1. Prospective and Explicit Clinical Validation of the Ottawa HF
Risk Scale, with and without Use of Quantitative NT-proBNP.
Stiell IG, et
al. Acad Emerg Med. 2017 Mar;24(3):316-327
OBJECTIVES:
We previously developed the Ottawa Heart Failure Risk Scale (OHFRS) to assist
with disposition decisions for acute heart failure patients in the emergency
department (ED). We sought to prospectively evaluate the accuracy,
acceptability, and potential impact of OHFRS.
METHODS: This
prospective observational cohort study was conducted at six tertiary hospital
EDs. Patients with acute heart failure were evaluated by ED physicians for the
10 OHFRS criteria and then followed for 30 days. Quantitative NT-proBNP was
measured where feasible. Serious adverse event (SAE) was defined as death
within 30 days, admission to monitored unit, intubation, noninvasive
ventilation, myocardial infarction, or relapse resulting in hospital admission
within 14 days.
RESULTS: We
enrolled 1,100 patients with mean (±SD) age 77.7 (±10.7) years. SAEs occurred
in 170 (15.5%) cases (19.4% if admitted and 10.2% if discharged). Compared to
actual practice, using an admission threshold of OHFRS score above 1 would have
increased sensitivity (71.8% vs. 91.8%) but increased admissions (57.2% vs.
77.6%). For 684 cases with NT-proBNP values, using a threshold score above 1
would have significantly increased sensitivity (69.8% vs. 95.8%) while
increasing admissions (60.8% vs. 88.0%). In only 11.9% of cases did physicians
indicate discomfort with use of OHFRS.
CONCLUSION:
Prospective clinical validation found the OHFRS tool to be highly sensitive for
SAEs in acute heart failure patients, albeit with an increase in admission
rates. When available, NT-proBNP values further improve sensitivity. With
adequate physician training, OHFRS should help improve and standardize
admission practices, diminishing both unnecessary admissions for low-risk
patients and unsafe discharge decisions for high-risk patients.
The Ottawa
Heart Failure Risk Scale
2. Choosing Thoracentesis Insertion Sites: Three Alternatives
US-guided
pleural puncture in supine or recumbent lateral position - feasibility study.
Soldati G, et
al. Multidiscip Respir Med. 2013;8(1):18.
BACKGROUND:
The aim of this study is to evaluate feasibility, safety and efficacy of
accessing the pleural space with the patient supine or in lateral recumbent
position, under constant ultrasonic guidance along the costophrenic sinus.
METHODS: All
patients with pleural effusion, referred to thoracentesis or pleural drainage
from February 2010 to January 2011 in two institutions, were drained either
supine or in lateral recumbent position through an echomonitored cannulation of
the costophrenic sinus. The technique is described in detail and an analysis of
safety and feasibility is carried out.
RESULTS: One
hundred and one thoracenteses were performed on 76 patients and 30 pigtail
catheters were inserted in 30 patients (for a total of 131 pleural procedures
in 106 patients enrolled). The feasibility of the procedures was 100% and in
every case it was possible to follow real time needle tip passage in the
pleural space. Ninety eight thoracenteses (97%) and all catheter drainages were
successfully completed. Four thoracenteses were stopped because of the
appearance of complications while no pigtail drainage procedure was stopped.
After 24 hour follow up, one chest pain syndrome (1.3% of completed
thoracenteses) and two pneumothoraces (1.4%) occurred. The mean acquisition
time of pleural space was 76 ± 9 seconds for thoracentesis and 185 ± 46 seconds
for drainage insertion (p less than 0.05).
CONCLUSIONS:
This study highlights the safety and efficacy of this technique of real time
echo-monitored pleural space puncture that offers a more comfortable patient
position, an easier approach for the operator, a very low rate of complications
with short acquisition time of pleural space.
Study Figure (left). Patients’ positions described in the
text: A) supine with head and chest elevated at 30-45°; B) lateral recumbent
with head and chest elevated at 30-45°. Black arrows indicate the site of
pleural procedures.
Excerpt from the Discussion
Thoracentesis
is to date generally performed with the patient sitting at the edge of the bed
and leaning forward with arms resting on a bedside table. Lateral recumbent or
supine positions are limited to patients unable to sit. The advantage of the
above described technique is being easily performed in the lying position thus
increasing patient comfort and reducing vasovagal syncope rate and being as
well easily performed in patients with obligate decubitus for example in
Intensive Care Unit beds.
The lateral
recumbent or supine position with head and chest elevated at 30-45° allows
fluid to accumulate in the deepest part of the pleural space following gravity
as it would be in the “usual” position (patient sitting at the edge of the bed
and leaning forward) making it easily detectable by ultrasound and available
for pleural procedures even if in small quantity.
Textbook Figure 9-11 (right). A-C: Various patient positions for
thoracentesis. Taken from Adler EH, Blok BK. Thoracentesis in Roberts JR, ed. Roberts and Hedges’ Clinical Procedures in
Emergency Medicine, Sixth edition (Philadelphia, PA; Elsevier, 2014),
173-188.e1.
3. New Guidelines
A.
2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients with
Syncope
The goals of
the present guideline are:
• To define
syncope as a symptom, with different causes, in different populations and
circumstances.
• To provide
guidance and recommendations on the evaluation and management of patients with
suspected syncope in the context of different clinical settings, specific
causes, or selected circumstances.
• To identify
key areas in which knowledge is lacking, to foster future collaborative
research opportunities and efforts.
Ryan
Radecki’s Comments: Done Fall Out
This is the
ACC/AHA guideline for evaluation of syncope – and, thankfully, it’s quite
reasonable.
I attribute
this, mostly (and possibly erroneously) to the fantastic ED syncope guru Ben
Sun being on the writing committee. Only a very small part of this document is
devoted to the initial evaluation of syncope in the Emergency Department, and
their strong recommendations boil down to:
•Perform a
history and physical examination
•Perform an
electrocardiogram
•Try to
determine the cause of syncope, and estimate short- and long-term risk
•Don’t send
people home from the hospital if you identify a serious medical cause
These are all
straightforward things we already routinely do as part of our basic evaluation
of syncope. They go on further to clearly state, with weaker recommendations,
there are no other mandated tests – and that routine screening bloodwork,
imaging, or cardiac testing is likely of no value.
With regard
to disposition: “The disposition decision is complicated by varying resources
available for immediate testing, a lack of consensus on acceptable short-term
risk of serious outcomes, varying availability and expertise of outpatient
diagnostic clinics, and the lack of data demonstrating that hospital-based
evaluation improves outcomes.”
B.
American Association for Emergency Psychiatry Task Force on Medical Clearance
of Adults Part I: Introduction, Review and Evidence-Based Guidelines
Introduction:
In the United States, the number of patients presenting to the emergency
department for a mental health concern is significant and expected to grow. The
breadth of the medical evaluation of these patients is controversial. Attempts
have been made to establish a standard evaluation for these patients, but to
date no nationally accepted standards exist.
Objective: A
task force of the American Association of Emergency Psychiatry, consisting of
physicians from Emergency Medicine, physicians from Psychiatry, and a
psychologist was convened to form consensus recommendations on the medical
evaluation of psychiatric patients presenting to emergency departments.
Method: The
task force reviewed existing literature on the topic of medical evaluation of
psychiatric patients in the emergency department (Part I) and then combined
this with expert consensus (Part II)…
4. Pulmonary Embolism Diagnostics and Prognostics
A.
Diagnostic Performance of Wells Score Combined with Point-of-care Lung and
Venous US in Suspected PE
Nazerian P, et
al. Acad Emerg Med. 2017 Mar;24(3):270-280.
OBJECTIVE:
Lung and venous ultrasound are bedside diagnostic tools increasingly used in
the early diagnostic approach of suspected pulmonary embolism (PE). However,
the possibility of improving the conventional prediction rule for PE by
integrating ultrasound has never been investigated.
