Thursday, April 20, 2017

Lit Bits: April 20, 2017

From the recent medical literature...

0. The Science of Humor Is No Laughing Matter (in honor of April Fools’ Day)

Alexandra Michel. Observer, April 2017, from the Association for Psychological Science

In 1957, the BBC aired a short documentary about a mild winter leading to a bumper Swiss spaghetti crop in the town of Ticino. In a dry, distinguished tone, BBC broadcaster Richard Dimbleby narrates how even in the last few weeks of March, the spaghetti farmers worry about a late frost, which might not destroy the pasta crop but could damage the flavor and hurt prices. The narration accompanies film footage of a rural family harvesting long spaghetti noodles from trees and laying them out to dry “in the warm Alpine sun.”

Naturally, the hundreds of people who called the BBC asking where they could get their own spaghetti bushes hadn’t noticed the air date of the news clip: April 1st. The prank was so successful that even some BBC staff were taken in, leading to some criticism about using a serious news show for an April Fool’s Day joke.

Why April 1st became a holiday devoted to pranks and laughter remains a mystery, although some historians trace it back to the Roman holiday of Hilaria. Humans start developing a sense of humor as early as 6 weeks old, when babies begin to laugh and smile in response to stimuli. Laughter is universal across human cultures and even exists in some form in rats, chimps, and bonobos. Like other human emotions and expressions, laughter and humor provide psychological scientists with rich resources for studying human psychology, ranging from the developmental underpinnings of language to the neuroscience of social perception.

The Hidden Language of Laughter

Theories focusing on the evolution of laughter point to it as an important adaptation for social communication. Studies have shown that people are more likely to laugh in response to a video clip with canned laughter than to one without a laugh track, and that people are 30 times more likely to laugh in the presence of others than alone.

“The necessary stimulus for laughter is not a joke, but another person,” writes laughter expert and APS Fellow Robert R. Provine, professor emeritus at University of Maryland, Baltimore County, in an article in Current Directions in Psychological Science…

BBC: Spaghetti-Harvest in Ticino: (one of the most famous hoaxes:

An aside: Geoffrey Chaucer's The Canterbury Tales (1392) contains the first recorded association between April 1 and foolishness.

1. A Short Course of Oral Steroids

A. Effect of Oral Dexamethasone Without Immediate Antibiotics vs Placebo on Acute Sore Throat in Adults: A RCT

Hayward GN, et al. JAMA. 2017 Apr 18;317(15):1535-1543.

Importance: Acute sore throat poses a significant burden on primary care and is a source of inappropriate antibiotic prescribing. Corticosteroids could be an alternative symptomatic treatment.

Objective: To assess the clinical effectiveness of oral corticosteroids for acute sore throat in the absence of antibiotics.

Design, Setting, and Participants: Double-blind, placebo-controlled randomized trial (April 2013-February 2015; 28-day follow-up completed April 2015) conducted in 42 family practices in South and West England, enrolled 576 adults recruited on the day of presentation to primary care with acute sore throat not requiring immediate antibiotic therapy.

Interventions: Single oral dose of 10 mg of dexamethasone (n = 293) or identical placebo (n = 283).

Main Outcomes and Measures: Primary: proportion of participants experiencing complete resolution of symptoms at 24 hours. Secondary: complete resolution at 48 hours, duration of moderately bad symptoms (based on a Likert scale, 0, normal; 6, as bad as it could be), visual analog symptom scales (0-100 mm; 0, no symptom to 100, worst imaginable), health care attendance, days missed from work or education, consumption of delayed antibiotics or other medications, adverse events.

Results: Among 565 eligible participants who were randomized (median age, 34 years [interquartile range, 26.0-45.5 year]; 75.2% women; 100% completed the intervention), 288 received dexamethasone; 277, placebo. At 24 hours, 65 participants (22.6%) in the dexamethasone group and 49 (17.7%) in the placebo group achieved complete resolution of symptoms, for a risk difference of 4.7% (95% CI, -1.8% to 11.2%) and a relative risk of 1.28 (95% CI; 0.92 to 1.78; P = .14). At 24 hours, participants receiving dexamethasone were not more likely than those receiving placebo to have complete symptom resolution. At 48 hours, 102 participants (35.4%) in the dexamethasone group vs 75 (27.1%) in the placebo group achieved complete resolution of symptoms, for a risk difference of 8.7% (95% CI, 1.2% to 16.2%) and a relative risk of 1.31 (95% CI, 1.02 to 1.68; P = .03). This difference also was observed in participants not offered delayed antibiotic prescription, for a risk difference of 10.3% (95% CI, 0.6% to 20.1%) and a relative risk of 1.37 (95% CI, 1.01 to 1.87; P = .046). There were no significant differences in any other secondary outcomes.

Conclusions and Relevance: Among adults presenting to primary care with acute sore throat, a single dose of oral dexamethasone compared with placebo did not increase the proportion of patients with resolution of symptoms at 24 hours. However, there was a significant difference at 48 hours.

Ryan Radecki comments:

B. Short term use of oral corticosteroids (less than 30d) is a/w harms among adults in the U.S.: population based cohort study.

Waljee AK, et al. BMJ. 2017 Apr 12;357:j1415.

Objective To determine the frequency of prescriptions for short term use of oral corticosteroids, and adverse events (sepsis, venous thromboembolism, fractures) associated with their use.

Design Retrospective cohort study and self controlled case series.

Setting Nationwide dataset of private insurance claims.

Participants Adults aged 18 to 64 years who were continuously enrolled from 2012 to 2014.

Main outcome measures Rates of short term use of oral corticosteroids defined as less than 30 days duration. Incidence rates of adverse events in corticosteroid users and non-users. Incidence rate ratios for adverse events within 30 day and 31-90 day risk periods after drug initiation.

Results Of 1 548 945 adults, 327 452 (21.1%) received at least one outpatient prescription for short term use of oral corticosteroids over the three year period. Use was more frequent among older patients, women, and white adults, with significant regional variation (all P less than 0.001). The most common indications for use were upper respiratory tract infections, spinal conditions, and allergies. Prescriptions were provided by a diverse range of specialties. Within 30 days of drug initiation, there was an increase in rates of sepsis (incidence rate ratio 5.30, 95% confidence interval 3.80 to 7.41), venous thromboembolism (3.33, 2.78 to 3.99), and fracture (1.87, 1.69 to 2.07), which diminished over the subsequent 31-90 days. The increased risk persisted at prednisone equivalent doses of less than 20 mg/day (incidence rate ratio 4.02 for sepsis, 3.61 for venous thromboembolism, and 1.83 for fracture; all P less than 0.001).

Conclusion One in five American adults in a commercially insured plan were given prescriptions for short term use of oral corticosteroids during a three year period, with an associated increased risk of adverse events

2. Ketamine successful as a first-line treatment for severely agitated ED pts.

Riddell J, et al. Am J Emerg Med. 2017 Feb 13 [Epub ahead of print]

OBJECTIVE: Emergency physicians often need to control agitated patients who present a danger to themselves and hospital personnel. Commonly used medications have limitations. Our primary objective was to compare the time to a defined reduction in agitation scores for ketamine versus benzodiazepines and haloperidol, alone or in combination. Our secondary objectives were to compare rates of medication redosing, vital sign changes, and adverse events in the different treatment groups.

METHODS: We conducted a single-center, prospective, observational study examining agitation levels in acutely agitated emergency department patients between the ages of 18 and 65 who required sedation medication for acute agitation. Providers measured agitation levels on a previously validated 6-point sedation scale at 0-, 5-, 10-, and 15-min after receiving sedation. We also assessed the incidence of adverse events, repeat or rescue medication dosing, and changes in vital signs.

RESULTS: 106 patients were enrolled and 98 met eligibility criteria. There was no significant difference between groups in initial agitation scores. Based on agitation scores, more patients in the ketamine group were no longer agitated than the other medication groups at 5-, 10-, and 15-min after receiving medication. Patients receiving ketamine had similar rates of redosing, changes in vital signs, and adverse events to the other groups.

CONCLUSION: In highly agitated and violent emergency department patients, significantly fewer patients receiving ketamine as a first line sedating agent were agitated at 5-, 10-, and 15-min. Ketamine appears to be faster at controlling agitation than standard emergency department medications.

3. C. difficile Infection in ED Patients with Diarrhea but No Vomiting

In a multicenter study, 10% of such patients were infected — 40% without risk factors!

Abrahamian FM et al. Ann Emerg Med 2017 Feb 24 [Epub ahead of print]

STUDY OBJECTIVE: The incidence of Clostridium difficile infection has increased and has been observed among persons from the community who have not been exposed to antibiotics or health care settings. Our aims are to determine prevalence of C difficile infection among emergency department (ED) patients with diarrhea and the prevalence among patients without traditional risk factors.

METHODS: We conducted a prospective observational study of patients aged 2 years or older with diarrhea (≥3 episodes/24 hours) and no vomiting in 10 US EDs (2010 to 2013). We confirmed C difficile infection by positive stool culture result and toxin assay. C difficile infection risk factors were antibiotic use or overnight health care stay in the previous 3 months or previous C difficile infection. We typed strains with pulsed-field gel electrophoresis.

