1. Effect of Cephalexin plus TMP-SMX vs Cephalexin Alone on
Clinical Cure of Uncomplicated Cellulitis: A RCT
Moran GJ, et
al. JAMA. 2017 May 23;317(20):2088-2096.
Key Points
Question Does cephalexin plus
trimethoprim-sulfamethoxazole yield higher clinical cure rates than cephalexin
alone for treatment of patients with uncomplicated cellulitis?
Findings In this randomized clinical trial of 500
patients with cellulitis, the clinical cure rate was not significantly
different between those treated with cephalexin plus
trimethoprim-sulfamethoxazole vs cephalexin plus placebo (83.5% vs 85.5% in the
per-protocol analysis and 76.2% vs 69.0% in the modified intention-to-treat
analysis). However, the 95% confidence interval for the difference in the
intention-to-treat analysis was −1.0% to +15.5%, which included the minimal
clinically important difference of 10%.
Meaning Addition of trimethoprim-sulfamethoxazole to
cephalexin did not result in a statistically significant improvement in
clinical cure for uncomplicated cellulitis. However, because the imprecision
around the findings in the modified intention-to-treat analysis included a
clinically important difference favoring the combination, further research may
be needed.
Abstract
IMPORTANCE: Emergency
department visits for skin infections in the United States have increased with
the emergence of methicillin-resistant Staphylococcus aureus (MRSA). For
cellulitis without purulent drainage, β-hemolytic streptococci are presumed to
be the predominant pathogens. It is unknown if antimicrobial regimens
possessing in vitro MRSA activity provide improved outcomes compared with
treatments lacking MRSA activity.
OBJECTIVE: To
determine whether cephalexin plus trimethoprim-sulfamethoxazole yields a higher
clinical cure rate of uncomplicated cellulitis than cephalexin alone.
DESIGN,
SETTING, AND PARTICIPANTS: Multicenter, double-blind, randomized superiority
trial in 5 US emergency departments among outpatients older than 12 years with
cellulitis and no wound, purulent drainage, or abscess enrolled from April 2009
through June 2012. All participants had soft tissue ultrasound performed at the
time of enrollment to exclude abscess. Final follow-up was August 2012.
INTERVENTIONS:
Cephalexin, 500 mg 4 times daily, plus trimethoprim-sulfamethoxazole, 320
mg/1600 mg twice daily, for 7 days (n = 248 participants) or cephalexin plus
placebo for 7 days (n = 248 participants).
MAIN OUTCOMES
AND MEASURES: The primary outcome determined a priori in the per-protocol group
was clinical cure, defined as absence of these clinical failure criteria at
follow-up visits: fever; increase in erythema (above 25%), swelling, or
tenderness (days 3-4); no decrease in erythema, swelling, or tenderness (days
8-10); and more than minimal erythema, swelling, or tenderness (days 14-21). A
clinically significant difference was defined as greater than 10%.
RESULTS: Among
500 randomized participants, 496 (99%) were included in the modified
intention-to-treat analysis and 411 (82.2%) in the per-protocol analysis
(median age, 40 years [range, 15-78 years]; 58.4% male; 10.9% had diabetes).
Median length and width of erythema were 13.0 cm and 10.0 cm. In the
per-protocol population, clinical cure occurred in 182 (83.5%) of 218
participants in the cephalexin plus trimethoprim-sulfamethoxazole group vs 165
(85.5%) of 193 in the cephalexin group (difference, -2.0%; 95% CI, -9.7% to
5.7%; P = .50). In the modified intention-to-treat population, clinical cure
occurred in 189 (76.2%) of 248 participants in the cephalexin plus
trimethoprim-sulfamethoxazole group vs 171 (69.0%) of 248 in the cephalexin
group (difference, 7.3%; 95% CI, -1.0% to 15.5%; P = .07). Between-group
adverse event rates and secondary outcomes through 7 to 9 weeks, including
overnight hospitalization, recurrent skin infections, and similar infection in
household contacts, did not differ significantly.
CONCLUSIONS
AND RELEVANCE: Among patients with uncomplicated cellulitis, the use of
cephalexin plus trimethoprim-sulfamethoxazole compared to cephalexin alone did
not result in higher rates of clinical resolution of cellulitis in the
per-protocol analysis. However, because imprecision around the findings in the
modified intention-to-treat analysis included a clinically important difference
favoring cephalexin plus trimethoprim-sulfamethoxazole, further research may be
needed.
2. H1-antihistamines Reduce Progression to Anaphylaxis among ED
Patients with Allergic Reactions.
Kawano T, et
al. Acad Emerg Med. 2017 Jun;24(6):733-741.
OBJECTIVES:
H1-antihistamines (H1a) can be used to treat emergency department (ED) patients
with allergic reactions; however, this is inconsistently done, likely because
there is no evidence that this therapy has an impact on serious outcomes. Among
ED patients initially presenting with allergic reactions, we investigated
whether H1a were associated with lower rates of progression to anaphylaxis.
METHODS: This
was a retrospective cohort study conducted at two urban Canadian EDs from April
1, 2007, to March 31, 2012. We included consecutive adult patients with
allergic reactions while excluding those presenting with anaphylaxis, according
to prespecified criteria. The primary outcome was the proportion of patients
who subsequently developed anaphylaxis during medical care, either by emergency
medical services (EMS) or in the ED. A prespecified subgroup analysis excluded
patients who received H1a prior to EMS or ED contact. We compared those who
received H1a and those who did not and used multivariable regression and propensity
score adjustment techniques to compare outcomes.
RESULTS: Of
2,376 overall patients included, 1,880 (79.1%) were managed with H1a. Of the
latter group, 36 of 1,880 (1.9%) developed anaphylaxis, compared to 17 of 496
(3.4%) in the non-H1a-treated group (adjusted odds ratio [AOR] = 0.34, 95%
confidence interval [CI] = 0.17-0.70; number needed to treat [NNT] to benefit =
44.74, 95% CI = 35.36-99.67). In the subgroup analysis of 1,717 patients who
did not receive H1a prior to EMS or ED contact, a similar association was
observed (AOR = 0.26, 95% CI = 0.10-0.50; NNT to benefit 38.20, 95% CI =
32.58-55.24).
CONCLUSIONS:
Among ED patient with allergic reactions, H1a administration was associated
with a lower likelihood of progression to anaphylaxis. These data indicate that
early H1a treatment in the ED or prehospital setting may decrease progression
to anaphylaxis.
3. Toxicology Corner
A.
CDC reports on poisonings from "death cap" mushrooms in California
CDC
researchers, including Steve Offerman from Kaiser Permamente Northern CA,
reported 14 cases of poisoning from ingestion of wild "death cap"
mushrooms in California last December. The findings in the agency's Morbidity
and Mortality Weekly Report showed that all patients eventually recovered but three
had to undergo liver transplants, including an 18-month-old infant who
developed irreversible liver failure and permanent neurologic damage after
eating one-half of a mushroom cap.
Vo KT, et al.
Amanita phalloides Mushroom Poisonings - Northern California, December 2016. MMWR
Morb Mortal Wkly Rep. 2017 Jun 2;66(21):549-553.
Excerpt
Amanita
phalloides, colloquially known as the “death cap,” belongs to the Phalloideae
section of the Amanita family of mushrooms and is responsible for most deaths
following ingestion of foraged mushrooms worldwide (1). On November 28, 2016,
members of the Bay Area Mycological Society notified personnel at the
California Poison Control System (CPCS) of an unusually large A. phalloides
bloom in the greater San Francisco Bay Area, coincident with the abundant
rainfall and recent warm weather. Five days later, CPCS received notification
of the first human A. phalloides poisoning of the season. Over the following 2
weeks, CPCS was notified of an additional 13 cases of hepatotoxicity resulting
from A. phalloides ingestion. In the past few years before this outbreak, CPCS
received reports of only a few mushroom poisoning cases per year. A summary of
14 reported cases is presented here. Data extracted from patient medical charts
revealed a pattern of delayed gastrointestinal manifestations of intoxication
leading to dehydration and hepatotoxicity. Three patients received liver
transplants and all but one recovered completely. The morbidity and potential
lethality associated with A. phalloides ingestion are serious public health
concerns and warrant medical provider education and dissemination of
information cautioning against consuming foraged wild mushrooms.
Initial case.
A man aged 37 years (patient A) picked two wild mushrooms in Santa Rosa,
California (Table). He cooked and ate one mushroom, and approximately 10 hours
later developed nausea, vomiting, and diarrhea. He was evaluated in a local
emergency department (ED) for abdominal discomfort 20.5 hours after ingestion.
A mycologist identified the uncooked mushroom sample provided by the patient as
A. phalloides. Initial laboratory findings were notable for an elevated white
blood cell count with lactate elevation and elevated creatinine suggesting
dehydration (Table). Liver function tests (LFTs) 6 hours later showed elevated
aspartate aminotransferase (AST) (92 IU/L; normal = 15–41) and alanine
aminotransferase (ALT) (95 IU/L; normal = 17–63) levels. He was treated with
aggressive intravenous (IV) fluid hydration, IV octreotide,* and IV silibinin.†
Two days after ingestion, the patient’s LFTs peaked at AST = 6,159 IU/L, ALT =
3,084 IU/L, total bilirubin = 2.9 mg/dL (normal = 0.2–1.2), and international
normalized ratio (INR) (standardized prothrombin time) 3.2 units (normal = 0.8–1.2).
Gastrointestinal symptoms and laboratory values gradually improved, and the
patient was discharged home on day 6…
B.