METHODS: We
performed lung and venous ultrasound in consecutive patients suspected of PE in
four emergency departments. Conventional Wells score (Ws) was adjudicated by
the attending physician, and ultrasound was performed by one of 20
investigators. Signs of deep venous thrombosis (DVT) at venous ultrasound and
signs of pulmonary infarcts or alternative diagnoses at lung ultrasound were
considered to recalculate two items of the Ws: signs and symptoms of DVT and
alternative diagnosis less likely than PE. The diagnostic performances of the
ultrasound-enhanced Ws (USWs) and Ws were then compared after confirmation of
the final diagnosis.
RESULTS: A
total of 446 patients were studied. PE was confirmed in 125 patients (28%).
USWs performed significantly better than Ws, with a sensitivity of 69.6% versus
57.6% and a specificity of 88.2% versus 68.2%. In combination with D-dimer,
USWs showed an optimal failure rate (0.8%) and a significantly superior
efficiency than Ws (32.3% vs. 27.2%). A strategy based on lung and venous
ultrasound combined with D-dimer would allow to avoid CT pulmonary angiography
in 50.5% of patients with suspected PE, compared to 27.2% when the rule without
ultrasound is applied.
CONCLUSIONS:
A pretest risk stratification enhanced by ultrasound of lung and venous
performs better than Ws in the early diagnostic process of PE.
B.
Role of physician perception of patient smile on pretest probability assessment
for acute PE
Kline JA, et
al. Emerg Med J. 2017;34(2):
Background
Many clinicians use a global visual interpretation of patient appearance to
decide if a patient looks sick or not. For patients with suspected acute
pulmonary embolism (PE), we tested the relationship between visual appearance
of a happy patient facial affect and probability of PE+ on CT pulmonary
angiography (CTPA).
Methods
Eligible patients were selected by usual care to undergo CTPA, the criterion
standard for PE+ or PE−. Prior to CTPA result, trained study personnel obtained
physician pretest probability using the gestalt method (visual analogue scale,
0%–100%), the Wells score (0–12) and physicians’ impression of whether the
patient smiled during the initial examination (smile+). Patients' faces were
also video recorded and analysed with an automated neural network-based
algorithm (Noldus FaceReader) for happy affect.
Results Of
the 208 patients enrolled, 27 were PE+ and smile+ was more frequent in patients
with PE+ than PE−, a finding confirmed by the Noldus. The diagnostic
sensitivity and specificity of smile was low, and physicians overestimated
presence of an alternative diagnosis more likely to PE with smile+ than smile−
patients in patients with true PE. As a result, the area under the receiver
operating characteristic curve (AUROC) was lower for the Wells score in smile+
patients. However, the physicians’ mean gestalt estimate of PE did not differ
with smile status, nor did smile status affect the AUROC for gestalt.
Conclusions
In patients with suspected PE, physician recollection of patients’ smile+ was
more common in PE+ patients, and was associated with a less accurate Wells
score, primarily because physicians overestimated probability of alternative
diagnosis. However, the overall diagnostic accuracy of physicians’ gestalt did
not differ with perceived smile status. These data suggest that the patients’
smile had less effect on the numeric gestalt pretest probability assessment
than on the binary decision about an alternative diagnosis.
C.
Assessment of RV Strain by CT vs Echo in Acute PE
Dudzinski DM,
et al. Acad Emerg Med. 2017 Mar;24(3):337-343.
BACKGROUND:
Right ventricular strain (RVS) identifies patients at risk of hemodynamic
deterioration from pulmonary embolism (PE). Our hypothesis was that chest
computed tomography (CT) can provide information about RVS analogous to
transthoracic echocardiography (TTE) and that RVS on CT is associated with
adverse outcomes after PE.
METHODS:
Consecutive emergency department patients with acute PE were prospectively
enrolled and clinical, biomarker, and imaging data were recorded. CTs were
overread by two radiologists. We compared diagnoses of RVS on CT (defined as
right ventricle:left ventricle ratio ≥ 0.9 or interventricular septal bowing)
to echocardiography (defined as right ventricular hypokinesis, right
ventricular dilatation, or interventricular septal bowing). We calculated the
test characteristics (with 95% confidence interval) of CT and TTE for a
composite outcome of severe clinical deterioration, thrombolysis/thrombectomy,
or death within 5 days.
RESULTS: A
total of 298 patients were enrolled; 274 had CT and 118 had formal TTE. Of the
104 patients who had both CT and TTE, the mean (±SD) age was 58 (±17) years; 50
(48%) were female and 88 (85%) were Caucasian. Forty-two (40%) had RVS by TTE
and 75 (72%) had RVS by CT. CT and TTE agreed on the presence or absence of RVS
in 61 (59%) cases (κ = 0.24). Using TTE as criterion standard, the test
characteristics of CT for RVS were as follows: sensitivity = 88%, specificity =
39%, positive predictive value = 49%, and negative predictive value = 83%.
Fourteen (13%) patients experienced severe clinical deterioration or required
hospital-based intervention within 5 days. This occurred in 30% of patients
with RVS on both TTE and CT, 20% of patients with RVS on TTE alone, 3% of
patients with RVS on CT alone, and 4% of patients without RVS on either
modality.
CONCLUSIONS:
In acute PE, CT is highly sensitive but only moderately specific for RVS
compared to TTE. RVS on both CT and TTE predicts more events than either
modality alone. TTE confers additional positive prognostic value compared to CT
in predicting post-PE clinical deterioration.
5. Initiating Diagnostic Studies on Patients c AP in the Waiting
Room Decreases Time Spent in an ED Bed (and Total ED LOS): A RCT
Begaz T, et
al. Ann Emerg Med. 2017 Mar;69(3):298-307.
STUDY
OBJECTIVE: The effect of clinician screening of patients in the emergency
department (ED) waiting room is unclear. This study aims to determine the
effect of initiating laboratory and imaging studies from the ED waiting room on
time in a bed, total ED time, and likelihood of patients leaving before
completion of service.
METHODS: This
was a prospective, randomized, controlled trial evaluating 1,659 nonpregnant
adults with a chief complaint of abdominal pain, conducted in a public hospital
ED when all ED beds were occupied and patients were in the waiting room
awaiting definitive evaluation. After a brief screening examination, stable
patients were randomized to either rapid medical evaluation (RME)+waiting room
diagnostic testing (WRDT) or RME-only groups. Patients randomized to the
RME+WRDT group had laboratory and imaging studies ordered at the discretion of
the screening provider while in the waiting room. The primary outcome was time
in an ED bed. Secondary outcomes were total ED time and rate of leaving before
completion of service. Linear and logistic regression models were used to
compare outcomes between groups.
RESULTS:
Between July 2014 and May 2015, 1,659 patients completed the study, 848
patients in the RME+WRDT group and 811 in the RME-only group. Baseline
demographic characteristics were similar between groups. Patients in the
RME+WRDT group had a significantly shorter mean time in an ED bed than the
RME-only group, 245 minutes compared with 277 minutes (adjusted difference of
31 minutes; 95% confidence interval [CI] 16 to 46 minutes). The RME+WRDT group
also had significantly shorter mean total ED time from arrival to disposition
than the RME-only group, 460 minutes compared with 504 minutes (adjusted
difference 42 minutes; 95% CI 22 to 63 minutes). Of the 1,659 patients
enrolled, 181 left before completion of service: 78 of 848 patients (9%) in the
RME+WRDT group compared with 103 of 811 (13%) in the RME-only group (difference
3.5%; 95% CI 0.5% to 6.5%). By the end of their ED visit, patients in the
RME+WRDT group had significantly more types of diagnostic studies ordered than
those in the RME-only group, 2.59 versus 2.03 total unique test categories by
location ordered (difference 0.56; 95% CI 0.44 to 0.68).
CONCLUSION:
Initiating diagnostic testing in the waiting room reduced time spent in an ED
bed, total ED time, and rates of leaving before completion of service. For
clinicians screening patients in the waiting room, initiating diagnostic
evaluations may improve throughput in crowded EDs.
6. Brief Lit Reviews from Ann Emerg Med
A.
Do Antiviral Medications Improve Symptoms in the Treatment of Bell’s Palsy?
