Saturday, November 26, 2016

Lit Bits: Nov 26, 2016

From the recent literature...

1. The Predictive Value of Preendoscopic Risk Scores to Predict Adverse Outcomes in ED Patients with UGI Bleeding: None Ready for Prime Time

Ramaekers R, et al. Acad Emerg Med. 2016;23(11): 1218–1227

OBJECTIVES: Risk stratification of emergency department (ED) patients with upper gastrointestinal bleeding (UGIB) using preendoscopic risk scores can aid ED physicians in disposition decision-making. We conducted a systematic review to assess the predictive value of preendoscopic risk scores for 30-day serious adverse events.

METHODS: We searched MEDLINE, PubMed, Embase, and the Cochrane Database of Systematic Reviews from inception to March 2015. We included studies involving adult ED UGIB patients evaluating preendoscopic risk scores and excluded reviews, case reports, and animal studies. The composite outcome included 30-day mortality, recurrent bleeding, and need for intervention. In two phases (screening and full review), two reviewers independently screened articles for inclusion and extracted patient-level data. The consensus data were used for analysis. We reported sensitivity, specificity, positive and negative predictive value, and positive and negative likelihood ratios with 95% confidence intervals.

RESULTS: We identified 3,173 articles, of which 16 were included: three studied Glasgow Blatchford score (GBS); one studied clinical Rockall score (cRockall); two studied AIMS65; six compared GBS and cRockall; three compared GBS, a modification of the GBS, and cRockall; and one compared the GBS and AIMS65. Overall, the sensitivity and specificity of the GBS were 0.98 and 0.16, respectively; for the cRockall they were 0.93 and 0.24, respectively; and for the AIMS65 they were 0.79 and 0.61, respectively. The GBS with a cutoff point of 0 had a sensitivity of 0.99 and a specificity of 0.08.

CONCLUSION: The GBS with a cutoff point of 0 was superior over other cutoff points and risk scores for identifying low-risk patients but had a very low specificity. None of the risk scores identified by our systematic review were robust and, hence, cannot be recommended for use in clinical practice. Future prospective studies are needed to develop robust new scores for use in ED patients with UGIB.

2. Rocuronium inferior to succinylcholine for RSI intubation.

Tran DT, et al. Cochrane Database Syst Rev. 2015;(10):CD002788.

BACKGROUND: Patients often require a rapid sequence induction (RSI) endotracheal intubation technique during emergencies or electively to protect against aspiration, increased intracranial pressure, or to facilitate intubation. Traditionally succinylcholine has been the most commonly used muscle relaxant for this purpose because of its fast onset and short duration; unfortunately, it can have serious side effects. Rocuronium has been suggested as an alternative to succinylcholine for intubation. This is an update of our Cochrane review published first in 2003 and then updated in 2008 and now in 2015.

OBJECTIVES: To determine whether rocuronium creates intubating conditions comparable to those of succinylcholine during RSI intubation.

SEARCH METHODS: In our initial review we searched all databases until March 2000, followed by an update to June 2007. This latest update included searching the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 2), MEDLINE (1966 to February Week 2 2015), and EMBASE (1988 to February 14 2015 ) for randomized controlled trials (RCTs) or controlled clinical trials (CCTs) relating to the use of rocuronium and succinylcholine. We included foreign language journals and handsearched the references of identified studies for additional citations.

SELECTION CRITERIA: We included any RCT or CCT that reported intubating conditions in comparing the use of rocuronium and succinylcholine for RSI or modified RSI in any age group or clinical setting. The dose of rocuronium was at least 0.6 mg/kg and succinylcholine was at least 1 mg/kg.

DATA COLLECTION AND ANALYSIS: Two authors (EN and DT) independently extracted data and assessed methodological quality for the 'Risk of bias' tables. We combined the outcomes in Review Manager 5 using a risk ratio (RR) with a random-effects model.

MAIN RESULTS: The previous update (2008) had identified 53 potential studies and included 37 combined for meta-analysis. In this latest update we identified a further 13 studies and included 11, summarizing the results of 50 trials including 4151 participants. Overall, succinylcholine was superior to rocuronium for achieving excellent intubating conditions: RR 0.86 (95% confidence interval (CI) 0.81 to 0.92; n = 4151) and clinically acceptable intubation conditions (RR 0.97, 95% CI 0.95 to 0.99; n = 3992, 48 trials). A high incidence of detection bias amongst the trials coupled with significant heterogeneity provides moderate-quality evidence for these conclusions, which are unchanged from the previous update. Succinylcholine was more likely to produce excellent intubating conditions when using thiopental as the induction agent: RR 0.81 (95% CI: 0.73 to 0.88; n = 2302, 28 trials). In the previous update, we had concluded that propofol was the superior induction agent with succinylcholine. There were no reported incidences of severe adverse outcomes. We found no statistical difference in intubation conditions when succinylcholine was compared to 1.2 mg/kg rocuronium; however, succinylcholine was clinically superior as it has a shorter duration of action.

AUTHORS' CONCLUSIONS: Succinylcholine created superior intubation conditions to rocuronium in achieving excellent and clinically acceptable intubating conditions. 

3. Adverse Events Following Diagnostic Urethral Catheterization in the Pediatric ED

Ouellet-Pelletier J, et al. CJEM 2016;18:437-442.

The purpose of this study was to assess adverse events associated with diagnostic urethral catheterization (UC) in young children and to determine their impact on the patient and their family.

This was a prospective cohort study conducted in the emergency department of a tertiary-care pediatric hospital. All 3- to 24-month-old children with fever who had a diagnostic UC were eligible. Parents who consented to participate were contacted by phone within 7 to 10 days after the UC to answer a standardized questionnaire inquiring about complications. The primary outcome was the occurrence of an unfavourable event in the seven days following UC, defined as painful urination, genital pain, urinary retention, hematuria or secondary urinary tract infection. Secondary outcomes included the need for further medical care and the need for parents to miss school or work.

Of the 199 patients who completed the study, 41 (21%) reported a complication: painful urination in 19 (10%) children, genital pain in 16 (8%), urinary retention in 11 (6%), gross hematuria in 9 (5%), and secondary urinary tract infection in 1 (0.5%). Three (1%) parents reported the need for further medical care and three (1%) missed work. Two independent variables (male sex and age 12-23 months) were associated with a higher risk of adverse events.

Urethral catheterization is associated with adverse events in 21% of young children in the week following the procedure. Accordingly, this procedure should be used judiciously in children, considering its potential to cause unfavourable events.

4. Systematic Reviews from JEM

A. Risk of Delayed ICH in Anticoagulated Patients with Mild TBI: Systematic Review and Meta-Analysis.

Chauny JM, et al. J Emerg Med. 2016 Nov;51(5):519-528.

BACKGROUND: Delayed intracranial hemorrhage is a potential complication of head trauma in anticoagulated patients.

OBJECTIVE: Our aim was to use a systematic review and meta-analysis to determine the risk of delayed intracranial hemorrhage 24 h after head trauma in patients who have a normal initial brain computed tomography (CT) scan but took vitamin K antagonist before injury.

METHODS: EMBASE, Medline, and Cochrane Library were searched using controlled vocabulary and keywords. Retrospective and prospective observational studies were included. Outcomes included positive CT scan 24 h post-trauma, need for surgical intervention, or death. Pooled risk was estimated with logit proportion in a random effect model with 95% confidence intervals (CIs).

RESULTS: Seven publications were identified encompassing 1,594 patients that were rescanned after a normal first head scan. For these patients, the pooled estimate of the incidence of intracranial hemorrhage on the second CT scan 24 h later was 0.60% (95% CI 0-1.2%) and the resulting risk of neurosurgical intervention or death was 0.13% (95% CI 0.02-0.45%).