RESULTS: Of 422 participants, median age was 46 years (range 2 to 94 years), with median illness duration of 3.0 days and 43.4% having greater than or equal to 10 episodes of diarrhea during the previous 24 hours. At least one risk factor for C difficile infection was present in 40.8% of participants; 25.9% were receiving antibiotics, 26.9% had health care stay within the previous 3 months, and 3.3% had previous C difficile infection. Forty-three participants (10.2%) had C difficile infection; among these, 24 (55.8%) received antibiotics and 19 (44.2%) had health care exposure; 17 of 43 (39.5%) lacked any risk factor. Among participants without risk factors, C difficile infection prevalence was 6.9%. The most commonly identified North American pulsed-field gel electrophoresis (NAP) strains were NAP type 1 (23.3%) and NAP type 4 (16.3%).

CONCLUSION: Among mostly adults presenting to US EDs with diarrhea and no vomiting, C difficile infection accounted for approximately 10%. More than one third of patients with C difficile infection lacked traditional risk factors for the disease. Among participants without traditional risk factors, prevalence of C difficile infection was approximately 7%.

4. AMI Corner

A. Rapid Rule-out of AMI with a Single High-Sensitivity Cardiac Trop T below the Limit of Detection: A Collaborative Meta-analysis

Pickering JW, et al. Ann Intern Med 2017 Apr 18 [Epub ahead of print]

Background: High-sensitivity assays for cardiac troponin T (hs-cTnT) are sometimes used to rapidly rule out acute myocardial infarction (AMI).

Purpose: To estimate the ability of a single hs-cTnT concentration below the limit of detection (less than 0.005 µg/L) and a nonischemic electrocardiogram (ECG) to rule out AMI in adults presenting to the emergency department (ED) with chest pain.

Data Sources: EMBASE and MEDLINE without language restrictions (1 January 2008 to 14 December 2016).

Study Selection: Cohort studies involving adults presenting to the ED with possible acute coronary syndrome in whom an ECG and hs-cTnT measurements were obtained and AMI outcomes adjudicated during initial hospitalization.

Data Extraction: Investigators of studies provided data on the number of low-risk patients (no new ischemia on ECG and hs-cTnT measurements less than 0.005 µg/L) and the number who had AMI during hospitalization (primary outcome) or a major adverse cardiac event (MACE) or death within 30 days (secondary outcomes), by risk classification (low or not low risk). Two independent epidemiologists rated risk of bias of studies.

Data Synthesis: Of 9241 patients in 11 cohort studies, 2825 (30.6%) were classified as low risk. Fourteen (0.5%) low-risk patients had AMI. Sensitivity of the risk classification for AMI ranged from 87.5% to 100% in individual studies. Pooled estimated sensitivity was 98.7% (95% CI, 96.6% to 99.5%). Sensitivity for 30-day MACEs ranged from 87.9% to 100%; pooled sensitivity was 98.0% (CI, 94.7% to 99.3%). No low-risk patients died.

Limitation: Few studies, variation in timing and methods of reference standard troponin tests, and heterogeneity of risk and prevalence of AMI across studies.

Conclusion: A single hs-cTnT concentration below the limit of detection in combination with a nonischemic ECG may successfully rule out AMI in patients presenting to EDs with possible emergency acute coronary syndrome.

B. The Fast and the Furious: A Review of Rapid Rule-Out Protocols for Low-Risk CP

Huis in 't Veld M, et al. West J Emerg Med 2017;18(3):474-8.

Accelerated diagnostic pathways (ADPs) have been designed to identify low risk chest pain patients in the emergency department. This review article discusses the ASPECT score, the ADAPT score, the EDACS score, the HEART score and the HEART pathway. These ADPs have been validated in various studies, and aid the emergency provider with identifying the low risk chest pain patient that is appropriate for discharge home, while at the same time highlighting those patients who would benefit from further in patient work up. These approaches should be pared with patient input and shared decision making strategies.

C. Marathons Pose Death Risk to Older Non-Participants

Delays in Emergency Care and Mortality during Major U.S. Marathons.

Jena AB, et al. N Engl J Med. 2017 Apr 13;376(15):1441-1450.

Background Large marathons frequently involve widespread road closures and infrastructure disruptions, which may create delays in emergency care for nonparticipants with acute medical conditions who live in proximity to marathon routes.

Methods We analyzed Medicare data on hospitalizations for acute myocardial infarction or cardiac arrest among Medicare beneficiaries (≥65 years of age) in 11 U.S. cities that were hosting major marathons during the period from 2002 through 2012 and compared 30-day mortality among the beneficiaries who were hospitalized on the date of a marathon, those who were hospitalized on the same day of the week as the day of the marathon in the 5 weeks before or the 5 weeks after the marathon, and those who were hospitalized on the same day as the marathon but in surrounding ZIP Code areas unaffected by the marathon. We also analyzed data from a national registry of ambulance transports and investigated whether ambulance transports occurring before noon in marathon-affected areas (when road closures are likely) had longer scene-to-hospital transport times than on nonmarathon dates. We also compared transport times on marathon dates with those on nonmarathon dates in these same areas during evenings (when roads were reopened) and in areas unaffected by the marathon.

Results The daily frequency of hospitalizations was similar on marathon and nonmarathon dates (mean number of hospitalizations per city, 10.6 and 10.5, respectively; P=0.71); the characteristics of the beneficiaries hospitalized on marathon and nonmarathon dates were also similar. Unadjusted 30-day mortality in marathon-affected areas on marathon dates was 28.2% (323 deaths in 1145 hospitalizations) as compared with 24.9% (2757 deaths in 11,074 hospitalizations) on nonmarathon dates (absolute risk difference, 3.3 percentage points; 95% confidence interval, 0.7 to 6.0; P=0.01; relative risk difference, 13.3%). This pattern persisted after adjustment for covariates and in an analysis that included beneficiaries who had five or more chronic medical conditions (a group that is unlikely to be hospitalized because of marathon participation). No significant differences were found with respect to where patients were hospitalized or the treatments they received in the hospital. Ambulance scene-to-hospital transport times for pickups before noon were 4.4 minutes longer on marathon dates than on nonmarathon dates (relative difference, 32.1%; P=0.005). No delays were found in evenings or in marathon-unaffected areas.

Conclusions Medicare beneficiaries who were admitted to marathon-affected hospitals with acute myocardial infarction or cardiac arrest on marathon dates had longer ambulance transport times before noon (4.4 minutes longer) and higher 30-day mortality than beneficiaries who were hospitalized on nonmarathon dates. (Funded by the National Institutes of Health.).

D. Self-taught artificial intelligence beats doctors at predicting heart attacks

By Matthew Hutson, Science Magazine, Apr. 14, 2017

Doctors have lots of tools for predicting a patient’s health. But—as even they will tell you—they’re no match for the complexity of the human body. Heart attacks in particular are hard to anticipate. Now, scientists have shown that computers capable of teaching themselves can perform even better than standard medical guidelines, significantly increasing prediction rates. If implemented, the new method could save thousands or even millions of lives a year.

“I can’t stress enough how important it is,” says Elsie Ross, a vascular surgeon at Stanford University in Palo Alto, California, who was not involved with the work, “and how much I really hope that doctors start to embrace the use of artificial intelligence to assist us in care of patients.”

Each year, nearly 20 million people die from the effects of cardiovascular disease, including heart attacks, strokes, blocked arteries, and other circulatory system malfunctions. In an effort to predict these cases, many doctors use guidelines similar to those of the American College of Cardiology/American Heart Association (ACC/AHA). Those are based on eight risk factors—including age, cholesterol level, and blood pressure—that physicians effectively add up.

But that’s too simplistic to account for the many medications a patient might be on, or other disease and lifestyle factors. “There’s a lot of interaction in biological systems,” says Stephen Weng, an epidemiologist at the University of Nottingham in the United Kingdom. Some of those interactions are counterintuitive: A lot of body fat can actually protect against heart disease in some cases. “That’s the reality of the human body,” Weng says. “What computer science allows us to do is to explore those associations.”

In the new study, Weng and his colleagues compared use of the ACC/AHA guidelines with four machine-learning algorithms: random forest, logistic regression, gradient boosting, and neural networks. All four techniques analyze lots of data in order to come up with predictive tools without any human instruction. In this case, the data came from the electronic medical records of 378,256 patients in the United Kingdom. The goal was to find patterns in the records that were associated with cardiovascular events.

First, the artificial intelligence (AI) algorithms had to train themselves. They used about 78% of the data—some 295,267 records—to search for patterns and build their own internal “guidelines.” They then tested themselves on the remaining records. Using record data available in 2005, they predicted which patients would have their first cardiovascular event over the next 10 years, and checked the guesses against the 2015 records. Unlike the ACC/AHA guidelines, the machine-learning methods were allowed to take into account 22 more data points, including ethnicity, arthritis, and kidney disease.

