Friday, January 20, 2017

Lit Bits: Jan 20, 2017

From the recent medical literature...

-1. BMJ on New Year’s Resolutions

Sixty seconds on . . . New Year resolutions.
Hawkes N. BMJ 2016;355:i6845

Made any New Year resolutions?

Not really. I follow Oscar Wilde: “Their origin is pure vanity. Their result is absolutely nil.”

Bit harsh, surely?

Possibly, but the psychological literature isn’t terribly encouraging. One study showed that 22% of people who made them admitted failure after only a week, 40% at a month, 50% at three months, and 81% after two years. Most likely the real figures were even higher, because these were self reported.1

Yet people still make resolutions

They do. The change of year seems to offer a chance to change lifestyle as well as date. Giving up smoking, losing weight, or drinking less are the commonest. Among students, resolving to work harder is common.

And they all come to naught?

Not entirely. People can change, though it’s hard. Even if only a small proportion succeed, that’s better than nothing.

The psychological literature agrees that, to have a chance of succeeding, resolutions must be autonomous, not imposed from outside by social pressure.

Any other tips?

Resolutions should be realistic, specific, and not too numerous. Most importantly, they should include a plan of implementation: not only what you want to achieve but how you plan to do it.2 Compliance with drug taking, for example, is greater if patients have a plan for when, and where, they will take their pills each day. Good intentions need to be reinforced by a good plan.

Shouldn’t this be trialled?

It has been. Male undergraduates at Bath University were encouraged to examine their testicles monthly for lumps (signs of testicular cancer). Those with a plan specifying when and where they would do it were nearly three times as likely to do it—and six times as likely to still be doing it a year later—as those without a plan.3 Granted, feeling your testicles once a month would be an unusual New Year resolution, but it shows the way forward. Oscar might have been wrong.

1. Marlatt GA, Kaplan BE. Self-initiated attempts to change behavior: a study of New Year’s Resolutions. Psychol Rep1972;30:123-31.
2. Gollwitzer PM. Implementation intentions: strong effects of simple plans. Am Psychol1999;54:493-503.
3. Sheeran P, Milne S, Webb TL, Gollwitzer PM. Implementation intentions and health behaviours. In: Conner M, Norman P, eds. Predicting health behaviour: research and practice with social cognition models.2nd ed. Open University Press.

0. Best of 2016

A. NEJM’s Journal Watch Emergency Medicine

Dear Readers,

It has been a remarkable year for practice-changing medical breakthroughs. This year has seen myriad advances and challenges, including a fundamental shift in the approach to pulmonary embolism as an outpatient disease, emergency physicians wrestling with the sudden legalization of marijuana and the impact of edible and synthetic cannabinoids, emergency medicine being placed in the center of the opioid addiction crisis, and continued change in resuscitation and sepsis guidelines. As difficult as it was to pick a top 10 list, we have done our best to highlight some of the most impactful articles published this year.

B. From ACEP Now by Ryan Radekci

C. From UpToDate by Grayzel and Wiley

D. Ten Inspiring Moments from 2016

By Greater Good Editors | January 3, 2017

There were bright lights in 2016 that reminded us that humans can be creative, generous, kind, self-sacrificing, contrite, and forgiving. Here are ten of them.

1. Infant LPs: Use US First to Mark your Landmarks

Prospective Investigation of a Novel US-assisted LP Technique on Infants in the Pediatric ED

Gorn M, et al. Acad Emerg Med. 2017 Jan;24(1):6-12.

OBJECTIVE: The objective was to describe a novel ultrasound-assisted lumbar puncture (UALP) technique and to compare it to standard lumbar puncture (SLP) technique in infants.

METHODS: A prospective, randomized, controlled study in infants 60 days old and younger undergoing a lumbar puncture (LP) in a pediatric emergency department. Patients with a spinal anomaly or ventriculoperitoneal shunt were excluded. Eligible infants were randomized to UALP or SLP. A spinal sonogram was performed on all patients by an investigator not involved in performing the LP. Spinal landmarks and maximum safe depth were identified for the UALP providers. Providers in the SLP group were blinded to sonographic measurements. A successful LP was defined as the collection of cerebrospinal fluid (CSF) with a red blood cell count of less than 10,000 cells/mm3 . Statistical analysis included chi-square, Mann-Whitney U-test, and number needed to treat (NNT).

RESULTS: Forty-three patients were enrolled, 21 in the UALP group and 22 in the SLP group. Prematurity, weight, length, provider experience, anesthesia use, stylet technique, and number of attempts were similar between groups. The median age in the UALP group was 38 days (interquartile range [IQR] = 33 days) versus 45 days (IQR = 19 days) in the SLP group (p = 0.02). CSF was obtained in all UALP subjects (100%) versus in 18 of 22 (82%) in the SLP group (p = 0.04); 20 (95%) UALP subjects versus 15 (68%) SLP subjects met our definition of success (p = 0.023). The odds ratio of successful LP using UALP technique was 9.33 (95% confidence interval [CI] = 1.034 to 84.026) and the NNT was 3.7 (95% CI = 2.02 to 24.18).

CONCLUSION: The UALP technique increases the rate of a successful LP in infants compared to standard technique.

Also see Neal JT, et al. The effect of bedside US skin marking on infant LP success: a RCT. Ann Emerg Med. 2016 Nov 14 [Epub].

Also see Halm BM, et al. Color Flow Doppler Point of Care Ultrasound to Evaluate Vessels before Infant Lumbar Puncture. J Emerg Med. 2017;52:70–73.

2. Interpretation of CSF WBC Counts in Young Infants with a Traumatic LP

Lyons TW, et al. Ann Emerg Med. 2016 Dec 29 [Epub ahead of print]

STUDY OBJECTIVE: We determine the optimal correction factor for cerebrospinal fluid WBC counts in infants with traumatic lumbar punctures.

METHODS: We performed a secondary analysis of a retrospective cohort of infants aged 60 days or younger and with a traumatic lumbar puncture (cerebrospinal fluid RBC count ≥10,000 cells/mm3) at 20 participating centers. Cerebrospinal fluid pleocytosis was defined as a cerebrospinal fluid WBC count greater than or equal to 20 cells/mm3 for infants aged 28 days or younger and greater than or equal to 10 cells/mm3 for infants aged 29 to 60 days; bacterial meningitis was defined as growth of pathogenic bacteria from cerebrospinal fluid culture. Using linear regression, we derived a cerebrospinal fluid WBC correction factor and compared the uncorrected with the corrected cerebrospinal fluid WBC count for the detection of bacterial meningitis.

RESULTS: Of the eligible 20,319 lumbar punctures, 2,880 (14%) were traumatic, and 33 of these patients (1.1%) had bacterial meningitis. The derived cerebrospinal fluid RBCs:WBCs ratio was 877:1 (95% confidence interval [CI] 805 to 961:1). Compared with the uncorrected cerebrospinal fluid WBC count, the corrected one had lower sensitivity for bacterial meningitis (88% uncorrected versus 67% corrected; difference 21%; 95% CI 10% to 37%) but resulted in fewer infants with cerebrospinal fluid pleocytosis (78% uncorrected versus 33% corrected; difference 45%; 95% CI 43% to 47%). Cerebrospinal fluid WBC count correction resulted in the misclassification of 7 additional infants with bacterial meningitis, who were misclassified as not having cerebrospinal fluid pleocytosis; only 1 of these infants was older than 28 days.

CONCLUSION: Correction of the cerebrospinal fluid WBC count substantially reduced the number of infants with cerebrospinal fluid pleocytosis while misclassifying only 1 infant with bacterial meningitis of those aged 29 to 60 days.

3. Stroke Pts receiving Mechanical Thrombectomy may not benefit from Antecedent IV Lytics

Combined IV Thrombolysis and Thrombectomy vs Thrombectomy Alone for Acute Ischemic Stroke: A Pooled Analysis of the SWIFT and STAR Studies.

Coutinho JM, et al. JAMA Neurol. 2017 Jan 9 [Epub ahead of print]

IMPORTANCE: Mechanical thrombectomy (MT) improves clinical outcomes in patients with acute ischemic stroke (AIS) caused by a large vessel occlusion. However, it is not known whether intravenous thrombolysis (IVT) is of added benefit in patients undergoing MT.

OBJECTIVE: To examine whether treatment with IVT before MT with a stent retriever is beneficial in patients undergoing MT.

DESIGN, SETTING, AND PARTICIPANTS: This post hoc analysis used data from 291 patients treated with MT included in 2 large, multicenter, prospective clinical trials that evaluated MT for AIS (Solitaire With the Intention for Thrombectomy performed from January 1, 2010, through December 31, 2011, and Solitaire Flow Restoration Thrombectomy for Acute Revascularization from January 1, 2010, through December 31, 2012). An independent core laboratory scored the radiologic outcomes in each trial.

INTERVENTIONS: Patients were treated with IVT with tissue plasminogen activator followed by MT (IVT and MT group) with the use of a stent retriever or MT with a stent retriever alone (MT group).

