1. NSAIDs increase risk of HF: nested case-control study
Arfe A, et
al. BMJ 2016;354:i4857
Introduction:
Non-steroidal anti-inflammatory drugs (NSAIDs) are a broad class of agents with
analgesic and anti-inflammatory properties that inhibit the two recognised
isoenzymes of prostaglandin G/H synthase (also known as cyclo-oxygenase
(COX))—namely, COX 1 and COX 2.1 Because the therapeutic action of these drugs
is mostly mediated by inhibition of COX 2, while their gastrointestinal adverse
reactions are largely due to COX 1 inhibition, NSAIDs selectively inhibiting
COX 2 were developed in the 1990s to reduce the risk of gastrointestinal
toxicity.2
Nevertheless,
reports of cardiovascular adverse reactions began to emerge in 2000-03,3 4 and
subsequent placebo controlled trials showed that COX 2 inhibitors were
associated with an increased risk of atherothrombotic vascular events.5 6
However, meta-analyses of randomised trials and observational studies have
since shown that the higher cardiovascular risk is not restricted to COX 2
inhibitors, but also applies to some traditional NSAIDs.7 8 9 10 11 12
In
particular, NSAID use has been found to be associated with an increased risk of
heart failure in several randomised clinical trials11 and observational
studies.13 14 A large meta-analysis of over 600 randomised trials showed that
COX 2 inhibitors and high doses of traditional NSAIDs (that is, diclofenac,
ibuprofen, and naproxen) increased the risk of hospital admission for heart
failure from 1.9-fold to 2.5-fold compared with placebo.11 In the light of this
evidence, current guidelines limit the use of NSAIDs in patients predisposed to
heart failure, with a full contraindication for patients with diagnosed heart
failure.15
Nevertheless,
there is still limited information on the risk of heart failure associated with
the use of individual NSAIDs (both COX 2 inhibitors and traditional NSAIDs) in
clinical practice, and especially on their dose-response associations.
Therefore, heart failure was included as an outcome of interest in the overall
cardiovascular and gastrointestinal risk evaluation of individual NSAIDs within
the Safety of Non-Steroidal Anti-Inflammatory (SOS) Project, a multinational
project funded by the European Commission under the seventh Framework
Programme. A large, common protocol, nested case-control study based on
electronic healthcare databases from four European countries was carried out.
Objectives To
investigate the cardiovascular safety of non-steroidal anti-inflammatory drugs
(NSAIDs) and estimate the risk of hospital admission for heart failure with use
of individual NSAIDs.
Design Nested
case-control study.
Setting Five
population based healthcare databases from four European countries (the
Netherlands, Italy, Germany, and the United Kingdom).
Participants
Adult individuals (age ≥18 years) who started NSAID treatment in 2000-10.
Overall, 92 163 hospital admissions for heart failure were identified and
matched with 8 246 403 controls (matched via risk set sampling according to
age, sex, year of cohort entry).
Main outcome
measure Association between risk of hospital admission for heart failure and
use of 27 individual NSAIDs, including 23 traditional NSAIDs and four selective
COX 2 inhibitors. Associations were assessed by multivariable conditional
logistic regression models. The dose-response relation between NSAID use and
heart failure risk was also assessed.
Results
Current use of any NSAID (use in preceding 14 days) was found to be associated
with a 19% increase of risk of hospital admission for heart failure (adjusted
odds ratio 1.19; 95% confidence interval 1.17 to 1.22), compared with past use
of any NSAIDs (use beyond 183 days in the past). Risk of admission for heart
failure increased for seven traditional NSAIDs (diclofenac, ibuprofen, indomethacin,
ketorolac, naproxen, nimesulide, and piroxicam) and two COX 2 inhibitors
(etoricoxib and rofecoxib). Odds ratios ranged from 1.16 (95% confidence
interval 1.07 to 1.27) for naproxen to 1.83 (1.66 to 2.02) for ketorolac. Risk
of heart failure doubled for diclofenac, etoricoxib, indomethacin, piroxicam,
and rofecoxib used at very high doses (≥2 defined daily dose equivalents),
although some confidence intervals were wide. Even medium doses (0.9-1.2
defined daily dose equivalents) of indomethacin and etoricoxib were associated
with increased risk. There was no evidence that celecoxib increased the risk of
admission for heart failure at commonly used doses.
Conclusions
The risk of hospital admission for heart failure associated with current use of
NSAIDs appears to vary between individual NSAIDs, and this effect is dose
dependent. This risk is associated with the use of a large number of individual
NSAIDs reported by this study, which could help to inform both clinicians and
health regulators.
2. California mandates use of prescription drug database
A new law in
California requires health care professionals to check a database before writing
first-time prescriptions for narcotics, steroids, sleep aids and psychiatric
drugs. Prescribers must recheck the database every four months for the duration
of the prescription.
Gov. Brown Signs Bill Targeting
'Doctor Shopping' For Opioids
By Associated
Press. Sept 27, 2016. SACRAMENTO.
California
doctors will be required to check a database of prescription narcotics before
writing scripts for addictive drugs under legislation Gov. Jerry Brown signed
Tuesday that aims to address the scourge of opioid abuse.
The measure
attempts to crack down on a practice known as “doctor-shopping,” in which
addicts visit multiple providers to obtain prescriptions for addictive drugs.
The action by the Democratic governor comes amid an intensifying national focus
on the problems that stem from prescription and illegal opiates. The U.S.
Centers for Disease Control and Prevention says more than 165,000 people died
nationwide from prescription opioid overdoses from 1999 to 2014.
California
maintained records of narcotic prescription histories for years in an early
paper version. The database has since been updated, but using it has been
optional for physicians, dentists, nurse practitioners and others who write
prescriptions.
For 20 years,
the influential doctors’ lobby thwarted efforts to mandate that California
prescribers review patients’ narcotic prescription histories, housed in the
nation’s first drug-monitoring program. That changed this year following a move
by state lawmakers to provide additional funding to staff and modernize the
program, quieting the disapproval of most health associations. Pharmaceutical
companies took no position on the bill.
