1. On Hemorrhaging in Pts on Dabigatran
A.
Idarucizumab for Dabigatran Reversal - Full Cohort Analysis.
Pollack CV Jr,
et al. N Engl J Med. 2017 Jul 11
[Epub ahead of print].
Introduction
Patients who
are receiving oral anticoagulant therapy for the prevention or treatment of
thrombosis may benefit from anticoagulant reversal if they present with
life-threatening bleeding or if they will be undergoing urgent surgery or
intervention. Therefore, the availability of specific reversal agents has the
potential to improve the benefit–risk profile of long-term anticoagulant
therapy and to increase patient and physician acceptance of such treatment. Idarucizumab
is a humanized monoclonal antibody fragment that binds dabigatran with high
affinity and specificity and rapidly reverses its anticoagulant activity.1
Idarucizumab has been licensed in many countries, in part on the basis of the
results of an interim analysis of data on the first 90 patients enrolled in the
Reversal Effects of Idarucizumab on Active Dabigatran (RE-VERSE AD) study.2
This report provides data on the entire cohort of 503 patients included in that
study and validates the results of the interim analysis.
Abstract
Background: Idarucizumab,
a monoclonal antibody fragment, was developed to reverse the anticoagulant
effect of dabigatran.
Methods: We
performed a multicenter, prospective, open-label study to determine whether 5 g
of intravenous idarucizumab would be able to reverse the anticoagulant effect
of dabigatran in patients who had uncontrolled bleeding (group A) or were about
to undergo an urgent procedure (group B). The primary end point was the maximum
percentage reversal of the anticoagulant effect of dabigatran within 4 hours
after the administration of idarucizumab, on the basis of the diluted thrombin
time or ecarin clotting time. Secondary end points included the restoration of
hemostasis and safety measures.
Results: A
total of 503 patients were enrolled: 301 in group A, and 202 in group B. The
median maximum percentage reversal of dabigatran was 100% (95% confidence
interval, 100 to 100), on the basis of either the diluted thrombin time or the
ecarin clotting time. In group A, 137 patients (45.5%) presented with
gastrointestinal bleeding and 98 (32.6%) presented with intracranial
hemorrhage; among the patients who could be assessed, the median time to the
cessation of bleeding was 2.5 hours. In group B, the median time to the
initiation of the intended procedure was 1.6 hours; periprocedural hemostasis
was assessed as normal in 93.4% of the patients, mildly abnormal in 5.1%, and
moderately abnormal in 1.5%. At 90 days, thrombotic events had occurred in 6.3%
of the patients in group A and in 7.4% in group B, and the mortality rate was
18.8% and 18.9%, respectively. There were no serious adverse safety signals.
Conclusions:
In emergency situations, idarucizumab rapidly, durably, and safely reversed the
anticoagulant effect of dabigatran. (Funded by Boehringer Ingelheim; RE-VERSE
AD ClinicalTrials.gov number, NCT02104947.).
Full-text
(free): http://www.nejm.org/doi/full/10.1056/NEJMoa1707278#t=article
Ryan Radekci’s
critique: http://www.emlitofnote.com/?p=3956
B.
Rate of ICH after Blunt Head Trauma in Pts on Dabigatran Presenting to a Level
1 Trauma Center
Chenoweth JA,
et al. West J Emerg Med 2017 July 14 [Epub ahead of print].
Study
Objective: Dabigatran etexilate was the first direct-acting oral anticoagulant
approved in the United States. The rate of intracranial hemorrhage after blunt
head trauma in patients on dabigatran is currently unknown, complicating
adequate ability to accurately compare the risks and benefits of dabigatran to
alternative anticoagulants. We aim to determine the prevalence of intracranial
hemorrhage for patients on dabigatran presenting to a level 1 trauma center.
Methods: This
is a retrospective observational study of adult patients on dabigatran who
presented to a Level 1 trauma center and received cranial computed tomography
(CT) following blunt head trauma. Patients who met inclusion criteria underwent
manual chart abstraction. Our primary outcome was intracranial hemorrhage on
initial cranial CT.
Results: A
total of 33 eligible patient visits were included for analysis. Mean age was
74.8 years (SD 11.2, range 55-91). The most common cause of injury was ground
level fall (n = 22, 66.7%). One patient (3.0%, 95% CI 0.1-15.8%) had
intracranial hemorrhage on cranial CT. No patients (0%, 95% CI 0-8.7%) required
neurosurgical intervention. One in-hospital death occurred.
Results: A
total of 33 eligible patient visits were included for analysis. Mean age was
74.8 years (SD 11.2, range 55-91). The most common cause of injury was ground
level fall (n = 22, 66.7%). One patient (3.0%, 95% CI 0.1-15.8%) had
intracranial hemorrhage on cranial CT. No patients (0%, 95% CI 0-8.7%) required
neurosurgical intervention. One in-hospital death occurred.
Conclusion:
To our knowledge, this is the first study to evaluate the rate of intracranial
hemorrhage after blunt head trauma for patients on dabigatran presenting to the
emergency department. The intracranial hemorrhage rate in our study is similar
to previous reports for patients on warfarin. Further studies are needed to
determine if the rate of intracranial hemorrhage seen in our patient population
is true for a larger patient population in more diverse clinical settings.
Full-text
(free): http://escholarship.org/uc/item/6dw824z4
2. More on Traumatic Hemorrhage
A.
Mild brain injury and anticoagulants: Less is enough (that is, if the first CT
is negative, you’re done)
Campiglio L,
et al. Neurol Clin Pract 22 June 2017 [Epub ahead of print]
Background:
Despite the higher theoretical risk of traumatic intracranial hemorrhage (ICH)
in anticoagulated patients with mild head injury, the value of sequential head
CT scans to identify bleeding remains controversial. This study evaluated the
utility of 2 sequential CT scans at a 48-hour interval (CT1 and CT2) in
patients with mild head trauma (Glasgow Coma Scale 13–15) taking oral
anticoagulants.
Methods: We
retrospectively evaluated the clinical records of all patients on chronic
anticoagulation treatment admitted to the emergency department for mild head
injury.
Results: A
total of 344 patients were included, and 337 (97.9%) had a negative CT1. CT2
was performed on 284 of the 337 patients with a negative CT1 and was positive
in 4 patients (1.4%), but none of the patients developed concomitant neurologic
worsening or required neurosurgery.
Conclusions:
Systematic routine use of a second CT scan in mild head trauma in patients
taking anticoagulants is expensive and clinically unnecessary.
________
This concurs
with the results from a large multicenter prospective observational study
published in 2012: “Discharging patients receiving anticoagulant or
antiplatelet medications from the ED after a normal cranial CT scan result is
reasonable…”
Full-text
(free): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3361700/
B.
Comparison of the safety and efficacy between 3-factor and 4-factor prothrombin
complex concentrates (PCC) for the reversal of warfarin
Kuroski JE,
et al. Am J Emerg Med. 2017;35(6):871-4.
PURPOSE:
Prior to the Food and Drug Administration approval of 4-factor prothrombin
complex concentrate (4F-PCC), only 3-factor PCC (3F-PCC) products were
available in the US. There is limited data comparing the safety and efficacy of
3F-PCC versus 4F-PCC. The purpose of our study, therefore, was to compare the
safety and efficacy profiles of 3F-PCC versus 4F-PCC for the emergent reversal
of warfarin.
METHODS: A
single-center, retrospective cohort analysis compared patients who received
3F-PCC or 4F-PCC for the emergent reversal of warfarin due to life-threating
bleeding from January 2013 to September 2015. The primary objective of this
study was the percentage of patients whose international normalized ratio (INR)
reversed to ≤1.5 within 8h of PCC administration. The secondary safety
objective was incidence of thromboembolic events at 7days post PCC.
RESULTS: A
total of 137 patients were included. The median baseline INR was 3.15 in the
3F-PCC group and 3.1 in the 4F-PCC group. The median post-PCC INR was 1.4 in the
3F-PCC group and 1.3 in the 4F-PCC group. INR ≤1.5 was achieved in 45/58 (78%)
patients in the 3F-PCC group and 46/58 (79%) patients in the 4F-PCC group
(p=0.61). The thromboembolic event rate between the two groups at 7days was
similar, 4/68 (5.9%) for 3F-PCC versus 4/69 (5.8%) for 4F-PCC (p=1.0).
CONCLUSIONS:
There was no significant difference in the percentage of patients who achieved
an INR ≤1.5 between the 3F-PCC and 4F-PCC groups for emergent reversal of
warfarin.
C.
Fluid resuscitation of trauma patients: How much fluid is enough to determine
the patient's response?
Mizushima Y,
et al. Amer J Emerg Med 2017;35(6):842-5.
Introduction
The topic of
damage control resuscitation has become increasingly popular during the last
several years [[1], [2], [3], [4]]. This topic involves several key concepts
that include permissive hypotension (restrictive fluid resuscitation), which is
a strategy that restricts fluid use before any bleeding is controlled to avoid
excessive blood loss. However, the related studies have mainly evaluated
patients with penetrating injury and in the pre-hospital setting. Therefore, it
is unclear whether this approach provides benefits in cases of blunt trauma or
in-hospital setting. In addition, patients with hypotension should be rapidly
stabilized with a moderate fluid infusion to maintain tissue perfusion.
Therefore, the American College of Surgeon's Advanced Trauma Life Support
training program emphasizes a “balanced” approach to ensure adequate tissue
perfusion and minimize the risk of re-bleeding by avoiding inadequate or
excessive fluid administration [5].
The Advanced
Trauma Life Support and Japan Advanced Trauma Evaluation and Care guidelines
both recommend an initial rapid infusion of fluid (1−2 L) as a diagnostic procedure
for patients who have experienced trauma or hemorrhage [[5], [6]]. However, the
appropriate volume of fluid infusion has not been clearly defined, despite the
patient's responses to the initial fluid resuscitation being critical to
selecting an appropriate therapeutic strategy. Therefore, this study aimed to
determine the optimal volume of fluid infusion during the initial resuscitation
of patients who had experienced trauma and hypotension.
