1. Acute HF in the ED: Door-to-Furosemide Time Matters
Megan Brooks. Medscape. July 07, 2017
CIBA, JAPAN — For acute heart failure (HF) patients arriving
in the emergency department (ED), administration of intravenous (IV) furosemide
within 1 hour is independently associated with lower in-hospital mortality,
according to results of the observational REALITY-AHF study[1].
Yet only about a third of these patients are treated within
the first hour, the study found. "That was the most surprising finding for
us, because we assumed that we are doing much better," Dr Yuya Matsue
(Kameda Medical Center, Ciba, Japan) told theheart.org|Medscape Cardiology.
"We don't know exactly what causes this delay, but our
results are suggesting that we are treating very obvious AHF quickly, but when
the diagnosis is not clear from their symptoms, we are taking our time even
though such patients could be at high risk," added Matsue.
The emergency department is a "major stage" for
hospitalized patients with acute HF, Matsue and colleagues point out in their
report, published June 27, 2017 in the Journal of the American College of
Cardiology. More than one million ED visits annually in the US involve acute
HF, and most result in hospital admission.
"The importance of the emergency-department phase in
managing AHF has become increasingly apparent as recent post hoc studies have
highlighted that although patient characteristics are important, the efficacy
of any intervention/treatment may be time dependent," they write. Recent
HF guidelines and recommendations also emphasize the importance of immediate
diagnosis and treatment of patients presenting with acute HF….
Matsue
Y, et al. Treatment and Mortality in Patients Hospitalized with Acute Heart Failure
JACC
2017;69:3042-51.
Background Acute heart failure (AHF) is a life-threatening disease
requiring urgent treatment, including a recommendation for immediate initiation
of loop diuretics.
Objectives The authors prospectively evaluated the association
between time-to-diuretic treatment and clinical outcome.
Methods REALITY-AHF (Registry Focused on Very Early Presentation
and Treatment in Emergency Department of Acute Heart Failure) was a
prospective, multicenter, observational cohort study that primarily aimed to
assess the association between time to loop diuretic treatment and clinical
outcome in patients with AHF admitted through the emergency department (ED).
Door-to-furosemide (D2F) time was defined as the time from patient arrival at
the ED to the first intravenous furosemide injection. Patients with a D2F
time less than 60 min were pre-defined as the early treatment group.
Primary outcome was all-cause in-hospital mortality.
Results Among 1,291 AHF patients treated with intravenous
furosemide within 24 h of ED arrival, the median D2F time was 90 min (IQR: 36
to 186 min), and 481 patients (37.3%) were categorized as the early treatment
group. These patients were more likely to arrive by ambulance and had more
signs of congestion compared with the nonearly treatment group. In-hospital
mortality was significantly lower in the early treatment group (2.3% vs. 6.0%
in the nonearly treatment group; p = 0.002). In multivariate analysis,
earlier treatment remained significantly associated with lower in-hospital
mortality (odds ratio: 0.39; 95% confidence interval: 0.20 to 0.76; p =
0.006).
Conclusions In this prospective multicenter, observational cohort
study of patients presenting at the ED for AHF, early treatment with
intravenous loop diuretics was associated with lower in-hospital mortality.
2. Angiotensin II for the Treatment of Vasodilatory Shock.
Khanna A, et al. N Engl J Med. 2017 Aug 3;377(5):419-430.
BACKGROUND: Vasodilatory shock that does not respond to
high-dose vasopressors is associated with high mortality. We investigated the
effectiveness of angiotensin II for the treatment of patients with this
condition.
METHODS: We randomly assigned patients with vasodilatory
shock who were receiving more than 0.2 μg of norepinephrine per kilogram of body
weight per minute or the equivalent dose of another vasopressor to receive
infusions of either angiotensin II or placebo. The primary end point was a
response with respect to mean arterial pressure at hour 3 after the start of
infusion, with response defined as an increase from baseline of at least 10 mm
Hg or an increase to at least 75 mm Hg, without an increase in the dose of
background vasopressors.
RESULTS: A total of 344 patients were assigned to one of the
two regimens; 321 received a study intervention (163 received angiotensin II,
and 158 received placebo) and were included in the analysis. The primary end
point was reached by more patients in the angiotensin II group (114 of 163
patients, 69.9%) than in the placebo group (37 of 158 patients, 23.4%) (odds
ratio, 7.95; 95% confidence interval [CI], 4.76 to 13.3; P less than 0.001). At
48 hours, the mean improvement in the cardiovascular Sequential Organ Failure
Assessment (SOFA) score (scores range from 0 to 4, with higher scores
indicating more severe dysfunction) was greater in the angiotensin II group
than in the placebo group (-1.75 vs. -1.28, P=0.01). Serious adverse events
were reported in 60.7% of the patients in the angiotensin II group and in 67.1%
in the placebo group. Death by day 28 occurred in 75 of 163 patients (46%) in
the angiotensin II group and in 85 of 158 patients (54%) in the placebo group
(hazard ratio, 0.78; 95% CI, 0.57 to 1.07; P=0.12).
CONCLUSIONS: Angiotensin II effectively increased blood
pressure in patients with vasodilatory shock that did not respond to high doses
of conventional vasopressors.
3. New or additional antiplatelet may be needed after TIA,
stroke
Patients who have had a transient ischemic attack or stroke
while taking aspirin may reduce their risk of future cardiovascular events or
recurrent stroke by adding another antiplatelet medication to preventive
therapy or switching to a new one, according to an analysis of studies in
Stroke. Making the change within days of the initial TIA or stroke was
associated with the best results.
Lee M, et al. Antiplatelet Regimen for Patients With
Breakthrough Strokes While on Aspirin
A Systematic Review and Meta-Analysis. Stroke. 2017 July 12
[Epub ahead of print]
Background and Purpose—Optimal antiplatelet therapy after an
ischemic stroke or transient ischemic attack while on aspirin is uncertain. We,
therefore, conducted a systematic review and meta-analysis.
Methods—We searched PubMed (1966 to August 2016) and
bibliographies of relevant published original studies to identify randomized
trials and cohort studies reporting patients who were on aspirin at the time of
an index ischemic stroke or transient ischemic attack and reported hazard ratio
for major adverse cardiovascular events or recurrent stroke associated with a
switch to or addition of another antiplatelet agent versus maintaining aspirin
monotherapy. Estimates were combined using a random effects model.
Results—Five studies with 8723 patients with ischemic stroke
or transient ischemic attack were identified. Clopidogrel was used in 4
cohorts, and ticagrelor was used in 1 cohort. Pooling results showed that
addition of or a switch to another antiplatelet agent, versus aspirin
monotherapy, was associated with reduced risks of major adverse cardiovascular
events (hazard ratio, 0.68; 95% confidence interval, 0.54–0.85) and recurrent
stroke (hazard ratio, 0.70; 95% confidence interval, 0.54–0.92). Each of the
strategies of addition of and switching another antiplatelet agent showed
benefit versus continued aspirin monotherapy, and studies with regimen
initiation in the first days after index event showed more homogenous evidence
of benefit.
Conclusions—Among patients who experience an ischemic stroke
or transient ischemic attack while on aspirin monotherapy, the addition of or a
switch to another antiplatelet agent, especially in the first days after index
event, is associated with fewer future vascular events, including stroke.
4. Falling Back in Love with Emergency Medicine
Austin AL. Ann Emerg Med. 2017;70:255-6.
“The most empathetic you’ll ever be is today,” said a weary
surgical resident to me on my first day of medical school clerkships. I
internally scoffed at the callousness of his statement. This was surely the
greatest job in the world and he would not squash my exuberance to see
patients.
During internship, I was enchanted by emergency medicine. I
was head over heels in love with the specialty. As a mentor once described
emergency medicine, “You’re the doctor that steps up on the plane.” Whether
it’s a newborn with a fever or an octogenarian with chest pain, we respond. Of
course, I was drawn to the harrowing cases, but I reveled in the mundane. I
loved that we accepted everyone at any hour and day of the week.
Then a strange thing started to happen. When I was a second-year
resident, the love was lost. I didn’t like my job; and most startling, I didn’t
like my patients. I found myself sitting at my desk a little longer, often
dreading going into a room. Once in the room, I immediately began to dread the
upcoming presentation to the attending, and worse, the notes. I hated the
notes. The seemingly minor complaint began to annoy me. “Really? They think
this is an emergency?”
Although we’re fairly sheltered as residents, I began to see
some of the challenges of emergency medicine. We are increasingly expected to
be faster, more accurate, and do it less expensively. And document; get every
cent of reimbursement possible for our groups and hospitals. Don’t forget
patient satisfaction. Oh, and the opioid epidemic: Make sure your patient is
100% satisfied, but don’t create more opioid addicts. Malpractice scared me.
All of these troubles weighed on me during a shift. I smiled and put up a good
front, but I was seriously questioning my choice of specialty and the field of medicine
in general.
I am fortunate that I attended a residency that is very
attuned to physician wellness and burnout. We completed burnout surveys every 6
months. We talked about self-care. If you ask any of my friends or family, I’m
the queen of spa days and relaxation. Days off, spas, epic vacations weren’t
filling me up. I didn’t like how I felt about my job or patients, and these
negative feelings compounded the problem. I felt guilty. I was still that eager
third-year medical student trapped in an older, somewhat embittered body.
I’m back in LOVE with emergency medicine. It took a period
of reconciliation and some new rules. I stayed with emergency medicine, but I’m
worried there’re a lot of good physicians suffering from work dysphoria, a term
I did not understand until after I had already developed a strategy.1 Schmitz
et al1 make a compelling case for a comprehensive wellness program, and
certainly we must do more to retain and enrich our emergency medicine careers.
Although each individual’s stressors and coping mechanisms differ, below are
the top 5 strategies that have positively affected my shifts.
1.
Stop complaining about patients. Emergency medicine takes all people at
all times; we will treat a hangnail at 3 am. Quibbling over the “why” is exhausting.
The patient is there and a negative attitude colors the interaction with the
patients and staff. If it is a minor complaint, I embrace the “easy” chart, and
look for a way to make it an awesome, quick, and maybe even pleasant visit for
the patient. My patients are happier, and sure enough, I am too.
2.
Embrace the interruptions. We’re all used to a lot of
interruptions in emergency medicine. There are certain shifts when the
intrusions grate on me. Although we are not immune to disruptions at the
bedside, there is some sanctity behind the curtain or door. This patient
interaction becomes a momentary solace among the chaos, one in which I may get
to know and help one of my fellow human beings.
3.
Recognize medicolegal risk but don’t allow it to paralyze.