Take-Home
Message: Antivirals, combined with corticosteroids, reduce the risk of
incomplete recovery of Bell's palsy more than corticosteroids alone.
B.
Are Antibiotics a Feasible Alternative to Surgery for Acute Appendicitis?
Take-Home
Message: Antibiotics alone may be a reasonable option for nonperforated acute
appendicitis as an alternative to surgery, but a significant number of
antibiotic-treated patients may develop recurrent appendicitis requiring
appendectomy by 1 year.
7. Efficacy and Safety of Nonoperative Treatment for Acute
Appendicitis: A Meta-analysis
Georgiou R.
et al. Pediatr 2017 Feb 17 [Epub ahead of print]
CONTEXT:
Nonoperative treatment (NOT) with antibiotics alone of acute uncomplicated
appendicitis (AUA) in children has been proposed as an alternative to
appendectomy.
OBJECTIVE: To
determine safety and efficacy of NOT based on current literature.
DATA SOURCES:
Three electronic databases.
STUDY
SELECTION: All articles reporting NOT for AUA in children.
DATA
EXTRACTION: Two reviewers independently verified study inclusion and extracted
data.
RESULTS: Ten
articles reporting 413 children receiving NOT were included. Six, including 1
randomized controlled trial, compared NOT with appendectomy. The remaining 4
reported outcomes of children receiving NOT without a comparison group. NOT was
effective as the initial treatment in 97% of children (95% confidence interval
[CI] 96% to 99%). Initial length of hospital stay was shorter in children
treated with appendectomy compared with NOT (mean difference 0.5 days [95% CI
0.2 to 0.8]; P = .002). At final reported follow-up (range 8 weeks to 4 years),
NOT remained effective (no appendectomy performed) in 79% of children (95% CI
73% to 86%). Recurrent appendicitis occurred in 14% (95% CI 7% to 21%).
Complications and total length of hospital stay during follow-up were similar
for NOT and appendectomy. No serious adverse events related to NOT were
reported.
LIMITATIONS:
The lack of prospective randomized studies limits definitive conclusions to
influence clinical practice.
CONCLUSIONS:
Current data suggest that NOT is safe. It appears effective as initial
treatment in 97% of children with AUA, and the rate of recurrent appendicitis
is 14%. Longer-term clinical outcomes and cost-effectiveness of NOT compared
with appendicectomy require further evaluation, preferably in large randomized
trials, to reliably inform decision-making.
8. A Cost Analysis of Salbutamol Administration by Metered-Dose
Inhalers with Spacers vs Nebs for Pts with Wheeze in the Pediatric ED: Evidence
from Observational Data in Nova Scotia
Spin P, et
al. Can J Emerg Med 2017;19(1):1-8.
Despite
evidence demonstrating the advantages of metered-dose inhalers with spacers
(MDI-s), nebulization (NEB) remains the primary method of asthma treatment in
some pediatric emergency departments (PEDs). There is a perception that
delivering salbutamol by MDI-s is more costly than by NEB. This research
evaluates the relative costs of MDI-s and NEB using local, hospital-specific,
patient-level data.
Regression
models estimated associations between the salbutamol inhalation method and
costs, length of stay (LOS) in the PED and hospital, and the probability of
admission. Our population was a random sample of 822 patients presenting with
wheeze to the PED in 2008/2009. Control variables included age, sex, triage
acuity, time of PED visit, other medications, and vitals. Costs were calculated
using the prices and quantities of medical resources used per treatment.
Probabilistic sensitivity analysis was used.
Treatment
with MDI-s versus NEB was associated with an absolute decrease in hospitalization
of 4.4% (p less than 0.05) and a 25-hour (p less than 0.001) reduction in
average inpatient stay, after controlling for triage acuity and patient
characteristics. This resulted in savings of $24/patient in the PED and
$180/patient overall (p less than 0.001). Inpatient care accounted for more
than 90% of total patient costs.
Our results
suggest economic gains associated with MDI-s for salbutamol inhalation in PEDs.
Sensitivity analyses show that this conclusion is not affected by changes in
model parameters that may differ by jurisdiction. Since most facilities already
collect the data used for this study, our methods could be adopted for a
cross-jurisdictional account of the cost effectiveness of MDI-s.
9. Applied Clinical Informatics
A.
Safe Practices for Copy and Paste in the EHR: Systematic Review,
Recommendations, and Novel Model for Health IT Collaboration
Tsou AY, et
al. Appl Clin Inform 2017 8 1: 12-34
Copy and
paste functionality can support efficiency during clinical documentation, but
may promote inaccurate documentation with risks for patient safety. The
Partnership for Health IT Patient Safety sought to characterize copy and paste
events in clinical care, identify safety risks, describe existing evidence, and
develop implementable practice recommendations for safe reuse of information
via copy and paste. They discovered that despite regular copy and paste use,
evidence regarding direct risk to patient safety remains sparse, with
significant study limitations. Drawing on this existing evidence, the
Partnership developed safe practice recommendations in this paper.
B.
Analysis of Smartphone Interruptions on Academic General Internal Medicine
Wards: Frequent Interruptions may cause a ‘Crisis Mode’ Work Climate
Vaisman A, et
al. Appl Clin Inform 2017 8 1: 1-11
Hospital-based
medical services are increasingly utilizing team-based pagers and smartphones
to streamline communications, but, an unintended consequence may be higher
volumes of interruptions potentially leading to medical error. The authors
retrospectively collected phone, text messaging, and email interruptions
directed to hospital-assigned smartphones and analyzed the correlation between
interruptions and date, site, and patient volumes. They discovered that site,
day of the week, and patient volumes all were correlated with at least 5
interruptions per 30 minutes, suggesting that future interventions should
target the culture of individual hospitals.
10. Images in Clinical Practice
Grouped
Pustules on an Erythematous Base
Iodide-Associated
Sialadenitis
Empyema
Necessitatis
Young Woman
With Strawberry Tongue
Erythroderma:
Not Your Everyday Sunburn: Commentary from EM-RAP
Elderly Woman
With Painful Swollen Fingers
Young Man
With Penile Pain and Swelling
Woman With
Left Leg Pain and Swelling
Man With
Vision Loss and Eye Pain
Teenager With
Scalp Mass
Elderly Woman
With a Cough
11. Epinephrine use in older patients with anaphylaxis: Clinical
outcomes and cardiovascular complications.
Kawano T, et
al. Resuscitation. 2017 Mar;112:53-58.
BACKGROUND:
There is little data describing the differences in epinephrine (epi)
administration and cardiac complications among older and younger patients with
anaphylaxis.
METHODS: This
retrospective cohort study was conducted at two urban emergency departments
(ED) over a 5 year-period, and included adults who met a pre-specified criteria
for anaphylaxis. Patients ≥50years of age were defined as "older".
Univariate logistic regression was performed to compare the difference in
frequency of epi administration between the "older" and
"younger" groups. Among those who received epi, the proportion of
patients who received doses exceeding the recommended maximum and who had
pre-specified cardiovascular complications were compared between the two
groups, stratified further by route of administration.
RESULTS: Of
2995 allergy-related visits, 492 met criteria for anaphylaxis, including 122
(24.8%) older patients. Older patients were less likely to receive epi
injection (36.1% vs. 60.5%). Of those who received epi, older patients were
more likely to receive excessive dose of epi (7/44, 15.9% vs 2/225, 0.9%,
unadjusted OR 20.7, 95% CI 3.8-211.7). Four (4/44, 9.1%) older patients
experienced cardiovascular complications, compared to 1/225 (0.4%) in the
younger group (unadjusted OR 22.4, 95% CI 2.1-1129.8). When examining only
intra-muscular epinephrine, 1/31 older patients had cardiac complications, compared
to 1/186 in the younger group.
CONCLUSION:
Older patients with anaphylaxis were less likely to receive epi injection.
Intramuscular epi appears safe in this population; however, the use of
intravenous epi should be avoided in older patients due to the potential of
developing serious cardiac complications.
12. Dietary sugars inferior to glucose tablets for first-aid
treatment of symptomatic hypoglycaemia in awake patients with diabetes: a
systematic review and meta-analysis
Carlson JN,
et al. Emerg Med J. 2017;34(2):100-106.
