0. Kids with Blunt Head Trauma
A.
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.
B.
Which Children with Mild Head Trauma and Intracranial Injury Need the ICU?
Greenberg JK,
et al. JAMA Pediatr. 2017 Feb 13 [Epub ahead of print]
Key Points
Question: Can
routine clinical and imaging variables predict the need for intensive care unit
admission among children with mild traumatic brain injury and intracranial
injury?
Findings:
This analysis found that the presence of midline shift, depressed skull
fracture, epidural hematoma, and lower Glasgow Coma Scale score are associated
with the need for intensive care unit admission in children with mild traumatic
brain injury and intracranial injury. The negative predictive value of having
none of these risk factors was 98.8%.
Meaning: Use
of these risk criteria can help guide the need for intensive care unit
admission in children with mild traumatic brain injury and intracranial injury.
Abstract
Importance:
The appropriate treatment of children with mild traumatic brain injury (mTBI)
and intracranial injury (ICI) on computed tomographic imaging remains unclear.
Evidence-based risk assessments may improve patient safety and reduce resource
use.
Objective: To
derive a risk score predicting the need for intensive care unit observation in
children with mTBI and ICI.
Design,
Setting, and Participants: This retrospective analysis of the prospective
Pediatric Emergency Care Applied Research Network (PECARN) head injury cohort
study included patients enrolled in 25 North American emergency departments
from 2004 to 2006. We included patients younger than 18 years with mTBI
(Glasgow Coma Scale [GCS] score, 13-15) and ICI on computed tomography. The
data analysis was conducted from May 2015 to October 2016.
Main Outcomes
and Measures: The primary outcome was the composite of neurosurgical
intervention, intubation for more than 24 hours for TBI, or death from TBI.
Multivariate logistic regression was used to predict the outcome. The C
statistic was used to quantify discrimination, and model performance was
internally validated using 10-fold cross-validation. Based on this modeling,
the Children's Intracranial Injury Decision Aid score was created.
Results:
Among 15 162 children with GCS 13 to 15 head injuries who received head
computed tomographic imaging in the emergency department, 839 (5.5%) had ICI.
The median ages of those with and without a composite outcome were 7 and 5
years, respectively. Among those patients with ICI, 8.7% (n = 73) experienced
the primary outcome, including 8.3% (n = 70) who had a neurosurgical
intervention. The only clinical variable significantly associated with outcome
was GCS score (odds ratio [OR], 3.4; 95% CI, 1.5-7.4 for GCS score 13 vs 15).
Significant radiologic predictors included midline shift (OR, 6.8; 95% CI,
3.4-13.8), depressed skull fracture (OR, 6.5; 95% CI, 3.7-11.4), and epidural
hematoma (OR, 3.4; 95% CI, 1.8-6.2). The model C statistic was 0.84 (95% CI,
0.79-0.88); the 10-fold cross-validated C statistic was 0.83. Based on this
modeling, we developed the Children's Intracranial Injury Decision Aid score,
which ranged from 0 to 24 points. The negative predictive value of having 0
points (ie, none of these risk factors) was 98.8% (95% CI, 97.3%-99.6%).
Conclusions
and Relevance: Lower GCS score, midline shift, depressed skull fracture, and
epidural hematoma are key risk factors for needing intensive care unit-level
care in children with mTBI and ICI. Based on these results, the Children's
Intracranial Injury Decision Aid score is a potentially novel tool to risk
stratify this population, thereby aiding management decisions.
1. New Sepsis Guidelines: January 2017
A.
Management of Sepsis and Septic Shock: JAMA Clinical Guidelines Synopsis
Howell MD, et
al. JAMA 2017 Jan 19 [Epub ahead of print]
Sepsis
results when the body’s response to infection causes life-threatening organ
dysfunction. Septic shock is sepsis that results in tissue hypoperfusion, with
vasopressor-requiring hypotension and elevated lactate levels.1 Sepsis is a
leading cause of death, morbidity, and expense, contributing to one-third to
half of deaths of hospitalized patients,2 depending on definitions.3 Management
of sepsis is a complicated clinical challenge requiring early recognition and
management of infection, hemodynamic issues, and other organ dysfunctions.
The guideline
was developed by the SSC, with funding and governance from the SCCM and the
ESICM (Table).4 More than 30 additional organizations endorsed the guidelines.
Guideline committee members were from numerous specialties and included methods
experts and a patient representative. A formal conflict of interest management
policy was followed.
The guideline
committee used the GRADE method. Population, intervention, control, and
outcomes questions were constructed; professional librarians assisted with
evidence reviews. Although the 2016 revision of definitions for sepsis were
published during the guideline development process,1 studies used for guideline
evidence used earlier definitions of sepsis syndromes.
The 2012
sepsis guidelines strongly recommended protocolized resuscitation with
quantitative end points (early goal-directed therapy [EGDT]). Recommendations
included specific goals for central venous pressure (CVP), MAP, and central
venous oxygen saturation and formed the basis of national quality and
performance metrics.5
Since the
2012 guideline, substantial evolution has occurred in understanding the value
of EGDT. Three key randomized trials enrolled patients presenting to the
emergency department who had sepsis with shock or hypoperfusion. In the PROCESS
trial (n=1341 patients from 31 US institutions), protocol-based approaches did
not reduce 60-day mortality vs usual care (19.5% vs 18.9%; relative risk [RR],
1.04; 95% CI, 0.82-1.31; P=.83).6 The similarly sized UK-based PROMISE7 and the
ARISE trial8 from Australia and New Zealand both compared EGDT and usual care
at 90 days and again found no difference in mortality (29.5% vs. 29.2%; RR,
1.01; 95% CI, 0.85-1.20; P=.90 and 18.6% vs 18.8%; RR, 0.98; 95% CI, 0.80-1.21;
P=.90, respectively). Taken together, these trials suggest that while EGDT is
safe, it is not superior to usual, nonprotocolized care. Usual care has also
evolved since these trials to include more aggressive fluid resuscitation.9 In
response, the 2016 guideline has removed standard EGDT resuscitation targets,
instead recommending that sepsis-induced hypoperfusion be treated with at least
30 mL/kg of intravenous crystalloid given in 3 hours or less. The authors note
that sparse controlled data support this volume but its delivery allows
resuscitation to begin during evaluation. In the absence of the former static
EGDT targets (eg, CVP), the guideline emphasizes frequent clinical reassessment
and the use of dynamic measures of fluid responsiveness (eg, arterial pulse
pressure variation), given evidence that dynamic measures predict fluid
responsiveness better than static measures do.
Because
infection causes sepsis, managing infection is perhaps the most critical
component of sepsis therapy. Mortality increases even with very short delays of
antimicrobials. To optimize the risk-benefit profile, the strategy of initial
broad-spectrum therapy requires meticulous attention to antimicrobial
stewardship, including early appropriate cultures and daily review to reduce or
stop antimicrobials. Additionally, anatomic source control (eg, identifying
infected central lines, pyelonephritis with ureteral obstruction, intestinal
perforation) should occur as soon as is practical.
The PROCESS,6
PROMISE,7 and ARISE8 trials have created substantial uncertainty in how to
guide clinicians managing patients with sepsis and septic shock.9 When usual
care is equivalent to EGDT, what is a clinician to do? The most significant
update to the guideline reflects this shift in evidence: removing most specific
EGDT end points and emphasizing frequent reevaluation and patient-specific
tailoring of hemodynamic therapy. Even with a change in consensus definitions
for sepsis,1 the guideline provides strong recommendations for a number of
elements of standardized care, such as antimicrobial therapy, initial fluid
volume, blood pressure goals, and vasopressor choice. Reflecting substantial
consensus among experts, voting was by 75% of panel members with at least 80%
agreement.
The guideline
also provides a BPS for hospitals and health systems to develop formal sepsis
performance improvement programs, given a suggestion of a mortality benefit.
The recent NICE guidelines include tips on patient populations at higher risk
of sepsis, clinical presentations, and initial laboratories for diagnosis and
risk stratification. Tools such as order sets, checklists, posters, reminder
cards, and electronic medical record decision support may assist clinicians in
early recognition and appropriate treatment of sepsis.10
Pediatric
sepsis guidelines will be published separately, with a specific guideline for
ventilation in ARDS expected in 2017…
Selected
major recommendations
Managing
infection:
Antibiotics:
Administer broad-spectrum intravenous antimicrobials for all likely pathogens
within 1 hour after sepsis recognition (strong recommendation; moderate quality
of evidence [QOE]).
Source
control: Obtain anatomic source control as rapidly as is practical (best
practice statement [BPS]).
Antibiotic
stewardship: Assess patients daily for deescalation of antimicrobials; narrow
therapy based on cultures and/or clinical improvement (BPS).
Managing
resuscitation:
Fluids: For
patients with sepsis-induced hypoperfusion, provide 30 mL/kg of intravenous
crystalloid within 3 hours (strong recommendation; low QOE) with additional
fluid based on frequent reassessment (BPS), preferentially using dynamic
variables to assess fluid responsiveness (weak recommendation; low QOE).
Resuscitation
targets: For patients with septic shock requiring vasopressors, target a mean
arterial pressure (MAP) of 65 mm Hg (strong recommendation; moderate QOE).
Vasopressors:
Use norepinephrine as a first-choice vasopressor (strong recommendation;
moderate QOE).
Mechanical
ventilation in patients with sepsis-related ARDS: Target a tidal volume of 6
mL/kg of predicted body weight (strong recommendation; high QOE) and a plateau
pressure of ≤30 cm H2O (strong recommendation; moderate QOE).
B.
Six Myths Promoted by the New Surviving Sepsis Guidelines (via EMCrit)
By Josh
Farkas. EMCrit · January 30, 2017
A. Combination
Therapy Is Beneficial For Gram-Negative Septic Shock.
B. Norepinephrine
Is The Best Vasopressor For All Septic Patients.
C. If One
Vasopressor Doesn’t Work, Additional Drugs Should Be Added In A Sequential
Fashion.
D. Lactate Is
A Measure Of Tissue Perfusion. Normalization Of Lactate Should Be Used As A
Resuscitation Target.
E. All Septic
Patients Must Receive 30 Ml/Kg Fluid Initially.
F. It’s
Helpful To Mandate That Specific Sepsis Therapies Be Given Within A Rigid Time
Frame.
2. Four Appy Studies from Acad Emerg Med
A.
MRI vs. US as the initial imaging modality for pediatric and young adult
patients with suspected appendicitis.
Imler D, et
al. Acad Emerg Med. 2017 Feb 16 [Epub ahead of print]
BACKGROUND:
While ultrasound (US), given its lack of ionizing radiation is currently the
recommended initial imaging study of choice for the diagnosis of appendicitis
in pediatric and young adult patients, it does have significant shortcomings.
US is time intensive, operator dependent, and results in frequent inconclusive
studies, thus necessitating further imaging, and admission for observation or
repeat clinical visits. A rapid focused Magnetic Resonance Imaging (MRI) for appendicitis
has been shown to have definitive sensitivity and specificity, similar to
Computed tomography (CT) but without radiation and offers a potential
alternative to US.
OBJECTIVE: In
this single-center prospective cohort study, we sought to determine the
difference in total length of stay and charges between rapid MRI and US as the
initial imaging modality in pediatric and young adult patients presenting to
the Emergency Department (ED) with suspected appendicitis. We hypothesized that
rapid MRI would be more efficient and cost effective than US as the initial
imaging modality in the ED diagnosis of appendicitis.
METHODS: A
prospective randomized cohort study of consecutive patients was conducted in
patients 2-30 years of age in an academic ED with access to both rapid MRI and
US imaging modalities 24/7. Prior to the start of the study, the days of the
week were randomized to either rapid MRI or US as the initial imaging modality.