This is someone’s mom, dad, daughter, son who came to me for help. I may get
sued. This will be terrible, painful, and challenging. Good physicians are sued
and bad physicians may go their entire career without a lawsuit. Yet lawsuits
are infrequent. I care about my patients and I love this profession. I educate
myself on medicolegal topics because knowing the high-risk chief complaints and
case features, along with the strategies to provide good care and document
appropriately, help me feel like I can mitigate a lot of the risk. I do my best
to do right by my patients and document accordingly. This has to be enough; the
alternative is that we drive ourselves crazy and demonize our patients.
4.
No more charting in the room. I dislike charting, and thus I refuse
to combine it with my patient interactions. I truly believe the electronic
medical record has created huge chasms in our patient interactions. I strive to
give the patient my undivided attention. I fully understand and, albeit rarely,
have experience with medical providers who don’t let the computer overtake the
patient-physician interaction; but I haven’t found a way to combine the two
effectively.
5.
Forget perfection. I haven’t had a perfect ED shift. I
don’t think I ever will. There’s always something that could go better: an
interaction with a patient, colleague, or staff member, a quicker diagnosis, a
smoother procedure, better documentation, you name it. The list is endless. As
another one of my mentors often says, this is a practice. That really annoys
me. I want perfection; I believe my patients deserve perfection, but this is
not truly attainable. I strive for the best emergency care and experience for
all my patients and colleagues, but the ED is a rough-and-tumble place. We must
remain humble, open to feedback, and resilient. Bad interactions, depleting
shifts, and stressful procedures come with the territory. Positive self-talk is
a learned behavior. Most of us learned the model of “you suck,” ie, be your
toughest critic. Self-love, care, and kindness should at least equal our
critiques, and we are seldom capable of a fair self-critique in the heat of an
ED shift.
Third year of medical school was 7 years ago. I can honestly
say that I am more empathetic now. Empathy is the ability to share another’s
emotions and experience. The more patients we see, the more we are truly
present and connect with our patients, thus deepening our capacity for empathy.
Although I fully support the movement for physician wellness, I believe the
missing key is a real discussion about empathy. The greatest burnout I’ve
experienced is during periods of depersonalization and the intense guilt I felt
for these feelings. Our capacity for empathy is lessened with fatigue and
stress, but empathy can be the salve on our professional souls. Sometimes when
I’m most tired on a shift, taking a break, biting into a piece of chocolate
doesn’t really help. Rather, sitting down with another patient, turning down
the surrounding chaos, and opening myself to that most special
patient-physician bond does a soul good.
5. Bronchiolitis with Hypoxia? Order Oxygen to Go
ED-initiated Home Oxygen for Bronchiolitis: A Prospective
Study of Community Follow-up, Caregiver Satisfaction, and Outcomes.
Freeman JF, et al. Acad Emerg Med. 2017 Aug;24(8):920-929.
OBJECTIVE: Retrospective studies have shown home oxygen to
be a safe alternative to hospitalization for some patients with bronchiolitis
living at high altitudes. We aimed to prospectively describe adverse events,
follow-up, duration of home oxygen, factors associated with failure, and
caregiver preferences.
METHODS: This was a prospective observational study of
hypoxemic bronchiolitis patients ages 3 to 18 months who were discharged from a
tertiary care pediatric emergency department on home oxygen over three winters
(2011-2014). Caregivers were contacted on postdischarge days ~3, 7, 14, and 28
while on oxygen. Caregivers not reached by phone were sent a survey and their
primary care physicians were contacted. Records of admitted subjects were
reviewed. Outcome measures included hospital readmission, positive pressure ventilation
(noninvasive or intubation), outpatient follow-up, duration of home oxygen
therapy, and caregiver satisfaction.
RESULTS: A total of 274 patients were enrolled. Forty-eight
(17.5%) were admitted and 225 (82.1%) were discharged on oxygen. The median age
was 8 months. Eighteen subjects were lost to follow-up. A total of 196 (87.1%)
were successfully treated with outpatient oxygen, and 11 (4.9%) failed
outpatient therapy and were hospitalized. Only one hospitalized patient
required invasive ventilation. The median duration of home oxygen was 7 days.
Child noncompliance was the most common problem (reported by 14%). The median
caregiver comfort level with home oxygen was 9 of 10. Eighty-eight percent of
caregivers would again choose home oxygen over admission.
CONCLUSIONS: This study confirms that outpatient oxygen
therapy can reduce hospitalizations due to bronchiolitis in a relatively
high-altitude setting, with low failure and complication rates. Caregivers are
comfortable with home oxygen and prefer it to hospitalization.
6. Ketamine Corner
A. A prospective randomized, double-dummy
trial comparing IV push low-dose ketamine to short infusion of low-dose
ketamine for treatment of pain in the ED
Motov S, et al. Amer J Emerg Med. 2017;35:1095-1100.
STUDY OBJECTIVE: Compare adverse effects and analgesic
efficacy of low-dose ketamine for acute pain in the ED administered either by
single intravenous push (IVP) or short infusion (SI).
METHODS: Patients 18-65, presenting to ED with acute
abdominal, flank, or musculoskeletal pain with initial pain score≥5, were
randomized to ketamine 0.3mg/kg by either IVP or SI with placebo double-dummy.
Adverse effects were evaluated by Side Effects Rating Scale for Dissociative
Anesthetics (SERSDA) and Richmond Agitation-Sedation Scale (RASS) at 5, 15, 30,
60, 90, and 120min post-administration; analgesic efficacy was evaluated by
Numerical Rating Scale (NRS).
RESULTS: 48 patients enrolled in the study. IVP group had
higher overall rates of feeling of unreality on SERSDA scale: 92% versus 54%
(difference 37.5%; p=0.008; 95% CI 9.3-59.5%). At 5min median severity of
feeling of unreality was 3.0 for IVP versus 0.0 for SI (p=0.001). IVP also
showed greater rates of sedation on RASS scale at 5min: median RASS -2.0 versus
0.0 (p=0.01). Decrease in mean pain scores from baseline to 15min was similar
across groups: 5.2±3.53 (95% CI 3.7-6.7) for IVP; 5.75±3.48 (95% CI 4.3-7.2)
for SI. There were no statistically significant differences with respect to
changes in vital signs and need for rescue medication.
CONCLUSION: Low-dose ketamine given as a short infusion is
associated with significantly lower rates of feeling of unreality and sedation
with no difference in analgesic efficacy in comparison to intravenous push.
Definitions:
The push dose was given over 5 minutes
The short infusion was mixed in 100 mL 0.9% sodium chloride and
was given over 15 minutes
B. Medically Clear: Get from Agitation
to ‘oK’ Faster with Special K
Ballard DW, et al. Emerg Med News. 2017:39(8):7.
The call from EMS was for a psychotic patient who was
ripping the siding off a neighbor's house with his bare hands. The medic who
gave the report sounded distracted and a bit frightened. No response to
intranasal midazolam, he said. They arrive, and you're immediately a bit
frightened too.
The patient is built like an All-American linebacker, and
his rippling musculature barely fits on the gurney. He is handcuffed and
restrained on a backboard that bends with each of his freedom-seeking abdominal
crunches. Blood trickles from his wrists, and you hear crunching from his
mouth. He is actually cracking his own teeth, and attempting to spit them
against his facemask. A few pockets of foam bubble out above his philtrum.
You note the diameter and superficiality of his mid-arm
veins, wishing for access to an IV dart device, each vessel a prime target from
across the room. Alas, sedation will start with the standard approach—a B52 of
intramuscular haloperidol 5 mg/lorazepam 2 mg. The backboard is really creaking
now. Could it actually snap? Boom, the B52 has landed. Minutes pass, the
contorting, spitting, crunching, and grunting continue. It's just a matter of
time before this patient seriously hurts himself or someone else. What next?
We've all had patients like this, but we'd like to thank our
colleague Jason Nau, MD, for sharing this particular story. Like Dr. Nau, we
would consider more Haldol and Ativan, droperidol, or RSI. There is no
consensus on the best approach yet, but perhaps an old therapy is the key to
safe sedation for the profoundly agitated…
The rest of the essay (free): http://journals.lww.com/em-news/Fulltext/2017/08000/Medically_Clear__Get_from_Agitation_to__oK__Faster.6.aspx
C. Ketamine or Ketofol: Do we have
enough evidence to know which one to use?
Miner J. Acad Emerg Med. 2017 Aug 12 [Epub ahead of print].
Ketamine and propofol are both commonly used emergency
department (ED) procedural sedation agents. Their concurrent administration,
often referred to as "ketofol", is widely used for procedural
sedation. A simple google search can lead to a lot of opinions on why we should
use propofol, ketamine, or ketofol in a given situation for moderate or deep
procedural sedation in the ED, but finding evidence that supports differences
these opinions assume is much harder to come by.
Full-text (requires subscription): http://onlinelibrary.wiley.com/doi/10.1111/acem.13276/abstract
7. Haloperidol undermining gastroparesis symptoms (HUGS) in the ED
Ramirez R, et al. Am J Emerg Med. 2017 Aug;35(8):1118-1120.
BACKGROUND: Gastroparesis associated nausea, vomiting &
abdominal pain (GP N/V/AP) are common presentations to the emergency department
(ED). Treatment is often limited to antiemetic, prokinetic, opioid, &
nonopioid agents. Haloperidol (HP) has been shown to have analgesic &
antiemetic properties. We sought to evaluate HP in the ED as an alternative
treatment of GP N/V/AP.
METHODS: Using an electronic medical record, 52 patients who
presented to the ED w/GP N/V/AP secondary to diabetes mellitus and were treated
w/HP were identified. Patients who received HP were compared to themselves
w/the most recent previous encounter in which HP was not administered. ED
length of stay (LOS), additional antiemetics/prokinetics administered, hospital
LOS, and morphine equivalent doses of analgesia (ME) from each visit were
recorded. Descriptive statistics, categorical (Chi Square Test or Z-Test for
proportion) and continuous (Wilcoxon Signed Rank Test) comparisons were
calculated. Statistical significance was considered for two tail p-values less
than 0.05.
RESULTS: A statistically significant reduction in ME (Median
6.75 [IQR 7.93] v 10.75 [IQR12]: p=0.001) and reduced admissions for GP (5/52 v
14/52: p=0.02) when HP was administered was observed. There were no
statistically significant differences in ED or hospital LOS, and additional
antiemetics administered between encounters in which HP was administered and
not administered. No complications were identified in patients who received HP.
CONCLUSIONS: The rate of admission and ME was found to be
significantly reduced in patients with GP secondary to diabetes mellitus who
received HP. HP may represent an appropriate, effective, and safe alternative
to traditional analgesia and antiemetic therapy in the ED management of GP
associated N/V/AP.