Sodium Nitrite and Sodium Thiosulfate Are Effective Against Acute Cyanide
Poisoning When Administered by IM Injection
Bebarta VS,
et al. Ann Emerg Med. 2017 Jun;69(6):718-725.e4.
STUDY
OBJECTIVE: The 2 antidotes for acute cyanide poisoning in the United States
must be administered by intravenous injection. In the out-of-hospital setting,
intravenous injection is not practical, particularly for mass casualties, and
intramuscular injection would be preferred. The purpose of this study is to
determine whether sodium nitrite and sodium thiosulfate are effective cyanide
antidotes when administered by intramuscular injection.
METHODS: We
used a randomized, nonblinded, parallel-group study design in 3 mammalian
models: cyanide gas inhalation in mice, with treatment postexposure;
intravenous sodium cyanide infusion in rabbits, with severe hypotension as the
trigger for treatment; and intravenous potassium cyanide infusion in pigs, with
apnea as the trigger for treatment. The drugs were administered by intramuscular
injection, and all 3 models were lethal in the absence of therapy.
RESULTS: We
found that sodium nitrite and sodium thiosulfate individually rescued 100% of
the mice, and that the combination of the 2 drugs rescued 73% of the rabbits
and 80% of the pigs. In all 3 species, survival in treated animals was
significantly better than in control animals (log rank test, P less than 0.05).
In the pigs, the drugs attenuated an increase in the plasma lactate
concentration within 5 minutes postantidote injection (difference: plasma
lactate, saline solution-treated versus nitrite- or thiosulfate-treated 1.76
[95% confidence interval 1.25 to 2.27]).
CONCLUSION:
We conclude that sodium nitrite and sodium thiosulfate administered by
intramuscular injection are effective against severe cyanide poisoning in 3
clinically relevant animal models of out-of-hospital emergency care.
4. Can Comfort Care At The ER Help Older People Live Longer And
Suffer Less?
Melissa
Bailey, NPR. May 26, 2017
A man sobbed
in a New York emergency room. His elderly wife, who suffered from advanced
dementia, had just had a breathing tube stuck down her throat. He knew she
never would have wanted that. Now he had to decide whether to reverse the
life-sustaining treatment that medics had begun.
When Dr. Kei
Ouchi faced this family as a young resident at Long Island Jewish Medical
Center, he had no idea what to say. The husband, who had cared for his wife for
the past 10 years, knew her condition had declined so much that she wouldn't
want to be rescued. But when Ouchi offered to take out the tube, the man cried
more: "She's breathing. How can we stop that?"
Ouchi had
pursued emergency medicine to rescue victims of gunshot wounds and car crashes.
He was unprepared, he says, for what he encountered: a stream of older patients
with serious illnesses like dementia, cancer and heart disease — patients for
whom the life-saving techniques he was trained to perform often only prolonged
the suffering.
As baby
boomers age, more of them are visiting the emergency room, which can be an
overcrowded, disorienting and even traumatic place. Adults 65 and older made
20.8 million emergency room visits in 2013, up from 16.2 million in 2000,
according to the most recent hospital survey by the Centers for Disease Control
and Prevention. The survey found 1 in 6 visits to the ER were made by an older
patient, a proportion that's expected to rise.
Half of
adults in this age group visit the ER in their last month of life, according to
a study in the journal Health Affairs. Of those, half die in the hospital, even
though most people say they'd prefer to die at home.
Some states
on board
The influx is
prompting more clinicians to rethink what happens in the fast-paced emergency
room, where the default is to do everything possible to extend life. Hospitals
across the country — including in Ohio, Texas, Virginia and New Jersey — are
bringing palliative care, which focuses on improving quality of life for
patients with advanced illness, into the emergency department.
Interest is growing
among doctors: 149 emergency physicians have become certified in palliative
care since that option became available just over a decade ago, and others are
working closely with palliative care teams. But efforts to transform the ER
face significant challenges, including a lack of time, staffing and expertise,
not to mention a culture clash.
Researchers
who interviewed emergency room staff at two Boston hospitals, for instance,
found resistance to palliative care. ER doctors questioned how they could
handle delicate end-of-life conversations for patients they barely knew. Others
argued that the ER, with its "cold, simple rooms" and drunken
patients screaming, is not an appropriate place to provide palliative care,
which tends to physical, psychological and spiritual needs.
Ouchi saw
some of these challenges during his residency in New York, when he visited the
homes of older patients who frequently visited the emergency room. He saw how
obstacles like transportation, frailty and poor vision made it difficult for
them to leave the house to see a doctor.
"So what
do they do?" Ouchi asks. "They call 911."
When these
patients arrive at the emergency room, doctors treat their acute symptoms, but
not their underlying needs, Ouchi says. In more severe cases, when the patient
can't talk and doesn't have an advanced directive or a medical decision-maker
available, doctors pursue the most aggressive care possible to keep them alive:
CPR, intravenous fluids, breathing tubes.
"Our
default in the ER is pedal to the metal," says Dr. Corita Grudzen, an
emergency physician at NYU Langone Medical Center who studies palliative care
in the ER. But when doctors learn after the fact that the patient would not
have wanted that, the emergency rescue forces families to choose whether to
remove life support…
Now Ouchi and
others are trying to come up with systematic ways to identify which patients
could benefit from palliative care.
One such
screening tool, dubbed P-CaRES, developed at Brown University in Providence,
R.I., gives ER doctors a list of questions. Does the patient have life-limiting
conditions such as advanced dementia or sepsis? How often does the patient
visit the ER? Would the doctor be surprised if the patient died within 12
months?
Doctors are
using the tool to refer patients at the University of California-San Francisco
Medical Center at Parnassus to palliative care doctors, says Dr. Kalie
Dove-Maguire, a clinical instructor there. The questions pop up automatically
on the electronic medical record for every ER patient who is about to be
admitted to the hospital.
Dove-Maguire
says UCSF hasn't published results, but the tool has helped individual
patients, including a middle-aged man with widespread cancer who showed up at
the ER with low blood pressure. The man "would have been admitted to the
ICU with lines and tubes and invasive procedures," she says, but staff
talked to his family, learned his wishes and sent him to home hospice.
"Having
that conversation in the ER, which is the entry point to the hospital, is
vital," Dove-Maguire says….
References
Half Of Older
Americans Seen In ED In Last Month Of Life; Most Admitted To Hospital, And Many
Die There: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3736978/
Demonstrations
of clinical initiatives to improve palliative care in the ED: a report from the
IPAL-EM Initiative: https://www.ncbi.nlm.nih.gov/pubmed/23548402
Am I doing
the right thing? Provider perspectives on improving palliative care in the ED:
https://www.ncbi.nlm.nih.gov/pubmed/18930337
Acceptability
and Reliability of a Novel Palliative Care Screening Tool Among ED Providers:
https://www.ncbi.nlm.nih.gov/pubmed/26990541
PV Card:
Palliative Care Screening in the ED: https://www.aliem.com/2015/08/pv-card-palliative-care-screening/
5. Peds Corner
A.
Ultrasound not helpful for children with abdominal trauma
The focused
assessment with sonography in trauma (FAST) exam did not reduce use of
abdominal CT, ED length of stay, or hospital charges in this single center
study.
Holmes JF, et
al. Effect of Abdominal Ultrasound on Clinical Care, Outcomes, and Resource Use
Among Children With Blunt Torso Trauma: A Randomized Clinical Trial. JAMA. 2017;317(22):2290-2296.
Key Points
Question Does the focused assessment with sonography
for trauma (FAST) examination safely improve care when used in the emergency
department (ED) evaluation of hemodynamically stable children with blunt torso
trauma?
Findings In this trial of 925 hemodynamically stable
children with blunt torso trauma, randomization to the FAST vs standard trauma
examination did not result in significant improvement in the rate of abdominal
computed tomographic scans, time in the ED, hospital charges, or missed
intra-abdominal injuries vs children randomized to standard trauma evaluation.
Meaning The study findings do not support the routine
use of FAST in the ED for hemodynamically stable children with blunt torso
trauma.
Abstract
Importance The utility of the focused assessment with
sonography for trauma (FAST) examination in children is unknown.
Objective To determine if the FAST examination during
initial evaluation of injured children improves clinical care.
Design,
Setting, and Participants A randomized
clinical trial (April 2012-May 2015) that involved 975 hemodynamically stable
children and adolescents younger than 18 years treated for blunt torso trauma
at the University of California, Davis Medical Center, a level I trauma center.
Interventions Patients were randomly assigned to a standard
trauma evaluation with the FAST examination by the treating ED physician or a
standard trauma evaluation alone.
Main Outcomes
and Measures Coprimary outcomes were
rate of abdominal computed tomographic (CT) scans in the ED, missed
intra-abdominal injuries, ED length of stay, and hospital charges.
Results Among the 925 patients who were randomized
(mean [SD] age, 9.7 [5.3] years; 575 males [62%]), all completed the study. A
total of 50 patients (5.4%, 95% CI, 4.0% to 7.1%) were diagnosed with
intra-abdominal injuries, including 40 (80%; 95% CI, 66% to 90%) who had
intraperitoneal fluid found on an abdominal CT scan, and 9 patients (0.97%; 95%
CI, 0.44% to 1.8%) underwent laparotomy. The proportion of patients with
abdominal CT scans was 241 of 460 (52.4%) in the FAST group and 254 of 465 (54.6%)
in the standard care–only group (difference, −2.2%; 95% CI, −8.7% to 4.2%). One
case of missed intra-abdominal injury occurred in a patient in the FAST group
and none in the control group (difference, 0.2%; 95% CI, −0.6% to 1.2%). The
mean ED length of stay was 6.03 hours in the FAST group and 6.07 hours in the
standard care–only group (difference, −0.04 hours; 95% CI, −0.47 to 0.40
hours). Median hospital charges were $46 415 in the FAST group and $47 759 in
the standard care–only group (difference, −$1180; 95% CI, −$6651 to $4291).
