Monday, July 17, 2017

Lit Bits: July 17, 2017

From the recent medical literature...

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].

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.

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 number, NCT02104947.).

Ryan Radekci’s critique:

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.

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…”

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.

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.

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…

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%....

…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.


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:

And if you prefer the video:

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….

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):

Select References
2. The Talan article abstract (previously posted on Lit Bits):

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.

Pediatric appendicitis is a common, potentially serious condition. Determining perforation status is crucial to planning effective management.

Determine the efficacy of serum total bilirubin concentration [STBC] in distinguishing perforation status in children with appendicitis.

Retrospective review of 257 cases of appendicitis who received abdominal CT scan and measurement of STBC.

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.

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].

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.

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).

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.

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]

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.

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.;
 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.; 2013 Accessed March 25, 2017.

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.

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…

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…”

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…

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.

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…

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.

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.

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).

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.

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…

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.

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 ( and evidence summary ( 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

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.

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