8. ED CT Use
A. Implementation of the Canadian CT
Head Rule and Its Association with Use of CT Among Pts with Head Injury
Sharp AL, et al. Ann Emerg Med. 2017 Jul 21 [Epub ahead of
print]
STUDY OBJECTIVE: Approximately 1 in 3 computed tomography
(CT) scans performed for head injury may be avoidable. We evaluate the
association of implementation of the Canadian CT Head Rule on head CT imaging
in community emergency departments (EDs).
METHODS: We conducted an interrupted time-series analysis of
encounters from January 2014 to December 2015 in 13 Southern California EDs.
Adult health plan members with a trauma diagnosis and Glasgow Coma Scale score
at ED triage were included. A multicomponent intervention included clinical
leadership endorsement, physician education, and integrated clinical decision
support. The primary outcome was the proportion of patients receiving a head
CT. The unit of analysis was ED encounter, and we compared CT use pre- and
postintervention with generalized estimating equations segmented logistic
regression, with physician as a clustering variable. Secondary analysis
described the yield of identified head injuries pre- and postintervention.
RESULTS: Included were 44,947 encounters (28,751
preintervention and 16,196 postintervention), resulting in 14,633 (32.6%) head
CTs (9,758 preintervention and 4,875 postintervention), with an absolute 5.3%
(95% confidence interval [CI] 2.5% to 8.1%) reduction in CT use
postintervention. Adjusted pre-post comparison showed a trend in decreasing
odds of imaging (odds ratio 0.98; 95% CI 0.96 to 0.99). All but one ED reduced
CTs postintervention (0.3% to 8.7%, one ED 0.3% increase), but no interaction
between the intervention and study site over time existed (P=.34). After the
intervention, diagnostic yield of CT-identified intracranial injuries increased
by 2.3% (95% CI 1.5% to 3.1%).
CONCLUSION: A multicomponent implementation of the Canadian
CT Head Rule was associated with a modest reduction in CT use and an increased
diagnostic yield of head CTs for adult trauma encounters in community EDs.
B. Physicians Are Not Aware of How
Their Utilization of CT Compares to Their Peers'
A study of actual and self-reported utilization demonstrates
variability and poor insight
Kadhim-Saleh A, et al. CJEM 2017 Jul 4.
OBJECTIVES: Physician variation in the use of computed
tomography (CT) is concerning due to the risks of ionizing radiation, cost, and
downstream effects of unnecessary testing. The objectives of this study were to
describe variation in CT-ordering rates among emergency physicians (EPs), to
measure correlation between perceived and actual CT-ordering rates, to assess
attitudes that influence decisions to order imaging tests, and to identify EP
attitudes associated with higher CT utilization.
METHODS: This study was a retrospective review of imaging
and administrative billing records at two emergency department sites of a
tertiary care adult teaching hospital. The study also included a
cross-sectional survey of EPs at this hospital. We asked physicians about their
perceived ordering behaviour, and what factors influenced their decision to
order a CT. We examined correlations between perceived and actual CT-ordering rates.
We adjusted ordering rates for shift distribution using a logistic regression
model and identified outlier physicians whose ordering rate was significantly
lower or higher than expected. We used multivariable regression analysis to
determine which survey responses predicted higher CT utilization.
RESULTS: During the study period, 59 EPs saw 45,854
patients, and ordered 6,609 CTs - a mean ordering rate of 14.4% (standard
deviation (SD)=4.3%). The ordering rate for individual physicians ranged from
5.9% to 25.9%. Of the 59 EPs, 13 EPs were low-ordering outliers; 12 were
high-ordering outliers. Forty-five EPs (76.3%) completed the survey. Mean
perceived ordering rate was 12.6%, and was weakly correlated with actual
ordering (r=0.19, p=0.21). 42 EPs (93.3%) believed they ordered "about the
same" or "fewer" CTs than their peers. Of the 17 EPs in the two
highest ordering quintiles, only 3 (18%) knew they were high orderers. In the
multivariable analysis, higher ordering was associated with increasing strength
of response to the following predictors: medico-legal risk (relative risk
[RR]=1.18, 95% CI: 1.03-1.21), risk of contrast (RR=1.14, 95% CI: 1.07-1.22),
what colleagues would do (RR=1.09, 95% CI: 0.99-1.19), risk of missing a
diagnosis (RR=1.08, 95% CI: 0.98-1.21), and patient wishes (RR=1.07, 95% CI:
0.97-1.17).
CONCLUSIONS: There is large variation in CT ordering among
EPs. Physicians' self-reported ordering rate correlates poorly with actual
ordering. High CT orderers were rarely aware that they ordered more than their
colleagues. Higher rates of ordering were observed among physicians who
reported increased concern with 1) risk of missing a diagnosis, 2) medico-legal
risk, 3) risk of contrast, 4) patient wishes, and 5) what colleagues would do.
9. More on Appendicitis
A. Time to Appendectomy and Risk of
Complicated Appendicitis and Adverse Outcomes in Children.
Serres SK, et al. JAMA Pediatr. 2017 Aug 1;171(8):740-746.
IMPORTANCE: Management of appendicitis as an urgent rather
than emergency procedure has become an increasingly common practice in
children. Controversy remains as to whether this practice is associated with
increased risk of complicated appendicitis and adverse events.
OBJECTIVE: To examine the association between time to
appendectomy (TTA) and risk of complicated appendicitis and postoperative
complications.
DESIGN, SETTING, AND PARTICIPANTS: In this retrospective
cohort study using the Pediatric National Surgical Quality Improvement Program
appendectomy pilot database, 2429 children younger than 18 years who underwent
appendectomy within 24 hours of presentation at 23 children's hospitals from
January 1, 2013, through December 31, 2014, were studied.
EXPOSURES: The main exposure was TTA, defined as the time
from emergency department presentation to appendectomy. Patients were further
categorized into early and late TTA groups based on whether their TTA was
shorter or longer than their hospital's median TTA. Exposures were defined in
this manner to compare rates of complicated appendicitis within a time frame
sensitive to each hospital's existing infrastructure and diagnostic practices.
MAIN OUTCOMES AND MEASURES: The primary outcome was
complicated appendicitis documented at operation. The association between
treatment delay and complicated appendicitis was examined across all hospitals
by using TTA as a continuous variable and at the level of individual hospitals
by using TTA as a categorical variable comparing outcomes between late and early
TTA groups. Secondary outcomes included length of stay (LOS) and postoperative
complications (incisional and organ space infections, percutaneous drainage
procedures, unplanned reoperation, and hospital revisits).
RESULTS: Of the 6767 patients who met the inclusion
criteria, 2429 were included in the analysis (median age, 10 years;
interquartile range, 8-13 years; 1467 [60.4%] male). Median hospital TTA was
7.4 hours (range, 5.0-19.2 hours), and 574 patients (23.6%) were diagnosed with
complicated appendicitis (range, 5.2%-51.1% across hospitals). In multivariable
analyses, increasing TTA was not associated with risk of complicated
appendicitis (odds ratio per 1-hour increase in TTA, 0.99; 95% CI, 0.97-1.02).
The odds ratios of complicated appendicitis for late vs early TTA across
hospitals ranged from 0.39 to 9.63, and only 1 of the 23 hospitals had a
statistically significant increase in their late TTA group (odds ratio, 9.63;
95% CI, 1.08-86.17; P = .03). Increasing TTA was associated with longer LOS (increase
in mean LOS for each additional hour of TTA, 0.06 days; 95% CI, 0.03-0.08 days;
P less than .001) but was not associated with increased risk of any of the
other secondary outcomes.
CONCLUSIONS AND RELEVANCE: Delay of appendectomy within 24
hours of presentation was not associated with increased risk of complicated
appendicitis or adverse outcomes. These results support the premise that
appendectomy can be safely performed as an urgent rather than emergency
procedure.
B. Outcomes of Nonoperative Management
of Uncomplicated Appendicitis
Bachur RG, et al.
Pediatr. 2017;140(1): e20170048.
BACKGROUND AND OBJECTIVES: Nonoperative management (NOM) of
uncomplicated pediatric abstract appendicitis has promise but remains poorly
studied. NOM may lead to an increase in
resource utilization. Our objective was to investigate the
trends in NOM for uncomplicated appendicitis and study the relevant clinical
outcomes including subsequent appendectomy, complications, and resource
utilization.
METHODS: Retrospective analysis of administrative data from
45 US pediatric hospitals.
Patients less than 19 years of age presenting to the
emergency department (ED) with appendicitis between 2010 and 2016 were studied.
NOM was defined by an ED visit for uncomplicated appendicitis treated with
antibiotics and the absence of appendectomy at the index encounter. The main
outcomes included trends in NOM among children with uncomplicated appendicitis
and frequency of subsequent diagnostic imaging, ED visits, hospitalizations, and
appendectomy during 12-month follow-up.
RESULTS: 99 001 children with appendicitis were identified,
with a median age of 10.9 years.
Sixty-six percent were diagnosed with nonperforated
appendicitis, of which 4190 (6%) were managed nonoperatively. An increasing
number of nonoperative cases were observed over
6 years (absolute difference, +20.4%). During the 12-month
follow-up period, NOM patients were more likely to have the following: advanced
imaging (+8.9% [95% confidence interval
(CI) 7.6% to 10.3%]), ED visits (+11.2% [95% CI 9.3% to
13.2%]), and hospitalizations
(+43.7% [95% CI 41.7% to 45.8%]). Among patients managed
nonoperatively, 46% had a subsequent appendectomy.
CONCLUSIONS: A significant increase in NOM of nonperforated
appendicitis was observed over
6 years. Patients with NOM had more subsequent ED visits and
hospitalizations compared with those managed operatively at the index visit. A
substantial proportion of patients initially managed nonoperatively eventually
had an appendectomy.
C. The Threat of Diagnostic Uncertainty
in the Medical Management of Uncomplicated Appendicitis.
Bachur RG, et al. JAMA Pediatr. 2017 Jun 1;171(6):505-506.
Appendicitis is the most common acute surgical condition,
with a lifetime risk of 8%. Over the last 2 decades, there have been
significant improvements in the diagnosis and surgical management, which has
led to fewer negative appendectomies, shorter hospitalizations, and faster
recoveries.1 The prospect of nonoperative management has been proposed as the
next major advance in appendicitis care, which shows promise but also brings
challenges….
The concept of medical management of uncomplicated
appendicitis is attractive, and some of the early studies among adults and
children have shown 58% to 75% 1-year cure rates and, importantly, no increase
in complications when antibiotics fail.2- 4 Recent studies have provided
insight into which patients may be amenable to nonoperative management; those
with a more advanced disease, evidence of perforation, or an appendicolith
appear to be at higher risk for early failure. Accordingly, recent pediatric
comparative trials have only considered nonoperative management if the
patient’s symptoms were fewer than 48 hours along with the absence of the
following findings: signs of peritonitis by examination, perforation by imaging
studies, or significant fever or leukocytosis. Through the patient-centered
lens, nonoperative care may be enticing, even with the potential of treatment
failure. Furthermore, it provides an opportunity for parents (and patients) to
engage in shared decision making in choosing a treatment plan.