Conclusions
and Relevance Among hemodynamically
stable children treated in an ED following blunt torso trauma, the use of FAST
compared with standard care only did not improve clinical care, including use
of resources; ED length of stay; missed intra-abdominal injuries; or hospital
charges. These findings do not support the routine use of FAST in this setting.
B.
Concomitant Bacterial Meningitis in 1% of Infants less than 28 days with UTI
Grether-Jones
KL, et al. Pediatr Infect Dis J. 2017 May 2 [Epub ahead of print]
To determine
age-stratified prevalence of concomitant bacterial meningitis in infants ≤ 60
days with a urinary tract infection (UTI), we performed a 23-center
retrospective study of 1,737 infants with UTI. Concomitant bacterial meningitis
was rare, but more common in infants 0-28 days (0.9%, 95% CI: 0.4-1.9%)
compared with infants 29-60 days (0.2%, 95% CI: 0-0.8%).
C.
A Vibrating Cold Device to Reduce Pain in the Pediatric ED: A RCT
Potts DA, et
al. Pediatr Emerg Care. 2017 Jan 24 [Epub ahead of print]
OBJECTIVE: Pain
of intravenous (IV) catheter insertion can be mitigated with appropriate
analgesia, thereby avoiding unnecessary distress. Our objective was to compare
the self-reported pain of IV catheter insertion in children when using a
vibrating cold device (VCD) versus standard of care 4% topical lidocaine cream
(TL).
METHODS: This
was a 2-arm randomized controlled noninferiority trial with a convenience
sample of 4- to 18-year-olds requiring nonemergent IV catheter insertion.
Self-reported pain was measured with the Faces Pain Scale-Revised, anxiety with
the Child's Rating of Anxiety scale, and observed pain with the Face, Legs,
Activity, Crying, Consolability scale. Caregivers and nurses completed
satisfaction surveys.
RESULTS: Two
hundred twenty-four children were included in the analysis: 114 (90%) of 127 in
the VCD group and 110 (89%) of 124 in the TL group. Faces Pain Scale-Revised
scores for both groups were equivalent (median, 2.0 cm; interquartile range,
0-5 cm; linear regression difference, 0 [95% confidence interval, -0.82 to
0.82]), as were median Face, Legs, Activity, Crying, Consolability scale scores
(difference, 0.33 [95% confidence interval, -0.01 to 0.68]). The time of
completion for the IV procedure was significantly shorter for the VCD group
compared with the TL group (median, 3.0 vs 40.5 minutes; P less than 0.0001).
There were no significant differences between groups for self-reported state or
trait anxiety, success of IV catheter insertion on first attempt, or
satisfaction of caregivers or staff.
CONCLUSIONS: A
VCD and TL showed equal effectiveness in reducing pain and distress for
children undergoing IV catheter insertion. The VCD has the added benefit of
quick onset time and an acceptable alternative for caregivers and nurses.
D.
Increase in Medical Management of Nonperforated Pediatric Appendicitis
The rate of
nonoperative management of pediatric appendicitis increased 20% from 2010 to
2016, although failure rates were high.
Bachur RG et
al. Pediatrics 2017 Jun 1;171(6):505-506.
Appendicitis
is the most common acute surgical condition, with a lifetime risk of 8%. Over
the last 2 decades, there have been significant improvements in the diagnosis
and surgical management, which has led to fewer negative appendectomies,
shorter hospitalizations, and faster recoveries.1 The prospect of nonoperative
management has been proposed as the next major advance in appendicitis care,
which shows promise but also brings challenges.
6. An Observational Study to Determine Whether Routinely Sending
Patients Home With a 24-Hour Supply of Topical Tetracaine From the ED for
Simple Corneal Abrasion Pain Is Potentially Safe.
Waldman N, et
al. Ann Emerg Med. 2017 May 2 [Epub ahead of print]
STUDY
OBJECTIVE: To determine if the number of emergency department (ED) rechecks,
persistent fluorescein uptake, ophthalmology referrals, or complications would
be affected by the prescription of topical tetracaine for pain relief from
simple corneal abrasions (SCAs).
METHODS: This
retrospective cohort study was conducted in an ED where policy change allowed
physicians to use topical tetracaine hydrochloride 1% eye drops for 24 hours
for pain treatment for patients with corneal abrasions. Outcomes were compared
between patients who did or did not received tetracaine (adjusting for the
propensity for treatment).
RESULTS: Of
1,576 initial ED presentations, 532 were SCAs, with 1,044 deemed nonsimple
corneal abrasions (NSCAs). Tetracaine was dispensed at the initial visit for
303 SCA presentations (57%) and inappropriately for 141 NSCA presentations
(14%). There were no serious complications or uncommon adverse events
attributed to tetracaine for all SCAs and NSCAs combined (0/459; upper 95%
confidence interval [CI] 0.80%). The relative risks (RRs) of ED recheck and
fluorescein staining were increased overall among patients who received
tetracaine (RR 1.67, 95% CI 1.25 to 2.23; and RR 1.65, 95% CI 1.07 to 2.53 for
recheck and staining, respectively). However, the relative risks for only SCAs
receiving tetracaine was 1.16 (95% CI 0.69 to 1.93) and 0.77 (95% CI 0.37 to
1.62), respectively. Referrals to ophthalmology were significantly decreased
for all patients (SCAs and NSCAs) dispensed tetracaine (relative risk 0.33; 95%
CI 0.19 to 0.59). The number of complications was too small to permit modeling.
CONCLUSION:
There was no evidence that up to 24-hour topical tetracaine for the treatment
of pain caused by SCA was unsafe; however, CIs were wide and some increased
risks were observed for NSCAs.
7. American Association for Emergency Psychiatry Task Force on
Medical Clearance of Adult Psychiatric Patients
Part
I: Introduction, Review and Evidence-Based Guidelines
Anderson EL,
et al. West J Emerg Med 2017;18(2):235-242.
INTRODUCTION:
In the United States, the number of patients presenting to the emergency
department (ED) for a mental health concern is significant and expected to
grow. The breadth of the medical evaluation of these patients is controversial.
Attempts have been made to establish a standard evaluation for these patients,
but to date no nationally accepted standards exist. A task force of the
American Association of Emergency Psychiatry, consisting of physicians from emergency
medicine and psychiatry, and a psychologist was convened to form consensus
recommendations on the medical evaluation of psychiatric patients presenting to
EDs.
METHODS: The
task force reviewed existing literature on the topic of medical evaluation of
psychiatric patients in the ED (Part I) and then combined this with expert
consensus (Part II).
RESULTS: In
Part I, we discuss terminological issues and existing evidence on medical exams
and laboratory studies of psychiatric patients in the ED.
CONCLUSION:
Emergency physicians should work cooperatively with psychiatric receiving
facilities to decrease unnecessary testing while increasing the quality of
medical screening exams for psychiatric patients who present to EDs.
Part
II: Controversies over Medical Assessment, and Consensus Recommendations
Wilson MP, et
al. West J Emerg Med. 2017;18(4):640-646.
Introduction:
The emergency medical evaluation of psychiatric patients presenting to United
States emergency departments (ED), usually termed “medical clearance,” often
varies between EDs. A task force of the American Association for Emergency
Psychiatry (AAEP), consisting of physicians from emergency medicine, physicians
from psychiatry and a psychologist, was convened to form consensus
recommendations for the medical evaluation of psychiatric patients presenting
to U.S.EDs.
Methods: The
task force reviewed existing literature on the topic of medical evaluation of
psychiatric patients in the ED and then combined this with expert consensus.
Consensus was achieved by group discussion as well as iterative revisions of
the written document. The document was reviewed and approved by the AAEP Board
of Directors.Results: Eight recommendations were formulated. These
recommendations cover various topics in emergency medical examination of
psychiatric patients, including goals of medical screening in the ED, the identification
of patients at low risk for co-existing medical disease, key elements in the ED
evaluation of psychiatric patients including those with cognitive disorders,
specific language replacing the term “medical clearance,” and the need for
better science in this area.
Conclusion:
The evidence indicates that a thorough history and physical examination,
including vital signs and mental status examination, are the minimum necessary
elements in the evaluation of psychiatric patients. With respect to laboratory
testing, the picture is less clear and much more controversial.
8. Ketamine as an Adjunct to Opioids for Acute Pain in the ED: A
RCT
Bowers KJ, et
al. Acad Emerg Med. 2017 Jun;24(6):676-685.
OBJECTIVES: This
study had five objectives: 1) to measure and compare total opioid use and
number of opioid doses in patients treated with opioids versus ketamine in
conjunction with opioids; 2) to measure pain scores up to 2 hours after
presentation in the ED patient with pain, comparing standard opioid pain
control to ketamine in conjunction with opioids; 3) to compare patient
satisfaction with pain control using opioids alone versus ketamine in conjunction
with opioids; 4) to monitor and compare side effects in patients treated with
opioids versus ketamine in conjunction with opioids; and 5) to identify effect
variation between different subgroups of patients, with the purpose of focusing
future research. We hypothesized that low-dose ketamine, compared to placebo,
as an adjunctive treatment to opioids would result in better pain control over
2 hours and greater patient satisfaction with pain control; further, this
protocol will result in a lower opioid dosage over 2 hours.
