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…
The rest of
the essay (free): http://www.psychologicalscience.org/observer/the-science-of-humor-is-no-laughing-matter
BBC:
Spaghetti-Harvest in Ticino: https://www.youtube.com/watch?v=tVo_wkxH9dU (one of the most famous hoaxes: http://hoaxes.org/aprilfool)
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.
Full-text
(free): http://jamanetwork.com/journals/jama/fullarticle/2618622
Ryan Radecki comments: http://www.emlitofnote.com/?p=3862
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.
Excerpt
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…
The rest of
the essay (free): http://epmonthly.com/article/praxbind-pradaxas-effective-yet-pricey-reversal-agent/
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]: https://www.ncbi.nlm.nih.gov/pubmed/28286262
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.
Excerpts
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…
The rest of
the essay: https://www.washingtonpost.com/news/to-your-health/wp/2017/03/07/surgeons-were-told-to-stop-prescribing-so-many-painkillers-the-results-were-remarkable/
The study
itself: http://journals.lww.com/annalsofsurgery/Abstract/publishahead/An_Educational_Intervention_Decreases_Opioid.96203.aspx
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
Full-text
(free): http://annals.org/aim/article/2613555/health-public-policy-facilitate-effective-prevention-treatment-substance-use-disorders
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
Osteopetrosis
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
Abstract
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…
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…
The remainder
of the essay: https://www.nytimes.com/2017/02/27/well/family/what-happens-when-parents-are-rude-in-the-hospital.html
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…
The rest of
the essay: https://www.nytimes.com/2017/04/10/well/family/rude-doctors-rude-nurses-rude-patients.html
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.
Full-text (free): http://annals.org/aim/article/2614079/putting-patients-first-reducing-administrative-tasks-health-care-position-paper
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.
NY Daily News: http://www.nydailynews.com/life-style/health/depression-no-1-illness-disability-worldwide-article-1.3014312
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.