CONCLUSIONS: The present study is the first published meta-analysis estimating the risk of delayed intracranial hemorrhage 24 h after head trauma in patients anticoagulated with vitamin K antagonist and normal initial CT scan. In most situations, a repeat CT scan in the emergency department 24 h later is not necessary if the first CT scan is normal. Special care may be required for patients with serious mechanism of injury, patients showing signs of neurologic deterioration, and patients presenting with excessive anticoagulation or receiving antiplatelet co-medication.

B. Cervical Artery Dissections: A Review.

Robertson JJ, et al. J Emerg Med. 2016 Nov;51(5):508-518.

BACKGROUND: Cervical artery dissection (CeAD) is an infrequent, yet potentially devastating, cause of stroke. While uncommon, CeAD is important for emergency physicians to quickly diagnose and treat because of the potential for cerebral ischemia, stroke, blindness, or death. To our knowledge, no review articles in the emergency medicine literature have been published on CeAD. A literature search of MEDLINE/PubMed, Embase, and other major abstracts in the English language was performed for the following terms: cervical artery, vertebral artery, and carotid artery dissection. The search included all titles from January 1, 2010 to February 28, 2015 and other relevant articles.

OBJECTIVES: We sought to review the epidemiology, pathophysiology, risk factors, and clinical presentation for extracranial CeAD in the adult population, explore recent research on diagnosing this disorder, evaluate the most current research on treatment options, and summarize the prognosis of CeAD.

DISCUSSION: CeAD is an uncommon but important cause of stroke in the young that is likely caused by multifactorial processes. The diagnosis should be considered in those with underlying risk factors, a remote history of minor trauma, and concerning signs and symptoms. The condition should be pursued via magnetic resonance imaging or computed tomography angiography. Treatment should be aimed at preventing additional complications, including recurrent stroke or transient ischemic attack, with antiplatelets, anticoagulants, or even endovascular or surgical therapy.

CONCLUSION: Overall, the prognosis of patients with CeAD is good, with relatively low death rates. However, the diagnosis should not be missed, because treatment may help prevent worsening or persistent ischemia, recurrent dissection, and death.

5. What are the Best Recent Blogs and Podcasts for Neurologic Emergencies?

Grock A, et al. West J Emerg Med. 2016 Nov;17(6):726-733.

Introduction: The Academic Life in Emergency Medicine (ALiEM) Blog and Podcast Watch presents high quality open access educational blogs and podcasts in emergency medicine (EM) based on the ongoing ALiEM Approved Instructional Resources (AIR) and AIR-Professional series. Both series critically appraise resources using an objective scoring rubric. This installment of the Blog and Podcast Watch highlights the topic of neurologic emergencies from the AIR series.

Methods: The AIR series is a continuously building curriculum which follows the Council of Emergency Medicine Residency Director’s (CORD) annual testing schedule. For each module, relevant content is collected from the top 50 Social Media Index sites published within the previous 12 months, and scored by 8 board members using 5 equally weighted measurement outcomes: Best Evidence in Emergency Medicine (BEEM) score, accuracy, educational utility, evidence based, and references. Resources scoring ≥30 out of 35 available points receive an AIR label. Resources scoring 27-29 receive an Honorable Mention label, if the executive board agrees that the post is accurate and educationally valuable.

Results: A total of 125 blog posts and podcasts were evaluated. Key educational pearls from the 14 AIR posts are summarized, and the 20 Honorable Mentions are listed.

Conclusion: The WestJEM ALiEM Blog and Podcast Watch series is based on the AIR and AIR-Pro series, which attempts to identify high quality educational content on open-access blogs and podcasts. This series provides an expert-based, post-publication curation of educational social media content for EM clinicians with this installment focusing on neurologic emergencies.

For the list and links, see full-text (free) here:

6. Intranasal ketamine for acute traumatic pain in the ED: a prospective, randomized clinical trial of efficacy and safety

Shimonovich S, et al. BMC Emerg Med. 2016 Nov 9;16(1):43.

BACKGROUND: Ketamine has been well studied for its efficacy as an analgesic agent. However, intranasal (IN) administration of ketamine has only recently been studied in the emergency setting. The objective of this study was to elucidate the efficacy and adverse effects of a sub-dissociative dose of IN Ketamine compared to IV and IM morphine.

METHODS: A single-center, randomized, prospective, parallel clinical trial of efficacy and safety of IN ketamine compared to IV and IM morphine for analgesia in the emergency department (ED). A convenience sample of 90 patients aged 18-70 experiencing moderate-severe acute traumatic pain (≥80 mm on 100 mm Visual Analog Scale [VAS]) were randomized to receive either 1.0 mg/kg IN ketamine, 0.1 mg/kg IV MO or 0.15 mg/kg IM MO. Pain relief and adverse effects were recorded for 1 h post-administration. The primary outcome was efficacy of IN ketamine compared to IV and IM MO, measured by "time-to-onset" (defined as a ≥15 mm pain decrease on VAS), as well as time to and degree of maximal pain reduction.

RESULTS: The 3 study groups showed a highly significant, similar maximal pain reduction of 56 ± 26 mm for IN Ketamine, and 59 ± 22 and 48 ± 30 for IV MO and IM MO, respectively. IN Ketamine provided clinically-comparable results to those of IV MO with regards to time to onset (14.3 ± 11.2 v. 8.9 ± 5.6 min, respectively) as well as in time to maximal pain reduction (40.4 ± 16.3) versus (33.4 ± 18), respectively.

CONCLUSIONS: IN ketamine shows efficacy and safety comparable to IV and IM MO. Given the benefits of this mode of analgesia in emergencies, it should be further studied for potential clinical applications.

7. Medically Clear: What I Learned Re-learned Studying for ConCert

Ballard DW. Emerg Med News. 2016;38)11):23-24.

This summer I have had the pleasure chore of studying for the Continuing Certification examination (ConCert). Remarkably, 10 years after my last go, my brain is nimbly haltingly recovering details it carefully stored in my youth: neglected formulas, minutiae, and zebras of many hues. With excitement annoyance, I have launched into the review material, cognizant that several months' worth of appraisal are likely to bring a lasting temporary upgrade in my emergency medicine knowledge base. Not wanting to forfeit a week of vacation for this opportunity toil, I've embarked on a slow and steady self-study algorithm:

Step 1: Use continuing education funds to purchase the deluxe package of the National Emergency Board Review Self-Study.

Step 2: Revel in the massive package that arrives in the mail: a binder bigger than my head, 225 image-laden “BizzBuzz!” flashcards, 28 audio CDs, 14 DVDs, and a flash drive (the contents of which remain a mystery.) I think I also received a pocket-sized DSM-V, just in case this caused a psychotic break.

Step 3: To complete the self-flagellation, I cued up the PEER VIII on my tablet, replete with 450 questions and detailed answers.

Step 4: Oh, months of endless enlightenment, poorly deployed hippocampal effort!

My summer is nearly wasted over, and my brain is a lean, mean diagnostic medical trivia machine. Before I shut the cognitive door on this experience, I jotted down some tips to help those who will take the ConCert in the next few years. After all of my cramming efforts, here's my big takeaway. The ConCert actually stands for: C. O. N. C. E. R. T.

C=Calculating Formulas

I did not realize how much I missed calculating formulas on my own. If the Y2K glitch finally strikes and I am without access to the internet, a smartphone, or EHR-based calculators, I will not have struggle to remember the Parkland, the Winters, or the osmolal gaps.

Is it just me, or is it a waste of precious brain space to know that in a hyperglycemic patient the sodium is actually the measured sodium + 1.6 * (glucose-100)/100)? Isn't it enough to recognize that the sodium level in hyperglycemia is artificially low and the potassium level artificially high?