All four AI methods performed significantly better than the ACC/AHA guidelines. Using a statistic called AUC (in which a score of 1.0 signifies 100% accuracy), the ACC/AHA guidelines hit 0.728. The four new methods ranged from 0.745 to 0.764, Weng’s team reports this month in PLOS ONE. The best one—neural networks—correctly predicted 7.6% more events than the ACC/AHA method, and it raised 1.6% fewer false alarms. In the test sample of about 83,000 records, that amounts to 355 additional patients whose lives could have been saved. That’s because prediction often leads to prevention, Weng says, through cholesterol-lowering medication or changes in diet…

Several of the risk factors that the machine-learning algorithms identified as the strongest predictors are not included in the ACC/AHA guidelines, such as severe mental illness and taking oral corticosteroids. Meanwhile, none of the algorithms considered diabetes, which is on the ACC/AHA list, to be among the top 10 predictors. Going forward, Weng hopes to include other lifestyle and genetic factors in computer algorithms to further improve their accuracy…

Source: Weng SF, et al. Can machine-learning improve cardiovascular risk prediction using routine clinical data? PLoS One. 2017 Apr 4;12(4):e0174944

E. Trends in Incidence of Hospitalized AMI in the Cardiovascular Research Network (CVRN)

Reynolds K, et al. Am J Med. 2017 Mar;130(3):317-327.

BACKGROUND: Monitoring trends in cardiovascular events can provide key insights into the effectiveness of prevention efforts. Leveraging data from electronic health records provides a unique opportunity to examine contemporary, community-based trends in acute myocardial infarction hospitalizations.

METHODS: We examined trends in hospitalized acute myocardial infarction incidence among adults aged ≥25 years in 13 US health plans in the Cardiovascular Research Network. The first hospitalization per member for acute myocardial infarction overall and for ST-segment elevation myocardial infarction and non-ST-segment elevation myocardial infarction was identified by International Classification of Diseases, Ninth Revision, Clinical Modification primary discharge codes in each calendar year from 2000 through 2008. Age- and sex-adjusted incidence was calculated per 100,000 person-years using direct adjustment with 2000 US census data.

RESULTS: Between 2000 and 2008, we identified 125,435 acute myocardial infarction hospitalizations. Age- and sex-adjusted incidence rates (per 100,000 person-years) of acute myocardial infarction decreased an average 3.8%/y from 230.5 in 2000 to 168.6 in 2008. Incidence of ST-segment elevation myocardial infarction decreased 8.7%/y from 104.3 in 2000 to 51.7 in 2008, whereas incidence of non-ST-segment elevation myocardial infarction increased from 126.1 to 129.4 between 2000 and 2004 and then decreased thereafter to 116.8 in 2008. Age- and sex-specific incidence rates generally reflected similar patterns, with relatively larger decreases in ST-segment elevation myocardial infarction rates in women compared with men. As compared with 2000, the age-adjusted incidence of ST-segment elevation myocardial infarction in 2008 was 48% lower among men and 61% lower among women.

CONCLUSIONS AND RELEVANCE: Among a large, diverse, multicenter community-based insured population, there were significant decreases in incidence of hospitalized acute myocardial infarction and the more serious ST-segment elevation myocardial infarctions between 2000 and 2008. Decreases in ST-segment elevation myocardial infarctions were most pronounced among women. While ecologic in nature, these secular decreases likely reflect, at least in part, results of improvement in primary prevention efforts.

4. All About Praxbind: Pradaxa’s Effective Yet Pricey Reversal Agent

Karen Serrano et al. EP Monthly. April 3, 2017

New oral anticoagulants (NOACs) are skyrocketing in popularity. Here’s what you need to know about this target-specific reversal agent for Dabigatran.

Studies show that administration of idarucizumab to healthy young volunteers, older volunteers aged 65-80, and volunteers aged 45-80 with mild or moderate renal impairment resulted in complete reversal of dabigatran’s anticoagulant effects within minutes without any procoagulant effects. This reversal of anticoagulation lasts 24 hours, which is an advantage over PCC, which has more transient effects. One important caveat is that there must be dabigatran in the bloodstream for idarucizumab to have any effect. Once the dabigatran is cleared by the kidney, idarucizumab will have nothing to bind to and will have no effect. It is recommended to give it if the last dose of dabigatran was in the last 24-48 hours. There may be some benefit of longer time frames in patients with renal failure, who will have a slower clearance rate of the dabigatran. Finally, since it is a monoclonal antibody, it is highly specific for dabigatran. It will not reverse the anticoagulant effects of coumadin, plavix, or other NOACs such as rivaroxaban.

The data on idarucizumab in patients who are actually bleeding or being operated on looks favorable as well. The Reversal Effects of Idarucizumab on Active Dabigaran (RE-VERSE AD) trial, a large international prospective cohort study of patients on dabigatran who receive idarucizumab either for serious bleeding or prior to an urgent surgical procedure, is still ongoing. A preliminary analysis of the first 90 patients revealed that idarucizumab rapidly and completely restored coagulation parameters in 88 to 98% of patients who had elevated clotting times at baseline. Among patients who underwent surgery, normal hemostasis was reported in 92%, with mild to moderate impairment in 8%. Only 1 of 90 patients (1%) had a thrombotic event within 72 hours of administration of idarucizumab. These data mirror the safety and efficacy data on idarucizumab from earlier human and animal studies…

5. Patterns of Multiple ED Visits: Do Primary Care Physicians Matter?

Maeng DD, et al. Perm J 2017;21:16-055

Context: Overutilization and overreliance on Emergency Departments (EDs) as a usual source of care can lead to unnecessarily high costs and undesirable consequences, such as a gap in care coordination and inadequate provision of preventive care.

Objective: To identify factors associated with multiple ED visits by patients, in particular, the impact of primary care physicians (PCPs) on their patients’ multiple ED visit rates.

Design: Geisinger Health Plan claims data among adult patients who averaged more than 1 ED visit within a 12-month period between 2013 and 2014 were obtained (N = 20,351).

Main Outcome Measures: Rate of ED visits. Three linear regression models using patient characteristics and utilization patterns as covariates along with PCP fixed effects were estimated to explain the variation in the multiple ED visit rates.

Results: Multiple ED visits were significantly associated with younger age (18-39 years), having Medicaid insurance, and greater comorbidity. Higher rates of physician office visits and inpatient admissions were also associated with higher rates of multiple ED visits. Accounting for PCP characteristics only marginally improved the explained variation (R2 increased from 0.14 to 0.16).

Conclusions: Multiple ED visit patterns are likely driven by patients’ health conditions and care needs rather than by their PCPs. Multiple ED visits also appear to be complementary, rather than substitutionary, to PCP visits, suggesting that PCP-focused interventions aimed at reducing ED use are unlikely to have a major impact.

6. Pediatrics Corner

A. Does the Use of Ibuprofen in Children with Extremity Fractures Increase their Risk for Bone Healing Complications?

DePeter KC, et al. J Emerg Med. 2017 Apr;52(4):426-432.

BACKGROUND: Despite being an effective analgesic for children with fractures, some clinicians may avoid prescribing ibuprofen due to its potentially harmful effect on bone healing.

OBJECTIVE: To determine if exposure to ibuprofen is associated with an increased risk of bone healing complications in children with fractures.

METHODS: We performed a retrospective study of children aged 6 months to 17 years who presented to the pediatric emergency department (PED) with a fracture of the tibia, femur, humerus, scaphoid, or fifth metatarsus and who followed up with the orthopedic service. We chose these fractures due to their higher risk for complications. We classified patients as exposed if they received ibuprofen in the PED or during hospitalization or were prescribed ibuprofen at discharge. The main outcome was a bone healing complication as evidenced by nonunion, delayed union, or re-displacement on follow-up radiographs.

RESULTS: Of the 808 patients included in the final analysis, 338 (42%) were exposed to ibuprofen. Overall, 27 (3%) patients had a bone healing complication; 8 (1%) developed nonunion, 3 (0.4%) developed delayed union, and 16 (2%) developed re-displacement. Ten (3%) patients who were exposed to ibuprofen, and 17 (4%) who were not, developed a bone healing complication (odds ratio 0.8, 95% confidence interval 0.4-1.8; p = 0.61). There was no significant association between ibuprofen exposure and the development of a bone healing complication despite adjustment for potential confounders.

CONCLUSION: Children with extremity fractures who are exposed to ibuprofen do not seem to be at increased risk for clinically important bone healing complications.

B. Successful Outpt Management of Febrile Infants without a Lumbar Puncture or Antibiotics

Low-risk febrile neonates who were discharged from an ED in Spain without a lumbar puncture or antibiotics recovered well.

Mintegi S et al. Arch Dis Child 2017 Mar;102(3):244-249.

OBJECTIVE: To analyse the outpatient management of selected febrile infants younger than 90 days without systematic lumbar puncture and antibiotics.

METHODS: A prospective registry-based cohort study including all the infants ≤90 days with fever without a source (FWS) who were evaluated in a paediatric emergency department (ED) over a 7-year period (September 2007-August 2014). We analysed the outcome of those infants with low-risk criteria for serious bacterial infection (SBI) managed as outpatients without antibiotics and without undergoing a lumbar puncture. Low-risk criteria: Well appearing, older than 21 days of age, no leucocyturia, absolute neutrophil count ≤10 000, serum C reactive protein ≤20 mg/L, procalcitonin less than 0.5 ng/mL and no clinical deterioration during the stay in the ED (always less than 24 hours).

RESULTS: 1472 infants with FWS attended the ED. Of these, 676 were classified to be at low risk for SBI without performing a lumbar puncture. After staying less than 24 hours in the short-stay unit of the ED, 586 (86.6%) were managed as outpatients without antibiotics. Two patients were diagnosed with SBI: one occult bacteraemia and one bacterial gastroenteritis. Both were afebrile when evaluated again and did well. No patient returned to the ED due to clinical deterioration. Fifty-one infants (8.7%) returned to the ED mainly due to persistence of fever or irritability. None was diagnosed with definite SBI or non-bacterial meningitis.

