms and
Flesh-Eating Bacteria? The Worst Day of Your Life
Man With a
Bump on the Chest
Young Women
With Acute Lower Gastrointestinal Bleeding
Man With
Swelling in Legs and Forearms
Herpes Zoster
Mandibularis
Dysphagia
Lusoria
Thyroid
Ophthalmopathy, Dermopathy, and Acropachy
Milk of Urate
Bulla
Jejunal
Diverticulosis with Midgut Volvulus and Intestinal Malrotation
11. Is Ultrasonographic Guidance More Successful Than Direct
Palpation for Arterial Line Placement?
Take-Home
Message
The use of
ultrasonography for arterial line placement is associated with decreased
first-attempt failure, mean attempts to successful placement, mean time to
successful placement, and associated complications compared with direct
palpation.
Full-text
(free): http://www.annemergmed.com/article/S0196-0644(16)00222-5/fulltext
12. Seasonality of Ankle Swelling: Population Symptom Reporting
Using Google Trends
Liu F, et al.
Ann Fam Med. 2016;14:356-358
In our
experience, complaints of ankle swelling are more common in summer, typically
from patients with no obvious cardiovascular disease. Surprisingly, this
observation has never been reported. To objectively establish this phenomenon,
we sought evidence of seasonality in the public’s Internet searches for ankle
swelling. Our data, obtained from Google Trends, consisted of all related
Google searches in the United States from January 4, 2004, to January 26, 2016.
Consistent with our expectations and confirmed by similar data for Australia,
Internet searches for information on ankle swelling are highly seasonal
(highest in midsummer), with seasonality explaining 86% of search volume
variability.
Full-text
(free): http://www.annfammed.org/content/14/4/356.full
13. The “IV Antibiotics” Sham
Ryan Radecki,
KP Portland, July 11, 2016
Among the
many overused tropes in medicine is the myth of the supremacy of intravenous
antibiotics. In the appropriate clinical
context, it’s just a waste.
This is a
retrospective analysis of 36,405 patients hospitalized for community-acquired
pneumonia, and for whom a fluoroquinolone was selected as therapy. The vast majority – 94% – received an
intravenous dose, while the remaining 2,205 (6%) were treated orally. Unadjusted mortality favored the oral dose –
unsurprisingly, as those patients also generally has fewer comorbid
conditions. In their multivariate,
propensity-matched analysis, there was no difference in mortality, intensive
care unit escalation, or mechanical ventilation.
These results
are wholly unsurprising, and the key feature is the class of antibiotic
involved. Commonly used antibiotics in
the fluoroquinolone class, trimethoprim-sulfamethoxazole, metronidazole, and
clindamycin, among others, have excellent oral absorption. I have seen many a referral to the Emergency
Department for “intravenous antibiotics” prior to an anticipated discharge to
home therapy when any one of these choices could have obviated the entire
encounter.
“Association
Between Initial Route of Fluoroquinolone Administration and Outcomes in
Patients Hospitalized for Community-acquired Pneumonia”
14. IV procainamide beats IV amiodarone for the acute treatment
of tolerated wide QRS tachycardia: a RCT
Ortiz M, et
al. Eur Heart J. 2016 Jun 28 [Epub ahead of print]
AIMS: Intravenous
procainamide and amiodarone are drugs of choice for well-tolerated ventricular
tachycardia. However, the choice between them, even according to Guidelines, is
unclear. We performed a multicentre randomized open-labelled study to determine
the safety and efficacy of intravenous procainamide and amiodarone for the
acute treatment of tolerated wide QRS complex (probably ventricular)
tachycardia.
METHODS AND
RESULTS: Patients were randomly assigned to receive intravenous procainamide
(10 mg/kg/20 min) or amiodarone (5 mg/kg/20 min). The primary endpoint was the
incidence of major predefined cardiac adverse events within 40 min after
infusion initiation. Of 74 patients included, 62 could be analysed. The primary
endpoint occurred in 3 of 33 (9%) procainamide and 12 of 29 (41%) amiodarone
patients (odd ratio, OR = 0.1; 95% confidence interval, CI 0.03-0.6; P =
0.006). Tachycardia terminated within 40 min in 22 (67%) procainamide and 11
(38%) amiodarone patients (OR = 3.3; 95% CI 1.2-9.3; P = 0.026). In the
following 24 h, adverse events occurred in 18% procainamide and 31% amiodarone
patients (OR: 0.49; 95% CI: 0.15-1.61; P: 0.24). Among 49 patients with
structural heart disease, the primary endpoint was less common in procainamide
patients (3 [11%] vs. 10 [43%]; OR: 0.17; 95% CI: 0.04-0.73, P = 0.017).
