1. Does How We Administer Oxygen Matter? Studies on Cardiogenic
Pulmonary Edema and on Intubation
A. High-Flow Nasal
Cannula Versus Conventional Oxygen Therapy in ED Patients with Cardiogenic
Pulmonary Edema: A RCT
Makdee O, et al. Ann Emerg Med. 2017 Oct;70(4):465-472.e2.
Introduction
Background
Many patients present to the emergency department (ED) with
cardiogenic pulmonary edema. In addition to reversing the specific underlying
causes, conventional approaches to oxygen and ventilation therapy for these
patients include nasal cannula oxygen, or face mask oxygen, noninvasive
ventilation, and intubation.
A novel approach to oxygen and ventilation therapy is
high-flow nasal cannula oxygen, which delivers oxygenated air up to 60 L/min.
High-flow nasal cannula is reported to achieve FiO2 ranging from 21% to 100%.
The flow levels are high enough to generate positive airway pressure,
potentially decreasing entrapment of ambient air and providing support to
reduce the work of breathing. Because high-flow oxygen can be uncomfortable,
modern high-flow nasal cannula systems integrate oxygen warming and
humidification to enhance patient comfort.
Importance
There have been previous studies of high-flow nasal cannula
in both adult volunteers and critically ill patients with hypoxemic respiratory
failure, with results generally supporting its efficacy in reducing respiratory
rate and improving oxygenation. Most of these studies have involved cases of
pneumonia in the ICU. Few studies and no randomized controlled trials, to our
knowledge, have investigated the use of high-flow nasal cannula for the treatment
of cardiogenic pulmonary edema in the ED setting. Because dyspnea rescue
therapy often begins in the ED, evaluation of high-flow nasal cannula
application in the ED setting is important.
Goals of This Investigation
The aim of this randomized study was to compare the
effectiveness of high-flow nasal cannula with conventional oxygen therapy in ED
patients with cardiogenic pulmonary edema.
Abstract
STUDY OBJECTIVE: High-flow nasal cannula is a new method for
delivering high-flow supplemental oxygen for victims of respiratory failure.
This randomized controlled trial compares high-flow nasal cannula with
conventional oxygen therapy in emergency department (ED) patients with
cardiogenic pulmonary edema.
METHODS: We conducted an open-label randomized controlled
trial in the ED of Siriraj Hospital, Bangkok, Thailand. Patients aged 18 years
or older with cardiogenic pulmonary edema were randomly assigned to receive
either conventional oxygen therapy or high-flow nasal cannula. The primary
outcome was the respiratory rate 60 minutes postintervention.
RESULTS: We enrolled 128 participants (65 in the
conventional oxygen therapy and 63 in the high-flow nasal cannula groups).
Baseline high-flow nasal cannula and conventional oxygen therapy mean
respiratory rates were 28.7 breaths/min (SD 3.2) and 28.6 breaths/min (SD 3.5).
Mean respiratory rates at 60 minutes postintervention were lower in the
high-flow nasal cannula group (21.8 versus 25.1 breaths/min; difference 3.3;
95% confidence interval 1.9 to 4.6). No significant differences were found in
the admission rate, ED and hospital lengths of stay, noninvasive ventilation,
intubation, or mortality.
CONCLUSION: In patients with cardiogenic pulmonary edema in
the ED, high-flow nasal cannula therapy may decrease the severity of dyspnea
during the first hour of treatment.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(17)30324-4/fulltext
B. Two
Systematic Reviews of Apneic Oxygenation
B1. Effectiveness of Apneic Oxygenation
During Intubation: A Systematic Review and Meta-Analysis
Oliveira J E Silva L, et al. Ann Emerg Med. 2017
Oct;70(4):483-494.e11.
Introduction
Background
Apneic oxygenation consists in the administration of oxygen
during the apneic period of the intubation procedure to extend the safe apnea
time beyond that which can be achieved by preoxygenation alone. This concept
was first introduced in the operating room setting,6 and more recently its use
has been rapidly adopted during airway management in the emergency department
(ED) and ICU. The rationale for apneic oxygenation revolves around the
physiologic capacity of continuous oxygen capture by alveoli through a passive
process without providing ventilation. During laryngoscopy, apneic oxygenation
may be provided as continuous oxygen delivery throughout the intubation with
nasal cannulas, nasopharyngeal catheters, and modified laryngoscopes.