Methods
This
prospective descriptive 3-year study (2008–2011) evaluated ≥16-year-old
patients with blunt trauma and a systolic blood pressure (SBP) of ≤90 mm Hg at
admission. We excluded patients who had received any fluids before the
admission, such as patients who had been transferred from other hospitals. The
standard trauma resuscitation protocols were used for all other components of
care. The patients' hemodynamic parameters were recorded after 1 L and 2 L of
fluid resuscitation…
Results
We enrolled
69 patients, who had an average age of 50.3 ± 20.7 years and an average injury
severity score of 29.9 ± 13.9. Thirty-nine patients required an intervention,
and 30 patients did not require an intervention for control hemorrhage. The
sites of hemorrhage for the cases that required an intervention were pleural
hemorrhage (n = 3), peritoneal hemorrhage (n = 12), retroperitoneal hemorrhage
(n = 19), and other sites (n = 6). The overall mortality rate was 23.2%....
Conclusions
…Our results
indicate that non-response after 1 L of fluid resuscitation provided a better
ability to predict the need for intervention, compared to non-response after
2 L of fluid resuscitation. Furthermore, the receiver operating characteristic
curve for SBP provided the highest value after 1 L of fluid resuscitation (vs.
at admission or after 2 L of fluid resuscitation). Therefore, it might be more
appropriate to evaluate patient response after 1 L of fluid administration (vs.
after 2 L) to assess the need for an intervention to stop bleeding
The findings
of this study are limited by the single-center design and small sample size.
Thus, large multicenter studies are needed to confirm these preliminary
results, and to evaluate the utility of 1-L fluid resuscitation. Nevertheless,
fluid resuscitation at a moderate rate and volume may help provide better
identification of patients who require immediate interventions.
3. On Health Care in America
A.
Mistreated: Why We Think We're Getting Good Health Care—and Why We're Usually
Wrong
By Robert
Pearl; New York: Public Affairs, 2017.
A WASHINGTON
POST BESTSELLER
Do you know
how to tell good health care from bad health care? Guess again. As patients, we
wrongly assume the "best" care is dependent mainly on the newest
medications, the most complex treatments, and the smartest doctors. But
Americans look for health-care solutions in the wrong places. For example,
hundreds of thousands of lives could be saved each year if doctors reduced
common errors and maximized preventive medicine.
For Dr.
Robert Pearl, these kinds of mistakes are a matter of professional importance,
but also personal significance: he lost his own father due in part to poor
communication and treatment planning by doctors. And consumers make costly
mistakes too: we demand modern information technology from our banks, airlines,
and retailers, but we passively accept last century's technology in our health
care.
Solving the
challenges of health care starts with understanding these problems. Mistreated
explains why subconscious misperceptions are so common in medicine, and shows
how modifying the structure, technology, financing, and leadership of American
health care could radically improve quality outcomes. This important book
proves we can overcome our fears and faulty assumptions, and provides a roadmap
for a better, healthier future.
Podcast with the Author from the
Commonwealth National Podcast:
B.
The Smart-Medicine Solution to the Health-Care Crisis
Our
healthcare system won’t be fixed by insurance reform. To contain costs and
improve results, we need to move aggressively and adopt the tools of
information-age medicine.
By Eric Topol,
MD. Wall Street Journal, July 7, 2017
The
controversy over Obamacare and now the raucous debate over its possible repeal
and replacement have taken center stage recently in American politics. But
health insurance isn’t the only health-care problem facing us—and maybe not
even the most important one. No matter how the debate in Washington plays out
in the weeks ahead, we will still be stuck with astronomical and ever-rising
health-care costs. The U.S. now spends well over $10,000 per capita on health
care each year….
https://www.wsj.com/articles/the-smart-medicine-solution-to-the-health-care-crisis-1499443449
C.
Medi-Cal Patients Flocking To ERs More than Before ACA
By Kellen
Browning, California Healthline, June 12, 2017
Medi-Cal
patients are swamping California emergency rooms in greater numbers than they
did before the Affordable Care Act took effect, despite predictions that the
health law would ease the burden on ERs.
Emergency
room visits by people on Medi-Cal rose 75 percent over five years, from 800,000
in the first quarter of 2012 to 1.4 million in the last quarter of 2016,
according to data recently released by the state’s Office of Statewide Health
Planning and Development.
The most
dramatic increase began roughly around the time the ACA expanded health care
benefits in January 2014. More than 5 million Californians have gained coverage
under the ACA, either through the expansion of Medi-Cal, California’s version
of the Medicaid program for low-income people, or by purchasing health plans
from Covered California, the state’s Obamacare insurance exchange.
The
architects and proponents of Obamacare had argued that once people got health
coverage they would stop going to the ER so much, because they could visit
primary care doctors instead. But in reality, people who were uninsured before
the ACA were actually reluctant to go to the ER unless they were “about to
die,” because they would be saddled with big bills, said state Sen. Richard Pan
(D-Sacramento), a pediatrician. Under Medi-Cal, though, patients aren’t worried
about those expenses.
And old
habits die hard: A newly-insured patient accustomed to visiting the ER for
treatment might not immediately switch to a primary care doctor who is, “just a
name — not somebody you know,” Pan added.
Still,
experts believe fewer Medi-Cal patients would be visiting the ER if there were
more doctors willing to treat them.
Though “we
have seen a very strong increase in the number of Medi-Cal patients … the
number of doctors willing to see Medi-Cal patients has not increased accordingly,”
said Jan Emerson-Shea, vice president of external affairs for the California
Hospital Association.
Dr. Marc
Futernick, the immediate past president of the California American College of
Emergency Physicians, agreed that “there aren’t adequate providers for the
demands.” He said he believes Medi-Cal’s low payment rates for physicians play
a role.
Historically,
doctors across the country have been reimbursed less for treating Medicaid
patients than those on private insurance or Medicare — especially in
California, which ranks 47th in the country in fee-for-service reimbursement
rates.
This means
the state’s doctors are less likely to accept Medi-Cal patients, who will then
seek treatment wherever they can get it, Futernick said. The ER is always open
and cannot legally turn people away, even though many of the Medi-Cal patients’
ills could be treated by primary care providers, Emerson-Shea said.
California
doctors have long lobbied to increase Medi-Cal reimbursements. They are pushing
hard to use some revenue from California’s recently passed tobacco tax to
increase Medi-Cal rates. But Gov. Jerry Brown wants to use it more broadly for
overall Medi-Cal spending.
Pan, the
state senator, noted other factors that could explain the surge in ER use.
Health clinics,
which see many Medi-Cal patients, generally cannot provide specialty care on
site, he said. “What’s the quickest way to see a specialist? Send them to the
emergency room.”
Moreover,
many Medi-Cal patients work jobs without flexible hours or sick leave, which
means they are not able to make appointments or visit health care providers
during regular hours, Pan said.
“When I
worked in the emergency room,” he recalled, “people would show up early in the
morning with their kids who had an ear infection or cold or something and the
parents would tell me, ‘Well, I have to go to work today or I’ll get fired.’”
California is
not the only state where the ACA has failed to produce a drop in ER use. A
study published in 2014 found that Oregon residents who won Medicaid coverage
in a 2008 lottery made 40 percent more trips to the ER in the first 18 months
they were covered than those who entered the lottery but were not selected.
4. Pediatric Appendicitis
A.
Antibiotics Only for Appendicitis?
Werner S, et
al. Ann Emerg Med 2017;70(1):12–14. (EM-RAP Commentary)
Annals Case
A 28-year-old
otherwise healthy male patient presented with one day of right lower quadrant
abdominal pain. As if he read the textbook, he reported associated nausea and
anorexia. The examination was remarkable for temperature to 38.5°C (101.3°F)
and right lower quadrant tenderness without peritoneal signs. Of interest to
our surgery colleagues, his WBC count was 18,000 cells/mm3, and a computed
tomography (CT) scan revealed an 11-mm appendix without evidence of
perforation. Slam dunk! Easy case and disposition: antibiotics and call the
surgeon!…until the patient said, “Hey, Doc, I don’t want surgery, and I just
read on the JAMA [Journal of the American Medical Association] patient page that
appendicitis can be treated with antibiotics alone.1 Can we just do that
instead?”
Can you?
Should you? What’s the evidence? Is this patient a candidate? Which
antibiotics? What’ll the surgeon say?
The article
by Talan et al2 in this month’s Annals of Emergency Medicine evaluated and
established the feasibility of antibiotics without surgery for acute
noncomplicated appendicitis, which is generally defined as absence of
peritonitis and no evidence of perforation or abscess on imaging.
But wait: it
is on the Internet, so it must be true, right? There must be more out there
already in terms of evidence for this approach. Actually, there is a growing
body of evidence addressing the safety and efficacy of antibiotic-only
nonoperative treatment (AONOT) for noncomplicated appendicitis.
The Evidence for Nonoperative
Treatment
Surgery has
been the mainstay of appendicitis treatment for more than a century, based on
the assumption that inflammation inevitably leads to perforation. However,
since the discovery of antibiotics, reports of AONOT have dotted the
literature. In 1956, Coldrey3 reported treating 471 patients with antibiotics
alone, with a recurrence rate of only 14% and one death in an elderly patient.
In the last
20 years, several studies have assessed antibiotics versus surgery in both
adult and pediatric populations. But in case you don’t want to grab a giant cup
of coffee and comb through decades of medical literature yourself, here’s a
summary.
What’s in the Literature?
For the adult
population, there have been 7 European randomized controlled trials or quasi-randomized
controlled trials4, 5, 6, 7, 8, 9, 10 and several subsequent meta-analyses,
including 2 published this year.11, 12, 13, 14, 15 Not all studies were
included in each meta-analysis. Impressively, 1,300 total patients were
included in the studies, with roughly half in the antibiotic treatment group.
Upper age limits were 50 to 60 years.
For the
pediatric population, there have been 4 nonrandomized controlled trials and 1
randomized controlled trial (pilot study), with ages ranging from 5 to 15
years,16, 17, 18, 19, 20 a number of lesser-quality studies, and 2
meta-analyses.21, 22 More than 400 children receiving AONOT were included in
the various studies.
Who’s a Candidate?
Adult and pediatric
studies included only patients with noncomplicated appendicitis. Inclusion and
exclusion criteria varied across the studies, but, in general, our 28-year-old
man with no health problems and CT-diagnosed noncomplicated appendicitis would
meet inclusion criteria and not meet the typical exclusion criteria. The
studies reviewed tended to have more stringent exclusion criteria, including
but not limited to perforation or abscess, peritonitis or sepsis, steroid use,
anticoagulant use, or comorbidities. In the article by Talan et al,2
comorbidities included high-risk diabetes, suspected acute coronary syndrome,
heart failure, and liver and kidney disease. So, aside from being sick with
acute appendicitis, you have to be pretty healthy.
What Antibiotics Were Used?...
