Wednesday, December 21, 2016

Lit Bits: Dec 21, 2016

From the recent medical literature...

0. Light-hearted Studies from the 2016 BMJ Christmas Issue

A. Gotta catch’em all! Pokémon GO and physical activity among young adults: difference in differences study

Conclusions: Pokémon GO was associated with an increase in the daily number of steps after installation of the game. The association was, however, moderate and no longer observed after six weeks.

B. Do celebrity endorsements matter? Observational study of BRCA gene testing and mastectomy rates after Angelina Jolie’s New York Times editorial

Conclusions: Celebrity endorsements can have a large and immediate effect on use of health services. Such announcements can be a low cost means of reaching a broad audience quickly, but they may not effectively target the subpopulations that are most at risk for the relevant underlying condition.

C. Dispelling the nice or naughty myth: retrospective observational study of Santa Claus

Conclusions: The results of this study dispel the traditional belief that Santa Claus rewards children based on how nice or naughty they have been in the previous year. Santa Claus is less likely to visit children in hospitals in the most deprived areas. Potential solutions include a review of Santa’s contract or employment of local Santas in poorly represented regions.

D. Sniffing out significant “Pee values”: genome wide association study of asparagus anosmia

Conclusion: A large proportion of people have asparagus anosmia. Genetic variation near multiple olfactory receptor genes is associated with the ability of an individual to smell the metabolites of asparagus in urine. Future replication studies are necessary before considering targeted therapies to help anosmic people discover what they are missing.

1. Shared decision making in patients with low risk CP: prospective randomized pragmatic trial.

Hess EP, et al. BMJ. 2016 Dec 5;355:i6165.

OBJECTIVE:  To compare the effectiveness of shared decision making with usual care in choice of admission for observation and further cardiac testing or for referral for outpatient evaluation in patients with possible acute coronary syndrome.

DESIGN:  Multicenter pragmatic parallel randomized controlled trial.

SETTING:  Six emergency departments in the United States.

PARTICIPANTS:  898 adults (aged over 17 years) with a primary complaint of chest pain who were being considered for admission to an observation unit for cardiac testing (451 were allocated to the decision aid and 447 to usual care), and 361 emergency clinicians (emergency physicians, nurse practitioners, and physician assistants) caring for patients with chest pain.

INTERVENTIONS:  Patients were randomly assigned (1:1) by an electronic, web based system to shared decision making facilitated by a decision aid or to usual care. The primary outcome, selected by patient and caregiver advisers, was patient knowledge of their risk for acute coronary syndrome and options for care; secondary outcomes were involvement in the decision to be admitted, proportion of patients admitted for cardiac testing, and the 30 day rate of major adverse cardiac events.

RESULTS:  Compared with the usual care arm, patients in the decision aid arm had greater knowledge of their risk for acute coronary syndrome and options for care (questions correct: decision aid, 4.2 v usual care, 3.6; mean difference 0.66, 95% confidence interval 0.46 to 0.86), were more involved in the decision (observing patient involvement scores: decision aid, 18.3 v usual care, 7.9; 10.3, 9.1 to 11.5), and less frequently decided with their clinician to be admitted for cardiac testing (decision aid, 37% v usual care, 52%; absolute difference 15%; P less than 0.001). There were no major adverse cardiac events due to the intervention.

CONCLUSIONS:  Use of a decision aid in patients at low risk for acute coronary syndrome increased patient knowledge about their risk, increased engagement, and safely decreased the rate of admission to an observation unit for cardiac testing.

Journal Watch overview: thumbs up
Daniel M. Lindberg, MD

Use of a Web-based tool improved patient engagement and knowledge about risk and treatment options and decreased observation-unit admissions.

For chest pain patients with normal electrocardiogram and initial troponin results, adverse events are rare but serious. Some emergency physicians, guidelines, and clinical pathways recommend admission or observation for routine provocative testing in patients with low-risk chest pain, which can result in additional testing and significant cost.

Investigators studied 898 patients from six U.S. emergency departments who had low-risk chest pain and were being considered for admission for cardiac testing (stress test or coronary computed tomography). Patients were randomized to usual care or shared decision making facilitated by a decision aid. The Web-based decision aid took into account patients' personalized risk factors and reported their 45-day risk for major adverse cardiac events. Patients in both groups were surveyed immediately after the visit.

Patients randomized to the decision aid had increased knowledge of their risk and available options for their care and were more involved in decision making compared with those randomized to usual care. Conversations between the patient and physician took approximately 1 minute longer in the decision aid group. Significantly fewer patients in the decision aid group decided (with their clinician) to be admitted for further testing (37% vs. 52%). There were no major adverse events related to the intervention.

Beyond the concept of shared decision making, this study demonstrates the value of this particular publicly available tool. I plan to use the tool with all my low-risk chest pain patients, prior to observation-unit admission.

The KP CREST Network responds (excerpt)

Vinson DR, Ballard DW, Mark DG, Chettipally UK. Shared decision making in low risk chest pain: looking ahead [letter]. BMJ. 2016;355:i6165/rr-1.

We commend Hess et al for their well-designed and clinically useful pragmatic shared decision making study (1). This is sure to serve as an example for shared decision making research addressing other clinical scenarios, both in the emergency department and beyond.

Shared decision making is best suited for the fork in the road, a divergence of care where neither course is clearly superior (2). Such a decision, though equivocal from the clinician’s perspective, is “preference-sensitive” when seen in a patient-centered light. The Centers for Medicare and Medicaid Services applies shared decision making to conditions “for which the clinical evidence does not clearly support one treatment option, and the appropriate course of treatment depends on the values or preferences of the beneficiary regarding the benefits, harms, and scientific evidence for each treatment option” (3). This appears to be true at the moment regarding the site-of-care decision for many low-risk chest pain patients: should they go home to follow-up with their primary care provider or should they be admitted for short-term observation and provocative testing? Let’s educate our patients and help them decide.

But the field is rapidly changing: what is equivocal today may not be so in the coming years. The advent of highly sensitive troponin assays, with or without the use of refined risk stratification pathways, will help us identify emergency department patients with short-term risks of acute coronary syndrome sufficiently low to obviate the need for observation and advanced cardiac testing prior to home discharge (4-6). As evidence continues to accumulate that this practice is safe, clinicians will feel empowered to confidently shift the site of care in an outpatient direction for a growing number of low-risk chest pain patients. This shift in emergency department disposition is a familiar transition, and when done safely can be associated with increased patient convenience and satisfaction as well as a more responsible stewardship of healthcare resources. We have learned to do this with low-risk pneumonia (7) and are learning to do it with low-risk pulmonary embolism (8).

Even in this projected future of increasing outpatient care for low-risk chest pain, the best emergency department disposition will at times remain an open question. Here the patient’s preference elicited during shared decision making can be called upon to guide management, as Hess et al have shown (1). But absent the equipoise of “preference-sensitive” conditions, when the clinician believes that home management is the optimal disposition, we still need to do better at educating our patients about their risks and explaining to them the rationale of the recommendations we provide. The well-conceived, field-tested patient-centered decision aid that Hess and colleagues used in this study is readily adaptable for just this task. Whether we’re soliciting a patient’s tie-breaking opinion on site of care (shared decision making) or we’re informing them why we think a certain disposition is most appropriate (patient education), a clear, accessible pictographic decision aid can help us more clearly communicate our thoughts and leave the patient with a fuller understanding of their situation (1)…

The remainder of the essay (free):

Ryan Radecki’s critique (excerpt)
…In short, it seems to me the authors are not using their decision aid to help patients choose between equally valued clinical pathways, but rather to try and convince more patients to choose to be discharged.

In a sense, it represents offering patients a menu of options where overtreatment is one of them.  If a dyspneic patient meets PERC, we don’t offer them a visual aid where a CTPA is an option – and that shouldn’t be our expectation here, either.  These authors have put in tremendous effort over many years to integrate many important tools, but it feels like the end result is a demonstration of a shared decision-making instrument intended to nudge patients into choosing the disposition we think they ought, but are somehow afraid to outright tell them.

The full essay (free):

For more on shared decision making in the ED:
See this month’s issue of Acad Emerg Med. TOC here:

2. GCS Motor Component ("Patient Does Not Follow Commands") Performs Similarly to Total GCS in Predicting Severe Injury in Trauma Patients.

Better for Field Triage

Kupas DF, et al. Ann Emerg Med. 2016 Dec;68(6):744-750.e3.

STUDY OBJECTIVE: Trauma victims are frequently triaged to a trauma center according to the patient's calculated Glasgow Coma Scale (GCS) score despite its known inconsistencies. The substitution of a simpler binary assessment of GCS-motor (GCS-m) score less than 6 (ie, "patient does not follow commands") would simplify field triage. We compare total GCS score to this binary assessment for predicting trauma outcomes.

METHODS: This retrospective analysis of a statewide trauma registry includes records from 393,877 patients from 1999 to 2013. Patients with initial GCS score less than or equal to 13 were compared with those with GCS-m score less than 6 for outcomes of Injury Severity Score (ISS) greater than 15, ISS greater than 24, death, ICU admission, need for surgery, or need for craniotomy. We judged a priori that differences less than 5% lack clinical importance.

