1. Using RNA expression profiling to differentiate children with
bacterial disease from those with viral disease
A.
Genetics and the Evaluation of the Febrile Child
Bauchner H. JAMA.
2016;316(8):824-825.
Clinicians
who care for children have encountered the same questions for decades: does the
child have an infection, is it likely bacterial or viral, and is an antibiotic
indicated? These questions were further complicated by the “discovery” of
bacteremia. In 1973-1974, Teele et al1 obtained blood cultures from 600
consecutive febrile children younger than 2 years with temperatures of 38.3°C
or higher and found that 19 (3.2%) had pathogens in their blood. Streptococcus
pneumoniae was the most common pathogen (n = 15), followed by Haemophilus
influenzae type b (n = 2). Further analysis suggested that children with a
temperature higher than 38.9°C and a white blood cell count greater than
15 000/μL had about an 8% to 10% risk of “bacteremia.” For the following 3
decades, the focus was on determining how to identify these children; how these
children could be differentiated into groups at high and low risk for
bacteremia by various clinical scores or laboratory tests, such as C-reactive
protein, erythrocyte sedimentation rate, or neutrophil-to-band ratio; and if
expectant antibiotics are necessary.2,3
Following the
introduction of the conjugate H Influenzae vaccine in the late 1980s, the
number of children with bacteremia (and meningitis) declined substantially,
with a further decline following the introduction of the conjugate pneumococcal
vaccine in 1990s.4- 7 Prior to the introduction of these 2 vaccines,
approximately 20 000 children each year were diagnosed with meningitis and
other serious bacterial infections, such as epiglottitis, caused by these organisms.6,7
In 2015, fewer than 500 children were diagnosed with invasive H influenzae type
b or invasive pneumococcal disease.4,5
At the same
time invasive disease was declining among older children, the focus shifted to
identifying infants younger than 90 days with serious bacterial infection
(SBI), such as meningitis, septicemia, and urinary tract infections.8- 10 Many
febrile infants younger than 30 days presenting to an emergency department were
admitted to the hospital, often after they had blood cultures, urine cultures,
and a lumbar puncture performed. The vast majority received antibiotics. In
this age group, approximately 5% to 8% of infants presenting with fever to an
emergency department have serious bacterial infection.8- 10 Management is
different in infants older than 30 days (in some settings older than 2 weeks),
for whom various approaches have been adopted that help clinicians categorize
children into high and low risk for SBI and potentially discharge them home
from an emergency department, with or without antibiotics. However, these
scenarios are often not the same in office practice, with apparently few
“missed” infants with SBI.11 Although the data are uncertain, it is likely that
infants presenting to an emergency department have a higher risk of SBI than
those in practice, and follow-up may be more difficult, necessitating a
different clinical approach.
Two articles
in this issue of JAMA contribute to the 5-decades-long discussion of the
evaluation of febrile infants and children and represent an important
advance—the potential of genetics to help in the evaluation of febrile
children.12,13 Specifically, can RNA expression profiling be successful when
clinical scores and other laboratory tests (aside from blood culture results)
have largely failed to differentiate children with bacterial disease from those
with viral disease? The questions are different depending on the age of the
child. Among very young infants, the goal of a laboratory test is to rule out
SBI, with a very high degree of certainty (high sensitivity). Among older
children, in whom the risk of SBI is much lower, the goal is to differentiate
bacterial from viral infection, so the clinician does not have to prescribe
antibiotics, an increasingly important consideration because of concerns about
antibiotic resistance.
In one study
in this issue of JAMA, Mahajan and colleagues12 assessed the association
between RNA biosignatures and bacterial infection in 279 randomly selected
febrile infants 60 days of age and younger (median age, 37 days; 56% male), of
whom 89 had bacterial infections—including 32 with bacteremia and 58 with
urinary tract infection—190 without bacterial infections, and 19 afebrile
healthy infants. Sixty-six genes were identified that best discriminated
infants with and without bacterial infection. In the validation test set, the
sensitivity was 87% (95% CI, 73%-95%) and the specificity was 89% (95% CI,
81%-93%). In a subset of infants with bacteremia, the sensitivity in the
validation test set was 94% (95% CI, 70%-100%) and the specificity was 95% (95%
CI, 88%-98%). The authors acknowledge a number of limitations, including a
convenience sample of patients, viral testing was not consistently performed on
all patients, and the assays were performed on frozen batched samples in a
central laboratory.
In another
study in this issue, Herberg and colleagues13 determined if RNA expression
measured by microarray could be used to differentiate bacterial from viral
infection in 370 children (median age, approximately 18 months), of whom 86 had
a definitive bacterial infection, 120 a viral infection, and 175 an
indeterminate infection. The authors identified a 2-transcript RNA biosignature
that could differentiate bacterial from viral infection. In the validation set,
the sensitivity was 100% (95% CI, 100%-100%) and the specificity was 96.4% (95%
CI, 89.3%-100%). This study also has a number of limitations, such as use of a
case-control design with a high acuity of illness for many of the cases, so the
actual number of children with bacterial and viral infection does not reflect
the frequency of infections in clinical practice. In addition, the spectrum of
the type of infections is likely different in practice. That being said, a
2-transcript biosignature, if proven to be robust in future studies, might be
amenable to the development of a near real-time clinical assay.
The results
of these 2 preliminary studies represent promissory notes. Clearly, RNA
sequencing and other techniques for RNA quantitation are in the early days of development
and evaluation for clinical applications. There have been other promissory
notes—for example, the utility of C-reactive protein to differentiate children
into high and low risk and the availability of rapid diagnostic testing to
confirm a viral infection. The substantial decline in the prevalence of SBI,
following the introduction of conjugate vaccines, has made clinical decision
making more difficult—the needle has become much smaller, and the haystack much
larger, particularly in young infants. However, if the promises of findings
reported in the studies by Mahajan and colleagues and Herberg and colleagues
are fulfilled by replication and refinement in other rigorous investigations,
it may be possible that such advances will further reduce morbidity, mortality,
and costs associated with caring for febrile children. The day when a parent of
a febrile child may do a laboratory test at home, call a physician, and
mutually decide if that child should be seen for evaluation may soon be here.
B.
Association of RNA Biosignatures with Bacterial Infections in Febrile Infants
Aged 60 Days or Younger
Mahajan P, et
al. JAMA. 2016;316(8):846-857.
Key Points
Question Can
the host response measured by RNA biosignatures distinguish young febrile
infants with and without bacterial infections?
Findings In
this prospective observational study of 279 febrile infants 60 days or younger,
66 classifier genes distinguished infants with and without bacterial infections
with 87% sensitivity and 89% specificity. Ten classifier genes distinguished
infants with bacteremia from those without bacterial infections with 94%
sensitivity and 95% specificity.
Meaning In
this preliminary study, host RNA biosignatures accurately distinguished febrile
infants 60 days or younger with and without bacterial infections
Abstract
Importance Young febrile infants are at substantial risk
of serious bacterial infections; however, the current culture-based diagnosis
has limitations. Analysis of host expression patterns (“RNA biosignatures”) in
response to infections may provide an alternative diagnostic approach.
Objective To assess whether RNA biosignatures can
distinguish febrile infants aged 60 days or younger with and without serious
bacterial infections.
Design,
Setting, and Participants Prospective
observational study involving a convenience sample of febrile infants 60 days
or younger evaluated for fever (temperature greater than 38° C) in 22 emergency
departments from December 2008 to December 2010 who underwent laboratory evaluations
including blood cultures. A random sample of infants with and without bacterial
infections was selected for RNA biosignature analysis. Afebrile healthy infants
served as controls. Blood samples were collected for cultures and RNA
biosignatures. Bioinformatics tools were applied to define RNA biosignatures to
classify febrile infants by infection type.
Exposure RNA biosignatures compared with cultures for
discriminating febrile infants with and without bacterial infections and
infants with bacteremia from those without bacterial infections.
Main Outcomes
and Measures Bacterial infection
confirmed by culture. Performance of RNA biosignatures was compared with
routine laboratory screening tests and Yale Observation Scale (YOS) scores.
Results Of 1883 febrile infants (median age, 37 days;
55.7% boys), RNA biosignatures were measured in 279 randomly selected infants
(89 with bacterial infections—including 32 with bacteremia and 15 with urinary
tract infections—and 190 without bacterial infections), and 19 afebrile healthy
infants. Sixty-six classifier genes were identified that distinguished infants
with and without bacterial infections in the test set with 87% (95% CI,
73%-95%) sensitivity and 89% (95% CI, 81%-93%) specificity. Ten classifier
genes distinguished infants with bacteremia from those without bacterial
infections in the test set with 94% (95% CI, 70%-100%) sensitivity and 95% (95%
CI, 88%-98%) specificity. The incremental C statistic for the RNA biosignatures
over the YOS score was 0.37 (95% CI, 0.30-0.43).
Conclusions
and Relevance In this preliminary study,
RNA biosignatures were defined to distinguish febrile infants aged 60 days or
younger with vs without bacterial infections. Further research with larger
populations is needed to refine and validate the estimates of test accuracy and
to assess the clinical utility of RNA biosignatures in practice.