For the rest
of the article, full-text (free): http://www.annemergmed.com/article/S0196-0644(17)30584-X/fulltext
Select References
2. The Talan
article abstract (previously posted on Lit Bits): http://www.annemergmed.com/article/S0196-0644(16)30924-6/abstract
See also Nonoperative Management of
Appendicitis: A Paradigm Shift? July 2017 Annals of Emergency Medicine Journal
Club
B.
Lack of utility of measuring serum bilirubin concentration in distinguishing
perforation status of pediatric appendicitis
Bonadio W, et
al. Amer J Emerg Med 2017;35(6):885-8.
Background
Pediatric
appendicitis is a common, potentially serious condition. Determining
perforation status is crucial to planning effective management.
Purpose
Determine the
efficacy of serum total bilirubin concentration [STBC] in distinguishing
perforation status in children with appendicitis.
Methods
Retrospective
review of 257 cases of appendicitis who received abdominal CT scan and
measurement of STBC.
Results
There were
109 with perforation vs 148 without perforation. Although elevated STBC was
significantly more common in those with [36%] vs without perforation [22%], the
mean difference in elevated values between groups [0.1 mg/dL] was clinically
insignificant. Higher degrees of hyperbilirubinemia [over 2 mg/dL] were rarely
encountered [5%]. Predictive values for elevated STBC in distinguishing
perforation outcome were imprecise [sensitivity 38.5%, specificity 78.4%, PPV
56.8%, NPV 63.4%]. ROC curve analysis of multiple clinical and other laboratory
factors for predicting perforation status was unenhanced by adding the STBC
variable. Specific analysis of those with perforated appendicitis and
percutaneously-drained intra-abdominal abscess which was culture-positive for
Escherichia coli showed an identical rate of STBC elevation compared to all
with perforation.
Conclusions
The routine
measurement of STBC does not accurately distinguish perforation status in
children with appendicitis, nor discern infecting organism in those with
perforation and intra-abdominal abscess.
5. On Treatment of Abscesses
A.
Youths, adults with skin abscesses may benefit from antibiotics in addition to
I&D
Researchers
found that more than 80% of children and adults with skin abscesses who took
the antibiotic clindamycin or trimethoprim-sulfamethoxazole had resolved
methicillin-resistant Staphylococcus aureus infections after 10 days, compared
with 63% of those who received placebo. The findings in The New England Journal
of Medicine also showed that standard S. aureus infections resolved in 89% and
80% of those in clindamycin and TMP-SMX groups, respectively, compared with 66%
of those in the placebo group.
Daum RS, et
al. A Placebo-Controlled Trial of Antibiotics for Smaller Skin Abscesses. N
Engl J Med. 2017 Jun 29;376(26):2545-2555.
BACKGROUND:
Uncomplicated skin abscesses are common, yet the appropriate management of the
condition in the era of community-associated methicillin-resistant
Staphylococcus aureus (MRSA) is unclear.
METHODS: We
conducted a multicenter, prospective, double-blind trial involving outpatient
adults and children. Patients were stratified according to the presence of a
surgically drainable abscess, abscess size, the number of sites of skin
infection, and the presence of nonpurulent cellulitis. Participants with a skin
abscess 5 cm or smaller in diameter were enrolled. After abscess incision and
drainage, participants were randomly assigned to receive clindamycin,
trimethoprim-sulfamethoxazole (TMP-SMX), or placebo for 10 days. The primary
outcome was clinical cure 7 to 10 days after the end of treatment.
RESULTS: We
enrolled 786 participants: 505 (64.2%) were adults and 281 (35.8%) were
children. A total of 448 (57.0%) of the participants were male. S. aureus was
isolated from 527 participants (67.0%), and MRSA was isolated from 388 (49.4%).
Ten days after therapy in the intention-to-treat population, the cure rate
among participants in the clindamycin group was similar to that in the TMP-SMX
group (221 of 266 participants [83.1%] and 215 of 263 participants [81.7%],
respectively; P=0.73), and the cure rate in each active-treatment group was
higher than that in the placebo group (177 of 257 participants [68.9%], P less
than 0.001 for both comparisons). The results in the population of patients who
could be evaluated were similar. This beneficial effect was restricted to
participants with S. aureus infection. Among the participants who were
initially cured, new infections at 1 month of follow-up were less common in the
clindamycin group (15 of 221, 6.8%) than in the TMP-SMX group (29 of 215
[13.5%], P=0.03) or the placebo group (22 of 177 [12.4%], P=0.06). Adverse
events were more frequent with clindamycin (58 of 265 [21.9%]) than with
TMP-SMX (29 of 261 [11.1%]) or placebo (32 of 255 [12.5%]); all adverse events
resolved without sequelae. One participant who received TMP-SMX had a
hypersensitivity reaction.
CONCLUSIONS:
As compared with incision and drainage alone, clindamycin or TMP-SMX in
conjunction with incision and drainage improves short-term outcomes in patients
who have a simple abscess. This benefit must be weighed against the known
side-effect profile of these antimicrobials.
B.
Comparison of loop and primary I&D techniques in adult patients with
cutaneous abscess: A preliminary RCT
Özturan İU,
et al. Am J Emerg Med. 2017;35(6):830-4.
OBJECTIVES:
The aim of this study is to compare efficacy of loop drainage and standard
incision & drainage (I&D) in adult patients with cutaneous abscess in
the emergency department.
METHODS: This
study is an interventional, parallel group, randomized clinical trial. Adult
patients with cutaneous abscess were randomized into loop drainage and standard
I&D groups. The primary outcome was defined as change in diameter of
abscess and cellulitis 7days after procedure. Secondary outcome measures were
pain intensity at the end of the procedure and procedure duration. Also patient
satisfaction, need for antibiotics and repetitive drainage were recorded.
RESULTS: A
total of 46 patients were included in the study (23 in each group). Both groups
had similar baseline characteristics. Median abscess diameters were 3.2
(1.9-4.0) cm and 3.0 (2.4-4.8) cm in loop drainage and I&D groups
respectively. In the loop drainage group there was a -0.6cm (95% CI: -1.7-0.5)
difference in abscess diameter compared to the I&D group. There was also a
reduction in cellulitis diameter (-1.3cm, 95% CI: -3.4-0.8). No statistically
significant difference was found between groups in patient satisfaction, use of
antibiotics or need for repetitive drainage.
CONCLUSION:
This preliminary study revealed that, loop drainage technique is similar to
standard I&D technique in abscess resolution and complications.
6. Outcomes following possible undiagnosed aneurysmal SAH: a
contemporary analysis.
Mark DG, Acad
Emerg Med. 2017 Jul 4 [Epub ahead of print].
Objectives
Existing
literature suggests that patients with aneurysmal subarachnoid hemorrhage
(aSAH) and “sentinel” aSAH symptoms prompting health care evaluations prior to
aSAH diagnosis are at increased risk of unfavorable neurologic outcomes and
death. Accordingly these encounters have been presumed to be unrecognized
opportunities to diagnose aSAH, and the worse downstream outcomes
representative of the added risks of delayed diagnoses. We sought to
reinvestigate this paradigm among a contemporary cohort of patients with aSAH.
Methods
A
case-control cohort was retrospectively assembled among patients diagnosed with
aSAH between January 1, 2007 and June 30, 2013 within an integrated healthcare
delivery system. Patients with a discrete clinical evaluation for headache or
neck pain within 14 days prior to formal aSAH diagnosis were identified as
cases, and the remaining patients served as controls. Modified Rankin Scale
(mRS) scores at 90 days and 1 year were determined by structured chart review.
Multivariable logistic regression controlling for age, gender, ethnicity,
presence of intracerebral or intraventricular hemorrhage at diagnosis, and
aneurysm size was used to compare adjusted outcomes. Sensitivity analyses were
performed using varying definitions of favorable neurologic outcomes, a
restricted control subgroup of patients with normal mental status at hospital
admission, inclusion of additional cases that were diagnosed outside of the
integrated health system, and exclusion of patients without evidence of
subarachnoid blood on initial non-contrast cranial computed tomography at the
diagnostic encounter (i.e. “CT-negative” SAH).
Results
450 patients
with aSAH were identified, 46 (10%) of whom had clinical evaluations for
possible aSAH-related symptoms in the 14 days preceding formal diagnosis
(cases). In contrast to prior reports, no differences were observed among cases
as compared to control patients in adjusted odds of death or unfavorable
neurologic status at 90 days (0.35, 95%CI 0.11-1.15; 0.59, 95%CI 0.22-1.60,
respectively) or at 1 year (0.58, 95%CI 0.19-1.73; 0.52, 95%CI 0.18-1.51,
respectively). Likewise, neither restricting the analysis to a control subgroup
of patients with normal mental status at hospital admission, varying the
dichotomous definition of unfavorable neurologic outcome, inclusion of cases
diagnosed outside the integrated health system, or exclusion of patients with
CT-negative SAH resulted in significant adjusted outcome differences.
Conclusion
In a
contemporary cohort of patients with aSAH, we observed no statistically significant
increase in the adjusted odds of death or unfavorable neurologic outcomes among
patients with clinical evaluations for possible aSAH-related symptoms in the 14
days preceding formal diagnosis of aSAH. While these findings cannot exclude a
smaller risk difference than previously reported, they can help refine decision
analyses and testing threshold determinations for patients with possible aSAH.
7. Development and Implementation of a Comprehensive,
Multidisciplinary ED Extracorporeal Membrane Oxygenation Program
Tonna JE, et
al. Ann Emerg Med 2017;70(1):32–40
Despite
advances in the medical and surgical management of cardiovascular disease,
greater than 350,000 patients experience out-of-hospital cardiac arrest in the
United States annually, with only a 12% neurologically favorable survival rate.
Of these patients, 23% have an initial shockable rhythm of ventricular
fibrillation/pulseless ventricular tachycardia (VF/VT), a marker of high
probability of acute coronary ischemia (80%) as the precipitating factor.
However, few patients (22%) will experience return of spontaneous circulation
and sufficient hemodynamic stability to undergo cardiac catheterization and
revascularization.
Previous case
series and observational studies have demonstrated the successful application
of intra-arrest extracorporeal life support, including to out-of-hospital
cardiac arrest victims, with a neurologically favorable survival rate of up to
53%. For patients with refractory cardiac arrest, strategies are needed to
bridge them from out-of-hospital cardiac arrest to the catheterization
laboratory and revascularization. To address this gap, we expanded our ICU and
perioperative extracorporeal membrane oxygenation (ECMO) program to the
emergency department (ED) to reach this cohort of patients to improve survival.