RESULTS: The relative differences between GCS and GCS-m scores less than 6 were less than 5% and thus clinically unimportant for all outcomes tested, even when statistically significant. For the 6 outcomes, the differences in areas under receiver operating characteristic curves ranged from 0.014 to 0.048. Total GCS score less than or equal to 13 was slightly more sensitive (difference 3.3%; 95% confidence interval 3.2% to 3.4%) and slightly less specific (difference -1.5%; 95% confidence interval -1.6% to -1.5%) than GCS-m score less than 6 for predicting ISS greater than 15, with similar overall accuracy (74.1% versus 74.2%).

CONCLUSION: Replacement of the total GCS score with a simple binary decision point of GCS-m score less than 6, or a patient who "does not follow commands," predicts serious injury, as well as the total GCS score, and would simplify out-of-hospital trauma triage.

3. Spontaneously resolved STEMI after a hymenoptera sting. Yikes!

Kim SW, et al. Amer J Emerg Med 2016 Nov 4 [Epub ahead of press].

Bee stings can cause various clinical manifestations, especially symptoms and signs similar to those of acute coronary syndrome.

We experienced a case of 56-year-old male without a prior diagnosis of cardiologic disease. The patient was found collapsed 10 min after he left a cafeteria for a cigarette. He told the emergency medical service (EMS) team that he had been stung by a hornet. During the transfer, he became pale and unconscious. The EMS team could not obtain his blood pressure, and his heart rate was 40/min.

As he arrived at the local hospital, he was intubated immediately. Bolus crystalloid fluids, intravenous antihistamine, intravenous methylprednisolone and intramuscular epinephrine were given to the patient. After his vital signs had been stabilized, an electrocardiogram (ECG) of the patient was obtained. It showed about 9 mm of ST-segment elevation in lead II, III, aVF with a reciprocal change in lead I, aVL. He was diagnosed with inferior wall ST-segment elevation myocardial infarction (STEMI) and transferred to the tertiary medical center. When he arrived at our regional emergency center, he was alert then. His ECG and blood sample was taken immediately. The ECG showed a regression of ST-segment elevation, and all laboratory test results were normal. On portable transthoracic echocardiography, the ejection fraction was well preserved without regional wall motion abnormality.

The coronary angiography revealed normal coronary arteries. Diagnosis of Kounis syndrome was made. He was extubated on the day of admission and discharged 2 days later without any complication.

The first report associating cardiovascular symptoms and signs with anaphylaxis was published in 1950[1]. However, the relationship between an allergic reaction and acute coronary syndrome was not fully discovered until 1991 when Kounis et al. described in detail about allergic angina syndrome, called Kounis syndrome (KS), which could progress to acute allergic myocardial infarction[2].

KS is the concurrence of acute coronary syndromes with conditions associated with mast cell activation including allergic or hypersensitivity and anaphylactic or anaphylactoid insults. It is caused by inflammatory mediators released through mast cell activation[3] . It presents a variety of allergic reactions followed by cardiac symptoms and signs including acute chest pain, chest discomfort, dyspnea, faintness, nausea, pruritus, syncope, vomiting, urticaria, palpitation, diaphoresis, pallor, tachycardia or bradycardia and hypotension. It is also associated with ECG abnormalities such as arterial fibrillation, ST-segment depression or elevation, T-wave inversion, QT segment prolongation or ventricular ectopics/fibrillation[4] .

There are several causes that have been reported to trigger KS, such as prior allergic conditions, several drugs, contrast media, insect or jellyfish sting, latex contact and viper venom poisoning[3]. When these factors induce mast cell degranulation, several inflammatory mediators such as histamine, tryptase, chymase and leukotrienes are released locally and within the systemic circulation. Histamine induces coronary vasoconstriction and platelet activation, while tryptase and chymase can induce plaque erosion and rupture. Leukotrienes also play an important role on vasoconstriction[5].The first report associating cardiovascular symptoms and signs with anaphylaxis was published in 1950[1]. However, the relationship between an allergic reaction and acute coronary syndrome was not fully discovered until 1991 when Kounis et al. described in detail about allergic angina syndrome, called Kounis syndrome (KS), which could progress to acute allergic myocardial infarction[2].

4. Annals Review: Is Nebulized Hypertonic Saline Solution Effective for Acute Bronchiolitis? …Who Knows!

Both systematic reviews (links below) emphasized that the majority of studies demonstrating a larger effect for hypertonic saline solution compared with 0.9% saline solution were of high or uncertain risk of biases. In summary, the evidence for the use of hypertonic saline solution in bronchiolitis is evolving, and there is a need for rigorously designed studies focused on ED–relevant outcomes to provide guidance for emergency physicians.

Take-Home Message
Hypertonic saline solution is possibly effective in decreasing hospital admission and length of stay for infants with bronchiolitis.

Their Two Systematic Reviews
Everad et al. Health Technol Assess. 2015.

See also Macguire in BMC Pulm Med 2015:

The 2014 AAP Bronchiolitis Guidelines Don’t Want Nebbed Hypertonic Saline Given in the ED

4a. Nebulized hypertonic saline should not be administered to infants with a diagnosis of bronchiolitis in the ED (Evidence Quality: B; Recommendation Strength: Moderate Recommendation).

4b. Clinicians may administer nebulized hypertonic saline to infants and children hospitalized for bronchiolitis (Evidence Quality: B; Recommendation Strength: Weak Recommendation [based on randomized controlled trials with inconsistent findings]).

5. Two Cases of Anti-NMDA Receptor Encephalitis

Baker J, et al. West J Emerg Med. 2016; 17(5): 623–626.

Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is a form of autoimmune encephalitis with prominent neuropsychiatric features. Patients present with acute psychosis, memory impairment, dyskinesias, seizures, and/or speech disorders. The clinical course is often complicated by respiratory failure, requiring intubation. Approximately half of patients are found to have an associated ovarian tumor, which expresses NMDAR.

Recognition of anti-NMDAR encephalitis by emergency physicians is essential in order to initiate early treatment and avoid psychiatric misdiagnosis. The disease is highly treatable with tumor removal and immunosuppression, and most patients demonstrate a full recovery. In this case series, we report two cases of anti-NMDAR encephalitis in adult women in the United States and provide a review of the literature.

6. Alpha blockers for treatment of ureteric stones: systematic review and meta-analysis.

Hollingsworth JM, et al. BMJ. 2016 Dec 1;355:i6112.

OBJECTIVE:  To investigate the efficacy and safety of alpha blockers in the treatment of patients with ureteric stones.

DESIGN:  Systematic review and meta-analysis.

DATA SOURCES:  Cochrane Central Register of Controlled Trials, Web of Science, Embase, LILACS, and Medline databases and scientific meeting abstracts to July 2016.

REVIEW METHODS:  Randomized controlled trials of alpha blockers compared with placebo or control for treatment of ureteric stones were eligible. : Two team members independently extracted data from each included study. The primary outcome was the proportion of patients who passed their stone. Secondary outcomes were the time to passage; the number of pain episodes; and the proportions of patients who underwent surgery, required admission to hospital, and experienced an adverse event. Pooled risk ratios and 95% confidence intervals were calculated for the primary outcome with profile likelihood random effects models. Cochrane Collaboration's tool for assessing risk of bias and the GRADE approach were used to evaluate the quality of evidence and summarize conclusions.

RESULTS:  55 randomized controlled trials were included. There was moderate quality evidence that alpha blockers facilitate passage of ureteric stones (risk ratio 1.49, 95% confidence interval 1.39 to 1.61). Based on a priori subgroup analysis, there seemed to be no benefit to treatment with alpha blocker among patients with smaller ureteric stones (1.19, 1.00 to 1.48). Patients with larger stones treated with an alpha blocker, however, had a 57% higher risk of stone passage compared with controls (1.57, 1.17 to 2.27). The effect of alpha blockers was independent of stone location (1.48 (1.05 to 2.10) for upper or middle stones; 1.49 (1.38 to 1.63) for lower stones). Compared with controls, patients who received alpha blockers had significantly shorter times to stone passage (mean difference -3.79 days, -4.45 to -3.14; moderate quality evidence), fewer episodes of pain (-0.74 episodes, -1.28 to -0.21; low quality evidence), lower risks of surgical intervention (risk ratio 0.44, 0.37 to 0.52; moderate quality evidence), and lower risks of admission to hospital (0.37, 0.22 to 0.64; moderate quality evidence). The risk of a serious adverse event was similar between treatment and control groups (1.49, 0.24 to 9.35; low quality evidence).

CONCLUSIONS:  Alpha blockers seem efficacious in the treatment of patients with ureteric stones who are amenable to conservative management. The greatest benefit might be among those with larger stones. These results support current guideline recommendations advocating a role for alpha blockers in patients with ureteric stones.

Ryan Radecki: Not So Fast!