Physicians evaluated patients with suspected appendicitis per their usual
manner. If the physician decided to obtain radiologic imaging, the
pre-determined imaging modality for the day of the week was used. All decisions
regarding other diagnostic testing and/or further imaging were left to the
physician's discretion. Time intervals (min) between triage, order placement,
start of imaging, end of imaging, image result and disposition (discharge vs.
admission), as well as total charges (diagnostic testing, imaging and repeat ED
visits) were recorded.
RESULTS: Over
a 100-day period, 82 patients were imaged to evaluate for appendicitis; 45/82
(55%) of patients were in the US first group; and 37/82 (45%) patients were in
the rapid MRI first group. There were no differences in patient demographics or
clinical characteristics between the groups and no cases of missed appendicitis
in either group. 11/45 (24%) of US first patients had inconclusive studies,
resulting in follow-up rapid MRI and 5 return ED visits contrasted with no
inconclusive studies or return visits (p less than 0.05) in the rapid MRI
group. The rapid MRI compared to US group was associated with longer ED length
of stay (mean difference 100 min; 95% CI 35-169) and increased ED charges (mean
difference $4,887; 95% CI $1,821 - $8,513).
CONCLUSIONS:
In the diagnosis of appendicitis, US first imaging is more time efficient and
less costly than rapid MRI despite inconclusive studies after US imaging.
Unless the process of obtaining a rapid MRI becomes more efficient and less
expensive, US should be the first line imaging modality for appendicitis in
patients 2-30 years of age.
B.
Diagnostic Value and Effect of Bedside US in Acute Appendicitis in the ED
Gungor F, et
al. Acad Emerg Med. 2017 Feb 7 [Epub ahead of print]
OBJECTIVE:
Early and accurate diagnosis of acute appendicitis (AA) with ultrasound can
minimize the morbidity and mortality of the patients. In this regard,
ultrasound can help to the emergency physicians (EPs) in the diagnosing process
and clinical decision making for AA. Therefore, we primarily aimed to evaluate
the effectiveness of point of care ultrasound (POCUS) in clinical decision
making of EPs for the diagnostic evaluation for AA in the emergency department
(ED).
METHODS: The
study sample consisted of patients aged over 18 years that presented to the ED
with an abdominal pain and underwent diagnostic evaluation for AA. All patients
were examined initially with POCUS by EPs and then with radiology-performed
ultrasound (RADUS) by radiologists. Pre- and post-POCUS median diagnostic
certainty values (MDCVs) for AA were determined with visual analogue scale
(VAS) scores (0 not present, 100 certainly present) by POCUS performers.
Definitive diagnoses were determined by surgery, pathologic evaluation of
appendectomy specimens, or clinical follow results. The sensitivity, specificity,
positive likelihood ratio (PLR), and negative likelihood ratio (NLR) for POCUS
and RADUS together with pre- and post-POCUS VAS scores for MDCVs were compared.
RESULTS: A
total of 264 patients were included into the final analysis and 169 (64%) had a
diagnosis of AA. The sensitivity, specificity, PLR, and NLR of ultrasound
examinations were 92.3% (95% CI; 87.2-95.8%), 95.8% (89.5-98.8%), 21.9
(8.4-57.2) and 0.08 (0.05-0.1) for POCUS, and 76.9% (69.8-83%), 97.8%
(84.9-99.7%), 36.4 (9.25-144.3) and 0.24 (0.18-0.31) for RADUS, respectively.
Pre-POCUS and post-POCUS VAS scores for MDCVs were 60 (IQR: 50-65) and 95 (IQR:
20-98), respectively (p=0.000).
CONCLUSION:
POCUS, when performed in ED for the diagnosis of AA, has high sensitivity and
specificity, and had a positive impact on the clinical decision making of EPs.
This article is protected by copyright. All rights reserved.
C.
Diagnostic Accuracy of Hx, PE, Lab Tests and Point-of-Care-US for Pediatric
Acute Appendicitis in the ED: A Systematic Review and Meta-Analysis.
Benabbas R,
et al. Acad Emerg Med. 2017 Feb 18 [Epub ahead of print]
BACKGROUND:
Acute appendicitis (AA) is the most common surgical emergency in children.
Accurate and timely diagnosis is crucial but challenging due to atypical presentations
and the inherent difficulty of obtaining a reliable history and physical
examination in younger children.
OBJECTIVES:
To determine the utility of history, physical exam, laboratory tests, Pediatric
Appendicitis Score (PAS) and Emergency Department-Point-of-Care Ultrasound
(ED-POCUS) in the diagnosis of AA in ED pediatric patients. We performed a
systematic review and meta-analysis and used a test-treatment threshold model
to identify diagnostic findings that could rule in/out AA and obviate the need
for further imaging studies specifically, CT scan, MRI and Radiology Department
Ultrasound (RUS).
METHODS: We
searched PUBMED, EMBASE, and SCOPUS up to October 2016 for studies on ED
pediatric patients with abdominal pain. Quality Assessment Tool for Diagnostic
Accuracy Studies (QUADAS-2) was used to evaluate the quality and applicability
of included studies. Positive and negative Likelihood Ratios (LR+ and LR-) for
diagnostic modalities were calculated and when appropriate data was pooled
using Meta-DiSc. Based on the available literature on the test characteristics
of different imaging modalities and applying Pauker-Kassirer method we
developed a test-treatment threshold model.
RESULTS:
Twenty-one studies were included encompassing 8,605 patients with AA prevalence
of 39.2%. Studies had variable quality using the QUADAS-2 tool with most
studies at high risk of partial verification bias. We divided studies based on
their inclusion criteria into two groups of "undifferentiated abdominal
pain" and abdominal pain "suspected of AA". In patients with
"undifferentiated abdominal pain" history of "pain migration to
RLQ" (LR+ 4.81, 95% CI 4.81-6.44) and presence of "cough/hop
pain" in the physical exam (LR+ 7.64, 95% CI 5.94-9.83) were most strongly
associated with AA. In patients "suspected of AA" none of the history
or laboratory findings were strongly associated with AA. Rovsing's sign was the
physical exam finding most strongly associated with AA (LR+ 3.52, 95% CI
2.65-4.68). Among different PAS cutoff points PAS≥ 9 (LR+ 5.26, 95% CI
3.34-8.29) was most associated with AA. None of the history, physical exam, lab
tests findings or PAS alone could rule in or rule out AA in patients with
"undifferentiated abdominal pain" or those "suspected of AA".
Emergency Department Point-of-Care Ultrasound (ED-POCUS) had LR+ 9.24 (95% CI
6.24-13.28) and LR- 0.17 (95% CI 0.09-0.30). Using our test-treatment threshold
model, positive ED-POCUS could rule in AA without the use of CT and MRI, but
negative ED-POCUS could not rule out AA.
CONCLUSION:
Presence of AA is more likely in patients with undifferentiated abdominal pain
migrating to the RLQ or when cough/hop pain is present in the physical exam.
Once AA is suspected, no single history, physical exam, lab finding or score
attained on PAS can eliminate the need for imaging studies. Test
characteristics of ED-POCUS are similar to those reported for RUS in literature
for diagnosis of AA. In ED patients suspected of AA, a positive ED-POCUS is
diagnostic and obviates the need for CT or MRI while negative ED-POCUS is not
enough to rule out AA.
D.
Association of Hospital Resources and Imaging Choice for Appendicitis in
Pediatric EDs.
Fullerton K,
et al. Acad Emerg Med. 2016 Dec 31 [Epub ahead of print]
OBJECTIVE:
Abdominal pain and concern for appendicitis are common chief complaints in
patients presenting to the pediatric emergency department (PED)1 . Although
many professional organizations recommend decreasing use of CT and choosing
ultrasound as first line imaging for pediatric appendicitis, significant
variability persists in imaging utilization2,3,4 . This study investigated
practice variation across children's hospitals in the diagnostic imaging
evaluation of appendicitis and determined hospital-level characteristics associated
with the likelihood of ultrasound as the first imaging modality.
METHODS: This
was a multicenter (seven children's hospitals) retrospective investigation.
Data from chart review of 160 consecutive patients aged 3-18 years diagnosed
with appendicitis from each site was compared with a survey of site medical
directors regarding hospital resource availability, usual practices, and
departmental level demographics.
RESULTS: In
the diagnostic evaluation of 1090 children with appendicitis, CT scan was
performed first for 22.4% of patients, with a range across PEDs of 3.1-83.8%.
Ultrasound was performed for 54.0% of patients with a range of 2.5-96.9%. The
only hospital level factor significantly associated with ultrasound as the
first imaging modality was 24-hour availability of in-house ultrasound (OR
29.2, 95% CI 1.2-691.8).
CONCLUSION:
Across children's hospitals, significant practice variation exists regarding
diagnostic imaging in the evaluation of patients with appendicitis. Variation
in hospital level resources may impact the diagnostic evaluation of patients
with appendicitis. Availability of 24-hour in house ultrasound significantly
increases the likelihood of ultrasound as first imaging and decreases CT scans.
Hospitals aiming to increase the use of ultrasound should consider adding
24-hour in house coverage.
3. Simple Acute Low Back Pain: “Naproxen and Heat are Hard to
Beat”
A.
Diazepam Is No Better Than Placebo When Added to Naproxen for Acute Low Back
Pain.
Friedman BW,
et al. Ann Emerg Med. 2017 Jan 19 [Epub ahead of print]
STUDY
OBJECTIVE: Low back pain causes more than 2.5 million visits to US emergency
departments (EDs) annually. Low back pain patients are often treated with
nonsteroidal anti-inflammatory drugs and benzodiazepines. The former is an
evidence-based intervention, whereas the efficacy of the latter has not been
established. We compare pain and functional outcomes 1 week and 3 months after
ED discharge among patients randomized to a 1-week course of naproxen+diazepam
versus naproxen+placebo.
METHODS: This
was a randomized, double-blind, comparative efficacy clinical trial conducted
in an urban health care system. Patients presenting with acute, nontraumatic,
nonradicular low back pain of no more than a duration of 2 weeks were eligible
for enrollment immediately before discharge from an ED if they had a score
greater than 5 on the Roland-Morris Disability Questionnaire, a validated
24-item inventory of functional impairment caused by low back pain. Higher
scores on the questionnaire indicate greater functional disability. The primary
outcome in the trial was improvement in the score between ED discharge and 1
week later. Secondary outcomes included pain intensity 1 week and 3 months
after ED discharge, as measured on a 4-point descriptive scale (severe,
moderate, mild, and none). All patients were given 20 tablets of naproxen 500
mg, to be taken twice a day as needed for low back pain. Additionally, patients
were randomized to receive either 28 tablets of diazepam 5 mg or identical placebo,
to be received as 1 or 2 tablets every 12 hours as needed for low back pain.
All patients received a standardized 10-minute low back pain educational
session before discharge. Using a between-group mean difference of 5
Roland-Morris Disability Questionnaire points, a previously validated threshold
for clinical significance, we calculated the need for at least 100 patients
with primary outcome data.
RESULTS:
Enrollment began in June 2015 and continued for 9 months. Five hundred
forty-five patients were screened for eligibility. One hundred fourteen
patients met selection criteria and were randomized. Baseline demographic
characteristics were not substantially different between the 2 groups. One
hundred twelve patients (98%) provided 1-week outcome data. The mean
Roland-Morris Disability Questionnaire score of patients randomized to
naproxen+diazepam improved by 11 (95% confidence interval [CI] 9 to 13), as did
the mean score of patients randomized to naproxen+placebo (11; 95% CI 8 to 13).
At 1-week follow-up, 18 of 57 diazepam patients (32%; 95% CI 21% to 45%)
reported moderate or severe low back pain versus 12 of 55 placebo patients
(22%; 95% CI 13% to 35%). At 3-month follow-up, 6 of 50 diazepam patients (12%;
95% CI 5% to 24%) reported moderate or severe low back pain versus 5 of 53
placebo patients (9%; 95% CI 4% to 21%). Adverse events were reported by 12 of
57 diazepam patients (21%; 95% CI 12% to 33%) and 8 of 55 placebo patients
(15%; 95% CI 7% to 26%).
