1. Oxygen Therapy in the ED
A. Suspected AMI
Hofman R, et al. N Engl J Med 2017 Aug 28 [Epub ahead of
print].
Background The clinical effect of routine oxygen therapy in
patients with suspected acute myocardial infarction who do not have hypoxemia
at baseline is uncertain.
Methods In this registry-based randomized clinical trial, we
used nationwide Swedish registries for patient enrollment and data collection.
Patients with suspected myocardial infarction and an oxygen saturation of 90%
or higher were randomly assigned to receive either supplemental oxygen (6
liters per minute for 6 to 12 hours, delivered through an open face mask) or
ambient air.
Results A total of 6629 patients were enrolled. The median
duration of oxygen therapy was 11.6 hours, and the median oxygen saturation at
the end of the treatment period was 99% among patients assigned to oxygen and
97% among patients assigned to ambient air. Hypoxemia developed in 62 patients
(1.9%) in the oxygen group, as compared with 254 patients (7.7%) in the
ambient-air group. The median of the highest troponin level during
hospitalization was 946.5 ng per liter in the oxygen group and 983.0 ng per
liter in the ambient-air group. The primary end point of death from any cause
within 1 year after randomization occurred in 5.0% of patients (166 of 3311)
assigned to oxygen and in 5.1% of patients (168 of 3318) assigned to ambient
air (hazard ratio, 0.97; 95% confidence interval [CI], 0.79 to 1.21; P=0.80).
Rehospitalization with myocardial infarction within 1 year occurred in 126
patients (3.8%) assigned to oxygen and in 111 patients (3.3%) assigned to
ambient air (hazard ratio, 1.13; 95% CI, 0.88 to 1.46; P=0.33). The results
were consistent across all predefined subgroups.
Conclusions Routine use of supplemental oxygen in patients
with suspected myocardial infarction who did not have hypoxemia was not found
to reduce 1-year all-cause mortality.
Journal Watch review: Suspected MI and Normal Oxygen
Saturation? Don't Bother with Supplemental Oxygen
See AVOID study: http://circ.ahajournals.org/content/131/24/2143.long
B. High-flow nasal cannula oxygen
therapy is superior to conventional oxygen therapy but not to noninvasive
mechanical ventilation on intubation rate: a systematic review and
meta-analysis
Zhao H, et al. Critical Care 2017;21:184
BACKGROUND: High-flow nasal cannula oxygen (HFNC) is a
relatively new therapy used in adults with respiratory failure. Whether it is
superior to conventional oxygen therapy (COT) or to noninvasive mechanical
ventilation (NIV) remains unclear. The aim of the present study was to
investigate whether HFNC was superior to either COT or NIV in adult acute
respiratory failure patients.
METHODS: A review of the literature was conducted from the
electronic databases from inception up to 20 October 2016. Only randomized
clinical trials comparing HFNC with COT or HFNC with NIV were included. The
intubation rate was the primary outcome; secondary outcomes included the
mechanical ventilation rate, the rate of escalation of respiratory support and
mortality.
RESULTS: Eleven studies that enrolled 3459 patients (HFNC,
n = 1681) were included. There were eight studies comparing HFNC with COT, two
comparing HFNC with NIV, and one comparing all three. HFNC was associated with
a significant reduction in intubation rate (OR 0.52, 95% CI 0.34 to 0.79,
P = 0.002), mechanical ventilation rate (OR 0.56, 95% CI 0.33 to 0.97,
P = 0.04) and the rate of escalation of respiratory support (OR 0.45, 95% CI
0.31 to 0.67, P less than 0.0001) when compared to COT. There was no difference
in mortality between HFNC and COT utilization (OR 1.01, 95% CI 0.67 to 1.53,
P = 0.96). When HFNC was compared to NIV, there was no difference in the
intubation rate (OR 0.96; 95% CI 0.66 to 1.39, P = 0.84), the rate of
escalation of respiratory support (OR 1.00, 95% CI 0.77 to 1.28, P = 0.97) or
mortality (OR 0.85, 95% CI 0.43 to 1.68, P = 0.65).
CONCLUSIONS: Compared to COT, HFNC reduced the rate of
intubation, mechanical ventilation and the escalation of respiratory support.
When compared to NIV, HFNC showed no better outcomes. Large-scale randomized
controlled trials are necessary to prove our findings.
Full-text (free): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5508784/
C. British Thoracic Society Guideline
for Oxygen Use in Adults in Healthcare and Emergency Settings
O'Driscoll BR, et al. BMJ Open Respir Res. 2017;4(1)
Executive summary: Philosophy of the guideline
✓ Oxygen is a treatment for hypoxaemia,
not breathlessness. Oxygen has not been proven to have any consistent effect on
the sensation of breathlessness in non-hypoxaemic patients.
✓ The essence of this guideline can be
summarised simply as a requirement for oxygen to be prescribed according to a
target saturation range and for those who administer oxygen therapy to monitor
the patient and keep within the target saturation range.
✓ The guideline recommends aiming to
achieve normal or near-normal oxygen saturation for all acutely ill patients
apart from those at risk of hypercapnic respiratory failure or those receiving
terminal palliative care.
In myocardial infarction and acute coronary syndromes, aim
at an oxygen saturation of 94–98% or 88–92% if the patient is at risk of
hypercapnic respiratory failure (grade D).
Full-text
(free): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5531304/
2. Why Do People Choose Emergency and Urgent Care Services? A
Rapid Review Utilizing a Systematic Literature Search and Narrative Synthesis.
Coster JE, et al. Acad Emerg Med. 2017;24(9):1137-1149.
OBJECTIVES: Rising demand for emergency and urgent care
services is well documented, as are the consequences, for example, emergency
department (ED) crowding, increased costs, pressure on services, and waiting
times. Multiple factors have been suggested to explain why demand is
increasing, including an aging population, rising number of people with
multiple chronic conditions, and behavioral changes relating to how people
choose to access health services. The aim of this systematic mapping review was
to bring together published research from urgent and emergency care settings to
identify drivers that underpin patient decisions to access urgent and emergency
care.
METHODS: Systematic searches were conducted across Medline
(via Ovid SP), EMBASE (via Ovid), The Cochrane Library (via Wiley Online
Library), Web of Science (via the Web of Knowledge), and the Cumulative Index
to Nursing and Allied Health Literature (CINAHL; via EBSCOhost). Peer-reviewed
studies written in English that reported reasons for accessing or choosing
emergency or urgent care services and were published between 1995 and 2016 were
included. Data were extracted and reasons for choosing emergency and urgent
care were identified and mapped. Thematic analysis was used to identify themes
and findings were reported qualitatively using framework-based narrative
synthesis.
RESULTS: Thirty-eight studies were identified that met the
inclusion criteria. Most studies were set in the United Kingdom (39.4%) or the
United States (34.2%) and reported results relating to ED (68.4%). Thirty-nine
percent of studies utilized qualitative or mixed research designs. Our thematic
analysis identified six broad themes that summarized reasons why patients chose
to access ED or urgent care. These were access to and confidence in primary
care; perceived urgency, anxiety, and the value of reassurance from
emergency-based services; views of family, friends, or healthcare
professionals; convenience (location, not having to make appointment, and
opening hours); individual patient factors (e.g., cost); and perceived need for
emergency medical services or hospital care, treatment, or investigations.
CONCLUSIONS: We identified six distinct reasons explaining
why patients choose to access emergency and urgent care services: limited
access to or confidence in primary care; patient perceived urgency;
convenience; views of family, friends, or other health professionals; and a
belief that their condition required the resources and facilities offered by a
particular healthcare provider. There is a need to examine demand from a whole
system perspective to gain better understanding of demand for different parts
of the emergency and urgent care system and the characteristics of patients
within each sector.
3. Lung-Protective Ventilation Initiated in the ED (LOV-ED): A
Quasi-Experimental, Before-After Trial.
Fuller BM, et al. Ann Emerg Med. 2017 Sep;70(3):406-418.e4.
STUDY OBJECTIVE: We evaluated the efficacy of an emergency
department (ED)-based lung-protective mechanical ventilation protocol for the
prevention of pulmonary complications.
METHODS: This was a quasi-experimental, before-after study
that consisted of a preintervention period, a run-in period of approximately 6
months, and a prospective intervention period. The intervention was a
multifaceted ED-based mechanical ventilator protocol targeting lung-protective
tidal volume, appropriate setting of positive end-expiratory pressure, rapid
oxygen weaning, and head-of-bed elevation. A propensity score-matched analysis
was used to evaluate the primary outcome, which was the composite incidence of
acute respiratory distress syndrome and ventilator-associated conditions.