Background
While glucose tablets have been advocated for treating symptomatic
hypoglycaemia in awake patients, dietary sugars may be more convenient. We
performed a systematic review to compare the impact of these treatment options
on the relief of symptomatic hypoglycaemia, time to resolution of symptoms,
blood glucose levels, complications and hospital length of stay.
Method We
searched PubMed, Embase and the Cochrane Library through 28 June 2016 and
assessed the quality of evidence using the Grades of Recommendation,
Assessment, Development and Evaluation approach. Reference lists from a subset
of the resulting articles were mined for additional, potentially eligible
papers. We calculated the risk ratio (RR) of each treatment option for the
preselected outcomes of interest.
Results Of
the 1774 identified papers, four studies met the inclusion criteria; three
randomised controlled trials totalling 502 hypoglycaemic events treated with
dietary sugars and 223 with glucose tablets and one observational study with 13
events treated with dietary sugars and 9 with glucose tablets. The dietary
forms of sugar included sucrose, fructose, orange juice, jelly beans, Mentos,
cornstarch hydrolysate, Skittles and milk. In the pooled analysis, patients
treated with dietary sugars had a lower resolution of symptoms 15 min after
treatment compared with glucose tablets (RR 0.89, 95% CI 0.83 to 0.95).
Conclusions
When compared with dietary sugars, glucose tablets result in a higher rate of
relief of symptomatic hypoglycaemia 15 min after ingestion and should be
considered first, if available, when treating symptomatic hypoglycaemia in
awake patients.
13. Pain Management and Sedation Studies from Ann Emerg Med
A.
Midazolam-Droperidol, Droperidol, or Olanzapine for Acute Agitation: A
Randomized Clinical Trial
Taylor DM, et
al. Ann Emerg Med. 2017 Mar;69(3):318-326.e1.
STUDY
OBJECTIVE: We aim to determine the most efficacious of 3 common medication
regimens for the sedation of acutely agitated emergency department (ED)
patients.
METHODS: We
undertook a randomized, controlled, double-blind, triple-dummy, clinical trial
in 2 metropolitan EDs between October 2014 and August 2015. Patients aged 18 to
65 years and requiring intravenous medication sedation for acute agitation were
enrolled and randomized to an intravenous bolus of midazolam 5 mg-droperidol 5
mg, droperidol 10 mg, or olanzapine 10 mg. Two additional doses were
administered, if required: midazolam 5 mg, droperidol 5 mg, or olanzapine 5 mg.
The primary outcome was the proportion of patients adequately sedated at 10
minutes.
RESULTS:
Three hundred forty-nine patients were randomized to the 3 groups. Baseline
characteristics were similar across the groups. Ten minutes after the first
dose, significantly more patients in the midazolam-droperidol group were
adequately sedated compared with the droperidol and olanzapine groups:
differences in proportions 25.0% (95% confidence interval [CI] 12.0% to 38.1%)
and 25.4% (95% CI 12.7% to 38.3%), respectively. For times to sedation, the
differences in medians between the midazolam-droperidol group and the
droperidol and olanzapine groups were 6 (95% CI 3 to 8) and 6 (95% CI 3 to 7)
minutes, respectively. Patients in the midazolam-droperidol group required
fewer additional doses or alternative drugs to achieve adequate sedation. The 3
groups' adverse event rates and lengths of stay did not differ.
CONCLUSION:
Midazolam-droperidol combination therapy is superior, in the doses studied, to
either droperidol or olanzapine monotherapy for intravenous sedation of the
acutely agitated ED patient.
B.
A Prospective Observational Study of Patients Receiving IV and IM Olanzapine in
the ED.
Cole JB, et
al. Ann Emerg Med. 2017 Mar;69(3):327-336.e2.
STUDY
OBJECTIVE: Parenteral olanzapine is an emerging therapy for a variety of
conditions in the emergency department (ED). Intramuscular administration is
standard; however, intravenous administration has been proposed as a safe
alternative route. We investigate the safety and efficacy of both intramuscular
and intravenous olanzapine in the ED when used for a variety of indications.
METHODS: This
was a prospective observational study of patients presenting to an urban Level
I trauma center ED. Trained research associates screened the ED for patients
receiving parenteral olanzapine. The primary outcome of the study was incidence
of respiratory depression measured with standard markers. Secondary outcomes
included use of additional doses or sedatives, corrected QT interval (QTc)
data, time to nadir sedation, adverse events, and physician assessment of
efficacy.
RESULTS:
There were 784 patients included in the final analysis. Intravenous olanzapine
was administered to 295 patients; 489 received intramuscular olanzapine.
Respiratory depression occurred in 11 of 295 patients (3.7%; 95% confidence
interval [CI] 1.6% to 5.9%) receiving intravenous olanzapine and 10 of 489
(2.0%; 95% CI 0.8% to 3.3%) receiving intramuscular olanzapine. Seven patients
required intubation, 2 in the intravenous group and 5 in the intramuscular
group. Nonrespiratory complications occurred in 8 patients, 6 of 295 (2.0%; 95%
CI 0.4% to 3.6%) in the intravenous group and 2 of 489 (0.4%; 95% CI 0% to
0.96%) in the intramuscular group. Dysrhythmias were isolated to 2 episodes of
bradycardia requiring only supportive care.
CONCLUSION:
These data suggest that, with proper monitoring, administration of olanzapine,
both intramuscular and intravenous, is safe for several indications in the ED.
C.
Editorial: Droperidol or Olanzapine, Intramuscularly or Intravenously,
Monotherapy or Combination Therapy for Sedating Acute Behavioral Disturbance.
Isbister GK. Ann
Emerg Med. 2017 Mar;69(3):337-339.
First page
(full-text requires subscription): http://www.annemergmed.com/article/S0196-0644(16)31094-0/abstract
Bonus:
Management of Pain and Procedural Sedation in Acute Care E-Book
This is an
open access, online textbook through which we hope to disseminate best
practices in analgesia that accounts for what we have known for centuries about
pain and pain management but may have forgotten; what the past two decades of
expanded opioid use and resulting opioid addiction epidemic has taught us; and
what evidence and consensus tells us about the best way forward.
Chapters (to date):
1. Pain and
PSA in Older Adults (by Joshua Long and Christina Shenvi)
2. Procedural
Sedation in Adults (by Reuben Strayer)
3. Headache
(by Benjamin Friedman)
14. A literature-based algorithm for the treatment of children
with radial head subluxation who fail to respond to initial hyperpronation
Makin CW, et
al. Amer J Emerg Med. 2017 Mar 3 [Epub ahead of print].
An excerpt
from this letter to the editor:
We are
grateful to Bexkens et al for their excellent systematic review of reduction
maneuvers for radial head subluxation [1]. In demonstrating the superiority of
hyperpronation (HP) compared to supination-flexion (SF) (90.8% vs 72.6%; Number
Needed to Treat, 5.5), their study is sure to be of great help to practicing
clinicians. Despite its excellent success rates, HP still fails to reduce a
Nursemaid’s elbow about 10% of the time. What then? Though Bexkens et al did
not address this question directly in their review, their identification of the
trial literature on this topic set the stage for our review of these same
trials with this question in mind: what sequence of steps does the literature
suggest as a reasonable approach to the patient who fails to respond to initial
HP?
…Using this
trial evidence as a guide to the treatment of children with presumed radial
head subluxation, we propose the following approach. HP should be the initial
maneuver with the elbow positioned between 70-90 degrees of flexion [1]. Up to
three attempts can be pursued if needed, each separated by 10-15 minutes.
Either HP or SF can be employed for the second maneuver, followed by the alternate
for the third maneuver. Children who fail to regain normal elbow function after
three reduction attempts should undergo radiographic evaluation. If the elbow
x-rays are negative, it seems prudent to immobilize the arm and arrange close
outpatient follow-up.
…We summarize
in Figure 1 our approach to the child with presumed radial head subluxation.