CONCLUSIONS: This
study compares for the first time in a randomized design intravenous
procainamide and amiodarone for the treatment of the acute episode of sustained
monomorphic well-tolerated (probably) ventricular tachycardia. Procainamide
therapy was associated with less major cardiac adverse events and a higher
proportion of tachycardia termination within 40 min.
Full-text
(free): http://eurheartj.oxfordjournals.org/content/early/2016/06/27/eurheartj.ehw230.long
15. Anti-N-Methyl-D-Aspartate Receptor Encephalitis, an
Underappreciated Disease in the ED
Lasoff DR, et
al. West J Emerg Med. 2016;17(3):280-2
Anti-N-Methyl-D-Aspartate
Receptor (NMDAR) Encephalitis is a novel disease discovered within the past 10
years. Antibodies directed at the NMDAR cause the patient to develop a
characteristic syndrome of neuropsychiatric symptoms. Patients go on to develop
autonomic dysregulation and often have prolonged hospitalizations and intensive
care unit stays. There is little literature in the emergency medicine community
regarding this disease process, so we report on a case we encountered in our
emergency department to help raise awareness of this disease process.
Full-text
(free): http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4899058/
16. Comparison of Temperature Acquisition Methods in the ED
Jennifer L.
Wiler, MD, MBA, FACEP. Journal Watch Emerg Med 2016 July 15
As has been
shown with pediatric and critically ill patient populations, noninvasive
temperature measurement has poor diagnostic accuracy in adult emergency
department patients.
In a study of
987 emergency department (ED) patients (mean age 55 years, 65% female) who
received a rectal temperature measurement as part of routine care, researchers
assessed the accuracy of oral, tympanic membrane, and temporal artery
thermometry.
Overall, the
noninvasive temperature readings were inaccurate; they differed by ≥0.5°C from
rectal temperatures 36% of the time and from oral temperatures 50% of the time.
The most accurate noninvasive method was tympanic membrane thermometry.
The
sensitivity and specificity for detecting fever of 38°C or higher measured
rectally were as follows:
- Tympanic membrane: 68% and 98%
- Temporal artery: 71% and 92%
- Oral: 37% and 99%
When the
cutoff temperature for defining fever was lowered to 37.5°C, the sensitivity
and specificity were as follows:
- Tympanic membrane: 91% and 90%
- Temporal artery: 91% and 72%
- Oral: 58% and 97%
Comment
Accurate
temperature measurement can be important to patient care. Rectal temperatures
have long been considered the gold standard for accurate thermometry, but it is
not feasible or appropriate for evaluation of all acute care patients. If
hospitals want to continue to use noninvasive modes for temperature collection,
then a cutoff value of 37.5°C should be used to define fever, or at least to
trigger taking a rectal temperature.
Source: Bijur
PE et al. Emerg Med J 2016 Jun 22. Abstract:
http://www.ncbi.nlm.nih.gov/pubmed/27334759
17. Safe and effective implementation of telestroke in a US
community hospital setting.
Sauser-Zachrison
K, et al. Perm J. 2016; 20(4):15-217.
Context:
There is substantial hospital-level variation in use of tissue plasminogen
activator (tPA) for treatment of acute ischemic stroke. Telestroke services can
bring neurologic expertise to hospitals with fewer resources.
Objective: To
determine whether implementation of a telestroke intervention in a large
integrated health system would lead to increased tPA utilization and would
change rates of hemorrhagic complications.
Design: A
stepped-wedge cluster randomized trial of 11 community hospitals connected to 2
tertiary care centers via telestroke, implemented at each hospital
incrementally during a 1-year period. We examined pre- and postimplementation
data from July 2013 through January 2015. A 2-level mixed-effects logistic
regression model accounted for the staggered rollout.