The Existing Evidence
Along with the reasonable success rates of nonoperative
care, there may be consequences with the loss of diagnostic feedback to
clinicians based on definitive pathology reviews. We have concerns over the
diagnostic uncertainty associated with medical management and how this
uncertainty may result in a drift toward the overdiagnosis and overtreatment of
presumed appendicitis. We believe that this may occur through 3 related
mechanisms: (1) increasing reliance on ultrasonography as the primary
diagnostic imaging modality, (2) transitions toward more liberal
interpretations of ultrasonography findings because of the absence of critical
feedback from a pathology standard (ie, a higher proportion of positive or
borderline-positive study results at the expense of negative or indeterminate
study results), and (3) a trend toward a lower threshold for initiating
treatment because of the convenience and relatively low morbidity of antibiotic
therapy. From the perspective of research integrity and quality assurance,
these factors may have important implications on critically evaluating the
effectiveness of nonoperative management through comparative effectiveness
studies. The intention to measure and better understand these potentially unanticipated
effects (if and when they emerge) will be essential to ensure that patients
will optimally benefit from this novel treatment approach.
The diagnosis and treatment of suspected appendicitis has
evolved considerably over the past few decades. Before widespread diagnostic
imaging, negative appendectomy rates were 15% to 20% (and higher among young
children); with the rapid increase in computed tomography (CT) use, negative
appendectomies were significantly reduced, but increasing concerns over medical
radiation led to a shift away from CT and toward ultrasonography as the
preferred diagnostic imaging modality. The reported accuracy of an
ultrasonography has varied widely across hospitals, and compared with CT,
ultrasonography has been associated with a much higher rate of indeterminate
and false-positive study results. This is likely because of variation among
hospitals in identifying and reporting sonographic findings, which are more
subjective and dependent on operator experience as compared with CT.
In the most recent prospective multicenter study of
ultrasonography performance, 51% of ultrasounds were found to have
indeterminate results.5 When the ultrasonography study is not definitive,
current practice demands a decision to obtain further imaging, admit for serial
examinations, or proceed with diagnostic laparoscopy. As medical management
becomes increasingly applied at institutions that primarily use
ultrasonography, the final diagnosis will be uncertain: there will be no
pathologic diagnosis to provide a “check and balance” against trends in
overreading by well-meaning radiologists or acting on such reads by equally
well-meaning pediatric surgeons. Without such feedback, we anticipate a shift
away from conservative toward more liberal reads, with a relative increase in
the proportion of studies interpreted as having borderline or positive results
at the expense of indeterminate and negative results.
A parallel drift toward the overtreatment of patients with
equivocal or borderline ultrasonography results is also possible, as the
threshold for initiating treatment is likely to be lower for antibiotics
compared with an operative exploration, especially when considering the
consequences of a “wrong” treatment decision. The sum effect is that early
appendicitis may become an increasingly more common diagnosis with a reduced
threshold for initiating treatment unless a novel biomarker or other diagnostic
imaging modality (other than CT) emerges with an improved diagnostic certainty
to keep such “drift” in check. Regarding the latter, magnetic resonance imaging
holds promise but has limited use because of availability and cost
considerations.6 The potential effect on antibiotic stewardship by such
practices is another important consideration, especially given that
appendicitis currently ranks fourth among all pediatric conditions with respect
to relative antibiotic use.7
Conclusions
It is important to emphasize that the intent of this
Viewpoint is not to challenge the promise of nonoperative therapy as an
important advancement in the management of appendicitis. On the contrary,
ongoing efforts should be well supported to inform a disciplined diagnostic
approach, standardize treatment strategies, and further characterize outcomes
associated with this approach. However, we must also be vigilant in identifying
unanticipated consequences of nonoperative management, as well as challenges
posed by such consequences in tracking and comparing relevant outcomes for the
purpose of research and quality assurance. Regarding the latter, future
comparative effectiveness studies must be transparent in their reporting of the
diagnostic approaches used for both operative and nonoperative treatment arms.
This must include not only the relative distribution of diagnostic imaging
studies used among each comparison group, but also the relative frequency (and
predictive value) of specific ultrasonographic findings when ultrasonography is
used as the definitive imaging modality. Finally, as medical management of
suspected appendicitis is increasingly implemented, newer quality metrics will
be needed to monitor the blurring of the diagnosis, prevent the overuse of
antibiotics, preserve the restricted use of CT, and balance the cost of an
appendectomy against the ongoing care required for many patients with medically
managed appendicitis.
10. Images in Clinical Practice
Crusted Scabies
Xanthomas in Familial Hypercholesterolemia
Cholelithiasis
Nystagmus from Wernicke’s Encephalopathy
Severe Plantar Warts in an Immunocompromised Patient
Bronchoscopic Removal of an Obstructing Broncholith
Coronary-Artery Vasospasm
Elderly Female With Elbow Pain
Young Girl With Swollen Wrists and Ankles
Young Male With Severe Ankle Pain
Woman with right upper quadrant pain
11. Does the Intranasal Route Pass the Sniff Test?
Joshi N, et al. Ann Emerg Med. 2017 Aug;70(2):212-214.
Medication Route Options
Physicians and scientists have developed creative and varied
routes of medication administration to patients. Some of the many options
include intravenous, intramuscular, intrathecal, intraosseous, per os,
subcutaneous, intravaginal, and per rectum routes. The intravenous route is
further divided into peripheral and central and use, depending on the clinical
situation. For example, line infiltration of specific drugs can lead to
necrosis; thus, these drugs should be given only through central access.
Another intravenous access, the umbilical line, is available only at certain
times, typically only within the first week of life.1 The latest up-and-comer
is the intranasal route, which has increased application in many different clinical
scenarios and is potentially underused in many emergency departments (EDs). But
does it pass the sniff test?
How do we choose the ideal route for each medication and
each patient? There are so many factors to consider that we may not even
consciously acknowledge the many decision points in choosing a route. Different
routes vary in bioavailability and time of onset of drug effect. Some routes
are more operator dependent and some take longer to obtain. Some routes cause
more discomfort, are more invasive, or can put patients at risk for adverse
events. Certain drugs can be administered to target specific body parts and
limit systemic absorption and adverse effects, such as the intrathecal route or
nebulized medications. In a pinch, the intraosseous route can be lifesaving for
many resuscitation medications, but taking a drill to a patient’s bone is less
palatable to the general public for obvious reasons. Although the per os route
clearly uses the fewest resources and has minimal patient discomfort, the bioavailability
is delayed and patients who cannot protect their airway are clearly not
candidates. We rely on the intramuscular route when per os is less effective
but intravenous placement is unnecessary. In the ED, the careful, longer
process of obtaining intravenous access is much less preferable for agitated
patients because a great benefit is placed on decreasing time during which a
provider wields a sharp object in a small tornado of chaos.
Anecdotally, the intranasal route is frequently discussed in
the literature and used in pediatrics, but less often for adults, despite their
having the same pain receptors and perhaps a more matured and refined fear of
needles. Considering that the intranasal route is well tolerated, easy to
administer, and effective, perhaps it should be more frequently used for adult
patients. Aren’t they just big kids anyway?
Why Intranasal?
The purpose of this review is to reflect specifically on the
intranasal route as described as well in the recent publication by Rech et al.2
Let's (nose) dive right into it!
The benefits of intranasal administration are clear:
absorption is independent of body habitus, hydration, or nutrition. There is no
need for painful and potentially dangerous needles, and a minimal level of
technical skill is needed to administer medications.
Intranasal medications vary from pain control (fentanyl), to
sedation (eg, midazolam, dexmedetomidine), to opioid overdose reversal
(naloxone), to seizure cessation (midazolam). A free Web site called
Intranasal.net3 is a helpful resource to learn more about intranasal medication
administration and to review available references supporting its use.
Here are 3 general pharmacokinetic or pharmacodynamic
principles that explain why intranasal administration is effective. First, the
nose contains a full vascular plexus that provides a straight path into the
bloodstream. Small-molecule, nonionized, lipid-soluble drugs can cross mucous
membranes more easily and work better for intranasal administration. Second,
most orally administered medications undergo first-pass metabolism before
reaching their target within the body. Intranasal administration, on the other
hand, bypasses this first-pass effect, which can produce higher drug
concentrations (bioavailability) faster. So intranasal administration might be
the best route in emergency settings such as seizure, trauma, agitation, or
severe pain. Similarly, drugs that must undergo first-pass metabolism for
activation would not be ideal candidates for intranasal administration. Third,
as you will remember from your rigorous medical school anatomy training, the
nose is geographically close to the brain. Therefore, absorption across the
nasal mucosa produces cerebrospinal fluid drug concentrations that in some
studies exceeded plasma concentrations. This is particularly useful in
centrally acting drugs such as antiepileptics. There is also some evidence that
some drugs administered intranasally are directly transported to the brain.4,
5, 6
For intranasal administration, a potential drawback is that
only 1 mL can be maximally absorbed per naris, with ideal volume less than 0.5
mL. Therefore, depending on the medication, higher concentrations may be needed
than are normally stocked in the ED or by emergency medical services (EMS). For
example, the midazolam used for intravenous or intramuscular administration is
commonly a solution of 1 mg/mL, but for intranasal administration, the 5 mg/mL
concentration is preferred. Stocking more than one concentration in the ED can
increase the risk for medication errors. When intranasal protocols or
guidelines are created, it is important to consider how and where different
concentrations will be stocked and how staff will be trained to minimize the
risk of error.
Here are 4 important concepts to consider with intranasal
administration7, 8: minimize barriers to absorption and ensure that the nasal
mucosa is available and free of secretions and blood, minimize the volume and
maximize drug concentration to stay below the 1-mL volume limitation, take advantage
of maximal absorption by using both nostrils, and use a delivery system that
maximizes drug dispersion.
What Is an Atomizer?
Next, to highlight real-life application, let's discuss how
to administer intranasal medications and options for delivery systems…
12. Clinical Mimics: An EM-Focused Review of Asthma Mimics.
Kann K, et al., J Emerg Med. 2017;53(2):195-201.
BACKGROUND: Asthma is a common diagnosis or preexisting
condition, and many patients with acute asthma exacerbation may present to the
emergency department with wheezing and respiratory distress. However, many
conditions may mimic this presentation.
OBJECTIVES: This review provides an overview of common
asthma mimics and an approach to evaluation and management.