O=OMG, Rashes

There is nothing an EP loves more than a well patient visiting the ED for a nonspecific rash. If I had wanted to be a dermatologist, I would have done a pimple-popping residency. Unfortunately, ABEM takes a different approach to rashes. Jodie Craig, MD, a residency colleague of mine who recertified last year, pointed out that the exam does not allow access to Google images or the derm teleservice. I guess I'll be on the lookout for the Christmas tree appearance of Pityriasis rosea and the distinctive gray-white appearance of disseminated gonococcal infection.

N=Negative Reinforcement

EM Board Review pictorial flashcards are a great way to scare your children out of any interest in medical school. Here's what happened when my 7-year-old picked up my cards.

7-year-old: “Aaargh. Dad, what happened to his wiener?”

Me: “Chancre, son. Not painful but still not good. Needs some penicillin.”

7-year old looking at another card: “Gross!”

Me: “Fournier's gangrene. Bad news. Smells bad, too.”

7-year-old throwing cards across room: “You're weird, Dad.”

C=Cold Calorics

Amal Mattu, MD, is fond of advising his board review students what things are like at ABEM General and which rare conditions and tests we're expected to know, despite the fact that we may never encounter or use them in our day-to-day practice. Cold calorics are a perfect example. I have never performed this test, not even in the ICU.

I have to think that the only relevant aspect of the exam is to remind us not to use cold water when performing earwax irrigation. And what about the perimortem C-section? I am unlikely to ever perform it in real life, but I can guarantee that I will encounter it on the ConCert. As for the DPL, Dr. Craig wonders, “Seriously?”

8. Weight Gain over the Holidays in Three Countries

Helander EE. N Engl J Med 2016; 375:1200-1202.

Different countries celebrate different holidays, but many such celebration periods have one thing in common: an increased intake of favorite foods. How do holidays — such as Thanksgiving in the United States, Christmas in Germany, and Golden Week in Japan — affect weight gain in those countries? The use of wireless scales to measure weight patterns could alleviate some of the limitations possibly seen in traditional studies, such as demand characteristics,1,2 and provide useful insights regarding holiday weight gain.

Using data obtained from wireless scales (WS50, Withings), we recorded or interpolated the daily weight change of 2924 participants from three countries and extracted data for the 12-month period from August 1, 2012, to July 31, 2013. Data were obtained from 1781 residents of the United States (mean age, 42.2 years; mean body-mass index [BMI; the weight in kilograms divided by the square of the height in meters], 27.7), of whom 34% were women and 24% were obese (BMI ≥30.0); from 760 residents of Germany (mean age, 42.9 years; mean BMI, 26.6), of whom 34% were women and 19% were obese; and 383 residents of Japan (mean age, 41.6 years; mean BMI, 24.7), of whom 26% were women and 11% were obese. Additional details regarding the methods are provided in the Supplementary Appendix, available with the full text of this letter at

The daily weight of each person was normalized by first subtracting their starting weight at the beginning of August and dividing by their average weight over the year. The resulting weight-change curve was smoothed over a 7-day running-average window, subtracted by a linear trend, and averaged over all the participants in each country. We used a two-sided, paired Student’s t-test to assess whether the maximum weight at no more than 10 days after the start of the holiday differed from the weight that was measured 10 days before the holiday.

In all three countries, the participants’ weight rose within 10 days after Christmas Day, as compared with 10 days before Christmas Day (weight increases of 0.4% in the United States, P less than 0.001; 0.6% in Germany, P less than 0.001; and 0.5% in Japan, P=0.005). Significant weight gain was also observed around other major holidays in each country: participants’ weight increased by 0.3% in Japan during Golden Week (P less than 0.001), 0.2% in Germany during the Easter holiday (P less than 0.001), and 0.2% in the United States during the Thanksgiving holiday (P less than 0.001). Overall, from the minimum annual weight, weight increased by 0.7% (0.6 kg) in the participants from the United States and 1.0% (0.8 kg) in those from Germany during the Christmas–New Year holiday season and 0.7% (0.5 kg) in participants from Japan during Golden Week.

In these three prosperous countries, weight gain occurs during national holidays. Although this population sample may be wealthier, better educated, and more motivated toward weight loss than average, it still provides insights for practice. Advising a patient to have better self-control over the holidays is one approach.3,4 Yet given the weight-loss patterns shown in Figure 1, it might be better to advise patients that although up to half of holiday weight gain is lost shortly after the holidays, half the weight gain appears to remain until the summer months or beyond. Of course, the less one gains, the less one then has to worry about trying to lose it.

9. Lung US to Diagnose Pneumonia? Not as Good as CXR

Llamas-Álvarez AM, et al. Accuracy of lung ultrasound in the diagnosis of pneumonia in adults: systematic review and meta-analysis. Chest. 2016 Nov 3 [Epub ahead of print]

BACKGROUND: Some studies suggest that lung ultrasound could be useful for diagnosing pneumonia; moreover, it has a more favorable safety profile and lower cost than chest X-ray (CXR) and computed tomography (CT). The aim of this study is to assess the accuracy of bedside lung ultrasound for diagnosing pneumonia in adults through a systematic review and meta-analysis.

METHODS: We searched MEDLINE, Scopus, The Cochrane Library, Web of Science, DARE, HTA Database, Google Scholar, LILACS,, TESEO and OpenGrey. In addition, we reviewed the bibliographies of relevant studies. Two researchers independently selected studies that met the inclusion criteria. Quality of the studies was assessed in accordance with the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. The summary receiver operating characteristics (SROC) curve and a pooled estimation of the diagnostic odds ratio (DOR) was estimated using using a bivariate random-effects analysis. The sources of heterogeneity were explored using predefined subgroup analyses and bivariate meta-regression.

RESULTS: Sixteen studies (2359 participants) were included. There was significant heterogeneity of both sensitivity and specificity according to Q test, without clear evidence of threshold effect. The area under the SROC curve was 0.93, with a DOR at the optimal cutpoint of 50 (95% confidence interval (CI): 21, 120). A tendency towards a higher area under the SROC curve in high quality studies was detected, however these differences were not significant after applying the bivariate meta-regression.

CONCLUSIONS: Lung ultrasound can help to accurately diagnose pneumonia, and it may be promising as an adjuvant resource to traditional approaches.

10. Images in Clinical Practice

Point-of-Care Sonographic Findings in Acute Upper Airway Edema

Point-of-Care Ultrasound to Diagnose a Simple Ranula

Point-of-Care Ultrasound for Rapid Diagnosis of Rhabdomyolysis

Emphysematous Cystitis

Ocular Flutter in the Serotonin Syndrome

Hemothorax after Thoracentesis

Diagnosing Myasthenia Gravis with an Ice Pack

Heterotopic Pregnancy

Tabes Dorsalis and Argyll Robertson Pupils

Large Hiatal Hernia

Dizziness and Vertigo during MRI

11. Assessment of heart rate, acidosis, consciousness, oxygenation, and respiratory rate to predict noninvasive ventilation failure in hypoxemic patients.

Duan J, et al. Intensive Care Med. 2016 Nov 3. [Epub ahead of print]

PURPOSE: To develop and validate a scale using variables easily obtained at the bedside for prediction of failure of noninvasive ventilation (NIV) in hypoxemic patients.

METHODS: The test cohort comprised 449 patients with hypoxemia who were receiving NIV. This cohort was used to develop a scale that considers heart rate, acidosis, consciousness, oxygenation, and respiratory rate (referred to as the HACOR scale) to predict NIV failure, defined as need for intubation after NIV intervention. The highest possible score was 25 points. To validate the scale, a separate group of 358 hypoxemic patients were enrolled in the validation cohort.