In this report, we illustrate our process and initial experience of developing
a multidisciplinary team for rapid deployment of ED ECMO as a template for
institutions interested in building their own ED ECMO programs.
8. Online Resources
A.
The Transient Effect of Calcium on Severe Hyperkalemia
This patient
had a K of 8.1 mEq/L and a very low ionized Calcium of 2.4 mg/dl (normal: 4.4 -
5.2). Both were from a blood sample drawn 13 minutes prior to the following ECG…
B.
Three Apps You’ll Actually Use
EP Monthly July
2017
9. Does Conjunctivitis Require Abx? Usually Not
Shekhawat NS,
et al. Antibiotic Prescription Fills for Acute Conjunctivitis among Enrollees
in a Large United States Managed Care Network. Ophthalmology. 2017 Jun 14 [Epub
ahead of print]
INTRODUCTION
Acute
conjunctivitis is one of the most common ocular conditions encountered in
general medical practice, affecting 6 million persons in the United States each
year.1 Approximately one half of all
eye-related diagnoses seen in primary care offices2 and nearly one third of all emergency
department visits for ocular problems are for conjunctivitis.3 Unlike other common ocular conditions, such
as refractive error or cataract, most cases of acute conjunctivitis are
diagnosed and managed by non–eye-care providers rather than by ophthalmologists
and optometrists.
Accurate
differentiation among viral, bacterial, allergic, and other causes of acute
conjunctivitis can be challenging because all these causes can show similar
clinical features. However, because acute conjunctivitis is often
self-limiting, most patients with this condition do not require topical
antibiotic therapy.3 It is estimated
that more than 60% of patients with acute conjunctivitis have adenovirus or
other viral infections4,5 that do not
respond to antibiotics.3 Allergic
conjunctivitis is also quite common and does not respond to antibiotics.
Bacterial infections account for a much smaller proportion of acute
conjunctivitis cases. These cases are usually mild and self-limiting, often
resolving within 7 to 14 days without antibiotic therapy.6 Although topical antibiotics may hasten
resolution of symptoms among persons with bacterial conjunctivitis,6 this benefit must be weighed against the risk
of ocular surface toxicity,3 antibiotic
resistance,7, 8 and the cost associated
with their use.1 Topical corticosteroids
are contraindicated in most cases of acute conjunctivitis because they can
prolong adenoviral infections, can worsen underlying ocular herpes simplex
virus infections, and if taken for prolonged periods, can increase the risk of
cataract and glaucoma.3
In the United
States, researchers have determined that nearly one third of outpatient
antibiotic prescriptions for common viral or mild bacterial conditions, such as
sinusitis, influenza, and pharyngitis, are unnecessary or inappropriate,
representing an opportunity to improve patient safety and conserve health care
resources.9 Like these other conditions,
acute conjunctivitis is also very common and seldom requires antibiotics. In
2013, as part of the nationwide Choosing Wisely initiative to reduce wasteful
or unnecessary medical testing and treatment, the American Academy of
Ophthalmology recommended avoiding antibiotic prescriptions for viral
conjunctivitis and deferring immediate antibiotic therapy when the cause of
conjunctivitis is unknown.10 To our
knowledge, no prior study has assessed antibiotic use for acute conjunctivitis
among a large, diverse segment of the United States population. We assessed
filled prescriptions for topical antibiotics for acute conjunctivitis among
enrollees in a large United States managed care network, identified factors
associated with filled prescriptions for antibiotics for this condition, and
explored how this practice varies among communities throughout the country.
INTRO REFERENCES
1. Udeh B.L.,
Schneider J.E., and Ohsfeldt R.L.: Cost effectiveness of a point-of-care test
for adenoviral conjunctivitis. Am J Med Sci 2008; 336: pp. 254-264
2. Shields
T., and Sloane P.D.: A comparison of eye problems in primary care and
ophthalmology practices. Fam Med 1991; 23: pp. 544-546
3. American
Academy of Ophthalmology Cornea/External Disease Panel. Preferred Practice
Pattern® guidelines. Conjunctivitis. San Francisco, CA: American Academy of
Ophthalmology; 2013.
https://www.aao.org/preferred-practice-pattern/conjunctivitis-ppp---2013;
4. Sambursky R.P., Fram N., and Cohen E.J.:
The prevalence of adenoviral conjunctivitis at the Wills Eye Hospital Emergency
Room. Optometry 2007; 78: pp. 236-239
5. Woodland
R.M., Darougar S., Thaker U., et al: Causes of conjunctivitis and
keratoconjunctivitis in Karachi, Pakistan. Trans R Soc Trop Med Hyg 1992; 86:
pp. 317-320
6. Sheikh A.,
Hurwitz B., van Schayck C.P., et al: Antibiotics versus placebo for acute
bacterial conjunctivitis. Cochrane Database Syst Rev 2012; undefined: pp.
CD001211
7. Haas W.,
Pillar C.M., Torres M., et al: Monitoring antibiotic resistance in ocular
microorganisms: results from the Antibiotic Resistance Monitoring in Ocular
micRorganisms (ARMOR) 2009 surveillance study. Am J Ophthalmol 2011; 152: pp.
567-574
8. Dave S.B.,
Toma H.S., and Kim S.J.: Ophthalmic antibiotic use and multidrug-resistant .
Ophthalmology 2011; 118: pp. 2035-2040
9.
Fleming-Dutra K.E., Hersh A.L., Shapiro D.J., et al: Prevalence of
inappropriate antibiotic prescriptions among US ambulatory care visits,
2010–2011. JAMA 2016; 315: pp. 1864-1873
10. American
Academy of Ophthalmology. Choosing wisely: five things physicians and patients
should question. http://www.choosingwisely.org/societies/american-academy-of-ophthalmology;
2013 Accessed March 25, 2017.
ABSTRACT
PURPOSE: Antibiotics
are seldom necessary to treat acute conjunctivitis. We assessed how frequently
patients with newly diagnosed acute conjunctivitis fill prescriptions for
topical antibiotics and factors associated with antibiotic prescription fills.
DESIGN: Retrospective,
observational cohort study.
PARTICIPANTS:
A total of 340 372 enrollees in a large nationwide United States managed care
network with newly diagnosed acute conjunctivitis, from 2001 through 2014.
METHODS: We
identified all enrollees newly diagnosed with acute conjunctivitis, calculating
the proportion filling 1 or more topical antibiotic prescription within 14 days
of initial diagnosis. Multivariate logistic regression assessed
sociodemographic, medical, and other factors associated with antibiotic
prescription fills for acute conjunctivitis. Geographic variation in
prescription fills also was studied.
MAIN OUTCOME
MEASURES: Odds ratios (ORs) with 95% confidence intervals (CIs) for filling an
antibiotic prescription for acute conjunctivitis.
RESULTS: Among
340 372 enrollees with acute conjunctivitis, 198 462 (58%) filled ≥1 topical
antibiotic prescriptions; 38 774 filled prescriptions for
antibiotic-corticosteroid combination products. Compared with whites, blacks
(OR, 0.89; 95% CI, 0.86-0.92) and Latinos (OR, 0.83; 95% CI, 0.81-0.86) had
lower odds of filling antibiotic prescriptions. More affluent and educated
enrollees had higher odds of filling antibiotic prescriptions compared with
those with lesser affluence and education (P less than 0.01 for all). Compared
with persons initially diagnosed with acute conjunctivitis by ophthalmologists,
enrollees had considerably higher odds of antibiotic prescription fills if
first diagnosed by an optometrist (OR, 1.26; 95% CI, 1.21-1.31), urgent care
physician (OR, 3.29; 95% CI, 3.17-3.41), internist (OR, 2.79; 95% CI,
2.69-2.90), pediatrician (OR, 2.27; 95% CI, 2.13-2.43), or family practitioner
(OR, 2.46; 95% CI, 2.37-2.55). Antibiotic prescription fills did not differ for
persons with versus without risk factors for development of serious infections,
such as contact lens wearers (P = 0.21) or patients with human immunodeficiency
virus infection or AIDS (P = 0.60).
CONCLUSIONS: Nearly
60% of enrollees in this managed care network filled antibiotic prescriptions
for acute conjunctivitis, and 1 of every 5 antibiotic users filled
prescriptions for antibiotic-corticosteroids, which are contraindicated for
acute conjunctivitis. These potentially harmful practices may prolong infection
duration, may promote antibiotic resistance, and increase costs. Filling
antibiotic prescriptions seems to be driven more by sociodemographic factors
and type of provider diagnosing the enrollee than by medical indication.
10. Images in Clinical Practice
Salt-and-Pepper
Skin Changes
Mobile Aortic
Thrombi
Cerebral
Cavernous Malformations
Unmasking
Ptosis in Both Eyes
Coronary-Artery
Vasospasm
Eye Injury
from a Firecracker
Achenbach’s
Syndrome
Elderly Woman
With Fever and Abdominal Discomfort
Male Infant
With Rapidly Progressive Skin Lesions
Female With
Vaginal Spotting
Elderly Man
With Painless Vision Loss
Young Woman
With Abdominal Pain and Distention
11. Simplified diagnostic management of suspected PE (the YEARS study):
a prospective, multicentre, cohort study.
van der
Hulle, et al. Lancet. 2017 May 23 [Epub ahead of print]
BACKGROUND:
Validated diagnostic algorithms in patients with suspected pulmonary embolism
are often not used correctly or only benefit subgroups of patients, leading to
overuse of computed tomography pulmonary angiography (CTPA). The YEARS clinical
decision rule that incorporates differential D-dimer cutoff values at
presentation, has been developed to be fast, to be compatible with clinical practice,
and to reduce the number of CTPA investigations in all age groups. We aimed to
prospectively evaluate this novel and simplified diagnostic algorithm for
suspected acute pulmonary embolism.
METHODS: We
did a prospective, multicentre, cohort study in 12 hospitals in the
Netherlands, including consecutive patients with suspected pulmonary embolism
between Oct 5, 2013, to July 9, 2015. Patients were managed by simultaneous
assessment of the YEARS clinical decision rule, consisting of three items (clinical
signs of deep vein thrombosis, haemoptysis, and whether pulmonary embolism is
the most likely diagnosis), and D-dimer concentrations. In patients without
YEARS items and D-dimer less than 1000 ng/mL, or in patients with one or more
YEARS items and D-dimer less than 500 ng/mL, pulmonary embolism was considered
excluded. All other patients had CTPA. The primary outcome was the number of
independently adjudicated events of venous thromboembolism during 3 months of
follow-up after pulmonary embolism was excluded, and the secondary outcome was
the number of required CTPA compared with the Wells' diagnostic algorithm. For
the primary outcome regarding the safety of the diagnostic strategy, we used a
per-protocol approach. For the secondary outcome regarding the efficiency of
the diagnostic strategy, we used an intention-to-diagnose approach. This trial
is registered with the Netherlands Trial Registry, number NTR4193.