Main Outcome
Measures: Receipt of tPA. Secondary outcome was the rate of significant
hemorrhagic complications.
Results: Of
the 2657 patients, demographic and clinical characteristics were similar in
pre- and postintervention cohorts. Utilization of tPA increased from 6.3%
before the intervention to 10.9% after the intervention, without a significant
change in complication rates. Postintervention patients were more likely to
receive tPA than were preintervention patients (odds ratio = 2.0; 95%
confidence interval = 1.2-3.4). Before implementation, 8 of the 10 community
hospitals were significantly less likely to administer tPA than the
highest-volume tertiary care center; however, after implementation, 9 of the 10
were at least as likely to administer tPA as the highest-volume center.
Conclusion:
Telestroke implementation in a regional integrated health system was safe and
effective. Community hospitals’ rates of tPA utilization quickly increased and
were similar to the largest-volume tertiary care center.
18. Papoose Boards for the Removal of Foreign Bodies from the
Ear and Nose
Krauss BS, et
al. N Engl J Med 2016; 375:194.
To the
Editor:
In the Video
in Clinical Medicine “Removal of Foreign Bodies from the Ear and Nose” (Feb. 18
issue),1 the author shows the use of a papoose board — a technique that
requires placing the child in a restraining device and forcefully holding the
child’s head still. A child so restrained typically attempts to free himself or
herself from restraint while crying in distress. In the past quarter century,
in developed nations, forceful restraint of children for minor procedures has
been largely supplanted by safe and effective procedural sedation.2,3 Restraint
is emotionally disturbing for the child and his or her parents and can lead to
apprehension about medical personnel and future medical treatment.
References
1 Friedman
EM. Removal of foreign bodies from the ear and nose. N Engl J Med
2016;374:e7-e7
2 Krauss BS,
Krauss BA, Green SM. Procedural sedation and analgesia in children. N Engl J
Med 2014;371:91-91
3 Krauss B,
Green SM. Procedural sedation and analgesia in children. Lancet
2006;367:766-780
Friedman
replies: http://www.nejm.org/doi/full/10.1056/NEJMc1603663
19. Effect of Electronic Device Use on Pedestrian Safety: A
Literature Review
National
Highway Traffic Safety Administration. Ann Emerg Med. 2016;68:233–234
Distracted
driving killed 3,179 people in the United States and injured an estimated
431,000 others in distraction-affected motor vehicle crashes in 2014.2
Distraction
among pedestrians also is a significant safety risk, although the exact number
of distraction-related pedestrian injuries is difficult to estimate. This
project using literature review on the effect of electronic device use on
pedestrian safety sought to quantify the risk of pedestrian crash involvement
caused by pedestrian and driver distraction and to inform the methodology for a
naturalistic field observation study and analysis of state crash data.
A thorough and
targeted literature review was conducted to accomplish 3 goals: to characterize
the pedestrian distraction problem, especially as it relates to pedestrian use
of electronic devices while crossing streets; to examine the likely interface
between pedestrian and driver distraction as both road users try to navigate
through intersections; and to inform field data collection methodology
according to the successes and failures of previous research.
Although
there are many inconsistencies in the published literature, most studies
indicate an association between distraction of pedestrians or drivers and
adverse behavioral outcomes. Most studies have used simulation or laboratory
experiments versus naturalistic observations to investigate the potential risks
associated with distraction. Engineering studies, using conflict analysis,
generally have focused on behaviors related to evading collisions rather than
the precursor behaviors of drivers and pedestrians. Although there is general
agreement that distraction causes changes in drivers’ responses, some recent
studies indicate that performance decrements because of distraction caused by
cell telephone conversations may actually disappear with increased experience.
Simulation
studies, although practical, have documented limitations. The virtual
environment disrupts the automatic nature of driving or walking, and there are
many obvious differences between it and the real world with respect to the
“crash” frequency; similarly, the removal of real risk and crash consequences
may significantly alter the subconscious reactions of research subjects,
allowing them tolerate much higher risks of a virtual collision that they would
never tolerate when driving on a road in a car. Although there are no actual
comparative studies of cell telephone use in simulated versus real walking or
driving, the distraction caused by them and other devices may be larger in a
simulator study simply because of the virtual nature of the risks in the
virtual environment. If so, reliance on simulator studies alone could lead to
overestimation of cell telephone–related distraction’s effect on safety.