C.
Diagnostic Test Accuracy of a 2-Transcript Host RNA Signature for
Discriminating Bacterial vs Viral Infection in Febrile Children
Herberg JA,
et al. JAMA. 2016;316(8):835-845.
Key Points
Question Can
febrile children with bacterial infection be distinguished from those with
viral infection and other common causes of fever using whole-blood gene
expression profiling?
Findings In
this cross-sectional study that included 370 febrile children, those with
bacterial infection were distinguished from those with viral infection with a
sensitivity in the validation group of 100% (95% CI, 100%-100%) and specificity
of 96.4% (95% CI, 89.3%-100%), using a 2-transcript signature.
Meaning This
study provides preliminary data on the performance of a 2-transcript host RNA
signature for discriminating bacterial from viral infection in febrile
children. Further studies are needed in diverse groups of patients to assess
accuracy and clinical utility of this test in different clinical settings.
Abstract
Importance Because clinical features do not reliably
distinguish bacterial from viral infection, many children worldwide receive
unnecessary antibiotic treatment, while bacterial infection is missed in
others.
Objective To identify a blood RNA expression signature
that distinguishes bacterial from viral infection in febrile children.
Design,
Setting, and Participants Febrile
children presenting to participating hospitals in the United Kingdom, Spain,
the Netherlands, and the United States between 2009-2013 were prospectively
recruited, comprising a discovery group and validation group. Each group was
classified after microbiological investigation as having definite bacterial
infection, definite viral infection, or indeterminate infection. RNA expression
signatures distinguishing definite bacterial from viral infection were
identified in the discovery group and diagnostic performance assessed in the
validation group. Additional validation was undertaken in separate studies of
children with meningococcal disease (n = 24) and inflammatory diseases (n = 48)
and on published gene expression datasets.
Exposures A 2-transcript RNA expression signature
distinguishing bacterial infection from viral infection was evaluated against
clinical and microbiological diagnosis.
Main Outcomes
and Measures Definite bacterial and
viral infection was confirmed by culture or molecular detection of the
pathogens. Performance of the RNA signature was evaluated in the definite
bacterial and viral group and in the indeterminate infection group.
Results The discovery group of 240 children (median
age, 19 months; 62% male) included 52 with definite bacterial infection, of
whom 36 (69%) required intensive care, and 92 with definite viral infection, of
whom 32 (35%) required intensive care. Ninety-six children had indeterminate
infection. Analysis of RNA expression data identified a 38-transcript signature
distinguishing bacterial from viral infection. A smaller (2-transcript)
signature (FAM89A and IFI44L) was identified by removing highly correlated
transcripts. When this 2-transcript signature was implemented as a disease risk
score in the validation group (130 children, with 23 definite bacterial, 28
definite viral, and 79 indeterminate infections; median age, 17 months; 57%
male), all 23 patients with microbiologically confirmed definite bacterial
infection were classified as bacterial (sensitivity, 100% [95% CI, 100%-100%])
and 27 of 28 patients with definite viral infection were classified as viral
(specificity, 96.4% [95% CI, 89.3%-100%]). When applied to additional
validation datasets from patients with meningococcal and inflammatory diseases,
bacterial infection was identified with a sensitivity of 91.7% (95% CI,
79.2%-100%) and 90.0% (95% CI, 70.0%-100%), respectively, and with specificity
of 96.0% (95% CI, 88.0%-100%) and 95.8% (95% CI, 89.6%-100%). Of the children
in the indeterminate groups, 46.3% (63/136) were classified as having bacterial
infection, although 94.9% (129/136) received antibiotic treatment.
Conclusions
and Relevance This study provides
preliminary data regarding test accuracy of a 2-transcript host RNA signature
discriminating bacterial from viral infection in febrile children. Further
studies are needed in diverse groups of patients to assess accuracy and
clinical utility of this test in different clinical settings.
2. Age-adjusted DD Wins…Again
Wells Rule and d-Dimer Testing to Rule
Out PE: A Systematic Review and Individual-Patient Data Meta-analysis
van Es N, et
al. Ann Intern Med. 2016;165(4):253-261.
Background:
The performance of different diagnostic strategies for pulmonary embolism (PE)
in patient subgroups is unclear.
Purpose: To
evaluate and compare the efficiency and safety of the Wells rule with fixed or
age-adjusted d-dimer testing overall and in inpatients and persons with cancer,
chronic obstructive pulmonary disease, previous venous thromboembolism, delayed
presentation, and age 75 years or older.
Data Sources:
MEDLINE and EMBASE from 1 January 1988 to 13 February 2016.
Study Selection:
6 prospective studies in which the diagnostic management of PE was guided by
the dichotomized Wells rule and quantitative d-dimer testing.
Data
Extraction: Individual data of 7268 patients; risk of bias assessed by 2
investigators with the QUADAS-2 (Quality Assessment of Diagnostic Accuracy
Studies 2) tool.
Data
Synthesis: The proportion of patients in whom imaging could be withheld based
on a “PE-unlikely” Wells score and a negative d-dimer test result (efficiency)
was estimated using fixed (≤500 µg/L) and age-adjusted (age × 10 µg/L in
patients aged greater than 50 years) d-dimer thresholds; their 3-month
incidence of symptomatic venous thromboembolism (failure rate) was also
estimated. Overall, efficiency increased from 28% to 33% when the age-adjusted
(instead of the fixed) d-dimer threshold was applied. This increase was more
prominent in elderly patients (12%) but less so in inpatients (2.6%). The
failure rate of age-adjusted d-dimer testing was less than 3% in all examined
subgroups.
Limitation:
Post hoc analysis, between-study differences in patient characteristics, use of
various d-dimer assays, and limited statistical power to assess failure rate.
Conclusion:
Age-adjusted d-dimer testing is associated with a 5% absolute increase in the
proportion of patients with suspected PE in whom imaging can be safely withheld
compared with fixed d-dimer testing. This strategy seems safe across different
high-risk subgroups, but its efficiency varies.
Bottom line
In most
patients older than 50 years with suspected PE, an age-adjusted cutoff for
D-dimer should be used with the Wells rule to exclude the diagnosis.
An
age-adjusted D-dimer cutoff seems to be safe across a wide range of subgroups
(including patients with chronic obstructive pulmonary disease, cancer, venous
thrombosis, and age older than 75 years).
In
hospitalized patients, the age-adjusted D-dimer cutoff was associated with a
modest 2.6% increase in the number of patients who could be ruled out for PE.
Therefore, the efficiency of this approach for inpatients may be somewhat
limited.
3. Neither Acetaminophen nor Ibuprofen Aggravate Pediatric
Asthma
There has
been concern that acetaminophen may exacerbate asthma. These investigators
found no difference in asthma control among young children treated for minor
illnesses with acetaminophen as compared with ibuprofen.
Sheehan WJ,
et al. Acetaminophen versus Ibuprofen in Young Children with Mild Persistent
Asthma. N Engl J Med. 2016 Aug 18;375(7):619-630.
Background
Studies have suggested an association between frequent acetaminophen use and
asthma-related complications among children, leading some physicians to
recommend that acetaminophen be avoided in children with asthma; however,
appropriately designed trials evaluating this association in children are
lacking.
Methods In a
multicenter, prospective, randomized, double-blind, parallel-group trial, we
enrolled 300 children (age range, 12 to 59 months) with mild persistent asthma
and assigned them to receive either acetaminophen or ibuprofen when needed for
the alleviation of fever or pain over the course of 48 weeks. The primary
outcome was the number of asthma exacerbations that led to treatment with
systemic glucocorticoids. Children in both groups received standardized
asthma-controller therapies that were used in a simultaneous, factorially
linked trial.
Results
Participants received a median of 5.5 doses (interquartile range, 1.0 to 15.0)
of trial medication; there was no significant between-group difference in the
median number of doses received (P=0.47). The number of asthma exacerbations
did not differ significantly between the two groups, with a mean of 0.81 per
participant with acetaminophen and 0.87 per participant with ibuprofen over 46
weeks of follow-up (relative rate of asthma exacerbations in the acetaminophen
group vs. the ibuprofen group, 0.94; 95% confidence interval, 0.69 to 1.28;
P=0.67). In the acetaminophen group, 49% of participants had at least one
asthma exacerbation and 21% had at least two, as compared with 47% and 24%,
respectively, in the ibuprofen group. Similarly, no significant differences
were detected between acetaminophen and ibuprofen with respect to the
percentage of asthma-control days (85.8% and 86.8%, respectively; P=0.50), use
of an albuterol rescue inhaler (2.8 and 3.0 inhalations per week, respectively;
P=0.69), unscheduled health care utilization for asthma (0.75 and 0.76 episodes
per participant, respectively; P=0.94), or adverse events.
Conclusions
Among young children with mild persistent asthma, as-needed use of
acetaminophen was not shown to be associated with a higher incidence of asthma
exacerbations or worse asthma control than was as-needed use of ibuprofen.