MAIN OUTCOMES AND MEASURES: Successful reperfusion, functional independence (modified Rankin Scale score of 0-2) and mortality at 90 days, symptomatic intracranial hemorrhage, emboli to new territory, and vasospasm were compared.

RESULTS: Of 291 patients included in the analysis, 160 (55.0%) underwent IVT and MT (mean [SD] age, 67 [13] years; 97 female [60.6%]), and 131 (45.0%) underwent MT alone (mean [SD] age, 69 [12] years; 71 [55.7%] female). Median Alberta Stroke Program Early CT Score at baseline was lower in the IVT and MT group (8 vs 9, P = .04). There was no statistically significant difference in the duration from symptom onset to groin puncture (254 minutes for the IVT and MT group vs 262 minutes for the MT group, P = .10). The number of passes, rate of successful reperfusion, functional independence at 90 days, mortality at 90 days, and emboli to new territory were also similar among groups. Symptomatic intracranial hemorrhage (1% vs 4%) and parenchymal hemorrhages type 1 (1% vs 3%) or type 2 (1% vs 2%) did not differ significantly (P = .25). Vasospasm occurred more often in patients who received IVT and MT vs MT alone (27% vs 14%, P = .006). In multivariate analysis, no statistically significant association was observed between IVT and MT vs MT alone for any of the outcomes.

CONCLUSIONS AND RELEVANCE: The results indicate that treatment of patients experiencing AIS due to a large vessel occlusion with IVT before MT does not appear to provide a clinical benefit over MT alone. A randomized clinical trial seems warranted.

4. Increasing Single-dose IV Ketorolac above 10mg is without Additional Benefit

Comparison of IV Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the ED: A RCT

STUDY OBJECTIVE: Nonsteroidal anti-inflammatory drugs are used extensively for the management of acute and chronic pain, with ketorolac tromethamine being one of the most frequently used parenteral analgesics in the emergency department (ED). The drugs may commonly be used at doses above their analgesic ceiling, offering no incremental analgesic advantage while potentially adding risk of harm. We evaluate the analgesic efficacy of 3 doses of intravenous ketorolac in ED patients with acute pain.

METHODS: We conducted a randomized, double-blind trial to assess the analgesic efficacy of 3 doses of intravenous ketorolac (10, 15, and 30 mg) in patients aged 18 to 65 years and presenting to the ED with moderate to severe acute pain, defined by a numeric rating scale score greater than or equal to 5. We excluded patients with peptic ulcer disease, gastrointestinal hemorrhage, renal or hepatic insufficiency, allergies to nonsteroidal anti-inflammatory drugs, pregnancy or breastfeeding, systolic blood pressure less than 90 or greater than 180 mm Hg, and pulse rate less than 50 or greater than 150 beats/min. Primary outcome was pain reduction at 30 minutes. We recorded pain scores at baseline and up to 120 minutes. Intravenous morphine 0.1 mg/kg was administered as a rescue analgesic if subjects still desired additional pain medication at 30 minutes after the study drug was administered. Data analyses included mixed-model regression and ANOVA.

RESULTS: We enrolled 240 subjects (80 in each dose group). At 30 minutes, substantial pain reduction was demonstrated without any differences between the groups (95% confidence intervals 4.5 to 5.7 for the 10-mg group, 4.5 to 5.6 for the 15-mg group, and 4.2 to 5.4 for the 30-mg group). The mean numeric rating scale pain scores at baseline were 7.7, 7.5, and 7.8 and improved to 5.1, 5.0, and 4.8, respectively, at 30 minutes. Rates of rescue analgesia were similar, and there were no serious adverse events. Secondary outcomes showed similar rates of adverse effects per group, of which the most common were dizziness, nausea, and headache.

CONCLUSION: Ketorolac has similar analgesic efficacy at intravenous doses of 10, 15, and 30 mg, showing that intravenous ketorolac administered at the analgesic ceiling dose (10 mg) provided effective pain relief to ED patients with moderate to severe pain without increased adverse effects.

5. Management and Outcomes of Bleeding Events in Pts in the ED Taking Warfarin or a Non–Vit K Antagonist Oral Anticoagulant

Singer AJ, et al. J Emerg Med 2017;52:1–7.e1

Most comparisons of bleeding patients who are taking warfarin or a non–vitamin K oral anticoagulant (NOAC) have been limited to admitted patients and major bleeding events in well-controlled, clinical trial settings.

We describe the clinical characteristics, interventions, and outcomes in patients who are taking warfarin or a NOAC who presented to the emergency department (ED) with any bleeding event.

We conducted a structured, retrospective, observational study of nonvalvular atrial fibrillation, pulmonary embolism, or deep vein thrombosis warfarin- or NOAC-treated patients presenting with any bleeding event to a large, academic ED between January 2012 and March 2015. We used descriptive statistics to summarize baseline characteristics, treatments, and outcomes and performed subgroup analyses based on the type of anticoagulant and site of bleeding.

The electronic search yielded 95 cases of patients taking a NOAC (i.e., dabigatran [33], rivaroxaban [32], or abixaban [30]) and 342 patients taking warfarin. Reversal agents were rarely used in all anticoagulant groups. Case fatality rates were similar among warfarin- and NOAC-treated patients for gastrointestinal bleeding (7% vs. 7%) and intracranial hemorrhage (18% vs. 4%), respectively. After adjustment for other factors, only intracranial hemorrhage (odds ratio 4.4; 95% confidence interval 1.4–13.3) was associated with mortality.

Despite the rare use of reversal strategies, mortality was low and outcomes were comparable among patients with bleeding events presenting to the ED while taking a NOAC compared with warfarin.

6. On ED ECGs

A. Initial ECG as determinant of hospital course in STEMI

Millard MA, et al.  Ann Noninv Electrocardiol 2017 Jan 3 [Epub ahead of print]

A proportion of patients with ST elevation myocardial infarction (STEMI) have an initial electrocardiogram (ECG) that is nondiagnostic and are definitively diagnosed on a subsequent ECG. Our aim was to assess whether patients with a nondiagnostic initial ECG are different than those with a diagnostic initial ECG.

We collected demographic, ECG, medication, angiographic, and in-hospital clinical outcome data in consecutive patients undergoing primary percutaneous coronary intervention for STEMI at our institution from June 2009 to June 2013.

A total of 334 patients were included, 285 (85%) diagnosed on the initial ECG and 49 (15%) on a subsequent ECG. Patients with a nondiagnostic initial ECG had more comorbidities including prior congestive heart failure (14% vs. 3%, p less than .001), coronary artery disease (47% vs. 24%, p = .001), diabetes (37% vs. 16%, p = .001), and hyperlipidemia (55% vs. 40%, p = .048); higher rates of chronic medication use including aspirin (47% vs. 27%, p = .005), beta-blocker (47% vs. 22%, p less than .001), and statins (53% vs. 28%, p = .001); longer door-to-balloon times (106 min vs. 45 min, p less than .001); lower peak troponin levels (25 ng/ml vs. 50 ng/ml, p = .004), longer diagnostic ECG to balloon times (84 min vs. 75 min, p = .006); and higher rates of a patent infarct-related artery on baseline angiography (41% vs. 24%, p = .018) which remained significant in a multivariable logistic regression model.

Approximately one in seven STEMI patients had an initial ECG that was nondiagnostic for STEMI. These patients had more comorbidities, higher rates of medication use, and received delayed intervention (even after the diagnosis was definitive).

B. Safety of Computer Interpretation of Normal Triage ECGs

Hughes KE, et al. Acad Emerg Med 2017;24:120-124.

Frequent interruptions within the emergency department may lead to errors that negatively impact patient care. The immediate review of electrocardiograms (ECGs) obtained from triage patients is one source of interruption. Limiting triage ECGs requiring immediate attending review to those interpreted by the computer as abnormal may be one way to reduce interruption. We hypothesize that triage ECGs interpreted by the computer as “normal ECG” are unlikely to have clinical significance that would affect triage care.

All triage ECGs performed at the University of North Carolina were collected between November 14, 2014, and March 3, 2015, according to a standard nursing triage protocol using GE machines running Marquette 12SL software. Triage ECGs with a computer interpretation of “normal ECG” were compared to an attending cardiologist's final interpretation. Triage ECGs for which the cardiologist's interpretation differed from the computer interpretation of normal ECG were presented to two emergency physicians (EPs) blinded to the goals of the study. The physicians were asked to evaluate the ECG for clinical significance. Clinical significance was defined as any change from normal that would alter triage care. Triage ECGs were considered true negatives if either the cardiologist agreed with the normal computer interpretation or if both EPs agreed that the ECG did not show clinical significance.