DISCUSSION: Asthma is characterized by an obstructive
pulmonary disease with recurrent exacerbations. The disease may present with a
variety of symptoms, including wheezing, chest tightness, shortness of breath,
and even respiratory failure. Mimics include anaphylaxis, angioedema, central
airway obstruction, heart failure, allergic reaction, foreign body aspiration,
pulmonary embolism, and vocal cord dysfunction. The approach to evaluation and
management of these patients includes assessment for life-threatening
conditions while treatment and resuscitation is underway. Providers should
assess for red flags, including no history of asthma, lack of severe asthma, and
no improvement with standard treatments. Focused assessment with history,
physical examination, chest imaging, electrocardiogram, and laboratory studies
may provide benefit. Through consideration of these mimics and treatment,
providers can provide rapid management.
CONCLUSIONS: While asthma is a common disease, many asthma
mimics exist. Through consideration of other diseases with wheezing and
assessing for red flags, such as patients presenting without a history of
asthma or patients with a history of only mild asthma presenting with severe
symptoms, emergency providers may decrease the chance of early diagnostic
closure and anchoring while improving the care of these patients.
13. IV Lidocaine Beats IV Morphine for Pts with Renal Colic in
the ED
Blast from the Past: Something Worth Repeating; from our Jan
13, 2013 Issue of Lit Bits
Soleimanpour H, et al. BMC Urol. 2012;12(13)
Intro
Affecting 1–5 % of the population in industrialized
countries, renal colic is considered as a major concern in medicine. Renal
colic has been reported to be experienced by 20 % of white males and 5-10 % of
white females. [1] The classic presentation of acute renal colic includes
sudden pain onset radiating from the flank to the lower extremities which is
usually accompanied by microscopic hematuria (85 % of cases), nausea and
vomiting. Costovertebral angle tenderness is a common finding as well. [2]
To relieve the pain until being discharged or undergoing the
required operation is mostly performed in emergency departments. [1] To achieve
this, numerous medications including antiemetics, narcotics, non-steroidal
anti-inflammatory drugs, antispasmodics, anti-diuretics, ketorolac, nifedipine,
prednisone, acetaminophen and prochlorperazine have been introduces. [2]
Lidocaine, being an appropriate choice in treating visceral
and central pain, might also be useful wherever narcotics are inefficient or
lead to undesirable side effects. Intravenous lidocaine is effective in
controlling neuropathic pains such as: diabetic neuropathy, post-operative
pain, post-herpetic pain, headaches and neurological malignancies. [3,4]
Therefore we aimed at investigating and reviewing the analgesic effects of
intravenous lidocaine compared with intravenous morphine in patients with renal
colic.
Abstract
Background: Despite the fact that numerous medications have
been introduced to treat renal colic, none has been proven to relieve the pain
rapidly and thoroughly. In this study, we aimed at comparing the effects of
intravenous lidocaine versus intravenous morphine in patients suffering from
renal colic.
Methods: In a prospective randomized double-blind clinical
trial performed in the emergency department of Imam Reza educational hospital
of Tabriz, Iran, we studied 240 patients, 18–65 years old, who were referred
due to renal colic. Patients were divided into two groups. In group I (120
people) single-dose intravenous lidocaine (1.5 mg/kg) was administered and in
group II (120 people) single-dose intravenous morphine (0.1 mg/kg) was
administered slowly. Visual Analogue Pain Scale (VAS) was recorded while
admission, 5, 10, 15 and 30 minutes after injection. Statistical data and
results were studied using descriptive statistics as percentage and Mean ± SD.
To compare the response to treatment, Mann–Whitney U-test was used in two
groups. Consequently, the data were analyzed using the SPSS16 software.
Results Pain score measured in two groups five minutes after
the injection of lidocaine and morphine were 65 % and 53 % respectively (95% CI
0.60 - 0.69, CI 0.48 – 0.57, p = 0.0002).108 (90 %) patients (95 % CI 0.84 –
0.95) from group I and 84 (70%) patients (95 % CI 0.62 - 0.78) from group II
responded appropriately at the end of the complete treatment. The difference
was statistically significant (p = 0.0001).
Conclusions Changing the smooth muscle tone and reducing the
transmission of afferent sensory pathways, lidocaine causes a significant
reduction in pain.
14. C-spine evaluation and clearance in the intoxicated pt: a
prospective western trauma association multi-institutional trial and survey.
In intoxicated pts, if the CT of the C spine is negative, believe
it. You’re done.
Martin MJ, et al. J Trauma Acute Care Surg. 2017 Jul 19 [Epub
ahead of print]
INTRODUCTION: Intoxication often prevents clinical clearance
of the cervical spine (Csp) after trauma leading to prolonged immobilization
even with a normal CT scan. We evaluated the accuracy of CT at detecting
clinically significant Csp injury, and surveyed participants on related
opinions and practice.
METHODS: A prospective multicenter study (2013-2015) at 17
centers. All adult blunt trauma patients underwent structured clinical
examination and imaging including a Csp CT, with follow-up thru discharge. EtOH
and drug intoxicated patients (TOX+) were identified by serum and/or urine
testing. Primary outcomes included the incidence and type of Csp injuries, the
accuracy of CT scan, and the impact of TOX+ on the time to Csp clearance. A
36-item survey querying local protocols, practices, and opinions in the TOX+
population was administered.
RESULTS: 10,191 patients were prospectively enrolled and
underwent CT Csp during the initial trauma evaluation. The majority were male
(67%), vehicular trauma or falls (83%), with mean age=48, and mean ISS=11. The
overall incidence of Csp injury was 10.6%. TOX+ comprised 30% of the cohort
(19% EtOH only, 6% drug only, and 5% both). TOX+ were significantly younger (41
vs 51, p less than 0.01) but with similar mean ISS (11) and GCS (13). The TOX+
cohort had a lower incidence of Csp injury vs non-intoxicated (8.4 vs 11.5%, p less
than 0.01). In the TOX+ group, CT had a sens=94%, spec=99.5%, and NPV=99.5% for
all Csp injuries. For clinically significant injuries, the NPV was 99.9%, and
there were no unstable Csp injuries missed by CT (NPV=100%). When CT Csp was
negative, TOX+ led to longer immobilization vs sober patients (mean 8 hrs vs 2
hrs, p less than 0.01), and prolonged immobilization (over 12hrs) in 25%. The
survey showed marked variations in protocols, definitions, and Csp clearance
practices among participating centers, although 100% indicated willingness to
change practice based on this data.
CONCLUSIONS: For intoxicated patients undergoing Csp
imaging, CT scan was highly accurate and reliable for identifying clinically
significant spine injuries, and had a
100% NPV for identifying unstable
injuries. CT-based clearance in TOX+ patients appears safe and may avoid
unnecessary prolonged immobilization. There was wide disparity in practices,
definitions, and opinions among the participating centers.
15. Medication Corner
A. Reminder: Steroids are Helpful for Sick
Pts with Pneumonia
Wu WF, et al. Efficacy of corticosteroid treatment for
severe community-acquired pneumonia: A meta-analysis. Am J Emerg Med. 2017 Jul
15 [Epub ahead of print]
BACKGROUND: The benefits and adverse effects of
corticosteroids in the treatment of severe community-acquired pneumonia (CAP)
have not been well assessed. The aim of this systematic review of the
literature and meta-analysis was to evaluate the clinical efficacy of adjuvant
corticosteroid therapy in patients with severe CAP.
METHODS: The following databases were searched: PubMed, the
Cochrane database, Embase, Wanfang, the China National Knowledge Infrastructure
(CNKI), and the WeiPu (VIP) database in Chinese. Published randomized
controlled clinical trial results were identified that compared corticosteroid
therapy with conventional therapy for patients with severe CAP, up to November
2016. The relative risk (RR), weighted mean difference (WMD), and 95%
confidence interval (CI) were evaluated. Statistical analysis was performed
using STATA 10.0. The quality of the published studies was evaluated using the
Oxford quality scoring system (Jadad scale).
RESULTS: Ten randomized controlled trials (RCTs) were
identified that included 729 patients with severe CAP. Data analysis showed that
corticosteroid therapy did not have a statistically significant clinical effect
in patients with severe CAP (RR: 1.19; 95% CI: 0.99-1.42), mechanical
ventilation time (WMD: -2.30; 95% CI: -6.09-1.49). However, corticosteroids
treatment was significantly associated with reduced in-hospital mortality (RR:
0.49; 95% CI: 0.29-0.85), reduced length of hospital stay (WMD: -4.21; 95% CI:
-6.61 to -1.81).
CONCLUSION: Corticosteroids adjuvant therapy in patients
with severe CAP may reduce the rate of in-hospital mortality, reduce the length
of hospital stay, and reduce CRP levels.
B. Clinical Review: Loperamide Toxicity
Wu PE, et al, Ann
Emerg Med. 2017;70:245-52.
Loperamide is a nonprescription opioid widely used for the
treatment of diarrhea. Although it is relatively safe at therapeutic doses,
increasing reports describe its misuse and abuse at very high doses either for
euphoric effects or to attenuate symptoms of opioid withdrawal.
Life-threatening loperamide toxicity can result from the relatively new
clinical syndrome of loperamide-induced cardiac toxicity. These patients are
often young and may present in cardiac arrest or with unheralded, recurrent
syncope in conjunction with ECG abnormalities, including marked QT-interval
prolongation, QRS-interval widening, and ventricular dysrhythmias. Features of
conventional opioid toxicity may also be present. The mainstays of treatment
include advanced cardiac life support and supportive care, although selected
patients may be candidates for overdrive pacing, intravenous lipid emulsion, or
extracorporeal membrane oxygenation. In patients who survive loperamide
toxicity, consideration should be given to the treatment of an underlying
opioid use disorder, if present.
Full-text (requires subscription): http://www.annemergmed.com/article/S0196-0644(17)30424-9/fulltext
C. FDA Puts the Kibosh on
Fluoroquinolones – So Should You
The latest “black box” warning focuses on an array of
neurological problems associated with these antibiotics.
By Richard Bukata, MD. EP Monthly. July 17, 2017
Bottom line – Don’t prescribe fluoroquinolones unless they
are absolutely needed and there are no good alternatives (and there usually are
at least a few). It will be very difficult to defend your practice if a patient
is seriously harmed, as there was an FDA Black Box about the side effect
caused, and there were other alternatives. It is surprising that more hospitals
haven’t responded to this new Black Box despite the medicolegal risks they may
incur by not warning their medical staffs about the use of these drugs. Compare
the response to the current fluoroquinolone Black Box with the exaggerated
response to the Black Box on droperidol regarding arrhythmias. Most hospitals
quickly made droperidol unavailable while nothing similar has occurred regarding
the quinolones.
