Saturday, March 18, 2017

Lit Bits: March 18, 2017

From the recent medical literature...

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

 Radekci’s perspective:

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):

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)

Full-text (free):

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.

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).

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.

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.

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…

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…

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.

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…

The remainder of the essay (full-text free):

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):

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.

Full-text (free in Circulation):

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 ( 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.