A total of 855 triage ECGs were collected over 16 weeks. A total of 222 (26%) were interpreted by the computer as normal. The negative predictive value for a triage ECGs interpreted by the computer as “normal” was calculated to be 99% (95% confidence interval = 97% to 99%). Of the ECGs with a computer interpretation of normal ECG, 13 had an interpretation by an attending cardiologist other than normal. Two attending EPs reviewed these triage ECGs. One of the 13 ECGs was found to have clinical significance that would alter triage care by one of the EPs. The stated triage intervention was “bed immediately.”

Our data suggest that triage ECGs identified by the computer as normal are unlikely to have clinical significance that would change triage care. Eliminating physician review of triage ECGs with a computer interpretation of normal may be a safe way to improve patient care by decreasing physician interruptions.

C. Novel ECG changes in ACS. Would improvement in the recognition of 'STEMI-equivalents' affect time until reperfusion?

Wall J, et al. Intern Emerg Med. 2016 Dec 31 [Epub ahead of print]

Current guidelines recommend that patients with non-ST elevation myocardial infarction (NSTEMI) are treated with medical management alone, or in combination with coronary angiography within 24 h. Recent research suggests that NSTEMIs show angiographic evidence of complete occlusion at rates comparable to STEMIs, suggesting a subgroup of NSTEMI patients who require urgent angiography. Novel ECG changes, termed 'STEMI-equivalents', have been described as a way of identifying this subgroup. The aim of this study was to determine whether patients with STEMI-equivalent ECG changes experience similar degrees of myocardial damage, and would thus benefit from urgent PCI. Cardiac catheterisation databases at The Wollongong Hospital were searched for STEMI, and NSTEMI patients with complete occlusion of the culprit vessel, between January 2011 and December 2013. A total of 1429 patients underwent angiography during this time period. Of these, 220 were eligible for ECG analysis. We found 10-25% of NSTEMIs with 'STEMI equivalent' ECG changes correlated with complete vessel occlusion on angiography. These patients demonstrated equivalent initial troponin readings. Recognition of STEMI-equivalents represent a chance for earlier intervention with prompt coronary angiography, as these findings are often associated with complete occlusion of the culprit vessel. These findings provide further evidence supporting the potential inclusion of STEMI-equivalents in future ACS guidelines.

D. Is this an ECG pattern on this Phil Church Sweater?

7. Selected Essays

From the N Engl J Med: Compassionate Care and Board Recert

A. A View from the Edge — Creating a Culture of Caring

Rana L.A. Awdish, M.D. N Engl J Med 2017; 376:7-9

In 2008, an occult adenoma in my liver ruptured, and I effectively bled to death in my own hospital. I lost my entire blood volume into my abdomen, triggering what’s known in trauma as the Triad of Death — a kind of suicidal spiral of the blood in which it becomes too acidic and too cold to clot. I would receive more than 26 units of blood products that night — packed red cells, platelets, cryoprecipitate, fresh frozen plasma. I would go into multisystem organ failure, my liver and kidneys would shut down, I would be put on a ventilator, have a stroke and a complete hemodynamic collapse. The baby I was 7 months pregnant with would not survive, but I would — thanks to the incredible skill and grace of the teams of professionals who cared for me.

My recovery involved five major operations including a right hepatectomy. I had to relearn to walk, speak, and do many other things I had taken for granted. But in the process, as a patient, I learned things about us — physicians and other medical professionals — that I might not have wanted to know. I learned that though we do so many difficult, technical things so perfectly right, we fail our patients in many ways.

As a patient, I was privy to failures that I’d been blind to as a clinician. There were disturbing deficits in communication, uncoordinated care, and occasionally an apparently complete absence of empathy. I recognized myself in every failure.

When I overheard a physician describe me as “trying to die on us,” I was horrified. I was not trying to die on anyone. The description angered me. Then I cringed. I had said the same thing, often and thoughtlessly, in my training. “He was trying to die on me.” As critical care fellows, we had all said it. Inherent in that accusation was our common attribution of intention to patients: we subconsciously constructed a narrative in which the doctor–patient relationship was antagonistic. It was one of many revelatory moments for me.

I heard my colleagues say things to me in ways that inflicted more suffering, even when they believed they were helping.

“We’re going to have to find you a new liver, unless you want to live here forever.”

“Are you sure your pain is an eight? I just gave you morphine an hour ago.”

“You should hold the baby,” someone said. “I don’t want to be graphic, but after a few days in the morgue, their skin starts to break down and you won’t be able to anymore, even if you change your mind.”

Small things would gut me. Receiving a bill for the attempted resuscitation of the baby, for example…

The remainder of the essay, including the hospital’s constructive response to their failures, can be found here:

B. Knowing What We Don’t Know — Improving Maintenance of Certification

Richard J. Baron, M.D., and Clarence H. Braddock, III, M.D., M.P.H. N Engl J Med 2016; 375:2516-2517.

In order to provide the best possible care for their patients, most physicians devote considerable effort to staying current on developments in their field. But keeping up with the rapid evolution of knowledge and changes in patient expectations and standards of care can be challenging. Electronic resources available at the point of care can help physicians access the latest information, but, given time pressures, such tools aren’t always used. Yet current clinical knowledge remains the foundation of high-quality care.

How do physicians know if they have succeeded in keeping up with changing foundational knowledge? Strong evidence suggests that none of us are good at knowing what we don’t know.1 Performance scores on quality measures provide some feedback on practice, but these measures aren’t always relevant, particularly for specialists, and they tend to reflect overall team performance rather than the abilities of individual physicians. Comprehensive independent assessments provide critical guidance for — and evidence of — staying current. Maintenance of certification (MOC) plays a key role in supporting this important professional responsibility.

Board certification differs from medical licensure in important ways. Administered by state governments, licensure is quite broad: states allow licensed physicians to practice without restrictions, whether they are administering chemotherapy, replacing heart valves, or delivering babies. It is the profession that has created and applied higher standards for physicians who claim to have specialized knowledge. States don’t regulate claims of special expertise, so we rely on board certification to verify that a physician has received specialized training and achieved and maintained knowledge and skills in a particular field. The medical profession has broadly embraced this credential: 79.1% of all licensed physicians in the United States are board certified by an American Board of Medical Specialties (ABMS) organization.2

Despite critics’ claims to the contrary, we believe the evidence is convincing, albeit incomplete, that certain outcomes are better for patients treated by board-certified physicians. Published data show, for example, that the risk of both death and emergency coronary artery bypass grafting is lower when patients undergoing percutaneous coronary interventions are treated by board-certified interventional cardiologists, and the cost of care for Medicare beneficiaries is 2.5% lower among physicians who were obliged to complete MOC than among those who were not.3 Because the vast majority of physicians are board-certified, certification can easily be taken for granted. But in an Internet-based world where anyone can become, for example, an ordained minister online, reliable credentials based on solid standards have become even more valuable.

Founded in 1970, the American Board of Family Medicine became the first board to exclusively issue time-limited certification. By then, it was widely recognized that a certificate issued at the completion of training meant less as physicians progressed in their careers. Other boards eventually moved to time-limited certification. The American Board of Internal Medicine (ABIM) stopped issuing lifetime certificates in 1990. Boards that never issued lifetime certificates have had a smoother path to time-limited continuous certification since they never had lifetime certificate holders.

Over the years, there has been ongoing and spirited debate about how boards could best make the transition to time-limited certification. In 1979, the American Medical Association debated the possibility of imposing a moratorium on recertification in favor of relying on continuing medical education (CME). Arnold Relman, the editor-in-chief of the Journal at the time, wrote in an editorial, “Those who believe that mandatory CME is a better way to assure the maintenance of clinical skills need to recognize why it hasn’t been used as the criterion for initial specialty certification. The reason is, of course, that CME alone, without some kind of test, cannot possibly assure competence.” After citing the many challenges associated with creating a meaningful and valuable recertification program, he added, “The development of an acceptable method of recertification ought to be an achievable goal for any specialty board that commits itself to this task. . . . but for a profession that takes such pride in its self-imposed discipline, total abandonment of the recertification idea would be a mistake.”4

The world has unquestionably changed since 1979, and so must our thinking about certification. We at the ABIM have revised our organizational structure and are reimagining our relationship with practicing physicians to align with these changes.5 We are discussing with 32 different specialty societies the best way to design an MOC program that is relevant and meaningful for a very diverse community of physicians. And we are taking advantage of new tools — for example, by “crowd-sourcing” decisions on what knowledge certified physicians should possess. By asking colleagues in each discipline what knowledge is most important and what knowledge they use most frequently and combining their responses with national data on disease prevalence, we’re able to refine assessments to focus on the areas that are most relevant to practice.

Recognizing that doctors are utilizing a variety of resources to stay current, the ABIM has partnered with the Accreditation Council for Continuing Medical Education to create standards so that many more CME offerings can also confer MOC credit and to streamline the process through which physicians can claim that credit. As of mid-November, more than 4651 activities had been registered through this collaboration, with 45,200 individual physicians earning a total of 2.02 million MOC points.

