Thursday, September 29, 2016

Lit Bits: Sept 29, 2016

From the recent medical literature...

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 [ 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.

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.

With increasing utilization of computed tomography pulmonary angiography (CTPA) for the diagnosis of pulmonary embolism (PE), many patients undergo repeat CTs.

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.

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.

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.

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):

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…

The remainder of the essay (free):

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.

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.

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

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

It worked! Who would have guessed?