There are few
large databases with information about driver and pedestrian distraction and
injury. The National Automotive Sampling System Crashworthiness Data Set data
set is perhaps the best resource for this type of study among drivers, but it
does not contain a systematic sample of pedestrian data. Other data sources,
including emergency department (ED) and hospital admissions and telephone
records, can bolster our knowledge of the role of distraction in injury crashes
but generally do not provide a good measure of exposure or injured persons’
interaction with the distractor. In contrast, naturalistic observation studies
of pedestrians can provide a reliable estimate of exposure (such as the
prevalence of electronic device use among pedestrians) but may be less reliable
in estimating risk because few pedestrian-vehicle interactions result in a
crash. The traffic conflict method allows naturalistic observation studies to
collect surrogate measures of crash risk. The method is well developed and
accepted in the engineering world but has yet to see much use in behavioral
analysis. It represents an improvement over previous behavioral studies in that
it has the potential to help link pedestrian and driver distraction to
increased risk of a traffic conflict.
Two important
gaps in the existing literature were identified; specifically, there are few
studies investigating risks to pedestrian safety caused by electronic device
use by drivers or pedestrians, and most previous studies have focused primarily
on cell telephone use while ignoring risks posed by other types of electronic
devices, eg, tablets, MP3 players.
Copies of the
67-page report Effect of Electronic Device Use on Pedestrian Safety: A
Literature Review can be obtained from the National Highway Traffic Safety
Administration, 1200 New Jersey Avenue, SE, Washington, DC 20590 or downloaded
from the National Highway Traffic Safety Administration (NHTSA) Web site at http://www.nhtsa.gov/staticfiles/nti/pdf/812256-EffectElectronicDeviceUsePedestrianSafety.pdf.
Commentary:
Death by Distraction: http://www.annemergmed.com/article/S0196-0644(16)30298-0/fulltext
20. AAP Guidelines for Monitoring and Management of Pediatric
Patients Before, During, and After Sedation for Diagnostic and Therapeutic
Procedures: Update 2016.
Coté CJ, et
al. Pediatrics. 2016 Jul;138(1).
The safe
sedation of children for procedures requires a systematic approach that
includes the following: no administration of sedating medication without the
safety net of medical/dental supervision, careful presedation evaluation for
underlying medical or surgical conditions that would place the child at
increased risk from sedating medications, appropriate fasting for elective
procedures and a balance between the depth of sedation and risk for those who
are unable to fast because of the urgent nature of the procedure, a focused
airway examination for large (kissing) tonsils or anatomic airway abnormalities
that might increase the potential for airway obstruction, a clear understanding
of the medication's pharmacokinetic and pharmacodynamic effects and drug
interactions, appropriate training and skills in airway management to allow
rescue of the patient, age- and size-appropriate equipment for airway
management and venous access, appropriate medications and reversal agents,
sufficient numbers of staff to both carry out the procedure and monitor the
patient, appropriate physiologic monitoring during and after the procedure, a
properly equipped and staffed recovery area, recovery to the presedation level
of consciousness before discharge from medical/dental supervision, and
appropriate discharge instructions.
This report
was developed through a collaborative effort of the American Academy of
Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric
providers updated information and guidance in delivering safe sedation to
children.
Full-text
(free): http://pediatrics.aappublications.org/content/138/1/e20161212.long
21. ER death rate drops by half over 15-year period
Fierce
Healthcare. By Paige Minemyer. July 7, 2016
Emergency
department deaths dropped by nearly 50 percent between 1997 and 2011, according
to a study published in Health Affairs, and the research team points to
advances in palliative care, prehospital and emergency care as factors for the
decline.
Researchers
analyzed emergency room visit data from the National Hospital Ambulatory
Medical Care Survey, including all ED visits by adults over the 15-year study
period. The data was divided further by race, age, sex, insurance status,
geographic location and other factors, according to the study. The team studied
more than 365,000 observations, representing more than 1.3 billion ED visits in
the United States.
Over the
course of the study’s 15-year data period, deaths in the ER decreased by 48
percent. In comparison, there was no significant change in inpatient hospital
mortality between 2005 and 2011, according to the study.