In consultation with practicing physicians, we have developed a new format for reporting scores on certification exams that provides more detailed feedback, increasing the value of assessment to guide further learning. We are also conducting a study of the effect of making electronic resources available during our assessments.

Perhaps the most dramatic change the ABIM is planning is the creation of a new maintenance pathway through which most certified physicians will be able to demonstrate continuing maintenance of knowledge without having to take the long-form exam every 10 years…

From Best-selling Author Atul Gawande, MD


We devote vast resources to intensive, one-off procedures, while starving the kind of steady, intimate care that often helps people more.

We have a certain heroic expectation of how medicine works. Following the Second World War, penicillin and then a raft of other antibiotics cured the scourge of bacterial diseases that it had been thought only God could touch. New vaccines routed polio, diphtheria, rubella, and measles. Surgeons opened the heart, transplanted organs, and removed once inoperable tumors. Heart attacks could be stopped; cancers could be cured. A single generation experienced a transformation in the treatment of human illness as no generation had before. It was like discovering that water could put out fire. We built our health-care system, accordingly, to deploy firefighters. Doctors became saviors.

But the model wasn’t quite right. If an illness is a fire, many of them require months or years to extinguish, or can be reduced only to a low-level smolder. The treatments may have side effects and complications that require yet more attention. Chronic illness has become commonplace, and we have been poorly prepared to deal with it. Much of what ails us requires a more patient kind of skill.

I was drawn to medicine by the aura of heroism—by the chance to charge in and solve a dangerous problem. I loved learning how to unravel diagnostic mysteries on the general-medicine ward, and how to deliver babies in the obstetrics unit, and how to stop heart attacks in the cardiology unit. I worked in a DNA virus lab for a time and considered going into infectious diseases. But it was the operating room that really drew me in…

Fields like primary-care medicine seemed, by comparison, squishy and uncertain. How often could you really achieve victories by inveigling patients to take their medicines when less than half really do; to lose weight when only a small fraction can keep it off; to quit smoking; to deal with their alcohol problem; to show up for their annual physical, which doesn’t seem to make that much difference anyway? I wanted to know I was doing work that would matter. I decided to go into surgery…

…I finally had to submit. Primary care, it seemed, does a lot of good for people—maybe even more good, in the long run, than I will as a surgeon. But I still wondered how. What, exactly, is the primary-care physician’s skill?...

Brief interview on PBS Newshour: Reassessing the value of care for chronic health conditions

January 18. Surgeon Atul Gawande says we need to reconsider health care’s focus on generously rewarding physicians who practice heroic interventions, rather than those who practice incremental medicine for chronic conditions. Gawande talks with William Brangham about the value of that kind of care, and the potential effects of a Republican repeal of the Affordable Care Act.

8. Diazepam and Meclizine Are Equally Effective in the Treatment of Vertigo: An ED Randomized Double-Blind Placebo-Controlled Trial.

Shih RD, et al. J Emerg Med. 2017 Jan;52(1):23-27.

BACKGROUND: Vertigo is a debilitating disease that is commonly encountered in the emergency department (ED). Diazepam and meclizine are oral medications that are commonly used to alleviate symptoms.

OBJECTIVES: We sought to determine whether meclizine or diazepam is superior in the treatment of patients with peripheral vertigo in the ED.

METHODS: We performed a double-blind clinical trial at a suburban, teaching ED. We randomized a convenience sample of adult patients with acute peripheral vertigo (APV) to diazepam 5 mg or meclizine 25 mg orally. Demographic and historical features were recorded on a standardized data form. Patients recorded their initial level (t0) of vertigo on a 100-mm visual analog scale (VAS) and after 30 min (t30) and 60 min (t60). The primary outcome parameter was the mean change in VAS score from t0 to t60. Differences between groups and 95% confidence intervals were calculated. Our a priori power calculation estimated that a sample size of 20 patients in each group was required to have an 80% power to detect a difference of 20 mm between treatment groups.

RESULTS: There were 20 patients in the diazepam group and 20 in the meclizine group. The two groups were similar with respect to patient demographics and presenting signs and symptoms. At t60, the mean improvements in the diazepam and meclizine groups were 36 and 40, respectively (difference -4; 95% confidence interval -20 to 12; p = 0.60).

CONCLUSION: We found no difference between oral diazepam and oral meclizine for the treatment of ED patients with acute peripheral vertigo.

9. Continued Use of Warfarin in Veterans with AF After Dementia Diagnosis is Beneficial

Orkaby AR, et al. J Am Geriatr Soc. 2016 Dec 30 [Epub ahead of print]

OBJECTIVES: To determine the effectiveness of warfarin in older adults with dementia.

DESIGN: Retrospective cohort study.

SETTING: Department of Veterans Affairs national healthcare system.

PARTICIPANTS: Veterans aged 65 and older (73% aged ≥75, 99% male, 91% white) who had been receiving warfarin for nonvalvular atrial fibrillation for at least 6 months, were newly diagnosed with dementia in fiscal year 2007 or 2008, and were not enrolled in Medicare Advantage (n = 2,572).

MEASUREMENTS: The onset of dementia was defined according to International Classification of Diseases, Ninth Revision, code. Participants were followed for up to 4 years for persistence of warfarin therapy, anticoagulation control, major hemorrhage, ischemic stroke, and all-cause mortality.

RESULTS: The average CHADS2 score was 3.3 ± 1.3. After a diagnosis of dementia, 405 individuals (16%) persisted on warfarin therapy. Unadjusted Cox proportional hazards analysis demonstrated a protective effect of warfarin in prevention of ischemic stroke (hazard ratio (HR) = 0.64, 95% confidence interval (CI) = 0.46-0.89, P = .008), major bleeding (HR = 0.72, 95% CI = 0.55-0.94, P = .02), and all-cause mortality (HR = 0.66, 95% CI = 0.55-0.79, P less than .001). Using propensity score matching, the protective effect of continuing warfarin persisted in prevention of stroke (HR = 0.74, 95% CI = 0.54-0.996, P = .047) and mortality (HR = 0.72, 95% CI = 0.60-0.87, P less than .001), with no statistically significant decrease in risk of major bleeding (HR = 0.78, 95% CI = 0.61-1.01, P = .06).

CONCLUSION: Discontinuing warfarin after a diagnosis of dementia is associated with a significant increase in stroke and mortality.

10. Images in Clinical Practice

ECG Diagnosis: Deep T Wave Inversions Associated with Intracranial Hemorrhage

Acute Rheumatic Fever with Erythema Marginatum

Adult Female With Abdominal Pain

Young Child With Breathlessness

Postpartum Woman With Seizures

EM:RAP and Hippo Commentary

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

Circinate Balanitis

Fibromuscular Dysplasia of the Brachial Artery

Gastric Cancer in Chest Radiograph

Acromioclavicular Joint Separation

Infected Urachal Cyst

Disseminated Cysticercosis

Acute Rheumatic Fever with Erythema Marginatum

11. Antibiotic Recommendation Varies by Age for Pediatric Otitis Media

A. Aged 6 mos to 2 years: treat for 10 days

Longer antibiotic treatment better for young children with ear infections

Researchers examined 520 children ages 6 months to 23 months with acute middle ear infections and found that 16% of those who received the antibiotic amoxicillin-clavulanate for 10 days had treatment failure, compared with 34% of those who received the five-day regimen. The findings in The New England Journal of Medicine also showed worse symptoms among those who received the shorter regimen and similar rates of diarrhea and diaper rash between both groups.

B. 2-12 years old: expectant observation is recommended (including delayed antibiotic prescribing)

Choosing Wisely® Antibiotics for Otitis Media

Don't prescribe antibiotics for otitis media in children aged 2-12 years with non-severe symptoms where the observation option is reasonable.

The “observation option” refers to deferring antibacterial treatment of selected children for 48 to 72 hours and limiting management to symptomatic relief.

The decision to observe or treat is based on the child’s age, diagnostic certainty, and illness severity. To observe a child without initial antibacterial therapy, it is important that the parent or caregiver has a ready means of communicating with the clinician. There also must be a system in place that permits reevaluation of the child.

UpToDate’s advice
We suggest that children ≥2 years who appear toxic; have persistent otalgia for more than 48 hours; have temperature ≥102.2°F (39°C) in the past 48 hours; have bilateral AOM or otorrhea; or have uncertain access to follow-up be immediately treated with an appropriate antibiotic.

For children ≥2 years who are normal hosts (eg, immune competent, without craniofacial abnormalities) with mild symptoms and signs and no otorrhea, initial observation may be appropriate if the caretakers understand the risks and benefits of such an approach.

12. Discussing Opioid Risks May Reduce Likelihood of Misuse, Abuse
Dec. 9, 2016 — Research recently published in Annals of Family Medicine found that when physicians counseled patients about long-term risks of prescription opioid abuse, they were 60 percent less likely to save pills for later use.

13. On Trauma

A. Performance of a simplified termination of resuscitation rule for adult traumatic cardiopulmonary arrest in the prehospital setting.