FINDINGS:
3616 consecutive patients with clinically suspected pulmonary embolism were
screened, of whom 151 (4%) were excluded. The remaining 3465 patients were
assessed of whom 456 (13%) were diagnosed with pulmonary embolism at baseline.
Of the 2946 patients (85%) in whom pulmonary embolism was ruled out at baseline
and remained untreated, 18 patients were diagnosed with symptomatic venous
thromboembolism during 3-month follow-up (0·61%, 95% CI 0·36-0·96) of whom six
had fatal pulmonary embolism (0·20%, 0·07-0·44). CTPA was not indicated in 1651
(48%) patients with the YEARS algorithm compared with 1174 (34%) patients, if
Wells' rule and fixed D-dimer threshold of less than 500 ng/mL would have been
applied, a difference of 14% (95% CI 12-16).
INTERPRETATION:
In our study pulmonary embolism was safely excluded by the YEARS diagnostic
algorithm in patients with suspected pulmonary embolism. The main advantage of
the YEARS algorithm in our patients is the absolute 14% decrease of CTPA
examinations in all ages and across several relevant subgroups.
12. The definite risks and questionable benefits of liberal
pre-hospital spinal immobilisation.
Purvis TA, et
al. Am J Emerg Med. 2017;35(6):860-6.
INTRODUCTION:
The routine practice of pre-hospital spinal immobilisation (phSI) for patients
with suspected spinal injury has existed for decades. However, the controversy
surrounding it resulted in the 2013 publication of a Consensus document by the
Faculty of Pre-Hospital Care. The question remains as to whether the quality of
evidence in the literature is sufficient to support the Consensus guidelines. This
critical review aims to determine the validity of current recommendations by
balancing the potential benefits and side effects of phSI.
METHOD: A
review of the literature was carried out by two independent assessors using
Medline, PubMed, EMBASE and the Cochrane Library databases. Manual searches of
related journals and reference lists were also completed. The selected body of
evidence was subsequently appraised using a checklist derived from SIGN and
CASP guidelines, as well as Crombie's guide to critical appraisal.
RESULTS: No
reliable sources were found proving the benefit for patient immobilisation. In
contrast there is strong evidence to show that pre-hospital spinal
immobilisation is not benign with recognised complications ranging from
discomfort to significant physiological compromise. The published literature
supports the Consensus guideline recommendations for safely reducing the impact
of these side effects without compromising the patient.
CONCLUSION:
The literature supports the Consensus Guidelines but raises the question as to
whether they go far enough as there is strong evidence to suggest phSI is an
inherently harmful procedure without having any proven benefit. These results
demonstrate an urgent need for further studies to determine its treatment
effect.
13. Parental Report of Penicillin Allergy: Is it Reliable?
Deborah
Lehman, MD, Journal Watch EM, Reviewing Vyles D et al. Pediatrics 2017 Jul 3.
Testing did
not confirm penicillin allergy in any of 100 children with parent-reported
penicillin allergy and low-risk symptoms.
Antibiotic
allergy is commonly reported in pediatric patients, and is usually based on
parental history rather than allergy testing. When allergy is reported, an
alternative, and sometimes broader, antibiotic is usually prescribed. Allergy
to penicillin is the most commonly reported antibiotic allergy, and testing to
confirm parental or patient history is available but rarely done.
Researchers
identified nearly 600 children ages 3 to 18 years who presented to a single
urban emergency department over a 19-month period and had history of
parent-reported penicillin allergy. Parents completed a questionnaire about
penicillin allergy symptoms; based on the responses, the researchers classified
434 children as having low-risk symptoms (non IgE mediated symptoms, including
rash, itching, diarrhea, vomiting, runny nose, nausea, cough; or reported
family history of allergy) and 163 as having high-risk symptoms (e.g.,
anaphylaxis or other IgE-mediated symptoms).
The first 100
interested and available children with low-risk symptoms underwent standard
3-tier allergy testing: percutaneous skin testing followed by intracutaneous
skin testing and oral amoxicillin challenge. No child was found to be allergic
based on 3-tier testing; 3 children (3%) had a reaction to the percutaneous
component of testing.
Comment
Results of
this small study suggest that children with low-risk, non IgE-mediated
penicillin allergy symptoms can safely be given penicillin. Physicians should
review the child's clinical symptoms when a parent reports penicillin allergy
and consider prescribing a penicillin antibiotic if the symptoms are low risk.
14. With This Ring, I Thee Send to the Emergency Room
By Nina
Reyes, NY Times. June 17, 2017
The
Matchmaking
The couple
met in October 2011 at a weekly happy hour event, when a matchmaking friend of
Mr. Alderdice approached Ms. Abugo and said that the groom was interested in
her but shy, and then went back to Mr. Alderdice and told him the same story
but with Ms. Abugo cast as the hesitant party.
The First
Date
The ploy
worked. “We ended up going on a date a week or so later and have been dating
ever since,” Ms. Abugo said.
The two found
over time that they complemented each other well.
“I’ve grown
to really appreciate his temperament — he’s very even-keeled, very reliable,”
she said. “It’s nice to have someone who brings me down to earth a lot when I
tend to be a lot more excitable.”
He said he
was enchanted by her brilliant smile, but the effort she puts into looking
after other people, her intelligence and her sharp judgment are what make her
special. “She keeps everything always interesting,” he said. “I don’t have to
worry about us getting bored together.”
Then the
Wedding
“The ring
didn’t fully fit on, but we had to have the picture of the ring in the proper
position with the flowers in the background, so she kind of pushed it on.”
A few minutes
later, Ms. Abugo realized that the blood had stopped flowing to her finger,
which was turning a dark shade of purple..
Then the ER…
Full story: https://www.nytimes.com/2017/06/17/fashion/weddings/uzezi-abugo-jacob-alderdice-married.html
15. Ann Emerg Med
A.
What Is the Utility of Thrombolytic Therapy for Acute Deep Venous Thrombosis?
Take-Home
Message
Thrombolytic
therapy increases the patency of veins and reduces the likelihood of
post-thrombotic syndrome. However, this must be balanced against the increased
risk of bleeding.
B.
Does This Patient With Chest Pain Have Acute Coronary Syndrome?
Take-Home
Message
The accuracy
of individual risk factors, symptoms, and signs in isolation to diagnose acute
coronary syndrome is poor. The history, ECG, age, risk factors, and troponin
score (HEART) and the Thrombolysis in Myocardial Infarction (TIMI) score have
strong diagnostic value and should be used as part of the clinical assessment
of these patients.
16. Words to Remember: 20 Medical School Commencement Speech
Highlights
Ryan Syrek,
MA | June 12, 2017 Medscape
Quote
#1: Former Surgeon General Vivek Murthy Urges ‘Moral Leadership’ in 2017 UCSF
Commencement Address
Vivek Murthy,
MD, MBA, the 19th Surgeon General of the United States, urged UC San
Francisco’s graduating medical students to stand up for truth, science and the
most vulnerable among us, in a commencement address delivered Monday.
Murthy spoke
about the many national challenges the new graduates will be inheriting, from
the millions of underinsured and uninsured people, to an epidemic of substance
abuse and addiction, to “a deep sense of division in our country that is fueled
by fear.” As physicians embarking in this world, he said, they will have to go
beyond providing the best possible care for their patients.
“The world
needs you to embrace your role as a moral leader in society,” he told the UCSF
School of Medicine graduates at Davies Symphony Hall. “Being a moral leader
means standing up for truth, reason and science. It means speaking out for the
most vulnerable among us.”
Murthy
acknowledged that health care professionals have traditionally shied away from
controversy and politics, but he urged them to put tradition aside. Now is the
time to make their voices heard, whether that means writing op-eds for the
newspaper or holding elected leaders accountable.
“Your
obligation from today onward is to stand up for the vulnerable and the
voiceless. And if that means engaging in controversy, then do it anyway,” he
said, to a round of applause. “If that means taking the risk of being labeled
as political, do it anyway because principles are only worth having if you have
the courage to act on them…”
The rest of
the UCSF article: https://www.ucsf.edu/news/2017/05/407001/former-surgeon-general-vivek-murthy-urges-moral-leadership-2017-ucsf
Quote
#4: Dr Jonathan LaPook, CBS News, on “What it Takes to be a True Healer”, May
17, 2017
Be
comfortable with uncertainty. If you've been practicing medicine for five years
and you think you have all the answers, you're in the wrong profession.
Patients get understandably frustrated when one year we say one thing, and the
next year it appears we're saying the exact opposite—whether it's about
postmenopausal hormone replacement, mammography, PSA screening, or whatever.
But YOU shouldn't be frustrated. Medicine has always been about trying to think
logically, based on the best available data. And thank goodness that data
changes. For thousands of years, holes were drilled into the skulls of patients
to release evil spirits, and people were bled to help restore the correct
balance of "bodily humors." What are we doing now that doctors a
hundred years from now will look back at and think, "Can you believe they
used to do that? Antibiotics for infections? Didn't they know about drilling a
hole into the skull to release the evil spirits?" Don't laugh; we're using
leeches again, not for bloodletting but to help improve microcirculation and
wound healing…
The rest of
the speech (full-text and video): http://www.cbsnews.com/news/dr-jon-lapook-commencement-address-quinnipiac-medical-school/
For the rest of the quotes, see here: http://www.medscape.com/slideshow/commencement-speech-moments-6006777
17. Cardiovascular Testing and Clinical Outcomes in ED Patients
with Chest Pain.
Sandhu AT, et
al. JAMA Intern Med. 2017 Jun 26 [Epub ahead of print]
Importance: Noninvasive
testing and coronary angiography are used to evaluate patients who present to
the emergency department (ED) with chest pain, but their effects on outcomes
are uncertain.
Objective: To
determine whether cardiovascular testing-noninvasive imaging or coronary
angiography-is associated with changes in the rates of coronary
revascularization or acute myocardial infarction (AMI) admission in patients
who present to the ED with chest pain without initial findings of ischemia.