RESULTS: A total of 1,192 patients in the preintervention
group and 513 patients in the intervention group were included. Lung-protective
ventilation increased by 48.4% in the intervention group. In the propensity
score-matched analysis (n=490 in each group), the primary outcome occurred in
71 patients (14.5%) in the preintervention group compared with 36 patients
(7.4%) in the intervention group (adjusted odds ratio 0.47; 95% confidence
interval [CI] 0.31 to 0.71). There was an increase in ventilator-free days
(mean difference 3.7; 95% CI 2.3 to 5.1), ICU-free days (mean difference 2.4;
95% CI 1.0 to 3.7), and hospital-free days (mean difference 2.4; 95% CI 1.2 to
3.6) associated with the intervention. The mortality rate was 34.1% in the
preintervention group and 19.6% in the intervention group (adjusted odds ratio
0.47; 95% CI 0.35 to 0.63).
CONCLUSION: Implementing a mechanical ventilator protocol in
the ED is feasible and is associated with significant improvements in the
delivery of safe mechanical ventilation and clinical outcome.
4. Can low-dose of ketamine reduce the need for morphine in
renal colic? [Yes!] A double-blind randomized clinical trial.
Abbasi S, et al. Am J Emerg Med. 2017 Aug 14 [Epub ahead of
print]
BACKGROUND: The combination of morphine with low doses of
ketamine (MK) has been utilized in the Emergency Department (ED) compared with
morphine and placebo (MP) for the treatment of acute pain in few studies. The
purpose of this study was to compare the effect of MP with MK for the treatment
of severe pain with renal colic of patients who had been referred to the ED.
METHODS: This study is a double blind randomized clinical
trial on patients with severe renal colic pain who were referred to the ED.
Patients were enrolled with pain severity of at least 6 of the 10 visual
analogue scales (VAS). Patients were divided into two groups: Morphine 0.1mg/kg
and placebo (MP group) and morphine 0.1mg/kg and ketamine 0.15mg/kg (MK group).
Pain of patients was studied in 10, 30, 60, 90, and 120min after injection.
RESULTS: Totally, 106 patients were enrolled in study
groups. Assessment of the average pain during 120min at 10 and 30min after the
start in the drug, MK group was significantly lower than the MP group (p=0.019
and p=0.003 respectively).
CONCLUSION: Given that combinations of morphine with low
doses of ketamine in patients with renal colic pain causes more pain and
morphine consumption reduction then this combination is suggested as an
alternative treatment that could be utilized in patients with renal colic.
5. Categorical Risk Perception Drives Variability in Antibiotic
Prescribing in the ED: A Mixed Methods Observational Study.
Klein EY, et al. J Gen Intern Med. 2017 Jun 20 [Epub ahead
of print]
BACKGROUND: Adherence to evidence-based antibiotic therapy
guidelines for treatment of upper respiratory tract infections (URIs) varies
widely among clinicians. Understanding this variability is key for reducing
inappropriate prescribing.
OBJECTIVE: To measure how emergency department (ED)
clinicians' perceptions of antibiotic prescribing risks affect their decision-making.
DESIGN: Clinician survey based on fuzzy-trace theory, a
theory of medical decision-making, combined with retrospective data on
prescribing outcomes for URI/pneumonia visits in two EDs. The survey predicts
the categorical meanings, or gists, that individuals derive from given
information.
PARTICIPANTS: ED physicians, residents, and physician
assistants (PAs) who completed surveys and treated patients with URI/pneumonia
diagnoses between August 2014 and December 2015.
MAIN MEASURES: Gists derived from survey responses and their
association with rates of antibiotic prescribing per visit.
KEY RESULTS: Of 4474 URI/pneumonia visits, 2874 (64.2%) had
an antibiotic prescription. However, prescribing rates varied from 7% to 91%
for the 69 clinicians surveyed (65.2% response rate). Clinicians who framed
therapy-prescribing decisions as a categorical choice between continued illness
and possibly beneficial treatment ("why not take a risk?" gist, which
assumes antibiotic therapy is essentially harmless) had higher rates of
prescribing (OR 1.28 [95% CI, 1.06-1.54]). Greater agreement with the
"antibiotics may be harmful" gist was associated with lower
prescribing rates (OR 0.81 [95% CI, 0.67-0.98]).
CONCLUSIONS: Our results indicate that clinicians who perceive
prescribing as a categorical choice between patients remaining ill or possibly
improving from therapy are more likely to prescribe antibiotics. However, this
strategy assumes that antibiotics are essentially harmless. Clinicians who
framed decision-making as a choice between potential harms from therapy and
continued patient illness (e.g., increased appreciation of potential harms) had
lower prescribing rates. These results suggest that interventions to reduce
inappropriate prescribing should emphasize the non-negligible possibility of
serious side effects.
6. ED Boarders: Problems and Solutions
A. Delayed Second Dose Antibiotics for
Patients Admitted From the Emergency Department With Sepsis:
Prevalence, Risk Factors, and Outcomes
Leisman D, et al. Crit Care Med. 2017;45(6):956-965.
OBJECTIVE: 1) Determine frequency and magnitude of delays in
second antibiotic administration among patients admitted with sepsis; 2)
Identify risk factors for these delays; and 3) Exploratory: determine
association between delays and patient-centered outcomes (mortality and
mechanical ventilation after second dose).
DESIGN: Retrospective, consecutive sample sepsis cohort over
10 months.
SETTING: Single, tertiary, academic medical center.
PATIENTS: All patients admitted from the emergency
department with sepsis or septic shock (defined: infection, ≥ 2 systemic
inflammatory response syndrome criteria, hypoperfusion/organ dysfunction)
identified by a prospective quality initiative.
EXCLUSIONS: less than 18 years old, not receiving initial
antibiotics in the emergency department, death before antibiotic redosing, and
patient refusing antibiotics.
INTERVENTIONS: We determined first-to-second antibiotic time
and delay frequency. We considered delay major for first-to-second dose time
greater than or equal to 25% of the recommended interval. Factors of interest
were demographics, recommended interval length, comorbidities, clinical
presentation, location at second dose, initial resuscitative care, and antimicrobial
activity mechanism.
MEASUREMENTS AND MAIN RESULTS: Of 828 sepsis cases, 272
(33%) had delay greater than or equal to 25%. Delay frequency increased dose
dependently with shorter recommended interval: 11 (4%) delays for 24-hour
intervals (median time, 18.52 hr); 31 (26%) for 12-hour intervals (median,
10.58 hr); 117 (47%) for 8-hour intervals (median, 9.60 hr); and 113 (72%) for
6-hour intervals (median, 9.55 hr). In multivariable regression, interval
length significantly predicted major delay (12 hr: odds ratio, 6.98; CI,
2.33-20.89; 8 hr: odds ratio, 23.70; CI, 8.13-69.11; 6 hr: odds ratio, 71.95;
CI, 25.13-206.0). Additional independent
risk factors were inpatient boarding in the emergency department (odds ratio,
2.67; CI, 1.74-4.09), initial 3-hour sepsis bundle compliance (odds ratio,
1.57; CI, 1.07-2.30), and older age (odds ratio, 1.16 per 10 yr, CI,
1.01-1.34). In the exploratory multivariable analysis, major delay was
associated with increased hospital mortality (odds ratio, 1.61; CI, 1.01-2.57)
and mechanical ventilation (odds ratio, 2.44; CI, 1.27-4.69).
CONCLUSIONS: Major second dose delays were common,
especially for patients given shorter half-life pharmacotherapies and who
boarded in the emergency department. They were paradoxically more frequent for
patients receiving compliant initial care. We observed association between
major second dose delay and increased mortality, length of stay, and mechanical
ventilation requirement.
B. Impact of inpatient Care in ED on
outcomes: a quasi-experimental cohort study.
Lateef A, et al. BMC Health Serv Res. 2017 Aug 14;17(1):555.
BACKGROUND: Hospitals around the world are faced with the
issue of boarders in emergency department (ED), patients marked for admission
but with no available inpatient bed. Boarder status is known to be associated
with delayed inpatient care and suboptimal outcomes. A new care delivery system
was developed in our institution where boarders received full inpatient care
from a designated medical team, acute medical team (AMT), while still residing
at ED. The current study examines the impact of this AMT intervention on
patient outcomes.
METHODS: We conducted a retrospective quasi-experimental
cohort study to analyze outcomes between the AMT intervention and conventional
care in a 1250-bed acute care tertiary academic hospital in Singapore. Study
participants included patients who received care from the AMT, a matched cohort
of patients admitted directly to inpatient wards (non-AMT) and a sample of
patients prior to the intervention (pre-AMT group). Primary outcomes were
length of hospital stay (LOS), early discharges (within 24 h) and bed
placement. Secondary outcomes included unplanned readmissions within 3 months,
and patient's bill size. χ2- and Mann-Whitney U tests were used to test for
differences between the cohorts on dichotomous and continuous variables
respectively.