The suggestions beyond initial HP are not hard and fast, nor are they solidly
evidence-based. But they are reasonable and emerge from the trial data as sensible
steps to follow in the 10% of children whose Nursemaid’s elbow needs something
more than initial HP.
Figure 1. An
algorithmic approach to Nursemaid’s elbow reduction derived from trial data.
15. Two New Dyspnea Studies by the AANZDEM
A.
An Observational Study of Dyspnea in EDs: The Asia, Australia, and New Zealand
Dyspnea in ED Study (AANZDEM).
Kelly AM, et
al. Acad Emerg Med. 2017 Mar;24(3):328-336.
OBJECTIVES:
The objective was to describe the epidemiology of dyspnea presenting to
emergency departments (EDs) in the Asia-Pacific region, to understand how it is
investigated and treated and its outcome.
METHODS:
Prospective interrupted time series cohort study conducted at three time points
in EDs in Australia, New Zealand, Singapore, Hong Kong, and Malaysia of adult
patients presenting to the ED with dyspnea as a main symptom. Data were
collected over three 72-hour periods and included demographics, comorbidities,
mode of arrival, usual medications, prehospital treatment, initial assessment,
ED investigations, treatment in the ED, ED diagnosis, disposition from ED,
in-hospital outcome, and final hospital diagnosis. The primary outcomes of
interest are the epidemiology, investigation, treatment, and outcome of
patients presenting to ED with dyspnea.
RESULTS: A
total of 3,044 patients were studied. Patients with dyspnea made up 5.2% (3,105/60,059,
95% confidence interval [CI] = 5.0% to 5.4%) of ED presentations, 11.4% of ward
admissions (1,956/17,184, 95% CI = 10.9% to 11.9%), and 19.9% of intensive care
unit (ICU) admissions (104/523, 95% CI = 16.7% to 23.5%). The most common
diagnoses were lower respiratory tract infection (20.2%), heart failure
(14.9%), chronic obstructive pulmonary disease (13.6%), and asthma (12.7%).
Hospital ward admission was required for 64% of patients (95% CI = 62% to 66%)
with 3.3% (95% CI = 2.8% to 4.1%) requiring ICU admission. In-hospital
mortality was 6% (95% CI = 5.0% to 7.2%).
CONCLUSION:
Dyspnea is a common symptom in ED patients contributing substantially to ED,
hospital, and ICU workload. It is also associated with significant mortality.
There are a wide variety of causes however chronic disease accounts for a large
proportion.
B.
HF in patients presenting with dyspnoea to the ED in the Asia Pacific region:
an observational study.
Keijzers G,
et al. BMJ Open. 2017 Feb 28;7(2):e013812.
OBJECTIVES:
To describe demographic features, assessment, management and outcomes of
patients who were diagnosed with heart failure after presenting to an emergency
department (ED) with a principal symptom of dyspnoea.
DESIGN:
Planned substudy of the prospective, descriptive cohort study: Asia, Australia
and New Zealand Dyspnoea in Emergency Departments (AANZDEM).
SETTING: 46
EDs in Australia, New Zealand, Singapore, Hong Kong and Malaysia collected data
over 3 72-hour periods in May, August and October 2014.
PARTICIPANTS:
Patients with an ED diagnosis of heart failure.
OUTCOME
MEASURES: Outcomes included patient epidemiology, investigations ordered,
treatment modalities used and patient outcomes (hospital length of stay (LOS)
and mortality).
RESULTS: 455
(14.9%) of the 3044 patients had an ED diagnosis of heart failure. Median age
was 79 years, half were male and 62% arrived via ambulance. 392 (86%) patients
were admitted to hospital. ED diagnosis was concordant with hospital discharge
diagnosis in 81% of cases. Median hospital LOS was 6 days (IQR 4-9) and
in-hospital mortality was 5.1%. Natriuretic peptide levels were ordered in 19%,
with lung ultrasound (less than 1%) and echocardiography (2%) uncommonly
performed. Treatment modalities included non-invasive ventilation (12%),
diuretics (73%), nitrates (25%), antibiotics (16%), inhaled β-agonists (13%)
and corticosteroids (6%).
CONCLUSIONS:
In the Asia Pacific region, heart failure is a common diagnosis among patients
presenting to the ED with a principal symptom of dyspnoea. Admission rates were
high and ED diagnostic accuracy was good. Despite the seemingly suboptimal
adherence to investigation and treatment guidelines, patient outcomes were
favourable compared with other registries.
16. ED Cardiopulmonary Evaluation of Low-Risk CP Pts with
Self-Reported Stress and Anxiety.
Musey PI Jr,
Kline J. J Emerg Med. 2017 Mar;52(3):273-279.
BACKGROUND:
Chest pain is a high-risk emergency department (ED) chief complaint; the
majority of clinical resources are directed toward detecting and treating
cardiopulmonary emergencies. However, at follow-up, 80%-95% of these patients
have only a symptom-based diagnosis; a large number have undiagnosed anxiety
disorders.
OBJECTIVE:
Our aim was to measure the frequency of self-identified stress or anxiety among
chest pain patients, and compare their pretest probabilities, care processes,
and outcomes.
METHODS:
Patients were divided into two groups: explicitly self-reported anxiety and
stress or not at 90-day follow-up, then compared on several variables: ultralow
(less than 2.5%) pretest probability, outcome rates for acute coronary syndrome
(ACS) and pulmonary embolism (PE), radiation exposure, total costs at 30 days,
and 90-day recidivism.
RESULTS:
Eight hundred and forty-five patients were studied. Sixty-seven (8%) explicitly
attributed their chest pain to "stress" or "anxiety"; their
mean ACS pretest probability was 4% (95% confidence interval 2.9%-5.7%) and 49%
(33/67) had ultralow pretest probability (0/33 with ACS or PE). None (0/67)
were diagnosed with anxiety. Seven hundred and seventy-eight did not report
stress or anxiety and, of these, 52% (403/778) had ultralow ACS pretest
probability. Only one patient (0.2%; 1/403) was diagnosed with ACS and one
patient (0.4%; 1/268) was diagnosed with PE. Patients with self-reported
anxiety had similar radiation exposure, associated costs, and nearly identical
(25.4% vs. 25.7%) ED recidivism to patients without reported anxiety.
CONCLUSIONS:
Without prompting, 8% of patients self-identified "stress" or
"anxiety" as the etiology for their chest pain. Most had low pretest
probability, were over-investigated for ACS and PE, and not investigated for
anxiety syndromes.
17. Clinicians’ (Mistaken) Expectations of the Benefits and
Harms of Treatments, Screening, and Tests: A Systematic Review
Hoffmann TC,
et al. JAMA Intern Med. 2017 Mar 1;177(3):407-419.
Importance:
Inaccurate clinician expectations of the benefits and harms of interventions
can profoundly influence decision making and may be contributing to increasing
intervention overuse.
Objective: To
systematically review all studies that have quantitatively assessed clinicians'
expectations of the benefits and/or harms of any treatment, test, or screening
test.
Evidence
Review: A comprehensive search strategy of 4 databases (MEDLINE, EMBASE,
Cumulative Index of Nursing and Allied Health Literature, and PsycINFO) from
the start years to March 17-20, 2015, with no language or study type
restriction, was performed. Searches were also conducted on cited references of
the included studies, and experts and study authors were contacted. Two
researchers independently evaluated methodologic quality and extracted
participants' estimates of benefit and harms and authors' contemporaneous
estimates.
Findings: Of
the 8166 records screened, 48 articles (13 011 clinicians) were eligible.
Twenty studies focused on treatment, 20 on medical imaging, and 8 on screening.
Of the 48 studies, 30 (67%) assessed only harm expectations, 9 (20%) evaluated
only benefit expectations, and 6 (13%) assessed both benefit and harm
expectations. Among the studies comparing benefit expectations with a correct
answer (total of 28 outcomes), most participants provided correct estimation
for only 3 outcomes (11%). Of the studies comparing expectations of harm with a
correct answer (total of 69 outcomes), a majority of participants correctly
estimated harm for 9 outcomes (13%). Where overestimation or underestimation
data were provided, most participants overestimated benefit for 7 (32%) and
underestimated benefit for 2 (9%) of the 22 outcomes, and underestimated harm
for 20 (34%) and overestimated harm for 3 (5%) of the 58 outcomes.