7. Some New DVT/PE Research

A. Test Characteristics of EP-Performed Limited Compression US for Lower-Extremity DVT

Kim DJ, et al. J Emerg Med. 2016 Dec;51(6):684-690.

BACKGROUND: The current literature suggests that emergency physician (EP)-performed limited compression ultrasound (LCUS) is a rapid and accurate test for deep vein thrombosis (DVT).

OBJECTIVE: Our primary objective was to determine the sensitivity and specificity of LCUS for the diagnosis of DVT when performed by a large heterogeneous group of EPs.

METHODS: This was a prospective diagnostic test assessment of LCUS conducted at two urban academic emergency departments. The scanning protocol involved compression at the common femoral, superficial femoral, and popliteal veins. Patients were eligible if undergoing radiology department ultrasound of the lower extremity with moderate or high pretest probability for DVT, or low pretest probability for DVT with a positive d-dimer. The enrolling EP performed LCUS before radiology department ultrasound of the same lower extremity. Sensitivity, specificity, and associated 95% confidence intervals (CIs) were calculated with the radiologist interpretation of the radiology department ultrasound as the criterion standard.

RESULTS: A total of 56 EPs enrolled 296 patients for LCUS, with a median age of 50 years and 50% female. Fifty (17%) DVTs were identified by radiology department ultrasound, and another five (2%) cases were deemed indeterminate. The sensitivity and specificity of EP-performed LCUS was 86% (95% CI 73-94%) and 93% (95% CI 89-96%), respectively.

CONCLUSIONS: A large heterogeneous group of EPs with limited training can perform LCUS with intermediate diagnostic accuracy. Unfortunately, LCUS performed by EPs with limited ultrasound training is not sufficiently sensitive or specific to rule out or diagnose DVT as a single testing modality.

B. Age-adjusted D-dimer excludes PE and reduces unnecessary radiation exposure in older adults: retrospective study

Nobes J, et al. Postgrad Med J 2016 Dec 9 [Epub ahead of print]

Background Patients in whom a diagnosis of pulmonary embolism (PE) is suspected and whose D-dimers are elevated frequently require CT pulmonary angiogram (CTPA) for diagnosis. Because D-dimer rises with age, an age-adjusted D-dimer threshold may prevent unnecessary radiation exposure from CTPA in older patients.

Objective To determine the efficacy and safety of implementing an age-adjusted D-dimer threshold to exclude PE.

Design, settings and patients Retrospective comparison of conventional and age-adjusted D-dimer thresholds in 1000 consecutive patients who had both D-dimer and CTPA.

Main outcome measures Conventional and age-adjusted D-dimer thresholds for excluding PE were less than 250 ng/mL and 5× age for patients older than 50 years, respectively. We defined patients as unlikely to have PE using the revised Geneva score (RGS) and two different categories of clinical risk: RGS ≤5 and RGS ≤10.

Results We diagnosed PE by CTPA in 244 (24.4%) patients. 3/86 patients (3.5%) whose D-dimer was below the conventional threshold of 250 ng/mL had PE (RGS 3, 9 and 14), all of which were judged to be light clot load (group 1). 3/108 patients (2.8%) whose D-dimer lay between 250 ng/mL and the age-adjusted threshold had PE (RGS 6, 8 and 9), all of which were again judged to be light clot load (group 2). 62/108 group 2 patients with RGS ≤5 were considered unlikely to have PE as were 102/108 using the RGS clinical risk category ≤10. None of the 62 patients with RGS ≤5 had PE while 3/102 patients with RGS ≤10 had PE. 236/806 patients (29.3%) whose D-dimer was above the age-adjusted threshold had PE (group 3).

Conclusions In a consecutive series of 1000 patients, an RGS ≤5 and an age-adjusted D-dimer would have led to 62 fewer CTPA at a cost of no missed PEs.

C. RESPECT-ED: Rates of PE and Sub-Segmental PE with Modern CTPAs in EDs: A Multi-Center Observational Study Finds Significant Yield Variation, Uncorrelated with Use or Small PE Rates.

Mountain D, et al. PLoS One. 2016 Dec 5;11(12):e0166483.

INTRODUCTION: Overuse of CT Pulmonary Angiograms (CTPA) for diagnosing pulmonary embolism (PE), particularly in Emergency Departments (ED), is considered problematic. Marked variations in positive CTPA rates are reported, with American 4-10% yields driving most concerns. Higher resolution CTPA may increase sub-segmental PE (SSPE) diagnoses, which may be up to 40% false positive. Excessive use and false positives could increase harm vs. benefit. These issues have not been systematically examined outside America.

AIMS: To describe current yield variation and CTPA utilisation in Australasian ED, exploring potential factors correlated with variation.

METHODS: A retrospective multi-centre review of consecutive ED-ordered CTPA using standard radiology reports. ED CTPA report data were inputted onto preformatted data-sheets. The primary outcome was site level yield, analysed both intra-site and against a nominated 15.3% yield. Factors potentially associated with yield were assessed for correlation.

RESULTS: Fourteen radiology departments (15 ED) provided 7077 CTPA data (94% ≥64-slice CT); PE were reported in 1028 (yield 14.6% (95%CI 13.8-15.4%; range 9.3-25.3%; site variation p less than 0.0001) with four sites significantly below and one above the 15.3% target. Admissions, CTPA usage, PE diagnosis rates and size of PE were uncorrelated with yield. Large PE (≥lobar) were 55% (CI: 52.1-58.2%) and SSPE 8.8% (CI: 7.1-10.5%) of positive scans. CTPA usage (0.2-1.5% adult attendances) was correlated (p less than 0.006) with PE diagnosis but not SSPE: large PE proportions.

DISCUSSION/ CONCLUSIONS: We found significant intra-site CTPA yield variation within Australasia. Yield was not clearly correlated with CTPA usage or increased small PE rates. Both SSPE and large PE rates were similar to higher yield historical cohorts. CTPA use was considerably below USA 2.5-3% rates. Higher CTPA utilisation was positively correlated with PE diagnoses, but without evidence of increased proportions of small PE. This suggests that increased diagnoses seem to be of clinically relevant sized PE.

8. ED Use: Two Studies of a Changing Dynamic

A. Insurance Expansion and Hospital ED Access: Evidence from the Affordable Care Act.

Garthwaite C, et al. Ann Intern Med. 2016 Dec 20 [Epub ahead of print]

BACKGROUND: Little is known about whether insurance expansion affects the location and type of emergency department (ED) use. Understanding these changes can inform state-level decisions about the Medicaid expansion under the Patient Protection and Affordable Care Act (ACA).

OBJECTIVE: To investigate the effect of the 2014 ACA Medicaid expansion on the location, insurance status, and type of ED visits.

DESIGN: Quasi-experimental observational study from 2012 to 2014.

SETTING: 126 investor-owned, hospital-based EDs.

PARTICIPANTS: Uninsured and Medicaid-insured adults aged 18 to 64 years.

INTERVENTION: ACA expansion of Medicaid in January 2014.

MEASUREMENTS: Number of ED visits overall, type of visit (for example, nondiscretionary or nonemergency), and average travel time to the ED. Interrupted time-series analyses comparing changes from the end of 2013 to end of 2014 for patients from Medicaid expansion versus nonexpansion states were done.

RESULTS: There were 1.06 million ED visits among patients from 17 Medicaid expansion states, and 7.87 million ED visits among patients from 19 nonexpansion states. The EDs treating patients from Medicaid expansion states saw an overall 47.1% decrease in uninsured visits (95% CI, -65.0% to -29.3%) and a 125.7% (CI, 89.2% to 162.6%) increase in Medicaid visits after 12 months of ACA expansion. Average travel time for nondiscretionary conditions requiring immediate medical care decreased by 0.9 minutes (-6.2% [CI, -8.9% to -3.5%]) among all Medicaid patients from expansion states. We found little evidence of similar changes among patients from nonexpansion states.

LIMITATION: Results reflect shifts in ED care at investor-owned facilities, which limits generalizability to other hospital types.

CONCLUSION: Meaningful changes in insurance status and location and type of ED visits in the first year of ACA Medicaid expansion were found, suggesting that expansion provides patients with a greater choice of hospital facilities.

B. Retail clinics fail to curb non-emergency ER use, study says

Patient use of hospital emergency departments for non-emergency care has not decreased despite the growth of retail clinics. RAND Corp. researcher Grant Martsolf noted retail clinics increased in number when off-hours care was not readily available, but now many primary care offices have same-day visits and extended hours to expand options for patients.

9. Adult epiglottitis: a case series.

Lindquist B, Zachariah S, Kulkarni A. Perm J. 2017;21:16-089.

Introduction: Emergency Departments are inundated by patients with respiratory illness during the winter months. Emergency physicians are required to quickly identify critically ill patients among the large volume of patients with mild upper respiratory illness. Among these life-threatening conditions is acute epiglottitis.