RESULTS: The failure rate of NIV was 47.8 and 39.4% in the test and validation cohorts, respectively. In the test cohort, patients with NIV failure had higher HACOR scores at initiation and after 1, 12, 24, and 48 h of NIV than those with successful NIV. At 1 h of NIV the area under the receiver operating characteristic curve was 0.88, showing good predictive power for NIV failure. Using 5 points as the cutoff value, the sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy for NIV failure were 72.6, 90.2, 87.2, 78.1, and 81.8%, respectively. These results were confirmed in the validation cohort. Moreover, the diagnostic accuracy for NIV failure exceeded 80% in subgroups classified by diagnosis, age, or disease severity and also at 1, 12, 24, and 48 h of NIV. Among patients with NIV failure with a HACOR score of greater than 5 at 1 h of NIV, hospital mortality was lower in those who received intubation at ≤12 h of NIV than in those intubated later [58/88 (66%) vs. 138/175 (79%); p = 0.03).

CONCLUSIONS: The HACOR scale variables are easily obtained at the bedside. The scale appears to be an effective way of predicting NIV failure in hypoxemic patients. Early intubation in high-risk patients may reduce hospital mortality.

12. Effect of Conservative vs Conventional Oxygen Therapy on Mortality among Patients in an Intensive Care Unit: The Oxygen-ICU Randomized Clinical Trial.

Girardis M, et al. JAMA. 2016 Oct 18;316(15):1583-1589.

Importance: Despite suggestions of potential harm from unnecessary oxygen therapy, critically ill patients spend substantial periods in a hyperoxemic state. A strategy of controlled arterial oxygenation is thus rational but has not been validated in clinical practice.

Objective: To assess whether a conservative protocol for oxygen supplementation could improve outcomes in patients admitted to intensive care units (ICUs).

Design, Setting, and Patients: Oxygen-ICU was a single-center, open-label, randomized clinical trial conducted from March 2010 to October 2012 that included all adults admitted with an expected length of stay of 72 hours or longer to the medical-surgical ICU of Modena University Hospital, Italy. The originally planned sample size was 660 patients, but the study was stopped early due to difficulties in enrollment after inclusion of 480 patients.

Interventions: Patients were randomly assigned to receive oxygen therapy to maintain Pao2 between 70 and 100 mm Hg or arterial oxyhemoglobin saturation (Spo2) between 94% and 98% (conservative group) or, according to standard ICU practice, to allow Pao2 values up to 150 mm Hg or Spo2 values between 97% and 100% (conventional control group).

Main Outcomes and Measures: The primary outcome was ICU mortality. Secondary outcomes included occurrence of new organ failure and infection 48 hours or more after ICU admission.

Results: A total of 434 patients (median age, 64 years; 188 [43.3%] women) received conventional (n = 218) or conservative (n = 216) oxygen therapy and were included in the modified intent-to-treat analysis. Daily time-weighted Pao2 averages during the ICU stay were significantly higher (P  less than .001) in the conventional group (median Pao2, 102 mm Hg [interquartile range, 88-116]) vs the conservative group (median Pao2, 87 mm Hg [interquartile range, 79-97]). Twenty-five patients in the conservative oxygen therapy group (11.6%) and 44 in the conventional oxygen therapy group (20.2%) died during their ICU stay (absolute risk reduction [ARR], 0.086 [95% CI, 0.017-0.150]; relative risk [RR], 0.57 [95% CI, 0.37-0.90]; P = .01). Occurrences were lower in the conservative oxygen therapy group for new shock episode (ARR, 0.068 [95% CI, 0.020-0.120]; RR, 0.35 [95% CI, 0.16-0.75]; P = .006) or liver failure (ARR, 0.046 [95% CI, 0.008-0.088]; RR, 0.29 [95% CI, 0.10-0.82]; P = .02) and new bloodstream infection (ARR, 0.05 [95% CI, 0.00-0.09]; RR, 0.50 [95% CI, 0.25-0.998; P = .049).

Conclusions and Relevance: Among critically ill patients with an ICU length of stay of 72 hours or longer, a conservative protocol for oxygen therapy vs conventional therapy resulted in lower ICU mortality. These preliminary findings were based on unplanned early termination of the trial, and a larger multicenter trial is needed to evaluate the potential benefit of this approach.

13. Causes of Elevated Cardiac Trops in the ED and Their Associated Mortality.

Meigher S, et al. Acad Emerg Med. 2016;23(11):1267–1273.

OBJECTIVE: Cardiac troponins (cTn) are structural components of myocardial cells and are expressed almost exclusively in the heart. Elevated cTn levels indicate myocardial cell damage/death but not reflect the underlying etiology. The third universal definition of myocardial infarction (MI) differentiates MI into various types. Type 1 (T1MI) is due to plaque rupture with thrombus, while type 2 (T2MI) is a result of a supply:demand mismatch. Non-MI cTn elevations are also common. We determined the causes of elevated cTn in a tertiary care emergency department (ED) and the associated in-hospital mortality.

METHODS: We performed a structured, retrospective review of all consecutive adult ED patients with elevated troponin I (defined as above the 99th percentile of the normal population, as run on the ADVIA Centaur platform; Siemens USA) during 1 year. Causes of elevated cTn were classified based on the third universal definitions. Comparisons between groups were performed using chi-square and Mann-Whitney U-tests.

RESULTS: Of 96,612 ED patients presenting from May 2012 to April 2013, a total of 13,502 (14%) had cTn measured, of which 1,310 (9.7%) were elevated. Of these, 340 (26.5%, 95% confidence interval [CI], 24.2% to 29.0%) were T1MI, 452 (35.2%, 95% CI = 32.7% to 37.9%) T2MI, 458 (35.7%, 95% CI = 33.1% to 38.4%) multifactorial, and 33 (2.5%, 95% CI = 1.8% to 3.5%) due to nonischemic injury. Non-T1MI patients were slightly older, more likely female, and had higher blood urea nitrogen and creatinine. Comorbidities were more common in non-T1MI while cardiac risk factors were more common in T1MI. Non-T1MI patients were less likely to have diagnostic ECGs and had lower initial and subsequent cTn levels. In-hospital mortality rates were similarly high for T1MI and non-T1MI (11% [95% CI = 8% to 15%] vs. 10% [95% CI = 8% to 12%], p = 0.48).

CONCLUSIONS: Of all ED patients with elevated cTn, ~75% have a non-T1MI. The mortality of patients with non-T1MI is similar to the mortality in patients with T1MI.

14. Not Thinking Clearly? Play a Game, Seriously!

Mohan D, et al. JAMA. 2016;316(18):1867-1868.

According to a report from the National Academy of Medicine, every individual in the United States will experience at least 1 diagnostic error during his or her lifetime. The 2015 report, Improving Diagnosis in Health Care,1 stated there was “a moral, professional, and public health imperative” to improve the diagnostic process. Although the report attributed diagnostic failures to many factors, including poorly designed health care systems, limitations of health information technology, and the increasing complexity of medicine, it poignantly identified timely, accurate, patient-centered diagnosis as the quintessential competency of the clinician.

The Problem: Poorly Calibrated Heuristics
When clinicians make a diagnosis, they have to process information and estimate the probability that the patient has x, y, or z condition. In other words, they have to render a judgment. Over the last 40 years, many experts in psychology and economics debunked the idea that judgment occurs in a consistent, reproducible, rational fashion. Rather, judgment arises from 2 separate cognitive processes: the first, “System 1,” provides rapid solutions based on pattern recognition (heuristics), while the other, “System 2,” is a slower analytic process that produces answers derived from rule-based algorithms. Although the 2 systems generally work cooperatively to produce adequately accurate or sensible answers,2 there are key limitations.