METHODS: This
was a randomized, double-blinded, placebo-controlled trial at a single academic
emergency department evaluating the use of ketamine versus placebo in
conjunction with opioids for moderate to severe pain. Subjects with a continued
high level of pain after an initial dose of opioid analgesia were randomized to
receive either 0.1 mg/kg ketamine or placebo prior to protocol-based dosing of
additional opioid analgesia, if required. Over 120 minutes, subjects were
assessed for pain level (0-10), satisfaction with pain control (0-4), side
effects, sedation level, and need for additional pain medication. Total opioid
dose, including the initial dose, was compared between groups.
RESULTS: Sixty-three
subjects were randomized to the placebo group and 53 to the ketamine group. No
significant differences were found in demographics between the groups. Patients
receiving ketamine reported lower pain scores over 120 minutes than patients
receiving placebo (p = 0.015). Total opioid dose was lower in the ketamine
group (mean ± SD = 9.95 ± 4.83 mg) compared to placebo (mean ± SD = 12.81 ±
6.81 mg; p = 0.02). Satisfaction did not differ between groups. Fewer patients
in the ketamine group required additional opioid doses. More patients reported
light-headedness and dizziness in the ketamine group.
CONCLUSIONS: Ketamine,
as an adjunct to opioid therapy, was more effective at reducing pain over 120
minutes and resulted in a lower total opioid dose as well as fewer repeat doses
of analgesia. More side effects were reported in the ketamine group (51% vs.
19%), but the side effect profile appears tolerable.
9. Management of Septic Shock
Berger RE,
River E, Levy MM. N Engl J Med 2017; 376:2282-2285.
CASE VIGNETTE: A Woman with Septic
Shock
Ms. Jones is
a 65-year-old woman with a history of hypertension who presents to the
emergency department with a 3-day history of chills and dysuria. The only
medication she is taking is amlodipine, at a dose of 10 mg daily; she had had
normal electrolyte levels and renal function at a routine visit 6 weeks
earlier. On arrival at the emergency department, she reports feeling dizzy.
She is 165 cm
(65 in.) tall and weighs 70 kg (154 lb). Her temperature is 38.6°C (101.5°F),
heart rate 125 beats per minute, blood pressure 85/55 mm Hg (mean arterial
pressure, 65 mm Hg), respiratory rate 28 breaths per minute, and oxygen
saturation as measured by pulse oximetry 94% while she is breathing ambient
air. A physical examination reveals dry mucous membranes; undetectable jugular
venous pulsation; tachycardia without gallops, rubs, or murmurs; clear lungs;
and warm extremities. She has tenderness on palpation of her suprapubic region.
You begin intravenous administration of a bolus of crystalloid solution.
Laboratory
testing shows a creatinine level of 1.8 mg per deciliter (159 μmol per liter)
(normal range, 0.5 to 1.1 mg per deciliter [44 to 97 μmol per liter]), blood
urea nitrogen 76 mg per deciliter (27 mmol per liter) (normal range, 7 to 20 mg
per deciliter [2 to 7 mmol per liter]), lactate 5.0 mmol per liter (normal
value, less than 2.0), anion gap 25 mmol per liter (normal range, 8 to 15),
white-cell count 20,000 per cubic millimeter (normal range, 4500 to 11,000),
and hemoglobin 9.0 g per deciliter (normal range, 12.0 to 15.5). Urinalysis
shows 3+ leukocyte esterase, more than 100 white cells per high-power field,
and abundant bacteria.
You make a
presumptive diagnosis of sepsis from a urinary source and begin treatment with
intravenous antibiotics to target likely urinary pathogens. Ultrasonography of
the kidneys and bladder reveals no hydronephrosis or evidence of obstruction.
After
administration of 2100 ml of crystalloid fluid (30 ml per kilogram of body
weight), the patient’s jugular venous pressure is 8 cm of water, but her
systemic arterial pressure has decreased to 80/50 mm Hg (mean arterial
pressure, 60 mm Hg). During the 3 hours that she has been in the emergency
department, she has produced 20 ml of urine, as measured through a Foley
catheter that was placed on her arrival.
You place a
central venous catheter and initiate a norepinephrine infusion, which you
adjust with a goal of raising her mean arterial pressure to 65 to 70 mm Hg. She
is transferred to the intensive care unit (ICU); on arrival in the ICU, her
mean arterial pressure is 65 mm Hg while she is receiving 40 μg of
norepinephrine per minute, and her heart rate is 100 beats per minute. A chest
radiograph shows early evidence of acute lung injury and good central catheter
placement. Her arterial oxygen saturation is 100% while she is receiving 4
liters of oxygen through a nasal cannula.
You are aware
that there are two main approaches to the management of septic shock in a
patient such as Ms. Jones. One approach involves serial measurement of central
venous pressure, central venous oxygen saturation (Scvo2), and hemoglobin, and
following the early, goal-directed therapy (EGDT) protocol, in which specified
targets are used for the initiation of inotropic agents or transfusion of red
cells.1 For example, if the central venous pressure is less than 8 mm Hg,
additional fluid resuscitation is administered; if the Scvo2 is less than 70%,
the patient receives a transfusion of red cells until a hematocrit goal of at
least 30% is reached, and if the Scvo2 remains less than 70%, inotropic support
is initiated.
The second
approach involves continuing intravenous administration of antibiotics and
vasopressors, guided by clinical signs including blood pressure and urine
output, without serial central venous pressure monitoring, serial Scvo2
monitoring, transfusion of red cells, or administration of inotropic agents.
You are undecided about which of these approaches would maximize the chance of
survival for your patient with septic shock.
TREATMENT
OPTIONS
Which of the
following treatment strategies should you pursue for this patient?....
For the
remainder of the discussion, full-text (free): http://www.nejm.org/doi/full/10.1056/NEJMclde1705277
10. Images in Clinical Practice
Rapidly
enlarging scrotal hematoma: A complication of femoral access?
Seesaw
Nystagmus
Large
Arachnoid Cyst
Evolution of
Purpura Fulminans
Galloping
Heart
Adolescent
With Chest Pain
Young Boy
With Unilateral Facial Flushing
Middle-Aged
Woman With Right Upper Quadrant Pain
Elderly Woman
With Diffuse Abdominal Pain
Young Male
With Shoulder Mass
Adolescent
Male With Syncope
11. Ureteral Stone Research
A.
Ultrasound vs. CT for Severity of Hydronephrosis and Its Importance in Renal
Colic
Leo MM, et
al. West J Emerg Med. 2017;18(4):559-568.
Introduction:
Supporting an “ultrasound-first” approach to evaluating renal colic in the
emergency department (ED) remains important for improving patient care and
decreasing healthcare costs. Our primary objective was to compare emergency
physician (EP) ultrasound to computed tomography (CT) detection of
hydronephrosis severity in patients with suspected renal colic. We calculated
test characteristics of hydronephrosis on EP-performed ultrasound for detecting
ureteral stones or ureteral stone size over 5mm. We then analyzed the
association of hydronephrosis on EP-performed ultrasound, stone size over 5mm, and proximal stone location with
30-day events.
Methods: This
was a prospective observational study of ED patients with suspected renal colic
undergoing CT. Subjects had an EP-performed ultrasound evaluating for the
severity of hydronephrosis. A chart review and follow-up phone call was
performed.
Results: We
enrolled 302 subjects who had an EP-performed ultrasound. CT and EP ultrasound
results were comparable in detecting severity of hydronephrosis (x2=51.7, p less
than 0.001). Hydronephrosis on EP- performed ultrasound was predictive of a
ureteral stone on CT (PPV 88%; LR+ 2.91), but lack of hydronephrosis did not
rule it out (NPV 65%). Lack of hydronephrosis on EP-performed ultrasound makes
larger stone size over 5mm less likely (NPV 89%; LR-0.39). Larger stone size over
5mm was associated with 30-day events (OR 2.30, p=0.03).
Conclusion:
Using an ultrasound-first approach to detect hydronephrosis may help physicians
identify patients with renal colic. The lack of hydronephrosis on ultrasound
makes the presence of a larger ureteral stone less likely. Stone size over 5mm
may be a useful predictor of 30-day events.
B.
A Comparison of Urolithiasis in the Presence and Absence of Microscopic
Hematuria in the ED
Mefford JM,
et al. West J Emerg Med 2017;18(4):775-779.
Introduction:
Urolithiasis is a common medical condition that accounts for a large number of
emergency department (ED) visits each year and contributes significantly to
annual healthcare costs. Urinalysis is an important screening test for patients
presenting with symptoms suspicious for urolithiasis. At present there is a
paucity of medical literature examining the characteristics of ureteral stones
in patients who have microscopic hematuria on urinalysis versus those who do
not. The purpose of this study was to examine mean ureteral stone size and its
relationship to the incidence of clinically significant hydronephrosis in
patients with and without microscopic hematuria.
Methods: This
is a retrospective chart review of patient visits to a single, tertiary
academic medical center ED between July 1, 2008, and August 1, 2013, of
patients who underwent non-contrast computed tomography of the abdomen and
pelvis and urinalysis. For patient visits meeting inclusion criteria, we
compared mean stone size and the rate of moderate-to-severe hydronephrosis
found on imaging in patients with and without microscopic hematuria on
urinalysis.
Results: Out
of a total of 2,370 patient visits 393 (16.6%) met inclusion criteria. Of
those, 321 (82%) had microscopic hematuria present on urinalysis. Patient
visits without microscopic hematuria had a higher rate of moderate-to-severe
hydronephrosis (42%), when compared to patients with microscopic hematuria
present (25%, p=.005). Mean ureteral stone size among patient visits without
microscopic hematuria was 5.7 mm; it was 4.7 mm for those patients with
microscopic hematuria (p=.09). For ureteral stones 5 mm or larger, the
incidence of moderate-to-severe hydronephrosis was 49%, whereas for ureteral
calculi less than 5 mm in size, the incidence of moderate-to-severe
hydronephrosis was 14% (p less than 0.0001).