Case Presentation: We report a rare series of four adult patients who presented to our Emergency Department during a period of only one week in April 2015 and were ultimately diagnosed with acute epiglottitis. Three of the patients improved with conservative measures and were observed in the intensive care unit. One patient required an emergent tracheostomy.

Discussion: This series of patients is unique in that all four patients presented to a single Emergency Department within a few days of each other and, despite a myriad of presenting chief complaints, the patients were eventually found to have the same potentially life-threatening diagnosis. These cases reinforce the variability of presenting symptoms and physical examination findings that can occur in patients with epiglottitis. They also highlight clinical findings and adjunctive testing that can help identify patients who would most benefit from intervention.

10. Tons of Images in Clinical Practice

Tinea Imbricata 

Tongue Fasciculations in Organophosphate Poisoning 

Skin Mottling

Neurogenic Megacolon in Spinal Cord Injury

Patellar Fracture with Sleeve Avulsion

African Trypanosomiasis

Woman With Lower Back Pain

Young Woman With Rash on Left Thigh

Elderly Woman With Altered Mental Status and Hypoxia

Adolescent Male With Knee Pain and Swelling

Young Child With Abdominal and Back Pain

Young Male With Neck Pain

Young Woman With Paraplegia Following a Motor Vehicle Crash

EM-RAP Commentary: “A Clinical Decision Rule for Thoracolumbar Spine Imaging in Blunt Trauma?”

Newborn With Scalp Swelling

Postpartum Woman With Seizures

EM:RAP Commentary on Postpartum Headaches

Elderly Man With Abdominal Discomfort and Circulatory Failure

Young Man With Scrotal Swelling and Pain

Elderly Man with Syncope

Wrist Pain after a Fall

Elderly Man With Headache and Neck Pain

Young Man With Abdominal Pain

11. Are reductions in ED LOS associated with improvements in quality of care? A difference-in-differences analysis.

Vermeulen MJ, et al. BMJ Qual Saf. 2016;25(7):489-98.

BACKGROUND: We sought to determine whether patients seen in hospitals who had reduced overall emergency department (ED) length of stay (LOS) in the 2 years following the introduction of the Ontario Emergency Room Wait Time Strategy were more likely to experience improvements in other measures of ED quality of care for three important conditions.

METHODS: Retrospective medical record review using difference-in-differences analysis to compare changes in performance on quality indicators over the 3-year period between 11 Ontario hospitals where the median ED LOS had improved from fiscal year 2008 to 2010 and 13 matched sites where ED LOS was unchanged or worsened. Patients with acute myocardial infarction (AMI), asthma and paediatric and adult upper limb fractures in these hospitals in 2008 and 2010 were evaluated with respect to 18 quality indicators reflecting timeliness and safety/effectiveness of care in the ED. In a secondary analysis, we examined shift-level ED crowding at the time of the patient visit and performance on the quality indicators.

RESULTS: Median ED LOS improved by up to 26% (63 min) from 2008 to 2010 in the improved hospitals, and worsened by up to 47% (91 min) in the unimproved sites. We abstracted 4319 and 4498 charts from improved and unimproved hospitals, respectively. Improvement in a hospital's overall median ED LOS from 2008 to 2010 was not associated with a change in any of the other ED quality indicators over the same time period. In our secondary analysis, shift-level crowding was associated only with indicators that reflected timeliness of care. During less crowded shifts, patients with AMI were more likely to be reperfused within target intervals (rate ratio 1.59, 95% CI 1.03 to 2.45), patients with asthma more often received timely administration of steroids (rate ratio 1.88, 95% CI 1.59 to 2.24) and beta-agonists (rate ratio 1.47, 95% CI 1.25 to 1.74), and adult (but not paediatric) patients with fracture were more likely to receive analgesia or splinting within an hour (rate ratio 1.66, 95% CI 1.22 to 2.26).

CONCLUSIONS: These results suggest that a policy approach that targets only reductions in ED LOS is not associated with broader improvements in selected quality measures. At the same time, there is no evidence that efforts to address crowding have a detrimental effect on quality of care.

12. Burn Out: What Is It and How Can We Address It?

A. Controlled Interventions to Reduce Burnout in Physicians: A Systematic Review and Meta-analysis

Question: Are interventions for reducing burnout in physicians effective?

Findings: This meta-analysis of 20 controlled interventions on 1550 physicians found that existing interventions were associated with small and significant reductions in burnout. The strongest evidence for effectiveness was found for organization-directed interventions, but these interventions were rare.

Meaning:  More effective models of interventions are needed to mitigate risk for burnout in physicians. Such models could be organization-directed approaches that promote healthy individual-organization relationships.

B. Burnout Research on Emergency Providers?

a. Compassion Fatigue (CF) among Healthcare, Emergency and Community Service Workers: A Systematic Review.

Cocker F, et al. Int J Environ Res Public Health. 2016;13(6).

Conclusion: This review revealed that evidence of the effectiveness of CF interventions in at-risk health and social care professions is relatively recent. Therefore, we recommend more research to determine how best to protect vulnerable workers at work to prevent not only CF, but also the health and economic consequences related to the ensuing, and more disabling, physical and mental health outcomes.

b. Comparing Burnout across Emergency Physicians, Nurses, Technicians, and Health Information Technicians Working for the Same Organization.

Schooley B, et al. Medicine (Baltimore). 2016 Mar;95(10):e2856

Studies on the topic of burnout measure the effects of emotional exhaustion (EE), depersonalization (DP) (negative or cynical attitudes toward work), and reduced sense of personal accomplishment (PA). While the prevalence of burnout in practicing emergency medicine (EM) professionals has been studied, little is known of the prevalence and factors across physicians, nurses, technicians, and health information technicians working for the same institution. The aim of this study was to assess burnout differences across EM professional types.

The total population of 250 EM professionals at 2 public urban hospitals in Turkey were surveyed using the Maslach Burnout Inventory and basic social- and work-related demographics. Descriptive statistics, ANOVA, and additional post hoc tests were computed.

Findings show that EE and DP scores were high across all occupational groups, while scores on PA were low. There was a statistically significant difference between nurses and medical technicians (P  less than 0.05) for EE; and between physicians and both nurses and medical technicians (P  less than  0.05) for PA; while no group differences were found for DP. Age, gender, economic well-being, and income level were all significant; while patient load and marital status showed no significance.

Burnout can be high across occupational groups in the emergency department. Burnout is important for EM administrators to assess across human resources. Statistically significant differences across socio-demographic groups vary across occupational groups. However, differences between occupational groups may not be explained effectively by the demographic factors assessed in this or other prior studies. Rather, the factors associated with burnout are incomplete and require further institutional, cultural, and organizational analyses including differentiating between job tasks carried out by each EM job type.

C. Why Some People Get Burned Out and Others Don’t

Kandi Wiens, Annie McKee. Harvard Business Review · November 23, 2016

Stress and burnout are not the same thing. And while we know that stress often leads to burnout, it’s possible to handle the onslaught of long hours, high pressure, and work crises in a way that safeguards you from the emotional exhaustion, cynicism, and a lack of confidence in one’s abilities that characterizes burnout. The key is tapping into your emotional intelligence.

This is what one of us (Kandi) discovered in a recent study (“Leading Through Burnout”) where we assessed 35 chief medical officers (CMOs) at 35 large hospitals for their level of stress and tried to determine what, if anything, they do to deal with burnout. The findings surprised us: despite the fact that an overwhelming 69% of the CMOs described their current stress level as severe, very severe, or worst possible, the majority were not burned out according to the Maslach Burnout Inventory. In our interviews with these CMOs, we found…

D. Burnout and the Brain

Burnout is not just a state of mind. Psychological research that draws on neuroscience and endocrinology shows it to be a condition that leads to distinctive changes in the anatomy and functioning of the brain.

[DRV: Scary! I posted this in the Jan 2016 issue of Lit Bits. Given the importance of the topic and the scientific insights of the article, it deserves a re-posting.]

By Alexandra Michel. Observer. 2016;29(2):26-31. (a publication of the Association for Psychological Science)

One of the greatest threats to workplace safety may be from an unexpected source: stress…

It’s a mistake to assume that burnout is merely an emotional response to long hours or a challenging job. Rather, mounting scientific evidence shows that burnout takes a profound physical toll that cascades well beyond our professional lives. Using cutting-edge techniques, integrative research teams are demonstrating that burnout is not just a state of mind, but a condition that leaves its mark on the brain as well as the body.

Just as the impact of burnout stifles healthy professional growth, emerging research shows that the chronic psychosocial stress that characterizes burnout not only impairs people’s personal and social functioning, it also can overwhelm their cognitive skills and neuroendocrine systems — eventually leading to distinctive changes in the anatomy and functioning of the brain.

Burnout Begins
The psychologist Herbert Freudenberger is credited with bringing the term “burnout” into the research lexicon in 1974, defining it as the loss of motivation, growing sense of emotional depletion, and cynicism he observed among volunteers working at a free clinic in New York City. Formerly idealistic mental health workers were finding themselves depleted and weary, resenting patients and the clinic.