CONCLUSIONS: Outpatient management without antibiotics and systematic lumbar puncture is appropriate for selected febrile infants younger than 3 months of age with close follow-up. 

C. Development and Internal Validation of a Clinical Risk Score for Treating Children with Mild Head Trauma and Intracranial Injury.

Greenberg JK, et al. JAMA Pediatr. 2017 Feb 13. [Epub ahead of print]

Importance: The appropriate treatment of children with mild traumatic brain injury (mTBI) and intracranial injury (ICI) on computed tomographic imaging remains unclear. Evidence-based risk assessments may improve patient safety and reduce resource use.

Objective: To derive a risk score predicting the need for intensive care unit observation in children with mTBI and ICI.

Design, Setting, and Participants: This retrospective analysis of the prospective Pediatric Emergency Care Applied Research Network (PECARN) head injury cohort study included patients enrolled in 25 North American emergency departments from 2004 to 2006. We included patients younger than 18 years with mTBI (Glasgow Coma Scale [GCS] score, 13-15) and ICI on computed tomography. The data analysis was conducted from May 2015 to October 2016.

Main Outcomes and Measures: The primary outcome was the composite of neurosurgical intervention, intubation for more than 24 hours for TBI, or death from TBI. Multivariate logistic regression was used to predict the outcome. The C statistic was used to quantify discrimination, and model performance was internally validated using 10-fold cross-validation. Based on this modeling, the Children's Intracranial Injury Decision Aid score was created.

Results: Among 15 162 children with GCS 13 to 15 head injuries who received head computed tomographic imaging in the emergency department, 839 (5.5%) had ICI. The median ages of those with and without a composite outcome were 7 and 5 years, respectively. Among those patients with ICI, 8.7% (n = 73) experienced the primary outcome, including 8.3% (n = 70) who had a neurosurgical intervention. The only clinical variable significantly associated with outcome was GCS score (odds ratio [OR], 3.4; 95% CI, 1.5-7.4 for GCS score 13 vs 15). Significant radiologic predictors included midline shift (OR, 6.8; 95% CI, 3.4-13.8), depressed skull fracture (OR, 6.5; 95% CI, 3.7-11.4), and epidural hematoma (OR, 3.4; 95% CI, 1.8-6.2). The model C statistic was 0.84 (95% CI, 0.79-0.88); the 10-fold cross-validated C statistic was 0.83. Based on this modeling, we developed the Children's Intracranial Injury Decision Aid score, which ranged from 0 to 24 points. The negative predictive value of having 0 points (ie, none of these risk factors) was 98.8% (95% CI, 97.3%-99.6%).

Conclusions and Relevance: Lower GCS score, midline shift, depressed skull fracture, and epidural hematoma are key risk factors for needing intensive care unit-level care in children with mTBI and ICI. Based on these results, the Children's Intracranial Injury Decision Aid score is a potentially novel tool to risk stratify this population, thereby aiding management decisions.

D. Use of Traumatic Brain Injury Prediction Rules with Clinical Decision Support

Dayan PS, et al, with PECARN and CREST. Pediatrics. 2017 Mar 24 [Epub ahead of print]

OBJECTIVES: We determined whether implementing the Pediatric Emergency Care Applied Research Network (PECARN) traumatic brain injury (TBI) prediction rules and providing risks of clinically important TBIs (ciTBIs) with computerized clinical decision support (CDS) reduces computed tomography (CT) use for children with minor head trauma.

METHODS: Nonrandomized trial with concurrent controls at 5 pediatric emergency departments (PEDs) and 8 general EDs (GEDs) between November 2011 and June 2014. Patients were less than 18 years old with minor blunt head trauma. Intervention sites received CDS with CT recommendations and risks of ciTBI, both for patients at very low risk of ciTBI (no Pediatric Emergency Care Applied Research Network rule factors) and those not at very low risk. The primary outcome was the rate of CT, analyzed by site, controlling for time trend.

RESULTS: We analyzed 16 635 intervention and 2394 control patients. Adjusted for time trends, CT rates decreased significantly (P less than .05) but modestly (2.3%-3.7%) at 2 of 4 intervention PEDs for children at very low risk. The other 2 PEDs had small (0.8%-1.5%) nonsignificant decreases. CT rates did not decrease consistently at the intervention GEDs, with low baseline CT rates (2.1%-4.0%) in those at very low risk. The control PED had little change in CT use in similar children (from 1.6% to 2.9%); the control GED showed a decrease in the CT rate (from 7.1% to 2.6%). For all children with minor head trauma, intervention sites had small decreases in CT rates (1.7%-6.2%).

CONCLUSIONS: The implementation of TBI prediction rules and provision of risks of ciTBIs by using CDS was associated with modest, safe, but variable decreases in CT use. However, some secular trends were also noted.

E. Accuracy of PECARN, CATCH, and CHALICE head injury decision rules in children: a prospective cohort study

Babl FE, et al. Lancet. 2017 Apr 11 [Epub ahead of print]. 

BACKGROUND: Clinical decision rules can help to determine the need for CT imaging in children with head injuries. We aimed to validate three clinical decision rules (PECARN, CATCH, and CHALICE) in a large sample of children.

METHODS: In this prospective observational study, we included children and adolescents (aged less than 18 years) with head injuries of any severity who presented to the emergency departments of ten Australian and New Zealand hospitals. We assessed the diagnostic accuracy of PECARN (stratified into children aged less than 2 years and ≥2 years), CATCH, and CHALICE in predicting each rule-specific outcome measure (clinically important traumatic brain injury [TBI], need for neurological intervention, and clinically significant intracranial injury, respectively). For each calculation we used rule-specific predictor variables in populations that satisfied inclusion and exclusion criteria for each rule (validation cohort). In a secondary analysis, we compiled a comparison cohort of patients with mild head injuries (Glasgow Coma Scale score 13-15) and calculated accuracy using rule-specific predictor variables for the standardised outcome of clinically important TBI. This study is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12614000463673.

FINDINGS: Between April 11, 2011, and Nov 30, 2014, we analysed 20 137 children and adolescents attending with head injuries. CTs were obtained for 2106 (10%) patients, 4544 (23%) were admitted, 83 (less than 1%) underwent neurosurgery, and 15 (less than 1%) died. PECARN was applicable for 4011 (75%) of 5374 patients younger than 2 years and 11 152 (76%) of 14 763 patients aged 2 years and older. CATCH was applicable for 4957 (25%) patients and CHALICE for 20 029 (99%). The highest point validation sensitivities were shown for PECARN in children younger than 2 years (100·0%, 95% CI 90·7-100·0; 38 patients identified of 38 with outcome [38/38]) and PECARN in children 2 years and older (99·0%, 94·4-100·0; 97/98), followed by CATCH (high-risk predictors only; 95·2%; 76·2-99·9; 20/21; medium-risk and high-risk predictors 88·7%; 82·2-93·4; 125/141) and CHALICE (92·3%, 89·2-94·7; 370/401). In the comparison cohort of 18 913 patients with mild injuries, sensitivities for clinically important TBI were similar. Negative predictive values in both analyses were higher than 99% for all rules.

INTERPRETATION: The sensitivities of three clinical decision rules for head injuries in children were high when used as designed. The findings are an important starting point for clinicians considering the introduction of one of the rules.

F. Faster clean catch urine collection (Quick-Wee method) from infants: randomised controlled trial.

Kaufman J, et al. BMJ. 2017 Apr 7;357:j1341.

Objective To determine if a simple stimulation method increases the rate of infant voiding for clean catch urine within five minutes.

Design Randomised controlled trial.

Setting Emergency department of a tertiary paediatric hospital, Australia.

Participants 354 infants (aged 1-12 months) requiring urine sample collection as determined by the treating clinician. 10 infants were subsequently excluded.

Interventions Infants were randomised to either gentle suprapubic cutaneous stimulation (n=174) using gauze soaked in cold fluid (the Quick-Wee method) or standard clean catch urine with no additional stimulation (n=170), for five minutes.

Main outcome measures The primary outcome was voiding of urine within five minutes. Secondary outcomes were successful collection of a urine sample, contamination rate, and parental and clinician satisfaction with the method.

Results The Quick-Wee method resulted in a significantly higher rate of voiding within five minutes compared with standard clean catch urine (31% v 12%, P less than 0.001), difference in proportions 19% favouring Quick-Wee (95% confidence interval for difference 11% to 28%). Quick-Wee had a higher rate of successful urine sample collection (30% v 9%, P less than 0.001) and greater parental and clinician satisfaction (median 2 v 3 on a 5 point Likert scale, P less than 0.001). The difference in contamination between Quick-Wee and standard clean catch urine was not significant (27% v 45%, P=0.29). The number needed to treat was 4.7 (95% confidence interval 3.4 to 7.7) to successfully collect one additional urine sample within five minutes using Quick-Wee compared with standard clean catch urine.

Conclusions Quick-Wee is a simple cutaneous stimulation method that significantly increases the five minute voiding and success rate of clean catch urine collection.

G. IV Magnesium Doesn't Reduce Time to Improvement for Acute Bronchiolitis

In a randomized, placebo-controlled trial, intravenous magnesium showed no benefit in infants with moderate to severe acute bronchiolitis.