Conclusion:
Patients visiting the ED with single-stone ureterolithiasis without microscopic
hematuria on urinalysis could be at increased risk of having moderate-to-severe
hydronephrosis compared to similar patients presenting with microscopic
hematuria on urinalysis. Although the presence of hematuria on urinalysis is a
moderately sensitive screening test for urolithiasis, these results suggest
patients without hematuria tend to have more clinically significant ureteral
calculi, making their detection more important. Clinicians should maintain a
high index of suspicion for urolithiasis, even in the absence of hematuria,
since ureteral stones in these patients were found to be associated with a
higher incidence of obstructive uropathy.
C.
Are α-Blockers Beneficial for Outpatient Management of Uncomplicated Ureteric
Stones?
Take-Home
Message
α-Blockers
may accelerate passage and prevent complications such as hospital admission or
surgery when ureteric stones are 5 to 10 mm, but there is no evidence to
support their use in stones less than 5 mm. Benefits appear to be similar
regardless of location in the ureter.
12. Chest Pain Evaluation Research
A.
CP associated with cocaine use
Although
hospital admissions for chest pain are not uncommon among cocaine users, the
outcomes and associated burden on the health care system are not well known.
Identifying and recategorizing patients presenting to the emergency department
with cocaine-related chest pain into low, intermediate, and high risk can help
avoid unnecessary hospital admissions and lessen the need for cardiac
procedures. For the low-risk cohort, where acute coronary syndrome has been ruled
out, hospitalization may not be beneficial.
Singh V, et
al. Hospital Admissions for Chest Pain Associated with Cocaine Use in the
United States. Am J Med. 2017 Jun;130(6):688-698.
BACKGROUND: The
outcomes related to chest pain associated with cocaine use and its burden on
the healthcare system are not well studied.
METHODS: Data
were collected from the Nationwide Inpatient Sample (2001-2012). Subjects were
identified by using the International Classification of Diseases, Ninth
Revision, Clinical Modification codes. Primary outcome was a composite of
mortality, myocardial infarction, stroke, and cardiac arrest.
RESULTS: We
identified 363,143 admissions for cocaine-induced chest pain. Mean age was 44.9
(±21.1) years with male predominance. Left heart catheterizations were
performed in 6.7%, whereas the frequency of acute myocardial infarction and
percutaneous coronary interventions were 0.69% and 0.22%, respectively. The
in-hospital mortality was 0.09%, and the primary outcome occurred in 1.19% of
patients. Statistically significant predictors of primary outcome included
female sex (odds ratio [OR], 1.16; confidence interval [CI], 1.00-1.35; P =
.046), age over 50 years (OR, 1.24, CI, 1.07-1.43; P = .004), history of heart
failure (OR, 1.63, CI, 1.37-1.93; P less than .001), supraventricular
tachycardia (OR, 2.94, CI, 1.34-6.42; P = .007), endocarditis (OR, 3.5, CI,
1.50-8.18, P = .004), tobacco use (OR, 1.3, CI, 1.13-1.49; P less than .001),
dyslipidemia (OR, 1.5, CI, 1.29-1.77; P less than .001), coronary artery
disease (OR, 2.37, CI, 2.03-2.76; P less than .001), and renal failure (OR,
1.27, CI, 1.08-1.50; P = .005). The total annual projected economic burden
ranged from $155 to $226 million with a cumulative accruement of more than $2
billion over a decade.
CONCLUSION: Hospital
admissions due to chest pain and concomitant cocaine use are associated with
low rates of adverse outcomes. For the low-risk cohort in whom acute coronary
syndrome has been ruled out, hospitalization may not be beneficial and may
result in unnecessary cardiac procedures.
B.
Utility of the History and Physical Examination in the Detection of ACS in ED
Patients
Dezman ZDW,
Mattu A, et al. West J Emerg Med 2017;18(4):752-760.
Chest pain
accounts for approximately 6% of all emergency department (ED) visits and is
the most common reason for emergency hospital admission. One of the most
serious diagnoses emergency physicians must consider is acute coronary syndrome
(ACS). This is both common and serious, as ischemic heart disease remains the
single biggest cause of death in the western world. The history and physical
examination are cornerstones of our diagnostic approach in this patient group. Their
importance is emphasized in guidelines, but there is little evidence to support
their supposed association. The purpose of this article was to summarize the
findings of recent investigations regarding the ability of various components
of the history and physical examination to identify which patients presenting
to the ED with chest pain require further investigation for possible ACS.
Previous
studies have consistently identified a number of factors that increase the
probabilityof ACS. These include radiation of the pain, aggravation of the pain
by exertion, vomiting, and diaphoresis. Traditional cardiac risk factors
identified by the Framingham Heart Study are of limited diagnostic utility in
the ED. Clinician gestalt has very low predictive ability, even in patients
with anon-diagnostic electrocardiogram (ECG), and gestalt does not seem to be
enhanced appreciably by clinical experience. The history and physical alone are
unable to reduce a patient’s risk of ACS to a generally acceptable level (less
than 1%).
Ultimately,
our review of the evidence clearly demonstrates that “atypical” symptoms cannot
rule out ACS, while “typical” symptoms cannot rule it in. Therefore, if a
patient has symptoms that are compatible with ACS and an alternative cause
cannot be identified, clinicians must strongly consider the need for further investigation
with ECG and troponin measurement.
C.
Pitfalls in ECG Diagnosis of ACS in Low-Risk Chest Pain
Tewelde S,
Mattu A, et al. West J Emerg Med. 2017;18(4):601-606.
Less than
half of patients with a chest pain history indicative of acute coronary
syndrome have a diagnostic electrocardiogram (ECG) on initial presentation to
the emergency department. The physician must dissect the ECG for elusive, but
perilous, characteristics that are often missed by machine analysis.
ST depression
is interpreted and often suggestive of ischemia; however, when exclusive to
leads V1‒V3 with concomitant tall R waves and upright T waves, a posterior
infarction should first and foremost be suspected. Likewise, diffuse ST
depression with elevation in aVR should raise concern for left main- or
triple-vessel disease and, as with the aforementioned, these ECG findings are
grounds for acute reperfusion therapy. Even in isolation, certain
electrocardiographic findings can suggest danger. Such is true of the lone
T-wave inversion in aVL, known to precede an inferior myocardial infarction.
Similarly,
something as ordinary as an upright and tall T wave or a biphasic T wave can be
the only marker of ischemia. ECG abnormalities, however subtle, should give
pause and merit careful inspection since misinterpretation occurs in 20-40% of
misdiagnosed myocardial infarctions.
D.
Less-Aggressive Approach to Non-ST Segment Elevation ACS Advised
By Scott Baltic.
Reuters Health Information. May 01, 2017
NEW YORK
(Reuters Health) - Holding off on coronary angiography for patients with
non-ST-segment elevation acute coronary syndromes (NSTE-ACS) and elevated
cardiac troponin T is not associated with higher long-term risks of death or
myocardial infarction (MI), a new report by Dutch researchers indicates.
The ICTUS
trial compared a routine early invasive treatment strategy with an
ischemia-driven strategy, both of which included anti-anginal and
anti-thrombotic medical treatment.
In the early
invasive group, coronary angiography was done within 24 to 72 hours, followed
by appropriate angiography-guided treatment, either revascularization or
continued pharmacological therapy. In the ischemia-driven group, angiography
was done only for refractory angina or when ischemia was inducible by
noninvasive stress testing.
The study
recruited 1,200 patients, about three-quarters male, with a median age of 62,
of whom 14% had diabetes. More procedure-related MI occurred in the early
invasive group, but after 10 years of follow-up there was no significant
difference between the groups in risk of death or spontaneous MI.
“The current
result confirms and extends the results of previous studies, with one-third of
patients enduring death or spontaneous MI within 10 years despite treatment,”
the authors wrote.
“We conclude
that a strategy of selective invasive management is an option for selected
patients. Not everyone with a positive troponin needs to be rushed to the cath
lab,” coauthor Dr. R.J. de Winter, of the Academic Medical Center in Amsterdam
told Reuters Health by email.
The authors
point out that their findings contrast with the long-term results of two other
studies (FRISC-II and RITA-3), “where a benefit of an early invasive strategy
was shown.” To explain
this disparity, they note that the trials “enrolled patients in different time
periods, and there were differences in clinical practice.”
Full essay: http://www.acepnow.com/less-aggressive-approach-non-st-segment-elevation-acute-coronary-syndromesadvised/
13. A Modified Lung and Cardiac US Protocol Saves Time and Rules
in the Diagnosis of Acute HF.
Russell FM,
et al. J Emerg Med. 2017 Jun;52(6):839-845.
BACKGROUND:
Multiorgan ultrasound (US), which includes evaluation of the lungs and heart,
is an accurate method that outperforms clinical gestalt for diagnosing acutely
decompensated heart failure (ADHF). A known barrier to ultrasound use is the
time needed to perform these examinations.
OBJECTIVE:
The primary goal of this study was to determine the test characteristics of a
modified lung and cardiac US (LuCUS) protocol for the accurate diagnosis of
ADHF.