Importance
Airway management is commonly performed by anesthesiologists,
emergency physicians, and critical care providers as part of their daily
practice. Most intubations are performed in the operating room under
controlled, often ideal situations. However, out-of-operating-room intubations
have been associated with higher risks of adverse events because they are
frequently performed urgently in critically ill patients, for whom the rates of
severe complications can be as high as 28%. Hypoxemia is an adverse effect that
can occur during intubation. If oxygen were administered through the pharynx
during the apneic period, one could increase the uptake of oxygen into the
bloodstream, thus reducing occurrences of potentially harmful oxygen
desaturation events.
Goals of This investigation
The use of apneic oxygenation has been recommended by
experts for management of high-risk airway situations, including emergency
intubations in the ED, and for patients at risk for difficult laryngoscopy and
intubation in the operating room; however, the evidence supporting apneic
oxygenation is still not well established. The objective of this systematic
review and meta-analysis was to evaluate the effectiveness of apneic
oxygenation on hypoxemia, first-pass success, and lowest oxygen saturation
during emergency intubation.
Abstract
STUDY OBJECTIVE: We conduct a systematic review and
meta-analysis to evaluate the effectiveness of apneic oxygenation during
emergency intubation.
METHODS: We searched Ovid MEDLINE, Ovid EMBASE, Ovid
CENTRAL, and Scopus databases for randomized controlled trials and
observational studies from 2006 until July 2016, without language restrictions.
Gray literature, clinicaltrials.gov, and reference lists of articles were hand
searched. We conducted a meta-analysis with random-effects models to evaluate
first-pass success rates, incidence of hypoxemia, and lowest peri-intubation
SpO2 between apneic oxygenation and standard oxygenation cases.
RESULTS: A total of 1,386 studies were screened and 77
selected for full-text review. A total of 14 studies were included for qualitative
analysis, and 8 studies (1,837 patients) underwent quantitative analysis. In
the meta-analysis of 8 studies (1,837 patients), apneic oxygenation was
associated with decreased hypoxemia (odds ratio [OR] 0.66; 95% confidence
interval [CI] 0.52 to 0.84), but was not associated with decreased severe
hypoxemia (6 studies; 1,043 patients; OR 0.86; 95% CI 0.47 to 1.57) or
life-threatening hypoxemia (5 studies; 1,003 patients; OR 0.90; 95% CI 0.52 to
1.55). Apneic oxygenation was associated with increased first-pass success rate
(6 studies; 1,658 patients; OR 1.59; 95% CI 1.04 to 2.44) and increased lowest
peri-intubation SpO2 (6 studies; 1,043 patients; weighted mean difference 2.2%;
95% CI 0.8% to 3.6%).
CONCLUSION: In this meta-analysis, apneic oxygenation was
associated with increased peri-intubation oxygen saturation, decreased rates of
hypoxemia, and increased first-pass intubation success.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(17)30582-6/fulltext
B2. Apneic oxygenation during
intubation in the ED and during retrieval: A systematic review and
meta-analysis
Binks MJ, et al. Am J Emerg Med. 2017;35:1542-6.
Background
Hypoxemia increases the risk of intubation markedly. Such
concerns are multiplied in the emergency department (ED) and during retrieval
where patients may be unstable, preparation or preoxygenation time limited and
the environment uncontrolled. Apneic oxygenation is a promising means of
preventing hypoxemia in this setting.
Aim
To test the hypothesis that apnoeic oxygenation reduces the
incidence of hypoxemia during endotracheal intubation in the ED and during
retrieval.
Methods
We undertook a systematic review of six databases for all
relevant studies published up to November 2016. Included studies evaluated
apneic oxygenation during intubation in the ED and during retrieval. There were
no exemptions based on study design. All studies were assessed for level of
evidence and risk of bias. The Review Manager 5.3 software was used to perform
meta-analysis of the pooled data.
Results
Six trials and a total 1822 cases were included for
analysis. The study found a significant reduction in the incidence of
desaturation (RR = 0.76, p = 0.002) and critical desaturation (RR = 0.51,
p = 0.01) when apneic oxygenation was implemented. There was also a significant
improvement in first pass intubation success rate (RR = 1.09, p = 0.004).
Conclusion
Apneic oxygenation may reduce patient hypoxemia during
intubation performed in the ED and during retrieval. It also improves
intubation first-pass success rate in this setting.