Abstract: Alansari K et al. Chest 2017 Mar 9 [Epub ahead of print]:    

8. Randomized Trial of Adding Parenteral Acetaminophen to Prochlorperazine and Diphenhydramine to Treat Headache in the ED

Meyering SH, et al. West J Emerg Med. 2017;18(3):373-381.

Introduction: Headaches represent over 3 million Emergency Department visits per year comprising 2.4 percent of all ED visits. Headaches are thought to be one of the three most common complaints of patient presentations to EDs across the country. There are many proposed methods and clinical guidelines of treating acute headache presentations however data on intravenous acetaminophen usage in these settings are lacking.

Objectives: The study attempts to determine the efficacy of IV Acetaminophen as an adjunct to a standard therapy for the treatment of patients who present to the emergency department with a chief complaint of “headache” or variants thereof.

Design: Randomized, double-blind, placebo-controlled trial. Institutional IRB approval was obtained prior to implementation.

Setting: Academic Community Hospital.

Patients: Key elements of eligibility included adults ages 18-65 who had no mental or physical hindrances to pain assessment or to receiving acetaminophen. Exclusion criteria included those who had received total cumulative dose of acetaminophen above 2600mg within past 24 hours, documented or suspected pregnancy, dementia, psychosis, liver cirrhosis, hemodynamic instability or other medical conditions prohibiting acetaminophen use. Ability to understand informed consent was necessary.

Interventions: All patients received prochlorperazine, diphenhydramine, 1000ml 0.9% normal saline IV, and were randomized to receive either parenteral acetaminophen (1000mg/100ml) or 100ml of 0.9% NS as control in the placebo group.

Main outcome measures: Subjective pain scores rated on a 1-10 Visual Assessment Scale were assessed repeatedly at 30 minute intervals. Length of stay and time to disposition were also noted. The incidence of rescue medications required outside of the initial regimen was also noted, with particular attention to narcotic utilization.

Results: Of the (n=45) patients who received IV acetaminophen, 36 reported a statistically significant decrease by pain score of 2 or greater from presentation at the 90 minute mark. Of the (n=45) patients who received placebo, 25 reported a statistically significant decrease by pain score reporting from presentation at the 90 minute mark. (p 0.01,  over 95% CI).  For the acetaminophen group the initial mean VAS pain score was 8.7, for the placebo group 8.6. At 90 minutes 2.2 for Acetaminophen, 4.0 for placebo group. (p less than 0.01, over 99% CI). Length of stay was decreased a mean 36.6 minutes in the Acetaminophen group. 17 patients in the IV acetaminophen and 24 patients in the placebo group received rescue medications, with 18% less in the acetaminophen group requiring narcotics (p 0.01, CI over 95).

Conclusion: In Emergency Department patients with acute headache, IV Acetaminophen when used as an adjunct to prochlorperazine and diphenhydramine resulted in increased pain reduction, decreased length of stay and less rescue medications utilized including narcotics when compared to treatment with prochlorperazine and diphenhydramine alone.

9. Opioid Corner

A. With a 10-day supply of opioids, 1 in 5 become long-term users

The longer you use opioids, the greater the risks—and the risks rise fast.

Beth Mole. Ars Technica 3/18/2017

The longer a person uses opioids, the greater the risk of forming a deadly addiction. But just how long does it take to switch from being a short-term user—say, while you’re dealing with pain after a surgery—to a long-term, potentially problematic user? A few weeks? A month?

According to a new study, that transition could take just a matter of days.

When patients get an initial opioid prescription that’s just a one-day supply, they have about a six-percent chance of being on opioids for a year or longer. But if that first prescription is for a three-day supply, the probability of long-term use starts inching up. With an initial five-day supply, the chance jumps to about 10 percent. With a six-day supply, the chance hits 12 percent. With 10-day’s worth, the odds of still being on opioids a year later hits roughly 20 percent.

So, with an initial 10-day opioid prescription, about one-in-five patients become long-term users. That’s according to the new study’s lead author Bradley Martin, a professor of pharmaceutical evaluation and policy at the University of Arkansas for Medical Science. It’s a fast rise, Martin said to Ars. “We really didn’t expect that.”

And, according to the rest of the data—published Friday in the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report (MMWR)—things just keep getting worse from there. [Link below]

To calculate the probabilities, Martin and his colleagues tracked the prescription records of nearly 1.3 million patients. Those patients were all 18 or older, cancer-free, and got at least one opioid prescription between June 2006 and September 2015. They also didn’t have any history of opioid abuse.

For patients who get a 30-day stash of opioid all at once for their initial prescription, the chance of being on opioids for a year rose to 45 percent. But, Martin says, getting that much in one go is uncommon. Only about seven percent of patients get such long-duration prescriptions in the study. Most people get about a week’s worth at a time.

People who got 30 days of opioid total—meaning they may have gotten multiple prescriptions or refills over time—had about a 30-percent probability of using opioids for a year. And they had a nearly 20-percent chance of being on them for three years.

Other factors that kicked up the chances of long-term use were long-acting opioids, getting a cumulative dose equivalent to more than 700 milligrams of morphine, and getting multiple prescriptions. One in seven who got a second opioid or a refill were on the addictive drugs for at least a year.

Martin says he hopes the fresh data will help prescribers make smart and informed choices when doling out the powerful drugs. Early last year, the CDC released guidelines for prescribing opioids, recommending weak, short doses, ideally three days for acute pain. The agency urged doctors to refrain from prescribing opioids for chronic pain, except for cancer patients and end-of-life care.

In the study, Martin and colleagues found that less than one percent of patients were prescribed powerful, long-acting opioids, which are used for chronic pain. This suggests that intentional chronic pain prescriptions are uncommon. But the authors did note that 10 percent of patients got tramadol, which is considered a relatively safe opioid. So this may hint that some intentional prescriptions for chronic pain is going on.

Source: Shah A, et al. Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use - United States, 2006-2015. MMWR Morb Mortal Wkly Rep. 2017 Mar 17;66(10):265-269.

B. Something for pain: Responsible opioid use in emergency medicine.

Strayer RJ, et al. Am J Emerg Med. 2017 Feb;35(2):337-341.

The United States is currently experiencing a public health crisis of opioid addiction, which has its genesis in an industry marketing effort that successfully encouraged clinicians to prescribe opioids liberally, and asserted the safety of prescribing opioids for chronic non-cancer pain, despite a preponderance of evidence demonstrating the risks of dependence and misuse. The resulting rise in opioid use has pushed drug overdose deaths in front of motor vehicle collisions to become the leading cause of accidental death in the country.

Emergency providers frequently treat patients for complications of opioid abuse, and also manage patients with acute and chronic pain, for which opioids are routinely prescribed. Emergency providers are therefore well positioned to both prevent new cases of opioid misuse and initiate appropriate treatment of existing opioid addicts. In opioid-naive patients, this is accomplished by a careful consideration of the likelihood of benefit and harm of an opioid prescription for acute pain. If opioids are prescribed, the chance of harm is reduced by matching the number of pills prescribed to the expected duration of pain and selecting an opioid preparation with low abuse liability. Patients who present to acute care with exacerbations of chronic pain or painful conditions associated with opioid misuse are best managed by treating symptoms with opioid alternatives and encouraging treatment for opioid addiction.

Acute physical dependence can develop within several days and its attendant withdrawal symptoms may be mistaken for ongoing discomfort from the injury or illness, which the patient effectively treats with more opioids.

…opioids sensitize patients to pain: opioid-induced hyperalgesia may occur within a week of opioid therapy and accounts for the commonly observed phenomenon in which regular opioid users experience pain and distress out of proportion to what is expected for the stimulus (e.g. when starting an IV)

The majority of patients discharged from acute care settings with acute pain can be effectively managed with opioid alternatives. Ibuprofen 400 mg and acetaminophen 1000 mg every six hours will provide effective analgesia for most adult patients with acute pain–in many cases more effective analgesia than opioids.

The goal is not zero pain, but reducing pain enough to allow the patient to function well for the duration of the painful condition

Most acute pain improves within days and if one patient in hundred discharged with an opioid prescription is set down the path of opioid misuse, the resulting harm to that patient is so immense that it almost certainly exceeds the incremental analgesic benefit opioids may offer to everyone else.

Though data is limited, given the harms associated with alternatives, we recommend immediate-release morphine, 15 mg tablets, when outpatient opioids are thought to be indicated.

Rather than dispute what claims are true or how much pain the patient is in, we find the best approach is to frame an unwillingness to use opioids as coming from a conviction that they are not in the patient's best interests. “I know you are in pain and I want to relieve your pain, but I will not use narcotic medications because I believe those medications are harming you.”

C. State ED Opioid Guidelines: Current Status

Broaida RI, et al. West J Emerg Med 2017;18(3):340-344.

Study Objective: The purpose of this study was to evaluate and categorize current state-sponsored opioid guidelines which affect Emergency Medicine practice.

Methods: We conducted a comprehensive search of emergency medicine-specific opioid prescribing guidelines and/or policies in each state to determine current state involvement in emergency medicine opioid prescribing, as well as to evaluate some of the specifics of each guideline or policy.  The search was conducted using an online query and a follow-up email request to each state chapter of ACEP.