Burnout is now recognized as a legitimate medical disorder by much of mainstream medicine and has even been given its own ICD-10 code (Z73.0 – Burn-out state of vital exhaustion). Many of the symptoms of burnout overlap with the hallmarks of depression, including extreme fatigue, loss of passion, and intensifying cynicism and negativity.

APS Fellow Christina Maslach, professor emerita at the University of California, Berkeley, and one of the foremost researchers on burnout, began studying this emerging phenomenon in the 1970s through a series of extensive interviews with employees in service organizations. In analyzing the interviews, Maslach and colleagues noticed a trend: Workers often reported feelings of profound emotional exhaustion, negativity directed at clients and patients, and a crisis in feelings of professional competence. Much like symptoms of depression, burnout was asphyxiating people’s ambitions, idealism, and sense of worth.

The 1976 publication of Maslach’s article “Burned-Out,” published in the magazine Human Behavior, generated a huge public response — popularizing the concept of burnout within the popular press. Maslach received an incredible outpouring of letters and phone calls from people who were grateful to find out that they were not alone in their experience of burnout.
“I had not expected at all that kind of reaction,” Maslach said. “The impact of that article was just huge.” The article led to more research, more books, and more attention from academic journals.

Maslach and APS Fellow Susan E. Jackson (Rutgers University) collaborated on what would become the most influential framework for defining and assessing burnout. Published in 1981, the original paper describing the Maslach Burnout Inventory has been cited well over 6,000 times to date, according to Google Scholar. The scale evaluates burnout based on three key stress responses: an overwhelming sense of exhaustion, feelings of cynicism and detachment, and a sense of professional ineffectiveness and lack of accomplishment.

At its core, burnout emerges when the demands of a job outstrip a person’s ability to cope with the stress. People in careers focused on caregiving — teachers, nurses, social workers, and physicians — report the most prevalent rates of burnout, but the condition ultimately doesn’t discriminate among call center representatives, professional athletes, or CEOs. Over time, jobs that require too much of employees will cultivate feelings of negativity and hopelessness as people struggle to meet impossible deadlines, deal with rude customers, or cope with the emotional toll of professional caretaking.

It’s a common misconception that the culprit behind burnout is simply working too long or too hard — research indicates that other factors, both individual and organizational, can be just as detrimental. For example, a comprehensive report on psychosocial stress in the workplace published by the World Health Organization identified consistent evidence that “high job demands, low control, and effort–reward imbalance are risk factors for mental and physical health problems.” Ultimately, burnout results when the balance of deadlines, demands, working hours, and other stressors outstrips rewards, recognition, and relaxation.

Over the past 20 years, Maslach and her collaborators have developed a comprehensive model identifying six key components of the workplace environment that contribute to burnout: workload, control, reward, community, fairness, and values. Burnout emerges when one or more of these six areas is chronically mismatched between an individual and his job. Over time, Maslach explained, passion erodes not only because people have too much to do, but because of these other factors…

13. Flush Rate Oxygen for Emergency Airway Preoxygenation.

Driver BE, et al. Ann Emerg Med. 2017 Jan;69(1):1-6.

STUDY OBJECTIVE: Recent data suggest that emergency airway preoxygenation with a bag-valve-mask (BVM) device (held with a tight mask seal but without squeezing the bag) is superior to a nonrebreather (NRB) mask at standard oxygen flow rates. We seek to determine whether preoxygenation with an NRB mask with flush rate oxygen (over 40 L/min by fully opening a standard oxygen flowmeter) is noninferior to BVM device with standard-flow oxygen (15 L/min). We also seek to compare the efficacy of preoxygenation with NRB mask at flush rate oxygen with both NRB mask with oxygen at 15 L/min and simple mask at flush rate oxygen.

METHODS: We performed a crossover trial using healthy volunteers. In random sequence, subjects underwent 3-minute trials of preoxygenation with nonrebreather mask with oxygen at 15 L/min (NRB-15), nonrebreather mask with flush rate oxygen (NRB-Flush), BVM device with oxygen at 15 L/min (BVM-15), and simple mask with flush rate oxygen. The primary outcome measure was the FeO2 in a single exhaled breath. We compared the FeO2 of NRB-Flush to other study groups, using a prespecified noninferiority margin of 10%.

RESULTS: We enrolled 26 subjects. Mean FeO2 values for NRB-15, NRB-Flush, BVM-15, and simple mask with flush rate oxygen were 54% (95% confidence interval [CI] 50% to 57%), 86% (95% CI 84% to 88%), 77% (95% CI 74% to 81%), and 72% (95% CI 69% to 76%), respectively. FeO2 for NRB-Flush was noninferior to BVM-15 (difference 8%; 95% CI 5% to 11%). FeO2 for NRB-Flush was higher than both NRB-15 (FeO2 difference 32%; 95% CI 29% to 35%) and simple mask with flush rate oxygen (FeO2 difference 13%; 95% CI 10% to 17%).

CONCLUSION: Preoxygenation with NRB-Flush was noninferior to BVM-15. NRB with flush rate oxygen may be a reasonable preoxygenation method for spontaneously breathing patients undergoing emergency airway management.

14. Pneumonia and UTI Often Resolve without Antibiotics

A. Disease Course of Lower Respiratory Tract Infection with a Bacterial Cause Untreated with Antibiotics

Teepe J, et al. Ann Fam Med. 2016;14:534-539.

PURPOSE Bacterial pathogens are assumed to cause an illness course different from that of nonbacterial causes of acute cough, but evidence is lacking. We evaluated the disease course of lower respiratory tract infection (LRTI) with a bacterial cause in adults with acute cough.

METHODS We conducted a secondary analysis of a multicenter European trial in which 2,061 adults with acute cough (28 days’ duration or less) were recruited from primary care and randomized to amoxicillin or placebo. For this analysis only patients in the placebo group (n = 1,021) were included, reflecting the natural course of disease. Standardized microbiological and serological analyses were performed at baseline to define a bacterial cause. All patients recorded symptoms in a diary for 4 weeks. The disease course between those with and without a bacterial cause was compared by symptom severity in days 2 to 4, duration of symptoms rated moderately bad or worse, and a return consultation.

RESULTS Of 1,021 eligible patients, 187 were excluded for missing diary records, leaving 834 patients, of whom 162 had bacterial LRTI. Patients with bacterial LRTI (and no antibiotic treatment) had worse symptoms at day 2 to 4 after the first office visit (P = .014) and returned more often for a second consultation, 27% vs 17%, than those without bacterial LRTI (P = .004). Resolution of symptoms rated moderately bad or worse did not differ (P = .375).

CONCLUSIONS Patients with acute bacterial LRTI (and no antibiotic treatment) have a slightly worse course of disease when compared with those without an identified bacterial cause, but the relevance of this difference is not meaningful.

B. Ibuprofen versus fosfomycin for uncomplicated UTI in women: randomised controlled trial

Gágyor I, et al.  BMJ 2015;351:h6544

Study question Can treatment of the symptoms of uncomplicated urinary tract infection (UTI) with ibuprofen reduce the rate of antibiotic prescriptions without a significant increase in symptoms, recurrences, or complications?

Methods Women aged 18-65 with typical symptoms of UTI and without risk factors or complications were recruited in 42 German general practices and randomly assigned to treatment with a single dose of fosfomycin 3 g (n=246; 243 analysed) or ibuprofen 3×400 mg (n=248; 241 analysed) for three days (and the respective placebo dummies in both groups). In both groups additional antibiotic treatment was subsequently prescribed as necessary for persistent, worsening, or recurrent symptoms. The primary endpoints were the number of all courses of antibiotic treatment on days 0-28 (for UTI or other conditions) and burden of symptoms on days 0-7. The symptom score included dysuria, frequency/urgency, and low abdominal pain.

Study answer and limitations The 248 women in the ibuprofen group received significantly fewer course of antibiotics, had a significantly higher total burden of symptoms, and more had pyelonephritis. Four serious adverse events occurred that lead to hospital referrals; one of these was potentially related to the trial drug. Results have to be interpreted carefully as they might apply to women with mild to moderate symptoms rather than to all those with an uncomplicated UTI.

What this paper adds Two thirds of women with uncomplicated UTI treated symptomatically with ibuprofen recovered without any antibiotics. Initial symptomatic treatment is a possible approach to be discussed with women willing to avoid immediate antibiotics and to accept a somewhat higher burden of symptoms.

15. Antiemetics May Be No Better than IV Fluids for Adults in the ED

A. For Adults With Nausea and Vomiting in the ED, What Medications Provide Rapid Relief?

Meltzer AC, et al. Ann Emerg Med 2016;68:6:717-718.

Take-Home Message
Although a number of medications are often used to treat nausea and vomiting in the emergency department (ED), only droperidol has been demonstrated to decrease nausea at 30 minutes.

B. The Cochrane Review on Treatment of n/v in the ED Setting

Furyk JS, Meek RA, Egerton-Warburton D. Drugs for the treatment of nausea and vomiting in adults in the emergency department setting. Cochrane Database Syst Rev 2015;CD010106.