METHODS: This
was a secondary analysis of a prospective observational study that enrolled
adult patients presenting to the emergency department with undifferentiated
dyspnea. Intervention consisted of a modified LuCUS protocol performed by
experienced emergency physician sonographers. A positive modified LuCUS protocol
was defined as the presence of B+ lines in both the left and right
anterosuperior lung zones, plus a left ventricular ejection fraction less than 45%.
If all three of these findings were not present, the modified LuCUS result was
interpreted as negative for ADHF. The primary objective was measured by
comparing US findings to final diagnosis independently determined by two
physicians, both blinded to US findings and each other's final diagnosis.
RESULTS: We
analyzed data on 99 patients; 36% had a final diagnosis of ADHF. The
sensitivity, specificity, positive likelihood ratio, and negative likelihood
ratio of the modified LuCUS protocol are 25% (95% confidence interval [CI]
14-41%), 100% (95% CI 94-100%), undefined, and 0.75 (95% CI 0.62-0.91%),
respectively. This modified protocol takes on average 1 min and 32 sec to
complete.
CONCLUSION:
The point estimate for the specificity of the modified LuCUS protocol in this
pilot study, accomplished by a reanalysis of data collected for a previously
reported investigation of the full LuCUS protocol, was 100% for the diagnosis
of ADHF.
14. Dual sequential external defibrillation: not much literature
to go on
A.
Make it two: A case report of dual sequential external defibrillation
Bell CR, et
al. CJEM 2017 Jun 7 [Epub ahead of print]
Dual
sequential external defibrillation (DSED) is the process of near simultaneous
discharge of two defibrillators with differing pad placement to terminate
refractory arrhythmias. Previously used in the electrophysiology suite, this
technique has recently been used in the emergency department and prehospital
setting for out-of-hospital cardiac arrest (OHCA). We present a case of
successful DSED in the emergency department with neurologically intact survival
to hospital discharge after refractory ventricular fibrillation (RVF) and
review the putative mechanisms of action of this technique.
B.
Use of double sequential external defibrillation for refractory VF during
out-of-hospital cardiac arrest.
Cortez E, et
al. Resuscitation. 2016 Nov;108:82-86.
INTRODUCTION:
Survival from out of hospital cardiac arrest (OHCA) is highest in victims with
shockable rhythms when early CPR and rapid defibrillation are provided.
However, a subset of individuals present with ventricular fibrillation (VF)
that does not respond to defibrillation (refractory VF). One intervention that
may be a possible option in refractory VF is double sequential external
defibrillation (DSD). The objective of this case series was to describe the
outcome of prehospital victims with refractory VF treated with DSD in the
out-of-hospital setting.
METHODS: This
evaluation is a retrospective chart review of VF patients treated with DSD in
the prehospital setting from August 1st, 2010 through June 30th, 2014. Patients
were excluded if less than 17 years of age. The outcomes we evaluated were the
number of patients with return of spontaneous circulation, conversion from VF,
survival-to-hospital discharge, and Cerebral Performance Category score.
RESULTS:
Total of 2428 OHCA events were reviewed with twelve patients treated with DSD.
Median DSD and prehospital resuscitation times were 27min (IQR 22-33) and 32
(IQR 24-38), respectively. Of the 12 patients treated, return of spontaneous
circulation was achieved in three patients, nine patients were converted out of
ventricular fibrillation, three patients survived to hospital discharge, and
two patients (2/12, 17%) were discharged with Cerebral Performance Category
scores of 1 (good cerebral performance).
CONCLUSIONS:
Double sequential defibrillation may be another tool to improve neurologically
intact survival from OHCA. Further studies are needed to demonstrate direct
benefits to patient outcomes.
C.
Double Sequential External Defibrillation and Survival from Out-of-Hospital
Cardiac Arrest: A Case Report.
Johnston M, et
al. Prehosp Emerg Care. 2016 Sep-Oct;20(5):662-6.
BACKGROUND:
Patients who present in ventricular fibrillation are typically treated with
cardiopulmonary resuscitation (CPR), epinephrine, antiarrhythmic medications,
and defibrillation. Although these therapies have shown to be effective, some
patients remain in a shockable rhythm. Double sequential external
defibrillation has been described as a viable option for patients in refractory
ventricular fibrillation.
OBJECTIVE: To
describe the innovative use of two defibrillators used to deliver double
sequential external defibrillation by paramedics in a case of refractory
ventricular fibrillation resulting in prehospital return of spontaneous
circulation and survival to hospital discharge with good neurologic function.
CASE: A
28-year-old female sustained a witnessed out-of-hospital cardiac arrest (OHCA).
Bystander CPR was performed by her husband followed by paramedics providing
high-quality CPR, antiarrhythmic medication, and 6 biphasic defibrillations
using standard energy levels. Double sequential external defibrillation was
applied and a return of spontaneous circulation was attained on scene and
maintained through to arrival to the emergency department. Following admission
to hospital the patient was diagnosed with long QT syndrome. An implantable
cardioverter defibrillator was placed and the patient was discharged with a
Cerebral Performance Category of 2 as well as a modified Rankin Scale of 2
after an 18-day hospital stay. The patient's functional status continued to
improve post discharge.
CONCLUSION:
The addition of double sequential external defibrillation as part of a
well-organized resuscitation effort may be a valid treatment option for OHCA
patients who present in refractory ventricular fibrillation.
15. Chest X-Ray Misses Most Rib Fractures
In a large
multicenter cohort of blunt trauma patients, 24% had rib fractures and two
thirds of these were missed by plain films.
Murphy CE IV,
et al. Ann Emerg Med 2017 May 27 [Epub ahead of print]
STUDY
OBJECTIVE: With increased use of chest computed tomography (CT) in trauma
evaluation, traditional teachings in regard to rib fracture morbidity and
mortality may no longer be accurate. We seek to determine rates of rib fracture
observed on chest CT only; admission and mortality of patients with isolated
rib fractures, rib fractures observed on CT only, and first or second rib
fractures; and first or second rib fracture-associated great vessel injury.
METHODS: We
conducted a planned secondary analysis of 2 prospectively enrolled cohorts of
the National Emergency X-Radiography Utilization Study chest studies, which
evaluated patients with blunt trauma who were older than 14 years and received
chest imaging in the emergency department. We defined rib fractures and other
thoracic injuries according to CT reports and followed patients through their
hospital course to determine outcomes.
RESULTS: Of
8,661 patients who had both chest radiograph and chest CT, 2,071 (23.9%) had
rib fractures, and rib fractures were observed on chest CT only in 1,368 cases
(66.1%). Rib fracture patients had higher admission rates (88.7% versus 45.8%;
mean difference 42.9%; 95% confidence interval [CI] 41.4% to 44.4%) and
mortality (5.6% versus 2.7%; mean difference 2.9%; 95% CI 1.8% to 4.0%) than
patients without rib fracture. The mortality of patients with rib fracture
observed on chest CT only was not statistically significantly different from
that of patients with fractures also observed on chest radiograph (4.8% versus
5.7%; mean difference -0.9%; 95% CI -3.1% to 1.1%). Patients with first or
second rib fractures had significantly higher mortality (7.4% versus 4.1%; mean
difference 3.3%; 95% CI 0.2% to 7.1%) and prevalence of concomitant great
vessel injury (2.8% versus 0.6%; mean difference 2.2%; 95% CI 0.6% to 4.9%)
than patients with fractures of ribs 3 to 12, and the odds ratio of great
vessel injury with first or second rib fracture was 4.4 (95% CI 1.8 to 10.4).
CONCLUSION:
Under trauma imaging protocols that commonly incorporate chest CT, two thirds
of rib fractures were observed on chest CT only. Patients with rib fractures
had higher admission rates and mortality than those without rib fractures.
First or second rib fractures were associated with significantly higher
mortality and great vessel injury.
16. ED Pain Management Following Implementation of a Geriatric
Hip Fracture Program
Casey SD, et
al. West J Emerg Med. 2017;18(4):585-591.
Introduction:
Over 300,000 patients in the United States sustain low-trauma fragility hip
fractures annually. Multidisciplinary geriatric fracture programs (GFP)
including early, multimodal pain management reduce morbidity and mortality. Our
overall goal was to determine the effects of a GFP on the emergency department
(ED) pain management of geriatric fragility hip fractures.
Methods: We
performed a retrospective study including patients age ≥65 years with fragility
hip fractures two years before and two years after the implementation of the
GFP. Outcomes were time to (any) first analgesic, use of acetaminophen and
fascia iliaca compartment block (FICB) in the ED, and amount of opioid
medication administered in the first 24 hours. We used permutation tests to
evaluate differences in ED pain management following GFP implementation.
Results: We
studied 131 patients in the pre-GFP period and 177 patients in the post-GFP
period. In the post-GFP period, more patients received FICB (6% vs. 60%;
difference 54%, 95% confidence interval [CI] 45-63%; p less than 0.001) and
acetaminophen (10% vs. 51%; difference 41%, 95% CI 32-51%;p less than 0.001) in
the ED. Patients in the post-GFP period also had a shorter time to first
analgesic (103 vs. 93 minutes; p=0.04) and received fewer morphine equivalents
in the first 24 hours (15mg vs.10mg, p less than 0.001) than patients in the
pre-GFP period.
Conclusion:
Implementation of a GFP was associated with improved ED pain management for
geriatric patients with fragility hip fractures. Future studies should evaluate
the effects of these changes in pain management on longer-term outcomes.
See also Regional
Nerve Blocks For Hip and Femoral Neck Fractures in the Emergency Department: A
Systematic Review.
Ritcey B, et
al. CJEM. 2016 Jan;18(1):37-47.