C. ED use of Apneic Oxygenation Vs
Usual Care During Rapid Sequence Intubation: A RCT (The ENDAO Trial)
Caputo N, et al. Acad Emerg Med 2017 Aug 9 [Epub ahead of
print]
OBJECTIVES: Desaturation leading to hypoxemia may occur during
rapid sequence intubation (RSI). Apneic oxygenation (AO) was developed to
prevent the occurrence of oxygen desaturation during the apnea period. The
purpose of this study was to determine if the application of AO increases the
average lowest oxygen saturation during RSI when compared to usual care (UC) in
the emergency setting.
METHODS: A randomized controlled trial was conducted at an
academic, urban, Level I trauma center. All patients requiring intubation were
included. Exclusion criteria were patients in cardiac or traumatic arrest or if
preoxygenation was not performed. An observer, blinded to study outcomes and
who was not involved in the procedure, recorded all times, while all
saturations were recorded in real time by monitors on a secured server.
Two-hundred patients were allocated to receive AO (n = 100) or UC (n = 100) by
predetermined randomization in a 1:1 ratio.
RESULTS: A total of 206 patients were enrolled. There was no
difference in lowest mean oxygen saturation between the two groups (92, 95%
confidence interval [CI] = 91 to 93 in AO vs. 93, 95% CI = 92 to 94 in UC; p =
0.11).
CONCLUSION: There was no difference in lowest mean oxygen
saturation between the two groups. The application of AO during RSI did not
prevent desaturation of patients in this study population.
Wait a minute? Two systematic reviews
concluded that apneic oxygenation works, yet this RCT says it doesn’t. What’s
up?
Sakles JC. Maintenance of Oxygenation During RSI in the ED. Acad Emerg Med. 2017 October 13 [Epub ahead of print]
Sakles JC. Maintenance of Oxygenation During RSI in the ED. Acad Emerg Med. 2017 October 13 [Epub ahead of print]
Excerpt
At first glance, these results may seem surprising, but
close analysis of the data reveals the reason why no benefit was seen: most of
the patients in this trial were intubated very rapidly. The mean apnea time was
58 seconds in the control group and 64 seconds in the apneic oxygenation group.
Ninety percent of the patients were intubated in less than 100 seconds; all
were intubated by 3.3 minutes. We know from physiologic modeling experiments
and human studies that with complete preoxygenation several minutes of safe
apnea time can be expected in adults.[57-59] Since most of the patients in this
study were intubated within a couple of minutes, the preoxygenation alone
likely would have provided an adequate oxygen reservoir to prevent
desaturation. Apneic oxygenation would only be beneficial in those patients who
have exhausted their oxygen reserves, for example, patients who had prolonged
laryngoscopies. This study illustrates the problem of studying apneic
oxygenation in the critically ill—the necessity of rapid intubation and
restoration of alveolar oxygen delivery precludes evaluation of the outcome
measure of interest—an extended safe apnea time….
…Emergent tracheal intubation is one of the most critical,
yet risky procedures an emergency physician can perform. Desaturation during
RSI in the ED is common and, when severe, can result in life-threatening
complications. The risk of desaturation can be substantially reduced with
meticulous attention to preoxygenation, using the most appropriate method for
the given clinical circumstances. Portable oxygen analyzers are now available
and may be helpful in maximizing preoxygenation before emergent intubation.
Apneic oxygenation is a simple intervention that may help reduce the risk of
desaturation, but it will not rescue poor preoxygenation. An emphasis on the
maintenance of oxygenation during RSI in the ED is necessary to improve the
safety of this lifesaving procedure.
Full-text (requires subscription): http://onlinelibrary.wiley.com/doi/10.1111/acem.13271/full
2. 2017 Update on Medical Overuse: A Systematic Review
Morgan DJ, et al. JAMA Intern Med. 2017 October 2 [Epub
ahead of print].
IMPORTANCE: Overuse of medical care is a well-recognized
problem.
OBJECTIVE: To identify and highlight original research
articles published in 2016 that are most relevant to understanding medical
overuse or strategies to reduce it.
EVIDENCE REVIEW: A structured review of English-language
articles on PubMed published in 2016 coupled with examination of tables of
contents of high-impact journals to identify articles related to medical overuse
in adults. These articles were appraised for their importance to medicine.
FINDINGS: This study considered 2252 articles, 1224 of which
addressed medical overuse. Of these, 122 were deemed most relevant based on
originality, methodologic quality, and number of patients potentially affected.