Quinolones: review of psychiatric and neurological adverse
reactions: https://www.ncbi.nlm.nih.gov/pubmed/21585220
FDA warning: “Because the risk of these serious side effects
generally outweighs the benefits for patients with acute bacterial sinusitis,
acute exacerbation of chronic bronchitis and uncomplicated urinary tract
infections, the FDA has determined that
fluoroquinolones should be reserved for use in patients with these conditions
who have no alternative treatment options. For some serious bacterial
infections, including anthrax, plague and bacterial pneumonia among others, the
benefits of fluoroquinolones outweigh the risks and it is appropriate for them
to remain available as a therapeutic option.”
D. Cannabis for Medical Purposes?
D1.
The Effects of Cannabis Among Adults with Chronic Pain and an Overview of
General Harms: A Systematic Review
Nugent SM, et al. Ann Intern Med 2017 Aug 15 [Epub ahead of
print].
Background: Cannabis is increasingly available for the
treatment of chronic pain, yet its efficacy remains uncertain.
Purpose: To review the benefits of plant-based cannabis
preparations for treating chronic pain in adults and the harms of cannabis use
in chronic pain and general adult populations.
Data Sources: MEDLINE, Cochrane Database of Systematic
Reviews, and several other sources from database inception to March 2017.
Selection: Intervention trials and observational studies,
published in English, involving adults using plant-based cannabis preparations
that reported pain, quality of life, or adverse effect outcomes.
Data Extraction: Two investigators independently abstracted
study characteristics and assessed study quality, and the investigator group
graded the overall strength of evidence using standard criteria.
Data Synthesis: From 27 chronic pain trials, there is
low-strength evidence that cannabis alleviates neuropathic pain but
insufficient evidence in other pain populations. According to 11 systematic
reviews and 32 primary studies, harms in general population studies include
increased risk for motor vehicle accidents, psychotic symptoms, and short-term
cognitive impairment. Although adverse pulmonary effects were not seen in
younger populations, evidence on most other long-term physical harms, in heavy
or long-term cannabis users, or in older populations is insufficient.
Limitation: Few methodologically rigorous trials; the
cannabis formulations studied may not reflect commercially available products;
and limited applicability to older, chronically ill populations and patients
who use cannabis heavily.
Conclusion: Limited evidence suggests that cannabis may
alleviate neuropathic pain in some patients, but insufficient evidence exists
for other types of chronic pain. Among general populations, limited evidence
suggests that cannabis is associated with an increased risk for adverse mental
health effects.
Full-text (free): http://annals.org/aim/article/2648595/effects-cannabis-among-adults-chronic-pain-overview-general-harms-systematic
D2.
Benefits and Harms of Plant-Based Cannabis for Posttraumatic Stress Disorder: A
Systematic Review
O’Neil ME, et al. Ann Intern Med, 2017 Aug 15 [Epub ahead of
print].
Conclusion: Evidence is insufficient to draw conclusions
about the benefits and harms of plant-based cannabis preparations in patients
with PTSD, but several ongoing studies may soon provide important results.
Full-text (free): http://annals.org/aim/article/2648596/benefits-harms-plant-based-cannabis-posttraumatic-stress-disorder-systematic-review
16. Predatory Journals Hit By ‘Star Wars’ Sting
By Neuroskeptic | July 22, 2017
A number of so-called scientific journals have accepted a
Star Wars-themed spoof paper. The manuscript is an absurd mess of factual
errors, plagiarism and movie quotes. I know because I wrote it.
Inspired by previous publishing “stings”, I wanted to test
whether ‘predatory‘ journals would publish an obviously absurd paper. So I
created a spoof manuscript about “midi-chlorians” – the fictional entities
which live inside cells and give Jedi their powers in Star Wars. I filled it
with other references to the galaxy far, far away, and submitted it to nine
journals under the names of Dr Lucas McGeorge and Dr Annette Kin.
Four journals fell for the sting. The American Journal of
Medical and Biological Research (SciEP) accepted the paper, but asked for a
$360 fee, which I didn’t pay. Amazingly, three other journals not only accepted
but actually published the spoof. Here’s the paper from the International
Journal of Molecular Biology: Open Access (MedCrave), Austin Journal of
Pharmacology and Therapeutics (Austin) and American Research Journal of
Biosciences (ARJ) I hadn’t expected this, as all those journals charge
publication fees, but I never paid them a penny.
All of the above journals have now deleted the paper, so
I’ve made it available on Scribd.
So what did they publish? A travesty, which they should have
rejected within about 5 minutes – or 2 minutes if the reviewer was familiar
with Star Wars. Some highlights:
“Beyond supplying cellular energy, midichloria perform
functions such as Force sensitivity…”
“Involved in ATP production is the citric acid cycle, also
referred to as the Kyloren cycle after its discoverer”
“Midi-chlorians are microscopic life-forms that reside in
all living cells – without the midi-chlorians, life couldn’t exist, and we’d
have no knowledge of the force. Midichlorial disorders often erupt as brain
diseases, such as autism.”
Ironically, I’m not even a big Star Wars fan. I just like
the memes.
To generate the main text of the paper, I copied the
Wikipedia page on ‘mitochondrion’ (which, unlike midichlorians, exist) and then
did a simple find/replace to turn mitochondr* into midichlor*. I then Rogeted
the text, i.e. I reworded it (badly), because the main focus of the sting was
on whether journals would publish a ridiculous paper, not whether they used a
plagiarism detector (although Rogeting is still plagiarism in my book.)
For transparency, I admitted what I’d done in the paper
itself. The Methods section features the line “The majority of the text of this
paper was Rogeted [7]”. Reference 7 cited an article on Rogeting followed by
“The majority of the text in the current paper was Rogeted from Wikipedia:
https://en.wikipedia.org/wiki/Mitochondrion Apologies to the original authors
of that page.”
Credit where credit’s due, a number of journals rejected the
paper: Journal of Translational Science (OAText); Advances in Medicine
(Hindawi); Biochemistry & Physiology: Open Access (OMICS).
Two journals requested me to revise and resubmit the
manuscript. At JSM Biochemistry and Molecular Biology (JSciMedCentral) both of
the two peer reviewers spotted and seemingly enjoyed the Star Wars spoof, with
one commenting that “The authors have neglected to add the following
references: Lucas et al., 1977, Palpatine et al., 1980, and Calrissian et al.,
1983”. Despite this, the journal asked me to revise and resubmit.
At the Journal of Molecular Biology and Techniques (Elyns
Group), the two peer reviewers didn’t seem to get the joke, but recommended
some changes such as reverting “midichlorians” back to “mitochondria.”
Finally, I should note that as a bonus, “Dr Lucas McGeorge”
was sent an unsolicited invitation to serve on the editorial board of this
journal.
So does this sting prove that scientific publishing is
hopelessly broken? No, not really. It’s just a reminder that at some “peer reviewed”
journals, there really is no meaningful peer review at all. Which we already
knew, not least from previous stings, but it bears repeating.
This matters because scientific publishers are companies
selling a product, and the product is peer review. True, they also publish
papers (electronically in the case of these journals), but if you just wanted
to publish something electronically, you could do that yourself for free.
Preprint archives, blogs, your own website – it’s easy to get something on the internet.
Peer review is what supposedly justifies the price of publishing.
All of the nine publishers I stung are known to send spam to
academics, urging them to submit papers to their journals. I’ve personally been
spammed by almost all of them. All I did, as Lucas McGeorge, was test the
quality of the products being advertised.
The hilarious submission: https://www.scribd.com/document/354932509/Mitochondria-Structure-Function-and-Clinical-Relevance
17. Push-Dose Pressors
A. Safety considerations and
guideline-based safe use recommendations for “bolus- dose” vasopressors in the ED.
Holden D, et al. Ann Emerg Med. 2017 June 7 [Epub ahead of print]
The use of intermittently administered doses of vasopressors
to correct hypotension in the emergency department (ED), commonly referred to
as bolus-dose pressors, push-dose pressors, Neo-sticks, or phenyl sticks, has
been widely advocated outside of the traditional printed medical literature. No
outcomes data of this practice exist to demonstrate benefits over traditional
continuous infusion of vasopressors. Use of bolus-dose vasopressors in the ED
setting raises a number of patient safety concerns, and misuse and errors in
the preparation and administration of bolus-dose vasopressors may result in
patient harm. A systems-based approach should be implemented to maximize safety
and patient benefits if bolus-dose vasopressors are used. This article
discusses the wide range of issues to consider when evaluating the role of
bolus-dose vasopressors in the ED and provides recommendations based on current
safe medication practices guidelines.
B. Scott Weingart Weighs In.
EMCrit Podcast. August 7, 2017
Today, an update on Push-Dose Pressors. I coined the name
Push-Dose Pressors (PDPs) way back on episode 6. The idea was not new,
anesthesiologists and resus docs have been using bolus-dose vasopressors for
decades. I just thought the name was dumb, these are not boluses in the way I
have always thought of them (a brief iv drip). I also thought it was crazy that
the concept had not really penetrated very far into emergency medicine and the
ICU–at least in the States. My prehospital doc friends told me it was common in
their world. Since the podcast, I have received 100s of emails describing the
use of PDPs to lifesaving effect (or at least code-preventing), but there has
been scant published literature on this technique in EM. Recently that has all
changed.
C. Brief Lit Review
Weingart S. Push-dose pressors for immediate BP control.
Clin Exp Emerg Med. 2015 Jun 30;2(2):131-132.
Acquisto NM, et al. Medication errors with push dose pressors
in the ED and ICUs. Am J Emerg Med 2017 July 7 [Epub ahead of print].
Holden D, et al. Safety Considerations and Guideline-Based
Safe Use Recommendations for "Bolus-Dose" Vasopressors in the ED. Ann
Emerg Med. 2017 Jun 7 [Epub ahead of print].
Gottlieb M. Bolus dose of epinephrine for refractory
post-arrest hypotension. CJEM. 2017 Jan 10:1-5 [Epub ahead of print].
Bolus-Dose Vasopressors in the ED: First, Do No Harm;
Second, More Evidence Is Needed
18. Psychology Corner
A. Facial Features Predict Rise to
Leadership
Looking Leadership in the Face. Association of Psychological
Science
Is there such a thing as simply looking like a leader? A
large body of research suggests yes.
In a recent article published in Current Directions in
Psychological Science, John Antonakis (University of Lausanne) and Dawn L.
Eubanks (University of Warwick) provide an overview of several studies
suggesting that getting to the top of the corporate ladder may depend, at least
in part, on the structure of a person’s face.
“Given what we know about the predictors of leaders’
ability, facial appearance should play a small or a very limited role in
observers’ selection of leaders; however, research convincingly shows
otherwise,” Antonakis and Eubanks write.
