-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.
References
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
Background
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.
Objectives
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.
Methods
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.
Results
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.
Conclusions
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]
Background
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.
Methods
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.
Results
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.
Conclusions
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.
Objectives
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.
Methods
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.
Results
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.”
Conclusions
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: http://www.nejm.org/doi/full/10.1056/NEJMp1614078
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
THE HEROISM
OF INCREMENTAL CARE. The New Yorker; Jan 23, 2017
We devote
vast resources to intensive, one-off procedures, while starving the kind of
steady, intimate care that often helps people more.
Excerpts
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
Recommendation
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…
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.
Comment
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.
Methods
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.
Results
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).
Conclusion
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.
Comment
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.
The New York Times: http://www.nytimes.com/2016/12/21/well/move/savings-longevity-and-the-year-in-fitness.html
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.