Conclusions
and Relevance: Clinicians rarely had accurate expectations of benefits or
harms, with inaccuracies in both directions. However, clinicians more often
underestimated rather than overestimated harms and overestimated rather than
underestimated benefits. Inaccurate perceptions about the benefits and harms of
interventions are likely to result in suboptimal clinical management choices.
18. As physician well-being falls, rewards of medicine fade
Smith TM. AMA
Wire. MAR 03, 2017
Most
occupations probably cannot boast that 93 percent of their members find their
work rewarding and that 91 percent think it makes the world a better place, as
discovered in a recent survey of U.S. physicians. Yet that research also
suggests those numbers can drop precipitously when physician burnout increases.
The purpose
of the study, published in Mayo Clinic Proceedings, was to evaluate the
association between professional burnout and physicians’ sense of calling.
Researchers found physicians who experience burnout are, indeed, less likely to
view medicine as a calling, as measured by true-false responses to six survey
items, including “I find my work rewarding,” “My work is one of the most
important things in my life,” and “If I were financially secure, I would
continue with my current line of work even if I were no longer paid.”
Almost 30
percent of the more than 2,200 respondents reported experiencing some level of
burnout. Physician views on calling that varied the least between those who
were not burned out and those who were completely burned out were for the item,
“My work makes the world a better place.” More than 83 percent of physicians
who were completely burned out responded affirmatively to this item, which was only
14 percent lower than those who reported no burnout.
The calling
item with the greatest response difference was “I would choose my current work
life again if I had the opportunity,” to which completely burned-out physicians
responded affirmatively less than 32 percent of the time, a difference of 61
percent from those unaffected by burnout. On the “I find my work rewarding”
item, nearly all physician respondents unaffected by burnout—98 percent—agreed
with the statement. In contrast, just 65 percent of completely burned-out
physicians said they find their work rewarding.
“Given the
personal and collective-level consequences of medicine as a calling, concerns
have been raised that the changing physician workplace may be eroding such a
professional identity,” the study’s authors wrote. “Over the past decade, the
rapid adoption of electronic health records and the proliferation of
pay-for-performance metrics have markedly altered how physicians experience
their everyday work lives.”
Bonus: Study assesses how resident
burnout affects patient care
Pediatric residents who reported
burnout had a sevenfold higher risk of making treatment or medication errors
and were 3.5 times more likely not to fully discuss treatment options or answer
patient questions, compared with those who weren't burned out. The findings in
Pediatrics, based on online survey data involving 258 pediatric residents in
New England, also showed increased odds of discharging a patient to ease
workload among those who were burned out.
19. ICU Overuse? ICU Admission and Survival among Older Patients
with COPD, Heart Failure, or Myocardial Infarction
Valley TS, et al. Ann Am Thorac Soc 2017 Feb 16 [Epub ahead of
print]
Rationale:
Admission to an intensive care unit (ICU) may be beneficial to pneumonia patients
with uncertain ICU needs; however, evidence regarding the association between
ICU admission and mortality for other common conditions is largely unknown.
Objectives:
To estimate the relationship between ICU admission and outcomes for
hospitalized patients with exacerbation of chronic obstructive pulmonary
disease (COPD), exacerbation of heart failure (HF), or acute myocardial
infarction (AMI).
Methods: We
performed a retrospective cohort study of all acute care hospitalizations from
2010 to 2012 for U.S. fee-for-service Medicare beneficiaries aged 65 and older
admitted with COPD exacerbation, HF exacerbation, or AMI. We used multivariable
adjustment and instrumental variable analysis to assess each condition
separately. The instrumental variable analysis used differential distance to a
high ICU use hospital (defined separately for each condition) as an instrument
for ICU admission to examine marginal patients whose likelihood of ICU
admission depended on the hospital to which they were admitted. The primary
outcome was 30-day mortality. Secondary outcomes included hospital costs.
Results:
Among 1,555,798 Medicare beneficiaries with COPD exacerbation, HF exacerbation,
or AMI, 486,272 (31%) were admitted to an ICU. The instrumental variable
analysis found that ICU admission was not associated with significant
differences in 30-day mortality for any condition. ICU admission was associated
with significantly greater hospital costs for HF [$11,793 vs. $9,185, P less
than 0.001; absolute increase, 2,608 (95% CI: 1377, 3840)] and AMI [$19,513 vs.
$14,590, P less than 0.001; absolute increase, 4,922 (95% CI: 2665, 7180)], but
not for COPD.
Conclusions:
ICU admission did not confer a survival benefit for patients with uncertain ICU
needs hospitalized with COPD exacerbation, HF exacerbation, or AMI. These
findings suggest that the ICU may be overused for some patients with these
conditions. Identifying patients most likely to benefit from ICU admission may
improve healthcare efficiency while reducing costs.
20. Assessing the Risks Associated with MRI in Patients with a
Pacemaker or Defibrillator
Russo RJ, et
al. N Engl J Med 2017; 376:755-764.
BACKGROUND
The presence
of a cardiovascular implantable electronic device has long been a
contraindication for the performance of magnetic resonance imaging (MRI). We
established a prospective registry to determine the risks associated with MRI
at a magnetic field strength of 1.5 tesla for patients who had a pacemaker or
implantable cardioverter–defibrillator (ICD) that was “non–MRI-conditional”
(i.e., not approved by the Food and Drug Administration for MRI scanning).
METHODS
Patients in
the registry were referred for clinically indicated nonthoracic MRI at a field
strength of 1.5 tesla. Devices were interrogated before and after MRI with the
use of a standardized protocol and were appropriately reprogrammed before the
scanning. The primary end points were death, generator or lead failure, induced
arrhythmia, loss of capture, or electrical reset during the scanning. The
secondary end points were changes in device settings.
RESULTS
MRI was
performed in 1000 cases in which patients had a pacemaker and in 500 cases in
which patients had an ICD. No deaths, lead failures, losses of capture, or
ventricular arrhythmias occurred during MRI. One ICD generator could not be
interrogated after MRI and required immediate replacement; the device had not
been appropriately programmed per protocol before the MRI. We observed six
cases of self-terminating atrial fibrillation or flutter and six cases of
partial electrical reset. Changes in lead impedance, pacing threshold, battery
voltage, and P-wave and R-wave amplitude exceeded prespecified thresholds in a
small number of cases. Repeat MRI was not associated with an increase in
adverse events.
CONCLUSIONS
In this
study, device or lead failure did not occur in any patient with a
non–MRI-conditional pacemaker or ICD who underwent clinically indicated
nonthoracic MRI at 1.5 tesla, was appropriately screened, and had the device
reprogrammed in accordance with the prespecified protocol.
21. How Our Brains Think: Dual Process Theory Overview with
Illustrative ED CP Case
Manesh R, et
al. J Gen Intern Med 2017;
Introduction:
The Dual Process Theory has been adapted from the psychology literature to
describe how clinicians think when reasoning through a patient’s case.1 The
dual processes, or System 1 and System 2, work together by enabling a clinician
to think both fast and slow when reasoning through a patient's presentation.
System 1 is
intuitive, efficient, and based on pattern recognition.2 Reasoning using System
1 often occurs so quickly that we do not explicitly recognize it as a distinct
cognitive process. For example, a post-operative patient with sinus
tachycardia, asymmetric lower extremity edema, and hypoxia is recognized
immediately as having a pulmonary embolus by an experienced clinician. This
rapid thinking draws on prior clinical experience, and is invaluable in helping
busy clinicians accurately assess and treat patients with straightforward
presentations.
In contrast,
System 2 is an analytical cognitive process that is time intensive and
deliberate.3 It involves the conscious, explicit application of an analytical
approach to arrive at the correct diagnosis. An HIV positive patient with a CD4
count of 50 with fevers, weight loss, headaches, diarrhea, and recent travel to
South Africa would likely activate System 2 reasoning given the myriad
diagnostic possibilities. Complicated or atypical patient presentations that do
not closely match known patterns require clinicians to slow down and
systematically consider multiple potential etiologies to avoid making
diagnostic errors.