C. Antiemetic use for nausea and vomiting in adult ED patients: RCT comparing ondansetron, metoclopramide, and placebo.

Egerton-Warburton D, et al. Ann Emerg Med. 2014;64(5):526-532.e1.

CONCLUSION: Reductions in nausea severity for this adult ED nausea and vomiting population were similar for 4 mg intravenous ondansetron, 20 mg intravenous metoclopramide, and placebo. There was a trend toward greater reductions in VAS ratings and a lesser requirement for rescue medication in the antiemetic drug groups, but differences from the placebo group did not reach significance. The majority of patients in all groups were satisfied with treatment.

D. Oligoantiemesis or Inadequate Prescription of Antiemetics in the ED: A Local and National Perspective (also see letter below)

Singer AJ, et al. J Emerg Med. 2016;50(6):818-24.

BACKGROUND: Nausea and vomiting are common, but prevalence of antiemetic use in ED patients is unknown.

OBJECTIVES: We determined the use of antiemetics in emergency department (ED) patients presenting with nausea and vomiting (NV).

METHODS: We conducted a retrospective chart review of ED patients presenting to a local ED with NV and analyzed data from the National Hospital Ambulatory Care Survey for similar patients to determine the frequency of administration of antiemetics in the ED.

RESULTS: Of 3876 patients presenting to a local ED with NV in 2014, 2637 (68% [95% confidence interval (CI) 67-69%]) received an antiemetic. Of an estimated 11.3 million U.S. ED visits for NV in 2011 (the latest year available), antiemetics were prescribed in 56% (95% CI 53-59%). Females, older patients, and those with vomiting were more likely to receive antiemetics. Use of antiemetics was associated with reduced admissions in the single institution (odds ratio [OR] 0.62, 95% CI 0.52-0.74), but not in the national database (OR 1.08, 95% CI 0.74-1.60).

CONCLUSIONS: Many patients presenting with NV do not receive antiemetics while in the ED. Effort should be made to further study and reduce the phenomenon of undertreatment of nausea or vomiting, coined "oligoantiemesis."

E. Oligoantiemesis: A Premature Neologism for an Intervention Insufficiently Substantiated in the Emergency Setting (response to the study above).

Vinson DR, Nagam MR, Lugovskaya N, Nasrollahi FS, Egerton-Warburton D, Furyk JS, Meek RA. J Emerg Med. 2016 Oct 6 [Epub ahead of print].

We commend Drs. Singer et al for their excellent description of the prevalence and patterns of antiemetic use in emergency medicine in the U.S. (1). Their intriguing finding that a sizable proportion of patients with nausea or vomiting did not receive an antiemetic agent in their academic emergency department (ED) is validated by the similar results they report from the U.S. National Hospital Ambulatory Care Survey. They also observed that antiemetics were administered twice as often for ED patients with vomiting than for those with isolated nausea, which is consistent with physician survey data from Australia (2).

The authors believe the failure to provide antiemetics to a large proportion of ED patients with nausea or vomiting is a shortcoming of patient care, akin to the inadequate treatment of pain. To evoke this association with oligoanalgesia, they coin a similar word “oligoantiemesis,” around which the emergency care community can rally its efforts to increase the administration of antiemetics.

In exploring possible reasons for the “inadequate” use of antiemetics, Singer et al suggest that some practitioners may not be convinced of the efficacy of antiemetic agents in the ED. We are among the unconvinced. Why? Evidence strongly supports the use of antiemetics in the management of nausea and vomiting in other populations and settings, for example, chemotherapy-induced nausea and vomiting (3). But efficacy in one population doesn’t guarantee efficacy in another. In fact, in the ED, where people with undifferentiated nausea and vomiting most often receive diagnoses of non-specific abdominal pain or presumed gastroenteritis, evidence to support antiemetic efficacy is lacking.

One recent randomized trial found that ondansetron and metoclopramide were no better than placebo in emergency patients with a chief complaint of nausea or vomiting (4). Singer et al cite this study, but then minimize it and the concurring literature with the following disclaimer: “many of the previous studies may have used suboptimal drug doses, and many of the effects of the antiemetics may have been masked by the simultaneous administration of intravenous fluids. Yet other studies failed to include placebo as a control” (1). If that is the case, rather than push for more antiemetic use at this time, the authors should encourage more research, designed to meet their quality standards. If positive, claims of ED antiemetic efficacy, and calls for increased drug usage, would then be on more solid footing.

The evidence, however, that questions the efficacy of antiemetics in treatment of undifferentiated ED nausea and vomiting may not be as tenuous as these authors suggest. Several of us have co-authored a recent systematic review with the Cochrane database identifying eight randomized trials of drugs in the treatment of nausea and vomiting among adults in the ED (5). After describing the studies’ methods and results, we concluded that “there is no definite evidence to support the superiority of any one drug over any other drug, or the superiority of any drug over placebo.” In light of this, we suggested that “general supportive treatment such as intravenous fluids may be sufficient for the majority of people” (5). Forgoing ineffective medications has the additional benefits of avoiding drug toxicities and side-effects and better stewarding our healthcare resources.

We do agree with Singer et al that nausea and vomiting are serious complaints and that they should not be dismissed. But we are hesitant to rally around the concept of “oligoantiemesis” until evidence is forthcoming that “antiemetics” (the pharmaceutical category) live up to their name as true anti-emetics (the functional category) among ED patients with undifferentiated nausea or vomiting. For now, at least, we think “oligoantiemesis” is a premature neologism for an intervention that in this population is insufficiently substantiated. 

16. Inaccuracy in ECG lead placement among technicians, nurses, general physicians and cardiologists.

Rajaganeshan R, et al. Int J Clin Pract. 2008;62(1):65-70.

[DRV: An older article, but worth resurrecting]

The objective of the study was to determine the reliability of ECG precordial electrode placement by doctors and nurses involved in the emergency care of patients admitted with suspected cardiac diseases.

A total of 120 subjects were recruited within 2 days from six hospitals. They comprised physicians, nurses and cardiac technicians involved in the clinical assessment and care of patients with suspected cardiac disease. Subjects were asked to complete a questionnaire and marked on two diagrams of the chest wall the positions they would place precordial electrodes V1-V6.

This study showed wide inter-individual and inter-group variations in the placement of electrodes. Notably, V1 and V2 were frequently incorrectly positioned in the second intercostal space, especially by physicians. The correct position of V1 in the fourth right intercostal space was identified by 90% of cardiac technicians, 49% of nurses, 31% of physicians (excluding cardiologists) and--most disappointing of all--only 16% of cardiologists (p less than 0.001 for inter-group differences). V5 and V6 were also often mispositioned, too high on the lateral chest wall.

Nurses and doctors (especially cardiologists) do not know the correct positions for ECG electrodes. Because incorrect positioning of the precordial electrodes changes the ECG significantly, patients are at risk of potentially harmful therapeutic procedures. Equally, doctors who are aware of the possibility of lead misplacement may be inclined to ignore some ECG changes that may be genuine evidence of ischaemia. The only safe solution is proper precordial electrode placement, which requires training and an environment supporting precision.

17. Fatal Fentanyl: One Pill Can Kill.

Sutter ME, et al. Acad Emerg Med. 2016 Jun 20 [Epub ahead of print]

OBJECTIVE: The current national opioid epidemic is a public health emergency. We have identified an outbreak of exaggerated opioid toxicity caused by fentanyl adulterated tablets purchased on the street as hydrocodone/acetaminophen.

METHODS: Over an 8-day period in late March 2016, a total of 18 patients presented to our institution with exaggerated opioid toxicity. The patients provided a similar history: ingesting their "normal dose" of hydrocodone/acetaminophen tablets but with more pronounced symptoms. Toxicology testing and analysis was performed on serum, urine, and surrendered pills.

RESULTS: One of the 18 patients died in hospital. Five patients underwent cardiopulmonary resuscitation, one required extracorporeal life support, three required intubation, and two received bag-valve-mask ventilation. One patient had recurrence of toxicity after 8 hours after naloxone discontinuation. Seventeen of 18 patients required boluses of naloxone, and four required prolonged naloxone infusions (26-39 hours). All 18 patients tested positive for fentanyl in the serum. Quantitative assays conducted in 13 of the sera revealed fentanyl concentrations of 7.9 to 162 ng/mL (mean = 52.9 ng/mL). Pill analysis revealed fentanyl amounts of 600-6,900 μg/pill. The pills are virtually indistinguishable from authentic hydrocodone/acetaminophen tablets and are similar in weight. To date, our county has reported 56 cases of fentanyl opioid toxicity, with 15 fatalities. In our institution, the outbreak has stressed the capabilities and resources of the emergency department and intensive care units.

CONCLUSIONS: A serious outbreak of exaggerated opioid toxicity caused by fentanyl-adulterated tablets purchased on the street as hydrocodone/acetaminophen is under way in California. These patients required higher dosing and prolonged infusions of naloxone. Additionally, observation periods off naloxone were extended due to delayed, recurrent toxicity. The outbreak has serious ramifications for public health and safety, law enforcement, and healthcare facilities and resources.

