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.
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?”
The remainder
of the CONCERT acronym here: http://journals.lww.com/em-news/Fulltext/2016/11000/Medically_Clear__What_I_Learned_Re_learned.17.aspx
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 NEJM.org.
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, ClinicalTrials.gov, 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. https://www.ncbi.nlm.nih.gov/pubmed/10683058
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.
Interventions
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.
OBJECTIVES:
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).
METHODS:
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.
RESULTS:
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.
CONCLUSIONS:
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…
HC Manag Review: http://journals.lww.com/hcmrjournal/Abstract/publishahead/The_protective_role_of_self_efficacy_against.99778.aspx
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).