RESULTS: The sample comprised of 2279 patients (1092 in AMT,
1027 in non-AMT, and 160 in pre-AMT groups). Higher rates of early discharge
(without significant differences in the readmission rates) and shorter LOS were
noted for the AMT patients. They were also more likely to be admitted into a
ward allocated to their discipline and had lower bill size compared to non AMT
patients.
CONCLUSIONS: The AMT intervention improved patient outcomes
and resource utilization. This model was noted to be sustainable and provides a
potential solution for hospitals' ED boarders who face a gap in inpatient care
during their crucial first few hours of admissions while waiting for an inpatient
bed.
7. Development and Validation of a Tool to Identify Patients with
Type 2 Diabetes at High Risk of Hypoglycemia-Related ED or Hospital Use.
Karter AJ, et al. JAMA Intern Med. 2017 Aug 21 [Epub ahead
of print]
IMPORTANCE: Hypoglycemia-related emergency department (ED)
or hospital use among patients with type 2 diabetes (T2D) is clinically
significant and possibly preventable.
OBJECTIVE: To develop and validate a tool to categorize risk
of hypoglycemic-related utilization in patients with T2D.
DESIGN, SETTING, AND PARTICIPANTS: Using recursive
partitioning with a split-sample design, we created a classification tree based
on potential predictors of hypoglycemia-related ED or hospital use. The resulting
model was transcribed into a tool for practical application and tested in 1
internal and 2 fully independent, external samples. Development and internal
testing was conducted in a split sample of 206 435 patients with T2D from
Kaiser Permanente Northern California (KPNC), an integrated health care system.
The tool was externally tested in 1 335 966 Veterans Health Administration and
14 972 Group Health Cooperative patients with T2D.
EXPOSURES: Based on a literature review, we identified 156
candidate predictor variables (prebaseline exposures) using data collected from
electronic medical records.
MAIN OUTCOMES AND MEASURES: Hypoglycemia-related ED or
hospital use during 12 months of follow-up.
RESULTS: The derivation sample (n = 165 148) had a mean (SD)
age of 63.9 (13.0) years and included 78 576 (47.6%) women. The crude annual
rate of at least 1 hypoglycemia-related ED or hospital encounter in the KPNC
derivation sample was 0.49%. The resulting hypoglycemia risk stratification
tool required 6 patient-specific inputs: number of prior episodes of
hypoglycemia-related utilization, insulin use, sulfonylurea use, prior year ED
use, chronic kidney disease stage, and age. We categorized the predicted
12-month risk of any hypoglycemia-related utilization as high (greater than 5%),
intermediate (1%-5%), or low (less than 1%). In the internal validation sample,
2.0%, 10.7%, and 87.3% were categorized as high, intermediate, and low risk,
respectively, with observed 12-month hypoglycemia-related utilization rates of
6.7%, 1.4%, and 0.2%, respectively. There was good discrimination in the
internal validation KPNC sample (C statistic = 0.83) and both external
validation samples (Veterans Health Administration: C statistic = 0.81; Group
Health Cooperative: C statistic = 0.79).
CONCLUSIONS AND RELEVANCE: This hypoglycemia risk
stratification tool categorizes the 12-month risk of hypoglycemia-related
utilization in patients with T2D using only 6 inputs. This tool could
facilitate targeted population management interventions, potentially reducing
hypoglycemia risk and improving patient safety and quality of life.
8. Tongue-in-Cheek: Critical Research that Escaped the Press
A. Report: Saying ‘Smells Okay’
Precedes 85% Of Foodborne Illnesses Annually
ATLANTA—Presenting research with significant implications
for public health, a report published Wednesday by the Centers for Disease
Control and Prevention revealed that saying the phrase “smells okay” precedes
85 percent of foodborne illnesses in the United States annually. “We analyzed
data from thousands of cases involving food-related ailments over the last
decade and concluded that most individuals had given a quick once-over to
leftovers and uttered some variation of ‘probably still good’ before spending
the next several hours suffering intense stomach pain and vomiting,” said Dr.
Robert Husted, director of the CDC’s Division of Foodborne, Waterborne, and
Environmental Diseases, adding that cases of E. coli and botulism had been
directly linked to individuals observing that the contaminated food “hasn’t
been sitting out for that long.”
“In addition, determining that grayish chicken Alfredo
simply needed to be stirred or that an improperly covered week-old meatloaf
would be fine once an outer layer was cut off almost tripled the chances of
contracting salmonella.” The report also confirmed that thousands of Americans
across the country are infected with a foodborne illness every year shortly
after being asked by a friend or family member to “try this.”
Courtesy
of the Onion.
B. Study Finds Health Benefits
Associated with Seriously Considering Going Vegetarian for A While Now
ROCKVILLE, MD—In what researchers describe as a major
discovery in the field of dietetics, a study published in the American Journal
Of Clinical Nutrition Tuesday linked long-term health benefits to seriously
thinking about going vegetarian for a while now. “Our research found that
people who actively toss around the idea of cutting meat out of their diet
exhibited substantial and lasting improvements in their physical well-being,”
said study lead author Dr. Olivia Marlow, adding that regularly telling others
about one’s plan to transition to an exclusively plant-based diet sometime in
the near future was strongly associated with dramatic reductions in heart disease,
diabetes, and even cancer.
“The results also demonstrated a robust correlation between
improved cardiovascular health and telling acquaintances that while avoiding
bacon would be hard, it wasn’t like you were eating a steak every night to
begin with. In addition, the positive relationship between browsing vegetarian
cookbooks and restaurants online and overall longevity seems especially
promising.” The researchers went on to state, however, that the benefits of
considering a vegetarian diet still paled in comparison to those enjoyed by
individuals who inform friends they were now officially meat-free and haven’t
had a burger in more than a week.
Courtesy
of the Onion.
C. Report: Americans Most Physically
Active When Getting Comfy
BETHESDA, MD—Saying such activities overwhelmingly accounted
for calories burned in the U.S., a report released Tuesday by the National
Institutes of Health found that Americans are most physically active when
getting comfy. “Key indicators of physical activity such as increased heart
rate and respiration reach their peak when Americans are rolling over in bed or
wiggling around in order to find a more optimal sitting posture on the couch,”
the report read in part, adding that researchers observed an exceptionally high
flow of oxygen to muscles when participants lifted their legs onto an ottoman
or enlisted their upper body to spread a comforter when they were chilly.
“Using fitness trackers, we discovered that Americans take
most of their daily steps when walking back and forth in their home to ensure
that their desired snacks and the remote control were in reach while they’re
watching TV. Furthermore, most of their cardiovascular endurance can be
attributed to the regular, almost daily practice of throwing on sweatpants immediately
after getting home from work.” The report also noted, however, that most
serious injuries are sustained by Americans overexerting themselves while
stacking a second pillow behind the first.
Courtesy
of the Onion.
D. Boring PowerPoints New Leading Cause
of Death Among Health Care Practitioners
BY DR. 99
ATLANTA, GA – A new study published in the latest issue of
the Journal of Small Font &
Uninteresting Topics (JSFUT) revealed that sinfully boring PowerPoint
presentations is now the leading cause of death among health care practitioners
worldwide, overtaking both heart disease and cerebrovascular disease. The study led by Dr. Steven Doldrums and Dr.
Mara Tedium of Georgia Medical Center has sent shockwaves through the medical
community, waking everyone up abruptly.
“Monotonous PowerPoint presentations are lethal even in the
smallest doses,” wrote JSFUT editor Michael Ennui. “First, it’s altered mental status,
bradycardia, and respiratory depression, then eventual progression to
catatonia, coma, and ultimately death by boredom. What’s fascinating is that this occurs
independent of a health care practitioner’s sleep deprivation status.”
Tedium states that standard PowerPoint presentation (SPPs)
have a kill rate of 33% while “the most boring of boring” PowerPoints (TMBBPPs)
have a kill rate of 100%...
According to the study, certain types of PowerPoint
presentations led to higher mortality rates.
As number of PowerPoint slides or journal references increased, so did
the death rates among vulnerable health care practitioners. Boredom-induced death increased in direct
proportion to how much the presenter simply read off of the PowerPoint
slides. The death rate was inversely
proportional to both the number of pictures present and the size of font utilized. Finally, topics presented by hospital
administrators had a kill rate of 100%.
A PowerPoint slide with a funny cartoon, furry animal, or
cute child was protective for fifteen seconds but risk of death increased with
progression to the next dull slide.
Interestingly, PowerPoint presentations about diabetic foot infections
or intestinal worms didn’t cause death, but did produce high rates of
paroxysmal vomiting when given during lunch hour conferences.