The 10 most influential articles were selected by author consensus. Select
findings from the studies include the lack of benefit of transesophageal
echocardiography in the workup of cryptogenic stroke, increasing use of
computed tomography in the emergency department from 2.2% to 9.4% from 2001 to
2010, and carotid ultrasonography and revascularization being performed for
uncertain or inappropriate indications with 95% frequency. Likewise, services
for which harms are likely to outweigh benefits include treatment for
early-stage prostate cancer, which provides no mortality benefit but increases
absolute risk of erectile dysfunction by 10% to 30%, oxygen for patients with
moderate chronic obstructive pulmonary disease, surgery for meniscal tear with
mechanical symptoms, and nutritional interventions for inpatients with
malnutrition. This review highlights 2 methods for reducing overuse: clinician
audit and feedback with peer comparison for antibiotic use (reduction in inappropriate
antibiotic use from 20% to 4%) and a practical and sensible shared
decision-making tool for low-risk chest pain (reduction in emergency department
workup from 52% to 37%).
CONCLUSIONS AND RELEVANCE: The body of empirical work
continues to expand related to medical services that are provided for
inappropriate or uncertain indications. Engaging patients in conversations
aimed at shared decision making and giving practitioners feedback about their
performance relative to peers appear to be useful in reducing overuse.
Studies applicable to emergency medicine include:
Computed
Tomography Pulmonary Angiography (CTPA). The use of this test in
emergency departments has increased markedly in recent years. The researchers
found that the test is overused compared with less risky tests. Overuse of CTPA
is likely to result in delays, higher costs, and patient harm from unnecessary
exposure to radiation and contrast dye.
Strategies
to Reduce Overuse of Antibiotics: Up to half of all antibiotic use is
inappropriate. The researchers examined several methods to reduce the rate of
antibiotic prescriptions by doctors. The most effective approach was to show
doctors comparisons to their peers who prescribed correctly. In this group,
inappropriate prescriptions dropped from nearly 20% to less than 4%. In this
context, peer pressure can be effective, it appears.
Cardiac
Imaging. Advanced cardiac imaging for patients with chest pain has
more than tripled over the past decade. Many low-risk patients may receive noninvasive
testing that could lead to unnecessary hospitalisation and intervention. A
study in which doctors and patients shared decision-making over whether or not
to test found that this approach reduced the number of tests.
3. Sepsis Corner: Definitions, Antibiotic Timing, Fluid Timing, and
Antipyresis
A. An ED Validation of the SEP-3 Sepsis
and Septic Shock Definitions and Comparison With 1992 Consensus Definitions
Henning DJ, et al. Ann Emerg Med 2017;70(4): 544–552.e5.
Introduction
In 1992, Bone et al1 published consensus definitions for
sepsis, revolving around the systemic inflammatory response syndrome (SIRS)
criteria. The SIRS construct helped to identify an inflammatory response, which
in the presence of an infection defined “sepsis.” This unified communication in
both the clinical and research settings. However, criticism arose around the
definitions’ being overly sensitive and nonspecific. For example, a young adult
with routine streptococcal pharyngitis may exhibit fever and tachycardia, meeting
the definition of sepsis; this patient often has no increased risk of severe
short-term adverse effects from the infection. During the last 2 decades, many
individuals have noted the limitations of SIRS criteria, prompting calls to
revisit the definition of sepsis.
The Third International Consensus Definitions Task Force
(SEP-3) revisited the sepsis definitions and published a set of revised
definitions. To aid the effort, research using 2 large data sets guided
derivation of criteria to risk-stratify patients with infection according to
the likelihood of inhospital mortality. The quick Sequential Organ Failure
Assessment (qSOFA) score emerged as a tool to identify septic patients at
higher risk of short-term death, drawing observations from initial features in
the emergency department (ED) and other settings. The qSOFA score targets easy
bedside application and uses 3 clinical criteria, with each receiving 1 point
if present: respiratory rate greater than or equal to 22 breaths/min, altered
mental status, and hypotension defined by a systolic blood pressure less than
or equal to 100 mm Hg. A qSOFA score of 2 or greater was associated with an
increased risk of mortality. The definitions group proposed using a suspected
infection plus a qSOFA score greater than or equal to 2 to help identify
patients with potential sepsis in the non-ICU setting. The SEP-3 authors state
that qSOFA score greater than or equal to 2 should prompt clinicians to
investigate for organ dysfunction because these patients may be septic.