Chiang WC, et al. Emerg Med J. 2017 Jan;34(1):39-45. doi: 10.1136/emermed-2014-204493. Epub 2016 Sep 21.

OBJECTIVE: The prehospital termination of resuscitation (TOR) guidelines for traumatic cardiopulmonary arrest (TCPA) was proposed in 2003. Its multiple descriptors of cases where efforts can be terminated make it complex to apply in the field. Here we proposed a simplified rule and evaluated its predictive performance.

METHODS: We analysed Utstein registry data for 2009-2013 from a Taipei emergency medical service to test a simplified TOR rule that comprises two criteria: blunt trauma injury and the presence of asystole. Enrollees were adults (≥18 years) with TCPA. The predicted outcome was in-hospital death. We compared the areas under the curve (AUC) of the simple rule with each of four descriptors in the guidelines and with a combination of all four to assess their discriminatory ability. Test characteristics were calculated to assess predictive performance.

RESULTS: A total of 893 TCPA cases were included. Blunt trauma occurred in 459 (51.4%) cases and asystole in 384 (43.0%). In-hospital mortality was 854 (95.6%) cases. The simplified TOR rule had greater discriminatory ability (AUC 0.683, 95% CI 0.618 to 0.747) compared with any single descriptor in the 2003 guidelines (range of AUC: 0.506-0.616) although the AUC was similar when all four were combined (AUC 0.695, 95% CI 0.615 to 0.775). The specificity of the simplified rule was 100% (95% CI 88.8% to 100%) and positive predictive value 100% (95% CI 96.8% to 100%). The false positive value, false negative value and decreased rate of unnecessary transport were 0% (95% CI 0% to 3.2%), 94.8% (95% CI 92.9% to 96.2%) and 16.4% (95% CI 14.1% to 19.1%), respectively.

CONCLUSIONS: The simplified TOR rule appears to accurately predict non-survivors in adults with TCPA in the prehospital setting.

B. The Effect of Combined Out-of-Hospital Hypotension and Hypoxia on Mortality in Major Traumatic Brain Injury

It’s Bad. Very Bad.

C. Orbital blowout fractures: a novel CT measurement that can predict the likelihood of surgical management.

Mansour TN, et al. Am J Emerg Med. 2017;35:112-6.

OBJECTIVE: The purpose of this study is to identify an accurate and reliable computed tomographic (CT) measurement that can identify those patients presenting to the emergency department (ED) with orbital floor fracture (BOF) who require surgical repair to prevent ensuing visually debilitating diplopia and/or enophthalmos.

METHODS: In this retrospective institutional review board-approved study, we reviewed 99 patients older than 18 years with orbital fractures treated in a level I trauma center from 2011 through 2015. Thirty-three patients met the inclusion criteria of having an isolated BOFs with or without a minimally displaced medial wall fracture. The maxillofacial CT of these patients, which included axial, coronal, and sagittal reconstruction of the face in both soft tissue and bone algorithm, were independently reviewed by a neuroradiologist and an oculoplastic surgeon. Each reviewer analyzed the images to answer the following 3 questions: (1) extent of the fracture fragment; greater than or less than 50%? (2) involvement of the inframedial strut (IMS)? and (3) cranial-caudal discrepancy of the orbits. This novel measurement was defined as the difference between the cranial-caudal dimension (CCD), measured just posterior to the globe, of the fractured orbit minus the CCD of the normal side. Electronic medical record was reviewed to determine the course of recovery, ophthalmologist assessment of the globe, motility, diplopia, and the need for operative repair. Statistical analysis was performed to determine the accuracy of the measured CT parameters for the prediction of those who would ultimately require surgical repair.

RESULTS: Of the 33 patients included in the study, 8 patients required surgical correction of their BOFs. Others were managed conservatively. The accuracy of BOF over 50% for predicting those requiring surgical repair was 48%. The accuracy of IMS involvement was 74%. Using a threshold CCD value of 0.8 cm, the accuracy of CCD was 94%. Cranial-caudal discrepancy had a sensitivity of 100% and specificity of 92%. κ Agreement between the 2 readers evaluating the CT images was 0.93.

CONCLUSION: Initial maxillofacial CT studies obtained in the ED for those with BOF is used to predict which patients may need urgent surgical repair. In this report, we introduce a new CT measurement, called CCD. Cranial-caudal discrepancy greater than 0.8 cm is predictive of the development of diplopia and/or enophthalmos that will require surgical correction. Orbital floor fracture greater than 50% and IMS involvement were much less accurate in making similar predictions. Cranial-caudal discrepancy should be used by the ED physicians to identify those patients who should be referred sooner than later to an oculoplastic surgeon for surgical evaluation and intervention. Correct and timely triaging can prevent the complications of delayed correction including scarring, difficult surgical repair, and/or poor functional and aesthetic outcomes.

D. Comparison of Etomidate and Ketamine for Induction During Rapid Sequence Intubation of Adult Trauma Patients

They were very similar.

14. Short-term Effects of High-Dose Caffeine on Cardiac Arrhythmias in Patients With Heart Failure: A Randomized Clinical Trial

Zuchinali P, te al. JAMA Intern Med. 2016 Dec 1;176(12):1752-1759.

Question  Is there a proarrhythmic action of caffeine in patients with heart failure?

Findings  In this randomized clinical trial, we evaluated the short-term effects of high-dose caffeine in patients with heart failure at increased risk for arrhythmic events. After 500 mg of caffeine administered over a 5-hour period, we found no statistically significant effect of caffeine ingestion on the frequency of ventricular or supraventricular ectopies, even during the physical stress of a treadmill test.

Meaning  These results challenge the intuitive perception that caffeine intake should be limited in patients with heart disease and at risk for arrhythmia.

15. Female vs Male Physicians: Better Outcomes?

Diana Phillips, Medscape Medical News. December 19, 2016

Elderly hospitalized patients who receive care from a female physician have lower mortality and readmission rates than those who are cared for by male physicians within the same hospital, a study has shown.

The findings appear to validate to the results of earlier studies suggesting that patient-centered communications and other practice behaviors frequently associated with female providers may have important clinical implications, the researchers write.

Uysuke Tsugawa, MD, MPH, from Harvard T. H. Chan School of Public Health, Boston, Massachusetts, and colleagues published their study online December 19 in JAMA Internal Medicine.

The results also appear to refute the argument that quality of care provided by female physicians seeking to balance work and family responsibilities may be compromised, which has been used to explain differences in the pay and professional advancement of female physicians relative to their male colleagues.

The researchers analyzed a national sample of Medicare beneficiaries who were hospitalized for medical conditions in acute care facilities from January 1, 2011, through December 31, 2014. They looked specifically at 30-day mortality and readmission rates across more than 1.5 million patient hospitalizations for each outcome to determine whether or not and to what degree physician sex influences clinical outcomes of hospitalized patients.

Of 58,344 general internists who treated at least one Medicare beneficiary hospitalized with a medical condition, 18,751 (32.1%) were women. Compared with the male physicians included in the analysis, female physicians were younger (mean, 42.8 vs 47.8 years), were also more likely to have undergone osteopathic training (8.4% vs 7.0%), and treated fewer patients annually (131.9 vs 180.5 hospitalized patients).

The characteristics of patients who were treated by female physicians were similar to those treated by male physicians with respect to mean age (80.8 and 80.6 years, respectively), race, household income, Medicaid coverage, and coexisting conditions. The only slight between-group difference was a slightly higher proportion of female patients receiving care from a female physician (62.1% vs 60.2%).

For the analysis of 30-day mortality rates, overall mortality of the full sample (1,583,028 hospitalizations treated by 57,896 physicians) was 179,162. After adjusting for fixed hospital and physician characteristics, the rate for patients cared for by a female physician was 11.07% compared with 11.49% for those treated by male physicians (adjusted risk difference, −0.43%; 95% confidence interval, −0.57% to −0.28%; P less than .001; number needed to treat, 233).

For the 30-day readmission analysis, which included 1,540,797 hospitalizations treated by 57,876 physicians, the overall readmission rate was 15.42% (237,644 readmissions). The adjusted readmission rate for patients of female physicians was 15.02% compared with 15.57% for patients of male physicians (adjusted risk difference, −0.55%; 95% confidence interval, −0.71% to −0.39%; P less than .001; number needed to treat, 182), the authors report.

"Patients of female physicians had lower mortality and readmission rates across all medical conditions we examined," the authors write, noting that the magnitude and statistical significance of the differences varied by condition…

The remainder of the essay:

15. The Impact of ED Census on the Decision to Admit.

Gorski JK, et al. Acad Emerg Med. 2017 Jan;24(1):13-21.

OBJECTIVE: We evaluated the effect of emergency department (ED) census on disposition decisions made by ED physicians.