CONCLUSION:
Among ED patients with acute, nontraumatic, nonradicular low back pain,
naproxen+diazepam did not improve functional outcomes or pain compared with
naproxen+placebo 1 week and 3 months after ED discharge.
B.
Neither Flexeril nor Oxycodone prn Improved Naproxen for LBP
Friedman BW,
et al. Naproxen with Cyclobenzaprine, Oxycodone/Acetaminophen, or Placebo for
Treating Acute Low Back Pain: A RCT. JAMA. 2015 Oct 20;314(15):1572-80.
IMPORTANCE:
Low back pain (LBP) is responsible for more than 2.5 million visits to US
emergency departments (EDs) annually. These patients are usually treated with
nonsteroidal anti-inflammatory drugs, acetaminophen, opioids, or skeletal
muscle relaxants, often in combination.
OBJECTIVE: To
compare functional outcomes and pain at 1 week and 3 months after an ED visit
for acute LBP among patients randomized to a 10-day course of (1)
naproxen + placebo; (2) naproxen + cyclobenzaprine; or (3)
naproxen + oxycodone/acetaminophen.
DESIGN,
SETTING, AND PARTICIPANTS: This randomized, double-blind, 3-group study was
conducted at one urban ED in the Bronx, New York City. Patients who presented
with nontraumatic, nonradicular LBP of 2 weeks' duration or less were eligible
for enrollment upon ED discharge if they had a score greater than 5 on the
Roland-Morris Disability Questionnaire (RMDQ). The RMDQ is a 24-item
questionnaire commonly used to measure LBP and related functional impairment on
which 0 indicates no functional impairment and 24 indicates maximum impairment.
Beginning in April 2012, a total of 2588 patients were approached for
enrollment. Of the 323 deemed eligible for participation, 107 were randomized
to receive placebo and 108 each to cyclobenzaprine and to
oxycodone/acetaminophen. Follow-up was completed in December 2014.
INTERVENTIONS:
All participants were given 20 tablets of naproxen, 500 mg, to be taken twice a
day. They were randomized to receive either 60 tablets of placebo;
cyclobenzaprine, 5 mg; or oxycodone, 5 mg/acetaminophen, 325 mg. Participants
were instructed to take 1 or 2 of these tablets every 8 hours, as needed for
LBP. They also received a standardized 10-minute LBP educational session prior
to discharge.
MAIN OUTCOMES
AND MEASURES: The primary outcome was improvement in RMDQ between ED discharge
and 1 week later.
RESULTS:
Demographic characteristics were comparable among the 3 groups. At baseline,
median RMDQ score in the placebo group was 20 (interquartile range
[IQR],17-21), in the cyclobenzaprine group 19 (IQR,17-21), and in the
oxycodone/acetaminophen group 20 (IQR,17-22). At 1-week follow-up, the mean
RMDQ improvement was 9.8 in the placebo group, 10.1 in the cyclobenzaprine
group, and 11.1 in the oxycodone/acetaminophen group. Between-group difference
in mean RMDQ improvement for cyclobenzaprine vs placebo was 0.3 (98.3% CI, -2.6
to 3.2; P = .77), for oxycodone/acetaminophen vs placebo, 1.3 (98.3% CI, -1.5
to 4.1; P = .28), and for oxycodone/acetaminophen vs cyclobenzaprine, 0.9
(98.3% CI, -2.1 to 3.9; P = .45).
CONCLUSIONS
AND RELEVANCE: Among patients with acute, nontraumatic, nonradicular LBP
presenting to the ED, adding cyclobenzaprine or oxycodone/acetaminophen to
naproxen alone did not improve functional outcomes or pain at 1-week follow-up.
These findings do not support use of these additional medications in this
setting.
C.
Complementary therapies in addition to medication for patients with nonchronic,
nonradicular LBP: a systematic review.
Rothberg S,
et al. Am J Emerg Med. 2017 Jan;35(1):55-61.
BACKGROUND: A
total of 2.7 million patients present to US emergency departments annually for
management of low back pain (LBP). Despite optimal medical therapy, more than
50% remain functionally impaired 3 months later. We performed a systematic
review to address the following question: Among patients with nonchronic LBP,
does spinal manipulation, massage, exercise, or yoga, when combined with
standard medical therapy, improve pain and functional outcomes more than
standard medical therapy alone?
METHODS: We
used published searches to identify relevant studies, supplemented with our own
updated search. Studies were culled from the Cochrane Register of Controlled
Trials, Medline, EMBASE, CINAHL, and the Index to Chiropractic Literature. Our
goal was to identify randomized studies that included patients with
nonradicular LBP of less than 12 weeks' duration that compared the
complementary therapy to usual care, sham therapy, or interventions known not
to be efficacious, while providing all patients with standard analgesics. The
outcomes of interest were improvement in pain scores or measures of
functionality.
RESULTS: We
identified 2 randomized controlled trials in which chiropractic manipulation +
medical therapy failed to show benefit vs medical therapy alone. We identified
4 randomized controlled trials in which exercise therapy + medical therapy
failed to show benefit vs medical therapy alone. We did not identify any
eligible studies of yoga or massage therapy.
CONCLUSIONS:
In conclusion, for patients with nonchronic, nonradicular LBP, available
evidence does not support the use of spinal manipulation or exercise therapy in
addition to standard medical therapy. There is insufficient evidence to
determine if yoga or massage is beneficial.
D.
Predicting three-month functional outcomes after an ED visit for acute LBP.
Friedman BW,
et al. Am J Emerg Med. 2017 Feb;35(2):299-305.
BACKGROUND:
Nearly 30% of patients who present to an ED with acute, new onset, low back
pain (LBP) report LBP-related functional impairment three months later. These
patients are at risk of chronic LBP, a highly debilitating condition. It has
been reported previously that functional impairment, depression, and
psychosomatic symptomatology at the index visit are associated with poor LBP
outcomes. We wished to replicate those findings in a cohort of ED patients, and
also to determine if clinical features present at one week follow-up could
predict three-month outcomes in individual patients.
METHODS: This
was a planned analysis of data from a randomized comparative effectiveness
study of three analgesic combinations conducted in one ED. Patients were
followed by telephone one week and three months post-ED visit. The primary
outcome was a three-month Roland-Morris Disability Questionnaire (RMDQ) score over
0, indicating the presence of LBP-related functional impairment. At the index
visit, we measured functional impairment (using the RMDQ), depressive
symptomatology (using the Patient Health Questionnaire depression module), and
psychosomatic features (using the 5-item Cassandra scale). At the one-week
follow-up, we ascertained the presence or absence of LBP. We built a logistic
regression model in which all the predictors were entered and retained in the
model, in addition to socio-demographic variables and dummy variables
controlling for investigational medication. Results are reported as adjusted
odds ratios (adjOR) with 95% CI. To determine if statistically significant
associations could be used to predict three-month outcomes in individual
patients, we then calculated positive and negative likelihood ratios [LR(+) and
LR(-)] with 95% CI for those independent variables associated with the primary
outcome.
RESULTS: Of
295 patients who completed the study, 14 (5%) were depressed and 18 (6%)
reported psychosomatic symptoms. The median index visit RMDQ score was 19 (IQR:
17, 21) indicating substantial functional impairment. One week after the ED
visit, 193 (65%) patients reported presence of LBP. 294 patients provided a
three-month RMDQ score, 88 of whom (30%, 95% CI: 25, 35%) reported a score above
0. Neither depression (adjOR 0.7 [95% CI 0.2, 3.1]), psychosomatic
symptomatology (adjOR 0.5 [95% CI 0.1, 2.0]), nor index visit functional
impairment (adjOR 1.0 [95% CI 1.0, 1.1]) were associated with three-month outcome.
Pain at one week was strongly and independently associated with the three-month
outcome when examined at the group level (adjOR 4.0 [95% CI 2.1, 7.7]).
However, likelihood ratios for pain or its absence at one-week were
insufficiently robust to be clinically useful in predicting three-month
outcomes in individual patients (LR+: 1.4 [95% CI: 1.3, 1.7]; LR-: 0.4 [95% CI:
0.2, 0.6]).
CONCLUSIONS:
In spite of a strong association at the group level between presence of LBP at
one week and functional impairment at three months, when used to predict
outcomes in individual patients, presence of pain failed to discriminate with
clinically meaningful utility between acute LBP patients destined to have a
favorable versus unfavorable three-month outcome.
E.
Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A
Clinical Practice Guideline from the American College of Physicians
Qaseem A, et
al. Ann Intern Med. 2017 Feb 14 [Epub ahead of print]
Description: The
American College of Physicians (ACP) developed this guideline to present the
evidence and provide clinical recommendations on noninvasive treatment of low
back pain.
Methods: Using
the ACP grading system, the committee based these recommendations on a
systematic review of randomized, controlled trials and systematic reviews
published through April 2015 on noninvasive pharmacologic and nonpharmacologic
treatments for low back pain. Updated searches were performed through November
2016. Clinical outcomes evaluated included reduction or elimination of low back
pain, improvement in back-specific and overall function, improvement in
health-related quality of life, reduction in work disability and return to
work, global improvement, number of back pain episodes or time between
episodes, patient satisfaction, and adverse effects.
Target
Audience and Patient Population:
The target
audience for this guideline includes all clinicians, and the target patient
population includes adults with acute, subacute, or chronic low back pain.
Recommendation
1: Given that most patients with acute or subacute low back pain improve over
time regardless of treatment, clinicians and patients should select
nonpharmacologic treatment with superficial heat (moderate-quality evidence),
massage, acupuncture, or spinal manipulation (low-quality evidence). If
pharmacologic treatment is desired, clinicians and patients should select
nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants
(moderate-quality evidence). (Grade: strong recommendation)
Recommendation
2: For patients with chronic low back pain, clinicians and patients should
initially select nonpharmacologic treatment with exercise, multidisciplinary
rehabilitation, acupuncture, mindfulness-based stress reduction
(moderate-quality evidence), tai chi, yoga, motor control exercise, progressive
relaxation, electromyography biofeedback, low-level laser therapy, operant
therapy, cognitive behavioral therapy, or spinal manipulation (low-quality
evidence). (Grade: strong recommendation)
Recommendation
3: In patients with chronic low back pain who have had an inadequate response
to nonpharmacologic therapy, clinicians and patients should consider
pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line
therapy, or tramadol or duloxetine as second-line therapy. Clinicians should
only consider opioids as an option in patients who have failed the
aforementioned treatments and only if the potential benefits outweigh the risks
for individual patients and after a discussion of known risks and realistic
benefits with patients. (Grade: weak recommendation, moderate-quality evidence)
Full-text
(free): http://annals.org/aim/article/2603228/noninvasive-treatments-acute-subacute-chronic-low-back-pain-clinical-practice
4. Early death after discharge from EDs: analysis of national US
insurance claims data
Obermeyer Z,
et al. BMJ. 2017 Feb 1;356:j239.
OBJECTIVE: To
measure incidence of early death after discharge from emergency departments,
and explore potential sources of variation in risk by measurable aspects of
hospitals and patients.
DESIGN:
Retrospective cohort study.
SETTING: Claims data from the US Medicare program,
covering visits to an emergency department, 2007-12.
PARTICIPANTS: Nationally representative 20% sample of
Medicare fee for service beneficiaries. As the focus was on generally healthy
people living in the community, patients in nursing facilities, aged ≥90,
receiving palliative or hospice care, or with a diagnosis of a life limiting
illnesses, either during emergency department visits (for example, myocardial
infarction) or in the year before (for example, malignancy) were excluded.
MAIN OUTCOME
MEASURE: Death within seven days after
discharge from the emergency department, excluding patients transferred or
admitted as inpatients.