Results: We found that eighteen states had emergency department-specific guidelines. We further organized these into four categories; Limiting Prescriptions for Opioids with 67 total recommendations, Preventing/Diverting Abuse with 56 total recommendations, Addiction related guidelines with 29 total recommendations, and a Community Resources section with 24 total recommendations. Our results showed that current state guidelines focus on providers limiting opioid pain prescriptions and vetting patients for possible abuse/diversion..

Conclusion: This study highlights the 18 states that have addressed opioid prescribing guidelines and categorizes their efforts to date. It is hoped that this work will provide the basis for similar efforts in other states.

D. Surgeons were told to stop prescribing so many painkillers. The results were remarkable.

By Lenny Bernstein. Washington Post. March 7, 2017.

The head of general surgery at Dartmouth-Hitchcock Medical Center had a remarkably simple idea not long ago: What if the department suggested that surgeons limit prescriptions of narcotic pain pills to a specific number for different kinds of operations?

The results were dramatic: The number of pills prescribed by doctors for five common outpatient surgeries dropped by 53 percent, and patients didn't consume all the pills they were given, according to a study that will be published this week in the journal Annals of Surgery.

Even veteran surgeons really had no idea how many opioids to send home with their patients, said Richard J. Barth, who is chief of general surgery at the medical center in New Hampshire and led the team that conducted the study…

E. Health and Public Policy to Facilitate Effective Prevention and Treatment of Substance Use Disorders Involving Illicit and Prescription Drugs: An American College of Physicians Position Paper 

10. Images in Clinical Practice

Splenic Infarction Associated with Oral Contraceptive Pills in a Healthy Young Woman

Ten images of red eyes across the diagnostic spectrum

Adolescent Male With Right Shoulder Pain After Football Injury

A Man With Severe Back Pain

Man With Throat Pain

Boy With Fever and Abdominal Pain

Just How Good Are Handheld Metal Detectors for Ingested Foreign Bodies?

Woman With Left Shoulder Bumps

Young Woman With Epigastric Pain

Candida Esophagitis


Primary Hyperoxaluria

Regression of Coronary Atherosclerosis with Medical Therapy

Gartner’s Duct Cyst

Kaposi’s Sarcoma of the Oral Cavity

Tumbu Fly Larvae

Fournier’s Gangrene

11. Beyond Code Status: Palliative Care Begins in the ED

Wang DH. Ann Emerg Med. 2017 Apr;69(4):437-443.

Palliative Care Is Increasingly Relevant to the Scope of Emergency Medicine

The aging US population is increasingly dying from chronic rather than acute illnesses. By 2030, 1 of every 5 Americans will be older than 65 years.1 Advances in management of acute illnesses have helped more patients now live long enough to develop end-stage organ disease, cancer, and dementia. With increasingly complex medical needs, these patients present to their emergency department (ED) with challenging complaints such as functional loss, bounce-back visits for uncontrolled symptoms, and caregiver fatigue.2 Moreover, these visits point to a gradual decline that is often missed as a result of the usual focus on diagnosis and disposition. Patients may present their needs through subtle commentary (Table 1) that may be readily overlooked as subacute or social issues. However, although these concerns do not appear immediately actionable, early palliative intervention directly affects patients’ quality of life and downstream use of the health care system. Emergency physicians encounter but may not recognize palliative care–eligible patients far earlier than their terminal admission.

Palliative Care Starts Well Before the End of Life

Despite increasing interest, there remains significant heterogeneity in emergency provider understanding of what is meant by the phrase “palliative care.”3 Similarly, 90% of Americans have little to no knowledge of palliative care, but when read a simple definition, they would want early palliative care for themselves and their loved ones.4 Palliative care comprises an interdisciplinary team to provide relief to patients and their families from the symptoms and stress of incurable illnesses throughout the entire disease course. Although hospice and comfort care are subcomponents, palliative care adds significant value well before the final days of life. The best results are enjoyed when palliative care begins serving patients at their initial diagnosis of life-limiting illness (Figure 1), continuing along with their treatments from other specialists and taking on a greater role as their disease progresses. Palliative care teams preemptively address advanced care planning, caregiver needs (eg, housing, resources), streamlined communication between disparate provider teams, psychosocial support, and introducing hospice at the earliest opportunity to benefit. Through these channels, they provide an extra layer of support to ensure that the continuum of care is congruent with the patient’s life goals.5 Effective palliative care is a parallel process, not a handoff.

Palliative Care Is a Win for Emergency Medicine at a Systems Level

With the Patient Protection and Affordable Care Act, health care systems are searching for innovation to curb spending without compromising quality of care. Recognizing the stewarding role that emergency medicine plays in health care use, in 2013 the American College of Emergency Physicians (ACEP) prioritized earlier access to palliative care as one of its top 5 measures in the Choosing Wisely campaign to reduce undesired and unnecessary medical treatments.6 Early palliative care is a win-win for patients and health care systems. EDs are an opportune entry point into the palliative care continuum. During the last 5 years, a large body of research has shown that early integration into palliative care reduces ED visits and hospitalizations by up to 50%.7, 8, 9, 10 This has been corroborated across community, academic, and county practice settings, as well as in diverse disease populations. Even for admitted patients, initiating a palliative care consultation directly from the ED (versus later as an inpatient) shortens length of stay by an average of 4 days, resulting in fewer inhospital deaths11 while significantly increasing quality of life without reducing overall survival.12  A 2014 meta-analysis estimated that palliative care consultation reduced hospital inpatient costs by 10% to 30%.13 These financial implications are affecting downstream incentives for emergency physicians. In a shifting reimbursement landscape, hospitals are keen to minimize 30-day readmissions because these become unreimbursed care in the transition to bundled payment models. Many hospital budgets operate within a 2% to 4% profitability margin,14 and Medicare readmission penalties may reduce revenues by 3%.15 Given this slim buffer, there will be increasing scrutiny and effort on diverting readmissions. By proactively connecting eligible patients with early palliative care and thereby reducing ED revisits and hospital readmissions, emergency physicians continue to project their value in the health care system while enabling patients to receive treatment congruent with their goals of care…

See also
Spilsbury K et al. The Association of Community-Based Palliative Care With Reduced ED Visits in the Last Year of Life Varies by Patient Factors. Ann Emerg Med. 2017 Apr;69(4):416-425.

Palliative Care Decreases ED Visits for All, but Especially for Some: Effects were greatest among patients aged 90 years and older, those with a partner, and those living in areas of least social disadvantage.

12. The Patients Were Saved. That’s Why the Families Are Suing.

Paula Span. New York Times. April 10, 2017

What happened to Beatrice Weisman before dawn on Aug. 29, 2013, was not supposed to happen: The medical staff at Maryland General Hospital found her in cardiac arrest, resuscitated her and kept her alive.

The matriarch of a close-knit family on Maryland’s Eastern Shore, Ms. Weisman, then 83, had suffered a serious stroke in June and had spent weeks in two hospitals.

Fortunately, she and her husband had drafted advance directives; she named her husband, William, to make medical decisions if she became unable to.

In August, as her condition deteriorated, Mr. Weisman convened a wrenching family meeting at their Easton home. With the support of their four children, he authorized Medical Orders for Life-Sustaining Treatment, known as a Molst form, stating that if his wife’s heart or lungs failed, she should be allowed to die.

(In Maryland and most other states, Molst or Polst — Physician Orders for Life-Sustaining Treatment — forms become part of physicians’ orders; they apply in every health care setting and provide a clearer guide to patients’ wishes than standard advance directives.)

Yet when Ms. Weisman was discovered turning blue in her bed, staff members began to perform CPR, which caused broken ribs and collapsed lungs. They defibrillated her with electric shocks, injected epinephrine and succeeded in reviving her.

“My father was distraught,” said Christian Weisman, the couple’s eldest child.

He said his parents “had done everything the way they were supposed to — the wills, the advance directives, the Molst.” But when hospital personnel found their patient dying, “they still violated her wishes.”

Mr. Weisman has brought suit against Maryland General for its treatment of his mother, alleging assault, negligence, the “intentional infliction of emotional distress” and other claims.

Physicians and hospitals have grown accustomed to the threat of lawsuits when they fail to save a patient’s life. Now, some face legal action for failing to let a patient die.

Several similar lawsuits around the country say that health care providers disregarded or overrode advance directives, resuscitating people whose instructions clearly said not to…

13. Myths in the Evaluation and Management of Ovarian Torsion.

Robertson JJ, et al. J Emerg Med. 2017 Apr;52(4):449-456.

BACKGROUND: Ovarian torsion is a rare but serious cause of pelvic pain in females. Making the diagnosis is important because misdiagnosis can lead to an ischemic ovary and subsequent infertility.

OBJECTIVE: Although all emergency physicians are aware of ovarian torsion, there are several myths regarding its epidemiology, diagnosis, and treatment. This article attempts to review some of these myths to improve emergency diagnosis and evaluation.

DISCUSSION: Ovarian torsion is not an easy diagnosis to make and it is commonly missed. Signs and symptoms often mimic other disorders such as appendicitis, pyelonephritis, and nephrolithiasis. The diagnosis becomes more challenging in that torsion can occur in female patients of all ages, including infants and the elderly. Normal arterial blood flow on ultrasound does not rule out ovarian torsion and not every patient will have a mass on imaging or a palpable mass on examination. Patients may have symptoms for several hours or days, and thus, ovarian torsion may be present even with a longer duration of symptoms. Surgery is the definitive treatment and may still be effective after several hours of symptoms.