The SEP-3 group redefined septic shock as patients with
hypotension requiring vasopressor support to maintain a mean arterial pressure
of 65 mm Hg and a lactate level greater than 2.0 mmol/L after adequate
resuscitation. This definition sought to select patients with a higher acuity
by including vasopressors as a criterion along with a biochemical response.
This enhances specificity for the most ill septic patients, although the
overall effect on care across the sepsis spectrum is unknown.
The SEP-3 authors acknowledge that these new definitions
require validation in specific clinical settings, including the ED. We sought
to evaluate the performance of the SEP-3 qSOFA criteria and revised septic
shock definition in predicting mortality in ED patients with a suspected
infection, and to compare the performance of the SEP-3 definitions to the
previous 1992 consensus criteria of sepsis, severe sepsis, and septic shock.
Abstract
STUDY OBJECTIVE: The Third International Consensus
Definitions Task Force (SEP-3) proposed revised criteria defining sepsis and
septic shock. We seek to evaluate the performance of the SEP-3 definitions for
prediction of inhospital mortality in an emergency department (ED) population
and compare the performance of the SEP-3 definitions to that of the previous
definitions.
METHODS: This was a secondary analysis of 3 prospectively
collected, observational cohorts of infected ED subjects aged 18 years or
older. The primary outcome was all-cause inhospital mortality. In accordance
with the SEP-3 definitions, we calculated test characteristics of sepsis (quick
Sequential Organ Failure Assessment [qSOFA] score ≥2) and septic shock
(vasopressor dependence plus lactate level over 2.0 mmol/L) for mortality and
compared them to the original 1992 consensus definitions.
RESULTS: We identified 7,754 ED patients with suspected
infection overall; 117 had no documented mental status evaluation, leaving
7,637 patients included in the analysis. The mortality rate for the overall
population was 4.4% (95% confidence interval [CI] 3.9% to 4.9%). The mortality
rate for patients with qSOFA score greater than or equal to 2 was 14.2% (95% CI
12.2% to 16.2%), with a sensitivity of 52% (95% CI 46% to 57%) and specificity
of 86% (95% CI 85% to 87%) to predict mortality. The original systemic
inflammatory response syndrome-based 1992 consensus sepsis definition had a
6.8% (95% CI 6.0% to 7.7%) mortality rate, sensitivity of 83% (95% CI 79% to
87%), and specificity of 50% (95% CI 49% to 51%). The SEP-3 septic shock
mortality was 23% (95% CI 16% to 30%), with a sensitivity of 12% (95% CI 11% to
13%) and specificity of 98.4% (95% CI 98.1% to 98.7%). The original 1992 septic
shock definition had a 22% (95% CI 17% to 27%) mortality rate, sensitivity of
23% (95% CI 18% to 28%), and specificity of 96.6% (95% CI 96.2% to 97.0%).
CONCLUSION: Both the new SEP-3 and original sepsis
definitions stratify ED patients at risk for mortality, albeit with differing
performances. In terms of mortality prediction, the SEP-3 definitions had
improved specificity, but at the cost of sensitivity. Use of either approach
requires a clearly intended target: more sensitivity versus specificity.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(17)30023-9/fulltext
Letters
to the editor:
Prognostic Accuracy of Quick Sequential Organ Failure
Assessment Among Emergency Department Patients Admitted to an ICU: http://www.annemergmed.com/article/S0196-0644(17)30664-9/fulltext
B. The Timing of Early Antibiotics and
Hospital Mortality in Sepsis.
Liu VX, et al. Am J Respir Crit Care Med. 2017 Oct
1;196(7):856-863
RATIONALE: Prior sepsis studies evaluating antibiotic timing
have shown mixed results.
OBJECTIVE: To evaluate the association between antibiotic
timing and mortality among sepsis patients receiving antibiotics within 6 hours
of emergency department registration.
METHODS AND MEASUREMENTS: Retrospective study of 35,000
randomly selected sepsis inpatients treated at 21 emergency departments between
2010 and 2013 in Northern California. The primary exposure was antibiotics
given within six hours of emergency department registration. The primary
outcome was adjusted in-hospital mortality. We used detailed physiologic data
to quantify severity of illness within 1 hour of registration and logistic
regression to estimate the odds of hospital mortality based on antibiotic
timing and patient factors.