RESULTS: Among discharged patients, 0.12%
(12 375/10 093 678, in the 20% sample over 2007-12) died within seven days, or
10 093 per year nationally. Mean age at death was 69. Leading causes of death
on death certificates were atherosclerotic heart disease (13.6%), myocardial
infarction (10.3%), and chronic obstructive pulmonary disease (9.6%). Some 2.3%
died of narcotic overdose, largely after visits for musculoskeletal problems.
Hospitals in the lowest fifth of rates of inpatient admission from the
emergency department had the highest rates of early death (0.27%)-3.4 times
higher than hospitals in the highest fifth (0.08%)-despite the fact that
hospitals with low admission rates served healthier populations, as measured by
overall seven day mortality among all comers to the emergency department. Small
increases in admission rate were linked to large decreases in risk. In multivariate
analysis, emergency departments that saw higher volumes of patients (odds ratio
0.84, 95% confidence interval 0.81 to 0.86) and those with higher charges for
visits (0.75, 0.74 to 0.77) had significantly fewer deaths. Certain diagnoses
were more common among early deaths compared with other emergency department
visits: altered mental status (risk ratio 4.4, 95% confidence interval 3.8 to
5.1), dyspnea (3.1, 2.9 to 3.4), and malaise/fatigue (3.0, 2.9 to 3.7).
CONCLUSIONS: Every year, a substantial number of Medicare
beneficiaries die soon after discharge from emergency departments, despite no
diagnosis of a life limiting illnesses recorded in their claims. Further
research is needed to explore whether these deaths were preventable.
5. Two Studies on
Nursemaid's
Elbow
A.
Effectiveness of reduction maneuvers in the treatment of nursemaid's elbow: A
systematic review and meta-analysis shows hyperpronation is best (hands down--get it?)
Bexkens R, et
al. Am J Emerg Med. 2016 Nov 2 [Epub ahead of print].
BACKGROUND/AIM:
Nursemaid's elbow usually occurs in young children when longitudinal traction
is placed on the arm. Several manipulative maneuvers have been described,
although, the most effective treatment technique is yet unclear. The aim of
this systematic review and meta-analysis was to compare the two most commonly
performed maneuvers (supination-flexion and hyperpronation) in the treatment of
nursemaid's elbow.
METHODS: A
literature search was performed in PubMed, Embase, and Cochrane databases to
identify randomized controlled trials comparing supination-flexion and
hyperpronation. Data were extracted and pooled independently by two authors.
Methodological quality assessment of included studies was performed.
Meta-analysis was performed using a fixed-effect model in case of homogeneity
across studies, and using a random-effect model in case of heterogeneity.
Heterogeneity was calculated with the χ2 test and inconsistency in study
effects across trials was quantified by I2 values.
RESULTS:
Seven randomized trials, including 701 patients (62% female), were included. A
total of 350 patients were treated with the hyperpronation maneuver versus 351
patients who underwent the supination-flexion maneuver. Meta-analysis showed
that hyperpronation was more effective than supination-flexion (risk ratio,
0.34; 95% confidence interval, 0.23 to 0.49; I2, 35%). The absolute risk
difference between maneuvers was 26% in favor of hyperpronation, resulting in a
number needed to treat of 4 patients. Trials lacked blinding of assessors and
universal pain measures.
CONCLUSIONS:
Hyperpronation was more effective in terms of success rate and seems to be less
painful compared to the supination-flexion maneuver in children with
nursemaid's elbow.
B.
Radial Head Subluxation: Factors Associated with Its Recurrence and Radiographic
Evaluation in a Tertiary Pediatric ED
Wong K, et
al. J Emerg Med. 2016 Dec;51(6):621-627
BACKGROUND:
Radial head subluxation (RHS) is a common complaint seen in the pediatric
emergency department in children ages 6 months to 4 years. Classically, injury
occurs due to axial traction on the arm, but this mechanism is not universal.
Some patients will have recurrent RHS; some may undergo x-ray (XR) evaluation
for alternative diagnosis.
OBJECTIVES:
To determine factors associated with recurrences and radiographic evaluations
in RHS.
METHODS: A
retrospective study with inclusion criteria: under 10 years of age with
discharge diagnosis "nursemaid," "radial head," or
"subluxation." We examined factors associated with RHS recurrences,
circumstances when radiographic evaluations performed, physician's training
background (pediatric vs. general emergency medicine), mechanisms of injury,
and demographic factors including age, gender, and arm involved.
RESULTS: In
246 visits, median age was 27 months (interquartile range 16.1), with females
comprising 55.7% (n = 137), and left-sided predominance (52%, n = 130).
Mechanisms of injury were classified as "pull" (65.9%, n = 162),
"non-pull" (15.9%, n = 39), and "unknown" (18.3%, n = 45).
Eighteen patients with recurring RHS were more likely to be male (p = 0.008).
In 61 visits where radiography was performed, patients were older (p = 0.03),
with a higher frequency seen in non-pull and unknown mechanism (p = 0.0001). No
significant difference was found in frequency of radiographs obtained in regard
to physician training (p = 0.4660).
CONCLUSION:
RHS can result from a myriad of mechanisms. We found that recurrence was more
likely in male patients. Factors associated with radiographic evaluation
included atypical mechanism, older age, and unclear history, regardless of
physician training background.
6. Clinical Policy: Critical Issues in the Initial Evaluation
and Management of Patients Presenting to the ED in Early Pregnancy
Hahn SA, et
al. Ann Emerg Med 2017;69(2):241–250.e20.
This clinical
policy from the American College of Emergency Physicians is an update of the
2012 Clinical Policy: Critical Issues in the Initial Evaluation and Management
of Patients Presenting to the Emergency Department in Early Pregnancy.1
A writing
subcommittee reviewed the literature to derive evidence-based recommendations
to help clinicians answer the following critical questions: (1) Should the
emergency physician obtain a pelvic ultrasound in a clinically stable pregnant
patient who presents to the emergency department with abdominal pain and/or
vaginal bleeding and a β-human chorionic gonadotropin (β-hCG) level below a
discriminatory threshold? (2) In patients who have an indeterminate
transvaginal ultrasound result, what is the diagnostic utility of β-hCG for
predicting possible ectopic pregnancy?
Emergency
physicians frequently evaluate and manage patients with abdominal pain and/or
vaginal bleeding in the first trimester of pregnancy (also referred to here as
“early pregnancy”). Their primary concern in this group of patients is to
identify ectopic pregnancy. The prevalence of ectopic pregnancy in symptomatic
emergency department (ED) patients is as high as 13% in some series, which is
much higher than the incidence in the general population.2, 3
Ultrasound is
part of the usual workup for patients with symptomatic early pregnancy. A
meta-analysis4 and systematic review5 both found that bedside ultrasound
performed by emergency physicians can be used as a screening tool for ectopic
pregnancy; however, a review of the evidence supporting this practice is beyond
the scope of this policy. The term bedside ultrasound is used here to refer to
pelvic ultrasounds that are performed in the ED by the emergency clinician,
rather than in the radiology department. In this clinical policy, the term
pelvic ultrasound implies the use of a transvaginal approach unless
transabdominal images have identified an intrauterine pregnancy. According to
the 2014 American College of Emergency Physicians (ACEP) policy statement
“Emergency Ultrasound Imaging Criteria Compendium,” the primary indication for
bedside ultrasound of the pelvis is to evaluate for the presence of
intrauterine pregnancy, thus minimizing the likelihood of an ectopic pregnancy
when modifying factors such as infertility treatment (putting patients at risk
of heterotopic pregnancy) are not present.6 The multidisciplinary association
the American Institute of Ultrasound in Medicine (AIUM) further specifies that
the definitive diagnosis of an intrauterine pregnancy be based on visualizing
an intrauterine gestational sac containing a yolk sac or embryo-fetus with
cardiac activity.7 A bedside ultrasonographer may or may not visualize the
adnexa. A comprehensive ultrasound, in contrast, is usually performed in a
radiology department and is expected to include views of the uterus, adnexa,
and cul-de-sac. Studies using either or both categories of ultrasound were
reviewed and this distinction is highlighted in the text and Evidentiary Table.
Ultrasound
has facilitated the evaluation of complications of early pregnancy; however,
diagnostic algorithms still vary considerably among providers and institutions.
Algorithms guiding the evaluation of abdominal pain or vaginal bleeding in
early pregnancy generally incorporate the results of quantitative serum β-human
chorionic gonadotropin (β-hCG) measurements and pelvic ultrasonography. Many
algorithms apply the principle of the discriminatory threshold that
historically has been defined as the level at which the sensitivity of
ultrasound is thought to approach 100% for the detection of intrauterine
pregnancy for the presumptive diagnosis of ectopic pregnancy if an intrauterine
pregnancy is not visualized when the β-hCG is above that defined cutoff. This threshold
depends on the ultrasound criteria used to define an intrauterine pregnancy and
is institution, operator, and patient dependent, but is commonly reported as
ranging from 1,000 to 2,000 mIU/mL for transvaginal sonography performed in the
radiology department.8, 9 Although the traditionally defined discriminatory
threshold has been widely accepted, its applicability to ED practice is not as
well established, and the concept itself has been called into question.10, 11
For these reasons, this policy refers to the term “discriminatory threshold”
where necessary but does not endorse the concept or refer to any specific β-hCG
cutoff level.
The first
critical question deals with the diagnostic and management variability that
occurs when the clinician obtains a β-hCG result, and it is below a commonly
defined discriminatory threshold. Some clinicians may not perform an ultrasound
for these patients because of incorrect assumptions (eg, ectopic pregnancy is
unlikely because the β-hCG level is low, because of a misunderstanding that the
risk of rupture is low in this subgroup). However, it is well documented that
ectopic pregnancies can present at almost any β-hCG level, high or low,8 and
rupture has been documented at very low β-hCG levels.8, 12 In addition, ultrasound
determination of pregnancy location for symptomatic patients has been
designated as a Centers for Medicare & Medicaid Services (CMS) Core Quality
Measure, with few exclusions such as lack of ultrasound availability. A β-hCG
level is not part of the inclusion or exclusion criteria for this CMS core
measure.13
The emergency
physician is faced with another diagnostic and management question when an
ultrasound result is described as indeterminate, “nondiagnostic,” or a
“pregnancy of unknown location.” The second critical question examines this
subgroup of patients with indeterminate ultrasound results and addresses
whether the initial β-hCG level can help risk-stratify these patients….
7. Chest Pain Studies
A.
Finally! High-sensitive Trops approved by FDA for use in the U.S.
Breakthrough
development for Americans with suspected heart attack - Next generation
Troponin T test from Roche cleared by FDA
INDIANAPOLIS,
Jan. 19, 2017 /PRNewswire/ -- Roche (SIX: RO, ROG; OTCQX: RHHBY) announced that
it has received the 510(k) clearance for its Elecsys Troponin T Gen 5 STAT (TnT
Gen 5 STAT) blood test for patients with a suspected heart attack. With this
clearance, Roche is the first IVD company in the U.S. to provide the next
generation Troponin testing for patients as an aid in the diagnosis of
myocardial infarction, enabling clinicians to more accurately identify patients
experiencing a heart attack.
Every minute
counts
Every 43
seconds someone in the U. S. has a heart attack, or acute myocardial infarction
(AMI), which occurs when the blood supply to an area of the heart is
interrupted. The longer time the heart is without proper blood supply, the
greater the damage. Troponin, a specific
marker of cardiac cell death, is released into the blood stream when cardiac
cells are being damaged.