METHODS: We performed a retrospective analysis using 18 months of all adult patient encounters seen in the main ED at an academic tertiary care center. Patient census information was calculated at the time of physician assignment for each individual patient and included the number of patients in the waiting room (waiting room census) and number of patients being managed by the patient's attending (physician load census). A multiple logistic regression model was created to assess the association between these census variables and the disposition decision, controlling for potential confounders including Emergency Severity Index acuity, patient demographics, arrival hour, arrival mode, and chief complaint.

RESULTS: A total of 49,487 patient visits were included in this analysis, of whom 37% were admitted to the hospital. Both census measures were significantly associated with increased chance of admission; the odds ratio (OR) per patient increase for waiting room census was 1.011 (95% confidence interval [CI] = 1.001 to 1.020), and the OR for physician load census was 1.010 (95% CI = 1.002 to 1.019). To put this in practical terms, this translated to a modeled rise from 35.3% to 40.1% when shifting from an empty waiting room and zero patient load to a 12-patient wait and 16-patient load for a given physician.

CONCLUSION: Waiting room census and physician load census at time of physician assignment were positively associated with the likelihood that a patient would be admitted, controlling for potential confounders. Our data suggest that disposition decisions in the ED are influenced not only by objective measures of a patient's disease state, but also by workflow-related concerns.

16. More on Kids

A. Sweet Solutions Are Effective for Procedural Pain Control in Neonates

Daniel M. Lindberg, MD, Journal Watch, December 16, 2016.

Reviewing Harrison D et al. Pediatrics 2017 Jan.   

The evidence has been compelling for a long time, and placebo-controlled trials are no longer ethical.

Sweet solutions, such as those containing sucrose or glucose, have been shown to induce endogenous opioid analgesic mechanisms and improve pain for neonates during painful procedures. These authors conducted a cumulative meta-analysis to estimate the mean effect size and to demonstrate the strength of evidence in favor of sweet solutions. Cumulative meta-analyses chronologically add data based on study publication date to determine the point at which combined results first became statistically significant.

Using a robust search strategy, the authors identified 168 randomized, controlled trials of oral sweet solutions for procedural pain control in neonates, with outcomes of crying time or validated pain scores.

Meta-analysis of 29 trials involving 1775 neonates showed that sweet solutions reduce crying time by a mean of 23 seconds (95% confidence interval, 17–29 seconds). Meta-analysis of 50 trials involving 3341 infants showed a mean improvement in pain scores of 0.90 points (95% CI, 0.70–1.09 points). The cumulative results became statistically significant in 1999 for pain scores and in 2002 for crying time, yet dozens of studies have been performed since then.

Certainly, one statistically significant result should not foreclose future research. But at some point, it is unethical to ignore evidence that is clear and convincing. Sweet solutions improve crying time and pain scores for neonates, have virtually no untoward effects, and should be used for painful procedures. Future trials should not include a placebo arm.

B. The PECARN TBI rules do not apply to abusive head trauma

Magana JN, et al. Acad Emerg Med. 2016 Dec 31 [Epub ahead of print]

The Pediatric Emergency Care Applied Research Network (PECARN) traumatic brain injury (TBI) prediction rules were developed to identify children at very low risk for clinically-important TBIs (ciTBIs), for whom computed tomography (CT) scans can typically be obviated.1 The PECARN prediction rules have been validated in several settings and countries.2-5 The PECARN TBI rules, one developed for children younger than 2 years, and the other for those 2 years and older, rely on accurate patient history and physical examination findings gathered at the time of emergency department (ED) presentation.

17. On Out-of-Hospital Cardiac Arrest

A. Duration of Coma in Survivors of Out-of-Hospital Cardiac Arrest Treated With Targeted Temperature Management

Irisawa T. Ann Emerg Med 2017;69:36-43.

Study objective
We evaluate the time to awakening after out-of-hospital cardiac arrest in patients treated with targeted temperature management and determine whether there was an association with any patient or event characteristics.

This was a prospective, observational cohort study of consecutive adult survivors of out-of-hospital cardiac arrest of presumed cardiac cause who were treated with targeted temperature management between January 1, 2008, and March 31, 2014. Data were obtained from hospitals and emergency medical services agencies responding to approximately 90% of Arizona’s population as part of a state-sponsored out-of-hospital cardiac arrest quality improvement initiative.

Among 573 out-of-hospital cardiac arrest patients who completed targeted temperature management, 316 became responsive, 60 (19.0%) of whom woke up at least 48 hours after rewarming. Eight patients (2.5%) became responsive more than 7 days after rewarming, 6 of whom were discharged with a good Cerebral Performance Category score (1 or 2). There were no differences in standard Utstein variables between the early and late awakeners. The early awakeners were more likely to be discharged with a good Cerebral Performance Category score (odds ratio 2.93; 95% confidence interval 1.09 to 7.93).

We found that a substantial proportion of adult out-of-hospital cardiac arrest survivors treated with targeted temperature management became responsive greater than 48 hours after rewarming, with a resultant good neurologic outcome.

B. Use of early head CT following out-of-hospital cardiopulmonary arrest?

Reynolds AS, et al. Resuscitation. 2017 Jan 3 [Epub ahead of print]

AIM: Neurological emergencies can lead to cardiac arrest, and post-arrest patients can develop life-threatening neurological abnormalities. This study aims to estimate and characterize the use of early head CT (HCT), and its potential impact on post-resuscitation management.

METHODS: This retrospective study analyzed 213 adults who suffered an out-of-hospital cardiac arrest (OHCA) and survived for at least 24h. Demographics were collected and arrest-related variables were documented. Timing of HCT was recorded and if abnormalities were found on HCT within 24h of resuscitation, any resulting changes in management were recorded. Outcome was measured by cerebral performance category at discharge.

RESULTS: Only 54% of patients who survived OHCA underwent HCT in the first 24h after resuscitation. Patients who underwent HCT were healthier and had better pre-arrest functional status and shorter duration of arrest. Acute abnormalities were found on 38% of HCT and 34% of these abnormal scans resulted in management changes.

CONCLUSIONS: Early HCT is not consistently performed after OHCA and may be heavily influenced by a patient's premorbid status and duration of arrest. Early HCT can demonstrate acute abnormalities that can result in significant changes in patient management.

18. Acute Headache Presentations to the ED: A Statewide Cross-sectional Study.

Chu KH, et al. Acad Emerg Med. 2017 Jan;24(1):53-62.

OBJECTIVES: The objective of this study was to describe demographic and clinical characteristics including features that were consistent with subarachnoid hemorrhage (SAH), use of diagnostic tests, emergency department (ED) discharge diagnoses, and disposition of adult patients presenting with an acute headache to EDs statewide across Queensland, Australia. In addition, potential variations in the presentation and diagnostic workup between principal-referral and city-regional hospitals were examined.

METHODS: A prospective cross-sectional study was conducted over 4 weeks in September 2014. All patients ≥ 18 years presenting to one of 29 public and five private hospital EDs across the state with an acute headache were included. The headache had to be the principal presenting complaint and nontraumatic. The 34 study sites attend to about 90% of all ED presentations statewide. The treating doctor collected clinical information at the time of the ED visit including the characteristics of the headache and investigations performed. A study coordinator retrieved results of investigations, ED discharge diagnoses, and disposition from state databases. Variations in presentation, investigations, and diagnosis between city-regional and principal-referral hospitals were examined.

RESULTS: There were 847 headache presentations. Median (range) age was 39 (18-92) years, 62% were female, and 31% arrived by ambulance. Headache peaked instantly in 18% and ≤ 1 hour in 44%. It was "worst ever" in 37%, 10/10 in severity in 23%, and associated with physical activity in 7.4%. Glasgow Coma Scale score was less than 15 in 4.1%. Neck stiffness was noted on examination in 4.8%. Neurologic deficit persisting in the ED was found in 6.5%. A computed tomography (CT) head scan was performed in 38% (318/841, 95% CI = 35% to 41%) and an lumbar puncture in 4.7% (39/832, 95% CI = 3.4% to 6.3%). There were 18 SAH, six intraparenchymal hemorrhages, one subdural hematoma, one newly diagnosed brain metastasis, and two bacterial meningitis. Migraine was diagnosed in 23% and "primary headache not further specified" in 45%. CT head scans were more likely to be performed in principal-referral hospitals (41%) compared to city-regional hospitals (33%). The headache in patients presenting to the latter was less likely to be instantly peaking or associated with activity, but was no less severe in intensity and was more frequently accompanied by nausea and vomiting. Their diagnosis was more likely to be a benign primary headache. Variations in CT scanning could thus be due to differences in the case mix. The median (interquartile range) ED length of stay was 3.1 (2.2 to 4.5) hours. Patients was discharged from the ED or admitted to the ED short-stay unit prior to discharge in 57 and 23% of cases, respectively.

CONCLUSIONS: The majority of patients had a benign diagnosis, with intracranial hemorrhage and bacterial meningitis accounting for only 3% of the diagnoses. There are variations in the proportion of patients receiving CT head scans between city-regional and principal-referral hospitals. As 38% of headache presentations overall underwent CT scanning, there is scope to rationalize diagnostic testing to rule out life-threatening conditions.