Next week, the Food & Drug Administration (FDA) is
expected to start placing black box warnings on PowerPoint presentations
informing health care practitioners of the risk for death upon exposure to its
contents.
Courtesy
of Gomer Blog
E. A Study on the Coffee Spilling
Phenomena in the Low Impulse Regime
Han J. Achieve Life
Sci. 2016;10(1):87-101.
When a half-full Bordeaux glass is oscillated sideways at 4
Hz, calm waves of wine gently ripple upon the surface. However, when a
cylindrical mug is subject to the same motion, it does not take long for the
liquid to splash aggressively against the cup and ultimately spill. This is a
manifestation of the same principles that also make us spill coffee when we
walk. In this study, we first investigate the physical properties of the
fluid-structure interaction of the coffee cup…
9. Annals Brief Reviews
A. Update: D-dimer Test for Excluding
the Diagnosis of PE
Take-Home Message
Patients with a low pretest probability for pulmonary
embolism according to a structured clinical prediction rule and a negative
D-dimer result are unlikely to have pulmonary embolism, particularly among
those younger than 65 years.
B. Do Inhaled Anticholinergic Agents in
Addition to β-Agonists Improve Outcomes in Acute Asthma Exacerbations?
Take-Home Message
The addition of inhaled anticholinergic agents to β-2
agonists reduced hospitalization and improved pulmonary function testing, but
was also associated with increased rates of mild adverse events.
10. Images in Clinical Practice
Young Adult Male in a Coma
Middle-Aged Female With Chest Pain—Fleischner’s sign on CXR
(classic PE, right?)
Boy With Muscle Spasms—tetanus—in the US—in an immunized
boy!
Male With Severe Headache
Boy With Fever and Cough
Man With Suprapubic Pain
Man With Shortness of Breath
Eczema Herpeticum
Venous Congestion in Ischemic Bowel
Eosinophilic Bronchitis
Sturge–Weber Syndrome
Neobladder Stone
Left Ventricular Free-Wall Rupture
Iridodonesis
Image Diagnosis: Rapidly Enlarging Scrotal Hematoma: A
Complication of Femoral Access?
11. The HII Score - A Novel Tool to Assess Impairment from
Alcohol in ED Pts.
Hack JB, et al. Acad Emerg Med. 2017 Jul 30 [Epub ahead of
print]
BACKGROUND: Over 35 million alcohol impaired (AI) patients are
cared for in Emergency Departments (EDs) annually. Emergency physicians are
charged with ensuring AI patients' safety by identifying resolution of alcohol
induced impairment. The most common standard evaluation is an extemporized
clinical examination, as ethanol levels are not reliable or predictive of
clinical symptoms. There is no standard assessment of ED AI patients.
OBJECTIVE: To evaluate a novel standardized emergency
department assessment of alcohol impairment - Hack's Impairment Index (HII score),
in a busy urban Emergency Department.
METHODS: A retrospective chart review was performed for all
AI patients seen in our busy urban ED over 24 months. Trained nurses evaluated
AI patients with both "usual" and HII score every 2 hours. Patients
were stratified by frequency of visits for AI during this time: high (≥ 6),
medium (2-5), and low (1). Within each category, comparisons were made between
HII scores, measured ethanol levels, and usual nursing assessment of AI.
Changes in HII scores over time were also evaluated.
RESULTS: 8074 visits from 3219 unique patients were eligible
for study, including 7973 (98.7%) with ethanol levels, 5061 (62.7%) with
complete HII scores, and 3646 (45.2%) with HCP assessments. Correlations
between HII scores and ethanol levels were poor (Pearson's R2 = 0.09, 0.09, and
0.17 for high-, medium-, and low-frequency strata). HII scores were excellent
at discriminating nursing assessment of AI, while ethanol levels were less
effective. Omitting extrema, HII scores fell consistently an average 0.062
points per hour, throughout patients' visits.
CONCLUSIONS: The HII score applied a quantitative, objective
assessment of alcohol impairment. HII scores were superior to ethanol levels as
an objective clinical measure of impairment. The HII declines in a reasonably
predictable manner over time, with serial evaluations corresponding well with
HCP evaluations.
12. Errors in Diagnosis of Spinal Epidural Abscesses in the Era
of Electronic Health Records.
Bhise V, et al. Am J Med. 2017 Aug;130(8):975-981.
PURPOSE: With this study, we set out to identify missed
opportunities in diagnosis of spinal epidural abscesses to outline areas for
process improvement.
METHODS: Using a large national clinical data repository, we
identified all patients with a new diagnosis of spinal epidural abscess in the
Department of Veterans Affairs (VA) during 2013. Two physicians independently
conducted retrospective chart reviews on 250 randomly selected patients and
evaluated their records for red flags (eg, unexplained weight loss, neurological
deficits, and fever) 90 days prior to diagnosis. Diagnostic errors were defined
as missed opportunities to evaluate red flags in a timely or appropriate
manner. Reviewers gathered information about process breakdowns related to
patient factors, the patient-provider encounter, test performance and
interpretation, test follow-up and tracking, and the referral process.
Reviewers also determined harm and time lag between red flags and definitive
diagnoses.
RESULTS: Of 250 patients, 119 had a new diagnosis of spinal
epidural abscess, 66 (55.5%) of which experienced diagnostic error. Median time
to diagnosis in error cases was 12 days, compared with 4 days in cases without
error (P less than .01). Red flags that were frequently not evaluated in error
cases included unexplained fever (n = 57; 86.4%), focal neurological deficits
with progressive or disabling symptoms (n = 54; 81.8%), and active infection (n
= 54; 81.8%). Most errors involved breakdowns during the patient-provider
encounter (n = 60; 90.1%), including failures in information
gathering/integration, and were associated with temporary harm (n = 43; 65.2%).
CONCLUSION: Despite wide availability of clinical data,
errors in diagnosis of spinal epidural abscesses are common and involve
inadequate history, physical examination, and test ordering. Solutions should
include renewed attention to basic clinical skills.
13. Usefulness of lab and radiological
investigations in the management of SVT
Ashok A, et al. Emerg Med Australas. 2017 Aug;29(4):394-399.
OBJECTIVE: Although ED patients presenting with
supraventricular tachycardia (SVT) are commonly investigated, the value of
these investigations has been questioned. We aimed to determine the frequency
and utility of investigations in patients with SVT.
METHODS: We undertook an explicit retrospective medical
record audit of patients with SVT who presented to a single ED (January 2004 to
June 2014). Data on demographics, presenting complaints, investigations and
outcomes were extracted. The outcomes were nature and utility of
investigations.
RESULTS: A total of 633 patients were enrolled (mean [SD]
age 55.4 [17.7] years, 62% female). Laboratory investigations were common:
electrolytes (83.7% of patients), full blood count (81.2%), magnesium (57.5%),
calcium (39.3%) and thyroid function (30.3%). These investigations revealed
many mildly abnormal results but resulted in electrolyte supplementation in
only 19 patients: eight with mild hypokalaemia (potassium 3.0-3.5 mmol/L) and
11 with mild hypomagnesia (magnesium 0.49-1.1 mmol/L). Troponin was ordered for
302 (47.7%) patients, many of whom had no history or risk factors for cardiac
disease, or ischaemic symptoms associated with their SVT. The troponin was
normal, mildly and moderately elevated in 65.2, 24.5 and 10.2% of cases,
respectively. Only seven (1.1%) patients were diagnosed with acute myocardial
ischemia. Although 190 (30.0%) patients had a chest X-ray (CXR), it was normal
in 78.4% of cases. All CXR abnormalities were incidental and not relevant to
the immediate ED management.
CONCLUSION: Patients with uncomplicated SVT are
over-investigated. Guidelines for ED SVT investigation are recommended. Further
research is recommended to determine the indications for each investigation in
the setting of SVT.
14. External Validation of the Universal
Termination of Resuscitation Rule for Out-of-Hospital Cardiac Arrest in British
Columbia
Grunau B, et al. Ann Emerg Med. 2017 Sep;70(3):374-381.e1.
STUDY OBJECTIVE: The Universal Termination of Resuscitation
Rule (TOR Rule) was developed to identify out-of-hospital cardiac arrests
eligible for field termination of resuscitation, avoiding futile transportation
to the hospital. The validity of the rule in emergency medical services (EMS)
systems that do not routinely transport out-of-hospital cardiac arrest patients
to the hospital is unknown. We seek to validate the TOR Rule in British
Columbia.
METHODS: This study included consecutive, nontraumatic,
adult, out-of-hospital cardiac arrests treated by EMS in British Columbia from
April 2011 to September 2015. We excluded patients with active
do-not-resuscitate orders and those with missing data. Following consensus
guidelines, we examined the validity of the TOR Rule after 6 minutes of
resuscitation (to approximate three 2-minute cycles of resuscitation). To
ascertain rule performance at the different time junctures, we recalculated TOR
Rule classification accuracy at subsequent 1-minute resuscitation increments.