Most judgments arise exclusively from heuristics (System 1). Every physician, and every person, can make a host of spontaneous and cognitively effortless decisions based on judgments that come to mind instantaneously when presented with a pattern of information. This capacity of System 1 decision making works well under time pressure and uncertainty because it bypasses the need to carefully sift through all data and instead streamlines decision making. Heuristics generate accurate answers most of the time. However, when poorly calibrated (ie, developed via exposure to prior decision settings that are not adequately analogous), heuristics draw attention to the wrong contextual cues, resulting in systematic errors in judgment (biases). People develop good heuristics when they perform the same task repeatedly and receive feedback on their performance.2 However, most physicians do not have the luxury of performing a single task. Moreover, they receive feedback only for the rare cases tied to performance measures or perceived as outliers.

This problem is well illustrated by conditions like sepsis or trauma, for which physicians must make time-sensitive diagnoses with imperfect information and with competing demands on their attention. As the population ages, the likelihood that patients with sepsis or trauma or other complex conditions will present with comorbid conditions further adds diagnostic complexity. Additionally, these conditions, although common nationwide, are only a small proportion of each physician’s caseload. For example, some emergency medicine physicians practicing outside of academic centers treat 1000 patients for every 1 with severe trauma. In other words, time pressure and competing demands drive physicians to rely on heuristics when making critical decisions for these patients with severe trauma. The physicians use the degree to which a patient appears typical of the severely injured (the “representativeness” heuristic) or reminds them of a prior case (the “availability” heuristic) to make treatment decisions, rather than rule-based algorithms. But the lack of predictability and routine feedback result in poorly calibrated heuristics.3 Consequently, when managing the care of 2 patients who should both be promptly referred to a trauma center, physicians will act quickly and correctly with the obvious case (eg, a young man with a gunshot wound), whereas their judgment may fail with the other (eg, an elderly patient who fell and sustained a rib fracture): their heuristics may lead them astray.

Traditional Solutions to Overcome Poor Judgment and Diagnostic Error
Existing interventions typically involve 1 of 2 approaches to improve judgment. The first is to increase physicians’ use of System 2 processes, either implicitly through disseminating rule-based algorithms or explicitly by encouraging reflective reasoning (encouraging physicians to consider their diagnoses more carefully and recognize the shortcomings of their intuitive judgments). The second approach is to remove the clinician from the decision problem, shifting the burden of judgment to an external decision tool such as a treatment guideline or protocol. Both of these strategies have effectiveness and generalizability problems. In addition, decision tools rarely deal with the complex patient with comorbid conditions. However, most importantly, these 2 possible solutions share the same limitation: they waste human potential. Experts have unparalleled ability to parse complexity and sift through uncertainty. Instead of eliminating physicians (and their intuition) from difficult diagnostic problems, interventions are needed that make intuition better and more reliable.

An Alternative Solution: Using Serious Games to Recalibrate Intuition
Herbert Simon, winner of the Nobel Prize in economics for his work on the boundaries of rationality, defined expertise as follows: “The situation has provided a cue. The cue has given the expert access to information stored in memory, and the information provides the answer. Intuition is nothing more and nothing less than recognition.”2 If Simon is right, then improving heuristics requires that clinicians have additional experience. The key issue, particularly for rare events, is how to feasibly generate that experience. One solution is the use of so-called serious games—video games with an applied purpose. These games can range from virtual simulations to more imaginary or abstract tasks with the common feature that they rely on the engagement and challenge of game play to facilitate their objectives.

Games (even ones for entertainment) have the power to affect behavior, as demonstrated by Pokémon Go, the augmented-reality mobile phenomenon. This game—downloaded 100 million times during its first month—challenges players to capture virtual monsters by using a mobile app to search their environment.4 Some players report increased activity and weight loss as a by-product of their desire to win.

Serious games, which attempt to transform behavior deliberately, are being adopted in several arenas. The military has spent hundreds of millions of dollars in recent years on games for tactical training and skill development.5 The Transportation Security Administration wants to use games to improve threat detection by baggage screeners.6 The aviation industry has a long history of using simulators for pilot training. Although most of these games transmit information or promote the acquisition of new skills, a few have taken on the challenge of improving intuition. For example, Peacemaker, a simulation of the Israeli-Palestinian conflict, attempts to alter how players judge possible solutions to the problem. Practice reduces the correlation between religious-political affiliations and how people resolve conflict within the game.7

Serious Games in Health Care and Medicine
Over the last decade, serious games have gained traction as a method of influencing health outcomes. For example, NeuroRacer, a 3-dimensional driving game developed by researchers at the University of California–San Francisco, improves executive functioning in older adults, with gains lasting up to 6 months.8 However, fewer than 10% of serious games are designed for clinicians, and none explicitly attempts to recalibrate heuristics.9 This is a missed opportunity.

Serious games have 3 attributes that make them ideal for the task. First, games facilitate the retention of new data. People remember stories. Instead of forcing physicians to process data, games present that information within an overarching narrative, thereby facilitating its integration into a mental model of the decision problem. Second, games promote self-efficacy and response efficacy. By practicing desired behaviors in a safe environment, players can obtain confidence in their skills and experience the benefits of behavioral change. Third, games engage players both cognitively and emotionally. Identification with a character allows the player to absorb the message about best-practice decision principles in a way that transcends traditional forms of education. Using narrative engagement and character identification as surrogates for exposure to difficult cases, games can allow the player to create archetypes or patterns that serve as a reference in real life. Consequently, serious games have the potential to succeed where other methods have failed.

Will Physicians Play Video Games?
Video games are no longer the province of adolescent boys. More than 150 million people in the United States play video games, the average gamer is 34 years old, one-fourth (27%) are older than 50 years, and almost half (44%) are female.9 Statistics do not exist on the number of physicians who play games. However, states and professional organizations already require between 20 to 50 hours a year of continuing medical education—typically acquired through attending lectures, reading journals, or viewing online presentations—as a condition for licensure. Games could easily become part of the roster of accepted educational activities.

What Is Next?
There are early efforts to use games to recalibrate physicians’ heuristics. For example, a new adventure video game (Night Shift) is meant to change how physicians think about the “typical” trauma patient. Players take on the persona of an emergency medicine physician who accepts a job in a small town. Through a series of cases that go awry, players learn the characteristics of severely injured patients and experience the consequences of their diagnostic errors. Preliminary results suggest that physicians enjoy playing the game. The challenge ahead is to ensure they change their practice. If successful, games could potentially disrupt the current approach used for continuing medical education and, in doing so, may help to leverage the potential of the physicians at the heart of the patient-care relationship.

15. Accidental Pediatric Cannabis Ingestion

A. When the grass isn’t greener: a case series of young children with accidental marijuana ingestion

Murray D, et al. CJEM 2016;18:480-3.

Marijuana is the most commonly used illicit drug in Canada, with 10% of the general population admitting to its use in the past year. This high prevalence increases risk of accidental ingestion in young children.

We report four pediatric cases of accidental marijuana ingestion who presented to our local emergency department with altered mental status. Three patients had extensive testing, including one patient who underwent lumbar puncture and empirical treatment for meningitis. To our knowledge, this is the first Canadian case series since McNabb et al., published over 2 decades ago.

The case series aims to highlight the importance of considering acute marijuana intoxication in the differential diagnosis when assessing young children with altered level of consciousness.

B. Parental cannabis abuse and accidental intoxications in children: prevention by detecting neglectful situations and at-risk families.

Pélissier F, et al. Pediatr Emerg Care. 2014 Dec;30(12):862-6.

OBJECTIVES: Cannabis intoxication in toddlers is rare and mostly accidental. Our objectives were to focus on the characteristics and management of children under the age of 6 years who were admitted to our emergency department with cannabis poisoning reported as accidental by parents, and to point out the need to consider accidental cannabis ingestions as an indicator of neglect.