SB 482 by
Democratic Sen. Ricardo Lara requires doctors and nurses to check the database
for signs of abuse when initially prescribing narcotic painkillers like
OxyContin, Vicodin and Percocet, as well as steroids, sleep aids and
psychiatric medications. They then have to revisit the database every four
months, for as long as the drug regimen is continued.
Bob Pack has
been advocating for such a mandate since his son, Troy, 10, and daughter,
Alana, 7, were run down and killed in October 2003 by a drugged driver who also
had been drinking. The woman was later found to be “doctor shopping.” When
Brown was attorney general, Pack persuaded him to move a warehouse of
carbon-copy prescription histories online. Pack then focused on getting doctors
to use it.
“It’s too
late for my family, but it’s going to help a lot of others and that’s the whole
point of this program and me pushing all these years,” Pack said.
Medical
boards will be responsible for enforcing the law, but there is no requirement
for doctors to prescribe or withhold medication.
The
requirement will take effect six months after the Department of Justice certifies
it is prepared to handle increased use of the program.
“Our office
is ready for universal use,” Justice department spokeswoman Brenda Gonzalez
said.
There were
nearly 165,000 users on Sept. 15, Gonzalez said.
More than 20
other states with similar databases require health care providers to check them
before prescribing addictive drugs.
3. The Effectiveness of ED Visit Reduction Programs: A
Systematic Review.
Raven MC, et
al. Ann Emerg Med. 2016 Oct;68(4):467-483.e15.
STUDY
OBJECTIVE: Previous reviews of emergency department (ED) visit reduction
programs have not required that studies meet a minimum quality level and have
therefore included low-quality studies in forming conclusions about the
benefits of these programs. We conduct a systematic review of ED visit
reduction programs after judging the quality of the research. We aim to
determine whether these programs are effective in reducing ED visits and
whether they result in adverse events.
METHODS: We
identified studies of ED visit reduction programs conducted in the United
States and targeted toward adult patients from January 1, 2003, to December 31,
2014. We evaluated study quality according to the Grading of Recommendations
Assessment, Development, and Evaluation criteria and included moderate- to
high-quality studies in our review. We categorized interventions according to
whether they targeted high-risk or low-acuity populations.
RESULTS: We
evaluated the quality of 38 studies and found 13 to be of moderate or high
quality. Within these 13 studies, only case management consistently reduced ED
use. Studies of ED copayments had mixed results. We did not find evidence for
any increase in adverse events (hospitalization rates or mortality) from the
interventions in either high-risk or low-acuity populations.
CONCLUSION:
High-quality, peer-reviewed evidence about ED visit reduction programs is
limited. For most program types, we were unable to draw definitive conclusions
about effectiveness. Future ED visit reduction programs should be regarded as
demonstrations in need of rigorous evaluation.
4. Radiograph-Negative Lateral Ankle Injuries in Children:
Occult Growth Plate Fracture or Sprain?
Boutis K, et
al. JAMA Pediatr. 2016;170(1):e154114.
IMPORTANCE:
Lateral ankle injuries without radiographic evidence of a fracture are a common
pediatric injury. These children are often presumed to have a Salter-Harris
type I fracture of the distal fibula (SH1DF) and managed with immobilization
and orthopedic follow-up. However, previous small studies suggest that these
injuries may represent ankle sprains rather than growth plate fractures.
OBJECTIVES:
To determine the frequency of SH1DF using magnetic resonance imaging (MRI) and
compare the functional recovery of children with fractures identified by MRI vs
those with isolated ligament injuries.
DESIGN,
SETTING, AND PARTICIPANTS: A prospective cohort study was conducted between
September 2012 and August 2014 at 2 tertiary care pediatric emergency
departments. We screened 271 skeletally immature children aged 5 to 12 years
with a clinically suspected SH1DF; 170 were eligible and 140 consented to
participate.
INTERVENTIONS:
Children underwent MRI of both ankles within 1 week of injury. Children were
managed with a removable brace and allowed to return to activities as
tolerated.
MAIN OUTCOMES
AND MEASURES: The proportion with MRI-confirmed SH1DF. A secondary outcome
included the Activity Scale for Kids score at 1 month.
RESULTS: Of
the 135 children who underwent ankle MRI, 4 (3.0%; 95% CI, 0.1%-5.9%)
demonstrated MRI-confirmed SH1DF, and 2 of these were partial growth plate
injuries. Also, 108 children (80.0%) had ligament injuries and 27 (22.0%) had
isolated bone contusions. Of the 108 ligament injuries, 73 (67.6%) were
intermediate to high-grade injuries, 38 of which were associated with
radiographically occult fibular avulsion fractures. At 1 month, the mean (SD)
Activity Scale for Kids score of children with MRI-detected fibular fractures
(82.0% [17.2%]) was not significantly different from those without fractures
(85.8% [12.5%]) (mean difference, -3.8%; 95% CI, -1.7% to 9.2%).
CONCLUSIONS AND
RELEVANCE: Salter-Harris I fractures of the distal fibula are rare in children
with radiograph fracture-negative lateral ankle injuries. These children most
commonly have ligament injuries (sprains), sometimes associated with
radiographically occult avulsion fractures. Children with fractures detectable
only by MRI had a comparable recovery with those with sprains when treated with
a removable ankle brace and self-regulated return to activities. This work has
the potential to simplify the care of these common injuries, safely minimizing
the inconveniences and costs of overtreatment.
Editorial: Revisiting
Radiograph-Negative Ankle Injuries in Children: Is It a Fracture or a Sprain?
In this issue
of JAMA Pediatrics, Boutis and colleagues1 determine the true rate of
Salter-Harris I growth plate fractures of the distal fibula (SH1DF) among
children with ankle injuries. Ankle injuries are common in children, leading to
more than 2 million emergency department (ED) visits in Canada and the United
States each year.1,2 Most ankle injuries are minor—85% due to forced
inversion—and clinical decision rules help guide the need for radiography.3
Clinicians worry about missing a potential growth plate fracture, which could
result in growth arrest, although the likelihood of growth arrest is rare.4…
5. Early Identification of Patients with Out-of-Hospital Cardiac
Arrest with No Chance of Survival and Consideration for Organ Donation
Jabre P, et
al. Ann Intern Med. 2016 Sept 13 [Epub ahead of print]
Background:
In patients with out-of-hospital cardiac arrest (OHCA), care requirements can
conflict with the need to promptly focus efforts on organ donation in patients
who are pronounced dead.