Design,
Setting, and Participants: This retrospective cohort analysis used weekday
(Monday-Thursday) vs weekend (Friday-Sunday) presentation as an instrument to
adjust for unobserved case-mix variation (selection bias) between 2011 and
2012. National claims data (Truven MarketScan) was used. The data included a
total of 926 633 privately insured patients ages 18 to 64 years who presented
to the ED with chest pain without initial diagnosis consistent with acute
ischemia.
Exposures: Noninvasive
testing or coronary angiography within 2 days or 30 days of presentation.
Main Outcomes
and Measures: The primary end points were coronary revascularization
(percutaneous coronary intervention or coronary artery bypass graft surgery)
and AMI admission at 7, 30, 180, and 365 days. The secondary end points were
coronary angiography and coronary artery bypass grafting in those who underwent
angiography.
Results: The
patients were ages 18 to 64 years with an average age of 44.4 years. A total of
536 197 patients (57.9%) were women. Patients who received testing (224 973)
had increased risk at baseline and had greater risk of AMI admission than those
who did not receive testing (701 660) (0.35% vs 0.14% at 30 days). Weekday
patients (571 988) had similar baseline comorbidities to weekend patients
(354 645) but were more likely to receive testing. After risk factor
adjustment, testing within 30 days was associated with a significant increase
in coronary angiography (36.5 per 1000 patients tested; 95% CI, 21.0-52.0) and
revascularization (22.8 per 1000 patients tested; 95% CI, 10.6-35.0) at 1 year
but no significant change in AMI admissions (7.8 per 1000 patients tested; 95%
CI, -1.4 to 17.0). Testing within 2 days was also associated with a significant
increase in coronary revascularization but no difference in AMI admissions.
Conclusions
and Relevance: Cardiac testing in patients with chest pain was associated with
increased downstream testing and treatment without a reduction in AMI
admissions, suggesting that routine testing may not be warranted. Further
research into whether specific high-risk subgroups benefit from testing is
needed.
Ryan Radecki
comments: “[The study’s] primary value is in the context of the larger body of
evidence. At the least, it suggests we
have equipoise to examine which, if any, patients ought to be referred for
routine follow-up – or whether the role of the ED should be limited to ruling
out an acute coronary syndrome, and the downstream medical ecosystem is the
most appropriate venue for determining further testing when indicated.”
18. Peds Corner
A.
Do All Children Who Present With a Complex Febrile Seizure Need a LP?
Guedj R, et
al. Ann Emerg Med. 2017;70(1):52–62.e6.
STUDY
OBJECTIVE: We assess the prevalences of bacterial meningitis and herpes simplex
virus meningoencephalitis (HSV-ME) in children with a complex febrile seizure
and determine these prevalences in the subgroup of children with a clinical
examination result not suggestive of meningitis or encephalitis.
METHODS: This
multicenter retrospective study was conducted in 7 pediatric emergency
departments (EDs) in the region of Paris, France. Visits of patients aged 6
months to 5 years for a complex febrile seizure from January 2007 to December
2011 were analyzed. We defined a subgroup of patients whose clinical
examination result was not suggestive of meningitis or encephalitis. Bacterial
meningitis and HSV-ME were sequentially sought for by analyzing bacteriologic
and viral data at the visit, looking for data from a second visit to the
hospital after the index visit, and telephoning the child's parents.
RESULTS: From
a total of 1,183,487 visits in the 7 pediatric EDs, 839 patients presented for
a complex febrile seizure, of whom 260 (31.0%) had a lumbar puncture. The
outcomes bacterial meningitis and HSV-ME were ascertainable for 715 (85%) and
657 (78.3%) visits, respectively, and we found 5 cases of bacterial meningitis
(0.7% [95% confidence interval [CI] 0.2% to 1.6%]) and no HSV-ME (0% [95% CI 0%
to 0.6%]). Among the 630 visits of children with a clinical examination result
not suggesting meningitis or encephalitis, we found no bacterial meningitis (0%
[95% CI 0% to 0.7%]) and no HSV-ME (0% [95% CI 0% to 0.8%]).
CONCLUSION:
In children with a complex febrile seizure, bacterial meningitis and HSV-ME are
unexpected events when the clinical examination after complex febrile seizure
is not suggestive of meningitis or encephalitis.
B.
The Importance of Urine Concentration on the Diagnostic Performance of the
Urinalysis for Pediatric UTI
Chaudhari PP,
et al. Ann Emerg Med. 2017;70(1):63–71.e8.
STUDY
OBJECTIVE: The presence of leukocyte esterase by urine dipstick and microscopic
pyuria are both indicators of possible urinary tract infection. The effect of
urine concentration on the diagnostic performance of the urinalysis for pediatric
urinary tract infection has not been studied. Our objective is to determine
whether the urinalysis performance for detecting urinary tract infection varies
by urine concentration as measured by specific gravity.
METHODS: This
was a retrospective cross-sectional study of the urine laboratory results of
children younger than 13 years who presented to the emergency department during
68 months and had a paired urinalysis and urine culture obtained. Urinary tract
infection was defined as pure growth of a uropathogen at standard culture
thresholds. Test characteristics were calculated across 4 specific gravity
groups (1.000 to 1.010, 1.011 to 1.020, 1.021 to 1.030, and over 1.030).
RESULTS: In
total, 14,971 cases were studied. Median age was 1.5 years (interquartile range
0.4 to 5.5 years) and 60% were female patients. Prevalence of urinary tract
infection was 7.7%. For the presence of leukocyte esterase and a range of
pyuria cut points, the positive likelihood ratios decreased with increasing
specific gravity. From most dilute to most concentrated urine, the positive
likelihood ratio decreased from 12.1 (95% confidence interval [CI] 10.7 to
13.7) to 4.2 (95% CI 3.0 to 5.8) and 9.5 (95% CI 8.6 to 10.6) to 5.5 (95% CI
3.3 to 9.1) at a threshold of greater than or equal to 5 WBCs per high-power
field and presence of leukocyte esterase, respectively. The negative likelihood
ratios increased with increasing specific gravity for leukocyte esterase and
microscopic pyuria.
CONCLUSION:
For the detection of pediatric urinary tract infection, the diagnostic
performance of both dipstick leukocyte esterase and microscopic pyuria varies
by urine concentration, and therefore the specific gravity should be considered
when the urinalysis is interpreted.
C.
Where Are the Sick Kids? A Case for Increasing Simulation Training (in
Residency and Beyond)
McGovern T,
et al. Ann Emerg Med 2017;70(1):80-83.
There are
concerns that emergency medicine residents are not sufficiently exposed to
critically ill children during their pediatric emergency medicine rotations.1
In 2007, the Institute of Medicine Committee on the Future of Emergency Care in
the United States Health System expressed concern about a lack of substantial
training in pediatrics among emergency physicians.2 They observed that although
emergency physicians may be competent in caring for the pediatric population,
this competency seems to be gained through experience over time rather than
through formal training.2 In a national survey of 65 emergency medicine
programs in 1999, graduating residents logged an average of 107 adult medical
resuscitations compared with an average of 19 pediatric ones. Similarly, the
average number of adult trauma resuscitations was 74 per graduating resident
compared with only 13 for pediatric patients.3 The authors of this early
investigation into the extent of procedural exposure among emergency medicine
residents observed the need for alternative methods of gaining exposure to
these and other fundamental emergency procedures. Unfortunately, the majority
of existing literature exploring these questions has innate limitations owing
to study design, power, and recency and thus limited generalizability when
considered individually; nevertheless, the pooled information sheds light onto
a potential gap in emergency medicine postgraduate training.
In a national
assessment of 24 million annual pediatric-aged emergency department (ED) visits
in the United States, it was reported that 83% of the physicians providing care
were general emergency physicians.4 When a subgroup analysis of the EDs that
treat more than 10,000 pediatric patients a year was examined, the percentage
of general emergency physicians rendering care was 45%.4 Although the busier
pediatric EDs do have a greater proportion of pediatric emergency physicians
taking care of the children, this accounts for only a fraction of the total
number of children seeking emergency care. The majority of children in the
United States are receiving emergency care in general hospitals instead of
pediatric-specific facilities, and emergency medicine residency graduates must
be comfortable and competent in caring for these children after graduation.4
A thorough
review of pertinent medical literature revealed no current evidence comparing
the clinical outcomes of pediatric patients treated by general EDs and
pediatric EDs; however, data exist in regard to differences in the medical
problems the patients present with and the procedures they undergo. In a
retrospective study of the National Hospital Ambulatory Medical Care Survey
between 1995 and 2002, general EDs treated more injured children, whereas
pediatric EDs treated more with medical problems.5 The number of critical
procedures and resuscitations, such as intubation or cardiopulmonary
resuscitation (CPR), may be as common in general EDs as in pediatric ones.5 A
separate cross-sectional study using data from the 2008 Nationwide Emergency
Department Sample and the Healthcare Cost and Utilization Project compared the
emergency care of medically complex children, defined by having 1 or more
complex chronic medical conditions, in pediatric and general EDs.6 The majority
(79%) of pediatric medically complex children received their care at a general
ED.6 Analysis of available data about ED visits by children demonstrates that,
whether otherwise healthy or medically complex, they will be cared for by
general emergency physicians in general EDs.
Exposure to
critically ill children and the procedures necessary to care for them is
naturally accompanied by various levels of competence and confidence among
emergency medicine residents. Multiple small prospective studies have attempted
to elucidate the effects of various educational interventions on residents’
competence and confidence.7, 8, 9 Surcouf et al7 used an in situ simulation
program in which pediatric residents were tasked with managing an unannounced
neonatal resuscitation in their hospital. After the simulation education, there
were significant increases in both the residents’ confidence and competence
based on pre- and postself-assessments, as well as through an independent
skills observational assessment. Similarly, in a separate study with pediatric
residents undergoing an educational curriculum using mock code scenarios,
residents reported a significant increase in their comfort with and ability to
run a pediatric code one year after the intervention. These residents also
reported a significant decrease in anxiety after the educational intervention.9
Although actual competence was not ascertained, increased confidence and
perception of knowledge may encourage more active participation in critical
patient care when the occasion arises.
The available
data underscore the need for comprehensive and effective pediatric emergency
medicine education during residency. Incorporation of a simulation-based
pediatric emergency medicine curriculum to supplement residents’ clinical
rotations may provide residents with additional exposure, competence, and
confidence in caring for high-triage severity pediatric patients….
D.