METHODS: The medical records of children hospitalized for cannabis poisoning in a pediatric emergency department from January 2007 to November 2012 were retrospectively evaluated. Data collected included age, sex, drug ingested, source of drug, intentional versus accidental ingestion, pediatric intensive care unit or hospital admission, treatment and length of hospital stay, toxicology results, and rate of child protectives services referral.

RESULTS: Twelve toddlers (4 boys and 8 girls; mean age, 16.6 months) were included. All had ingested cannabis. Their parents reported the ingestion. Seven children experienced drowsiness or hypotonia. Three children were given activated charcoal. Blood screening for cannabinoids, performed in 2 cases, was negative in both, and urine samples were positive in 7 children (70%). All children had favorable outcomes after being hospitalized from 2 to 48 hours. Nine children were referred to social services for further assessment before discharge.

CONCLUSIONS: Cannabis intoxication in children should be reported to child protection services with the aim of prevention, to detect situations of neglect and at-risk families. Legal action against the parents may be considered. Accidental intoxication and caring parents should be no exception to this rule.

16. Tracheal Intubation during Pediatric In-Hospital Cardiac Arrest associated with Worse Survival

Andersen LW, et al. American Heart Association’s Get with The Guidelines–Resuscitation Investigators. JAMA. 2016 Nov 1;316(17):1786-1797.

IMPORTANCE: Tracheal intubation is common during pediatric in-hospital cardiac arrest, although the relationship between intubation during cardiac arrest and outcomes is unknown.

OBJECTIVE: To determine if intubation during pediatric in-hospital cardiac arrest is associated with improved outcomes.

DESIGN, SETTING, AND PARTICIPANTS: Observational study of data from United States hospitals in the Get With The Guidelines-Resuscitation registry. Pediatric patients (less than 18 years) with index in-hospital cardiac arrest between January 2000 and December 2014 were included. Patients who were receiving assisted ventilation, had an invasive airway in place, or both at the time chest compressions were initiated were excluded.

EXPOSURES: Tracheal intubation during cardiac arrest .

MAIN OUTCOMES AND MEASURES: The primary outcome was survival to hospital discharge. Secondary outcomes included return of spontaneous circulation and neurologic outcome. A favorable neurologic outcome was defined as a score of 1 to 2 on the pediatric cerebral performance category score. Patients being intubated at any given minute were matched with patients at risk of being intubated within the same minute (ie, still receiving resuscitation) based on a time-dependent propensity score calculated from multiple patient, event, and hospital characteristics.

RESULTS: The study included 2294 patients; 1308 (57%) were male, and all age groups were represented (median age, 7 months [25th-75th percentiles, 21 days, 4 years]). Of the 2294 included patients, 1555 (68%) were intubated during the cardiac arrest. In the propensity score-matched cohort (n = 2270), survival was lower in those intubated compared with those not intubated (411/1135 [36%] vs 460/1135 [41%]; risk ratio [RR], 0.89 [95% CI, 0.81-0.99]; P = .03). There was no significant difference in return of spontaneous circulation (770/1135 [68%] vs 771/1135 [68%]; RR, 1.00 [95% CI, 0.95-1.06]; P = .96) or favorable neurologic outcome (185/987 [19%] vs 211/983 [21%]; RR, 0.87 [95% CI, 0.75-1.02]; P = .08) between those intubated and not intubated. The association between intubation and decreased survival was observed in the majority of the sensitivity and subgroup analyses, including when accounting for missing data and in a subgroup of patients with a pulse at the beginning of the event.

CONCLUSIONS AND RELEVANCE: Among pediatric patients with in-hospital cardiac arrest, tracheal intubation during cardiac arrest compared with no intubation was associated with decreased survival to hospital discharge. Although the study design does not eliminate the potential for confounding, these findings do not support the current emphasis on early tracheal intubation for pediatric in-hospital cardiac arrest.

DRV Comments
These results remind me of the pre-hospital Gausche study in JAMA 2000.

Her conclusion: “These results indicate that the addition of out-of-hospital ETI to a paramedic scope of practice that already includes BVM did not improve survival or neurological outcome of pediatric patients treated in an urban EMS system.”

One of the major limitations, however, in this 2016 study is confounding by severity.
Let me quote from Kyriacou:
“A particularly important type of confounding in clinical research is confounding by indication, which occurs when the clinical indication for selecting a particular treatment (eg, severity of the illness) also affects the outcome. For example, patients with more severe illness are likely to receive more intensive treatments and, when comparing the interventions, the more intensive intervention will appear to result in poorer outcomes. This is called “confounding by severity” to emphasize that the degree of illness is the confounder. Because the degree of severity affects both treatment selection and patient outcome and is not an intermediate between the treatment and outcome, it fulfills the criteria for confounding.

“The nonrandomized assessment of tracheal intubation vs bag-valve-mask ventilation for pediatric cardiopulmonary arrest reported by Andersen et al2 in the November 1, 2016, issue of JAMA is likely to be complicated by confounding by indication. Clinical conditions (eg, asthma, cystic fibrosis, and upper airway obstruction) existing before and during a patient’s cardiopulmonary resuscitation will both affect the patient’s outcome and influence the type of airway management.2 In other words, it is likely that children with more severe disease and worse overall prognosis for survival had a greater probability to be intubated.2 This possibility is especially great because severity of illness is both a strong predictor of mortality and a strong predictor of the clinical decision to intubate...”

Kyriacou DN, Lewis RJ. Confounding by Indication in Clinical Research. JAMA. 2016 Nov 1;316(17):1818-1819.

17. Imaging of Soft Tissue Infections

A. Point-of-care US for Diagnosis of Abscess in Skin and Soft Tissue Infections

Subramaniam S, et al. Acad Emerg Med. 2016;23(11): 1298–1306.

BACKGROUND: Traditionally, emergency department (ED) physicians rely on their clinical examination to differentiate between cellulitis and abscess when evaluating skin and soft tissue infections (SSTI). Management of an abscess requires incision and drainage, whereas cellulitis generally requires a course of antibiotics. Misdiagnosis often results in unnecessary invasive procedures, sedations (for incision and drainage in pediatric patients), or a return ED visit for failed antibiotic therapy.

OBJECTIVE: The objective was to describe the operating characteristics of point-of-care ultrasound (POCUS) compared to clinical examination in identifying abscesses in ED patients with SSTI.

METHODS: We systematically searched Medline, Web of Science, EMBASE, CINAHL, and Cochrane Library databases from inception until May 2015. Trials comparing POCUS with clinical examination to identify abscesses when evaluating SSTI in the ED were included. Trials that included intraoral abscesses or abscess drainage in the operating room were excluded. The presence of an abscess was defined by drainage of pus. The absence of an abscess was defined as no pus drainage upon incision and drainage or resolution of SSTI without pus drainage at follow-up. Quality of trials was assessed using the QUADAS-2 tool. Operating characteristics were reported as sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-), with their respective 95% confidence intervals (CI). Summary measures were calculated by generating a hierarchical summary receiver operating characteristic (HSROC) model.

RESULTS: Of 3,203 references identified, six observational studies (four pediatric trials and two adult trials) with a total of 800 patients were included. Two trials compared clinical examination with clinical examination plus POCUS. The other four trials directly compared clinical examination to POCUS. The POCUS HSROC revealed a sensitivity of 97% (95% CI = 94% to 98%), specificity of 83% (95% CI = 75% to 88%), LR+ of 5.5 (95% CI = 3.7 to 8.2), and LR- of 0.04 (95% CI = 0.02 to 0.08).

CONCLUSION: Existing evidence indicates that POCUS is useful in identifying abscess in ED patients with SSTI. In cases where physical examination is equivocal, POCUS can assist physicians to distinguish abscess from cellulitis.

B. CT best for radiologic evaluation in necrotizing soft tissue infections.

Leichtle SW, et al. J Trauma Acute Care Surg. 2016 Nov;81(5):921-924.