Objective: To
evaluate objective criteria for identifying patients with OHCA with no chance
of survival during the first minutes of cardiopulmonary resuscitation to enable
prompt orientation toward organ donation.
Design:
Retrospective assessment using OHCA data from 2 registries and 1 trial.
Setting:
France (Paris Sudden Death Expertise Center [SDEC] prospective cohort [2011 to
2014] and PRESENCE multicenter cluster randomized trial [ClinicalTrials.gov:
NCT01009606] [2009 to 2011]) and the United States (King County, Washington,
prospective cohort [2006 to 2011]).
Patients:
1771 patients from the Paris SDEC 1-year cohort (2011 to 2012) and 5192 from
the validation cohorts.
Measurements:
Evaluation of 3 objective criteria (OHCA not witnessed by emergency medical
services personnel, nonshockable initial cardiac rhythm, and no return of
spontaneous circulation before receipt of a third 1-mg dose of epinephrine),
survival rate at hospital discharge among patients meeting these criteria,
performance of the criteria, and number of patients eligible for organ
donation.
Results: In
the Paris SDEC 1-year cohort, the survival rate among the 772 patients with
OHCA who met the objective criteria was 0% (95% CI, 0.0% to 0.5%), with a
specificity of 100% (CI, 97% to 100%) and a positive predictive value of 100%
(CI, 99% to 100%). These results were verified in the validation cohorts.
Ninety-five (12%) patients in the Paris SDEC 1-year cohort may have been
eligible for organ donation.
Limitation:
Several patients had unknown outcomes.
Conclusion: 3
objective criteria enable the early identification of patients with OHCA with
essentially no chance of survival and may help in decision making about the
organ donation process.
6. Spontaneous SAH: A Systematic Review and Meta-analysis
Describing the Diagnostic Accuracy of Hx, PE, Imaging, and LP with an
Exploration of Test Thresholds.
Carpenter CR,
et al. Acad Emerg Med. 2016 Sep;23(9):963-1003.
BACKGROUND:
Spontaneous subarachnoid hemorrhage (SAH) is a rare, but serious etiology of
headache. The diagnosis of SAH is especially challenging in alert,
neurologically intact patients, as missed or delayed diagnosis can be
catastrophic.
OBJECTIVES: The
objective was to perform a diagnostic accuracy systematic review and
meta-analysis of history, physical examination, cerebrospinal fluid (CSF)
tests, computed tomography (CT), and clinical decision rules for spontaneous
SAH. A secondary objective was to delineate probability of disease thresholds
for imaging and lumbar puncture (LP).
METHODS:
PubMed, Embase, Scopus, and research meeting abstracts were searched up to June
2015 for studies of emergency department patients with acute headache
clinically concerning for spontaneous SAH. QUADAS-2 was used to assess study
quality and, when appropriate, meta-analysis was conducted using random effects
models. Outcomes were sensitivity, specificity, and positive (LR+) and negative
(LR-) likelihood ratios. To identify test and treatment thresholds, we employed
the Pauker-Kassirer method with Bernstein test indication curves using the
summary estimates of diagnostic accuracy.
RESULTS: A
total of 5,022 publications were identified, of which 122 underwent full-text review;
22 studies were included (average SAH prevalence = 7.5%). Diagnostic studies
differed in assessment of history and physical examination findings, CT
technology, analytical techniques used to identify xanthochromia, and criterion
standards for SAH. Study quality by QUADAS-2 was variable; however, most had a
relatively low risk of biases. A history of neck pain (LR+ = 4.1; 95%
confidence interval [CI] = 2.2 to 7.6) and neck stiffness on physical
examination (LR+ = 6.6; 95% CI = 4.0 to 11.0) were the individual findings most
strongly associated with SAH. Combinations of findings may rule out SAH, yet
promising clinical decision rules await external validation. Noncontrast
cranial CT within 6 hours of headache onset accurately ruled in (LR+ = 230; 95%
CI = 6 to 8,700) and ruled out SAH (LR- = 0.01; 95% CI = 0 to 0.04); CT beyond
6 hours had a LR- of 0.07 (95% CI = 0.01 to 0.61). CSF analyses had lower
diagnostic accuracy, whether using red blood cell (RBC) count or xanthochromia.
At a threshold RBC count of 1,000 × 10(6) /L, the LR+ was 5.7 (95% CI = 1.4 to
23) and LR- was 0.21 (95% CI = 0.03 to 1.7). Using the pooled estimates of
diagnostic accuracy and testing risks and benefits, we estimate that LP only
benefits CT-negative patients when the pre-LP probability of SAH is on the
order of 5%, which corresponds to a pre-CT probability greater than 20%.
CONCLUSIONS:
Less than one in 10 headache patients concerning for SAH are ultimately
diagnosed with SAH in recent studies. While certain symptoms and signs increase
or decrease the likelihood of SAH, no single characteristic is sufficient to
rule in or rule out SAH. Within 6 hours of symptom onset, noncontrast cranial
CT is highly accurate, while a negative CT beyond 6 hours substantially reduces
the likelihood of SAH. LP appears to benefit relatively few patients within a
narrow pretest probability range. With improvements in CT technology and an
expanding body of evidence, test thresholds for LP may become more precise,
obviating the need for a post-CT LP in more acute headache patients. Existing
SAH clinical decision rules await external validation, but offer the potential
to identify subsets most likely to benefit from post-CT LP, angiography, or no
further testing.
7. Early-life antibiotic use may increase children's food
allergy risk
Researchers
found that youths who received antibiotics before age 1 had a 21% higher risk
of having food allergy diagnoses, compared with those who didn't receive
antibiotics, while those given additional antibiotic prescriptions were even
more likely to develop allergies.