In 62 percent
of the visits involving patient deaths, the patients were in cardiac arrest,
unconscious or dead upon arrival, according to the study. More than 8 percent
of patients who died in the ED reported shortness of breath as their primary
symptom, and more than 5 percent of those who died came to the ER to treat an
injury.
The study
team writes that further studies will be needed to pinpoint exactly why deaths
in the ED have dropped so significantly, but they listed to several possible
explanations for the decrease, including:
Patients are
surviving in the ED, but die after being admitted to the hospital. The team
points to the lack of a notable decrease in inpatient deaths as evidence of
this possible trend.
Palliative
care is gaining an increasing role in medicine, including the ED. Because of
this, patients are more likely to die in a hospice center or under hospice care
at home, the team writes. They noted that between 1989 and 2007, the number of
home deaths increased by more than 50 percent, leading to a reduction in
hospital deaths by more than 20 percent.
“Do Not
Resuscitate” orders may terminate care before patients reach the hospital. The
team suggested that this may be especially true of cardiac arrest patients, who
are now more likely to be declared dead before reaching the hospital than at
the ED.
Substantial
strides have been made in treating life-threatening conditions like stroke,
trauma and sepsis, including more effective therapies and enhanced training in
critical care.
The research
team included Hemal Kanzaria, M.D., assistant professor of clinical emergency
medicine at University of California San Francisco (UCSF); Marc Probst,
assistant professor of emergency medicine at the Icahn School of Medicine at
Mount Sinai in New York; and Renee Hsia, M.D., professor of emergency medicine
at UCSF.
22. For Coffee Drinkers, the Buzz May Be in Your Genes
Anahad O’Connor, New York Times.
July 12, 2016
Like most of my work, this
article would not have been possible without coffee.
I’m never fully awake until I
have had my morning cup of espresso. It makes me productive, energized and what
I can only describe as mildly euphoric. But as one of the millions of caffeine-loving
Americans who can measure out my life with coffee spoons, (to paraphrase T.S.
Eliot), I have often wondered: How does my coffee habit impact my health?
The health community can’t quite
agree on whether coffee is more potion or poison. The American Heart
Association says the research on whether coffee causes heart disease is
conflicting. The World Health Organization, which for years classified coffee
as “possibly” carcinogenic, recently reversed itself, saying the evidence for a
coffee-cancer link is “inadequate.” National dietary guidelines say that
moderate coffee consumption may actually be good for you – even reducing
chronic disease.
Why is there so much conflicting
evidence about coffee? The answer may be in our genes.
About a
decade ago, Ahmed El-Sohemy, a professor in the department of nutritional
sciences at the University of Toronto, noticed the conflicting research on
coffee and the widespread variation in how people respond to it. Some people
avoid it because just one cup makes them jittery and anxious. Others can drink
four cups of coffee and barely keep their eyes open. Some people thrive on it.
Dr. El-Sohemy
suspected that the relationship between coffee and heart disease might also
vary from one individual to the next. And he zeroed in on one gene in
particular, CYP1A2, which controls an enzyme – also called CYP1A2 – that
determines how quickly our bodies break down caffeine.
One variant
of the gene causes the liver to metabolize caffeine very quickly. People who
inherit two copies of the “fast” variant – one from each parent – are generally
referred to as fast metabolizers. Their bodies metabolize caffeine about four
times more quickly than people who inherit one or more copies of the slow
variant of the gene. These people are called slow metabolizers.
With funding
from the National Institutes of Health, Dr. El-Sohemy and his colleagues
recruited 4,000 adults, including about 2,000 who had previously had a heart
attack. Then they analyzed their genes and their coffee consumption. When they
looked at the entire study population, they found that consuming four or more
cups of coffee per day was associated with a 36 percent increased risk of a
heart attack.
But when they
split the subjects into two groups – fast and slow caffeine metabolizers – they
found something striking: Heavy coffee consumption only seemed to be linked to
a higher likelihood of heart attacks in the slow metabolizers…
The remainder
of the essay: http://well.blogs.nytimes.com/2016/07/12/for-coffee-drinkers-the-buzz-may-be-in-your-genes/
23. Micro Bits
A. Can You Multitask? Evidence and
Limitations of Task Switching and Multitasking in Emergency Medicine
Skaugset LM, et al. Ann Emerg
Med. 2016;68:189-195.