BACKGROUND: The role of diagnostic imaging in suspected necrotizing soft tissue infections (NSTIs) is not clear owing to concerns about its value and possible delays in definitive surgical care.

METHODS: Plain radiograph (XR) and computed tomography (CT) results of all patients who underwent operative debridement for a presumed NSTI from 2007 through 2014 at LAC + USC Medical Center were reviewed. Preoperative imaging was classified as being negative, suspicious (inflammatory changes), or diagnostic (soft tissue gas) for NSTI.

RESULTS: Of 226 patients undergoing operative exploration for a suspected NSTI, 172 (76.1%) were found to have a true NSTI based on intraoperative or pathology findings. In patients with true NSTI, preoperative XR and CT demonstrated soft tissue gas in 47.9% and 70.3% of cases, respectively. CT diagnosed or highly suspected NSTI in 97.3% of cases with true NSTI compared to 83.6% with XR; p less than 0.001).

CONCLUSION: CT was superior to XR in the radiologic evaluation of patients with suspected NSTIs.

18. Acupuncture vs IV morphine in the management of acute pain in the ED.

Grissa MH, et al. Am J Emerg Med. 2016 Nov;34(11):2112-2116.

BACKGROUND: Acupuncture is one of the oldest techniques to treat pain and is commonly used for a large number of indications. However, there is no sufficient evidence to support its application in acute medical settings.

METHODS: This was a prospective, randomized trial of acupuncture vs morphine to treat ED patients with acute onset moderate to severe pain. Primary outcome consists of the degree of pain relief with significant pain reduction defined as a pain score reduction ≥50% of its initial value. We also analyzed the pain reduction time and the occurrence of short-term adverse effects. We included in the protocol 300 patients with acute pain: 150 in each group.

RESULTS: Success rate was significantly different between the 2 groups (92% in the acupuncture group vs 78% in the morphine group P less than .001). Resolution time was 16±8 minutes in the acupuncture group vs 28±14 minutes in the morphine group (P less than .005). Overall, 89 patients (29.6%) experienced minor adverse effects: 85 (56.6%) in morphine group and 4 (2.6%) in acupuncture group (P less than .001). No major adverse effects were recorded during the study protocol. In patients with acute pain presenting to the ED, acupuncture was associated with more effective and faster analgesia with better tolerance.

CONCLUSION: This article provides an update on one of the oldest pain relief techniques (acupuncture) that could find a central place in the management of acute care settings. This should be considered especially in today's increasingly complicated and polymedicated patients to avoid adverse drug reactions.

Study Patients and Interventions
Inclusion criteria
Patients were included in the protocol if they were ≥18 years of age and met the following criteria: acute onset pain less than 72 hours of the ED presentation; pain intensity ≥40 of the VAS or NRS (ranging from 0 for no pain to 100 for maximum imaginable pain); acute musculoskeletal pain with no evidence of fracture or dislocation, including ankle and knee sprains without signs of severity (ligament rupture, laxity); shoulder and elbow tendonitis; upper and lower limb mechanical pains and lower back pain with no evidence of neurological deficit; acute abdominal pain with no urgent surgical intervention including renal colic and dysmenorrhea; and acute headache that meets the criteria of primary headache as described by the International Headache Society[7] .

Exclusion criteria
Patients were excluded from the study protocol if any of the following were applicable: temperature over 37.5°C, patients under anticoagulant drugs or with coagulation abnormalities, skin affections (infections, hematoma, dermatosis) that would impair the use of certain acupuncture points, patients that were judged unable to participate in the study at the discretion of the treating physician, refusal, inability to consent, inability to assess the degree of pain using the VAS or NRS, patients who had received analgesics in the 6 hours before the enrollment, an initial pain score ≤40 on the VAS or NRS, patients who had presented to the ED in the last 24 hours with the same complaint, and pregnancy.

Acupuncture group
After allocation to this group, patients were redirected to the ED acupuncture unit. The acupuncturist was an ED doctor with medical acupuncture qualification accredited by the National Tunisian Council of Doctors with 10-years experience in the field. Treatment protocols were determined through review of major clinical manuals and textbooks, literature review, and a panel of specialist acupuncturists from Chinese medicine backgrounds[8] . The protocols, which allow acupuncture points to be selected from a pool of predetermined points for each condition, provide sufficient standardization to assist replication, yet are flexible enough to allow individualized treatments. These protocols also allow for additional points, such as “ashi points”, to be used at the discretion of the acupuncturist. The location of the points, angle of insertion, and depth of insertion were sourced from a popular text “A Manual of Acupuncture”[9] and described in the annexe table ( Annexe 1 ). The average time to place needles is 5 minutes.

Morphine group
Patients in this group received IV titrated morphine. Morphine was prepared onsite and diluted in a manner to obtain a dose of 1 mg in each mL of normal saline. The initial dose was 0.1 mg/Kg and repeated regularly at the dose of 0.05 mg/Kg every 5 minutes until reaching objective. The maximum allowed dose was 15 mg.

A nondecrease of VAS by at least 50% within the first 30 minutes was considered as failure and the treatment was suspended. Patients were allowed to receive other treatments adapted to their conditions if judged necessary. Nonpharmacological measures, such as ice application, compression, elevation, and rest were allowed.

19. On ED Utilization

A. A Comprehensive View of Frequent ED Users Based on Data from a Regional HIE

Saef SH, et al. South Med J. 2016 Jul;109(7):434-9.

A small but significant number of patients make frequent emergency department (ED) visits to multiple EDs within a region. We have a unique health information exchange (HIE) that includes every ED encounter in all hospital systems in our region. Using our HIE we were able to characterize all frequent ED users in our region, regardless of hospital visited or payer class. The objective of our study was to use data from an HIE to characterize patients in a region who are frequent ED users (FEDUs).

We constructed a database from a cohort of adult patients (18 years old or older) with information in a regional HIE for a 1-year period beginning in April 2012. Patients were defined as FEDUs (those who made four or more visits during the study period) and non-FEDUs (those who made fewer than four ED visits during the study period). Predictor variables included age, race, sex, payer class, county of residence, and International Classification of Diseases, Ninth Revision codes. Bivariate (χ(2)) and multivariate (logistic regression) analyses were performed to determine associations between predictor variables and the outcome of being a FEDU.

The database contained 127,672 patients, 12,293 (9.6%) of whom were FEDUs. Logistic regression showed the following patient characteristics to be significantly associated with the outcome of being a FEDU: age 35 to 44 years; African American race; Medicaid, Medicare, and dual-pay payer class; and International Classification of Diseases, Ninth Revision codes 630 to 679 (complications of pregnancy, childbirth, and puerperium), 780 to 799 (ill-defined conditions), 280 to 289 (diseases of the blood), 290-319 (mental disorders), 680 to 709 (diseases of the skin and subcutaneous tissue), 710 to 739 (musculoskeletal and connective tissue disease), 460 to 519 (respiratory disease), and 520 to 579 (digestive disease). No significant differences were noted between men and women.

Data from an HIE can be used to describe all of the patients within a region who are FEDUs, regardless of the hospital system they visited. This information can be used to focus care coordination efforts and link appropriate patients to a medical home. Future studies can be designed to learn the reasons why patients become FEDUs, and interventions can be developed to address deficiencies in health care that result in frequent ED visits.

B. ED utilization in children less than 36 months is not an independent risk factor for maltreatment.

MacNeill EC, et al. Acad Emerg Med. 2016;23(11):1228–1234.

BACKGROUND AND OBJECTIVES: Early childhood high frequency use (HFU) of the emergency department (ED) has been endorsed as a marker for increased risk of child maltreatment. In a prior analysis of pediatric ED (PED) visits by 16,664 children, 0-36 months old, we defined early childhood HFU (the 90th percentile) as ≥5 visits. The purpose of this study was to follow HFU patients to determine if they had a higher likelihood of reported maltreatment.