Patients with
chest pain and other symptoms suggestive of AMI account for approximately 8
million of all emergency room consultations in the U.S., but only a fraction of
them (5-20%) are actually having an AMI. Hence, fast and accurate diagnosis of
AMI requires sensitive diagnostic tests that can detect early troponin release,
allowing healthcare providers to make confident clinical decisions for their
patients and appropriately manage hospital resources. In a heart attack, early
diagnosis and initiation of treatment can reduce the amount of cardiac cell death
thus potentially saving and improving quality of lives. This next generation
Troponin T test from Roche is able to provide accuracy at lower levels of
troponin to aid in correctly identifying patients having an AMI.
Moreover,
this next generation of TnT test from Roche has been available in the rest of
the world for the past seven years during which time it has been rapidly
adopted by clinicians and its clinical diagnostic utility is supported by more
than 600 peer-reviewed publications.
"As an
emergency doctor whose job is to make decisions on patients with chest pain, my
ability to do this safely and accurately is driven by the sensitivity of the
troponin assay. FDA clearance of this new Roche TnT assay is easily the best
news in the last decade for emergency medicine patients presenting with chest
pain." Frank Peacock MD, FACEP – ED Physician, Baylor Medical Center
Houston – Houston, TX
B.
Observation Status or Inpatient Admission: Impact of Patient Disposition on
Outcomes and Utilization among ED Patients w/ CP
Bellolio MF,
et al. Acad Emerg Med. 2017 Feb;24(2):152-160.
OBJECTIVES:
to compare healthcare utilization including coronary angiography, percutaneous
coronary intervention (PCI), rehospitalization, and rate of subsequent acute
myocardial infarction (AMI) within 30 days, among patients presenting to the
emergency department (ED) with chest pain admitted as short-term inpatient (≤2
days) versus observation (in-ED observation units combined with in-hospital
observation).
METHODS: We
identified adults diagnosed with acute chest pain in the ED from 2010 to 2014
using administrative claims from privately insured and Medicare Advantage.
Patients having AMI during the index visit were excluded. One-to-one
propensity-score matching and logistic regression were used. Odds ratios (ORs)
with 95% confidence intervals (CIs) were reported.
RESULTS: A
total of 774,017 chest pain visits were included. After matching, healthcare
utilization was lower among observation versus short inpatient, with 10.9%
versus 24.4% (OR = 0.38, 95% CI = 0.36 to 0.39) undergoing cardiac
catheterization and 1.8% versus 7.6% (OR = 0.23, 95% CI = 0.21 to 0.24) having
PCI. The incidence of subsequent AMI within the following 30 days was similar
in patients admitted as observation versus short inpatient (0.23% vs. 0.21%; OR
= 1.09, 95% CI = 0.84 to 1.42).
CONCLUSIONS:
There were higher rates of cardiac catheterization and PCI among those admitted
as a short inpatient compared to observation, while the incidence of subsequent
AMI within 30 days was similar.
8. The Conversation Placebo
Ofrijan D. NY
Times, 2017 Jan 19
In my daily
work as a primary care internist, I see no letup from pain. Every single
patient, it seems, has an aching shoulder or a bum knee or a painful back. “Our
bodies evolved to live about 40 years,” I always explain, “and then be finished
off by a mammoth or a microbe.” Thanks to a century of staggering medical
progress, we now live past 80, but evolution hasn’t caught up; the cartilage in
our joints still wears down in our 40s, and we are more obese and more
sedentary than we used to be, which doesn’t help.
So it’s no
surprise that chronic arthritis and back pain are the second and third most
common non-acute reasons that people go to the doctor and that pain costs
America up to $635 billion annually. The pain remedies developed by the
pharmaceutical industry are only modestly effective, and they have side effects
that range from nausea and constipation to addiction and death.
What’s often
overlooked is that the simple conversation between doctor and patient can be as
potent an analgesic as many treatments we prescribe.
In 2014,
researchers in Canada did an interesting study about the role of communication
in the treatment of chronic back pain. Half the patients in the study received
mild electrical stimulation from physical therapists, and half received sham
stimulation (all the equipment is set up, but the electrical current is never
activated). Sham treatment — placebo — worked reasonably well: These patients experienced
a 25 percent reduction in their levels of pain. The patients who got the real
stimulation did even better, though; their pain levels decreased by 46 percent.
So the treatment itself does work.
Each of these
groups was further divided in half. One half experienced only limited
conversation from the physical therapist. With the other half, the therapists
asked open-ended questions and listened attentively to the answers. They
expressed empathy about the patients’ situation and offered words of encouragement
about getting better.
Patients who
underwent sham treatment but had therapists who actively communicated reported
a 55 percent decrease in their pain. This is a finding that should give all
medical professionals pause: Communication alone was more effective than
treatment alone. The patients who got electrical stimulation from engaged
physical therapists were the clear winners, with a 77 percent reduction in
pain.
This type of
study provides hard evidence for what shamans, witch doctors and assorted
mystics have known for millenniums: A substantial portion of “healing” comes
from the communication and connection with the patient.
Before we had
treatments that could actually counteract the pathology of disease —
antibiotics, chemotherapy, stents, organ transplants, transfusions — placebo
was the mainstay of medical care, and in many cases it was remarkably
effective.
A good
example is patients suffering from vague diffuse pains with no discernible
cause. Frequently my patients ask if a multivitamin will give them more energy.
In the past I would say no, because there are no significant scientific studies
to demonstrate this, and also because in the absence of a vitamin deficiency
there’s not much for a basic multivitamin pill to do. Now I take a different
approach. I say something along the lines of “Many of my patients find that
they have more energy when they take a multivitamin.” I’m not lying, because
many have indeed said so. Without fail, there are always a few patients who
come back at the next visit and swear they feel much better.
There are
some who argue that it is unethical to promote placebos to patients. But
increasingly, many say it would be unethical not to give placebos a try in
situations where patients are not getting relief from traditional means (and
where it would not cause harm or replace a necessary treatment).
It’s clear
that how doctors and nurses communicate their treatment can have profound
effects on how patients experience the results of that treatment. Yet the
conversation between doctors and patients is one of the least valued aspects of
medical care…
The remainder
of the essay: https://www.nytimes.com/2017/01/19/opinion/sunday/the-conversation-placebo.html
9. Managing Migraine
Friedman BW.
Ann Emerg Med. 2017;69(2):202-7.
Migraine is a
recurrent headache disorder that afflicts 18% of US women and 9% of US men.1 It
causes at least 1.2 million visits to US emergency department (EDs) annually;
the actual number is probably substantially larger because many migraine
patients are assigned nonspecific headache diagnostic codes.2 Migraine
severity, as measured by the frequency with which it disrupts a patient’s life,
ranges from minimal to severe. On one end of this spectrum are patients who
have occasional headaches that are rapidly and effectively treated with
over-the-counter therapies. On the other end are patients with chronic
migraine. They have headache on more days than not and their work and social
life is detrimentally affected.
An aura is
one of several reversible neurologic phenomena that precede the headache and
resolve completely. Most commonly, these are visual or sensory, although they
may involve motor function or speech. Migraine patients also frequently report
neurologic phenomena including dizziness, sensory disturbances, and visual
symptoms during the acute attack. Because they occur during the headache, these
latter symptoms are not typically referred to as aura. The migraine prodrome is
a constellation of symptoms that precede the acute migraine attack by several
days and include changes in mood, alertness, and appetite. Allodynia, an
alteration of nociception that causes typically non-noxious sensory stimuli
(such as brushing one’s hair or shaving one’s face) to be perceived as painful,
develops as acute migraine duration increases. This is thought to indicate
involvement of higher-order central nervous system sensory relay stations,
notably, the thalamus.
Migraine was
once believed to be a vascular headache. Advanced imaging studies do not
support this description and indicate that migraine is a neurologic disorder
involving dysfunctional nociceptive processing.3 Abnormally activated sensory
pathways turn non-noxious stimuli into headache, photophobia, phonophobia, and
osmophobia. Cortical spreading depression, a slow wave of brain depolarization,
underlies migraine aura but has not been demonstrated clearly in migraine
patients without aura….
The remainder
of the review (full-text free): http://www.annemergmed.com/article/S0196-0644(16)30301-8/fulltext
10. Images in Clinical Practice
Gas in the
Left Atrium and Ventricle
Eosinophilic
Otitis Media
Calcific
Pancreatitis Associated with Alcohol Use
Taenia solium
Swirl Sign —
Intestinal Volvulus after Roux-en-Y Gastric Bypass
Intraabdominal
vibrator due to a vaginal cuff dehiscence
Infant With
Acute Respiratory Distress
EM-RAP
Discussion: The Neonatal Airway and the Goldilocks Phenomenon
Young Male
With Stab Wound
Woman With
Altered Behavior
Young Man
With Sudden Onset of Shortness of Breath
Man With
Stridor
Elderly
Female With Acute Vision Loss
Woman With
Progressively Worsening Retiform Purpura
An Infant
With Fever and Rash
Young Boy
With Rash
11. Endotracheal Intubation Studies from JAMA
A.
Negative Association between Tracheal Intubation During Adult In-Hospital
Cardiac Arrest and Survival
Andersen LW,
et al. JAMA. 2017;317(5):494-506.
Key
Points
Question Is tracheal intubation during adult
in-hospital cardiac arrest associated with survival?
Findings In a study of 86 628 adults with in-hospital
cardiac arrest using a propensity-matched cohort, tracheal intubation within
the first 15 minutes was associated with a significantly lower likelihood of
survival to hospital discharge compared with not being intubated (16.3% vs
19.4%, respectively).
Meaning These findings do not support early tracheal
intubation for adult in-hospital cardiac arrest.
Abstract
Importance Tracheal intubation is common during adult
in-hospital cardiac arrest, but little is known about the association between
tracheal intubation and survival in this setting.
Objective To determine whether tracheal intubation
during adult in-hospital cardiac arrest is associated with survival to hospital
discharge.
Design,
Setting, and Participants Observational
cohort study of adult patients who had an in-hospital cardiac arrest from
January 2000 through December 2014 included in the Get With The
Guidelines–Resuscitation registry, a US-based multicenter registry of
in-hospital cardiac arrest. Patients who had an invasive airway in place at the
time of cardiac arrest were excluded. Patients intubated at any given minute
(from 0-15 minutes) were matched with patients at risk of being intubated
within the same minute (ie, still receiving resuscitation) based on a
time-dependent propensity score calculated from multiple patient, event, and
hospital characteristics.
Exposure Tracheal intubation during cardiac arrest.
Main Outcomes
and Measures The primary outcome was
survival to hospital discharge. Secondary outcomes included return of
spontaneous circulation (ROSC) and a good functional outcome. A cerebral
performance category score of 1 (mild or no neurological deficit) or 2
(moderate cerebral disability) was considered a good functional outcome.
Results The propensity-matched cohort was selected
from 108 079 adult patients at 668 hospitals. The median age was 69 years
(interquartile range, 58-79 years), 45 073 patients (42%) were female, and
24 256 patients (22.4%) survived to hospital discharge. Of 71 615 patients
(66.3%) who were intubated within the first 15 minutes, 43 314 (60.5%) were
matched to a patient not intubated in the same minute. Survival was lower among
patients who were intubated compared with those not intubated: 7052 of 43 314
(16.3%) vs 8407 of 43 314 (19.4%), respectively (risk ratio [RR] = 0.84; 95%
CI, 0.81-0.87; P less than .001). The proportion of patients with ROSC was
lower among intubated patients than those not intubated: 25 022 of 43 311
(57.8%) vs 25 685 of 43 310 (59.3%), respectively (RR = 0.97; 95% CI,
0.96-0.99; P less than .001). Good functional outcome was also lower among
intubated patients than those not intubated: 4439 of 41 868 (10.6%) vs 5672 of
41 733 (13.6%), respectively (RR = 0.78; 95% CI, 0.75-0.81; P less than .001).
Although differences existed in prespecified subgroup analyses, intubation was
not associated with improved outcomes in any subgroup.