Emergency physicians work in a
fast-paced environment that is characterized by frequent interruptions and the
expectation that they will perform multiple tasks efficiently and without error
while maintaining oversight of the entire emergency department. However, there
is a lack of definition and understanding of the behaviors that constitute
effective task switching and multitasking, as well as how to improve these
skills. This article reviews the literature on task switching and multitasking
in a variety of disciplines—including cognitive science, human factors
engineering, business, and medicine—to define and describe the successful
performance of task switching and multitasking in emergency medicine.
Multitasking, defined as the performance of two tasks simultaneously, is not
possible except when behaviors become completely automatic; instead, physicians
rapidly switch between small tasks. This task switching causes disruption in
the primary task and may contribute to error. A framework is described to
enhance the understanding and practice of these behaviors.
B. Study ties thumb-sucking, nail-biting to
lower allergy risk in children
Thirty-eight percent of children
who sucked their thumbs or bit their nails and 31% of those who did both had
sensitivity to allergens such as grasses, dog dander and dust mites at age 13,
compared with 49% of those who didn't have either habit, according to a study
in Pediatrics. The findings, based on data involving 1,037 youths born from
1972 to 1973 in New Zealand and followed for more than three decades, also
showed that those who sucked their thumbs or bit their nails continued to have
lower allergic sensitization at age 32, but had no lower risk of developing hay
fever or asthma.
C. Patients Sometimes Take Antibiotics
Without Consulting A Doctor, Study Finds
Suffering from a sore throat or
runny nose? For some people, that many mean opting to use antibiotics without
seeing a doctor, a practice that health experts say may not help cure the
disease and could help aggravate the problem of antibiotic-resistant germs.
A study published Monday in the
journal Antimicrobial Agents and Chemotherapy concluded that many people are
tempted to use antibiotics without a doctor’s prescription. They rely on drugs
purchased from ethnic grocery or drug stores or the leftovers in their medicine
cabinets, potentially contributing to the spread of antibiotic-resistant
bacteria and causing damaging side effects.
“This kind of inappropriate use
is very risky,” said Larissa Grigoryan, coauthor of the study and an instructor
at the Baylor College of Medicine in Houston. “If you use antibiotics
irresponsibly like this then resistance rates will increase.”
D. Olympic fever is in the air! Or is that
sweat?
Angela Ballard, RN. July 2016
Sweat is natural and it’s part of
who we are – as men and women.
Interestingly, prepubescent girls
and boys sweat about the same volume. But once hormones kick in, sweating
starts to vary between the sexes with men tending to begin sweating sooner and
in higher volume (with activity or heat) than women. Why? Scientists point to
testosterone, which enhances men’s sweat response. Basically, women need to get
hotter before they start to sweat. Estrogen plays a role here, too, promoting
lower body temperatures in women.
Another reason why guys tend to
sweat more is because they’re often bigger; the bigger the body, the more heat
it generates, the more it needs to cool down.
But how does fitness factor in? A
Japanese study found that if you take women and men who are the same size, and
who have the same fitness level (i.e. top athletes), and put them in the same
temperature and exercise conditions – the men will still sweat more than the
women.
The scientists involved (at Osaka
International University and Kobe University) have a couple evolutionary
theories that could explain this:
- Perhaps our ancient male ancestors evolved to sweat more so they could be better hunters with more stamina in the sun?
- Or, did our female ancestors evolve to preserve precious body fluids necessary for successful survival and reproduction?
If, however, you sweat
uncontrollably and so excessively that swimming is your only athletic choice,
you drench your clothes, ruin your iPhone, turn leather shoes into sponges, or
have to layer up to hide sweat marks, you might have hyperhidrosis...
Full-text with references: http://sweathelp.org/sweatsolutions-newsletter/368-who-sweats-more-men-or-women.html
E. Treatment of Opioid-Use Disorders
Marc A. Schuckit, M.D. N Engl J
Med 2016; 375:357-368
This article provides an overview
of the current treatment of opioid-related conditions, including treatments
provided by general practitioners and by specialists in substance-use
disorders. The recent dramatic increase in misuse of prescription analgesics,
the easy accessibility of opioids such as heroin on the streets, and the
epidemic of opioid overdoses underscore how important it is for physicians to
understand more about these drugs and to be able to tell patients about
available treatments for substance-use disorders.