The findings
in the journal Allergy, Asthma and Clinical Immunology also showed that
allergies to milk, egg, peanut and seafood were most commonly identified.
Full-text
(free): https://aacijournal.biomedcentral.com/articles/10.1186/s13223-016-0148-7
News article: http://www.upi.com/Health_News/2016/09/01/Childrens-allergy-risk-linked-to-antibiotic-exposure-study-says/6611472759435/
News article: http://www.upi.com/Health_News/2016/09/01/Childrens-allergy-risk-linked-to-antibiotic-exposure-study-says/6611472759435/
8. Development and Validation of a Sudden Cardiac Death
Prediction Model for the General Population
Deo R, et al.
Circ 2016 Sep 13;134(11):806-16.
Background:
Most sudden cardiac death (SCD) events occur in the general population among
persons who do not have any prior history of clinical heart disease. We sought
to develop a predictive model of SCD among US adults.
Methods: We
evaluated a series of demographic, clinical, laboratory, electrocardiographic,
and echocardiographic measures in participants in the ARIC study
(Atherosclerosis Risk in Communities) (n=13 677) and the CHS (Cardiovascular
Health Study) (n=4207) who were free of baseline cardiovascular disease. Our
initial objective was to derive a SCD prediction model using the ARIC cohort
and validate it in CHS. Independent risk factors for SCD were first identified
in the ARIC cohort to derive a 10-year risk model of SCD. We compared the
prediction of SCD with non-SCD and all-cause mortality in both the derivation
and validation cohorts. Furthermore, we evaluated whether the SCD prediction
equation was better at predicting SCD than the 2013 American College of
Cardiology/American Heart Association Cardiovascular Disease Pooled Cohort risk
equation.
Results:
There were a total of 345 adjudicated SCD events in our analyses, and the 12
independent risk factors in the ARIC study included age, male sex, black race,
current smoking, systolic blood pressure, use of antihypertensive medication,
diabetes mellitus, serum potassium, serum albumin, high-density lipoprotein,
estimated glomerular filtration rate, and QTc interval. During a 10-year
follow-up period, a model combining these risk factors showed good to excellent
discrimination for SCD risk (c-statistic 0.820 in ARIC and 0.745 in CHS). The
SCD prediction model was slightly better in predicting SCD than the 2013
American College of Cardiology/American Heart Association Pooled Cohort risk
equations (c-statistic 0.808 in ARIC and 0.743 in CHS). Only the SCD prediction
model, however, demonstrated similar and accurate prediction for SCD using both
the original, uncalibrated score and the recalibrated equation. Finally, in the
echocardiographic subcohort, a left ventricular ejection fraction below 50% was
present in only 1.1% of participants and did not enhance SCD prediction.
Conclusions:
Our study is the first to derive and validate a generalizable risk score that
provides well-calibrated, absolute risk estimates across different risk strata
in an adult population of white and black participants without a clinical
diagnosis of cardiovascular disease.
9. The Use of Very Low Concentrations of High-sensitivity TropT
to r/o AMI Using a Single Blood Test.
Body R, et
al. TRAPID-AMI Investigators. Acad Emerg Med. 2016 Sep;23(9):1004-13.
BACKGROUND:
Recent single-center and retrospective studies suggest that acute myocardial
infarction (AMI) could be immediately excluded without serial sampling in
patients with initial high-sensitivity cardiac troponin T (hs-cTnT) levels
below the limit of detection (LoD) of the assay and no electrocardiogram (ECG)
ischemia.
OBJECTIVE: We
aimed to determine the external validity of those findings in a multicenter
study at 12 sites in nine countries.
METHODS:
TRAPID-AMI was a prospective diagnostic cohort study including patients with
suspected cardiac chest pain within 6 hours of peak symptoms. Blood drawn on
arrival was centrally tested for hs-cTnT (Roche; 99th percentile = 14 ng/L, LoD
= 5 ng/L). All patients underwent serial troponin sampling over 4-14 hours. The
primary outcome, prevalent AMI, was adjudicated based on sensitive troponin I
(Siemens Ultra) levels. Major adverse cardiac events (MACE) including AMI,
death, or rehospitalization for acute coronary syndrome with coronary revascularization
were determined after 30 days.
RESULTS: We
included 1,282 patients, of whom 213 (16.6%) had AMI and 231 (18.0%) developed
MACE. Of 560 (43.7%) patients with initial hs-cTnT levels below the LoD, four
(0.7%) had AMI. In total, 471 (36.7%) patients had both initial hs-cTnT levels
below the LoD and no ECG ischemia. These patients had a 0.4% (n = 2)
probability of AMI, giving 99.1% (95% confidence interval [CI] = 96.7% to
99.9%) sensitivity and 99.6% (95% CI = 98.5% to 100.0%) negative predictive
value. The incidence of MACE in this group was 1.3% (95% CI = 0.5% to 2.8%).
CONCLUSIONS:
In the absence of ECG ischemia, the detection of very low concentrations of
hs-cTnT at admission seems to allow rapid, safe exclusion of AMI in one-third
of patients without serial sampling. This could be used alongside careful
clinical assessment to help reduce unnecessary hospital admissions.
10. Images in Clinical Practice
Hemorrhagic
Bullae in a Primary Varicella Zoster Virus Infection
Male With
Shortness of Breath
Woman With
Pain in Left Leg
Boy With
Upper Neck Pain and Generalized Weakness
Elderly Man
With Abdominal Rash
Male With
Numbness and Muscle Spasms
Elderly Woman
With Severe Abdominal Pain
Man With
Abdominal Wall Abscess
Male With
Diabetes and a Rash
Female With
Fever
EM-RAP
Commentary: A Sample Rule-Out Tuberculosis Protocol
Emphysematous
Prostatitis
Pneumorrhachis,
Pneumothorax, and Subcutaneous Emphysema
Kerion — A
Boggy Lump
Generalized
Granuloma Annulare Associated with Diabetes Mellitus
Cholesterol
Embolization after Transcatheter Aortic-Valve Replacement
Lymphangitis
on the Abdomen
11. New PE Research
A. PEA in PE treated with
thrombolysis (from the "PEAPETT" study).