18. Adverse Drug Events in the ED: What are the leading offenders?

Shehab N, et al. JAMA.  2016;316(20):2115-2125.

Key Points

Question: What are the characteristics of adverse drug events that lead to US emergency department (ED) visits?

Findings:  Based on 2013-2014 nationally representative surveillance data, an estimated 4 ED visits for adverse drug events occurred per 1000 individuals annually. Among children (aged ≤5 years), antibiotics were most commonly implicated; among older children and adolescents (aged 6-19 years), antibiotics were most commonly implicated, followed by antipsychotics; and among older adults (aged ≥65 years), anticoagulants, diabetes agents, and opioid analgesics were implicated in approximately 60% of ED visits for adverse drug events.

Meaning: Adverse drug events from anticoagulants, antibiotics, diabetes agents, opioid analgesics, and antipsychotics are a common reason for ED visits and may benefit from patient safety initiatives.

19. Carbon Monoxide Corner (three CO articles—amazing)

A. Treatment in CO poisoning patients with HA: a prospective, multicenter, double-blind, controlled clinical trial.

Ocak T, et al. Am J Emerg Med. 2016 Nov;34(11):2140-2145.

BACKGROUND: There is a lack of specificity of the analgesic agents used to treat headache and underlying acute carbon monoxide poisoning.

OBJECTIVE: To compare effectiveness of "oxygen alone" vs "metoclopramide plus oxygen" vs "metamizole plus oxygen" therapy in treating carbon monoxide-induced headache.

DESIGN: A prospective, multicenter, double-blind, controlled trial.

SETTING: Three emergency departments in Turkey.

POPULATION: Adult carbon monoxide poisoning patients with headache.

METHODS: A total of 117 carbon monoxide-intoxicated patients with headache were randomized into 3 groups and assessed at baseline, 30 minutes, 90 minutes, and 4 hours.

MAIN OUTCOME MEASURE: The primary outcome was patient-reported improvement rates for headache. Secondary end points included nausea, need for rescue medication during treatment, and reduction in carboxyhemoglobin levels.

RESULTS: During observation, there was no statistical difference between drug type and visual analog scale score change at 30 minutes, 90 minutes, or 4 hours, for either headache or nausea. No rescue medication was needed during the study period. The reduction in COHgb levels did not differ among the 3 groups.

CONCLUSION: The use of "oxygen alone" is as efficacious as "oxygen plus metoclopramide" or "oxygen plus metamizole sodium" in the treatment of carbon monoxide-induced headache.

B. ACEP Clinical Policy: Critical Issues in the Evaluation and Management of Adult Pts Presenting to the ED with Acute CO Poisoning

This clinical policy from the American College of Emergency Physicians addresses key issues in the evaluation and management of adult patients presenting to the emergency department with acute carbon monoxide poisoning. A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: 1) In emergency department patients with suspected acute carbon monoxide poisoning, can noninvasive carboxyhemoglobin measurement be used to accurately diagnose carbon monoxide toxicity? 2) In emergency department patients diagnosed with acute carbon monoxide poisoning, does hyperbaric oxygen therapy as compared with normobaric oxygen therapy improve long-term neurocognitive outcomes? 3) In emergency department patients diagnosed with acute carbon monoxide poisoning, can cardiac testing be used to predict morbidity or mortality? Evidence was graded and recommendations were made based on the strength of the available data.

C. An antidote for CO poisoning?

Wudan Yan. Science. Dec. 7, 2016

On 26 January, Ling Wang and Qinzi Xu, two biomedical scientists at the University of Pittsburgh in Pennsylvania, placed a mouse under a chemical hood, anesthetized it, and hooked it up to monitors. Wang closed the hood and Xu turned on a switch to deliver 3% carbon monoxide (CO)—a concentration so high that it would kill most humans almost immediately—for 4.5 minutes. The mouse’s blood pressure dropped precipitously and its heart rate turned irregular. Then, through an intravenous tube, they delivered a molecule their lab had developed. Moments later, the animal’s blood pressure began to rise and it recovered. This was a first: There are no known antidotes for CO poisoning.

Given off by engines, heaters, and fireplaces, the tasteless, odorless gas sends more than 50,000 Americans to the emergency room—and kills approximately 500—every year. CO poisons in at least two ways. First, it binds tightly to the hemoglobin in blood and prevents it from delivering oxygen throughout the body. Second, it inhibits the process of respiration in mitochondria, cells’ powerhouses. About the best physicians can now offer in cases of poisoning is a treatment developed more than 50 years ago: high-pressure oxygen.

“People have attempted some biochemical tricks to free carbon monoxide from hemoglobin, but they don’t really work. That’s why we literally have a therapy that’s as old as oxygen,” says Lance Becker, a physician at the Hofstra Northwell School of Medicine in Manhasset, New York. “So the idea of finding something that might work better, faster, and stronger is very appealing.”

That something, described in this week’s issue of Science Translational Medicine, is neuroglobin—a protein typically found in the brain and retina that protects cells from injury by binding oxygen and nitric oxide—repurposed into a CO scavenger. The Pittsburgh research team, led by critical care physician Mark Gladwin, was originally studying its function when they noticed that isolated neuroglobin molecules almost always had CO, a natural byproduct of hemoglobin breakdown, bound to them. “I thought this was bad news at the time, because we needed to get the CO off the neuroglobin in an extra experimental step,” Gladwin said. But when a colleague asked in 2012 whether there was any antidote for CO poisoning, he realized that his lab might already have an answer.

In the mouse study, the group engineered a mutated version of neuroglobin that binds CO 500 times more tightly than it binds hemoglobin. The CO-laden molecules are excreted through the kidneys. When given within 5 minutes of a lethal dose of CO, the neuroglobin saved 87% of mice, the group reports. “This agent is phenomenal: It can rip carbon monoxide right off the hemoglobin,” says Lindell Weaver, a doctor who treats patients with high-pressure oxygen at Intermountain Healthcare in Salt Lake City.

Weaver notes, however, that CO poisoning also activates a series of immunological pathways that cause lingering damage to the nervous and cardiovascular systems. “The long-term effects of carbon monoxide are complicated, so just removing [it] might not be enough,” he says. “But this agent could be life-saving if it’s administered immediately.”

Gladwin’s team now plans to further explore the efficacy and safety of the neuroglobin in rats, larger mammals, and, eventually, patients. One challenge will be making the neuroglobin scavenger in the amounts needed for use in the field and clinic. The U.S. Food and Drug Administration, Gladwin says, has already promised an expedited review of the treatment given that CO poisoning is a “serious unmet need.”

21. The Good-Enough Physician-Parent

Gilsdorf JR. JAMA. 2016;316(20):2089.

The venue was a career development session for pediatric infectious diseases physicians, and mine was the voice of experience. Tension sizzled in the conference room air. “How do I do this?” someone asked. “I’m a constant wreck.” The comments continued. “My spouse travels a lot.” “My spouse is also a physician.” “Will it ever get better?” “I don’t see how I can keep this up much longer.” “My kids are so important to me, but so are my patients. And my research.”

“Life/Work Balance” was the title of the session. Balancing personal life and medical life? I thought. That’s a Sisyphean challenge, one doomed to failure, and to try to push that rock uphill will only feed into the problem: yet more anxiety, a greater sense of inadequacy, more internal torture. “Let’s be honest here,” I told the group. “There is no balance in personal life and medical life. It’s a matter of lurching from one crisis to the next.” But glorious islands of joy wedge themselves between the calamities.

My husband (a surgeon) and I (a pediatric infectious diseases physician-scientist) spent the years of our children’s youth straddling this imbalance. We had our own equation for success as physician-parents, or, rather, we had an equation that we invented, we applied to the issue, and we hoped for success: No television set. Cook together. Eat together. Read together. No long commutes to work. An army of helpers: babysitters, alternative babysitters, emergency babysitters, drivers, cleaning people; all of our relatives were many hundreds of miles away from our home, and we were on our own. We kept materials around the house for creative play. In truth, the kids found materials for clandestine play, such as boards and nails and hammers to a construct a skateboard ramp in the bedroom and a tree fort in the back yard. They secretly found laundry detergents and bathroom cleansers to concoct magic potions, blankets to make tents over the living room furniture, and rope and a shoe box for an elevator to ferry the guinea pig from the second-floor balcony to the first-floor carpet….

The world is a complex, imperfect place, and our children must learn to live in it and to weather the imperfections, their own, our own, and those of others. As with everything else important, they will learn that best from us, their good-enough physician-parents.

22. Diagnostic Accuracy of Pediatric Abdominal Ultrasound: Do You Need a Full Bladder?

Daniel M. Lindberg, MD. Journal Watch Emerg Med. November 21, 2016

Reviewing  Ross M et al. CJEM 2016 Nov.   

This study suggests the answer is no.