METHODS: This is a single-center, cross-sectional, observational study of the association between PED use in early life and subsequent intervention by child protective services (CPS). CPS data was obtained from a Department of Social Services database for subjects meeting criteria for PED HFU as well as gender, race and ethnicity-matched controls. Multivariable analyses were performed to assess if HFU was independently associated with child maltreatment.

RESULTS: While CPS involvement was more highly represented in the group with PED HFU, so were many confounding variables such as: African American race, history of hospital admissions and social work consultations in the PED for any reason. HFU, by itself, is not a risk factor a major intervention by CPS.

CONCLUSIONS: In efforts to identify children at risk for maltreatment, objective assessments such as PED utilization are potential markers to utilize to aid in recognition. Unfortunately, there are many risk factors for increased PED utilization that act as confounders for this marker. Future work is necessary to identify children at risk for maltreatment in the emergency department. This article is protected by copyright. All rights reserved.

20. Going to the Emergency Room without Leaving the Living Room

The Expanded Role of Community Paramedics

For a while, paramedics were rushing Maria Vitale to the emergency room at Long Island Jewish Medical Center every few weeks.

“It was constant,” said her son, Paul Vitale. “She would fall, and the ambulance would come and take her to the hospital. Her blood sugar would be low, and she’d go to the hospital.”

Like most older people, Mrs. Vitale, now 88, wanted to continue living in her home, a Cape Cod house on Long Island that she and her late husband bought 60 years ago.

And, like many older people, she contended with an array of chronic diseases: diabetes, kidney disease, a heart arrhythmia, dementia.

Her children (and Medicaid) had managed to keep her at home with full-time aides, but every 911 call led to hours of waiting in the emergency department, often followed by admission to the hospital.

“Sometimes we felt like the hospitalization hurt her,” said Mr. Vitale, 60, a health care executive who too often found himself driving from his Manhattan home to Long Island in the middle of the night. “She came home worse than when she went in.”

Since March 2015, however, paramedics have visited Mrs. Vitale’s home 10 times, and whisked her to the hospital just once.

When Mrs. Vitale falls or seems lethargic or short of breath, her aides no longer call 911. They dial the House Calls service at Northwell Health, the system that includes Long Island Jewish Medical Center and that dispatches what it calls community paramedics.

They often arrive in an S.U.V. instead of an ambulance. And with 40 hours of training in addition to the usual paramedic curriculum, they can treat most of Mrs. Vitale’s problems on the spot instead of bustling her away.

“A lot of what’s been done in the E.R. can safely and effectively be done in the home,” said Karen Abrashkin, an internist with the House Calls program and Mrs. Vitale’s primary care physician. For frail, older people with many health problems, Dr. Abrashkin noted, “the hospital is not always the safest or best place to be.”

Geriatricians have warned for years about the ways in which hospitalization can accelerate older patients’ decline, even when physicians succeed in fixing the medical problem at hand…

21. Micro Bits

A. Surgeon general's report targets alcohol, substance abuse

A US Surgeon General's report released this week analyzes addiction and chemical substance abuse, showing more people are using prescription opioids than tobacco and those with substance abuse disorders outnumber those with cancer. Surgeon General Vivek Murthy said there are strategies available to prevent and treat various substance abuse disorders, including many school-based programs.

B. Adding Value by Talking More

The prevailing fee-for-service payment model has led U.S. health care administrators and physician practices to impose severe constraints on the time physicians spend talking, for which they are reimbursed poorly or not at all. New value-based reimbursement models, however, such as bundled payments, accountable care organizations, and shared savings plans, provide powerful incentives for physicians to regain control over the quantity and quality of time they spend talking. As we have helped dozens of organizations to estimate total care-cycle costs, we’ve identified many situations in which having physicians and other clinical personnel talk more with patients and each other can be the least expensive and most effective approach for delivering better patient care.

One important role of physicians’ talking is to motivate patients to make earlier and better decisions about their care…

C. Meaning and the Nature of Physicians’ Work

…Perhaps the greatest opportunity for improving our professional satisfaction in the short term lies in restoring our connections with one another. We could work on rebuilding our practices and physical spaces to promote the sorts of human connections that can sustain us — between physicians and patients, physicians and physicians, and physicians and nurses. We could get back to the bedside with patients, families, and nurses. We could get to know our colleagues from other specialties in shared lunchrooms or meeting spaces…

But technology cannot restore our professional satisfaction. Our profession will have to rebuild a sense of teamwork, community, and the ties that bind us together as human beings. We believe that will require spending more time with each other and with our patients, restoring some rituals that are meaningful to both us and the people we care for and eliminating those that are not.

Solutions will not be easy, since the problems are entangled in the high cost of health care, reimbursement for our work, and obstacles to health care reform. But we can start by recalling the original purpose of physicians’ work: to witness others’ suffering and provide comfort and care. That remains the privilege at the heart of the medical profession.

D. Heavy Screen Time Rewires Young Brains, For Better And Worse

There's new evidence that excessive screen time early in life can change the circuits in a growing brain.

Scientists disagree, though, about whether those changes are helpful, or just cause problems. Both views emerged during the Society for Neuroscience meeting in San Diego this week.

The debate centered on a study of young mice exposed to six hours daily of a sound and light show reminiscent of a video game. The mice showed "dramatic changes everywhere in the brain," said Jan-Marino Ramirez, director of the Center for Integrative Brain Research at Seattle Children's Hospital.

"Many of those changes suggest that you have a brain that is wired up at a much more baseline excited level," Ramirez reported. "You need much more sensory stimulation to get [the brain's] attention."

So is that a problem?

E. Debunked by the BMJ

1. Pulsed ultrasound in treatment of tibial fractures

2. Early supervised physiotherapy on recovery from acute ankle sprain

3. The association between the use of PPIs and risk of community acquired pneumonia

F. To Beat Burnout, Be Good at Ignoring Things

In a new study in the journal Health Care Management Review written up by Stat’s Casey Ross, 596 Canadian nurses completed two mail surveys over the course of a year. It revealed, in Ross’s estimation, a “self-fulfilling prophecy”: The nurses who thought they could ignore “workplace incivility” (read: their co-workers’ bulls---) were less bothered by it and reported lower rates of burnout. If you think that your colleagues’ rudeness won’t get under your skin, it’s less likely to…

G. Teen Night Owls Struggle To Learn And Control Emotions At School

Findings provide new evidence pushing back school start times, to let adolescents sleep and wake up when it's more natural, researchers say. It's going to bed late that creates problems.

H. Warning labels may encourage adolescents to avoid sugar-sweetened beverages

California, New York, and the cities of San Francisco and Baltimore have introduced bills requiring health-related warning labels for sugar-sweetened beverages. This randomized trial measured the extent to which these warning labels influence adolescents' beliefs and hypothetical choices by randomly assigning 2,202 participants to one of six conditions: (1) no warning label; (2) calorie label; (3-6) one of four text versions of a warning label. Controlling for frequency of beverage purchases, significantly fewer adolescents chose a sugar-sweetened beverage under warning label conditions than under conditions with no label.

I. New Statin Guidelines in JAMA

The USPSTF recommends initiating use of low- to moderate-dose statins in adults aged 40 to 75 years without a history of CVD who have 1 or more CVD risk factors (dyslipidemia, diabetes, hypertension, or smoking) and a calculated 10-year CVD event risk of 10% or greater (B recommendation). The USPSTF recommends that clinicians selectively offer low- to moderate-dose statins to adults aged 40 to 75 years without a history of CVD who have 1 or more CVD risk factors and a calculated 10-year CVD event risk of 7.5% to 10% (C recommendation). The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of initiating statin use in adults 76 years and older (I statement).