Editorial: Acetaminophen and Asthma —
A Small Sigh of Relief?
Acetaminophen
is the drug of choice for fever in young children. Pediatricians, parents, and
caregivers consider it to be safe for most children when it is administered in
accordance with the manufacturer’s directions for use. In 2000, however,
concern was raised about the safety of acetaminophen as a result of the findings
of a case–control study by Shaheen et al.1 that suggested that frequent use of
acetaminophen (also known as paracetamol in the United Kingdom) among adults
was associated with asthma, and among those who already had asthma, with more
severe disease. The mechanism for this association was thought to be the
depletion of glutathione in the lung, leading to greater oxidative stress. This
concern led to more than a decade of observational research on acetaminophen
use and asthma in adults,2 as well as in children and in pregnant women. The
three main questions that the studies attempted to answer were whether frequent
acetaminophen use (either prenatal or postnatal) leads to asthma in children
who would otherwise be asthma-free, whether frequent acetaminophen use in
children and adults who already have asthma worsens symptoms, and whether
ibuprofen is safer than acetaminophen with respect to these asthma-related
issues.
The
limitation of observational studies in assessing the risk associated with these
common over-the-counter medications is confounding by indication3 (i.e., people
who use a drug more frequently differ in key characteristics from those who use
the drug less frequently or who do not use the drug at all). In the case of
studies evaluating an association between acetaminophen use and asthma in
children, viral respiratory illnesses are the most common causes of wheezing
among children with asthma, but because these illnesses also cause fever and
aches (two potential indications for acetaminophen), it is difficult to
determine a causal association. Therefore, there have been calls for
well-performed clinical trials to settle the issue of causation.2,4
4. ACEP Clinical Policy: Critical Issues in the Evaluation of
Adults with Suspected TIA in the ED
Lo BM, et al.
Ann Emerg Med. 2016;68(3):354–370.e29.
Abstract
This clinical
policy from the American College of Emergency Physicians addresses key issues
for adults presenting to the emergency department with suspected transient
ischemic attack. A writing subcommittee conducted a systematic review of the
literature to derive evidence-based recommendations to answer the following
clinical questions:
(1) In adult
patients with suspected transient ischemic attack, are there clinical decision
rules that can identify patients at very low short-term risk for stroke who can
be safely discharged from the emergency department?
(2) In adult
patients with suspected transient ischemic attack, what imaging can be safely
delayed from the initial emergency department workup?
(3) In adult
patients with suspected transient ischemic attack, is carotid ultrasonography
as accurate as neck computed tomography angiography or magnetic resonance
angiography in identifying severe carotid stenosis?
(4) In adult
patients with suspected transient ischemic attack, can a rapid emergency
department-based diagnostic protocol safely identify patients at short-term
risk for stroke? Evidence was graded and recommendations were made based on the
strength of the available data.
5. When diuretics may not be the place to start in the ED
treatment of HF
Collins SP,
et al. Clinical and Research Considerations for Patients With Hypertensive
Acute Heart Failure: A Consensus Statement from the Society for Academic
Emergency Medicine and the Heart Failure Society of America Acute Heart Failure
Working Group. Acad Emerg Med. 2016;23(8):922-931.
Excerpts
Abstract
Management
approaches for patients in the emergency department (ED) who present with acute
heart failure (AHF) have largely focused on intravenous diuretics. Yet, the
primary pathophysiologic derangement underlying AHF in many patients is not
solely volume overload. Patients with hypertensive AHF (H-AHF) represent a
clinical phenotype with distinct pathophysiologic mechanisms that result in
elevated ventricular filling pressures. To optimize treatment response and
minimize adverse events in this subgroup, we propose that clinical management
be tailored to a conceptual model of disease that is based on these mechanisms.
This consensus statement reviews the relevant pathophysiology, clinical
characteristics, approach to therapy, and considerations for clinical trials in
ED patients with H-AHF.
Suggested Management of Hypertensive
Acute HF
1. Administer
oxygen as needed to keep saturation 95% or greater, give sublingual
nitroglycerin. Sublingual nitroglycerin may be repeated up to one per minute
2. If severe
dyspnea, consider NIV or intubation.
3. If blood
pressure is greater than 150/100 mm Hg, add IV nitroglycerin or nitroprusside;
if blood pressure falls below 100 mm Hg, stop nitrates or nitroprusside,
monitor for persistent hypotension or symptoms. If blood pressure is less than
150/100 mm Hg after sublingual administration and if clinically improved,
consider transdermal nitroglycerin. See text for discussion of these agents.
4. Start IV
loop diuretic (furosemide or bumetanide or torsemide) in the setting of volume
overload. Initiate nitrates before
diuretics.
5. Assess for
severity of illness/high risk: altered mental status persistent, hypoxia
despite NIV, hypotension, troponin elevation, ischemic ECG changes, blood urea
nitrogen over 43, creatinine over 2.75, tachycardia, tachypnea, or inadequate
urine output.
6. Admit to
ICU if high severity of illness or risk of decompensation.
7. Choose
discharge or ED observation unit admission if good response to therapy and no
need for ongoing IV vasodilators, no high-risk features, and good social
support. Admit the rest, ICU if any ongoing cardiorespiratory compromise or
acute ischemia. Scoring systems may not reliably identify all patients at risk…
Conclusion and Future Directions
The hallmark
of patients presenting to the ED with hypertensive acute heart failure is an
altered relationship between ventricular and vascular function, leading to
reduced cardiovascular reserve and an inability to adequately accommodate
increases in venous return. Arterioles adapt to chronic increases in arterial
pressure associated with hypertension, resulting in increased afterload
triggering early aortic valve closure. An immediate consequence is increased
diastolic volume and pressure. Subsequent increases in pulmonary venous
pressures may result in pulmonary congestion. Many of these patients are older
with concomitant renal disease. Preliminary data raise the possibility that
future treatment might be better focused on preload and afterload reduction
with vasodilators rather than volume removal with diuretics…
Article link
(full-text requires subscription): http://onlinelibrary.wiley.com/doi/10.1111/acem.13025/abstract
6. External validation of the ED assessment of CP score
accelerated diagnostic pathway (EDACS-ADP).
Flaws D, et
al. Emerg Med J. 2016 Sep;33(9):618-25.
OBJECTIVE:
The emergency department assessment of chest pain score accelerated diagnostic
pathway (EDACS-ADP) facilitates low-risk ED chest pain patients early to
outpatient investigation. We aimed to validate this rule in a North American
population.
METHODS: We
performed a retrospective validation of the EDACS-ADP using 763 chest pain
patients who presented to St Paul's Hospital, Vancouver, Canada, between June
2000 and January 2003. Patients were classified as low risk if they had an
EDACS below 16, no new ischaemia on ECG and non-elevated serial 0-hour and
2-hour cardiac troponin concentrations. The primary outcome was the number of
patients who had a predetermined major adverse cardiac event (MACE) at 30 days
after presentation.
RESULTS: Of
the 763 patients, 317 (41.6%) were classified as low risk by the EDACS-ADP. The
sensitivity, specificity, negative predictive value and positive predictive
value of the EDACS-ADP for 30-day MACE were 100% (95% CI 94.2% to 100%), 46.4%
(95% CI 42.6% to 50.2%), 100% (95% CI 98.5% to 100.0%) and 17.5% (95% CI 14.1%
to 21.3%), respectively.
CONCLUSIONS:
This study validated the EDACS-ADP in a novel context and supports its safe use
in a North American population. It confirms that EDACS-ADP can facilitate
progression to early outpatient investigation in up to 40% of ED chest pain
patients within 2 hours.
7. FABS: An Intuitive Tool for Screening of Stroke Mimics in the
ED
Goyal N, et
al. Stroke. 2016 Sep;47(9):2216-20.
BACKGROUND
AND PURPOSE: A large number of patients with symptoms of acute cerebral
ischemia are stroke mimics (SMs). In this study, we sought to develop a scoring
system (FABS) for screening and stratifying SM from acute cerebral ischemia and
to identify patients who may require magnetic resonance imaging to confirm or
refute a diagnosis of stroke in the emergency setting.
METHODS: We
designed a scoring system: FABS (6 variables with 1 point for each variable
present): absence of Facial droop, negative history of Atrial fibrillation, Age
less than 50 years, systolic Blood pressure less than 150 mm Hg at
presentation, history of Seizures, and isolated Sensory symptoms without
weakness at presentation. We evaluated consecutive patients with symptoms of
acute cerebral ischemia and a negative head computed tomography for any acute
finding within 4.5 hours after symptom onset in 2 tertiary care stroke centers
for validation of FABS.
RESULTS: A
total of 784 patients (41% SMs) were evaluated. Receiver operating
characteristic curve (C statistic, 0.95; 95% confidence interval [CI],
0.93-0.98) indicated that FABS≥3 could identify patients with SM with 90%
sensitivity (95% CI, 86%-93%) and 91% specificity (95% CI, 88%-93%). The
negative predictive value and positive predictive value were 93% (95% CI,
90%-95%) and 87% (95% CI, 83%-91%), respectively.