When judging candidates for a leadership position, selectors
need accurate information on the competence and trustworthiness of the
individuals concerned, the researchers explain. Ideally, company board members
choosing a CEO or voters choosing a politician will rely on accurate cues of
these characteristics to make their decisions. But do they?
“Research has shown that facial appearance matters
considerably for leader selection,” Antonakis and Eubanks explain. “In
literally milliseconds, observers use slivers of information to make inferences
about a target’s character.”
When we don’t have much information to go on about a
person’s ability or trustworthiness, we may have to rely on anything we can
use, including looks, to make inferences about a leader’s abilities.
A number of experiments have shown that people can pick the
winner of an election at rates better than chance, just by comparing a couple
of photos. For example, in a 2009 experiment by Antonakis and Olaf Dalgas, 681
Swiss children were shown the faces of politicians from French parliamentary
runoff elections. The black and white photos paired 57 political rivals running
against each other (matched so that both individuals were the same sex and
race). The children were asked to pick the more competent individual. The
average probability of a child correctly choosing the winner of the runoff was
a stunning 71%.
“The results were fascinating because child participants’
choices of political candidates—in this case, in a poorly publicized election
in another country—were indistinguishable from those of adult participants who
rated the targets on competence, intelligence, and leadership ability,” the
researchers write. “That children with little experience evaluating leaders do
so in ways similar to adults suggests that it is not experiential learning
driving these results but something else.”
In business settings, research has found that individuals
with faces that are perceived as looking more powerful or competent are more
likely to be selected for leadership positions. Studies have also found that
people are unexpectedly good at identifying a person’s profession based on
nothing more than a cropped photo.
The rest of the essay: http://www.psychologicalscience.org/news/minds-business/looking-leadership-in-the-face.html
Antonakis study: http://journals.sagepub.com/doi/abs/10.1177/0963721417705888
B. A Systematic Review of the Impact of
Physician Implicit Racial Bias on Clinical Decision Making
Dehon E, et al. Acad Emerg Med. 2017 Aug;24(8):895-904.
OBJECTIVES: Disparities in diagnosis and treatment of racial
minorities exist in the emergency department (ED). A better understanding of
how physician implicit (unconscious) bias contributes to these disparities may
help identify ways to eliminate such racial disparities. The objective of this
systematic review was to examine and summarize the evidence on the association
between physician implicit racial bias and clinical decision making.
METHODS: Based on PRISMA guidelines, a structured electronic
literature search of PubMed, CINAHL, Scopus, and PsycINFO databases was
conducted. Eligible studies were those that: 1) included physicians, 2)
included the Implicit Association Test as a measure of implicit bias, 3)
included an assessment of physician clinical decision making, and 4) were
published in peer-reviewed journals between 1998 and 2016. Articles were
reviewed for inclusion by two independent investigators. Data extraction was
performed by one investigator and checked for accuracy by a second
investigator. Two investigators independently scored the quality of articles
using a modified version of the Downs and Black checklist.
RESULTS: Of the 1,154 unique articles identified in the
initial search, nine studies (n = 1,910) met inclusion criteria. Three of the
nine studies involved emergency providers including residents, attending
physicians, and advanced practice providers. The majority of studies used
clinical vignettes to examine clinical decision making. Studies that included
emergency medicine (EM) providers had vignettes relating to treatment of acute
myocardial infarction, pain, and pediatric asthma. An implicit preference
favoring white people was common across providers, regardless of specialty. Two
of the nine studies found evidence of a relationship between implicit bias and
clinical decision making; one of these studies included EM providers. This one
study found that EM and internal medicine residents who demonstrated an
implicit preference for white individuals were more likely to treat white
patients and not black patients with thrombolysis for myocardial infarction.
Evidence from the two studies reporting a relationship between physician
implicit racial bias and decision making was low in quality.
CONCLUSIONS: The current literature indicates that although
many physicians, regardless of specialty, demonstrate an implicit preference
for white people, this bias does not appear to impact their clinical decision
making. Further studies on the impact of implicit racial bias on racial
disparities in ED treatment are needed.
19. Predictive Utility of the Total GCS Versus the Motor
Component of the GCS for Identification of Pts with Serious Traumatic Injuries.
Chou R1, et al. Ann Emerg Med. 2017 Aug;70(2):143-157.e6.
STUDY OBJECTIVE: The motor component of the Glasgow Coma
Scale (mGCS) has been proposed as an easier-to-use alternative to the total GCS
(tGCS) for field assessment of trauma patients by emergency medical services.
We perform a systematic review and meta-analysis to compare the predictive
utility of the tGCS versus the mGCS or Simplified Motor Scale in field triage
of trauma for identifying patients with adverse outcomes (inhospital mortality
or severe brain injury) or who underwent procedures (neurosurgical intervention
or emergency intubation) indicating need for high-level trauma care.
METHODS: Ovid MEDLINE, Cumulative Index to Nursing and
Allied Health Literature, PsycINFO, Health and Psychosocial Instruments, and
the Cochrane databases were searched through June 2016 for English-language
cohort studies. We included studies that compared the area under the receiver
operating characteristic curve (AUROC) of the tGCS versus the mGCS or Simplified
Motor Scale assessed in the field or shortly after arrival in the emergency
department for predicting the outcomes described above. Meta-analyses were
performed with a random-effects model, and subgroup and sensitivity analyses
were conducted.
RESULTS: We included 18 head-to-head studies of predictive
utility (n=1,703,388). For inhospital mortality, the tGCS was associated with
slightly greater discrimination than the mGCS (pooled mean difference in
[AUROC] 0.015; 95% confidence interval [CI] 0.009 to 0.022; I2=85%; 12 studies)
or the Simplified Motor Scale (pooled mean difference in AUROC 0.030; 95% CI
0.024 to 0.036; I2=0%; 5 studies). The tGCS was also associated with greater
discrimination than the mGCS or Simplified Motor Scale for nonmortality outcomes
(differences in AUROC from 0.03 to 0.05). Findings were robust in subgroup and
sensitivity analyses.
CONCLUSION: The tGCS is associated with slightly greater
discrimination than the mGCS or Simplified Motor Scale for identifying severe
trauma. The small differences in discrimination are likely to be clinically
unimportant and could be offset by factors such as convenience and ease of use.
See also “Glasgow
Coma Scale Motor Component ("Patient Does Not Follow Commands")
Performs Similarly to Total Glasgow Coma Scale in Predicting Severe Injury in
Trauma Patients.” Abstract: https://www.ncbi.nlm.nih.gov/pubmed/27436703
See also
“How to Measure the Glasgow Coma Scale”
Green SM et al. Ann Emerg Med 2017;70(2):158-60. Full-text (free): http://www.annemergmed.com/article/S0196-0644(16)31578-5/fulltext
20. When High Deductibles Hurt: Even Insured Pts Postpone Care
By Pauline Bartolone. California Healthline July 27, 2017
In November 2015, Tina Heck was in her garage lifting
40-pound bags of wood pellets to fuel her heating stove, when something went
very wrong with her back.
“The next day, I could barely walk,” said the 55-year-old
who lives on an acre of land in Nevada City, Calif., 60 miles northeast of
Sacramento. The cause: a bulging disc in her lower spine, which shoots pain
down her leg and makes her back stiff.
The injury wasn’t Heck’s only setback. The initial MRI,
cortisone shot and doctor visit cost her $3,000 because her health plan
requires her to shell out $5,000 before insurer payments kick in. She doesn’t
want to explore other treatment options because of that high deductible. Heck,
who makes $68,000 a year in marketing for a nonprofit, is not willing to add
more debt on top of her credit-card and mortgage payments.
“I’m in pain every day,” she said, but “it’s not bad enough
to go into debt.”
The concept behind high-deductible plans was to lower
premiums and reduce overall health costs by ensuring that consumers shared the
financial burden of their own health care decisions. But evidence is mounting:
High deductibles have actually forced people to delay care that could prevent
health emergencies later or improve their quality of life.
Regardless of what happens to the Affordable Care Act, such
plans are likely to become more widespread as health care costs continue to
rise. Just over half of people with health plans from their employers now have
a deductible of $1,000 or more, up from 10% in 2006, according to the Kaiser
Family Foundation. (Kaiser Health News, which produces California Healthline,
is an editorially independent program of the foundation.)
“People who have medical problems that can be put off tend
to do so much more now because of the high deductible,” said Dr. Ted Mazer, a
San-Diego based head and neck surgeon who is president-elect of the California
Medical Association.
Annual deductibles can amount to many thousands of dollars
on some plans. Covered California bronze plans, with the lowest premiums
available on the exchange, carry deductibles of $6,300 for an individual and
$12,600 for a family. A Kaiser Family Foundation survey released this year
showed that 43% of insured people reported having trouble paying their
deductible, up from 34% in 2015.
In one study by the liberal advocacy group Families USA,
more than a quarter of people in high-deductible plans delayed some type of
medical service such as a doctor visit or diagnostic test. And 44% of adults
with high out-of-pocket expenses put off medical care, according to a
nonpartisan Commonwealth Fund study. Another recent study by researchers at the
University of California-Berkeley and Harvard University found that people with
high-deductible plans spent 42% less on health care before meeting their
deductibles, primarily by reducing the amount of health care they received, not
by shopping around for a better price.
Jonathan Kolstad, associate professor of economics at
UC-Berkeley’s business school and co-author of the study, said patients dropped
both needed care, such as diabetes medication, and potentially unnecessary
care, such as imaging for headaches. “Left to their own devices, people [in
high-deductible plans] seem ill-equipped to make their own decisions” about
what care they need, and what care they don’t, Kolstad said.
Mazer said that, in his practice, people have delayed all
kinds of treatment that may not save “life or limb” but involved medical
conditions that interfered with breathing or sleeping. He said he’s had
patients who needed a biopsy to determine if an abnormal vocal cord was
cancerous, and they put it off because of the cost.
“I have to make the phone call and say, ‘We’re looking at a
mass that may be malignant and if you put it off you’re putting yourself at
risk,’ ” Mazer said. “And I’ll tell you, we’ve had people take that risk.”
Recent Republican proposals to repeal Obamacare have
promoted the use of high-deductible plans by allowing people to put away more
tax-free dollars into the health savings accounts that consumers use in
conjunction with those plans. And experts said the proposals would also spur
the growth of these plans — by cutting the subsidies available through
exchanges, inducing customers to look for cheaper plans with higher
deductibles. Conservatives say insurance that promotes personal financial
responsibility helps tamp down overall health costs. Hoover Institution
analysts, for example, argue that high deductibles encourage patients to
“choose wisely.”