MAIN RESULTS: The median time to antibiotic administration
was 2.1 hours (interquartile range: 1.4-3.1 hours). The adjusted odds ratio for
hospital mortality based on each hour of delay in antibiotics after
registration was 1.09 (95% CI, 1.05-1.13) for each elapsed hour between
registration and antibiotic administration. The increase in absolute mortality
associated with an hours delay in antibiotic administration was: 0.3% (95% CI,
0.01%-0.6%; p=0.04) for sepsis; 0.4% (95% CI, 0.1%-0.8%; p=0.02) for severe
sepsis; and 1.8% (95% CI, 0.8%-3.0%; p=0.001) for shock.
CONCLUSIONS: In a large, contemporary, and multicenter
sample of sepsis patients in the emergency department, hourly delays in
antibiotic administration were associated with increased odds of hospital
mortality even among patients all of whom received antibiotics within 6 hours.
The odds increased within each sepsis severity strata and the increased odds of
mortality were greatest in septic shock.
Is it time to implement door-to-needle
time for “infection attacks”?
Laupland KB, et al. Intensive Care Medicine. 2017;43(11):1712–1713.
Despite decades of research investigation, efforts to increase
awareness and quality improvement initiatives efforts, morbidity and mortality
due to severe sepsis and septic shock remains unacceptably high [1]. There has
been an extensive search for novel adjunctive therapies and treatment
strategies not limited to an array of immune-modulatory agents,
anti-coagulants, and supportive treatments involving glucose control, fluid
therapy, and vasopressor, inotropic, and organ support [2]. While gains in
general associated with the outcomes of critical illness have been achieved,
improvement in outcomes associated specifically with severe sepsis and septic
shock management in recent years has been at best modest.
Antibiotic therapy has been a central aspect of sepsis and
septic shock management in the modern era. A substantial body of observational
studies has shown that delay in the time to receipt of antibiotics is
associated with adverse outcome among patients with severe sepsis and septic
shock [3 (Liu VX, et al. above), 4]. While guidelines recommend that antibiotics
be administered within 1 h, it must be recognized that this has not been proven
in a randomized trial and that controversy still exists as to what may define a
clinically significant delay or threshold for antibiotic initiation [5, 6].
In a recent article in this journal, Bloos et al. report the
results of a cluster randomized trial within 40 German ICUs comparing a
multi-faceted enhanced educational and feedback program with a control group
receiving standard education surrounding antibiotic therapy of sepsis and
septic shock for the primary outcome of 28-day mortality [7]. The multi-faceted
intervention resulted in neither a significant reduction in mortality nor a
reduced time to receipt of antimicrobial therapy. However, the overall finding
was that each 1-h delay in antibiotic therapy or source control was associated
with a 2 or 1% increase in mortality, respectively.
While not demonstrating that the study intervention reduces
time to antibiotic therapy (and thus in turn mortality), this study does provide
further evidence to add to the evolving body of literature supporting the
importance of early antibiotic therapy on improved sepsis outcome. Indeed, to
definitively prove that early therapy improves outcome, the best experimental
method would be to randomize patients to early compared to late therapy.
Obviously, ethical considerations would preclude such a study. Bloos et al. are
praised for their efforts to attempt to address this question though an
indirect, but ethically appropriate, design. Although not conclusively proven,
as a result of the large and increasing body of observational evidence,
clinical plausibility, and feasibility, the recommendation for early therapy in
sepsis and septic shock in our opinion remains prudent [1]…
The remainder of the editorial (free): https://link.springer.com/article/10.1007%2Fs00134-017-4797-x
C. Patterns and Outcomes Associated
with Timeliness of Initial Crystalloid Resuscitation in a Prospective Sepsis
and Septic Shock Cohort.
Leisman DE, et al. Crit Care Med. 2017 Oct;45(10):1596-1606.
OBJECTIVES: The objectives of this study were to 1) assess
patterns of early crystalloid resuscitation provided to sepsis and septic shock
patients at initial presentation and 2) determine the association between time
to initial crystalloid resuscitation with hospital mortality, mechanical
ventilation, ICU utilization, and length of stay.
DESIGN: Consecutive-sample observational cohort.
SETTING: Nine tertiary and community hospitals over 1.5
years.
PATIENTS: Adult sepsis and septic shock patients captured in
a prospective quality improvement database inclusion criteria: suspected or
confirmed infection, greater than or equal to two systemic inflammatory
response criteria, greater than or equal to one organ-dysfunction criteria.