RESULTS: Of 6,994 consecutive, adult, EMS-treated,
out-of-hospital cardiac arrests, overall survival was 15%. At 6 minutes of
resuscitation, rule performance was sensitivity 0.72, specificity 0.91,
positive predictive value 0.98, and negative predictive value 0.36. The TOR
Rule recommended care termination for 4,367 patients (62%); of these, 92
survived to hospital discharge (false-positive rate 2.1%; 95% confidence
interval 1.7% to 2.5%); however, this proportion steadily decreased with later
application. The TOR Rule recommended continuation of resuscitation in 2,627
patients (38%); of these, 1,674 died (false-negative rate 64%; 95% confidence
interval 62% to 66%). Compared with 6-minute application, test characteristics
at 30 minutes demonstrated nearly perfect positive predictive value (1.0) and specificity
(1.0) but a lower sensitivity (0.46) and negative predictive value (0.25).
CONCLUSION: In this cohort of adult out-of-hospital cardiac
arrest patients, the TOR Rule applied at 6 minutes falsely recommended care
termination for 2.1% of patients; however, this decreased with later
application. Systems using the TOR Rule to cease resuscitation in the field
should consider rule application at points later than 6 minutes.
15. IV Corticosteroid Premedication
Administered 5 Hours Before CT Compared with a Traditional 13-Hour Oral
Regimen.
Mervak BM, et al. Radiology. 2017 Jul 26 [Epub ahead of
print]
Purpose To determine if the allergic-like breakthrough
reaction rate of intravenous corticosteroid prophylaxis administered 5 hours
before contrast material-enhanced computed tomography (CT) is noninferior to
that of a traditional 13-hour oral regimen. Materials and Methods Institutional
review board approval was obtained and informed consent waived for this
retrospective noninferiority cohort study.
Subjects (n = 202) who completed an accelerated 5-hour
intravenous corticosteroid premedication regimen before low-osmolality
contrast-enhanced CT for a prior allergic-like or unknown-type reaction to
iodine-based contrast material from June 1, 2008, to June 30, 2016, were
identified. The breakthrough reaction rate was compared by using the Farrington
and Manning noninferiority likelihood score to test subjects premedicated with
a traditional 13-hour oral regimen (2.1% [13 of 626]). All subjects were
premedicated for a prior allergic-like or unknown-type reaction to iodine-based
contrast material. A noninferiority margin of 4.0% was selected to allow for no
more than a clinically negligible 6.0% breakthrough reaction rate in the cohort
that received 5-hour intravenous corticosteroid prophylaxis.
Results The breakthrough reaction rate for 5-hour
intravenous prophylaxis was 2.5% (five of 202 patients; 95% confidence
interval: 0.8%, 5.7%), which was noninferior to the 2.1% (13 of 626 patients;
95% confidence interval: 1.1%, 3.5%) rate for the 13-hour regimen (P = .0181).
The upper limits of the confidence interval for the difference between the two
rates was 3.7% (0.4%; 95% confidence interval: -1.6%, 3.7%), which was within
the 4.0% noninferiority margin. All breakthrough reactions were of equal or
lesser severity to those of the index reactions (two severe, one moderate, and
one mild reaction).
Conclusion Accelerated intravenous premedication with
corticosteroids beginning 5 hours before contrast-enhanced CT has a
breakthrough reaction rate noninferior to that of a 13-hour oral premedication
regimen
16. More Prognostic Tools
A. Severe Hyperkalemia: Can the ECG
Risk Stratify for Short-term Adverse Events?
Durfey N, et al. West J Emerg Med. 2017;18(5)963-971.
Introduction: The electrocardiogram (ECG) is often used to
identify which hyperkalemic patients are at risk for adverse events. However,
there is a paucity of evidence to support this practice. This study analyzes
the association between specific hyperkalemic ECG abnormalities and the
development of short-term adverse events in patients with severe hyperkalemia.
Methods: We collected records of all adult patients with
potassium (K+) ≥6.5 mEq/L in the hospital laboratory database from August 15,
2010, through January 30, 2015. A chart review identified patient demographics,
concurrent laboratory values, ECG within one hour of K+ measurement, treatments
and occurrence of adverse events within six hours of ECG. We defined adverse
events as symptomatic bradycardia, ventricular tachycardia, ventricular
fibrillation, cardiopulmonary resuscitation (CPR) and/or death. Two emergency
physicians blinded to study objective independently examined each ECG for rate,
rhythm, peaked T wave, PR interval duration and QRS complex duration. Relative
risk was calculated to determine the association between specific hyperkalemic
ECG abnormalities and short term adverse events.
Results: We included a total of 188 patients with severe
hyperkalemia in the final study group. Adverse events occurred within six hours
in 28 patients (15%): symptomatic bradycardia (n=22), death (n=4), ventricular
tachycardia (n=2) and CPR (n=2). All adverse events occurred prior to treatment
with calcium and all but one occurred prior to K+-lowering intervention. All
patients who had a short-term adverse event had a preceding ECG that
demonstrated at least one hyperkalemic abnormality (100%, 95% confidence interval
[CI] [85.7-100%]). An increased likelihood of short-term adverse event was
found for hyperkalemic patients whose ECG demonstrated QRS prolongation
(relative risk [RR] 4.74, 95% CI[2.01-11.15]), bradycardia (HR less than 50)
(RR 12.29, 95%CI [6.69-22.57]), and/or junctional rhythm (RR 7.46,95%CI
5.28-11.13). There was no statistically significant correlation between peaked
T waves and short-term adverse events (RR 0.77, 95% CI [0.35-1.70]).
Conclusion: Our findings support the use of the ECG to risk
stratify patients with severe hyperkalemia for short-term adverse events.
B. Predicting Short-Term Risk of
Arrhythmia among Patients with Syncope: The Canadian Syncope Arrhythmia Risk
Score.
Thiruganasambandamoorthy V, et al. Acad Emerg Med. 2017 Aug
9 [Epub ahead of print]
BACKGROUND: Syncope can be caused by serious occult
arrhythmias not evident during initial emergency department (ED) evaluation. We
sought to develop a risk-tool for predicting 30-day arrhythmia or death after
ED disposition.
METHODS: We conducted a multicenter prospective cohort study
at six tertiary-care EDs and included adults (≥16 years) with syncope. We
collected standardized variables from clinical evaluation, and investigations
including ECG and troponin at index presentation. Adjudicated outcomes included
death or arrhythmias including procedural interventions for arrhythmia within
30-days. We used multivariable logistic regression to derive the prediction
model and bootstrapping for interval validation to estimate shrinkage and
optimism.
RESULTS: 5,010 patients (mean age 53.4 years, 54.8% females,
and 9.5% hospitalized) were enrolled with 106 (2.1%) patients suffering 30-day
arrhythmia/death after ED disposition. We examined 39 variables and eight were
included in the final model: lack of vasovagal predisposition, heart disease,
any ED systolic blood pressure less than 90 or over 180mmHg, troponin (above the
99%ile), QRS duration greater than 130msec, QTc interval greater than 480msec
and ED diagnosis of cardiac/vasovagal syncope [optimism corrected c-statistic
0.90 (95% CI 0.87 - 0.93); Hosmer-Lemeshow p=0.08]. The Canadian Syncope
Arrhythmia Risk Score had a risk ranging from 0.2% to 74.5% for scores of -2 to
8. At a threshold score of ≥0, the sensitivity was 97.1% (95%CI 91.6%,99.4%)
and specificity was 53.4% (95%CI 52.0%,54.9%).
CONCLUSIONS: The Canadian Syncope Arrhythmia Risk Score can
improve patient safety by identification of those at-risk for arrhythmias and
aid in acute management decisions. . Once validated, the score can identify
low-risk patients who will require no further investigations. This article is
protected by copyright. All rights reserved.
C. Validation of the No Objective
Testing (NOT) Rule and Comparison to the HEART Pathway.
Stopyra JP, et al. Acad Emerg Med. 2017;24(9):1165-68.
BACKGROUND: The no objective testing rule (NOTR) is a
decision aid designed to safely identify emergency department (ED) patients
with chest pain who do not require objective testing for coronary artery disease.
OBJECTIVES: The objective was to validate the NOTR in a
cohort of U.S. ED patients with acute chest pain and compare its performance to
the HEART Pathway.
METHODS: A secondary analysis of 282 participants enrolled
in the HEART Pathway randomized controlled trial was conducted. Each patient
was classified as low risk or at risk by the NOTR. Sensitivity for major
adverse cardiac events (MACE) at 30 days was calculated in the entire study
population. NOTR and HEART Pathways were compared among patients randomized to
the HEART Pathway in the parent trial using McNemar's test and the net
reclassification improvement (NRI).