But new evidence suggests that putting off care can be
dangerous and, eventually, more costly to patients. A March 2017 Harvard study
found that low-income patients with diabetes who had high-deductible plans
delayed visits for complications such as skin infections and pneumonia. They
wound up getting more expensive care later on.
Patients may try to treat their conditions at home, or hope
they go away — but if that approach fails, “they then have to seek care at the
emergency department,” said Frank Wharam, a health policy researcher at Harvard
Medical School and lead author of the study.
Wharam said the middle-income earners he studied didn’t
suffer any adverse effects from health care choices they made in high-deductible
plans, adding that more studies are needed on that group.
Sabrina Corlette, from the Georgetown University Center on
Health Insurance Reforms, said that until national health policy addresses the
“underlying costs of care,” patients in high-deductible plans will likely be
stuck with the difficult task of figuring out what medical attention they need
or can afford.
Heck said the symptoms from her back injury have changed —
the pain is in a different part of the body than it was right after the injury.
But she’s not even considering a trip to a nearby clinic for a new assessment.
That would require another MRI, she said, which could cost at least $1,500, and
it might not even help her. If her deductible weren’t as high, she’d feel
“freer” to explore other health care options, she said.
For now, she’s taking a lot of ibuprofen and seeing a
chiropractor. “A lot of people get stuck in this place,” she said.
21. Micro Bits
A.
Your kitchen sponge harbors zillions of microbes. Cleaning it could make things
worse
Guglielmi G. Science
Mag. Jul. 28, 2017 , 2:01 PM
That sponge in your kitchen sink harbors zillions of
microbes, including close relatives of the bacteria that cause pneumonia and
meningitis, according to a new study. One of the microbes, Moraxella osloensis,
can cause infections in people with a weak immune system and is also known for
making laundry stink, possibly explaining your sponge’s funky odor. Researchers
made the discovery by sequencing the microbial DNA of 14 used kitchen sponges,
they report this month in Scientific Reports. Surprisingly, boiling or
microwaving the sponges didn’t kill off these microbes. Indeed, sponges that
had been regularly sanitized teemed with a higher percentage of bacteria
related to pathogens than sponges that had never been cleaned. This could be
because pathogen-related bacteria are more resistant to cleaning and rapidly
recolonize the areas abandoned by their susceptible brethren—similar to what
happens to our gut after an antibiotic treatment, the scientists say. When the
researchers put the sponges under the microscope, they discovered that a single
cubic centimeter could be packed with more than 5 x 1010 bacteria, which
corresponds to about seven times the number of people
inhabiting Earth. Such bacterial densities, the scientists say, are found
only in feces. But don’t worry—the solution to a clean sponge is simple:
Just replace it every week.
B.
The Power of Perception: Just Thinking You're Slacking On Exercise Could Boost
Risk Of Death
Angus Chen. NPR. All Things Considered. July 20, 2017.
In a fitness-crazed land of spin classes and CrossFit gyms,
Octavia Zahrt found it can be tough to feel as though you're doing enough.
"When I was in school in London, I felt really good about my activity.
Then I moved to Stanford, and everyone around me seems to be so active and
going to the gym every day," she says. "In the San Francisco Bay
Area, it's like 75 percent of people walk around here wearing exercise clothes
all day, every day, all the time, and just looking really fit."
She wasn't less active than when she lived in London, Zahrt
says, but in comparison she began to feel a bit like a slacker. "I felt
unhealthy. I was very stressed about fitting in more exercise," she says.
And just feeling less fit in comparison to others might trim
away years of life, says Zahrt, a Ph.D. candidate in health psychology at the
Stanford University Graduate School of Business. That's the conclusion of a
study she co-authored, published Thursday in Health Psychology.
Past studies have suggested that mindsets concerning one's
own health can have physiological consequences. In 2007, Stanford psychologist
Alia Crum ran a study on hotel attendants. "These women were getting lots
of exercise, but when we asked them they didn't have the mindset that their
work was good exercise," Crum says.
She gave some of the hotel staff a presentation explaining
that their work, which involves heavy lifting and walking, is good exercise,
and then tracked them for a month. "The women who started to look at their
work as good exercise had improvements in blood pressure and body fat,"
she says.
Crum and Zahrt collaborated on the new study, which looks at
what might happen decades down the line. They analyzed data from two large
national health surveys, the National Health Interview Survey and the National
Health and Nutrition Examination Survey. Along with a litany of health metrics
including activity, weight and smoking status, these surveys also ask
participants to assess how much they believe they exercise compared to others
their own age.
"Individuals who thought they were less active than
other people their age were more likely to die, regardless of health status,
body mass index, and so on," Crum says.
That was true even though the researchers looked at people
who were roughly the same in every way, including how much they actually
exercised based on self-report and step-tracking data, obesity and heart
health, except for how much they thought they worked out compared to others…
Full-text (free):
http://www.npr.org/sections/health-shots/2017/07/20/538157820/just-thinking-youre-slacking-on-exercise-could-boost-risk-of-death
C.
Gabapentin and Pregabalin for Pain — Is Increased Prescribing a Cause for
Concern?
D.
38% of Americans received opioid Rx in 2015. Really??!!
An estimated 38% of American adults were prescribed an
opioid painkiller in 2015, according to a National Institute on Drug Abuse
study published in Annals of Internal Medicine. Researchers found that around
5% of US adults did not follow physicians' orders for use of the drugs, and 1%
had an opioid use disorder, which was more common among people with no health
insurance, those who lacked jobs and those with lower family incomes.
E.
Have Smartphones Destroyed a Generation?
More comfortable online than out partying, post-Millennials
are safer, physically, than adolescents have ever been. But they’re on the
brink of a mental-health crisis.
Jean Twenge. The Atlantic. September 2017
One day last summer, around noon, I called Athena, a
13-year-old who lives in Houston, Texas. She answered her phone—she’s had an
iPhone since she was 11—sounding as if she’d just woken up. We chatted about
her favorite songs and TV shows, and I asked her what she likes to do with her
friends. “We go to the mall,” she said. “Do your parents drop you off?,” I
asked, recalling my own middle-school days, in the 1980s, when I’d enjoy a few
parent-free hours shopping with my friends. “No—I go with my family,” she
replied. “We’ll go with my mom and brothers and walk a little behind them. I
just have to tell my mom where we’re going. I have to check in every hour or
every 30 minutes.”
Those mall trips are infrequent—about once a month. More often,
Athena and her friends spend time together on their phones, unchaperoned.
Unlike the teens of my generation, who might have spent an evening tying up the
family landline with gossip, they talk on Snapchat, the smartphone app that
allows users to send pictures and videos that quickly disappear. They make sure
to keep up their Snapstreaks, which show how many days in a row they have
Snapchatted with each other. Sometimes they save screenshots of particularly
ridiculous pictures of friends. “It’s good blackmail,” Athena said. (Because
she’s a minor, I’m not using her real name.) She told me she’d spent most of
the summer hanging out alone in her room with her phone. That’s just the way
her generation is, she said. “We didn’t have a choice to know any life without
iPads or iPhones. I think we like our phones more than we like actual people.”
I’ve been researching generational differences for 25 years,
starting when I was a 22-year-old doctoral student in psychology. Typically,
the characteristics that come to define a generation appear gradually, and
along a continuum. Beliefs and behaviors that were already rising simply
continue to do so. Millennials, for instance, are a highly individualistic
generation, but individualism had been increasing since the Baby Boomers turned
on, tuned in, and dropped out. I had grown accustomed to line graphs of trends
that looked like modest hills and valleys. Then I began studying Athena’s
generation.
Around 2012, I noticed abrupt shifts in teen behaviors and
emotional states. The gentle slopes of the line graphs became steep mountains
and sheer cliffs, and many of the distinctive characteristics of the Millennial
generation began to disappear. In all my analyses of generational data—some
reaching back to the 1930s—I had never seen anything like it…
The rest of the essay: https://www.theatlantic.com/magazine/archive/2017/09/has-the-smartphone-destroyed-a-generation/534198/
F.
Rotavirus vaccine tied to lower pediatric diarrhea hospitalizations, costs
More than 380,000 diarrhea-related hospitalizations among
children younger than 5 were prevented between 2008 and 2013 after routine
rotavirus vaccination was implemented in 2006, resulting in medical cost
savings of about $1.2 billion, researchers reported in the Journal of the
Pediatric Infectious Diseases Society.
G.
Tenecteplase Not Better or Safer in Ischemic Stroke: First head-to-head trial
shows no advantage against alteplase
H.
Some scientists suggest it might be better not to finish course of antibiotics
The long-held belief that a course of antibiotics must be
completed even if the patient is feeling better after a few days is not based
on solid scientific evidence, according to an opinion piece published in The
BMJ. Routinely advising patients to finish their antibiotics may actually
encourage antibiotic resistance, write lead author and infectious disease expert
Martin Llewelyn and his colleagues.
I.
Poison center calls about dietary supplements increase 50%
Calls to poison control centers about dietary supplements
rose nearly 50% from 2005 to 2012, according to a study in the Journal of
Medical Toxicology. Researchers found 70% of exposures concerned children under
age 6 and 99% of those were unintentional exposures.
J.
Study looks at use of secure messaging systems in hospitals
A study in the Journal of Hospital Medicine showed that just
26% of hospital-based clinicians reported that their organization implemented a
secure messaging option used by some clinicians, while only 7% said their
organization had a secure messaging option that was used by most clinicians.
Meanwhile, 79.8% of respondents said they were given pagers for communication,
49% of whom receive patient care-related communication through these devices.
K.
Statin Denialism Is 'A Deadly Internet-Driven Cult': Steve Nissen says the
battle for patients' hearts and minds is being lost
A leading cardiologist has unleashed a blistering attack on
"statin denial," which he calls "an internet-driven cult with
deadly consequences."
In an editorial in Annals of Internal Medicine, Steve Nissen
(Cleveland Clinic) expressed grave concerns over statistics showing that only
61% of people given a prescription for a statin were adherent at 3 months.
"For a treatment with such well- documented morbidity and mortality
benefits, these adherence rates are shockingly low. Why?" he asks.
Nissen writes that "we are losing the battle for the
hearts and minds of our patients to Web sites developed by people with little
or no scientific expertise…
CardioBrief essay: https://www.medpagetoday.com/Cardiology/CardioBrief/66863
Annals editorial (subscription required): http://annals.org/aim/article/2645554/statin-denial-internet-driven-cult-deadly-consequences
Annals study: https://www.ncbi.nlm.nih.gov/pubmed/28738423
L.
Healthy living adds years to life, study finds
Healthy lifestyle habits, such as not smoking and
maintaining a healthy weight, could increase a person's lifespan by five to
seven years, researchers reported in Health Affairs. The added longevity
comprised years of good health without physical limitations, and they
underscore the importance of prevention, the authors said.