19. Are Antibiotics Necessary for Dental Pain Without Overt Infection?

Gottlieb M, et al. Ann Emerg Med 2017;69:128-130.

Atraumatic acute dental conditions account for 1.4% of all emergency department (ED) visits, with a 4% annual rate of increase between 1997 and 2007.1 Dental pain without overt infection is common, with irreversible pulpitis being a significant subset of this population. Pulpitis commonly presents with focal dental pain and percussion tenderness. It is an inflammatory reaction of the pulp, often occurring in the absence of bacteria in the pulp chamber.2-4 The recommended treatment for irreversible pulpitis is immediate pulpectomy.

The Bottom Line
According to the available evidence, empiric antibiotics do not appear to reduce the rates of infection or pain among patients presenting with dental pain without overt infection. The available evidence about the effect on pain was limited to 2 studies evaluating pain reduction in patients receiving antibiotics compared with placebo.8 10  Neither study demonstrated a clinically or statistically significant difference in pain with the use of antibiotics. Additionally, there was no significant reduction in the rate of infection in patients receiving antibiotics compared with placebo in the single study assessing this outcome.8 This review has several strengths, which include the evaluation of both clinical (ie, infection) and patient-centered outcomes (ie, pain), use of a common and standard initial treatment (ie, penicillin by mouth 4 times daily for 7 days), reasonable pain regimens, and concordance of results between both studies.

It is also important to consider several limitations with respect to the above studies. First, only 1 study assessed a difference in the rate of infections, and, although no significant difference was observed, there was a 31% rate of loss to follow-up, which may have led to a significant difference in outcomes if there was a disproportionate rate of infection in the placebo group. Additionally, among those who followed up, there were slightly more patients in the treatment group (n=64) than in the placebo group (n=70), which suggests a potential therapeutic effect. Only 2 studies were identified, comprising a total of 174 patients. The study by Nagle et al10  did not calculate a sample size, whereas Runyon et al8  based their calculation on a 15% difference in infection rates. Therefore, it is likely that both studies were underpowered to detect a smaller yet still clinically significant difference. The study by Nagle et al10  was further limited in that it involved patients presenting to an emergency dental clinic and may have represented a different population than patients presenting to the ED. Moreover, the investigators assessed only penicillin. Given increasing rates of drug resistance, it is unclear whether these results would apply to alternate antibiotics. Finally, our review assessed only pain and infection rates. Other considerations, such as adverse drug events, antibiotic resistance, and health care costs, should also affect the decision of whether to administer antibiotics to the above patient group.

According to the literature, there is insufficient evidence to support the use or disuse of empiric antibiotics to prevent pain or reduce infection rates. Further data are required to make definitive recommendations. However, the use of empiric antibiotics is not without risks, which should be considered in light of the current evidence. Additionally, it is important to provide pain control and close follow-up with a dentist for a pulpectomy.

20. What Level of Activity to Recommend after Concussion?

A. Evidence Against Restricting Physical Activity After Concussion

John D. Cowden, MD, MPH. Journal Watch, December 20, 2016

Engaging in physical activity within 7 days after concussion was associated with a lower rate of persistent postconcussive symptoms.

Reviewing Grool AM et al. JAMA 2016 Dec 20.    

Although physical and cognitive rest are universally recommended elements of concussion treatment (NEJM 2014 and Ontario Neurotrauma Foundation 2014), prolonged inactivity after concussion has been linked to negative health effects. Light aerobic activity that avoids risk for reinjury has been shown to treat refractory concussion symptoms in preliminary studies, suggesting that low-level physical activity after concussion might be beneficial, rather than harmful.

Researchers assessed the association between physical activity and postconcussive symptoms in a prospective cohort study of 2413 children aged 5–18 years presenting with acute concussion to nine Canadian emergency departments (EDs). Children and their parents were surveyed in the ED and at 7 and 28 days. Early physical activity was defined as any activity within 7 days after enrollment. The primary outcome was presence of persistent postconcussive symptoms (at least three new or worsening symptoms) at 28 days. Propensity matching was used to account for more than 20 covariates.

Overall, 69.5% of patients reported early physical activity and 30.4% had persistent symptoms. Early physical activity was associated with significantly lower rates of persistent symptoms than no physical activity in both unadjusted analyses (24.6% vs. 43.5%) and propensity score–adjusted analyses (28.7% vs. 40.1%). Among 1387 patients symptomatic on day 7, rates of persistent symptoms at 28 days were lower in those who engaged in early physical activity at any level — light aerobic, moderate, and full — compared with no activity.


Evolution of concussion management continues as there is more compelling evidence that we may be wrong to recommend that all children with concussions observe strict physical rest until symptom-free. Results from this and other recent studies justify a randomized, controlled trial to help define which children need rest and which can be active. Such trials might lead to more individualized concussion management than is available in current guidelines.

B. Cognitive Rest and Graduated Return to Usual Activities Vs Usual Care for Mild TBI: A RCT of ED Discharge Instructions.

Varner CE, et al. Acad Emerg Med. 2017 Jan;24(1):75-82.

OBJECTIVES: It is estimated that 15%-25% of patients with a mild traumatic brain injury (MTBI) diagnosed in the emergency department (ED) will develop postconcussive syndrome. The objective of this study was to determine if patients randomized to graduated return to usual activity discharge instructions had a decrease in their Post-Concussion Symptom Score (PCSS) 2 weeks after MTBI compared to patients who received usual care MTBI discharge instructions.

METHODS: This was a pragmatic, randomized trial of adult (18-64 years) patients of an academic ED (annual census 60,000) diagnosed with MTBI occurring within 24 hours of ED visit. The intervention group received cognitive rest and graduated return to usual activity discharge instructions, and the control group received usual care discharge instructions that did not instruct cognitive rest or graduated return. Patients were contacted by text message or phone 2 and 4 weeks post-ED discharge and asked to complete the PCSS, a validated, 22-item questionnaire, to determine if there was a change in their symptoms. Secondary outcomes included change in PCSS at 4 weeks, number follow-up physician visits, and time off work/school.

RESULTS: A total of 118 patients were enrolled in the study (58 in the control group and 60 in the intervention). The mean (±SD) age was 35.2 (±13.7) years and 43 (36.4%) were male. There was no difference with respect to change in PCSS at 2 weeks (10.5 vs. 12.8; ∆2.3, 95% confidence interval [CI] = 7.0 to 11.7) and 4 weeks post-ED discharge (21.1 vs 18.3; ∆2.8, 95% CI = 6.9 to 12.7) for the intervention and control groups, respectively. The number of follow-up physician visits and time off work/school were similar when the groups were compared. Thirty-eight (42.2%) and 23 (30.3%) of patients in this cohort had ongoing MTBI symptoms (PCSS over 20) at 2 and 4 weeks, respectively.

CONCLUSIONS: Results from this study suggest graduated return to usual activity discharge instructions do not impact rate of resolution of MTBI symptoms 2 weeks after ED discharge. Given that patients continue to experience symptoms 2 and 4 weeks after MTBI, more investigation is needed to determine how best to counsel and treat patients with postconcussive symptoms.

21. Use of nitroglycerin by bolus prevents ICU admission in pts with acute hypertensive HF.

Wilson SS, et al. Am J Emerg Med. 2017 Jan;35(1):126-131.

OBJECTIVES: The purpose of this study was to compare health care resource utilization among patients who were given intravenous nitroglycerin for acute heart failure (AHF) in the emergency department (ED) by intermittent bolus, continuous infusion, or a combination of both.

METHODS: We retrospectively identified 395 patients that received nitroglycerin therapy in the ED for the treatment of AHF over a 5-year period. Patients that received intermittent bolus (n=124) were compared with continuous infusion therapy (n=182) and combination therapy of bolus and infusion (n=89). The primary outcomes were the frequency of intensive care unit (ICU) admission and hospital length of stay (LOS).

RESULTS: On unadjusted analysis, rates of ICU admission were significantly lower in the bolus vs infusion and combination groups (48.4% vs 68.7% vs 83%, respectively; P less than .0001) and median LOS (interquartile range) was shorter (3.7 [2.5-6.2 days]) compared with infusion (4.7 [2.9-7.1 days]) and combination (5.0 [2.9-6.7 days]) groups; P=.02. On adjusted regression models, the strong association between bolus nitroglycerin and reduced ICU admission rate remained, and hospital LOS was 1.9 days shorter compared with infusion therapy alone. Use of intubation (bolus [8.9%] vs infusion [8.8%] vs combination [16.9%]; P=.096) and bilevel positive airway pressure (bolus [26.6%] vs infusion [20.3%] vs combination [29.2%]; P=.21) were similar as was the incidence of hypotension, myocardial injury, and worsening renal function.

CONCLUSIONS: In ED patients with AHF, intravenous nitroglycerin by intermittent bolus was associated with a lower ICU admission rate and a shorter hospital LOS compared with continuous infusion.