17. Anticoagulation Reversal for Supratherapeutic INR: A
Teachable Moment
Tummalapalli
SL, et al. JAMA Intern Med. 2017;177(6):869-870.
An
81-year-old woman with metastatic breast cancer, atrial fibrillation on
warfarin, and congestive heart failure presented with shortness of breath. She
was found to have a recurrent malignant pleural effusion and was admitted to
the medicine service. On laboratory evaluation, her international normalized
ratio (INR) was supratherapeutic to 7.4. She had no tachypnea, hypoxia, or
signs or symptoms of bleeding.
She was given
oral vitamin K, and 4 units of fresh frozen plasma (FFP) were ordered to
reverse her anticoagulation for a therapeutic thoracentesis. After the third
FFP unit, the patient developed diffuse and intensely pruritic urticaria on her
neck, chest, and legs, with no stridor or angioedema.
She
subsequently developed hypoxia with an oxygen saturation of 86%, tachypnea, and
increased work of breathing using accessory muscles. Systolic blood pressure
was in the 170s, and electrocardiogram demonstrated atrial fibrillation with
rapid ventricular rate. Chest radiography showed new bilateral opacities
consistent with acute pulmonary edema. The patient was placed on nonrebreather
oxygen, given intravenous furosemide, and her oxygen saturations subsequently
improved. Intravenous diphenhydramine was administered which led to lethargy
and mild confusion. Her urticaria persisted for several hours, and she was
transitioned to high-flow nasal cannula with improvement in her respiratory
status.
First page of
discussion: http://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2618821
18. Can Neutropenic Fever Ever Be Low Risk?
Paddock M, et
al. Ann Emerg Med. 2017 Jun;69(6):765-767.
Annals Case
While on a
typical, busy shift in the emergency department (ED), you are notified by a
nurse about a febrile patient. She is currently receiving chemotherapy and has
an absolute neutrophil count less than 500 × 103/µL. Finally, a case with an
unequivocal plan! We are obviously confident of the traditional management:
broad-spectrum antibiotics, source identification, and admission.1, 2
But what if
we told you there was some subtlety in the evaluation of neutropenic fever,
some gray area, some evidence that there might be another way? It turns out
that these well-appearing patients without signs of end-organ dysfunction may
be at low risk for serious complications.2, 3, 4 In fact, in the ambulatory
hematology-oncology setting, these low-risk patients, identified by
risk-stratification indices such as the Multinational Association for
Supportive Care in Cancer (MASCC) and Clinical Index of Stable Febrile
Neutropenia (CISNE) scores, are sent home with oral antibiotics.3, 4 These
risk-stratification tools, however, have yet to be applied to the ED…until now.
In this
article by Coyne et al,2 the authors retrospectively apply these risk-stratification
scores to a cohort of febrile, neutropenic ED patients and review adverse
outcome rates across the various risk groups.
But how does
this apply to the patient sitting in front of you?
The Case
A 54-year-old
woman with breast cancer who is currently undergoing chemotherapy with
docetaxel presents to the ED, reporting subjective fever and generalized
malaise for 6 hours. Review of systems reveals nausea with decreased oral
intake since her last chemotherapy 1 week ago. In the ED, she is febrile to
38.3°C (101°F) and has pulse rate 108, blood pressure 110/65 mm Hg, respiratory
rate 18 breaths/min, and oxygen saturation 99% on room air. Her physical
examination result demonstrates dry oral mucosa, painful mouth ulcerations, and
mild tachycardia, without any other significant findings. Chest radiography and
urinalysis results are negative for pneumonia or urinary tract infection. After
ibuprofen, antiemetics, intravenous fluids, and a delicious tray of hospital
food (including at least one mystery meat), she is no longer febrile or
tachycardic and is asking to be discharged.
Is she at low
risk for adverse outcomes? Can we discharge her?...
The rest of
the article (full-text free): http://www.annemergmed.com/article/S0196-0644(17)30416-X/fulltext
19. Randomized Trial Shows Icatibant Useless for
Angiotensin-Converting Enzyme Inhibitor-Induced Upper Airway Angioedema.
Sinert R, et
al. J Allergy Clin Immunol Pract. 2017 May 25 [Epub ahead of print].
BACKGROUND:
Upper airway angioedema is a rare, unpredictable, and at times life-threatening
adverse effect of angiotensin-converting enzyme inhibitors (ACE-Is) with no
existing effective pharmacologic treatment. Icatibant is a bradykinin B2
receptor antagonist that may be beneficial in patients with ACE-I-induced
angioedema.
OBJECTIVE: We
aimed to evaluate the efficacy of icatibant in subjects with ACE-I-induced
angioedema.
METHODS: At
31 centers in 4 countries, adults on ACE-Is who presented within 12 hours of
the onset of at least moderately severe angioedema were randomized 1:1 to
icatibant 30 mg or placebo administered subcutaneously. The primary efficacy
end point was time to meeting discharge criteria after study drug
administration, based on the severity of airway symptoms assessed hourly by a
blinded physician using clinical ratings across 4 domains.
RESULTS: A
total of 121 subjects were randomized (icatibant, n = 61; placebo, n = 60); 118
received treatment a median of 7.8 hours from symptom onset. We observed no
difference in time to meeting discharge criteria between groups (median, 4.0 hours
in each group; P = .63). There also was no difference in time to onset of
symptom relief (median, icatibant, 2.0 hours; placebo, 1.6 hours; P = .57) or
any other secondary end point. Similar findings were noted in prespecified and
post hoc subgroup analyses stratified by symptom severity, time interval to
treatment, age, and other clinical covariates. No new safety signals were
detected.
CONCLUSIONS:
Icatibant was no more efficacious than placebo in at least moderately severe
ACE-I-induced angioedema of the upper airway.
20. Low- Versus Standard-Dose Alteplase in Patients on Prior
Antiplatelet Therapy: The ENCHANTED Trial (Enhanced Control of Hypertension and
Thrombolysis Stroke Study).
Robinson TG,
et al. Stroke. 2017 Jun 15 [Epub ahead of print]
BACKGROUND
AND PURPOSE: Many patients receiving thrombolysis for acute ischemic stroke are
on prior antiplatelet therapy (APT), which may increase symptomatic
intracerebral hemorrhage risk. In a prespecified subgroup analysis, we report
comparative effects of different doses of intravenous alteplase according to
prior APT use among participants of the international multicenter ENCHANTED
study (Enhanced Control of Hypertension and Thrombolysis Stroke Study).
METHODS: Among
3285 alteplase-treated patients (mean age, 66.6 years; 38% women) randomly
assigned to low-dose (0.6 mg/kg) or standard-dose (0.9 mg/kg) intravenous
alteplase within 4.5 hours of symptom onset, 752 (22.9%) reported prior APT
use. Primary outcome at 90 days was the combined end point of death or
disability (modified Rankin Scale [mRS] scores, 2-6). Other outcomes included
mRS scores 3 to 6, ordinal mRS shift, and symptomatic intracerebral hemorrhage
by various standard criteria.
RESULTS: There
were no significant differences in outcome between patients with and without
prior APT after adjustment for baseline characteristics and management factors
during the first week; defined by mRS scores 2 to 6 (adjusted odds ratio [OR],
1.01; 95% confidence interval [CI], 0.81-1.26; P=0.953), 3 to 6 (OR, 0.95; 95%
CI, 0.75-1.20; P=0.662), or ordinal mRS shift (OR, 1.03; 95% CI, 0.87-1.21;
P=0.770). Alteplase-treated patients on prior APT had higher symptomatic
intracerebral hemorrhage (OR, 1.82; 95% CI, 1.00-3.30; P=0.051) according to
the safe implementation of thrombolysis in stroke-monitoring study definition.
Although not significant (P-trend, 0.053), low-dose alteplase tended to have
better outcomes than standard-dose alteplase in those on prior APT compared
with those not using APT (mRS scores of 2-6; OR, 0.84; 95% CI, 0.62-1.12 versus
OR, 1.16; 95% CI, 0.99-1.36).
CONCLUSIONS: Low-dose
alteplase may improve outcomes in thrombolysis-treated acute ischemic stroke
patients on prior APT, but this requires further evaluation in a randomized
controlled trial.
21. Syncope: Outcomes and Conditions Associated with
Hospitalization.
Joy PS, et
al. Am J Med. 2017 Jun;130(6):699-706.e6.
PURPOSE: Syncope
is a perplexing problem for which hospital admission and readmission are
contemplated but outcomes remain uncertain. Our purpose was to determine the
incidence of admissions and readmissions for syncope and compare associated
conditions, in-hospital outcomes, and resource utilization.
METHODS: The
2005-2011 California Statewide Inpatient Database was utilized. Patients of age
≥18 years admitted under International Classification of Diseases, Ninth
Revision, Clinical Modification code 780.2 ("syncope or collapse")
were selected. Records with a primary discharge diagnosis of syncope were classified
as primary syncope. Primary outcome was mortality and secondary outcome
measures were cardiopulmonary resuscitation, mechanical ventilation, discharge
disposition, length of stay, frequency of readmission and hospital charges.
RESULTS: An
estimated 1.52 ± 0.02% admissions every year are related to syncope. Among
admissions for syncope, in 42.1%, the cause remained unknown; 23% of syncope
admissions were for recurrent episodes. The top 5 associated new diagnoses were
hypokalemia (0.24%), ventricular tachycardia (0.17%), atrial fibrillation
(0.16%), dehydration (0.12%), and hyponatremia (0.12%). Mortality rates are
lower for primary vs secondary syncope (0.2% vs 1.4%; P less than .0001).