RESULTS: Major adverse cardiac events occurred in 22/282
(7.8%) participants, including no deaths, 16/282 (5.6%) with myocardial infarction
(MI), and 6/282 (2.1%) with coronary revascularization without MI. NOTR was
100% (95% confidence interval [CI] = 84.6%-100%) sensitive for MACE and
identified 78/282 patients (27.7%, 95% = CI 22.5-33.3%) as low risk. In the
HEART Pathway arm (n = 141), both NOTR and HEART Pathway identified all
patients with MACE as at risk. Compared to NOTR, the HEART Pathway was able to
correctly reclassify 27 patients without MACE as low risk, yielding a NRI of
20.8% (95% CI = 11.3%-30.2%).
CONCLUSIONS: Within a U.S. cohort of ED patients with chest
pain, the NOTR and HEART Pathway were 100% sensitive for MACE at 30 days.
However, the HEART Pathway identified more patients suitable for early
discharge than the NOTR.
17. Central venous catheter placement in
coagulopathic patients: risk factors and incidence of bleeding complications.
van de Weerdt EK, et al. Transfusion. 2017 Aug 30 [Epub
ahead of print]
BACKGROUND: Central venous catheters are frequently inserted
into patients with coagulation disorders. It is unclear whether preprocedural
correction of hemostasis is beneficial. We determined the incidence of bleeding
complications after central venous catheter placement in patients who had
severe coagulopathy and identified potential risk factors for bleeding.
STUDY DESIGN AND METHODS: The MEDLINE and Cochrane Library
databases were systematically searched through November 2015. To be included,
articles must have reported on hemorrhagic complications with specification of
abnormal coagulation testing results. Severe coagulopathy was defined as a
reduced platelet count of 50 × 109 /L or less, and/or an elevated international
normalized ratio of 1.5 or greater, and/or a partial thromboplastin time of 45
seconds or greater.
RESULTS: We included one randomized controlled trial and 21
observational studies. In total, there were 13,256 catheter insertions,
including 4213 in patients with severe coagulopathy. Before 3150 central venous
catheter placements, coagulopathy was not corrected. The bleeding incidence
varied from 0 to 32%. The severity of coagulopathy did not predict the risk of
bleeding. No study demonstrated a beneficial effect from the prophylactic
administration of platelets or fresh-frozen plasma to prevent bleeding
complications. Retrospective observational studies suggested that no
preprocedural correction is required up to a platelet count of 20 × 109 /L and
an international normalized ratio of 3.0.
CONCLUSION: The incidence of major bleeding complications
after central venous catheter placement is low, even in coagulopathic patients.
Based on a systematic research of the literature, strong evidence supporting
the correction of hemostatic defects before central venous catheter insertion
is lacking. However, well-powered randomized controlled trials will be
necessary to determine the minimal platelet count, the maximal international
normalized ratio, and an activated partial thromboplastin time that is safe
before central venous catheter insertion.
18. Day-Supply of Opioid Rx Factor in
Likelihood of Long-Term Use
Doctors should prescribe for the minimum numbers of days,
researchers say
WEDNESDAY, Aug. 23, 2017 (HealthDay News) -- The days
supplied is far more important than the dosage level or even the type of pain
being treated in risk of opioid use disorder following opioid prescription,
according to a study published recently in The Journal of Pain.
Bradley Martin, Pharm.D., Ph.D., a pharmacist at the
University of Arkansas for Medical Sciences in Little Rock, and colleagues
examined 2006 to 2015 medical records for 1,353,902 patients who were
prescribed opioids for the first time.
The overwhelming majority of patients discontinued opioid
use, the researchers found. Patients were more likely to continue using the
opioids if they were initially prescribed medications for a longer time.
"Comparing someone who has a one- or two-day supply of
opioids with someone who has a week's supply, the risk of use doubles,"
Martin said in a university news release. "This is something clinicians
can easily modify when they prescribe opioids." He and his team suggested
prescribers use "the minimum effective opioid dose and duration to reduce
unintended long-term use."
Factors Influencing Long-Term Opioid
Use Among Opioid Naive Patients: An Examination of Initial Prescription
Characteristics and Pain Etiologies.
Shah A, et al. J Pain. 2017 Jul 13 [Epub ahead of print]
The relationships between the initial opioid prescription
characteristics and pain etiology with the probability of opioid
discontinuation were explored in this retrospective cohort study using health
insurance claims data from a nationally representative database of commercially
insured patients in the United States.
We identified 1,353,902 persons aged 14 years and older with
no history of cancer or substance abuse, with new opioid use episodes and
categorized them into 11 mutually exclusive pain etiologies. Cox proportional
hazards models were estimated to identify factors associated with time to
opioid discontinuation. After accounting for losses to follow-up, the
probability of continued opioid use at 1 year was 5.3% across all subjects.
Patients with chronic pain had the highest probability for continued opioid use
followed by patients with inpatient admissions. Patients prescribed doses ≥90
morphine milligram equivalents (hazard ratio [HR] = .91; 95% confidence
interval [CI], .91-.92), initiated with tramadol (HR = .89; 95% CI, .89-.90) or
long-acting opioids (HR = .79; 95% CI, .77-.82) were less likely to discontinue
opioids. Increasing days' supply of the first prescription was consistently
associated with a lower likelihood of opioid discontinuation (HRs, CIs: 3-4
days' supply = .70, .70-.71; 5-7 days' supply = .48, .47-.48; 8-10 days' supply
= .37, .37-.38; 11-14 days' supply = .32, .31-.33; 15-21 days' supply = .29,
.28-.29; ≥22 days supplied = .20, .19-.20). The direction of this relationship
was consistent across all pain etiologies. Clinicians should initiate patients
with the lowest supply of opioids to mitigate unintentional long-term opioid
use.
PERSPECTIVE: This study shows that characteristics of the
first opioid prescription, particularly duration of the prescription, are
significant predictors of continued opioid use irrespective of the indication
for an opioid prescription. These data should encourage prescribers to initiate
patients using the minimum effective opioid dose and duration to reduce
unintended long-term use and could motivate policies that restrict the initial
supply of opioids.
19. Pediatric Corner
A. Is Tachycardia at Discharge from the
Pediatric ED a Cause for Concern? A Nonconcurrent Cohort Study.
Wilson PM, et al. Ann Emerg Med. 2017;70(3): 268–276.e2
STUDY OBJECTIVE: We evaluate the association between
discharge tachycardia and (1) emergency department (ED) and urgent care revisit
and (2) receipt of clinically important intervention at the revisit.
METHODS: The study included a nonconcurrent cohort of
children aged 0 to younger than 19 years, discharged from 2 pediatric EDs and 4
pediatric urgent care centers in 2013. The primary exposure was discharge
tachycardia (last recorded pulse rate ≥99th percentile for age). The main
outcome was ED or urgent care revisit within 72 hours of discharge. Additional
outcomes included interventions received and disposition at the revisit,
prevalence of discharge tachycardia at the index visit, and associations of
pain, fever, and medications with discharge tachycardia. Multivariable logistic
regression determined relative risk ratios for revisit and receipt of
clinically important intervention at the revisit.
RESULTS: Of eligible visits, 126,774 were included, of which
10,470 patients (8.3%) had discharge tachycardia. Discharge tachycardia was
associated with an increased risk of revisit (adjusted RR 1.3; 95% confidence
interval 1.2 to 1.5), increased risk of tachycardia at the revisit (relative risk
3.1; 95% confidence interval 2.6 to 3.7), and of the receipt of certain
clinically important interventions (supplemental oxygen, respiratory
medications and admission, antibiotics and admission, and peripheral
intravenous line placement and admission). However, there was no increased risk
for the composite outcome of receipt of any clinically important intervention
or admission on revisit.
CONCLUSION: Discharge tachycardia is associated with an
increased risk of revisit. It is likely that tachycardia at discharge is not a
critical factor associated with impending physiologic deterioration.
B. Risk Factors for Adverse Events in ED
Procedural Sedation for Children: Ketamine is Safest
Bhatt M, et al. JAMA Pediatr. 2017 Aug 21 [Epub ahead of
print]
Importance: Procedural sedation for children undergoing
painful procedures is standard practice in emergency departments worldwide.
Previous studies of emergency department sedation are limited by their
single-center design and are underpowered to identify risk factors for serious
adverse events (SAEs), thereby limiting their influence on sedation practice
and patient outcomes.
Objective: To examine the incidence and risk factors
associated with sedation-related SAEs.
Design, Setting, and Participants: This prospective,
multicenter, observational cohort study was conducted in 6 pediatric emergency
departments in Canada between July 10, 2010, and February 28, 2015. Children 18
years or younger who received sedation for a painful emergency department
procedure were enrolled in the study. Of the 9657 patients eligible for
inclusion, 6760 (70.0%) were enrolled and 6295 (65.1%) were included in the
final analysis.