CONCLUSIONS:
FABS seems to be reliable in stratifying SM from acute cerebral ischemia cases
among patients in whom the head computed tomography was negative for any acute
findings. It can help clinicians consider advanced imaging for further
diagnosis.
Full-text
(free): http://stroke.ahajournals.org/content/early/2016/08/04/STROKEAHA.116.013842.full.pdf+html
8. Short-term Prognosis and Current Management of Syncopal
Patients at Intermediate Risk: Results from the IRiS (Intermediate-Risk
Syncope) Study.
Numeroso F,
et al. Acad Emerg Med. 2016 Aug;23(8):941-8.
OBJECTIVES: Despite
guidelines, admission rates and expenditures for syncope remain high. This may
be caused by an imprecise definition of cardiovascular disease considered at
risk and an overestimation of the role of comorbidities and advanced age. In a
cohort of patients with undetermined syncope, we prospectively compared the
short-term prognosis of patients at intermediate risk (i.e., with stable heart
diseases or comorbidities, of any age) versus those at high risk for
cardiogenic syncope and identified factors associated with serious events.
Secondarily, we analyzed the current management of intermediate-risk patients.
METHODS: In a
cohort of patients with undetermined syncope, we analyzed personal data, the
presence of stable heart diseases or comorbidities, destination, length of
hospitalization, incidence of serious events at 30 days, and costs.
RESULTS: In a
6-month period, 347 patients (185 male and 162 female, age 72.8 years) with
undetermined syncope were enrolled, 250 at intermediate risk and 97 at high
risk. Intermediate-risk patients were younger, with less frequent comorbidities
and with a drastically lower incidence of serious events (0.8% vs. 27.8%, p less
than 0.001). Risk factors for cardiogenic syncope were the unique variable
associated with serious events. Intermediate-risk patients were mostly admitted
(62.8%) in an ordinary ward or into an emergency department observation unit;
in the case of ordinary admission we observed a mean prolonged hospitalization
(8.8 days), elevated costs ($270,183), and a high rate of unexplained syncope
(51%).
CONCLUSIONS: According
to the results of this study, the authors believe that intermediate-risk
patients could be safely discharged, with potentially significant costs saving.
In prognostic stratification, priority is to seek risk factors for cardiogenic
syncope while advanced age, stable heart diseases, or comorbidities likely lead
to inappropriate hospitalization.
A prospective
interventional study is needed to validate our results. In the prognostic
stratification of patients with syncope, factors such as stable cardiovascular
diseases or comorbidities and advanced age, which often characterize syncopal
patients at intermediate risk, should not lead per se to hospitalization
because they are not related to serious events. On the contrary, emergency
physicians should promptly identify patients at high risk for cardiogenic
syncope to be hospitalized for thorough evaluation, due to the high incidence
of serious short-term adverse events.
What constituted high risk?
FH
Family
history of SCD
HPI
Syncope
during exertion or supine
Palpitations
or chest pain
PE
Strong
systolic ejection murmur
ECG
Bifascicular
block or other block with QRS greater than 120 msec
Inadequate
sinus bradycardia or sinoatrial block
Preexcited
QRS complex
Prolonged or
short QT interval
Brugada
pattern type1 or ECG changes suggestive for arrhythmogenic RV cardiomyopathy
9. What is the purpose of log roll examination in the
unconscious adult trauma patient during trauma reception?
Singh Tveit M,
et al. Emerg Med J. 2016 Sep;33(9):632-5.
BACKGROUND:
During assessment after injury, the log roll examination, in particular
palpation of the thoracolumbar spine, has low sensitivity for detecting spinal
injury. The manoeuvre itself requires a pause during trauma resuscitation. The
aim of this study was to assess the utility of the log roll examination in
unconscious trauma patients for the diagnosis of soft tissue and thoracolumbar
spine injuries.
METHODS: A
retrospective cohort study was undertaken, reviewing the cases of unconscious
(Glasgow Coma Scale (GCS) less than 9) and/or intubated major trauma (Injury
Severity Scale (ISS) greater than 12, abbreviated injury scale 2008) patients
from the Alfred Trauma Registry, over a 2-year period from January 2011 to
December 2012. Log roll examination findings, as documented in the medical
record, were compared with CT reports. Out of the 624 screened records, 222
(35.6%) were excluded as the log roll or CT/MRI had not been performed.
RESULTS:
There were a total of 2028 major trauma presentations to the Alfred Hospital
Emergency and Trauma Centre during the study period. Excluded cases comprised
147 patients who did not have a documented log roll, and 75 patients who did
not have a CT or MRI. Of the 402 cases that met inclusion criteria, 35.3% had a
thoracolumbar fracture, and the sensitivity of log roll examination was found
to be 27.5%, with a specificity of 91%. The negative likelihood ratio for
abnormalities on log roll was low (0.8).
CONCLUSIONS:
Examination of the back in unconscious trauma patients could be limited to
visual inspection only to allow identification of penetrating wounds and other
soft tissue injuries (including of the posterior scalp) and removal of foreign
bodies, in patients planned for CT scans. The low sensitivity and poor negative
likelihood ratio suggest that a normal log roll examination does not accurately
predict the absence of bony injury to the thoracolumbar spine.
10. Images in Clinical Practice
I'd Want a
Natural Death
Takayasu’s
Arteritis
Gastric
Anisakiasis
Aortic
Calcification and Superior-Mesenteric-Artery Stenosis
Enlarged
Right Atrium
Urticaria
Multiforme
Giant
Thrombosed Intracranial Aneurysm
A Sneeze
Young Man
With Dyspnea
Young Male
With Painful Skin Necrosis
Man With
Altered Mental Status and Rash
Man With
Diminished Breath Sounds on the Right
Man With
Right-Sided Abdominal Pain
Woman With
Vision Loss in Left Eye
Newborn With
Vomiting
Man With
Bleeding Gums and Skin Rash
Discussion:
Remember to Take Your Vitamins…
Elderly Woman
With Chest Pain
Woman With
Sudden-Onset Headache
11. Treatment with Prothrombin Complex Concentrate to Enable
Emergency LP in Patients Receiving Vitamin K Antagonists.
Laible M, et
al. Ann Emerg Med. 2016;68(3):340–344.
STUDY
OBJECTIVE: Lumbar punctures are frequently necessary in neurologic emergencies,
but effective oral anticoagulation with vitamin K antagonists represents a
contraindication. We report the effectiveness of prothrombin complex
concentrates to reverse vitamin K antagonist to enable emergency lumbar
punctures, as well as evaluate lumbar puncture- and prothrombin complex
concentrates-related complications.
METHODS: Consecutive
patients treated with prothrombin complex concentrates between December 2004
and June 2014 to enable emergency lumbar puncture were included. International
normalized ratio (INR) before and after prothrombin complex concentrates
treatment and the time between start of reversal treatment and lumbar puncture
were recorded. A target INR of less than or equal to 1.5 was defined as
effective prothrombin complex concentrates treatment. Bleeding events,
thromboembolic events, and allergic reactions after prothrombin complex concentrates
treatment were identified and classified as "related,"
"probably," "possibly," "unlikely related," or
"not related" to the lumbar puncture and prothrombin complex
concentrates infusion.
RESULTS: Thirty-seven
patients were included (64.9% men; median age 76.0 years; interquartile range
[IQR] 71.0 to 84.0 years). The intervention with prothrombin complex
concentrates was effective in 33 of 37 patients (89.2%; 95% confidence interval
[CI], 78.4% to 97.3%). The median INR was 2.2 (IQR 1.8 to 2.9; 95% CI, 1.9 to
2.5) before and 1.3 (IQR 1.2 to 1.4; 95% CI, 1.2 to 1.3) after prothrombin
complex concentrates treatment. The median time between start of prothrombin
complex concentrates treatment and lumbar puncture was 135 minutes (IQR 76 to
266 minutes; 95% CI, 84 to 198 minutes). One clinically irrelevant intracranial
subdural hematoma "related" to the lumbar puncture developed. No
allergic reaction was observed, but 2 of 37 patients (5.4%; 95% CI, 0% to
13.5%) experienced a thromboembolic event (1 ischemic stroke, classified
"unlikely related," and 1 myocardial infarction, "possibly
related" to prothrombin complex concentrates treatment).
CONCLUSION: Reversing
the effect of vitamin K antagonist with prothrombin complex concentrates to
enable emergency lumbar puncture appears effective and safe, particularly in
regard to bleeding events.
12. Lancet Articles on ACS Management
A.
Early invasive versus non-invasive treatment in patients with non-ST-elevation
acute coronary syndrome (FRISC-II): 15 year follow-up of a prospective,
randomised, multicentre study
Wallentin L,
et al. Lancet 2016 Aug 29 [Epub ahead of print]
Background: The
FRISC-II trial was the first randomised trial to show a reduction in death or
myocardial infarction with an early invasive versus a non-invasive treatment
strategy in patients with non-ST-elevation acute coronary syndrome. Here we
provide a remaining lifetime perspective on the effects on all cardiovascular
events during 15 years' follow-up.