Ultrasound has replaced computed tomography (CT) as the initial imaging study for most children with suspected appendicitis. Some institutions require bladder filling to facilitate ultrasound examinations, but this can be uncomfortable and delay care. These authors evaluated the diagnostic accuracy of transabdominal ultrasound with and without filled bladders in a retrospective cohort of 678 children with suspected appendicitis at a single center.

Ultrasound images were reviewed to determine the percent of expected bladder capacity; bladders filled to less than 75% capacity were considered suboptimally filled. Ultrasound reports were considered to be “diagnostic” if they demonstrated a fully visualized normal appendix, appendicitis, or an alternative diagnosis for the patient's symptoms. Investigators also determined whether ovaries were fully visualized in girls.

Among 678 children aged 2 to 17 years, 283 had full bladders and 395 had suboptimally filled bladders. Ultrasound exams were diagnostic in 47% of children with full bladders and 52% of those with suboptimally filled bladders (difference not significant). This finding held in both sexes. Ovaries were visualized significantly more often in girls with full bladders (96%) than in those with suboptimally filled bladders (81%).

Routinely making patients wait for urine to accumulate or endure catheterization is not patient-centered and appears unwarranted based on the high rate of diagnostic studies obtained in patients with unfilled bladders. In order to decrease risk of perforation and to improve throughput and comfort, ultrasound should be attempted early in children with suspected appendicitis. Nondiagnostic studies in children with unfilled bladders can be repeated.

23. Anxiety Dreams

Do you have one? Examples include “lost passport, naked in public, spitting out teeth, forgotten exam, accidentally making out with cousin, smoking a cigarette after quitting, pregnant, missing flights, bad outfit, exposure of self as fraud.” Read on…

By Rosa Lyster, NY Times. Dec. 7, 2016

It is incredible to me how little I remember of what I was taught in high school. Whole subjects, entire years, have just dissolved. I need a calculator to do any kind of multiplication now. I recently tried to explain how electricity worked to a small child, and even she could tell I was making it up. But there are two things I recall with exceptional clarity: Napoleon’s retreat from Moscow (the hunger, the cold, the sleeping bags made of horse carcasses), and the opening soliloquy of “Richard III,” which I was required to memorize for English class at 16. I took this request very seriously, because I was not cool, and I spent many days slinking up and down the corridors hissing, “I am determined to prove a villain” to myself and narrowing my eyes. Though my ability to recite it remains useful as a party trick, that is not the reason it has remained lodged in my mind.

In the years since high school, that monologue has become the centerpiece of my most savage and recurring anxiety dream. I have it about once a month: I will be standing backstage under gloomy lighting, with people scampering around clutching wigs and swords, and I will realize with a sickening suddenness that soon, very soon, I will have to walk onstage and start reciting that speech, and everyone will realize that I am the worst Richard III in the history of the theater. Not even just the worst Richard III — the worst person, the biggest impostor, the No.1 catastrophe in this land. I always wake up just before the curtain opens.

I almost look forward to the dream whenever it descends. It is not fun, exactly, but it is interesting, and intense: a familiar thing that manages to knock me out afresh each time. It’s like being on a ride. And for this reason, anxiety dreams are the only sort that I permit myself to recount to those around me.

Other people’s dreams are mostly rubbish. They are dense and generally inconclusive and involve too many bits like, “I was in my house, but like, it wasn’t my house, you know?” For instance, my dream in which I become best friends with the rapper Danny Brown (probably my favorite dream I’ve ever had) and my friend’s dream in which she drives a Jetta up the stairs at a house party have far too much going on, way too many variables to be revealing.

Anxiety dreams, by contrast, are short in the telling — a rare commodity in the world of dream-relaying. Ask people about them, and they will usually offer a sentence at most, or even just a few key words: lost passport, naked in public, spitting out teeth, forgotten exam, accidentally making out with cousin, smoking a cigarette after quitting, pregnant, missing flights, bad outfit, exposure of self as fraud. This limited scope enables easy comparison; anxiety dreams can be held up to one another and scrutinized for what they say about the dreamer’s orientation toward the world…

The remainder of the essay:

24. Micro Bits

A. Testosterone treatment increases risk of venous thromboembolism

According to this observational study there is an increased risk of venous thromboembolism soon after the start of testosterone use, which peaks in the first six months.

B. Acute kidney injury 2016: diagnosis and diagnostic workup

C. New aspects in the management of pneumonia

D. Infants, mothers may benefit from immediate skin-to-skin contact after birth

Babies and mothers who immediately received skin-to-skin contact after birth had nearly 24% increased odds of breast-feeding after one to four months, compared with those who received various forms of usual care, according to a review in the Cochrane Library. The findings, based on 46 randomized controlled trials from 21 countries, also showed increased heart and lung function scores and blood glucose levels among newborns who received immediate skin-to-skin contact.

E. Improving Hypertension Control and Patient Engagement Using Digital Tools

F. Predictive performance of a Fall Risk Assessment Tool (FRAT-up)

Can a Fall Risk Tool (FRAT-up) accurately predict future falls? Data about fall risk factors from four European studies -- from Germany, England, Italy, and Ireland -- that used other fall risk tools were compared to the FRAT-up tool for each of those cohorts. It was found that FRAT-up was a valid tool for measuring future risk of falls. More studies should be done to try to understand the reasons for similarities across studies and to refine the tool.

G. Daily nut consumption tied to lower disease risk

An analysis of 29 studies found eating a handful of nuts each day may reduce the risk of heart disease, cancer, respiratory conditions, diabetes and infections, researchers reported in BMC Medicine. "We found a consistent reduction in risk across many different diseases, which is a strong indication that there is a real underlying relationship between nut consumption and different health outcomes," said researcher Dagfinn Aune of Imperial College London.

H. Older adults have higher levels of well-being, survey says

Survey data from Gallup-Healthways showed people ages 55 and older had higher levels of well-being than younger adults across five measures: financial well-being, community, purpose, social and health.

I. Everolimus-Eluting Stents or Bypass Surgery for Left Main Coronary Artery Disease

In patients with left main coronary artery disease and low or intermediate SYNTAX scores by site assessment, PCI with everolimus-eluting stents was noninferior to CABG with respect to the rate of the composite end point of death, stroke, or myocardial infarction at 3 years.

J. Linemen in Football Face Higher Cardiac Risks

K. Relationship Between Stress Rankings and the Overall Hospital Star Ratings: An Analysis of 150 Cities in the United States

L. Study quantifies benefits of widespread low-dose aspirin use

A study published in the journal PLOS ONE found that widespread daily intake of low-dose aspirin among older Americans could ensure 900,000 more Americans are alive by 2036 and deliver almost $692 billion in net health care benefits during the same period. Just 40% of Americans who the authors say should be taking aspirin are doing so, despite evidence that utilization is associated with lower heart disease and cancer risk and improved life expectancy.

M. Surgeon General releases first-ever report on substance misuse

The US Surgeon General's office released its first report covering alcohol and drug misuse, treatment and prevention, which examines the science behind addiction and substance use disorders and aims to address the stigma associated with substance misuse. AAFP President John Meigs, M.D., commented on the report, saying, "I am hopeful this report will help create new opportunities for increased access to effective treatment and prevention strategies, as well as help dispel the shame and misunderstanding that surrounds substance abuse disorders."

N. Pessimism may be a marker of heart disease

An 11-year Finnish study in BMC Public Health found those who were more pessimistic were twice as likely to die of heart disease, compared with those who were the least pessimistic. Pessimism could be used as a factor to determine an individual's risk of dying from heart disease, researcher Mikko Pankalainen, M.D., said.

O. Dispelling food safety myths

The Partnership for Food Safety Education says that contrary to common belief, cross-contamination can occur in the refrigerator, fruits and vegetables carry a risk for foodborne illness, and leftovers can harbor dangerous bacteria even if they smell OK. The Partnership and the US Food and Drug Administration discuss several other food safety myths and actions you can take to protect yourself and your family from foodborne illness.

P. Tetrahydrocannabinol Does Not Reduce Pain in Patients With Chronic Abdominal Pain in a Phase 2 Placebo-controlled Study

Q. In and out surgery for appendicitis

BMJ 2016;355:i6485

Go home, your appendix is out

Southern Californians who are covered by care consortium Kaiser Permanente and who have laparoscopic surgery for simple appendicitis are likely to be home within 24 hours. And if that happens, they are less likely to be readmitted within 30 days than similar patients who are kept in longer. These are the findings of a retrospective review that compared the records of 6710 patients who were discharged on the same day as their procedure with 5993 patients who were admitted overnight. Within the Kaiser system, 60% of patients who have laparoscopic surgery for non-perforated appendicitis are now discharged straight from the recovery room.

R. Screen time tied to increased obesity risk in adolescents

Teens who used screen devices such as smartphones and tablets for five or more hours daily had a twofold higher likelihood of getting too little physical activity and were 43% more likely to become obese than those who didn't use such devices. The findings in the Journal of Pediatrics also showed a 74% increased risk of poor sleep among those who used screen devices for at least five hours daily.

S. EpiPen Controversy Reveals Complexity Behind Drug Price Tags