Sharifi M, et
al. Am J Emerg Med. 2016;34(10):1963–1967.
OBJECTIVE: Pulseless
electrical activity (PEA) during cardiac arrest portends a poor prognosis.
There is a paucity of data in the use of thrombolytic therapy in PEA and
cardiopulmonary arrest due to confirmed pulmonary embolism (PE). We evaluated
the outcome of low-dose systemic thrombolysis with tissue plasminogen activator
(tPA) in patients presenting with PEA due to PE.
METHODS: During
a 34-month period, we treated 23 patients with PEA and cardiopulmonary arrest
due to confirmed massive PE. All patients received 50 mg of tPA as intravenous
push in 1 minute while cardiopulmonary resuscitation was ongoing. The time from
initiation of cardiopulmonary resuscitation to administration of tPA was 6.5 ±
2.1 minutes.
RESULTS: Return
of spontaneous circulation occurred in 2 to 15 minutes after tPA administration
in all but 1 patient. There was no minor or major bleeding despite chest
compression. Of the 23 patients, 2 died in the hospital, and at 22 ± 3 months
of follow-up, 20 patients (87%) were still alive. The right ventricular/left
ventricular ratio and pulmonary artery systolic pressure dropped from 1.79 ±
0.27 and 58.10 ± 7.99 mm Hg on admission to 1.16 ± 0.13 and 40.25 ± 4.33 mm Hg
within 48 hours, respectively (P less than .001 for both comparisons). There
was no recurrent venous thromboembolism or bleeding during hospitalization or
at follow-up.
CONCLUSION: Rapid
administration of 50 mg of tPA is safe and effective in restoration of
spontaneous circulation in PEA due to massive PE leading to enhanced survival
and significant reduction in pulmonary artery pressures.
B.
Risk of PE after a prior negative CTPA
Hammer MM, et
al. Amer J Emerg Med 2016; 34(10):1968-72.
Context
With
increasing utilization of computed tomography pulmonary angiography (CTPA) for
the diagnosis of pulmonary embolism (PE), many patients undergo repeat CTs.
Objective
The aim of
this study is to identify the rate of positive subsequent CTPAs after an
initial negative CTPA and whether there is a risk-free period after a negative
CTPA.
Methods
We evaluated
318 patients with at least 1 subsequent CTPA after an initial negative CTPA,
with 786 total CTPAs. We also evaluated a control group of 200 unselected
CTPAs.
Results
The positive
rate in the repeat group was 7% at the first repeat CTPA and 10% per-patient
within 1000 days. The positive rate in the control group was 9% (P= not
significant). No risk-free period was seen, with a positive rate of 5% within 2
weeks after a negative CTPA. The number of prior negative CTPAs showed a trend
towards decreasing rate of the subsequent CTPA being positive, but this did not
meet statistical significance.
Discussion
There is no
risk-free period after an initial negative CTPA, and therefore, patients with
clinical suspicion of PE should be rescanned even after a recent negative
study. Even patients with multiple negative prior CTPAs have a measurable risk
of subsequent PE. Established clinical prediction scoring systems must be used
to triage the patients who need CTPAs.
12. Human Trafficking: A Guide to Identification and Approach
for the Emergency Physician.
Shandro J, t
al. Ann Emerg Med. 2016 Oct;68(4):501-508.e1.
Human
trafficking is a significant human rights problem that is often associated with
psychological and physical violence. There is no demographic that is spared
from human trafficking. Traffickers maintain control of victims through
physical, sexual, and emotional violence and manipulation. Because victims of
trafficking seek medical attention for the medical and psychological
consequences of assault and neglected health conditions, emergency clinicians
are in a unique position to recognize victims and intervene. Evaluation of
possible trafficking victims is challenging because patients who have been
exploited rarely self-identify. This article outlines the clinical approach to
the identification and treatment of a potential victim of human trafficking in
the emergency department. Emergency practitioners should maintain a high index
of suspicion when evaluating patients who appear to be at risk for abuse and
violence, and assess for specific indicators of trafficking. Potential victims
should be evaluated with a multidisciplinary and patient-centered technique.
Furthermore, emergency practitioners should be aware of national and local
resources to guide the approach to helping identified victims. Having
established protocols for victim identification, care, and referrals can
greatly facilitate health care providers' assisting this population.
13. Top Ten Myths Regarding the Diagnosis and Treatment of UTI
Schulz L, et
al. J Emerg Med. 2016 Jul;51(1):25-30.
BACKGROUND:
Urinary tract infections (UTI) are the most common type of infection in the
United States. A Centers for Disease Control and Prevention report in March
2014 regarding antibiotic use in hospitals reported "UTI" treatment
was avoidable at least 39% of the time. The accurate diagnosis and treatment of
UTI plays an important role in cost-effective medical care and appropriate
antimicrobial utilization.
OBJECTIVE: We
summarize the most common misperceptions of UTI that result in extraneous
testing and excessive antimicrobial treatment. We present 10 myths associated
with the diagnosis and treatment of UTI and succinctly review the literature
pertaining to each myth. We explore the myths associated with pyuria,
asymptomatic bacteriuria, candiduria, and the elderly and catheterized
patients. We attempt to give guidance for clinicians facing these clinical
scenarios.
DISCUSSION:
From our ambulatory, emergency department, and hospital experiences, patients
often have urine cultures ordered without an appropriate indication, or receive
unnecessary antibiotic therapy due to over-interpretation of the urinalysis.
CONCLUSIONS:
Asymptomatic bacteriuria is common in all age groups and is frequently
over-treated. A UTI diagnosis should be based on a combination of clinical
symptoms with supportive laboratory information. This review will assist
providers in navigating common pitfalls in the diagnosis of UTI.
14. Predictive performance of quick Sepsis-related Organ Failure
Assessment (qSOFA) for mortality and ICU admission in pts with infection at the
ED.
Wang JY, et
al. Am J Emerg Med. 2016 Sep;34(9):1788-93.