Full-text (free): http://www.nejm.org/doi/full/10.1056/NEJMra1604339
F. Medical Considerations before
International Travel
Freedman DO, et al. N Engl J Med
2016; 375:247-260.
In 2015, international tourist
arrivals in all countries exceeded 1.2 billion persons. In 2014, the total
number of arrivals in countries with emerging markets nearly surpassed the
number in developed countries
(http://www.e-unwto.org/doi/book/10.18111/9789284416899). Depending on the
destination, 22 to 64% of travelers report some illness; most of these
illnesses are mild and self-limited, such as diarrhea, respiratory infections,
and skin disorders.1-4 Some travelers return to their own countries with
preventable life-threatening infections.5 Yet 20 to 80% of travelers do not
seek pretravel health consultation.6 Data about the effect of pretravel advice
are limited, although such advice has had a positive effect on the prevention
of malaria.7 Travelers visiting friends and relatives in their country of
origin constitute the group with the highest morbidity, especially from malaria
and typhoid; this group requires special approaches to illness prevention and
education.8,9
Persons who are planning to
travel to other countries often ask their health care providers for information
about preventive interventions. Nonspecialists can provide information and care
to healthy adults traveling to common destinations by following protocols such
as those offered in this review…
Full-text (free): http://www.nejm.org/doi/full/10.1056/NEJMra1508815
G. The economic burden of physical
inactivity: a global analysis of major non-communicable diseases
In addition to morbidity and
premature mortality, physical inactivity is responsible for a substantial
economic burden. This paper provides further justification to prioritise
promotion of regular physical activity worldwide as part of a comprehensive
strategy to reduce non-communicable diseases.
H. Cost and Outcome of Behavioural Activation
versus Cognitive Behavioural Therapy for Depression (COBRA): a randomised,
controlled, non-inferiority trial
Conclusion: We found that BA, a
simpler psychological treatment than CBT, can be delivered by junior mental
health workers with less intensive and costly training, with no lesser effect
than CBT. Effective psychological therapy for depression can be delivered
without the need for costly and highly trained professionals.
I. Comparative Effectiveness of Tai Chi
Versus Physical Therapy for Knee Osteoarthritis: A Randomized Trial
Conclusion: Tai Chi produced
beneficial effects similar to those of a standard course of physical therapy in
the treatment of knee osteoarthritis.
J. Management of Chronic Insomnia Disorder in
Adults: A Clinical Practice Guideline From the American College of Physicians
K. Sedentary people are advised to do at
least one hour of moderate activity a day
Doing at least an hour a day of
moderate physical activity, such as brisk walking or cycling, seems to
eliminate the increased risk of death associated with sitting for more than
eight hours a day, a study published in the Lancet shows.
L. FDA issues new warning about
fluoroquinolones
The FDA revised boxed warnings
for all fluoroquinolones to reflect concerns about potentially permanent side
effects involving muscles, tendons, joints, peripheral nerves and the central
nervous system. The FDA said this antibiotic class should be used for patients
with acute bacterial sinusitis, acute bacterial exacerbation of chronic
bronchitis and uncomplicated urinary tract infections only when no other
treatment options are available.
M. Study supports use of nasal irrigation for
sinus symptom relief
UK researchers reported in the
CMAJ that primary care patients with chronic or recurrent sinus problems may
get more symptom relief from nasal irrigation than from steam inhalation. Study
data indicated the results for nasal irrigation were modest, and researchers
suggested coaching and practice sessions used in previous research may improve
effectiveness.
N. Group warns of medications that may
trigger, worsen heart failure
The American Heart Association
has released a scientific statement warning about the risks of using metformin,
nonsteroidal anti-inflammatory drugs, antihypertensive drugs, and other
prescription and over-the-counter drugs -- including complementary and
alternative medications -- that may cause or exacerbate heart failure. The
group recommends educating patients about the impact of OTC and alternative
medications, encouraging them to actively take part in managing their
medications, and establishing a "captain" among a patient's
clinicians to oversee and monitor medications.