Conclusions
and Relevance Among adult patients with
in-hospital cardiac arrest, initiation of tracheal intubation within any given
minute during the first 15 minutes of resuscitation, compared with no
intubation during that minute, was associated with decreased survival to
hospital discharge. Although the study design does not eliminate the potential
for confounding by indication, these findings do not support early tracheal
intubation for adult in-hospital cardiac arrest.
B.
Video Laryngoscopy vs Direct Laryngoscopy on Successful First-Pass Orotracheal
Intubation Among ICU Patients: A Randomized Clinical Trial
Lascarrou JB,
et al. JAMA. 2017;317(5):483-493.
Key Points
Question: Should
video laryngoscopy be used for orotracheal intubation in the intensive care
unit (ICU) despite conflicting evidence that it improves the first-pass success
rate?
Findings:
Video laryngoscopy for orotracheal intubation in the ICU did not improve the
first-pass success rate compared with conventional direct laryngoscopy (67.7%
vs 70.3%, respectively).
Meaning:
Video laryngoscopy did not improve the frequency of successful first-pass intubation
in the ICU.
Abstract
Importance In the intensive care unit (ICU), orotracheal
intubation can be associated with increased risk of complications because the
patient may be acutely unstable, requiring prompt intervention, often by a
practitioner with nonexpert skills. Video laryngoscopy may decrease this risk
by improving glottis visualization.
Objective To determine whether video laryngoscopy
increases the frequency of successful first-pass orotracheal intubation
compared with direct laryngoscopy in ICU patients.
Design,
Setting, and Participants Randomized
clinical trial of 371 adults requiring intubation while being treated at 7 ICUs
in France between May 2015 and January 2016; there was 28 days of follow-up.
Interventions Intubation using a video laryngoscope
(n = 186) or direct laryngoscopy (n = 185). All patients received general
anesthesia.
Main Outcomes
and Measures The primary outcome was the
proportion of patients with successful first-pass intubation. The secondary
outcomes included time to successful intubation and mild to moderate and severe
life-threatening complications.
Results Among 371 randomized patients (mean [SD] age,
62.8 [15.8] years; 136 [36.7%] women), 371 completed the trial. The proportion
of patients with successful first-pass intubation did not differ significantly
between the video laryngoscopy and direct laryngoscopy groups (67.7% vs 70.3%;
absolute difference, −2.5% [95% CI, −11.9% to 6.9%]; P = .60). The proportion
of first-attempt intubations performed by nonexperts (primarily residents,
n = 290) did not differ between the groups (84.4% with video laryngoscopy vs 83.2%
with direct laryngoscopy; absolute difference 1.2% [95% CI, −6.3% to 8.6%];
P = .76). The median time to successful intubation was 3 minutes (range, 2 to 4
minutes) for both video laryngoscopy and direct laryngoscopy (absolute
difference, 0 [95% CI, 0 to 0]; P = .95). Video laryngoscopy was not associated
with life-threatening complications (24/180 [13.3%] vs 17/179 [9.5%] for direct
laryngoscopy; absolute difference, 3.8% [95% CI, −2.7% to 10.4%]; P = .25). In
post hoc analysis, video laryngoscopy was associated with severe
life-threatening complications (17/179 [9.5%] vs 5/179 [2.8%] for direct
laryngoscopy; absolute difference, 6.7% [95% CI, 1.8% to 11.6%]; P = .01) but
not with mild to moderate life-threatening complications (10/181 [5.4%] vs 14/181
[7.7%]; absolute difference, −2.3% [95% CI, −7.4% to 2.8%]; P = .37).
Conclusions
and Relevance Among patients in the ICU
requiring intubation, video laryngoscopy compared with direct laryngoscopy did
not improve first-pass orotracheal intubation rates and was associated with
higher rates of severe life-threatening complications. Further studies are
needed to assess the comparative effectiveness of these 2 strategies in
different clinical settings and among operators with diverse skill levels.
12. (Minimal!?) Risk of Acute Kidney Injury after IV Contrast
Media Administration.
Hinson JS, et
al. Ann Emerg Med. 2017 Jan 19 [Epub ahead of print]
STUDY
OBJECTIVE: The study objective was to determine whether intravenous contrast
administration for computed tomography (CT) is independently associated with
increased risk for acute kidney injury and adverse clinical outcomes.
METHODS: This
single-center retrospective cohort analysis was performed in a large, urban,
academic emergency department with an average census of 62,179 visits per year;
17,934 ED visits for patients who underwent contrast-enhanced, unenhanced, or
no CT during a 5-year period (2009 to 2014) were included. The intervention was
CT scan with or without intravenous contrast administration. The primary
outcome was incidence of acute kidney injury. Secondary outcomes included new
chronic kidney disease, dialysis, and renal transplantation at 6 months.
Logistic regression modeling and between-groups odds ratios with and without
propensity-score matching were used to test for an independent association
between contrast administration and primary and secondary outcomes. Treatment
decisions, including administration of contrast and intravenous fluids, were
examined.
RESULTS:
Rates of acute kidney injury were similar among all groups. Contrast
administration was not associated with increased incidence of acute kidney
injury (contrast-induced nephropathy criteria odds ratio=0.96, 95% confidence
interval 0.85 to 1.08; and Acute Kidney Injury Network/Kidney Disease Improving
Global Outcomes criteria odds ratio=1.00, 95% confidence interval 0.87 to
1.16). This was true in all subgroup analyses regardless of baseline renal
function and whether comparisons were made directly or after propensity
matching. Contrast administration was not associated with increased incidence
of chronic kidney disease, dialysis, or renal transplant at 6 months.
Clinicians were less likely to prescribe contrast to patients with decreased
renal function and more likely to prescribe intravenous fluids if contrast was
administered.
CONCLUSION:
In the largest well-controlled study of acute kidney injury following contrast
administration in the ED to date, intravenous contrast was not associated with
an increased frequency of acute kidney injury.
Ryan Radecki comments
13. Responsible opioid use in emergency medicine.
A.
Opioid-Prescribing Patterns of Emergency Physicians and Risk of Long-Term Use.
Barnett ML,
et al. N Engl J Med. 2017 Feb 16;376(7):663-673. doi: 10.1056/NEJMsa1610524.
Background
Increasing overuse of opioids in the United States may be driven in part by
physician prescribing. However, the extent to which individual physicians vary
in opioid prescribing and the implications of that variation for long-term
opioid use and adverse outcomes in patients are unknown.
Methods We
performed a retrospective analysis involving Medicare beneficiaries who had an
index emergency department visit in the period from 2008 through 2011 and had
not received prescriptions for opioids within 6 months before that visit. After
identifying the emergency physicians within a hospital who cared for the
patients, we categorized the physicians as being high-intensity or
low-intensity opioid prescribers according to relative quartiles of prescribing
rates within the same hospital. We compared rates of long-term opioid use,
defined as 6 months of days supplied, in the 12 months after a visit to the
emergency department among patients treated by high-intensity or low-intensity
prescribers, with adjustment for patient characteristics.
Results Our
sample consisted of 215,678 patients who received treatment from low-intensity
prescribers and 161,951 patients who received treatment from high-intensity
prescribers. Patient characteristics, including diagnoses in the emergency
department, were similar in the two treatment groups. Within individual
hospitals, rates of opioid prescribing varied widely between low-intensity and
high-intensity prescribers (7.3% vs. 24.1%). Long-term opioid use was
significantly higher among patients treated by high-intensity prescribers than
among patients treated by low-intensity prescribers (adjusted odds ratio, 1.30;
95% confidence interval, 1.23 to 1.37; P less than 0.001); these findings were
consistent across multiple sensitivity analyses.
Conclusions
Wide variation in rates of opioid prescribing existed among physicians
practicing within the same emergency department, and rates of long-term opioid
use were increased among patients who had not previously received opioids and
received treatment from high-intensity opioid prescribers.
B.
Something for pain: Responsible opioid use in emergency medicine.
Strayer RJ,
et al. Am J Emerg Med. 2017 Feb;35(2):337-341.
The United
States is currently experiencing a public health crisis of opioid addiction,
which has its genesis in an industry marketing effort that successfully
encouraged clinicians to prescribe opioids liberally, and asserted the safety
of prescribing opioids for chronic non-cancer pain, despite a preponderance of
evidence demonstrating the risks of dependence and misuse. The resulting rise
in opioid use has pushed drug overdose deaths in front of motor vehicle
collisions to become the leading cause of accidental death in the country.
Emergency providers frequently treat patients for complications of opioid
abuse, and also manage patients with acute and chronic pain, for which opioids
are routinely prescribed. Emergency providers are therefore well positioned to
both prevent new cases of opioid misuse and initiate appropriate treatment of
existing opioid addicts. In opioid-naive patients, this is accomplished by a
careful consideration of the likelihood of benefit and harm of an opioid prescription
for acute pain. If opioids are prescribed, the chance of harm is reduced by
matching the number of pills prescribed to the expected duration of pain and
selecting an opioid preparation with low abuse liability. Patients who present
to acute care with exacerbations of chronic pain or painful conditions
associated with opioid misuse are best managed by treating symptoms with opioid
alternatives and encouraging treatment for opioid addiction.
C.
Opioids and the Emergency Physician: Ducking Between Pendulum Swings (replay from August 2016 Lit Bits)
Yealy DM, et
al. Ann Emerg Med. 2016;68:209-212.
In the late
1980s, undertreated pain became a focus of many clinicians, investigators, and
industry. We coined a term, oligoanalgesia, to embolden earlier, titrated
opioids and other analgesic use. Regulators mandated pain assessments and
actions as a part of health care facility credentialing, and the prescribing of
opioids increased yearly from 1990 to 2010.
We now sit
amid another opioid epidemic with death and disability. Many know of the
patterns of use and abuse near the turn of the 20th century when opium was a
new agent; this triggered opioid regulations and control, notably, the US
Harrison Narcotics Tax Act of 1914 criminalizing nonmedical use. Despite
regulation of opioids, swings upward in medical and nonmedical use exist in
recent modern times. For example, a 1959 Readers Digest article noted a current opioid addiction
crisis, reminding us that the cycles reappear often, with varying frequency,
responses, and consequences.
The current
opioid upswing is rooted in prescribed and illicit use, the latter including
heroin (or other “street” opioids) and diversion of another’s or factitious
gain of a prescribed opioid. The widespread increase in opioid use correlates
with increased overdose deaths and deaths in all segments, including more
affluent and suburban or rural groups, not just in an inner-city or isolated
population. Although the peak of the current wave crested in approximately
2010, we retain a large group with this affliction. This triggered calls for
regulation and control in many facets of opioid deployment, including emergency
care, despite few data suggesting a clear link between emergency department
(ED) opioid use and later harm. Some seek governmental ED dose restrictions,
and others call for “an opioid-free ED.” The goal of these calls to action is
good: to avoid opioid harm, notably, death. At the same time, we seek to
provide relief of pain and wonder how our acute care episode affects the
broader epidemic.
With all the
dialogue, emergency physicians seek the answer to the question, “What am I
supposed to do: skip the pain relief that an opioid delivers or risk addiction
and overdose in some fraction of patients?”…
…More
important in assessing the risk is knowing how often ED opioid analgesia turns
patients into addicts. The data from Butler et al may help us estimate this
risk. Our crude estimate indicates that 1 new heroin abuser might result from
the administration of opioids to approximately 7,864 ED patients. An emergency
physician administering opioids in the usual fashion could “prime” a new heroin
addict once every 3 to 4 years of full-time practice. The number of total new
heroin abusers attributable to first ED exposures appears to approximate 3,179
annually, a 1.1% contribution to the total US heroin addiction burden. Although
the precise numbers we calculated could be inaccurate, we doubt these are
differences of orders of magnitude, retaining the basic relationship. On top of
this calculation, we posit that a much smaller unknown fraction will experience
overdose or death, the group driving calls for action...