Exposures: The primary risk factor was receipt of sedation
medication. The secondary risk factors were demographic characteristics,
preprocedural medications and fasting status, current or underlying health
risks, and procedure type.
Main Outcomes and Measures: Four outcomes were examined:
SAEs, significant interventions performed in response to an adverse event,
oxygen desaturation, and vomiting.
Results: Of the 6295 children included in this study, 4190
(66.6%) were male and the mean (SD) age was 8.0 (4.6) years. Adverse events
occurred in 736 patients (11.7%; 95% CI, 6.4%-16.9%). Oxygen desaturation (353
patients [5.6%]) and vomiting (328 [5.2%]) were the most common of these
adverse events. There were 69 SAEs (1.1%; 95% CI, 0.5%-1.7%), and 86 patients
(1.4%; 95% CI, 0.7%-2.1%) had a significant intervention. Use of ketamine
hydrochloride alone resulted in the lowest incidence of SAEs (17 [0.4%]) and
significant interventions (37 [0.9%]). The incidence of adverse sedation
outcomes varied significantly with the type of sedation medication. Compared
with ketamine alone, propofol alone (3.7%; odds ratio [OR], 5.6; 95% CI,
2.3-13.1) and the combinations of ketamine and fentanyl citrate (3.2%; OR, 6.5;
95% CI, 2.5-15.2) and ketamine and propofol (2.1%; OR, 4.4; 95% CI, 2.3-8.7)
had the highest incidence of SAEs. The combinations of ketamine and fentanyl (4.1%;
OR, 4.0; 95% CI, 1.8-8.1) and ketamine and propofol (2.5%; OR, 2.2; 95% CI,
1.2-3.8) had the highest incidence of significant interventions.
Conclusions and Relevance: The incidence of adverse sedation
outcomes varied significantly with type of sedation medication. Use of ketamine
only was associated with the best outcomes, resulting in significantly fewer
SAEs and interventions than ketamine combined with propofol or fentanyl.
C. Reliability of Examination Findings
in Suspected Community-Acquired Pneumonia in Kids.
Florin TA, et al. Pediatrics. 2017 Sep;140(3). pii:
e20170310. doi: 10.1542/peds.2017-0310.
BACKGROUND: The authors of national guidelines emphasize the
use of history and examination findings to diagnose community-acquired
pneumonia (CAP) in outpatient children. Little is known about the interrater
reliability of the physical examination in children with suspected CAP.
METHODS: This was a prospective cohort study of children
with suspected CAP presenting to a pediatric emergency department from July
2013 to May 2016. Children aged 3 months to 18 years with lower respiratory
signs or symptoms who received a chest radiograph were included. We excluded
children hospitalized ≤14 days before the study visit and those with a chronic
medical condition or aspiration. Two clinicians performed independent
examinations and completed identical forms reporting examination findings.
Interrater reliability for each finding was reported by using Fleiss' kappa (κ)
for categorical variables and intraclass correlation coefficient (ICC) for
continuous variables.
RESULTS: No examination finding had substantial agreement
(κ/ICC over 0.8). Two findings (retractions, wheezing) had moderate to
substantial agreement (κ/ICC = 0.6-0.8). Nine findings (abdominal pain,
pleuritic pain, nasal flaring, skin color, overall impression, cool
extremities, tachypnea, respiratory rate, and crackles/rales) had fair to
moderate agreement (κ/ICC = 0.4-0.6). Eight findings (capillary refill time,
cough, rhonchi, head bobbing, behavior, grunting, general appearance, and
decreased breath sounds) had poor to fair reliability (κ/ICC = 0-0.4). Only 3
examination findings had acceptable agreement, with the lower 95% confidence
limit over 0.4: wheezing, retractions, and respiratory rate.
CONCLUSIONS: In this study, we found fair to moderate
reliability of many findings used to diagnose CAP. Only 3 findings had
acceptable levels of reliability. These findings must be considered in the
clinical management and research of pediatric CAP
20. Overtreatment in the United States:
Physicians say 15% to 30% of medical care is unnecessary
Lyu H, et al. PLoS One. 2017 Sep 6;12(9):e0181970.
BACKGROUND: Overtreatment is a cause of preventable harm and
waste in health care. Little is known about clinician perspectives on the
problem. In this study, physicians were surveyed on the prevalence, causes, and
implications of overtreatment.
METHODS: 2,106 physicians from an online community composed
of doctors from the American Medical Association (AMA) masterfile participated
in a survey. The survey inquired about the extent of overutilization, as well
as causes, solutions, and implications for health care. Main outcome measures
included: percentage of unnecessary medical care, most commonly cited reasons
of overtreatment, potential solutions, and responses regarding association of
profit and overtreatment.
FINDINGS: The response rate was 70.1%. Physicians reported
that an interpolated median of 20.6% of overall medical care was unnecessary,
including 22.0% of prescription medications, 24.9% of tests, and 11.1% of
procedures. The most common cited reasons for overtreatment were fear of
malpractice (84.7%), patient pressure/request (59.0%), and difficulty accessing
medical records (38.2%). Potential solutions identified were training residents
on appropriateness criteria (55.2%), easy access to outside health records
(52.0%), and more practice guidelines (51.5%). Most respondents (70.8%)
believed that physicians are more likely to perform unnecessary procedures when
they profit from them. Most respondents believed that de-emphasizing
fee-for-service physician compensation would reduce health care utilization and
costs.
CONCLUSION: From the physician perspective, overtreatment is
common. Efforts to address the problem should consider the causes and solutions
offered by physicians.
21. Another benefit of propofol ! Who
would have guessed ??
Propofol Decreases Endoplasmic
Reticulum Stress-Mediated Apoptosis in Retinal Pigment Epithelial Cells.
Zhou X, et al. PLoS One. 2016 Jun 16;11(6):e0157590
Full-text (free), for you science nerds: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4910991/
22. Micro Bits
A.
What Happens When a Hurricane Hits a Hospital
Alice Park. TIME. Aug 28, 2017
When a hurricane hits Houston, it also threatens some of the
world's leading medical care.
South Texas has been enduring the worst storm to hit the
U.S. in years in Hurricane Harvey, with flooded streets expected to persist for
days. With more than 10 million patient visits each year, and more than a dozen
hospitals and medical facilities, the Texas Medical Center (TMC) in the heart
of Houston is the largest medical complex in the world. The largest children’s
hospital, as well as the largest cancer hospital, are also housed in the city.
As Harvey gathered steam before making landfall late Friday
night, the more than 106,000 TMC employees were prepared, but no one could have
predicted the sheer volume of water that would inundate the city. The lobby of
MD Anderson Cancer Center resembled a wading pool, and some of TMC’s facilities
effectively ended up in a moat, surrounded by water that prevented anyone from
getting in or out…
See related NY Times article: https://www.nytimes.com/2017/08/28/us/hurricane-harvey-houston-hospitals-rescue.html
B.
Education and coronary heart disease: mendelian randomisation study
Conclusions This mendelian randomisation study found support
for the hypothesis that low education is a causal risk factor in the
development of coronary heart disease. Potential mechanisms could include
smoking, body mass index, and blood lipids. In conjunction with the results
from studies with other designs, these findings suggest that increasing
education may result in substantial health benefits.
C.
Conventional vs invert-grayscale X-ray for diagnosis of pneumothorax in the
emergency setting
Conclusion: Inverted gray-scale imaging is not a superior
imaging modality over digital-conventional X-ray for the diagnosis of
pneumothorax. Prospective studies should be performed where diagnostic potency
of inverted gray-scale radiograms is tested against gold standard chest CT.
Further research should compare inverted grayscale to lung ultrasound to assess
them as alternatives prior to CT.
D.
Exploring the best predictors of fluid responsiveness in patients with septic
shock
Conclusion: Ultrasound assessment of ΔIVC and ΔVpeak brach,
especially ΔCDPV, could predict fluid responsiveness and might be recommended
as a continuous and noninvasive method to monitor functional hemodynamic
parameter in mechanically ventilated patients with septic shock.
E.
Comparison of UTI antibiograms stratified by ED patient disposition
Conclusions: We found higher antibiotic sensitivities in
ED-Only than the IP-Only Study-Specific Antibiograms. Our Study-Specific
Antibiograms offer an alternative guide for antibiotic selection in the ED.
F.
How can we identify patients with delirium in the emergency department? A
review of available screening and diagnostic tools
Tamune H, et al. Am J Emerg Med. 2017;35: 1332–1334.