Methods: The
FRISC-II prospective, randomised, multicentre trial was done at 58 Scandinavian
centres in Sweden, Denmark, and Norway. Between June 17, 1996, and Aug 28,
1998, we randomly assigned (1:1) 2457 patients with non-ST-elevation acute
coronary syndrome to an early invasive treatment strategy, aiming for
revascularisation within 7 days, or a non-invasive strategy, with invasive
procedures at recurrent symptoms or severe exercise-induced ischaemia. Plasma
for biomarker analyses was obtained at randomisation. For long-term outcomes,
we linked data with national health-care registers. The primary endpoint was a
composite of death or myocardial infarction. Outcomes were compared as the
average postponement of the next event, including recurrent events, calculated
as the area between mean cumulative count-of-events curves. Analyses were done
by intention to treat.
Findings: At
a minimum of 15 years' follow-up on Dec 31, 2014, data for survival status and
death were available for 2421 (99%) of the initially recruited 2457 patients,
and for other events after 2 years for 2182 (89%) patients. During follow-up,
the invasive strategy postponed death or next myocardial infarction by a mean
of 549 days (95% CI 204–888; p=0·0020) compared with the non-invasive strategy.
This effect was larger in non-smokers (mean gain 809 days, 95% CI 402–1175;
pinteraction=0·0182), patients with elevated troponin T (778 days, 357–1165;
pinteraction=0·0241), and patients with high concentrations of growth
differentiation factor-15 (1356 days, 507–1650; pinteraction=0·0210). The
difference was mainly driven by postponement of new myocardial infarction,
whereas the early difference in mortality alone was not sustained over time.
The invasive strategy led to a mean of 1128 days (95% CI 830–1366) postponement
of death or next readmission to hospital for ischaemic heart disease, which was
consistent in all subgroups (p less than 0·0001).
Interpretation:
During 15 years of follow-up, an early invasive treatment strategy postponed
the occurrence of death or next myocardial infarction by an average of 18
months, and the next readmission to hospital for ischaemic heart disease by 37
months, compared with a non-invasive strategy in patients with non-ST-elevation
acute coronary syndrome. This remaining lifetime perspective supports that an
early invasive treatment strategy should be the preferred option in most
patients with non-ST-elevation acute coronary syndrome.
B.
Platelet function monitoring to adjust antiplatelet therapy in elderly patients
stented for an acute coronary syndrome (ANTARCTIC): an open-label,
blinded-endpoint, randomised controlled superiority trial
Cayla G, et
al. Lancet 2016 Aug 28 [Epub ahead of print]
Background: Elderly
patients are at high risk of ischaemic and bleeding events. Platelet function
monitoring offers the possibility to individualise antiplatelet therapy to
improve the therapeutic risk–benefit ratio. We aimed to assess the effect of
platelet function monitoring with treatment adjustment in elderly patients
stented for an acute coronary syndrome.
Methods: We
did this multicentre, open-label, blinded-endpoint, randomised controlled
superiority study at 35 centres in France. Patients aged 75 years or older who
had undergone coronary stenting for acute coronary syndrome were randomly
assigned (1:1), via a central interactive voice-response system based on a
computer-generated permuted-block randomisation schedule with randomly selected
block sizes, to receive oral prasugrel 5 mg daily with dose or drug adjustment
in case of inadequate response (monitoring group) or oral prasugrel 5 mg daily
with no monitoring or treatment adjustment (conventional group). Randomisation
was stratified by centre. Platelet function testing was done 14 days after
randomisation and repeated 14 days after treatment adjustment in patients in
the monitoring group. Study investigators and patients were not masked to
treatment allocation, but allocation was concealed from an independent clinical
events committee responsible for endpoint adjudication. The primary endpoint
was a composite of cardiovascular death, myocardial infarction, stroke, stent
thrombosis, urgent revascularisation, and Bleeding Academic Research
Consortium-defined bleeding complications (types 2, 3, or 5) at 12 months'
follow-up. We did analysis by intention to treat. This trial is registered with
ClinicalTrials.gov, number NCT01538446.
Findings: Between
March 27, 2012, and May 19, 2015, we randomly assigned 877 patients to the
monitoring group (n=442) or the conventional group (n=435). The primary
endpoint occurred in 120 (28%) patients in the monitoring group compared with
123 (28%) patients in the conventional group (hazard ratio [HR], 1·003, 95% CI
0·78–1·29; p=0·98). Rates of bleeding events did not differ significantly
between groups.
Interpretation:
Platelet function monitoring with treatment adjustment did not improve the
clinical outcome of elderly patients treated with coronary stenting for an
acute coronary syndrome. Platelet function testing is still being used in many
centres and international guidelines still recommend platelet function testing
in high-risk situations. Our study does not support this practice or these
recommendations.
13. Waiting Room Medicine
A.
Fellowship Training Opportunities
Lund A. CJEM
2007;9(1):71
The
Department of Emergency Medicine at Any Canadian Hospital (ACH) is actively
seeking qualified applicants for a 6-month fellowship position in the emerging
Emergency Medicine (EM) subspecialty of Waiting Room (WR) Medicine.
This unique
opportunity is being offered through the busy waiting room of the Emergency
Department (ED) at ANY CANADIAN HOSPITAL, a premiere teaching institution with
the University of Said Province.
The Setting
The ED sees
in excess of 65,000 patients per year (mostly in the waiting room!), and is the
trauma receiving hospital for the region. Located in or near a great Canadian
city, there are many recreational opportunities for interested applicants (which
is important because, truth be told, the work is not so rewarding).
The Crowding
Problem
Access to
inpatient beds for acutely ill patients in Canada has been consistently
decreasing over the last decade. Many EDs have been paralyzed by the admitted
patients in their stretchers warehoused in their hallways. Emergency Physicians
(EPs) have little formal training in providing medical care outside of the
usual confines of an actual bed with a nurse available to provide care.
Clearly, this training deficit leaves most EPs behind the times. Much of the care provided in contemporary EDs
is done in chairs, on ambulance gurneys, behind temporary curtains, or in broom
closets, bathrooms, offices, and of course, in the waiting room. With the ever
increasing demand for Waiting Room Medicine, we see a fabulous opportunity to
foster the unique skill-set of WR medicine in EM learners and EPs seeking
higher levels of training.
Rotations
include
• Unmonitored
Cardiology — Make decisions about which of the 6 patients with crushing chest
pain should get the next available bed when it opens up in the morning.
• WR Surgery
— You’d be surprised how many things you can sew, lance, drain and wrap in a
simple WR chair.
•
Communication Skills — Key objectives for the communication skills module
include learning how to ask embarrassing questions in front of a crowd,
learning to say “I’m sorry for the care you’re receiving” in a manner that
doesn’t lead to your being assaulted by angry family members, and learning to
say “these curtains are soundproof” with a straight face.
• EMS — Deal
with ambulance diversion, critical care bypass; provide catering and
nutritional requirements for waiting ambulance crews. Gain valuable skills in
diverting ambulances with seriously ill patients from your ED to another
equally overcrowded ED.
• Lab &
Radiology — Learn to make judicious use of investigations based on a triage
note and/or EMS report; no need to bother yourself with talking to or examining
the patient until all the labs are back.
• Triage in
the Real World — Practise reverse triage, where CTAS (triage acuity score) IVs
and Vs are seen expeditiously, because they are “quick and easy,” and CTAS IIs
and IIIs are left to languish for hours.
• WR Ethics —
Triage the conflicting values of good patient care and maintaining the flow.
• WR Admin
Interactions — Dealing with disappointment; how to carry on after seeking help
from the administrators on call.
• WR Patients
as Monitors — Learning to use other WR patients for the reassessment of
critically ill patients (with a focus on teaching lay people about the
recognition of seizures, initial management of cardiac arrest, and guidelines for
involving the triage nurse in WR care)…
Full-text
(free): https://www.researchgate.net/publication/271507010_ACH_-_Career_Opportunity_in_Emergency_Medicine_Waiting_Room_Medicine_Fellowship
B.
Initiating Diagnostic Studies on Patients With AP in the Waiting Room Decreases
Time Spent in an ED Bed: A RCT
Begaz T. Ann
Emerg Med. 2016 Aug 12 [Epub ahead of print]
Study
objective
The effect of
clinician screening of patients in the emergency department (ED) waiting room
is unclear. This study aims to determine the effect of initiating laboratory
and imaging studies from the ED waiting room on time in a bed, total ED time,
and likelihood of patients leaving before completion of service.
Methods
This was a
prospective, randomized, controlled trial evaluating 1,659 nonpregnant adults
with a chief complaint of abdominal pain, conducted in a public hospital ED
when all ED beds were occupied and patients were in the waiting room awaiting
definitive evaluation. After a brief screening examination, stable patients
were randomized to either rapid medical evaluation (RME)+waiting room
diagnostic testing (WRDT) or RME-only groups. Patients randomized to the
RME+WRDT group had laboratory and imaging studies ordered at the discretion of
the screening provider while in the waiting room. The primary outcome was time
in an ED bed. Secondary outcomes were total ED time and rate of leaving before
completion of service. Linear and logistic regression models were used to
compare outcomes between groups.