Chen et al report
an opioid prescription analysis that includes 68% of the roughly 50 million US
residents with Medicare insurance, finding that emergency physicians were ninth
of the 25 specialties represented when the total number of opioid schedule II
prescriptions were ranked. Indeed, physicians in the 8 higher-ranking
specialties—most primary care or pain management—collectively wrote more than
25 times as many opioid prescriptions as emergency physicians did. In terms of
opioid prescriptions per individual physician, emergency physicians ranked very
low—18th of the 25 specialties. Although Medicare data sets do not include all
US residents, it is unlikely that another analysis could assign a more
prominent role in the opioid crisis to emergency physicians, tempering the need
for aggressive ED reduction efforts. When the number and type of ED discharge
opioid doses were examined, recent observations showed that prudence is common,
with a regimen of usually 20 doses or fewer of a moderate-potency, short-acting
agent. Not surprising is that efforts that have succeeded in cutting overdoses
and deaths targeted the high-frequency prescribers and dispensers rather than
ED prescribing.
Despite these
observations, some EDs are implementing policies to decrease all opioid
prescribing. One such approach withholds opioids for patients with migraine or
preexisting back pain, those unable to obtain timely refills from their primary
care provider, and those with any
previous opioid therapy from another physician. Many ED patients,
particularly the poor, lack short-notice access to their primary care
physicians. Are the sharp reductions in opioid use observed improving overall
ED patient health or are they mostly symbolic? How many patients should have
less relief to avoid the very small chance of downstream potential opioid
abuse? We can only estimate, but the numbers are high, depending on the
reduction in opioid prescribing sought.
The data from
Butler et al make it clear that we don’t
need to take a blanket approach to refusing opioids because patients who linked
an ED opioid exposure to heroin use are often men, young (average age of 18
years at first exposure), and with previous drug abuse, known commonalities for
heroin abuse. The real value in meaningful ED opioid-prescribing reduction
efforts is in focusing, especially on the addiction prone and those with opioid
abuse or a diversion history. Said more clearly, we doubt providing
short-course hydrocodone for Grandma’s flare of diverticulitis will drive her
into the streets for heroin; writing an opioid prescription for those who
“lost” their opioid is much more likely to trigger or enhance abuse and harm.
The zeal to
avoid oligoanalgesia encouraged opioid prescribing for some patients when
alternatives were a better choice; we wonder whether the backlash calling for
“opioid-free EDs” or marked restrictions such as “only give 2 to 3 days” may
create a different version of suboptimal care. We are uncertain what exactly “2
to 3 days” of analgesia entails, given the variability of need; can we
accurately estimate how many doses are needed to ease pain with an acute fracture
(opioids have a wide titration response range)
and then ensure follow-up by the
fourth day after the ED visit?
We think a
better ED approach to limiting opioid addiction entails avoiding frequent ED
opioid refills, placing prescription monitoring data at emergency providers’
fingertips during care, recognizing abuse patterns during an ED visit, and
addressing and regularly considering alternative analgesic options—but not
broad opioid restrictions. Let’s avoid a pendulum swing toward castigation or shackling
of emergency providers seeking to responsibly relieve acute pain. ED opioids
are a minor contributor to the current scourge of opioid addiction, with a
likely far greater influence on this epidemic coming through the targeting of
high-volume prescribers and illicit heroin sources.
14. ED Presentation of Patients with Spontaneous Coronary Artery
Dissection.
Lindor RA, et
al. J Emerg Med. 2017;52(3):286-91.
BACKGROUND:
Spontaneous coronary artery dissection (SCAD) is an infrequently recognized but
potentially fatal cause of acute coronary syndrome (ACS) that
disproportionately affects women. Little is currently known about how patients
with SCAD initially present.
OBJECTIVES:
We sought to describe patients who presented to the emergency department (ED)
with symptoms of SCAD to improve providers' awareness and recognition of this
condition.
PATIENTS AND
METHODS: We performed a retrospective medical record review of all patients who
presented to the ED of a single academic medical center from January 1, 2002
through October 31, 2015 and were subsequently diagnosed with SCAD by
angiography. These patients were identified by International Classification of
Diseases, Ninth Revision codes and a Boolean search of the diagnosis field of
the medical record. Data regarding patients' presentations and course were
abstracted by two independent reviewers.
RESULTS: We
identified 20 episodes of SCAD involving 19 patients, all of whom were female.
The majority of patients had 0-1 conventional cardiovascular disease risk
factors. Most patients had chest pain (85%), initial electrocardiograms without
evidence of ischemia (85%), and elevated initial troponin (72%). The most
common diagnosis in providers' differential was acute coronary syndrome (ACS).
CONCLUSION:
Patients with SCAD present with similar symptoms compared to patients with ACS
caused by atherosclerotic disease, but have different risk profiles. Providers
should consider SCAD in patients presenting with symptoms concerning for ACS,
especially in younger female patients without traditional cardiovascular
disease risk factors, as their risk may be significantly underestimated with
commonly used ACS risk-stratifiers.
15. Lidocaine Pretreatment Reduces the Discomfort of Intranasal
Midazolam Administration: A Randomized, Double-blind, Placebo-controlled Trial.
Smith D, et
al. Acad Emerg Med. 2017 Feb;24(2):161-167.
OBJECTIVE:
Intranasal (IN) midazolam is a commonly prescribed medication for pediatric
sedation and anxiolysis. One of its most frequently encountered adverse effects
is discomfort with administration. While it has been proposed that
premedicating with lidocaine reduces this undesirable consequence, this combination
has not been thoroughly researched. The objective of our study was to assess
whether topical lidocaine lessens the discomfort associated with IN midazolam
administration.
METHODS: This
was a double-blind, randomized, placebo-controlled trial performed in an urban,
academic pediatric emergency department. Children 6-12 years of age who were
receiving IN midazolam for procedural sedation received either 4% lidocaine or
0.9% saline (placebo) via mucosal atomizer. Subjects were subsequently given IN
midazolam in a similar fashion and then rated their discomfort using the
Wong-Baker FACES Pain Rating Scale (WBS). The primary endpoint of WBS score was
analyzed with a two-tailed Mann-Whitney U-test, with p less than 0.05
considered statistically significant.
RESULTS:
Seventy-seven patients were enrolled over a consecutive 8-month period. One
child was excluded from analysis due to a discrepancy in recording the drug
identification number. Study groups were similar in regard to demographic
information and indication for sedation. Subjects who received IN lidocaine
reported less discomfort with IN midazolam administration (median WBS = 3,
interquartile range [IQR] = 0-6) than those who received placebo (median WBS =
8, IQR = 2-9; p = 0.006).
CONCLUSIONS:
Premedication with topical lidocaine reduces the discomfort associated with
administration of IN midazolam
16. Best Clinical Practice: Controversies in TIA Evaluation and
Disposition in the ED
Long B, et
al. J Emerg Med. 2017;52(3):299-310.
BACKGROUND:
Transient ischemic attack (TIA) affects over 200,000 patients annually in the
United States, and it precedes approximately 14% to 23% of strokes. Patients
are typically admitted for evaluation and management.
OBJECTIVE:
This review investigates the controversies of emergency department (ED)
evaluation of TIA, including imaging, clinical risk scores, rapid diagnostic
protocols, and disposition.
DISCUSSION:
TIA is a common condition, with over 200,000 patients affected annually, and is
associated with risk of stroke. TIA is defined as a brief episode of neurologic
dysfunction with no permanent infarction. A great deal of literature has
evaluated the use of imaging, clinical risk scores, and diagnostic protocols in
the evaluation of TIA. Head computed tomography noncontrast is not reliable to
diagnose acute infarction. Magnetic resonance imaging with diffusion-weighted
imaging displays greater diagnostic ability. Carotid imaging includes magnetic
resonance angiography, computed tomography angiography, and Doppler with
ultrasound. Risk scores that predict future stroke are not reliable when
utilized alone. With imaging, including magnetic resonance imaging, patients
with low-risk scores can be discharged. The use of ED diagnostic protocols and
observation units can reduce length of stay while improving patient treatment
and reducing stroke rate. An algorithm is provided for evaluation and
disposition in the ED.
CONCLUSIONS:
TIA is a condition with high risk for stroke. Imaging is often not reliable,
nor is the use of risk scores alone. The American College of Emergency
Physicians provides a Level B Recommendation for the use of rapid diagnostic
protocols to determine patient short-term risk for stroke while avoiding the
reliance on stratification instruments to discharge patients from the ED.
17. Impact of scribes on ED patient throughput one year after
implementation.
Heaton HA, et
al. Am J Emerg Med. 2017 Feb;35(2):311-314.
OBJECTIVES:
Assess the impact of scribes on an academic emergency department's (ED)
throughput one year after implementation.
METHODS: A
prospective cohort design compared throughput metrics of patients managed when
scribes were and were not a part of the treatment team during pre-defined study
hours in a tertiary academic ED with both an adult and pediatric ED. An
alternating-day pattern one year following scribe implementation ensured
balance between the scribe and non-scribe groups in time of day, day of week,
and patient complexity.
RESULTS:
Adult: Overall length of stay (LOS) was essentially the same in both groups
(214 vs. 215min, p=0.34). In area A where staffing includes an attending and
residents, scribes made a significant impact in treatment room time in the
afternoon (190 vs 179min, p=0.021) with an increase in patients seen per hour on
scribed days (2.00 vs. 2.13). There was no statistically significant changes in
throughput metrics in area B staffed by an attending and a nurse
practitioner/physician assistant, however scribed days did average more
patients per hour (2.01 vs. 2.14). Pediatric: All throughput measurements were
significantly longer when the treatment team had a scribe; however, patients
per hour increased from 2.33 to 2.49 on scribed days.
CONCLUSIONS:
Overall patient throughput was not enhanced by scribes. Certain areas and
staffing combinations yielded improvements in treatment room and door to
provider time, however, scribes appear to have enabled attending physicians to
see more patients per hour. This effect varied across treatment areas and times
of day.
18. Leukoaraiosis predicts ICH after acute stroke thrombolysis
Kongbunkiat K,
et al. Leukoaraiosis, ICH, and functional outcome after acute stroke
thrombolysis Neurology. 2017 Feb 14;88(7):638-645.
OBJECTIVE: To
perform a systematic review and pooled meta-analysis of published studies to
assess whether the presence of leukoaraiosis on neuroimaging before treatment
with thrombolysis (IV or intra-arterial) is associated with an increased risk
of symptomatic intracerebral hemorrhage (sICH) or poor functional outcome.
METHODS: We
included studies of patients with acute ischemic stroke, treated with IV or
intra-arterial thrombolysis, which assessed functional outcome (3-month
modified Rankin Scale [mRS]) or sICH in relation to leukoaraiosis on
pretreatment neuroimaging (CT or MRI). We used random-effects models to
calculate pooled relative risks (RR) of sICH and poor functional outcome (mRS ≥
2) for any vs no leukoaraiosis (using any rating scale) and for no to mild vs
moderate to severe leukoaraiosis (using the Van Swieten or Fazekas Schmidt
scale).
RESULTS: We
identified 15 studies (total n = 6,967). For sICH outcome, the RR was 1.65 (n =
5,551; 95% confidence interval [CI] 1.26-2.16, p = 0.001) with an absolute risk
(AR) increase of 2.5% for any leukoaraiosis vs none. The RR was 2.4 (n = 4,192;
95% CI 1.83-3.14, p = 0.001) with an AR increase of 6.2% for moderate to severe
vs no to mild leukoaraiosis. For poor functional outcome; the RR was 1.30 (n =
3,401; 95% CI 1.19-1.42, p = 0.001) with an AR increase of 15.4% for any
leukoaraiosis vs none. The RR was 1.31 (n = 3,659; 95% CI 1.22-1.42, p = 0.001)
with an AR increase of 17.5% for moderate to severe vs no to mild
leukoaraiosis. No statistical heterogeneity was noted for any of the analyses.