Delirium is a widespread and serious but under-recognized
problem. Increasing evidence argues that emergency health care providers need
to assess the mental status of the patient as the “sixth vital sign”. A simple,
sensitive, time-efficient, and cost-effective tool is needed to identify
delirium in patients in the emergency department (ED); however, a stand-alone
measurement has not yet been established despite previous studies partly
because the differential diagnosis of dementia and delirium superimposed on
dementia (DSD) is too difficult to achieve using a single indicator. To fill up
the gap, multiple aspects of a case should be assessed including inattention
and arousal. For instance, we proposed the 100 countdown test as an effective
means of detecting inattention. Further dedicated studies are warranted to shed
light on the pathophysiology and better management of dementia, delirium and/or
“altered mental status”. We reviewed herein the clinical questions and
controversies concerning delirium in an ED setting.
G.
FDA panel recommends against pediatric cough medicine with opioids
The FDA's Pediatric Advisory Committee voted almost
unanimously that cough medicines with opioids such as codeine and hydrocodone
had greater health risks than benefits and shouldn't be given to youths younger
than 18. Some doctors on the panel said there is a lack of evidence that the
treatments work to suppress cough, but they can have serious side effects.
H.
What We Can Learn from a Mindful ER
An emergency physician shares what she has learned about
embedding mindfulness practice into a busy, complex, and chaotic ER.
BY SHAHINA BRAGANZA | Greater Good Science Center, SEPTEMBER
13, 2017
Full-text (free): https://greatergood.berkeley.edu/article/item/what_we_can_learn_from_a_mindful_emergency_room?utm
I.
Diagnostic Accuracy of Ultrasound for Identifying Shoulder Dislocations and
Reductions: A Systematic Review of the Literature
Ultrasound may be considered as an alternative diagnostic
method for the detectionof shoulder dislocation and reduction, but further
studies are necessary before routine use. [West JEmerg Med. 2017;18(5)937-942.]
Full-text (free): http://escholarship.org/uc/item/50c9s42z#
J.
Study looks at prevalence of chronic cough after respiratory illness in youths
Twenty-five percent of children treated for acute
respiratory illness continued to have a chronic cough after 28 days, with 35%
of those children having a wet cough and 26% having a dry cough, according to
an Australian study in the Archives of Disease in Childhood. Lead author and
physician Kerry-Ann O'Grady urged parents of youths with cough lasting more
than a month, especially those with a wet cough, to seek medical advice.
K.
Dental procedures, antibiotic prophylaxis, and endocarditis among people with
prosthetic heart valves: nationwide population based cohort and a case
crossover study
Conclusion Invasive dental procedures may contribute to the
development of infective endocarditis in adults with prosthetic heart valves.
L.
Accuracy of Cardiovascular Risk Prediction Varies by Neighborhood Socioeconomic
Position: A Retrospective Cohort Study
Conclusion: Neighborhood disadvantage may be a powerful
regulator of ASCVD event risk. In addition to supplemental risk models and
clinical screening criteria, population-based solutions are needed to
ameliorate the deleterious effects of neighborhood disadvantage on health
outcomes.
M.
Many patients may have undetected A-fib
About 1 in 3 patients at risk of atrial fibrillation were
found to have undiagnosed disease, following evaluation using long-term cardiac
monitor implants, researchers reported in JAMA Cardiology. Many patients were
ages 75 and older and had other health problems, and about 90% had atrial
fibrillation-related symptoms.
Full-text (free): http://jamanetwork.com/journals/jamacardiology/fullarticle/2650790
N.
Don't Tell John McCain to Fight His Cancer
Arthur L. Caplan, PhD. Medscape. July 25, 2017
Director, Division of Medical Ethics, NYU Langone Medical
Center, New York, New York
Cancer Doesn't Care If You're a Fighter
It is very common when learning that someone has been newly
diagnosed with a life-threatening cancer that well-meaning family and friends
weigh in with encouragement to fight. It is also unfortunate.
Cancer could not care less whether you are a fighter or not.
What evidence there is does not show that adopting a fighting stance helps in
terms of survival. I have seen many fighters die of cancer, and some who chose
not to be seen as fighters live longer than others who did.
And there is an implication that if you are not a fighter,
then you must be a coward or worse. This suggests that the only option
available to anyone who is courageous is to choose to fight—to utilize every
surgery, complementary medicine, chemotherapy, and experimental option. This is
unfortunate as well, because it takes courage to decide not to battle fatal
cancers, but rather to enjoy a better quality of life in the time that remains.
The latest example of this "you must be a fighter"
ethic is John McCain.
The senator from Arizona just found out he has a
glioblastoma, a very nasty form of brain cancer. Upon announcing his diagnosis,
McCain was greeted by a chorus of friends and admirers urging him to fight and
calling on him to be courageous in taking on the cancer.
This is advice McCain does not need.
People Mean Well, But It's the Wrong Tactic
Here is a sample from Twitter. Barack Obama said, "John
McCain is an American hero, and one of the bravest fighters I've ever known.
Cancer doesn't know what it's up against. Give it hell, John." Joe Biden:
"He is strong, and he will beat this."
Gabrielle Giffords: "You're tough! You can beat this.
Fight, fight, fight!" Mike Pence: "Cancer picked on the wrong guy.
John McCain is a fighter, and he'll win this fight too." A bunch of
editorials in many newspapers across the nation echoed similar thoughts.
This is advice McCain does not need.
The odds of beating this cancer are long. Whether he does or
doesn't has nothing to do with his character or courage. That is not, despite
some incredibly disrespectful comments President Trump made about him in the
run-up to the presidential election, up for dispute.
McCain is a military hero. The genuine article. The former
Navy pilot spent five and a half years in a notorious North Vietnamese prison
known as the "Hanoi Hilton," where he spent 2 years in solitary confinement
and was brutally tortured despite being severely injured when he bailed out of
his plane. Concerned about his fellow prisoners, he would not accept an early
release.
Whatever cancer does to John McCain and however he chooses
to treat it or not, he is a brave man who is certainly a fighter. As with
anyone, he will find his own best path to dealing with a grim diagnosis.
Whatever that is, he will remain a hero and a fighter.
O.
Less than half of mothers place sleeping infants supine
2-min Medicine: https://www.2minutemedicine.com/less-than-half-of-mothers-place-sleeping-infants-supine/
P.
Hospice Compare website goes live to the public
The CMS launched its Hospice Compare website this week,
including data from almost 4,000 hospice providers and covering seven quality
measures on hospice and palliative care that are endorsed by the National
Quality Forum. An AAFP policy statement notes that family physicians are in a
position to provide leadership in hospice care and serve as medical staff or
medical directors.
Q.
Medical Education in the Era of Alternative Facts
Wenzel RP. N Engl J Med 2017; 377:607-609.
Students currently entering U.S. medical schools arrive in
an era of increasing distrust of large institutions, expanded use of social
media for information, a political lexicon in which uncomfortable facts are
derided as “fake news” while fabrications masquerade as reality, and the
erosion of truth that such trends entail. The challenges for medical education
are imminent and formidable. How do we, as teachers, merit the trust of future
physicians? How do we pass on to them science’s preeminent legacy of propelling
advances in understanding, preventing, and curing illnesses? How do we instill
in them a lifelong appreciation for the importance of hypothesis testing, peer
review, and critical analysis of research? These questions should prompt an
immediate review of the goals and processes of education and the values we need
to emphasize in day-to-day interactions with students.
A useful early step in earning the warrants of students is a
transparent review of the history of ideas in medicine. Such a survey would
make clear that some ideas have worked, some have failed, and some have turned
out to be built on scientific fraud — but that developing and testing
hypotheses that might not pan out are essential to the scientific method. New
ideas have often been rebuffed strongly by people in authority who had reason
to fear challenges to the status quo. Some investigators didn’t live long
enough to see their novel ideas become widely accepted. Those who succeeded,
however, evinced not only unyielding perseverance, but also integrity and
dedication not for personal gain but for the public good. Renewing a strong
curriculum in the history of medicine would thus lay a foundation for a
realistic yet hopeful appreciation for the potential, advances, and truths of
science.
On the hopeful front, a related and necessary building block
for students is the intellectual curiosity to both identify and question those
truths. We can let medical students know that whereas throughout their previous
schooling they were judged by their answers, in their medical education and
their careers they will often be judged predominantly by their questions. We
should applaud students for curiosity and inquiry and for showing reasoned
doubt about what they read and hear. We can challenge them to pursue reliable
information beyond the classroom or ward discussions, as we avoid the pitfalls
of trying to transfer all our knowledge to them during our face-to-face time.
As William Butler Yeats (probably paraphrasing Plutarch) wrote, “Education is
not the filling of a pail but the lighting of a fire.” Providing the spark is
our job.
Full-text (free): http://www.nejm.org/doi/full/10.1056/NEJMp1706528