Firearm Deaths and Injuries among U.S. Children
Over 90% of
all pediatric firearm-related deaths in high-income countries occur in the
U.S., with approximately 20 U.S. children being killed or injured from gunshot
wounds each day.
Fowler KA et
al. Pediatrics 2017 Jun 19.
OBJECTIVES:
Examine fatal and nonfatal firearm injuries among children aged 0 to 17 in the
United States, including intent, demographic characteristics, trends,
state-level patterns, and circumstances.
METHODS:
Fatal injuries were examined by using data from the National Vital Statistics
System and nonfatal injuries by using data from the National Electronic Injury
Surveillance System. Trends from 2002 to 2014 were tested using joinpoint
regression analyses. Incident characteristics and circumstances were examined
by using data from the National Violent Death Reporting System.
RESULTS:
Nearly 1300 children die and 5790 are treated for gunshot wounds each year.
Boys, older children, and minorities are disproportionately affected. Although
unintentional firearm deaths among children declined from 2002 to 2014 and
firearm homicides declined from 2007 to 2014, firearm suicides decreased
between 2002 and 2007 and then showed a significant upward trend from 2007 to
2014. Rates of firearm homicide among children are higher in many Southern
states and parts of the Midwest relative to other parts of the country. Firearm
suicides are more dispersed across the United States with some of the highest
rates occurring in Western states. Firearm homicides of younger children often
occurred in multivictim events and involved intimate partner or family
conflict; older children more often died in the context of crime and violence.
Firearm suicides were often precipitated by situational and relationship
problems. The shooter playing with a gun was the most common circumstance
surrounding unintentional firearm deaths of both younger and older children.
CONCLUSIONS:
Firearm injuries are an important public health problem, contributing
substantially to premature death and disability of children. Understanding
their nature and impact is a first step toward prevention.
Full-text
(free): http://pediatrics.aappublications.org/content/140/1/e20163486
E.
No Benefit of Nebulized Hypertonic Saline for Acute Bronchiolitis
Nebulized
hypertonic saline did not decrease admission rates or hospital length of stay
compared with normal saline, but it did cause more minor adverse events.
Angoulvant F
et al. Effect of Nebulized Hypertonic Saline Treatment in Emergency Departments
on the Hospitalization Rate for Acute Bronchiolitis. A Randomized Clinical
Trial JAMA Pediatr 2017 Jun 5 [Epub ahead of print]
Key Points
Question What is the effect of treatment with
nebulized hypertonic saline, 3%, vs normal saline, 0.9%, on the admission rate
among infants with acute moderate to severe bronchiolitis in the emergency
department?
Findings In this randomized clinical trial of 777
healthy infants, the hospital admission rate in the hypertonic saline group was
48.1% compared with 52.2% in the normal saline group. Mild adverse events, such
as worsening of cough, occurred more frequently among children in the
hypertonic saline group.
Meaning Nebulized hypertonic saline treatment did not
significantly reduce the hospital admission rate among infants with a first
episode of acute bronchiolitis admitted to the pediatric emergency department.
19. Insurers Begin Denying Payment for “Unnecessary” ED Care
By Jesse
Pines, MD. EP Monthly, July 7, 2017
New coverage
policies by Blue Cross Blue Shield of Georgia and others could bankrupt
patients – or worse.
In May 2017,
Blue Cross Blue Shield (BCBS) of Georgia announced it will no longer cover
“unnecessary” emergency department (ED) care, starting July 1. According to
BCBS Georgia President Jeff Fusile, “…we have got to find a better way to do
some of this stuff, taking some unnecessary spending out of the system.” Fusile
would rather patients use urgent care, retail clinics, and their online app,
instead of costly EDs for conditions treatable in those settings. The BCBS
policy follows similar ones enacted by Anthem in New York, Kentucky, and
Missouri.
To many,
these policies seem well-intentioned for a fiscally responsible insurer in a
country with out-of-control healthcare costs. The simple goal: drive low-acuity
illness to cheaper settings, which will control costs and in turn, allow for
lower premiums.
Insurers are
partly right: inefficient setting selection is a real issue. It is not uncommon
for emergency physicians to face situations where a panicky ED patient realizes
their perceived health emergency was a false alarm. Some well known examples: a
toddler with a fever and listlessness who perks up after a weight-appropriate
dose of ibuprofen; a bout of severe, unrelenting abdominal pain that resolves
spontaneously right after the patient is triaged and passes gas; the allergic
reaction which initially felt like “throat closing” with not even a hive after
some Benadryl.
Some ED
patients could potentially be served elsewhere. Some patients come to the ED
when they didn’t need any medical attention at all. But the reality is there is
no systematic way for patients to reliably and safely determine whether their
symptoms represent an emergency. Many patients are referred to the ED by their
doctors, others have no easy access to physicians, and many do not know about
or think they should use telemedicine during a potential health emergency.
Bottom line,
it is playing with fire for BCBS and Anthem to systematically discourage ED
use. Sometimes, fever and listlessness is meningitis, unrelenting abdominal
pain can be a bursting appendix, and allergic reactions occasionally result in
life-threatening anaphylaxis. All are potentially lethal if untreated.
Insurers’ new ED deterrent policies create a new, unfair responsibility for
patients: self-diagnose accurately, or else. Patients choosing incorrectly face
steep financial penalties after seeking care in settings deemed “non-ideal,” decided
after the fact by their insurer using their final diagnosis…
The remainder
of the essay: http://epmonthly.com/article/insurers-begin-denying-payment-unnecessary-ed-care/
20. Adenosine induced VF in a structurally normal heart: a case
report.
Rajkumar CA,
et al. J Med Case Rep. 2017 Jan 22;11(1):21.
BACKGROUND: Adenosine
is the first-line pharmacotherapy for termination of supraventricular
tachycardia through its action on the atrioventricular node. However,
pro-arrhythmic effects of adenosine are also recognised, most notably in the
presence of pre-excited atrial fibrillation. In this case report, we describe
the induction of ventricular fibrillation in a patient with no demonstrable
accessory pathway, nor any other structural heart disease. This rare, idiosyncratic
reaction has never previously been reported and is of relevance given the
widespread and routine use of adenosine in clinical practice.
CASE
PRESENTATION: A 26-year-old woman of Cypriot origin presented to our emergency
department with a sudden onset of palpitations and chest discomfort. She was
healthy, with no previous medical history and no regular medications. An
electrocardiogram demonstrated a narrow complex tachycardia with a rate of 194
beats per minute. Following failure of vagal maneuvers to terminate the
tachycardia, the assessing physician administered a single intravenous dose of
6 mg adenosine. Our patient instantaneously developed coarse ventricular
fibrillation and circulatory collapse. Cardiopulmonary resuscitation was initiated
and our patient was rapidly defibrillated to sinus rhythm with a single 150 J
direct current shock. A 900-mg loading dose of intravenous amiodarone was
commenced and our patient was managed in the cardiac high dependency unit. No
further arrhythmias were identified on continuous cardiac monitoring. On
review, her presenting electrocardiogram had demonstrated rapidly conducted
atrial fibrillation with no evidence of ventricular pre-excitation.
Concordantly, her resting electrocardiogram was not suggestive of any accessory
pathway. This was conclusively excluded on invasive electrophysiology study,
with negative programmed ventricular stimulation up to three extrastimuli.
Extensive laboratory investigations were unremarkable and failed to identify an
underlying cause for her episode of atrial fibrillation. Furthermore, cardiac
magnetic resonance imaging demonstrated a structurally normal heart, with no
edema, fibrosis or infarction as well as normal coronary artery anatomy.
CONCLUSIONS: Adenosine
remains a safe and highly efficacious therapy for supraventricular tachycardia.
However, this unusual case demonstrates the ability of adenosine to induce
circulatory collapse and reminds the clinician that prompt access to
resuscitation, defibrillation, and transcutaneous pacing equipment is mandatory
with every administration of this drug.
21. Cluster-Randomized, Crossover Trial of Head Positioning in
Acute Stroke
Anderson CS,
et al. N Engl J Med 2017; 376:2437-2447.
Background
The role of
supine positioning after acute stroke in improving cerebral blood flow and the
countervailing risk of aspiration pneumonia have led to variation in head
positioning in clinical practice. We wanted to determine whether outcomes in
patients with acute ischemic stroke could be improved by positioning the
patient to be lying flat (i.e., fully supine with the back horizontal and the
face upwards) during treatment to increase cerebral perfusion.
Methods
In a
pragmatic, cluster-randomized, crossover trial conducted in nine countries, we
assigned 11,093 patients with acute stroke (85% of the strokes were ischemic)
to receive care in either a lying-flat position or a sitting-up position with
the head elevated to at least 30 degrees, according to the randomization
assignment of the hospital to which they were admitted; the designated position
was initiated soon after hospital admission and was maintained for 24 hours.
The primary outcome was degree of disability at 90 days, as assessed with the
use of the modified Rankin scale (scores range from 0 to 6, with higher scores
indicating greater disability and a score of 6 indicating death).
Results
The median
interval between the onset of stroke symptoms and the initiation of the
assigned position was 14 hours (interquartile range, 5 to 35). Patients in the
lying-flat group were less likely than patients in the sitting-up group to
maintain the position for 24 hours (87% vs. 95%, P less than 0.001). In a
proportional-odds model, there was no significant shift in the distribution of
90-day disability outcomes on the global modified Rankin scale between patients
in the lying-flat group and patients in the sitting-up group (unadjusted odds
ratio for a difference in the distribution of scores on the modified Rankin
scale in the lying-flat group, 1.01; 95% confidence interval, 0.92 to 1.10;
P=0.84). Mortality within 90 days was 7.3% among the patients in the lying-flat
group and 7.4% among the patients in the sitting-up group (P=0.83). There were
no significant between-group differences in the rates of serious adverse
events, including pneumonia.
Conclusions
Disability
outcomes after acute stroke did not differ significantly between patients
assigned to a lying-flat position for 24 hours and patients assigned to a
sitting-up position with the head elevated to at least 30 degrees for 24 hours.
22. Micro Bits
A. Why Curious People Have Better
Relationships: Research suggests that being curious might be a social glue that
strengthens our relationships.
BY Jill
Suttie, Greater Good Science Center, May 31, 2017
There’s an
old saying: “Curiosity killed the cat.” It implies curiosity is bad for you and
leads to dangerous risk-taking behavior. But this idea of curiosity is pretty
outdated—in humans, at least.