Results
Between July
2014 and May 2015, 1,659 patients completed the study, 848 patients in the
RME+WRDT group and 811 in the RME-only group. Baseline demographic
characteristics were similar between groups. Patients in the RME+WRDT group had
a significantly shorter mean time in an ED bed than the RME-only group, 245
minutes compared with 277 minutes (adjusted difference of 31 minutes; 95%
confidence interval [CI] 16 to 46 minutes). The RME+WRDT group also had
significantly shorter mean total ED time from arrival to disposition than the
RME-only group, 460 minutes compared with 504 minutes (adjusted difference 42
minutes; 95% CI 22 to 63 minutes). Of the 1,659 patients enrolled, 181 left
before completion of service: 78 of 848 patients (9%) in the RME+WRDT group
compared with 103 of 811 (13%) in the RME-only group (difference 3.5%; 95% CI
0.5% to 6.5%). By the end of their ED visit, patients in the RME+WRDT group had
significantly more types of diagnostic studies ordered than those in the
RME-only group, 2.59 versus 2.03 total unique test categories by location
ordered (difference 0.56; 95% CI 0.44 to 0.68).
Conclusion
Initiating
diagnostic testing in the waiting room reduced time spent in an ED bed, total
ED time, and rates of leaving before completion of service. For clinicians
screening patients in the waiting room, initiating diagnostic evaluations may
improve throughput in crowded EDs.
14. Reviews from Ann Emerg Med
A.
Can Ocular Ultrasonography Be Used to Assess Intracranial Pressure?
Take-Home
Message
Measurement
of the optic nerve sheath diameter demonstrates good diagnostic test accuracy
for differentiating between elevated and normal intracranial pressure when
compared with computed tomography (CT). Specifically, the high sensitivity
allows the clinician to rule out increased intracranial pressure in low-risk
patients, whereas the high specificity can confirm elevated intracranial
pressure in those at high risk.
B.
Can Noncontrast Head CT Within 6 Hours of Symptom Onset Exclude Aneurysmal SAH?
Take-Home
Message
A normal
result for noncontrast head computed tomography (CT) obtained within 6 hours of
symptom onset appears to substantially decrease the likelihood of subarachnoid
hemorrhage.
C.
Is a Single High-Sensitivity Troponin T Assay Accurate for the Detection of
Acute Myocardial Infarction?
Take-Home
Message
In high-risk
chest pain patients, a single, normal, high-sensitivity troponin T level
identifies those who are very unlikely to have acute myocardial infarction, yet
the optimal diagnostic threshold and timing remain unclear.
D.
Periprosthetic Joint Infection after Hip and Knee Arthroplasty: A Review for
Emergency Care Providers
Intro’s
opener: Periprosthetic joint infection is among the most common modes of
failure of a total hip or knee arthroplasty and can be a common concern when
patients present to the emergency department for care. The initial evaluation
for periprosthetic joint infection includes a history and physical examination,
followed by radiographs (to rule out other causes of pain or failure) and then
serum erythrocyte sedimentation rate and C-reactive protein testing. If the
erythrocyte sedimentation rate and C-reactive protein level are elevated or if
the clinical suspicion for infection is high, the joint should be aspirated and
the fluid sent for culture, as well as for a synovial WBC count and
differential, with optimal threshold values of 3,000 WBC/μL and 80%
polymorphonuclear cells, respectively…
15. Muscular fitness as a mediator of quality CPR
López-González
A, et al. Am J Emerg Med. 2016 Sep;34(9):1845-9.
BACKGROUND: It
has been hypothesized that body mass index (BMI) and muscle strength (MS) of
the rescuers are predictors of adequate external chest compressions (ECC). The
aims of this study were: (a) to analyze, in college students, the relationship
between BMI and MS with adequate ECC parameters; and (b) to examine whether the
association between BMI and adequate ECC parameters is mediated by MS.
METHODS: A
cross-sectional analysis of the evaluation of a CPR performance test involving
students (n=63). We determined BMI and MS. After previous training,
participants performed cardiopulmonary resuscitation on a mannequin for 20
minutes. PROCESS macro developed by Preacher and Hayes was used to assess
whether the association between BMI and ECC was mediated by MS.
RESULTS: Underweight
subjects achieved lower results than those with normal weight and
overweight/obese in several dependent variables including: correct compression
depth (P less than .001) and adequate ECC (P less than .001). This differences
remained after adjusting for muscle strength except for the compression rate
(P=.053). Moreover, participants in the low MS quartile were lower in both
correct compression depth (P=.001) and adequate ECC (P less than .001) than
participants in the medium/high quartile after adjusting for confounding
variables. The effect of BMI on adequate ECC was partially mediated by MS.
Similar results were obtained in the analysis of the mediator role of MS in the
relationship between BMI and correct compression depth.
CONCLUSIONS: The
ability to provide adequate ECC is influenced by the rescuer's MS. Rescuers
should be advised to exercise arm strength to improve the quality of CPR.
16. Updated Guidelines for Antiretroviral PEP after Sexual,
Injection Drug Use, or Other Nonoccupational Exposure to HIV—United States,
2016
Centers for
Disease Control and Prevention. Ann Emerg Med. 2016;98(3):335-338.
The purpose
of these guidelines is to provide health care providers in the United States
with updated guidelines to the 2005 US Department of Health and Human Services
nonoccupational postexposure prophylaxis (nPEP) recommendations1 on the use of
antiretroviral nPEP and other aspects of case management for persons with
isolated exposure outside health care settings to blood, genital secretions, or
other potentially infectious body fluids that might contain HIV. The use of
occupational postexposure prophylaxis for case management for persons with
possible HIV exposures occurring in health care settings is not addressed in
this guideline; updated occupational postexposure prophylaxis guidelines have
been published separately.2
This update
incorporates additional evidence about use of nPEP from animal studies and
human observational studies, and consideration of new antiretroviral
medications that were approved since the 2005 guidelines, some of which have
improved tolerability. New features are inclusion of guidelines for the use of
rapid antigen-antibody combination HIV tests, for revised preferred and
alternative 3-drug antiretroviral nPEP regimens, an updated schedule of
laboratory evaluations of source and exposed persons, updated antimicrobial
regimens for prophylaxis of sexually transmitted infections and hepatitis, and
a suggested procedure for transitioning patients between nPEP and HIV
preexposure prophylaxis, as appropriate…
17. Validation of the "Step-by-Step" Approach in the
Management of Young Febrile Infants.
Gomez B, et
al. Pediatrics. 2016 Aug;138(2).
BACKGROUND: A
sequential approach to young febrile infants on the basis of clinical and
laboratory parameters, including procalcitonin, was recently described as an
accurate tool in identifying patients at risk for invasive bacterial infection
(IBI). Our aim was to prospectively validate the Step-by-Step approach and
compare it with the Rochester criteria and the Lab-score.
METHODS:
Prospective study including infants ≤90 days with fever without source
presenting in 11 European pediatric emergency departments between September
2012 and August 2014. The accuracy of the Step-by-Step approach, the Rochester
criteria, and the Lab-score in identifying patients at low risk of IBI
(isolation of a bacterial pathogen in a blood or cerebrospinal fluid culture)
was compared.
RESULTS:
Eighty-seven of 2185 infants (4.0%) were diagnosed with an IBI. The prevalence
of IBI was significantly higher in infants classified as high risk or
intermediate risk according to the Step by Step than in low risk patients.
Sensitivity and negative predictive value for ruling out an IBI were 92.0% and
99.3% for the Step by Step, 81.6% and 98.3% for the Rochester criteria, and
59.8% and 98.1% for the Lab-score. Seven infants with an IBI were misclassified
by the Step by Step, 16 by Rochester criteria, and 35 by the Lab-score.
CONCLUSIONS:
We validated the Step by Step as a valuable tool for the management of infants
with fever without source in the emergency department and confirmed its
superior accuracy in identifying patients at low risk of IBI, compared with the
Rochester criteria and the Lab-score.
18. Prevalence and Localization of PE in Unexplained Acute
Exacerbations of COPD: A systematic review and meta-analysis.
Aleva FE, et
al. Chest. 2016 Aug 11 [Epub ahead of print]
BACKGROUND:
COPD patients encounter episodes of increased inflammation, so-called acute
exacerbations of COPD (AE-COPD). In 30% of AE-COPD no clear etiology is found.
Since there is a well-known crosstalk between inflammation and thrombosis, the
objectives of this study were to determine the prevalence, embolus localization
and clinical relevance, and clinical markers of pulmonary embolism (PE) in
unexplained AE-COPD.
METHODS: A
systematic search was performed using MEDLINE and EMBASE platforms from 1974 -
October 2015. Prospective- and cross-sectional studies that included patients
with an AE-COPD and used pulmonary CT-angiography for diagnosis of PE were
included.