Greatest risk factors for mortality in primary syncope were pulmonary hypertension
(odds ratio 12.3; 95% confidence interval, 3.34-45.04) and metastatic cancer
(odds ratio 7.22; 95% confidence interval, 4.50-11.58). Major adverse events
showed a decreasing trend for patients with multiple syncope admissions. Older
patients and defibrillators or pacemaker recipients are admitted more often but
experience negligible adverse events. Over a decade, median hospital charge for
a single syncope admission has increased by 1.5 times.
CONCLUSIONS: Despite
a good prognosis, syncope is a frequent cause for hospitalization, particularly
in the elderly. Present evaluation strategies are expensive and lack diagnostic
value.
22. Micro Bits
AA. New Online Clinical Resource
“Providing
medical educational content at affordable prices.
“StatPearls
offers the most comprehensive database of FREE multiple-choice questions with
explanations and short review chapters ever developed. This system helps
physicians, medical students, dentists, nurses, pharmacists, and allied health
professionals identify education deficits and learn new concepts.
“Our content
is updated continuously through a multi-step peer review process. Besides
online study quizzes, we also publish our peer-reviewed content in eBooks and
mobile Apps. We also offer inexpensive CME/CE, so our content can be used to
attain education credits while you study.
“Published
Multiple Choice Questions: 52136
Published
Flash Card Questions: 19517
Published
Articles: 1277”
A. Study finds inappropriate NOAC
dosing patterns in patients with AFib
Researchers
reviewed data for nearly 15,000 patients with atrial fibrillation who were
taking a non-vitamin K antagonist oral anticoagulant and found that the
standard dose was given to more than 40% of those with a renal indication for
dose reduction, and more than 10% of those with no indication for dose
reduction were underdosed. The findings, published in the Journal of the
American College of Cardiology, also found an association between inappropriate
dosing and increased risk of stroke.
B. Moderate alcohol consumption as
risk factor for adverse brain outcomes and cognitive decline: longitudinal
cohort study
Conclusions:
Alcohol consumption, even at moderate levels, is associated with adverse brain
outcomes including hippocampal atrophy. These results support the recent
reduction in alcohol guidance in the UK and question the current limits
recommended in the US.
C. AAFP, HHS collaborate to promote
myhealthfinder tool
The AAFP and
the HHS' Office of Disease Prevention and Health Promotion have joined to
promote the myhealthfinder tool, found on the Academy's familydoctor.org
website, which helps patients learn which preventive services the US Preventive
Services Task Force, the CDC Advisory Committee on Immunization Practices, and
the Health Resources and Services Administration recommends they receive.
Myhealthfinder offers information in either English or Spanish based on a
patient's age, sex and pregnancy status.
D. Combined low-dose BP meds may
effectively control hypertension
A study in
the journal Hypertension found a combination of quarter doses of four blood
pressure-lowering drugs had almost twice the effectiveness of a full dose of
one drug, while a combination of quarter doses of two drugs demonstrated
similar effectiveness to a full dose of one drug. The findings, based on data
from 42 studies that involved 20,284 participants with hypertension, also found
fewer side effects with quarter-dose therapies.
E. U.S. places 36th among best
countries for youths
The US ranked
36th out of 172 countries in providing a good childhood -- based on factors
such as health care, education, violence and quality of life -- with Norway and
Slovenia topping the list, according to a Save the Children report. An
accompanying report showed the top US states where childhood is the least
threatened, including New Hampshire, Massachusetts, New Jersey, Vermont and
Iowa, while Louisiana, Mississippi, New Mexico, Oklahoma and Georgia were at
the bottom of the list.
CBS News: http://www.cbsnews.com/news/save-the-children-end-of-childhood-index-2017-jill-biden-carolyn-miles/
F. More Aggressive BP Targets?
Key Points
Question What is the optimal target for reduction of
systolic blood pressure among patients with hypertension?
Findings In this systematic review and network
meta-analysis of 42 trials, including 144 220 patients, linear associations
were seen between mean achieved systolic blood pressure and risk of
cardiovascular disease and mortality, with the lowest risk at a systolic blood
pressure of 120 to 124 mm Hg.
Meaning Reducing systolic blood pressure below
currently recommended targets with commonly used antihypertensive medications
may significantly reduce the risk of cardiovascular disease and all-cause
mortality.
G. EHR study shows inpatient progress
notes often copied or imported
An analysis
of 23,630 inpatient progress notes in an Epic EHR system written by direct care
hospitalists, residents and medical students found that 18% of the text was
entered manually, 36% was imported and 46% was copied. Researchers noted in a
JAMA Internal Medicine research letter that importing or copying text can cause
clinical errors because of the possibility of including inaccurate or outdated
information.
JAMA Intern
Med abstract: http://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2629493
H. Chocolate and Afib
Chocolate has
been associated with heart health in as many varieties as, well, a box of
chocolates. Now researchers have added atrial fibrillation (Afib) to that list.
Reporting in
Heart, the population-based prospective Danish Diet, Cancer, and Health Study
showed a roughly 20% lower risk of clinically apparent Afib or flutter with
weekly chocolate intake and 10% reduced risk with a few servings a month
compared with less than once-a-month indulgence.
However, an
accompanying editorial cautioned about possible confounding, as chocolate
eaters in the study were healthier and more highly educated and the study did
not account for Afib risk factors like kidney disease and sleep apnea.
"Regardless
of the limitations of the Danish chocolate study, the findings are interesting
and warrant further consideration, especially given the importance of
identifying effective prevention strategies," the editorialists concluded.
"Perhaps what is bad for the pancreas is good for the atria."
I. Polyneuropathy patients at risk
with long-term opioids
A
population-based study in JAMA Neurology linked long-term opioid use among
polyneuropathy patients to an increased risk of adverse events without improved
function. Patients taking opioids for at least 90 days were more likely to rely
on gait aids, have trouble climbing stairs, have depression, and experience
opioid dependence and overdose, compared with patients in a control group.
J. Socially Assistive Robots Help
Patients Make Behavioral Changes
Jennifer
Abbasi. JAMA. Published online June 7, 2017.
Speaking to a
group of journalists last October at the annual meeting of the American Association
for the Advancement of Science, Maja Matarić, PhD, stated the problem bluntly:
“There aren’t enough people for people.”
Matarić is a
professor of computer science, neuroscience, and pediatrics at the University
of Southern California, where she oversees the development of socially
assistive robots. These intelligent machines are being designed to help
patients with convalescence, rehabilitation, and training through social
interactions rather than physical ones.
Socially
assistive robotics—a term Matarić and a graduate researcher coined 15 years
ago—is being studied at her pioneering Interaction Lab for use in stroke
rehabilitation, autism behavior therapy, dementia, and traumatic brain injury,
among other health applications. The robots monitor and chat with patients,
coaching and motivating their human companions to do tasks they might be
disinclined to do, like exercise a stroke-affected limb.
Matarić and
her collaborators in the growing field are harnessing the power of social
influence to change behavior. She says that interacting with socially
intelligent machines can give patients the “psychological oomph” they need to
do the work their physicians have prescribed.
Matarić hopes
to release the first commercially available socially assistive robots through
her Pasadena-based start-up Embodied in 2019. She recently spoke with JAMA
about her work and the future of socially assistive robots. The following is an
edited version of the interview.
JAMA: How
long have you been working on socially assistive robots?...
K. Evaluating the Laboratory Risk
Indicator to Differentiate Cellulitis from Necrotizing Fasciitis in the ED
Conclusion:
The LRINEC score may not be an accurate tool for NF risk stratification and
differentiation between cellulitis and NF in the ED setting. This decision
instrument demonstrated a high false positive rate when determining NF risk
stratification in confirmed cases of celulitis and a high false negative rate
in cases of confirmed NF.
L. Drones Deliver AEDs Faster Than
Ambulances in a Swedish Experiment
Claesson A et
al. JAMA 2017 Jun 13.
In 18
simulated cardiac arrests, aerial drones delivered automated external
defibrillators almost 17 minutes faster than ambulances had done in real life.
M. Detectable lead found in 20% of
baby food samples
The
Environmental Defense Fund looked at 2003 to 2013 FDA study data involving more
than 12,200 food samples and found that 20% of baby food samples had detectable
lead levels, compared with 14% of general food samples. The report also
determined that lead was most prevalent in fruit juices, root vegetables,
arrowroot cookies and teething biscuits and was more often detected in baby
food variants of apple and grape juices, compared with regular versions.
N. Older patients should take PPIs to
cut risk of bleed from aspirin, study says
Elderly
people who take long term daily aspirin have a higher than expected risk of
disabling or fatal upper gastrointestinal bleeding, a major UK study has found.
The researchers recommend prescribing proton pump inhibitors (PPIs) to prevent
bleeds.
From the Lancet
Interpretation
In patients
receiving aspirin-based antiplatelet treatment without routine PPI use, the
long-term risk of major bleeding is higher and more sustained in older patients
in practice than in the younger patients in previous trials, with a substantial
risk of disabling or fatal upper gastrointestinal bleeding. Given that half of
the major bleeds in patients aged 75 years or older were upper
gastrointestinal, the estimated NNT for routine PPI use to prevent such bleeds
is low, and co-prescription should be encouraged.
Full-text
(free): http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30770-5/fulltext
O. Excess weight, obesity affects more
than 2 billion people worldwide
A study in
the New England Journal of Medicine found that 2.2 billion people, or 30% of the
world's population, were overweight or obese in 2015, including nearly 108
million obese youths. The findings, based on 1980 to 2015 data from 195
countries, also showed that the US had the highest obesity rate among children
and young adults of the 20 most populated countries, while China and India had
the most number of obese youths.