Which system
is activated at a given time depends on two factors: the providers’ prior
experience with a particular clinical presentation, and their ability to
activate the appropriate illness script that sufficiently explains the
patient’s clinical syndrome.3,4 Medical students tend to utilize System 2
thinking more often than System 1 thinking since they have insufficient
clinical experience to accurately reason through a case using pattern
recognition alone. In contrast, seasoned clinicians practicing in a familiar
setting spend more time utilizing System 1 reasoning unless triggered to switch
to System 2 when a patient does not neatly match one of their stored illness
scripts.
Like most
models, the Dual Process Theory oversimplifies reality.5…
The remainder
of the essay (full-text free): http://www.sgim.org/web-only/clinical-reasoning-exercises/dual-process-theory-overview
Illustrative Teaching Case
A 59-year-old
African-American man with a history of hypertension, hyperlipidemia, and
cerebrovascular disease presented to the ED complaining of CP. He stated that
the pain began suddenly while he was seated at home several hours prior to
presentation. He described the pain as throbbing, 9 out of 10 in intensity,
substernal, and associated with nausea, diaphoresis, and dyspnea. He stated
that the pain radiated to his left leg but not to his arm or jaw. The pain
resolved spontaneously after an hour, but then recurred 3 hours later. He had
never experienced pain like this before. He initially delayed coming to the
hospital, expecting the chest pain to subside spontaneously again; but finally
his family brought him in when he became disoriented and confused…
Full-text
(free): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3599030/
Discussion from JGIM
In “NSTEMI or
Not: A 59-Year-Old Man with Chest Pain and Troponin Elevation,”7 the discussant
initially utilizes System 1 reasoning and intuitively prioritizes acute coronary
syndrome (ACS) as the most likely cause of the patient’s chest pain. However,
the clinician notices that the patient has radicular pain to his leg which
causes the discussant to pause, as it is not part of his illness script for
ACS. When there is a mismatch between the problem representation and a
physician’s leading illness script,
expert clinicians pause and switch from System 1 to System 2 thinking.8 In this
case, this pause allows the discussant to slow down and utilize an analytic
approach to consider other possibilities, eventually arriving at the correct
diagnosis.
The slides
for this case, which include an embedded teaching guide, provide a didactic
approach for teachers interested in developing their trainees’ understanding of
the clinical reasoning process. The
slides can be viewed online here but for best results, download the side deck
from Slideshare.
Slideshow of the
case: https://www.slideshare.net/Webjgim/dual-process-theory-overview
Dual processing in EM
22. Micro Bits
A. Chocolate really does worsen acne in teens
Delost GR, et al. The impact of
chocolate consumption on acne vulgaris in college students: A randomized
crossover study. J Amer Acad Derm. 2016;75(1):220-2.
The effect of individual foods on
dermatologic disease has received renewed attention.1 Fulton et al2 investigated
the relationship between chocolate and acne pathogenesis in an often cited, but
flawed study. The Chocolate Manufacturers Association of the USA sponsored the
Fulton study and the study subjects were prisoners.3 There were no baseline
data or quantitative analysis, and no difference in the sugar and fat content
between the chocolate bar and the control bar.3 The link of chocolate to acne
vulgaris was replaced by the theory that a high glycemic index may contribute
to acne vulgaris.4, 5, 6 In this study, we attempted to revisit the
controversial topic by assessing the development of new acne lesions following
ingestion of chocolate versus a nonchocolate candy with a similar glycemic
load.
Our study was a single-blind
randomized crossover study of 54 college students (Fig 1) with an average age
of 21.4 (±3.9) years with participant written informed consent and approval
from the Youngstown State University Institutional Review Board. Subjects
agreed to abstain from all other chocolate ingestion for the study duration;
exclusion criteria included diabetes mellitus, dietary restrictions, or
allergies to chocolate or jellybeans. Participants completed dietary logs and
demographic surveys. Participants were randomly assigned to receive a 1.55 oz
(43g) Hershey's milk chocolate bar or 15 Jelly Belly jellybeans which provided
the same glycemic load. Acne changes were blindly assessed after 48 hours by a
dermatologist who counted the number of acne lesions from photographs.
Crossover analysis was done 4 weeks later. There was no statistically
significant difference in the number of acne lesions between the 2 groups when
the crossover occurred (P = .322), which demonstrates adequate washout from the
first part of the study.
Fig 2 demonstrates that the
chocolate consumption group had a statistically significant (P less than .0001) increase in acne lesions (+4.8
lesions) compared with the jellybean consumption group (−0.7 lesions). The
increase in acne lesions was present across gender, age, frequency, and
severity classifications. To assess the effects of covariates on the number of
lesions, linear regression analysis (SPSS Software, Chicago) was performed.
None of the covariates (age, P = .424; stress, P = .901; gender, P = .843)
showed statistical significance for the number of acne lesions. Furthermore,
mixed model analysis assessing all combinations of the covariates did not show
statistical significance with regard to outcome.
Chocolate flavonoid consumption
modulates cytokine production, which may account for these observations. Netea
et al7 demonstrated that chocolate consumption primed human blood mononuclear
cells to release more proinflammatory cytokines, interleukin-1β, and TNFα, upon
stimulation with Propionibacterium acnes. Because overinflammation is an
important contributor to acne pathogenesis and the antiinflammatory dose effect
of antibiotics has been demonstrated to be most effective in treating acne, it
is plausible that altered cytokine profiles can contribute to worsening acne.
Future studies with a larger
study group using dark chocolate as well as specific components of chocolate,
such as the flavonoids coupled with more diligent documentation of the
participants' diets and menstrual cycles may provide valuable and comprehensive
dermatology guidance to acne patients.
B. Recreational Cannabis — Minimizing the
Health Risks from Legalization
Beau Kilmer, Ph.D. N Engl J Med
2017; 376:705-707.
The cannabis-policy landscape is
undergoing dramatic change. Although many jurisdictions have removed criminal
penalties for possessing small amounts of cannabis and more than half of U.S.
states allow physicians to recommend it to patients, legalizing the supply and
possession of cannabis for nonmedical purposes is a very different public
policy. Since the November 2016 election, 20% of the U.S. population lives in
states that have passed ballot initiatives to allow companies to sell cannabis
for any reason and adults 21 or older to purchase it. Although other states may
move toward legalization, uncertainty abounds because of the federal
prohibition on cannabis. The Obama administration tolerated these state laws;
it’s unclear what the Trump administration will do.
There is also tremendous
uncertainty about the net effect of cannabis legalization on public health.1
Most adults who occasionally use cannabis find it pleasurable and don’t
experience substantial problems. There is a growing body of research on the
medical benefits of consuming cannabis flowers or extracts,1,2 and legalization
should make it easier to study the therapeutic potential and allow access for
patients who could benefit.
But cannabis use comes with
important risks.1-4 For example, cannabis intoxication impairs cognitive and
psychomotor function, and there’s strong evidence that
delta-9-tetrahydrocannabinol (THC), the main psychoactive chemical in cannabis,
increases the risk of psychotic symptoms or panic attacks. Approximately 9% of
people who try cannabis meet criteria for cannabis dependence at some point.
The rate roughly doubles for those who initiate use before 17 years of age and
is much higher for adolescents who use cannabis weekly or more often.3
Adolescents and young adults are
central to many cannabis-policy discussions since there are questions about how
frequent cannabis use may affect their brain development and other outcomes.2,3
Authors from the National Institute on Drug Abuse recently wrote that regular
cannabis use by adolescents is particularly worrisome because it’s “associated
with an increased likelihood of deleterious consequences.”2 Policy debates are
often infused with heated disagreements about the extent to which these
associations are causal. Supporters of legalization are quick to note that
police contact or a criminal conviction for a cannabis-related offense can be
deleterious as well. Having a criminal record can make it harder to get a job
or obtain an occupational license, and there can be additional consequences
associated with a drug conviction (e.g., barriers to receiving federal
financial aid for college or obtaining public housing).