RESULTS: The
systematic search resulted in 1650 records. Main reports of 22 articles were
reviewed and 7 studies were included. The pooled prevalence of PE in
unexplained AE-COPD was 16.1% (95% confidence-interval 8.3%-25.8%) in a total
of 880 patients. Sixty-eight percent of the emboli found were located in the
main pulmonary arteries, lobar arteries or inter-lobar arteries. Mortality and
length of hospital admission seem to be increased in patients with unexplained
AE-COPD and PE. Pleuritic chest pain and cardiac failure were more frequently
reported in patients with unexplained AE-COPD and PE. In contrast, signs of
respiratory tract infection was less frequently related to PE.
CONCLUSIONS:
PE is frequently seen in unexplained AE-COPD. Two-thirds of emboli are found at
localizations that have a clear indication for anticoagulant treatment. These
findings merit clinical attention. PE should receive increased awareness in
patients with unexplained AE-COPD, especially when pleuritic chest pain and
signs of cardiac failure are present and no clear infectious origin can be
identified.
19. Physicians, Patients, and Firearms
A.
Yes, You Can: Physicians, Patients, and Firearms
Wintemute GJ,
et al. Ann Intern Med.
2016;165(3):205-213.
Physicians
have unique opportunities to help prevent firearm violence. Concern has
developed that federal and state laws or regulations prohibit physicians from
asking or counseling patients about firearms and disclosing patient information
about firearms to others, even when threats to health and safety may be
involved. This is not the case. In this article, the authors explain the
statutes in question, emphasizing that physicians may ask about firearms (with
rare exceptions), may counsel about firearms as they do about other health
matters, and may disclose information to third parties when necessary. The
authors then review circumstances under which questions about firearms might be
most appropriate if they are not asked routinely. Such circumstances include
instances when the patient provides information or exhibits behavior suggesting
an acutely increased risk for violence, whether to himself or others, or when
the patient possesses other individual-level risk factors for violence, such as
alcohol abuse.
The article
summarizes the literature on current physician practices in asking and
counseling about firearms, which are done far less commonly than recommended.
Barriers to engaging in those practices, the effectiveness of clinical efforts
to prevent firearm-related injuries, and what patients think about such efforts
and physicians who engage in them are discussed. Proceeding from the limited
available evidence, the authors make specific recommendations on how physicians
might counsel their patients to reduce their risk for firearm-related death or
serious injury. Finally, the authors review the circumstances under which
disclosure of patient information about firearms to third parties is supported
by regulations implementing the Health Insurance Portability and Accountability
Act…
B.
Curbing Firearm Violence: Identifying a Specific Target for Physician Action
Weinberger
SE. Ann Intern Med. 2016;165(3):221-222.
Physicians
not only have a responsibility to their patients to diagnose and treat illness;
they also have a broader societal obligation to improve population health. The
latter can be discharged in part through activities and conversations with
patients and families aimed at primary prevention of illness and injury. We
have witnessed many examples of successful public health efforts focused on
preventing illness and injury, such as immunization, use of seat belts, and
smoking cessation initiatives. In each case, physicians and other health care
providers have used various methods to inform and educate their patients and
the public at large to effect changes in behavior and adoption of important
preventive measures.
Many in the
medical and public health communities have been attempting to raise
consciousness about firearm-related violence as a similar public health problem
that deserves action by health care professionals to reduce its magnitude and
impact (1–4). Seven large and influential medical professional societies—the
American College of Physicians (ACP), the American Academy of Family
Physicians, the American Academy of Pediatrics, the American College of
Surgeons, the American College of Obstetricians and Gynecologists, the American
Psychiatric Association, and the American College of Emergency Physicians—have
joined with the American Public Health Association to issue a “call to action”
to address firearm-related violence as a major public health problem (5). The
American Bar Association (ABA) also partnered in this effort, noting that none
of the recommendations presented by these health professional organizations
violated the Second Amendment, as established by Supreme Court decisions. Among
these recommendations is a halt to physician gag laws that are intended to
forbid physicians from discussing a patient's gun ownership and attempting to
mitigate the associated risk. More than 50 organizations have now endorsed the
positions and recommendations espoused in this call-to-action paper (6)…
20. Association of Acetaminophen Use during Pregnancy With
Behavioral Problems in Childhood: Evidence Against Confounding.
Stergiakouli
E, et al. JAMA Pediatr. 2016 Aug 15 [Epub ahead of print]
Importance:
Acetaminophen (paracetamol) is used by a large proportion of pregnant women.
Research suggests that acetaminophen use in pregnancy is associated with abnormal
fetal neurodevelopment. However, it is possible that this association might be
confounded by unmeasured behavioral factors linked to acetaminophen use.
Objective: To
examine associations between offspring behavioral problems and (1) maternal
prenatal acetaminophen use, (2) maternal postnatal acetaminophen use, and (3)
partner's acetaminophen use.
Design,
Setting, and Participants: From February 2015 to March 2016, we collected and
analyzed data from the Avon Longitudinal Study of Parents and Children
(ALSPAC), a prospective birth cohort. We studied 7796 mothers enrolled in
ALSPAC between 1991 and 1992 along with their children and partners.
Exposures:
Acetaminophen use was assessed by questionnaire completion at 18 and 32 weeks
of pregnancy and when the child was 61 months old.
Main Outcomes
and Measures: Maternal reports of behavioral problems using the Strengths and
Difficulties Questionnaire (SDQ) when the children were 7 years old. We
estimated risk ratios for behavioral problems in children after prenatal,
postnatal, and partner's exposure to acetaminophen and mutually adjusted each
association.
Results: Maternal
prenatal acetaminophen use at 18 (n = 4415; 53%) and 32 weeks of pregnancy
(n = 3381; 42%) was associated with higher odds of having conduct problems
(risk ratio [RR], 1.42; 95% CI, 1.25-1.62) and hyperactivity symptoms (RR,
1.31; 95% CI, 1.16-1.49), while maternal acetaminophen use at 32 weeks was also
associated with higher odds of having emotional symptoms (RR, 1.29; 95% CI,
1.09-1.53) and total difficulties (RR, 1.46; 95% CI, 1.21-1.77). This was not
the case for maternal postnatal (n = 6916; 89%) or partner's (n = 3454; 84%)
acetaminophen use. We found the associations between maternal prenatal
acetaminophen use and all the SDQ domains unchanged even after adjusting for
maternal postnatal or partner's acetaminophen use.
Conclusions
and Relevance: Children exposed to acetaminophen prenatally are at increased
risk of multiple behavioral difficulties, and the associations do not appear to
be explained by unmeasured behavioral or social factors linked to acetaminophen
use insofar as they are not observed for postnatal or partner's acetaminophen
use. Although these results could have implications for public health advice,
further studies are required to replicate the findings and to understand
mechanisms.
21. Less is More: Redefining Balance
By Christina
Shenvi, MD, PHD. EP Monthly, AUGUST 3, 2016
Want a better
work/life balance? Hint – it’s not about being better at multitasking.
I am tired of
hearing about balance. We talk about it, we go to lectures on it, we give
mandatory presentations on it to our interns. Yet few people would say they
have actually achieved this elusive, zen state. In fact, more than 70% of ER
doctors have signs of burn-out [1] – the opposite of balance. Too many
presentations on balance give insipid suggestions to “make sure you exercise
and eat well,” or “find time to sleep.” I can’t imagine that advice would be
very helpful to someone who is already burning out and living in the margins of
their free time and energy. Something is wrong with this picture.
First of all,
let’s look at the language we use. We all talk about “finding” balance. Where
did it go? Did we lose it? Did we used to have it? I imagine that we did used
to have balance. Perhaps it was when we were in college, or in medical school.
Maybe it ended when residency started, or perhaps when we started having kids.
At some point, we jumped onto a treadmill called ‘career’. We ambled along,
excited at our new position. Then that treadmill started to move a little
faster. If you had a kid or four, then it felt like running on the treadmill
carrying the kids with you.
We are all
constantly adding more to our work lives, taking on new responsibilities,
chairing new committees, stepping into new leadership roles. All the while we
are trying to keep the peace at home with our spouses and children, stay
active, and still maintain some vestige of our former hobbies. (Hobbies you
ask? Those were those things we used to do for fun before we had busy jobs and
busy families, like rock climbing, crocheting, or peeing without little humans
storming the bathroom door.)
If you are
like me, you have started to notice signs of burnout. The struggle is real. At
work we have to take care of difficult and violent patients, meet core
measures, chart, and deal with patient complaints. After our shift ends we come
home to kids, errands, bills, and all the household stuff, like cooking
something other than grilled cheese for dinner. I hear these refrains day after
day, yet we all still seek this elusive thing called balance, as though we were
in search of a mystical unicorn that we’ll never find.
Why have we
arrived at this state of perpetual imbalance? What can we do to start to
reclaim our own wellness and find this mysterious balance? Here are some
suggestions, not from someone who has figured it all out, but as someone who is
in the thick of it, striving to do better.