Curiosity—the
desire to approach novel and challenging ideas and experiences in order to
increase one’s knowledge—has long been associated with intellectual pursuit,
engagement with the world, memory, and learning. Now, more recent research
suggests that curiosity may also play a role in our social relationships.
Studies have
found that people who are curious are often viewed in social encounters as more
interesting and engaging, and they are more apt to reach out to a wider variety
of people. In addition, being curious seems to protect people from negative
social experiences, like rejection, which could lead to better connection with
others over time.
Here are some
of the ways science suggests that curiosity can improve our relationships…
Full-text
here: https://greatergood.berkeley.edu/article/item/why_curious_people_have_better_relationships
B. CDC data show C. diff infection
rates are falling after steady increase
Preliminary
analysis of data from the CDC's Emerging Infections Program showed that the
rate of new Clostridium difficile infections in hospitals and nursing homes
nationwide declined by 9% to 15% from 2011 to 2014, suggesting revised
antibiotic use guidelines and more aggressive cleaning standards are working.
C. difficile infection rates climbed annually from 2000 to 2010, and in 2011
caused almost 500,000 illnesses and killed about 29,000 people in the US.
C. Give a voice to the voiceless
Abbasi K. BMJ
2017;357:j2996
Rudolf
Virchow’s investigation of a typhus epidemic in 1848 identified a root cause: “The
power of the aristocracy, propped up by the church.” Big business is today’s
aristocracy, politicians and the state today’s church. In society’s pursuit of
wealth and profit, it is poor people who carry the greatest burden of disease,
whose deaths are most likely when fire engulfs a tower block, the levees break
in New Orleans, or a Titanic sinks.
After last
week’s fire in London’s Grenfell Tower Martin McKee recalls Virchow to urge us
not to ignore the political and commercial determinants of public health
(doi:10.1136/bmj.j2966). Inadequate safety measures, despite warnings from
residents, contributed to and probably caused 79 people to be dead or missing.
This was a political failure leading to avoidable deaths and, says McKee, “it
is impossible to achieve a comprehensive understanding of events such as
Grenfell Tower without confronting the political determinants of health and
challenging the forces that shape them.”
D. Maybe exercise doesn’t forestall
cognitive decline.
Conclusion:
This study found no evidence of a neuroprotective effect of physical activity.
Previous findings showing a lower risk of dementia in physically active people
may be attributable to reverse causation—that is, due to a decline in physical
activity levels in the preclinical phase of dementia.
E. Bundled-care models can improve
quality, revenue
Expanded use
of bundled reimbursement models in health care could improve quality and reduce
Medicare spending while boosting revenue for hospitals and health care
providers, according to a report in the Journal of the American Medical
Association. Bundles offer a bridge to full value-based care participation, and
health care organizations can participate in several clinically distinct
bundles simultaneously, according to the report.
F. Lags in implementation of primary
prevention interventions behind unnecessary deaths
The US is
slow to implement primary prevention interventions that have been proven to be
efficacious. In a review of meta-analytic literature on primary prevention
interventions published between January 2000 and March 2014, the authors
estimated the number of US deaths that could have been averted in 2010 if all
rigorously studied, efficacious primary prevention interventions were
implemented nationwide. They estimated that of all US deaths in 2010, 15.1%, or
372,054, would have been averted, two-thirds of which would have been from
cardiovascular disease or malignancy.
G. Gwyneth Paltrow Wants To Heal You
With Magic Stickers
Steven
Salzberg, Forbes, June 26, 2017
Gwyneth
Paltrow has invented stickers that promote healing. Yes, stickers. Little
circular stick-on thingies that you might give to your first-grader as a reward
for doing her homework.
Gwyneth,
though, has discovered something much deeper about stickers. If you make them
with just the right materials, and then stick them on your body in the right
places, they "rebalance the energy frequency in our bodies."
(A quick
warning: if you follow the links in this article, put down your coffee first.
You might laugh so hard that you'll spill it all over yourself.)
Until a day
or two ago, Gwyneth Paltrow's Goop website–a "lifestyle" business
that sells all things Gwyneth–advertised these stickers as using "NASA
space suit material," which presumably was the source of their magic
healing properties. Then Gizmodo called someone at NASA to check out this
claim, and got a very clear answer….
H. The Relationship of Health
Insurance and Mortality: Is Lack of Insurance Deadly?
Woolhandler
S, et al. Ann Intern Med. 2017 June 27 [Epub ahead of print]
About 28
million Americans are currently uninsured, and millions more could lose
coverage under policy reforms proposed in Congress. At the same time, a growing
number of policy leaders have called for going beyond the Affordable Care Act
to a single-payer national health insurance system that would cover every
American. These policy debates lend particular salience to studies evaluating
the health effects of insurance coverage. In 2002, an Institute of Medicine
review concluded that lack of insurance increases mortality, but several
relevant studies have appeared since that time. This article summarizes current
evidence concerning the relationship of insurance and mortality. The evidence
strengthens confidence in the Institute of Medicine's conclusion that health
insurance saves lives: The odds of dying among the insured relative to the
uninsured is 0.71 to 0.97.
Full-text
(free): http://annals.org/aim/article/2635326/relationship-health-insurance-mortality-lack-insurance-deadly
See also How
Losing Health Insurance Affects Happiness
I. USPSTF Final Recommendation:
Evidence Supports Screening Children, Teens for Obesity
Chris
Crawford – On June 20, the U.S. Preventive Services Task Force (USPSTF)
published a final recommendation statement (www.uspreventiveservicestaskforce.org) and evidence summary (www.uspreventiveservicestaskforce.org) on screening children and teens for
obesity. Based on its evidence review, the USPSTF recommended obesity screening
for children and adolescents ages 6-18 and also recommended offering or
referring patients who are diagnosed with obesity to comprehensive, intensive
behavioral interventions to promote improved weight status. This is a
"B" recommendation. According to the task force, such comprehensive,
intensive interventions
- involve at least 26 patient contact hours;
- may include sessions that target both the child and his or her parents;
- provide information on healthy eating and safe exercise;
- may entail discussions about using stimulus control, such as limiting access to tempting foods and screen time; and
- incorporate supervised physical activity.
J. An Ancient Cure for Alzheimer’s?
Pagan
Kennedy. NY Times. July 14, 2017
Excerpt
Years ago,
while reporting a story about the Harvard Brain Tissue Resource Center, I had a
chance to peer through a microscope at a slice of brain collected from a
patient who’d died of Alzheimer’s disease. The tissue was pocked with amyloid
plaques that resembled black clouds. I also spied the tau tangles that look
like hair clogging a drain and are characteristic of Alzheimer’s pathology.
For decades,
most researchers have agreed that these plaques and tangles are the key
malefactors of dementia, and that if you could clear them from the brains of
patients, you would halt or reverse illness. Researchers have been especially
focused on finding a drug that could erase amyloid plaques, and we now have
dozens of compounds that do that in mice.
But this
approach has led to failure in humans. Even when drugs can clear the plaques in
patients’ brains, the disease continues to wreak damage.
Now some
scientists believe that the focus on amyloid plaques might have been a mistake.
Instead of looking at what goes wrong, they’re trying to understand what goes
right….
K. Association Between Contemporary
Trends in Inferior Vena Cava Filter Placement and the 2010 US Food and Drug
Administration Advisory
The effectiveness
of inferior vena cava filter (IVCF) insertion in reducing venous
thromboembolism (VTE)-associated morbidity and mortality is uncertain.1
Nevertheless, IVCF placement rates in the United States have been rapidly
increasing and are 25-fold higher than in Europe.1 Prompted by the report by
Nicholson et al2 in this journal of high prevalence of fracture and
embolization, with potentially life-threatening sequelae of the Bard Recovery
and Bard G2 IVC filters, the US Food and Drug Administration (FDA) issued a
device safety warning on August 9, 2010, after reviewing 921 adverse events
(ie, device migration, fracture, thrombosis) reported over a 5-year period.3 We
sought to assess the nationwide utilization rates of IVCF placement in the
United States and the impact of this FDA advisory. We also evaluated
VTE-related hospitalization rates during the same period to determine whether
any change in IVCF utilization could be accounted for by changes in VTE-related
hospitalizations.
L. CPAP for CV Prevention?
Treatment
with positive airway pressure -- continuous (CPAP) or adaptive
servo-ventilation -- does not prevent major cardiovascular adverse events or
related deaths, according to a meta-analysis of 10 randomized controlled trials
in the Journal of the American Medical Association.
The
researchers concluded "that the association of sleep apnea with vascular
outcomes and death seen in observational studies may represent disease
processes that cannot be ameliorated by PAP delivered at the average intensity
achieved in these clinical trials or currently feasible in clinical practice."
M. Tramadol helps reduce opioid
withdrawal symptoms, study says
A Johns
Hopkins University study found extended-release tramadol was better than
clonidine and similar to buprenorphine in reducing opioid withdrawal symptoms.
The study was published in JAMA Psychiatry.
N. Childhood intelligence in relation
to major causes of death in 68 year follow-up: prospective population study
O. FDA approves first drug to
specifically treat giant cell arteritis
P. Association of Gastric Acid
Suppression With Recurrent Clostridium difficile Infection
Question Does concomitant use of gastric acid
suppressant medications (proton pump inhibitors and histamine H2 receptor
blockers) increase the risk of recurrent Clostridium difficile infection?
Findings In this meta-analysis of 16 studies
comprising 7703 patients, the use of gastric acid suppressants was associated
with a significantly increased risk of recurrent C difficile infection.
Subgroup analyses of studies with potential confounders also confirmed an
increased risk of recurrent C difficile infection with use of these
medications.
Meaning It may be reasonable to stop gastric acid
suppressants in patients with C difficile infection; limiting unnecessary use
of these medications may help to decrease both recurrent C difficile infection
and health care costs.
Q. Coffee Consumption Associated with Lower
Total and Cause-Specific Mortality Among Nonwhite Populations
What are the
implications of the studies?
Although
drinking coffee cannot be recommended as being good for your health on the
basis of these kinds of studies, the studies do suggest that for many people,
no long-term harm will result from drinking coffee.
Drink up!
Abstract: https://www.ncbi.nlm.nih.gov/pubmed/28693036
Abstract: https://www.ncbi.nlm.nih.gov/pubmed/28693036
R. More People are Lighting Up on
Silver Screen: Tobacco use increased in PG-13 movies, reversing earlier decline
S. Threat of Untreatable Gonorrhea
Real, Growing
T. PPI use increases mortality