OBJECTIVE:
The objectives of this study are to investigate the performance of the quick
Sepsis-related Organ Failure Assessment (qSOFA) in predicting mortality and
intensive care unit (ICU) admission in patients with clinically diagnosed
infection and to compare its performance with that of Mortality in Emergency
Department Sepsis (MEDS), Acute Physiology and Chronic Health Evaluation
(APACHE) II, and Sepsis-related Organ Failure Assessment (SOFA).
METHODS: From
July to December 2015, we retrospectively analyzed 477 patients clinically diagnosed
with infection in the emergency department. We compared the performance of
SOFA, MEDS, APACHE II, and qSOFA in predicting ICU admission and 28-day
mortality.
RESULTS: All
scores were higher in nonsurvivors and ICU patients than in survivors and non-ICU
patients (P less than .001). The area under the receiver operating
characteristic curve of qSOFA was lower than that of MEDS (0.666 vs 0.751; P less
than .05) and similar to that of SOFA (0.729) and APACHE II (0.732) in
predicting 28-day mortality. The areas under the receiver operating
characteristic curve of qSOFA, SOFA, MEDS, and APACHE II in predicting ICU
admission were 0.636, 0.682, 0.661, and 0.640, respectively. There were no
significant differences among the score systems. In patients with qSOFA scores
less than 2 and greater than or equal to 2, 28-day mortality rates were 17.4%
and 42.9% (P less than .001), and ICU admission rates were 16.0% and 33.3% (P less
than .001).
CONCLUSIONS:
Quick SOFA predicted ICU admission with similar performance to that of SOFA,
MEDS, and APACHE II. Its prognostic ability was similar to that of SOFA and
APACHE II but slightly inferior to that of MEDS.
15. A RCT Evaluating the Efficacy of Oral Sucrose in Infants 1
to 3 Months Old Needing IV Cannulation.
Desjardins MP,
et al. Acad Emerg Med. 2016 Sep;23(9):1048-53.
OBJECTIVES:
The objective was to compare the efficacy of an oral sucrose versus placebo in
reducing pain in infants 1 to 3 months of age during intravenous (IV)
cannulation in the emergency department.
METHODS: A
randomized, double-blind, placebo clinical trial was conducted. Participants
were randomly allocated to receive 2 mL of an oral 88% sucrose solution or 2 mL
of a placebo solution orally. The outcome measure were mean difference in pain
score at 1 minute post-IV cannulation assessed by the Face, Legs, Activity,
Cry, and Consolability Pain Scale (FLACC) and the Neonatal Infant Pain Scale
(NIPS), crying time, and variations in heart rate.
RESULTS:
Eighty-seven participants completed the study, 45 in the sucrose group and 42
in the placebo group. There was no statistical difference in variations in both
the FLACC score (p = 0.49) and the NIPS score (p = 0.36) between the two groups
as per the Mann-Whitney U-test. With the same test, median crying times
following IV cannulation were statistically significantly different between
both groups (17 seconds in the sucrose group vs. 41 seconds in the placebo
group, p = 0.04). Mean changes in heart rate 1 minute after IV cannulation were
similar in both groups (16 ± 4 beats/min for sucrose vs. 18 ± 4 beats/min for
placebo, p = 0.74). Side effects were similar for both groups and no adverse
events were reported.
CONCLUSIONS:
Administration of an oral sucrose solution in infants 1 to 3 months of age
during IV cannulation did not lead to statistically significant changes in pain
scores. However, the cry time was significantly reduced.
16. Where do Medicare beneficiaries seek non-urgent care?
There is
limited information on where and how often Medicare beneficiaries seek care for
non-urgent conditions when a physician office visit is not available. Emergency
departments are often an alternative site of care, and urgent care centers have
now also emerged to fill this need. The purpose of the study was to characterize
the site of care for Medicare beneficiaries with non-urgent conditions; the
relationship between physician office, urgent care center, and emergency
department utilization; and specifically the role of urgent care centers.
Conclusions: Urgent
care centers are an important site of care for Medicare beneficiaries for
non-urgent conditions. There is regional variation in the use of urgent care
centers, emergency departments, and physician offices, with areas of low urgent
care center utilization having higher emergency department utilization. The
utilization of urgent care centers for treatment for non-urgent conditions may
decrease emergency department utilization.
Full-text
(free): http://www.amjmed.com/article/S0002-9343%2816%2930341-2/fulltext
17. Lactic acidosis: Treat the Cause
Acute lactic
acidosis due to sepsis or low-flow states is associated with cellular
dysfunction and high mortality. Currently, the only effective therapy is the
elimination or control of the triggering conditions. In this month's AJKD,
Kraut and Madias explore current treatments and potential therapies for lactic
acidosis by introducing the case of a 54-year-old man who was admitted with
palpitations, hyperventilation, and altered mental status. They stress that
resuscitative efforts to support the circulation and ventilation are the first
steps in treating lactic acidosis, and prompt initiation of cause-specific
measures is key to managing the condition.
18. Hospitalists and the Decline of Comprehensive Care
Gunderman R. N
Engl J Med 2016; 375:1011-1013.
Medical
specialization dates back at least to the time of Galen. For most of medicine’s
history, however, the boundaries of medical fields have been based on factors
such as patient age (pediatrics and geriatrics), anatomical and physiological
systems (ophthalmology and gastroenterology), and the physician’s toolset
(radiology and surgery). Hospital medicine, by contrast, is defined by the
location in which care is delivered. Whether such delineation is a good or bad
sign for physicians, patients, hospitals, and society hinges on how we understand
the interests and aspirations of each of these groups.
The
hospitalist model has provided such putative benefits as reductions in length
of stay, cost of hospitalization, and readmission rates — but these metrics are
all defined by the boundaries of the hospital. What we don’t yet know
sufficiently well is the impact of the rise of hospital medicine on overall
health status, total costs, and the well-being of patients and physicians. The
increasing number of hospitalists cannot, in and of itself, be taken as
conclusive evidence of benefit. Such increases can be driven by a variety of
perverse incentives, such as low payment rates for primary care that place a
premium on maximizing the number of patients a physician sees in a day and
therefore militate against taking the extra time required to see inpatients.