Redefine balance
Balance
should not be seen as ’doing it all’. A balanced life does not mean being in
five different leadership roles at work while also coaching your kid’s soccer
team, sewing hand-made Halloween costumes and growing your own organic
vegetables. If we define balance as doing everything and doing it well, we are
bound to fail. Perhaps we should define balance as living a life that meets
your own personal goals, understanding that there will have to be compromise.
Your ideal life may look like 12-hour workdays, and frequent travel in order to
reach further leadership positions at work. Someone else’s might look like
working part time and spending more time with kids, or working close to
quarter-time to have time to homeschool. We need to define what our own
personal goals are, and then try to bring our lives more into alignment with
them. Now obviously, we can’t define away doing medical charts, or define a higher
salary for ourselves. There are financial realities and time constraints we
have to deal with. We need to figure out what we want and what is negotiable in
terms of hours, responsibility, pay, and time. When the pie chart of what you
are actually doing matches the pie chart of your priorities – that is balance.
Choose what brings you joy
Ask yourself
what floats your boat? What gets you up in the morning (figuratively, not what
actually gets you up, which is probably a loud alarm, children, and coffee)? It
is easy to say yes to so many things that crowd out what you really love. That
one committee that will meet once a month? Reviewing a paper? Giving a lecture?
These are all good things. But they can easily squeeze away the time we have
for more important things. If it is something you love and are passionate
about, then do it! If it is something that you have no choice about and have to
do in order to meet your other goals that you are passionate about, then do it!
If you don’t really want to, and you don’t have to, then say no. Those little
things can add up and tip your balance. You are not a super hero with inhuman
strength or stamina. Give yourself permission to say no to things. Cull what
drags you down, and focus on the things that you love, both at work and at home…
22. Intraosseous access in the obese patient: assessing the need
for extended needle length.
Kehrl T, et
al. Am J Emerg Med. 2016 Sep;34(9):1831-4.
BACKGROUND: Intraosseous
(IO) access can be complicated by obesity. Successful placement of a 25 mm IO
needle is unlikely when soft tissue depth exceeds 20 mm.
OBJECTIVES: The
authors examined the relationship between body mass index (BMI), the ability to
palpate the tibial tuberosity (TT), and soft tissue depth at recommended IO
insertion sites.
METHODS: Obese
emergency department patients were assessed for a palpable TT and received ultrasound
measurement of the soft tissue depth at recommended IO insertion sites. Linear
and logistic regression were used to determine cut-off BMI values predicting
soft tissue depth greater than 20 mm.
RESULTS: Seventy-five
patients were enrolled with a mean BMI of 47.2. The mean soft tissue depth at
the proximal humerus, proximal tibial, and distal tibial were 29.6 [95% CI
27.5-31.7] mm, 11.0 [8.9-13.0] mm, and 10.7 [9.4-12.1] mm, respectively. In 5
patients without a palpable TT the soft tissue depth exceeded 20 mm at all
three anatomic sites. A BMI ≥43 and BMI ≥60 predicted a soft tissue depth greater
than 20 mm at the proximal tibia and distal tibia, respectively, while no
reliable BMI cut-off was identified at the proximal humerus.
CONCLUSIONS: In
obese adults with a palpable TT or BMI ≤43 a 25 mm IO needle is likely adequate
at the proximal and distal tibial insertion sites. Empiric use of an extended
45 mm IO needle is advisable at the proximal humeral insertion site in obese
patients.
23. Interactive Medical Case from the NEJM
A 19-year-old
woman presented to the ED with abdominal pain in the right upper quadrant that
had been progressively worsening for the past 2 days. She reported a 3-month
history of intermittent abdominal pain that caused what she described as a
"pressure-like" sensation. This pain was nonradiating and was
unrelated to food intake or bowel movements. The pain was associated with…
24. Micro Bits
A. Innate Immunity and Asthma Risk in Amish
and Hutterite Farm Children
The Amish and the Hutterites are
farming communities with similar gene pools, but asthma and allergy are more
common in Hutterites. The authors provide data that support the idea that the
Amish environment stimulates the innate immune response and protects the
children from asthma.
B. Fire-Related Inhalation Injury
Fire-related inhalation injury
results from a combination of direct exposures, systemic effects of inhaled
toxins, accrual of endobronchial debris, and secondary infection. This brief
review discusses the pathogenesis of and approach to fire-related inhalation
injury.
C. Changes in the Leading Cause of Death:
Recent Patterns in Heart Disease and Cancer Mortality
The mortality burden of cancer
has surpassed that of heart disease in several states. In 2000, there were only
2 states where cancer was the leading cause of death; in 2014, there were 22.
Heart disease remained the
leading cause of death for the non-Hispanic white and non-Hispanic black
populations in 2014.
Cancer is now the leading cause
of death for the non-Hispanic Asian or Pacific Islander and Hispanic
populations. The timing of the leading-cause crossover varied by group.
D. Nicer neighborhoods get creepier crawlies
Science News. By Jessica Boddy. Aug.
2, 2016
When you’re rich, you can have
more of everything—more opportunities for travel, more flashy gadgets, more
house, and now, something else: more bugs. A new study suggests that people in
affluent neighborhoods have a richer variety of arthropods in their homes,
something they call the “luxury effect.” It works like this: People in wealthy
zip codes tend to have more extensive landscaping with a greater variety of
plant species. That means, in turn, that the arthropods they attract—creepy
crawlies including spiders, flies, and millipedes—are also more diverse. To see
whether this idea had legs, a team of entomologists strapped on kneepads and
headlamps and scoured 50 different homes in Raleigh for any arthropod they
could find. They collected 10,000 specimens from more than 300 different
families, from the humble pill bug to the panic-inducing paper wasp. (Other
species they collected are in the slideshow above.) They found that houses in
neighborhoods with the highest average incomes had more species than those in
the lowest income bracket, they report today in Biology Letters….
E. Survey: Many physicians are not saving enough
for retirement
Almost 40% of some 125,000
practicing physicians surveyed said they were behind on their retirement
savings, according to a study from American Medical Association Insurance.
However, the study also found that from 2013 to 2016, the number of physicians
ahead of schedule on retirement savings increased from 6% to 11%.
F. Obesity is strong risk factor for heart
failure, study finds
Obesity, especially severe
obesity, has a strong link to heart failure that is unexplained by traditional
risk factors, researchers reported in the Journal of the American Heart
Association. The study found obesity was a bigger factor for heart failure than
for other cardiovascular diseases, and researchers said weight loss is critical
for heart failure prevention.
G. Suicide-Prone Occupations: Farming more
dangerous than Library Services says the CDC
A snapshot of suicide reports
from 17 states has shown that people working in farming, fishing, and forestry
jobs took their own lives at the highest rate among 22 occupation categories
studied.
H. Antibiotics in the first 2 years of life
and weight development
Alterations in the gut microbiome
have been documented to affect body weight. Although previous studies have
shown that early antibiotic exposure may affect weight development, the effects
of antibiotic class and timing of exposure are unknown. This study examined the
influence of timing of antibiotic exposure, type of antibiotics used, and
number of exposures on height and weight development up to 10 years of age.
Increased weight and height z-scores were observed in children exposed to one
course of antibiotics in the first 6 months of life and in children with two or
more courses during the second year of life. These associations were mainly
seen in exposure to broad- and narrow-spectrum β-lactams. Exposure later in
life was not associated with anthropometric outcomes. If causality of obesity
can be established in the future, this illustrates the need for judicious
antibiotic use early in life.
I. The CDC Speaks Out on Sepsis
J. New app helps doctors respond to in-flight
emergencies
If you're unlucky enough to be
one of the 150 to 200 people each day who have a medical emergency on an
airplane, your care is in the hands of whatever medical professionals happen to
be among your fellow passengers. The chances are they're not emergency
physicians and they haven't trained for this particular eventuality.
"When doctors are up in the
air, they really are not familiar with the environment," Dr. Raymond E.
Bertino, a clinical professor of radiology and surgery at the University of
Illinois College of Medicine, who has found himself in three such emergencies
-- twice as a doctor and once as a patient -- told MobiHealthNews. "Most
of them are not emergency doctors. You might have a radiologist, you might have
a pediatrician, you might have an OB doctor, who really doesn’t know how to
deal with emergencies in a day to day way. But the truth of the matter is,
there’s not that many things that can be done up in the air. There’s some
things that are very important, but they’re things that anybody with medical
training can handle as long as they know what to do and remember what to do."
K. Flossing not included in dietary
guidelines
The USDA's Dietary Guidelines for
Americans do not contain a recommendation that people floss their teeth, and a
report found a lack of scientific evidence to support flossing for good oral
health. AAFP Board Chair Robert Wergin, M.D., said although there is a lack of
evidence to support flossing, there also is "not much of a downside"
and cleaning between the teeth is an important part of oral health, which
affects overall health.
L. Study links time spent watching TV to risk
of pulmonary embolism
A study in the journal
Circulation found TV watching for 2.5 hours to five hours per day increased the
risk of a fatal blood clot by 70%, while more than five hours daily increased
the risk by 250%. Japanese researchers said the risk was independent of
physical exercise.