22. Glucagon for refractory asthma exacerbation

Cavallari JM, et al. Amer J Emerg Med 2017;35:144-145.

Glucagon, a hormone secreted by pancreatic alpha cells, causes bronchial smooth muscle relaxation by activating the synthesis of cyclic adenosine monophosphate. It was studied in the 1980s and 1990s as a treatment option for the management of asthma but has since not been evaluated. Data to support its use are limited, but it may serve as a last-line agent for refractory asthma exacerbation. Here we describe 4 cases in which intravenous glucagon was used to manage severe, refractory asthma exacerbation in the emergency department.

23. Micro Bits

A. Don't Miss These Changes to DEA Registration Renewal Process: No More Grace Period After Expiration, Agency Warn

B. Inactivity has physical, financial costs

A study published in July found that people who are out of shape have a 42% higher risk of dying prematurely than their in-shape peers, and another found that each person could save $2,500 annually on medical costs simply by walking 30 minutes most days. Various other studies showed the benefits of exercising regularly and "taught us that being inactive could potentially cost us years from our lives and many thousands of dollars from our wallets," Gretchen Reynolds writes.

C. HF Risk Predictors Don't Work Well at Individual Level: But mortality prediction tools work well at population level

D. Neonatal Abstinence Syndrome

E. Intranasal Dexmedetomidine Sedation as Adjuvant Therapy in Acute Asthma Exacerbation With Marked Anxiety and Agitation

We describe 2 patients with acute asthma exacerbation who were admitted to the emergency department (ED) with severe agitation and restlessness as a prominent finding, for which bedside asthma treatment sedation with intranasal dexmedetomidine was performed. In both cases, dexmedetomidine allowed the patients to rest and improved tolerance to treatment. Dexmedetomidine is a unique sedative with an excellent safety profile and minimal effect on respiratory function. These properties render it particularly promising for the management of severe agitation in children admitted to the ED with acute asthma exacerbation.

F.  Trial of Amitriptyline, Topiramate, and Placebo for Pediatric Migraine

Conclusions: There were no significant differences in reduction in headache frequency or headache-related disability in childhood and adolescent migraine with amitriptyline, topiramate, or placebo over a period of 24 weeks. The active drugs were associated with higher rates of adverse events.

G. AAFP, ACP guidance covers hypertension in older adults

A joint practice guideline from the AAFP and the American College of Physicians on systolic blood pressure for hypertensive adults ages 60 and older calls for treating patients with persistent readings at or above 150 mm Hg until levels reach less than 150 mm Hg. The full report was published in the Annals of Internal Medicine, and a summary will be published in the Annals of Family Medicine.

H. Infants with colic may benefit from mild acupuncture

Swedish researchers looked at 147 babies with colic and found that those who received either of two types of minimal acupuncture for two weeks had 40% lower crying duration between their first and last visits, compared with a 20% reduction among those who received standard care. The findings in the journal Acupuncture in Medicine also showed that 38% of those who received acupuncture met the criteria for colic during the second week of treatment, compared with 65% in the control group.

I. How does a US president settle on his science policy?

One of the president’s most important responsibilities is fostering science, technology and innovation in the U.S. economy. The relationship between science and policy runs in two directions: Scientific knowledge can inform policy decisions, and conversely, policies affect the course of science, technology and innovation.

Historically, government spending on science has been good for the economy. Innovation is estimated to drive approximately 85 percent of economic growth. Not only does it provide a means for “creative destruction” within the economy, it also results in reduced costs for products and services that consumers demand. The United States prides itself as the most innovative country in the world, but how did it get that way?

Many famously disruptive technologies were invented in the United States – the internet, shale gas fracking and solar photovoltaics are three examples – and subsequently led to the growth of major American industries and associated jobs. Such inventions are the fruits of investments and effort made both by the private sector and the U.S. government (usually at different points in time).

President-elect Trump has made clear he intends to boost the economy’s growth rate and supporting science and technology should be a vital part of his plan. So how does an American president settle on research priorities for the country? And once he has a science and innovation agenda, how does he move it forward to eventually seed new industries that have the potential to generate jobs and improve the country’s competitiveness?

Where does the president get scientific advice?

Every president since World War II has maintained a personal science advisor in the White House to inform key decisions about domestic and foreign policy, although some presidents proved more attentive than others.

Vannevar Bush had the ear of President Truman.  Abbie Rowe - US National Park Service
The very first science advisor, Vannevar Bush, demonstrated his value during World War II as head of the U.S. Office of Scientific Research and Development (OSRD). OSRD’s mission was to marshal and coordinate civilian and military scientists to develop and deploy new technology in wartime. OSRD helped to establish the Manhattan Project and was the origin of the military-industrial complex. (Perhaps unsurprisingly, Bush later founded the Raytheon Corporation.) Bush also pushed for the creation of the National Science Foundation.

Congress established the Office of Science and Technology Policy (OSTP) in 1976 to provide the president and others with scientific and technological expertise related to domestic and international affairs. It’s part of the Executive Office of the President, and its director (and associate directors) must be confirmed by the Senate…

J. New state rules are forcing opioid prescribers to confront ‘doctor shopping’

Over the objections of many doctors and their powerful advocacy groups, states are moving to force physicians to check on patients’ narcotic purchasing habits, one of the more effective ways of curbing opioid abuse as the deadly drug epidemic continues.

Eighteen states have adopted comprehensive mandates in the past four years requiring doctors who prescribe opioids and other controlled substances to check databases that show whether their patients are getting drugs elsewhere. About 13 other states have weaker mandates that cover more limited circumstances, according to a recent review by the Pew Charitable Trusts and Brandeis University.

K. Report: Opioid-dependent births surging in the US

The number of infants born to opioid-dependent mothers in the US annually has increased nearly fivefold in the last decade, and women ages 15 to 17 had the highest nonmedical opioid use during pregnancy, according to a report from the Substance Abuse and Mental Health Services Administration. The findings, based on 2012 data, also showed that substance abuse treatment programs for pregnant and postpartum women were only offered in 13% of outpatient facilities and 13% of residential facilities.

L. What Van Halen Can Teach Us About the Care of Older Patients

Schwartz AW. JAMA Intern Med. 2017 Jan 9

Van Halen, the American hard rock band, dominated the music scene of the 1980s, becoming known not only for their dramatic pyrotechnics and dance moves but also for their particular pickiness when it came to preparing their dressing rooms. Their lengthy 1982 contract rider contained a stipulation that, in addition to towels and chips, a bowl of M&Ms be provided for the band—with the brown M&Ms picked out. This unusual request was the pretext for several cancelled performances—if the band discovered on arrival that there were indeed brown M&Ms in their dressing room snack bowl, they would refuse to play the show.1
As a geriatrician, my curiosity was piqued by the explanation cited for this strange behavior in a story reported on NPR: Van Halen apparently used the brown M&Ms as evidence of attention to detail on the part of the concert venue. If the venue staff had not noticed this small detail buried in the rider, the band could not trust that the complex music system and stage had been set up correctly, that the elaborate pyrotechnics would function safely. The presence of the brown M&Ms called into doubt the stability and safety of the entire concert setup.
This tale from the entertainment industry resonates in the work we do as physicians caring for older adults: what are the analogous brown M&Ms we can notice when it comes to the care of frail patients with complex conditions? What are the details that, when amiss, can alert us to the risk level or stability of our patients and cause us to worry about the patient’s resilience to physiologic stress? Unlike Van Halen, when we notice these brown M&Ms we cannot cancel the show; we must use these warning signs as a reminder to check the functioning of the whole system in these high-risk patients and help support them…

Who knew?

M. Exercising just once a week lowers mortality risks

"Weekend warriors" who exercised just once or twice per week had lower mortality and cancer risks compared with people who did not exercise at all, researchers reported in JAMA Internal Medicine. The study found any exercise level was beneficial, compared with inactivity.

N. New Guidance: Dodge Peanut Allergy Using, Well, Peanuts
New evidence-based recommendations call for introducing certain infants at risk for developing peanut allergy to dietary peanut as early as age 4 months.

 O. New Earwax Clinical Practice Guideline

Guidance advises not using cotton swabs, candling to clean ears

The American Academy of Otolaryngology-Head and Neck Surgery Foundation issued updated guidance recommending against ear candling and using cotton swabs to clean ears and advising patients to see a physician for symptoms such as ear drainage or bleeding, pain, loss of hearing or fullness in the ears. The guidelines in Otolaryngology-Head and Neck Surgery noted about 1 in 10 children and 1 in 20 adults develop excessive earwax.

P. Study links heartburn drugs, gut infections

Proton pump inhibitors and H2 blockers may increase the risk of C. difficile and Campylobacter bacterial infections, according to a study in the British Journal of Clinical Pharmacology. Researchers said these medications may change the bacterial balance in the gut to make people more susceptible to infection.