CONCLUSIONS: Although ovarian torsion is a challenging diagnosis, understanding myths surrounding the disorder may help emergency physicians consider it in unusual populations. If there is any clinical concern for ovarian torsion, a gynecologic consult may be helpful, even if imaging findings are not conclusive. Surgery remains the standard method for definitive diagnosis and treatment.

14. Comparing the Effectiveness of a Novel Suction Set-up Using an Adult Endotracheal Tube Connected to a Meconium Aspirator vs. a Traditional Yankauer Suction Instrument.

Kei J, Mebust DP. J Emerg Med. 2017 Apr;52(4):433-437.

BACKGROUND: It has been suggested that an adult 8.0 endotracheal tube (ETT) connected to a neonatal meconium aspirator would improve suctioning during emergent endotracheal intubation compared to the Yankauer suction instrument, the standard tool used by emergency physicians.

OBJECTIVES: This study was designed to compare the effectiveness of a Yankauer vs. an ETT-meconium aspirator set-up in suctioning liquids of different viscosities.

METHODS: The Yankauer and ETT-meconium aspirator device underwent a head-to-head timed comparison, suctioning 250 mL of three different fluids, varying in viscosity. The first comparison test used tap water to represent simple oral secretions. The second comparison test used porcine whole blood as a proxy for human blood. The third comparison test used a coarsely blended mixture of a hamburger, French fries, and a soda to simulate emesis from a recently ingested meal. Five separate time trials were conducted for each liquid and for each suction device.

RESULTS: The ETT-meconium aspirator device compared to the Yankauer suctioned faster in both the water comparison test (mean = 2.6 s vs. 3.4 s; p less than 0.001) and the porcine whole blood comparison test (mean = 2.9 s vs. 4.3 s; p = 0.0015). In the emesis trial, the Yankauer immediately clogged, whereas the ETT-meconium aspirator apparatus managed to suction an average of 90 mL prior to clogging.

CONCLUSION: Compared to the Yankauer, an adult 8.0 ETT connected to a meconium aspirator was superior in suctioning liquids of varying viscosities and should be considered when encountering a difficult airway due to copious secretions, blood, or emesis.

15. ACEP Clinical Policy: Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the ED


This clinical policy from the American College of Emergency Physicians addresses key issues for the diagnosis and management of adult psychiatric patients in the emergency department. A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: (1) In the alert adult patient presenting to the emergency department with acute psychiatric symptoms, should routine laboratory tests be used to identify contributory medical conditions (nonpsychiatric disorders)? (2) In the adult patient with new-onset psychosis without focal neurologic deficit, should brain imaging be obtained acutely? (3) In the adult patient presenting to the emergency department with suicidal ideation, can risk-assessment tools in the emergency department identify those who are safe for discharge? (4) In the adult patient presenting to the emergency department with acute agitation, can ketamine be used safely and effectively? Evidence was graded and recommendations were made based on the strength of the available data.

16. Risk of VTE Very Low after a Single Normal Proximal Lower Extremity Venous US

Mitsunaga MM, et al. Perm J 2017;21:16-140

Context: The optimal lower extremity venous ultrasound (US) protocol to diagnose deep venous thrombosis of the popliteal and more proximal veins is unclear.

Objective: To determine the three-month rate of symptomatic venous thromboembolism (VTE) and clinical outcomes of inpatients and ambulatory patients with normal findings on single venous ultrasound of the popliteal and more proximal veins (single proximal US).

Design: Single proximal US results and clinical data of all inpatient and ambulatory patients with suspected acute deep venous thrombosis were retrospectively reviewed during a 12-month period between January and December 2014. Three-month follow-up data were reviewed for all these patients, who received all their care from a single geographically isolated health maintenance organization.

Main Outcome Measures: Three-month rate of symptomatic VTE and clinical outcomes after an initially normal single proximal US result.

Results: Of 1295 patients, 111 (8.6%) were found to have acute deep venous thrombosis on the initial proximal US. Of the remaining 1184 patients with initially normal results on proximal US who were sampled at 3-month follow-up, 1075 patients (90.8%) had no venous thromboembolic event. Among the others, 11 (0.9%) had a subsequent imaging-confirmed venous thromboembolic event, 53 (4.5%) died (none owing to venous thromboembolism), and 45 (3.8%) did not complete follow-up.

Conclusion: Symptomatic VTE after an initially normal single proximal US result occurred in less than 1% of this cohort. Therefore, serial proximal US is unnecessary for most of our patients, and its elimination will save time and out-of-pocket expenses.

17. Early, Goal-Directed Therapy for Septic Shock - A Patient-Level Meta-Analysis.

PRISM Investigators. N Engl J Med. 2017 Mar 21 [Epub ahead of print]

Background After a single-center trial and observational studies suggesting that early, goal-directed therapy (EGDT) reduced mortality from septic shock, three multicenter trials (ProCESS, ARISE, and ProMISe) showed no benefit. This meta-analysis of individual patient data from the three recent trials was designed prospectively to improve statistical power and explore heterogeneity of treatment effect of EGDT.

Methods We harmonized entry criteria, intervention protocols, outcomes, resource-use measures, and data collection across the trials and specified all analyses before unblinding. After completion of the trials, we pooled data, excluding the protocol-based standard-therapy group from the ProCESS trial, and resolved residual differences. The primary outcome was 90-day mortality. Secondary outcomes included 1-year survival, organ support, and hospitalization costs. We tested for treatment-by-subgroup interactions for 16 patient characteristics and 6 care-delivery characteristics.

Results We studied 3723 patients at 138 hospitals in seven countries. Mortality at 90 days was similar for EGDT (462 of 1852 patients [24.9%]) and usual care (475 of 1871 patients [25.4%]); the adjusted odds ratio was 0.97 (95% confidence interval, 0.82 to 1.14; P=0.68). EGDT was associated with greater mean (±SD) use of intensive care (5.3±7.1 vs. 4.9±7.0 days, P=0.04) and cardiovascular support (1.9±3.7 vs. 1.6±2.9 days, P=0.01) than was usual care; other outcomes did not differ significantly, although average costs were higher with EGDT. Subgroup analyses showed no benefit from EGDT for patients with worse shock (higher serum lactate level, combined hypotension and hyperlactatemia, or higher predicted risk of death) or for hospitals with a lower propensity to use vasopressors or fluids during usual resuscitation.

Conclusions In this meta-analysis of individual patient data, EGDT did not result in better outcomes than usual care and was associated with higher hospitalization costs across a broad range of patient and hospital characteristics.

One excerpt
As noted previously, all three trials are more recent than the trial by Rivers et al., and early recognition of sepsis and prompt delivery of intravenous fluids and antimicrobial agents were promoted in all treatment groups. It remains possible that general advances in the provision of care for sepsis and septic shock, to the benefit of all patients, explain part or all of the difference in findings between the trial by Rivers et al. and the more recent trials.

18. ED Visits Without Hospitalization Are Associated With Functional Decline in Older Persons.

Nagurney JM, et al. Ann Emerg Med. 2017 Apr;69(4):426-433.

STUDY OBJECTIVE: Among older persons, disability and functional decline are associated with increased mortality, institutionalization, and costs. The aim of the study was to determine whether illnesses and injuries leading to an emergency department (ED) visit but not hospitalization are associated with functional decline among community-living older persons.

METHODS: From a cohort of 754 community-living older persons who have been followed with monthly interviews for up to 14 years, we matched 813 ED visits without hospitalization (ED only) to 813 observations without an ED visit or hospitalization (control). We compared the course of disability during the following 6 months between the 2 matched groups. To establish a frame of reference, we also compared the ED-only group with an unmatched group who were hospitalized after an ED visit (ED-hospitalized). Disability scores (range 0 [lowest] to 13 [highest]) were compared using generalized linear models adjusted for relevant covariates. Admission to a nursing home and mortality were evaluated as secondary outcomes.

RESULTS: The ED-only and control groups were well matched. For both groups, the mean age was 84 years, and 69% were women. The baseline disability scores were 3.4 and 3.6 in the ED-only and control groups, respectively. During the 6-month follow-up period, the ED-only group had significantly higher disability scores than the control group, with an adjusted risk ratio of 1.14 (95% confidence interval [CI] 1.09 to 1.19). Compared with participants in the ED-only group, those who were hospitalized after an ED visit had disability scores that were significantly higher (risk ratio 1.17; 95% CI 1.12 to 1.22). Both nursing home admissions (hazard ratio 3.11; 95% CI 2.05 to 4.72) and mortality (hazard ratio 1.93; 95% CI 1.07 to 3.49) were higher in the ED-only group versus control group during the 6-month follow-up period.

CONCLUSION: Although not as debilitating as an acute hospitalization, illnesses and injuries leading to an ED visit without hospitalization were associated with a clinically meaningful decline in functional status during the following 6 months, suggesting that the period after an ED visit represents a vulnerable time for community-living older persons.

19. NEJM Cases

A. A 61-year-old man presents to the ED with SOB and cough.

A 61-year-old man presents to the emergency department with shortness of breath and cough. Earlier that morning, he had sudden onset of dyspnea and tightness in his chest. The chest tightness had resolved, but he continued to feel short of breath. He reported no fevers but did have a productive cough…

Test your clinical skills (free):

Each interactive case presents an evolving patient history and a series of questions and exercises designed to test your diagnostic and therapeutic skills. You will receive immediate feedback on your answers and treatment choices, along with the opportunity to compare your final score with those of your peers. Video, animation, and interactive content allow you to learn more about mechanisms, diagnostic tests, and treatments.