In fact,
increasing reliance on hospitalists entails a number of risks and costs for
everyone involved in the health care system — most critically, for the patients
that system is meant to serve. As the number of physicians caring for a patient
increases, the depth of the relationship between patient and physician tends to
diminish — a phenomenon of particular concern to those who regard the
patient–physician relationship as the core of good medical care…
19. Evidence Is Important: Safety Considerations for Emergency
Catheter Cricothyroidotomy.
Marshall SD.
Acad Emerg Med. 2016 Sep;23(9):1074-6.
It is an
unarguable truth that providing appropriate training and equipment leads to
improved outcomes in emergencies. Unfortunately, all too often the training and
equipment are suboptimal and designed without sufficient attention to current
evidence or an appreciation of the context of the emergency. Perhaps the
starkest of these examples is in the provision of equipment and training for
performance of the emergency surgical airway. A large, nationwide, year-long
audit in the United Kingdom has shown that success rates for emergency
cricothyroidotomy are highly variable.[1] Singled out for particular criticism
has been the catheter or “needle” method of accessing the airway and this is
likely to be almost solely due to a lack of appropriate equipment and training.
This commentary will outline the elements of safe practice of catheter
cricothyroidotomy based on evidence from clinical and animal studies. The
equipment, technique, and potential complications will be reviewed.
The provision
of oxygen via a catheter placed through the front of the neck into the trachea
was first described by Jacoby and colleagues some 60 years ago.[2] Although an
inherently risky technique, in the past decade the technique has been
scrutinized and refined based on data from elective head and neck surgery,
animal, and mannequin-based simulation studies such that complication rates are
now significantly lower.[3, 4] Catheter cricothyroidotomy provides some
advantages over scalpel techniques in terms of lower psychological barriers to
perform them and the ability to proceed to other more aggressive techniques
should they fail.[5] In the hands of appropriately trained practitioners it is
likely that failure rates of emergency scalpel and catheter techniques for
airway access are similar.[6]…
Related
procedural overview
Percutaneous
Cricothyroid Jet Ventilation Using Repetitive Airway Obstruction: A Quick and
Simple Way to Ventilate the “Impossible” Airway
20. Removal from Play after Concussion Speeds Recovery Time
What’s Known on This Subject:
Immediate
removal from play is recommended for athletes with suspected concussion. The
majority of concussions go unreported, and the catastrophic consequences of
continuing to play with concussion are documented. The impact of removal from
play on recovery outcomes is unknown.
What this Study Adds:
Athletes who
were not removed from play took longer to recover and demonstrated worse
neurocognitive and symptom outcomes after a sport-related concussion. Removal
from play status is a new predictor for protracted recovery and supports
consensus guidelines.
Elbin RJ, et
al. Pediatr 2016;138(3).
OBJECTIVE:
Despite increases in education and awareness, many athletes continue to play
with signs and symptoms of a sport-related concussion (SRC). The impact that
continuing to play has on recovery is unknown. This study compared recovery
time and related outcomes between athletes who were immediately removed from
play and athletes who continued to play with an SRC.
METHODS: A
prospective, repeated measures design was used to compare neurocognitive
performance, symptoms, and recovery time between 35 athletes (mean ± SD age,
15.61 ± 1.65 years) immediately removed after an SRC (REMOVED group) compared
with 34 athletes (mean ± SD age, 15.35 ± 1.73 years) who continued to play
(PLAYED group) with SRC. Neurocognitive and symptom data were obtained at
baseline and at 1 to 7 days and 8 to 30 days after an SRC.
RESULTS: The
PLAYED group took longer to recover than the REMOVED group (44.4 ± 36.0 vs 22.0
± 18.7 days; P = .003) and were 8.80 times more likely to demonstrate protracted
recovery (≥21 days) (P less than .001). Removal from play status was associated
with the greatest risk of protracted recovery (adjusted odds ratio, 14.27; P =
.001) compared with other predictors (eg, sex). The PLAYED group exhibited
significantly worse neurocognitive and greater symptoms than the REMOVED group.
CONCLUSIONS:
SRC recovery time may be reduced if athletes are removed from participation.
Immediate removal from play is the first step in mitigating prolonged SRC
recovery, and these data support current consensus statements and management
guidelines.
NY Times
essay: http://www.nytimes.com/2016/08/29/well/move/playing-with-a-concussion-doubles-recovery-time.html
21. Shabam!
A family-friendly science podcast.
The science
podcast that'll eat your brain. Shabam! is a new type of science show that
blends fictional stories with real science. If you love science but hate those
awkward scientist interviews that involve graphs and confusing metaphors, you’re
in luck. First off, Shabam! is an audio program - so no graphs. And second,
through the magic of sound effects and music, you’ll hear stories that reveal
the awesomeness in the world around us - like cellphones and vaccinations. In
season one, our main story is about three kids separated from their parents
during a Zombie apocalypse. Over the course of 10 episodes we follow their
quest to reunite with their families. But their experience leads us to another
conclusion - that there’s a lot of science all around us that we take for
granted. And finally, you may be wondering whether we’ve added silly songs and
jokes to make up for the fact that we can’t show you graphs. Yes we have. Also,
we only interview cool scientists who aren't awkward, which means the whole
family can enjoy it!
22. On Dogs
A.
Dogs would rather get a belly rub than a treat
Rachael Lallensack.
Science. Aug. 12, 2016.
When training
dogs, a pat on the head may be more effective than a treat. A new study
suggests that most dogs respond more positively to praise than to food.
Researchers scanned (pictured) the brains of 15 dogs of various breeds while
presenting objects paired with rewards. For example, after the scientists
showed the canines a toy car, their owners would praise them. In other tests,
the researchers gave the dogs a toy horse and a piece of hot dog. The scans
revealed that when praised, 13 of the dogs showed equal or greater levels of
brain activity in the region that controls decision-making and signals rewards
than when they received food, the scientists will report in an upcoming issue
of Social Cognitive and Affective Neuroscience…
B.
Your dog understands more than you think
By Virginia
Morell. Science News. Aug. 30, 2016
It’s the
eternal question for pet owners: Does your dog understand what you’re saying?