Whether cannabis legalization
leads to notable increases in consumption by young people or in the incidence
of cannabis-use disorders will probably depend on how such laws are implemented…
C. Association Between Dietary Factors and
Mortality From Heart Disease, Stroke, and Type 2 Diabetes in the United States
Micha R, et al. JAMA. 2017;317(9):912-924.
Key Points
Question What is the estimated mortality due to heart
disease, stroke, or type 2 diabetes (cardiometabolic deaths) associated with
suboptimal intakes of 10 dietary factors in the United States?
Findings In 2012, suboptimal intake of dietary factors
was associated with an estimated 318 656 cardiometabolic deaths, representing
45.4% of cardiometabolic deaths. The highest proportions of cardiometabolic
deaths were estimated to be related to excess sodium intake, insufficient
intake of nuts/seeds, high intake of processed meats, and low intake of seafood
omega-3 fats.
Meaning Suboptimal intake of specific foods and
nutrients was associated with a substantial proportion of deaths due to heart
disease, stroke, or type 2 diabetes.
D. Questioning a Taboo: Physicians’
Interruptions During Interactions With Patients
Mauksch LB. JAMA.
2017;317(10):1021-1022.
A seminal event occurred in 1984.
Howard Beckman, MD, and Richard Frankel, PhD, published a study1 reporting that
physicians interrupt patients, on average, after 18 seconds during an
encounter. According to Google Scholar,2 this study has been referenced 1115
times in academic journals and books, 50 times alone in 2016. The mainstream
press picked up on this study with titles such as “Study Finds Doctors Aren’t
Good Listeners” or “Prescription for Doctors: Listen More.”
In light of the 1984 finding, how
many students, residents, and practicing physicians in the last 30 years have
been told not to interrupt patients? This admonishment is well intentioned.
Most people associate interruption with rudeness, often leading to patient
complaints. Skillful listening is essential to accomplish critical health care
functions such as identifying the reasons patients request care, making
accurate diagnoses, conveying empathy and support, exploring self-management
challenges, and more. Yet there is a nagging question: Should physicians never
interrupt their patients?
Over the years I have asked
scores of physicians and many psychotherapists, “Do you ever interrupt your
patients?” I have received two answers: “Yes” and “Of course.” Frequently the
respondent laughs sheepishly as if to say, “I know I’m breaking a rule.” What
does the literature tell us about interruption in the medical encounter? Early
research examining interruption of patients stressed physicians’ tendency to
assert and retain power in the relationship. Subsequent studies provide a
broader, more nuanced view. Physicians and patients interrupt one another
often, and patients interrupt at least as frequently as physicians.3 Not all
interruptions are intrusive, competitive, or power-claiming.3 While some
interruptions are classified as neutral, others build rapport, offer support,
and express cooperation.4 The frequency of interruption varies among visit
phases.5 The first phase combines rapport building and agenda setting. A middle
phase focuses on diagnostic inquiry and hypothesis testing. The final phase is
treatment planning. Physicians tend to interrupt in the earlier phases of the
visit using questions to clarify symptoms or concerns. Later in the interview,
patients may interrupt more often using statements more than questions.3
Despite this research, writings
and teachings claim that interrupting patients is taboo…
The remainder of the essay
(full-text free): http://jamanetwork.com/journals/jama/fullarticle/2610340
E. More on opioids misuse
1. Association between concurrent use of
prescription opioids and benzodiazepines and overdose: retrospective analysis
Conclusion: From 2001 to 2013,
concurrent benzodiazepine/opioid use sharply increased in a large sample of
privately insured patients in the US and significantly contributed to the
overall population risk of opioid overdose.
2. Factors Associated With Participation in
an ED–Based Take-Home Naloxone Program for At-Risk Opioid Users
Conclusion: A two-thirds ED
take-home naloxone acceptance rate in patients using opioids should encourage
all EDs to dispense take-home naloxone. ED-based take-home naloxone programs
have the potential to improve access to take-home naloxone and awareness in
individuals most vulnerable to overdoses.
3. Study assesses risk for chronic opioid use
CDC researchers reviewed data for
nearly 1.3 million opioid-naive adults without cancer and found the probability
of long-term opioid use rose significantly after as few as five days of drug
use, as well as after a refill or second prescription and a cumulative dose of
700 morphine-milligram equivalents. The findings in the Morbidity and Mortality
Weekly Report also found the highest odds of chronic use among patients on
long-acting opioids and tramadol.
4. Association between concurrent use of
prescription opioids and benzodiazepines and overdose: retrospective analysis
F. Many patients with AFib who had a stroke
lacked preventive therapy
Study data showed 84% of patients
with atrial fibrillation were not taking adequate clot-prevention therapy
before they had a stroke, researchers reported in the Journal of the American
Medical Association. The study included more than 94,000 US patients and found
some were not taking any anticoagulant medicine, while others were taking only
aspirin or were on an inadequate dosage of warfarin.
G. Patient Attitudes and Participation in
Hand Co-Washing in an Outpatient Clinic Before and After a Prompt
Despite recent national emphasis,
outpatient hand washing can be less than optimal. We tested a new approach
involving both patient and physician hand washing. The study consisted of 384
questionnaires, 184 from phase 1 and 200 from phase 2. Patients stated doctors
washed their hands 96.6% before examining them pre-intervention and 99.5% of
the time post-intervention. Patients endorsed the importance of hand washing
98.7% of the time. “Co-washing” may offer a process to increase the practice of
hand washing and decrease infection risk.
H. Everyday Exposure to Electromagnetic
Fields Can Disrupt Pacemakers: Lower sensitivity and bipolar sensing
recommended
Like implantable
cardioverter-defibrillators (ICDs) before them, pacemakers were found to be
susceptible to interference from electromagnetic fields emitted from personal
electronics, household appliances, and power lines, German researchers
reported.
I. Poll: Most Americans unaware of
antibiotic-resistant "superbug" threat
A new survey conducted by The
Harris Poll and HealthDay found that 69% of those polled had little or no
knowledge about the threat about antibiotic-resistant pathogens, with 53%
incorrectly believing that antibiotics are efficient in battling viral infections.
One encouraging result of the survey was that 66% of the respondents mentioned
inappropriate antibiotic prescriptions as a probable cause of the
"superbug" health threat.
J. Federal Appeals Court Strikes Down
Physician Gag Law: Florida Law Restricted Questions About Guns in the Home
February 22, 2017 12:54 pm News
Staff – In a ruling that supports a physician's First Amendment rights, a
federal appeals court has overturned provisions of a Florida law that
restricted physicians' ability to discuss firearm safety with patients.
The AAFP and other medical
organizations objected to the Firearms Owners' Privacy Act, which imposed
restrictions on asking patients about the presence of guns in the home and on
making notes about the issue in patient records. The law threatened fines and
possible license suspensions for violations.
On Feb. 16, the full panel of the
U.S. Court of Appeals for the 11th Circuit issued a 10-1 decision (media.ca11.uscourts.gov)
striking down sections of the law that barred physicians from asking about
firearms and recording the information in patient records unless the issue was
relevant to patient safety, as well as sections barring them from unnecessarily
harassing patients about firearm ownership.
The court upheld a provision of
the law that bars physicians from discriminating against patients who own
firearms. That provision could be applied in instances such as failing to
return messages, charging patients who own firearms more for similar services
or delaying appointments. As applied to this type of conduct rather than to
physician speech, the court ruled, that section of the law passed
constitutional muster…
K. Direct Aspiration On Par with Stent
Retriever for Large-Vessel Strokes
Safety and efficacy similar in
randomized French trial
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. It's Time to Adopt Electronic
Prescriptions for Opioids
Gawande AA. Ann Surg
2017;265:693-4.
N. A Survey of Emergency Medicine Residents’
Use of Educational Podcasts
Conclusion: The results of this
survey study suggest most residents listen podcasts at least once a month,
prefer podcasts less than 30 minutes in length, have several motivations for
choosing podcasts, and report that podcasts change their clinical practice.
WJEM Full-text: http://escholarship.org/uc/item/4fg852z1