CONCLUSIONS:
Leukoaraiosis presence and severity are consistently associated with an increased
risk of sICH and poor functional outcome after IV or intra-arterial
thrombolysis for acute ischemic stroke.
Full-text
(free): http://www.neurology.org/content/early/2017/01/27/WNL.0000000000003605.full.pdf+html
19. Associations of ED LOS with Publicly Reported
Quality-of-care Measures.
Chang AM, et
al. Acad Emerg Med. 2017 Feb;24(2):246-250.
OBJECTIVE:
The Institute of Medicine identified emergency department (ED) crowding as a
critical threat to patient safety. We assess the association between changes in
publicly reported ED length of stay (LOS) and changes in quality-of-care
measures in a national cohort of hospitals.
METHODS:
Longitudinal analysis of 2012 and 2013 data from the American Hospital
Association (AHA) Survey, Center for Medicare and Medicaid Services (CMS) Cost
Reports, and CMS Hospital Compare. We included hospitals reporting Hospital
Compare timeliness measure of LOS for admitted patients. We used AHA and CMS
data to incorporate hospital predictors of interest. We used the method of
first differences to test for relationships in the change over time between
timeliness measures and six hospital-level measures.
RESULTS: The
cohort consisted of 2,619 hospitals. Each additional hour of ED LOS was
associated with a 0.7% decrease in proportion of patients giving a top
satisfaction rating, a 0.7% decrease in proportion of patients who would
"definitely recommend" the hospital, and a 6-minute increase in time
to pain management for long bone fracture (p less than 0.01 for all). A 1-hour
increase in ED LOS is associated with a 44% increase in the odds of having an
increase in left without being seen (95% confidence interval = 25% to 68%). ED
LOS was not associated with hospital readmissions (p = 0.14) or time to
percutaneous coronary intervention (p = 0.14).
CONCLUSION:
In this longitudinal study of hospitals across the United States, improvements
in ED timeliness measures are associated with improvements in the patient
experience.
20. PE in Patients Hospitalized for Syncope: the Controversial
NEJM Study from Italy
The responses from readers in the letters to the editor: N Engl J Med
2017; 376:494-497.
21. No asthma found in one third of adults previously diagnosed
with it
Researchers
blame the high number on misdiagnosis and spontaneous remission
Reevaluation
of Diagnosis in Adults With Physician-Diagnosed Asthma
Aaron SD, et
al. JAMA. 2017;317(3):269-279.
Importance Although asthma is a chronic disease, the
expected rate of spontaneous remissions of adult asthma and the stability of
diagnosis are unknown.
Objective To determine whether a diagnosis of current
asthma could be ruled out and asthma medications safely stopped in randomly
selected adults with physician-diagnosed asthma.
Design,
Setting, and Participants A prospective,
multicenter cohort study was conducted in 10 Canadian cities from January 2012
to February 2016. Random digit dialing was used to recruit adult participants
who reported a history of physician-diagnosed asthma established within the
past 5 years. Participants using long-term oral steroids and participants
unable to be tested using spirometry were excluded. Information from the diagnosing
physician was obtained to determine how the diagnosis of asthma was originally
made in the community. Of 1026 potential participants who fulfilled eligibility
criteria during telephone screening, 701 (68.3%) agreed to enter into the
study. All participants were assessed with home peak flow and symptom
monitoring, spirometry, and serial bronchial challenge tests, and those
participants using daily asthma medications had their medications gradually
tapered off over 4 study visits. Participants in whom a diagnosis of current
asthma was ultimately ruled out were followed up clinically with repeated
bronchial challenge tests over 1 year.
Exposure Physician-diagnosed asthma established within
the past 5 years.
Main Outcomes
and Measures The primary outcome was the
proportion of participants in whom a diagnosis of current asthma was ruled out,
defined as participants who exhibited no evidence of acute worsening of asthma
symptoms, reversible airflow obstruction, or bronchial hyperresponsiveness
after having all asthma medications tapered off and after a study pulmonologist
established an alternative diagnosis. Secondary outcomes included the
proportion with asthma ruled out after 12 months and the proportion who
underwent an appropriate initial diagnostic workup for asthma in the community.
Results Of 701 participants (mean [SD] age, 51 [16]
years; 467 women [67%]), 613 completed the study and could be conclusively
evaluated for a diagnosis of current asthma. Current asthma was ruled out in
203 of 613 study participants (33.1%; 95% CI, 29.4%-36.8%). Twelve participants
(2.0%) were found to have serious cardiorespiratory conditions that had been
previously misdiagnosed as asthma in the community. After an additional 12
months of follow-up, 181 participants (29.5%; 95% CI, 25.9%-33.1%) continued to
exhibit no clinical or laboratory evidence of asthma. Participants in whom
current asthma was ruled out, compared with those in whom it was confirmed,
were less likely to have undergone testing for airflow limitation in the
community at the time of initial diagnosis (43.8% vs 55.6%, respectively;
absolute difference, 11.8%; 95% CI, 2.1%-21.5%).
Conclusions
and Relevance Among adults with
physician-diagnosed asthma, a current diagnosis of asthma could not be
established in 33.1% who were not using daily asthma medications or had
medications weaned. In patients such as these, reassessing the asthma diagnosis
may be warranted.
22. Micro Bits
A. The Flexibility of Truth in the
Information Age: Research on Bovine Excrement Detection Wins Ig Nobel Prize
Berger E. Ann Emerg Med
2017;69(2):A17-19.
Before discussing the research itself
and its implications, it’s worth relating a few words about the apparent demise
of factual information in the United States. A Chicago Tribune columnist, Rex
Huppke, MA, wrote a tongue-in-cheek “obituary” for Facts 4 years ago, saying
Facts had lived a long life from 360 bc to ad 2012…
B. I’m not a doctor, but I play one on my CV
By Adam RubenJan. Science. Jan 18,
2017.
C. Do vitamin D supplements help prevent
respiratory tract infections?
No.
D. Financial ties of principal investigators
and randomized controlled trial outcomes: cross sectional study
Ahn R, et al. BMJ 2017;356:i6770.
E. 350 Organizations Send Letter to Trump
Touting Vaccines' Safety, Efficacy
Feb. 13, 2017 — The AAFP joined a
broad coalition of more than 350 organizations that sent a letter to President
Donald Trump emphasizing the safety and efficacy of vaccines.
Related: Most US adults favor required
childhood MMR vaccinations
Eighty-two percent of 1,549
adults in the US said they support mandatory measles, mumps and rubella
vaccinations for children in public schools and 88% said that MMR vaccines were
more beneficial than harmful, according to a Pew Research Center survey.
Researchers also found 73% said that decisions on childhood vaccine policies
should be primarily influenced by medical scientists, compared with 25% of
those who cited elected officials.
Washington Post: https://www.washingtonpost.com/news/to-your-health/wp/2017/02/02/trumps-vaccine-views-at-odds-with-those-of-most-americans-study-says
F. Top Preventive Services Recommendations
Ranked by Relative Efficacy: Pediatric Immunizations, Smoking
Cessation/Prevention, Alcohol Misuse, and Obesity Reduction
RESULTS The 3
highest-ranking services, each with a total score of 10, are immunizing
children, counseling to prevent tobacco initiation among youth, and tobacco-use
screening and brief intervention to encourage cessation among adults. Greatest
population health improvement could be obtained from increasing utilization of
clinical preventive services that address tobacco use, obesity-related
behaviors, and alcohol misuse, as well as colorectal cancer screening and
influenza vaccinations.
G. 'Overwhelming Efficacy': Rivaroxaban cut
CV events in coronary and peripheral disease patients
he first large trial of a newer
oral anticoagulant (NOAC) for prevention among coronary artery disease (CAD)
and peripheral artery disease (PAD) -- the COMPASS study -- has been stopped
early for "overwhelming efficacy," Bayer AG and Janssen,
manufacturers of rivaroxaban (Xarelto), announced.
The phase III trial randomized
27,402 CAD and PAD patients to receive either rivaroxaban 2.5 mg twice daily in
addition to aspirin 100 mg once daily, rivaroxaban 5 mg twice daily alone, or
aspirin 100 mg once daily alone.
The trial was stopped a year
ahead of its scheduled completion date following a recommendation by the Data
Monitoring Committee. That committee said the trial reached its prespecified
criteria for superiority on the primary endpoint of first occurrence of either
MI, stroke, or cardiovascular death.
In an open-label extension trial,
patients enrolled in the study will be offered rivaroxaban "owing to the
magnitude of effect and the confirmation of the existing safety profile of
rivaroxaban," the companies announced.
Full results of the study will be
presented later this year at a major medical meeting.
The study: Rivaroxaban for the
Prevention of Major Cardiovascular Events in Coronary or Peripheral Artery
Disease (COMPASS): https://clinicaltrials.gov/ct2/show/NCT01776424
H. NSAIDs during respiratory infections
increases AMI risk
A study in the Journal of
Infectious Diseases found patients who took nonsteroidal anti-inflammatory
drugs during a respiratory infection had a 3.4 times higher risk of heart
attack, compared with a 2.7 times increased risk in patients who did not use
the drugs during a respiratory infection. The findings, based on data for
almost 10,000 patients hospitalized for a heart attack, also showed a 7.2-fold
increased heart attack risk among patients who received the drugs intravenously
while hospitalized.
I. Diabetes is third leading cause of death
in US, study finds
Diabetes accounts for 11.5% and
11.7% of deaths based on self-reported diabetes in the National Health
Interview Survey and the National Health and Nutrition Examination Survey,
respectively, and 11.8% based on HbA1C levels in NHANES, making it the third
leading cause of death in the US, researchers reported in PLOS ONE. Researchers
found that the highest proportion of deaths linked to diabetes was among obese
people at 19.4%.
"Responsibility for
approximately 12% of deaths would make diabetes the third leading cause of
death in the United States in 2010, after diseases of the heart and malignant
neoplasms and ahead of chronic lower respiratory diseases and cerebrovascular
diseases," Drs Stokes and Preston write.
J. AHA: Meal planning, eating breakfast may
lower CVD risk
A scientific statement from the
American Heart Association said meal planning and eating breakfast daily may
help reduce cardiovascular disease risks. The statement, published in the
journal Circulation, also said eating more early in the day and less at night
may reduce the likelihood of cardiac and blood vessel diseases.
K. Prostate Cancer Screening Questions to
Think about for Men Aged 50-74
Video Decision Aids Help Patients
Follow USPSTF Recommendations: http://www.aafp.org/news/health-of-the-public/20170130annfammedvideo.html
L. Sepsis accounts for 12.2% of hospital
readmissions
A study in the Journal of the
American Medical Association showed sepsis accounted for 12.2% of hospital
readmissions, compared with 6.7% for heart failure, 5% for pneumonia, 4.6% for
chronic obstructive pulmonary disease and 1.3% for heart attack, which are
conditions included in a CMS readmission penalty program. Data showed sepsis also
had higher readmission-related costs compared with the other diagnoses.
M. Effect of a Scalp Cooling Device on
Alopecia in Women Undergoing Chemotherapy for Breast Cancer: The SCALP
Randomized Clinical Trial
Question What is the effectiveness of a scalp cooling
device in preventing alopecia in women with breast cancer undergoing
neoadjuvant or adjuvant chemotherapy?
Findings In a randomized clinical trial of 182 women
with breast cancer receiving chemotherapy with a taxane, anthracycline, or
both, those who underwent scalp cooling were significantly more likely to have
less than 50% hair loss compared with no scalp cooling (50.5% vs 0%). The trial
was stopped early for superiority, and there was no effect on measures of
quality of life.
Meaning This scalp cooling system was more likely to
prevent alopecia than no treatment, and further research is needed to assess
longer-term efficacy and adverse effects.
Patient page: http://jamanetwork.com/journals/jama/fullarticle/2601504