Even if Fido doesn’t “get” your words, surely he gets your tone when you let
loose about another accident on the carpet. But a new imaging study shows that
dogs’ brains respond to actual words, not just the tone in which they’re said.
The study will likely shake up research into the origins of language,
scientists say, as well as gratify dog lovers.
“It’s an
important study that shows that basic aspects of speech perception can be
shared with quite distant relatives,” says Tecumseh Fitch, a cognitive
biologist at the University of Vienna, who was not involved in the work.
Words, the
basic building blocks of human languages, are seldom found among other species.
Bottlenose dolphins and green-rumped parrotlets make sounds that function like
names, and animals including chickens, prairie dogs, and some primates utter
alarm calls that identify specific predators. Dogs don’t produce words, but
some are known to recognize more than 1000 human words—behavior that suggests
they may attach meaning to human sounds. The new study shows that it is indeed
the words themselves—and not the tone in which they're spoken or the context in
which they're used—that dogs comprehend.
To find out
how dogs process human speech, Attila Andics, a neuroscientist at Eötvös Loránd
University in Budapest, and his colleagues used brain scanners and 13 willing
family dogs from four breeds: border collies, golden retrievers, Chinese
crested dogs, and German shepherds. The dogs had been trained to lie motionless
in the scanner while they listened to recordings of their trainer’s voice. The
dogs heard meaningful words (“well done!” in Hungarian) in a praising tone and
in a neutral tone. They also heard meaningless words (“as if”) in a neutral or
praising tone of voice.
When the
scientists analyzed the brain scans, they saw that—regardless of the trainer’s
intonation—the dogs processed the meaningful words in the left hemisphere of
the brain, just as humans do, they write this week in Science. But the dogs
didn’t do this for the meaningless words. “There’s no acoustic reason for this
difference,” Andics says. “It shows that these words have meaning to dogs.”
The dogs also
processed intonation in the right hemisphere of their brains, also like humans.
And when they heard words of praise delivered in a praising tone, yet another
part of their brain lit up: the reward area. Meaning and tone enhanced each
other. “They integrate the two types of information to interpret what they
heard, just as we do,” Andics says.
The new
results add to scientists’ knowledge of how canine brains process human speech.
Dogs have brain areas dedicated to interpreting voices, distinguishing sounds
(in the left hemisphere), and analyzing the sounds that convey emotions (in the
right hemisphere).
The finding
“doesn’t mean that dogs understand everything we say,” says Julie Hecht, who
studies canine behavior and cognition at City University of New York in New
York City and who was not involved in the study. “But our words and intonations
are not meaningless to dogs.” Fitch hopes that similar studies will be done on
other domestic animals and on human-raised wolves to see how much of this
ability is hardwired in dogs and how much is due to growing up among talking
humans.
Link to 1-min
video: http://www.sciencemag.org/news/2016/08/video-your-dog-understands-more-you-think
23. Micro Bits
A. People over age 30 account for half of new
type 1 diabetes cases
A UK study presented at the
European Association for the Study of Diabetes meeting showed 47% of type 1
diabetes cases are diagnosed from ages 31 to 60, while 53% of cases are among
those ages 30 and younger. The findings, based on a UK Biobank cohort of
120,000 British white adults, ages 40 to 70, revealed that people genetically
classified with type 1 diabetes between ages 31 and 60 were more likely to be
on insulin within a year of being diagnosed, currently using insulin, had lower
body mass index and were significantly younger at diagnosis than peers
diagnosed with type 2 diabetes.
B. Canada has just approved prescription
heroin
OTTAWA — The Canadian government
has quietly approved new drug regulations that will permit doctors to prescribe
pharmaceutical-grade heroin to treat severe addicts who have not responded to
more conventional approaches.
The move means that Crosstown, a
trail-blazing clinic in Vancouver, will be able to expand its special
heroin-maintenance program, in which addicts come in as many as three times a
day and receive prescribed injections of legally obtained heroin from a nurse
free. The program is the only one of its kind in Canada and the United States
but is similar to the approach taken in eight European countries…
C. β blockers and mortality after myocardial
infarction in patients without heart failure: multicentre prospective cohort
study
Conclusions Early β blocker use
was associated with reduced 30 day mortality in patients with acute myocardial
infarction, and discontinuation of β blockers at one year was not associated
with higher five year mortality. These findings question the utility of
prolonged β blocker treatment after acute myocardial infarction in patients
without heart failure or left ventricular dysfunction.
D. Report warns against codeine in
prescriptions for children
Children should not be prescribed
codeine for pain or cough due to potential harms, including breathing problems
and even death, according to an American Academy of Pediatrics statement
published in Pediatrics. The AAP said physicians should weigh the risks of the
drug and consider whether evidence shows it is effective.
E. Study links sudden cardiac death risk to
thyroid hormone levels
A Dutch study of 10,318 adults
ages 45 and older with normal thyroid function found those with higher free
thyroxine levels had more than double the risk of sudden cardiac death. The
link between high FT4 levels and sudden cardiac death was independent of high
blood pressure, high cholesterol and other cardiovascular risk factors,
researchers reported in Circulation.
F. Televised food commercials and children's
food choices
This study set out to determine
whether children's food choices and/or brain activations were altered after the
viewing of typical food commercials. Functional MRI showed that watching food
commercials before making food choices may bias children's decisions based
solely on taste and may increase the likelihood that they make faster, more
impulsive food choices. The ventromedial prefrontal cortex showed increased
activity at the time of food choice after watching food commercials compared
with nonfood commercials. These effects may make it more difficult for
caregivers to encourage healthy food choices. Additionally, these findings may
have implications for policies related to food advertising to children.
G. More Cardiac Arrest Survivors Getting PCI:
National trend seen over past 12 years, with rising survival
H. Non-impact of scribes on patient
throughput in adult and pediatric academic EDs
Conclusions
Scribes failed to improve
patient-specific throughput metrics in the first few months post
implementation. Future work is needed to understand whether throughput
efficiencies may eventually be gained after scribe implementation.
I. Acupuncture for Chronic Severe Functional
Constipation: A Randomized, Controlled Trial
