Monday, August 01, 2016

Lit Bits: Aug 1, 2016

From the recent medical literature...

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.

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.

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, 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.

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)

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”):

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.

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.

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.

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.

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% 

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:

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.

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

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

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.

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…

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?
Although the jury is still out on why, it’s clear that gender differences in sweating are natural and ingrained. 

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...

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.

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 ( 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…

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.