B. Case Vignette: A Man with Sciatica Who is Considering Lumbar Disk Surgery

Mr. Winston, a 50-year-old bus driver, presented to your office with a 4-week history of pain in his left leg and lower back. He described a combination of severe sharp and dull pain that originated in his left buttock and radiated to the dorsolateral aspect of his left thigh, as well as vague aching over the lower lumbar spine. On examination, passive raising of his left leg off the table to 45 degrees caused severe pain that simulated his main symptom, and the pain was so severe that you could not lift his leg further. There was no leg or foot weakness. His body-mass index (the weight in kilograms divided by the square of the height in meters) was 35, and he had mild chronic obstructive pulmonary disease as a result of smoking one pack of cigarettes every day for 22 years. Mr. Winston had taken a leave of absence from his work because of his symptoms. You prescribed 150 mg of pregabalin per day, which was gradually increased to 600 mg daily because the symptoms had not abated.

Now, 10 weeks after the initial onset of his symptoms, he returns for an evaluation. The medication has provided minimal alleviation of his sciatic pain. He has to return to work and is concerned about his ability to complete his duties at his job. He undergoes magnetic resonance imaging, which shows a herniated disk on the left side at the L4–L5 root. You discuss options for the next steps in managing his sciatica. He is uncertain about invasive procedures such as lumbar disk surgery but feels limited by his symptoms of pain…

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

Coutinho JM, et al. JAMA Neurol. 2017 Mar 1;74(3):268-274.

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

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

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

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

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

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

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

21. Rudeness in Medical Care

Perri Klauss, MD. New York Times

A. What Happens When Parents Are Rude in the Hospital (Feb 27)

The neonatal intensive care unit is a place full of tiny, vulnerable and critically ill infants; fearful and anxious parents; and busy doctors and nurses working to save lives. But if a parent of a sick baby says something rude to the medical staff, the quality of care might suffer, a new Israeli study suggests.

“We weren’t looking at angry parents, we were looking at rude parents,” said Dr. Peter Bamberger, a study co-author and the associate dean for research at Coller School of Management at Tel Aviv University. The study used the kind of simulated crisis scenarios that are commonly performed to help medical staff practice, using actor “parents” and a realistic plastic baby “patient.” And the rude “mother” in the study said, loud enough for the staff to hear: “I knew we should have gone to a better hospital where they don’t practice Third World medicine.”

“It wasn’t anything horrible,” Dr. Bamberger said. “They weren’t going ballistic, they weren’t violent. They just said things that weren’t so pleasant for doctors to hear.”

But even such mild unpleasantness was enough to affect doctors’ and nurses’ medical skills. Individual performance and teamwork deteriorated to the point where diagnostic skills, procedural skills and team communication were impaired and medical errors were more likely, compared to control scenarios in which the mother would just say something general about being worried. The team’s ability to perform in critical medical situations with sick babies was affected for the rest of the day, the findings suggest…

B. Rude Doctors, Rude Nurses, Rude Patients (April 10)

Just how much rudeness is there in the hospital, and who bears the brunt of it?

A few weeks ago I wrote about a study that looked at what happens to medical teams when parents are rude to doctors. In these studies of simulated patient emergencies, doctors and nurses working in the neonatal intensive care unit were less effective in teamwork and communication, and in their diagnostic and technical skills, after an actor, playing a parent, made a rude remark about the quality of the hospital.

These results bothered me, not because I was surprised that there might be rudeness (and worse) coming from parents, but because I pride myself on a kind of professional immunity. Sure, parents are sometimes rude, and occasionally openly hostile; and sure, I acknowledge that that can be upsetting. But I wouldn’t have imagined that it would actually affect my medical skills or decision making.

If those supremely highly trained NICU personnel are actually worse at resuscitating newborns or diagnosing life-threatening complications after exposure to rudeness, though, what happens to the rest of us as we go through the lower-stakes but still important interactions of our clinical days?

Many of the readers who responded to that column seemed to think that the doctors and nurses were somehow doing it on purpose, responding punitively to the simulated “rude parent.” But in fact they were performing at a lower level on observed — and graded — tests of their medical abilities.

Other readers pointed out that it’s always good policy to be polite to the people taking care of you. And many others just wanted to register that the medical environment is full of rudeness on all sides: Patients complain about egregious rudeness by doctors, nurses, ward clerks and receptionists, while nurses tell stories of harsh patients and family members, not to mention rude doctors.

None of that is a surprise, and in fact, there is a good deal of literature to suggest that the medical environment includes all kinds of harshness, and that much of the rudeness you encounter as a doctor or nurse is likely to come from colleagues and co-workers. An often-cited British study from 2015 called “Sticks and Stones” reported that rude, dismissive and aggressive communication between doctors (inevitably abbreviated, in a medical journal, as RDA communication) affected 31 percent of doctors several times a week or more. The researchers found that rudeness was more common from certain medical specialties: radiology, general surgery, neurosurgery and cardiology. They also established that higher status was somewhat protective; junior doctors and trainees encountered more rudeness…

22. Micro Bits

A. The March for Science: April 22

The March for Science is the first step of a global movement to defend the vital role science plays in our health, safety, economies, and governments.

Why? Science, scientists, and evidence-based policymaking are under attack. Budget cuts, censorship of researchers, disappearing datasets, and threats to dismantle government agencies harm us all, putting our health, food, air, water, climate, and jobs at risk. It is time for people who support science to take a public stand and be counted.

B. The "True" Human Diet

From the standpoint of paleoecology, the so-called Paleo diet is a myth

By Peter Ungar. Scientific American. April 17, 2017

C. Strategy for reduction of pain during Foley catheterization

Placement of a Foley catheter in a male can be relatively uncomfortable. Strategies such as insertion of Xylocaine jelly prior to catheter insertion have been used to minimize discomfort. Most of the difficulty with placing a catheter is at the level of the external sphincter, prostate, and bladder neck. When there is difficulty due to an enlarged prostate, stricture, or bladder neck contracture, the catheter should not be forced because it can lead to a false passage. Pain level during urethral catheterization in males can be significantly reduced when the patient is instructed to void during the insertion of the catheter.

D. Pain intensity varies by education level, gender, study says

A review of patient pain scores after surgery found people with higher education levels had lower levels of pain intensity and greater self-management behavior compared with those who had less education. Researchers reported in the AORN Journal that women had higher pain intensity levels and lower pain self-management behavior than men.

E. USPSTF: Individualize Decisions on PSA Screening for Men Ages 55-69

April 11, 2017 — On April 11, the U.S. Preventive Services Task Force posted its new draft recommendation statement and three draft evidence reviews on screening for prostate cancer.

F. Development of the SaFETy Score: A Clinical Screening Tool for Predicting Future Firearm Violence Risk

Conclusion: The SaFETy score is a 4-item score based on clinically feasible questionnaire items and is associated with firearm violence. Although broader validation is required, SaFETy shows potential to guide resource allocation for prevention of firearm violence.

G. New Guidelines for Benign Paroxysmal Positional Vertigo

This update of a 2008 guideline from the American Academy of Otolaryngology-Head and Neck Surgery Foundation provides evidence-based recommendations to benign paroxysmal positional vertigo (BPPV), defined as a disorder of the inner ear characterized by repeated episodes of positional vertigo. Changes from the prior guideline include a consumer advocate added to the update group; new evidence from 2 clinical practice guidelines, 20 systematic reviews, and 27 randomized controlled trials; enhanced emphasis on patient education and shared decision making; a new algorithm to clarify action statement relationships; and new and expanded recommendations for the diagnosis and management of BPPV.

H. Putting Patients First by Reducing Administrative Tasks in Health Care: A Position Paper of the American College of Physicians

The growing number of administrative tasks imposed on physicians, their practices, and their patients adds unnecessary costs to the U.S. health care system, individual physician practices, and the patients themselves. Excessive administrative tasks also divert time and focus from more clinically important activities of physicians and their staffs, such as providing actual care to patients and improving quality, and may prevent patients from receiving timely and appropriate care or treatment. In addition, administrative tasks are keeping physicians from entering or remaining in primary care and may cause them to decline participation in certain insurance plans because of the excessive requirements. The increase in these tasks also has been linked to greater stress and burnout among physicians.

I. WHO: Depression tops list of illnesses worldwide

A new report from the World Health Organization estimates that depression affected more than 300 million people in 2015, an 18% increase from 2005, making it the world's leading cause of illness and disability. The condition isn't addressed adequately anywhere across the globe, largely due to the stigma and discrimination linked to it, researchers said.

J. Treating hypertension at age 90 -- Does it affect mortality?

Israeli researchers who examined data from the Jerusalem Longitudinal Study on 480 90-year-olds over a five-year period found no association between blood pressure levels and increased mortality risk in those with untreated raised blood pressure readings compared with those with normal readings.

K. Mortality drops when hospitals are being inspected, research finds

A study in JAMA Internal Medicine found that patient mortality is lower when Joint Commission inspectors are assessing a hospital than in the weeks before and after the visit. Researchers attribute the quality improvement, which translated to 1.5% lower 30-day mortality overall and a 5.9% reduction at major teaching hospitals, to greater overall vigilance, rather than specific measures.