INTERVENTIONS: The primary exposure was crystalloid
initiation within 30 minutes or lesser, 31-120 minutes, or more than 120
minutes from sepsis identification.
MEASUREMENTS AND MAIN RESULTS: We identified 11,182
patients. Crystalloid initiation was faster for emergency department patients
(β, -141 min; CI, -159 to -125; p less than 0.001), baseline hypotension (β,
-39 min; CI, -48 to -32; p less than 0.001), fever, urinary or skin/soft-tissue
source of infection. Initiation was slower with heart failure (β, 20 min; CI,
14-25; p less than 0.001), and renal failure (β, 16 min; CI, 10-22; p less than
0.001). Five thousand three hundred thirty-six patients (48%) had crystalloid
initiated in 30 minutes or lesser versus 2,388 (21%) in 31-120 minutes, and
3,458 (31%) in more than 120 minutes. The patients receiving fluids within 30
minutes had lowest mortality (949 [17.8%]) versus 31-120 minutes (446 [18.7%])
and more than 120 minutes (846 [24.5%]). Compared with more than 120 minutes,
the adjusted odds ratio for mortality was 0.76 (CI, 0.64-0.90; p = 0.002) for
30 minutes or lesser and 0.76 (CI, 0.62-0.92; p = 0.004) for 31-120 minutes.
When assessed continuously, mortality odds increased by 1.09 with each hour to
initiation (CI, 1.03-1.16; p = 0.002). We observed similar patterns for
mechanical ventilation, ICU utilization, and length of stay. We did not observe
significant interaction for mortality risk between initiation time and baseline
heart failure, renal failure, hypotension, acute kidney injury, altered gas
exchange, or emergency department (vs inpatient) presentation.
CONCLUSIONS: Crystalloid was initiated significantly later
with comorbid heart failure and renal failure, with absence of fever or hypotension,
and in inpatient-presenting sepsis. Earlier crystalloid initiation was
associated with decreased mortality. Comorbidities and severity did not modify
this effect.
Excerpt
We did not observe significant interaction effects between
time to fluid initiation and mortality by the phenotypes tested. This may be
particularly important for patients with preexisting heart or renal failure, as
physicians frequently employ more conservative volume expansion strategies for
resuscitation in these patients. This subset of our cohort had longer time to
initiation and lower initial volumes administered. Our results are consistent
with another population level investigation that found that sepsis bundle
application was associated with improved survival in these populations (13) and
suggest these patients benefit equally from rapid administration of initial
fluid resuscitation. This—likely generalizable—pattern may provide an arena for
improvement.
Reference 13: Liu VX, et al. Am J Respir Crit Care Med.
2016;193(11):1264-70. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4910898/
D. Does Antipyresis Improve Mortality
in Critically Ill Septic Patients?
Long B, et al. Ann Emerg Med 2017;70(4):573-5.
Take-Home Message
Antipyretic therapy through pharmacologic and physical
cooling decreases body temperature but does not reduce 28-day or inhospital
mortality in adult patients with sepsis.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(17)30623-6/fulltext
4. Effect of patient weight on first pass success and
neuromuscular blocking agent dosing for rapid sequence intubation in the ED
Patanwala AE, et al. Emerg Med J 16 August 2017 [Epub ahead of
print]
Objectives The primary objective of this study was to
determine the association between patient weight and first pass success (FPS)
during rapid sequence intubation (RSI) in the ED. The secondary objective was
to evaluate the association between patient weight and neuromuscular blocking
agent (NMBA) dosing.
Methods This was a retrospective cohort study conducted in a
tertiary care academic ED. Consecutive adult patients who underwent RSI in the
ED between January 2014 and June 2016 were included. Data were collected on
patient, operator and procedural characteristics. The cohort was categorised
into the following weight strata: less than 80 kg, 80 to 100 kg, 100 to 120 kg
and ≥120 kg. The primary outcome of interest was FPS. A multivariable logistic
regression analysis was conducted to evaluate the relationship between patient
weight category and FPS. NMBA dosing was reported descriptively.
Results The sample included 891 patients. FPS for each
weight category was as follows: less than 80 kg (91%), 80 to 100 kg (90%), 100
to 120 kg (91%) and ≥120 kg (76%). After adjusting for potential confounders,
the heaviest weight category was associated with decreased odds of FPS (OR 0.2,
95% CI 0.1 to 0.5, p less than 0.001). Median doses for succinylcholine (based
on total body weight) decreased as weight increased: less than 80 kg
(1.5 mg/kg), 80 to 100 kg (1.3 mg/kg), 100 to 120 kg (1.2 mg/kg) and ≥120 kg
(1.0 mg/kg). Median doses for rocuronium (based on ideal body weight) were
similar across weight categories: less than 80 kg (1.3 mg/kg), 80 to 100 kg
(1.4 mg/kg), 100 to 120 kg (1.3 mg/kg) and ≥120 kg (1.4 mg/kg).
Conclusions Very heavy patients (over 120 kg) undergoing RSI
in the ED had a reduced FPS, and succinylcholine was more commonly underdosed
than rocuronium in the heavier weight group.
5. CT Before LP for Possible Meningitis?
A. Emerg Med Myths: CT of the Head
Prior to LP in Adults with Suspected Bacterial Meningitis – Due Diligence or
Antiquated Practice?
April MD, et al. J Emerg Med 2017;53:313-321.
Background
Various sources purport an association between lumbar
puncture and brainstem herniation in patients with intracranial mass effect
lesions. Several organizations and texts recommend head computed tomography
(CT) prior to lumbar puncture in selected patients.
Objective
To review the evidence regarding the utility of obtaining
head CT prior to lumbar puncture in adults with suspected bacterial meningitis.
Discussion
Observational studies report a risk of post-lumbar puncture
brainstem herniation in the presence of intracranial mass effect (1.5%) that is
significantly lower than that reported among all patients with bacterial
meningitis (up to 13.3%). It is unclear from existing literature whether
identifying patients with intracranial mass effect decreases herniation risk.
Up to 80% of patients with bacterial meningitis experiencing herniation have no
CT abnormalities, and approximately half of patients with intracranial mass
effect not undergoing lumbar puncture herniate. Decision rules to selectively
perform CT on only those individuals most likely to have intracranial mass
effect lesions have not undergone validation. Despite recommendations for
immediate antimicrobial therapy prior to imaging, data indicate an association
between pre-lumbar puncture CT and antibiotic delays. Recent data demonstrate
shortened door-to-antibiotic times and lower mortality from bacterial
meningitis after implementation of new national guidelines, which restricted
generally accepted CT indications by removing impaired mental status as imaging
criterion.
Conclusions
Data supporting routine head CT prior to lumbar puncture are
limited. Physicians should consider selective CT for those patients at risk for
intracranial mass effect lesions based on decision rules or clinical gestalt.
Patients undergoing head CT must receive immediate antibiotic therapy.
B. CT (Almost) Never Before LP
Ryan Radecki. EM Lit on Note. October 12, 2017
The guidelines describing the patients with suspected
bacterial meningitis for whom neuroimaging is indicated prior to lumbar
puncture are quite broad. The Infectious Disease Society of America includes
virtually every imaginable mental status or immune system impairment, and
guidelines in Europe are similar. The anachronistic concern: cerebral
herniation in the setting of increased intracranial pressure leading to an
otherwise potentially avoidable death. But, guidelines in Sweden are different.
In Sweden, their neuroimaging guidelines suggest only those virtually comatose
or with focal neurologic signs should undergo CT prior to LP.
In this review of patients with acute bacterial meningitis
from a Swedish registry, the authors attempt to parse out whether a decision to
perform CT is not only unnecessary – but also potentially harmful. They analyze
815 patients ultimately diagnosed with bacterial meningitis and stratify them
by those who received LP without CT, LP before CT, and CT before LP. Presenting
features and comorbid medical conditions were abstracted retrospectively, and
the results were analyzed with respect to the varying guideline
recommendations, mortality, and functional outcomes.
The clear winner: CT rarely before LP, as in Sweden. By
their guidelines, only ~7% of those ultimately diagnosed with bacterial
meningitis had indication for CT prior to LP – but, unfortunately, 52% of
patients underwent imaging anyway. The reason for “winning” if adherent to the
Swedish strategy, however, was not just reduced resource utilization – it was
mortality and functional outcomes. Mortality was almost halved in those for
whom Swedish guidelines were followed, only rarely CT prior to LP. The authors
attribute the signals for the underlying mortality difference to a greater
percentage of patients receiving antibiotics within 1 hour or 2 hours when no
CT was performed.
This probably overstates the magnitude of harm relating to
CT use, as delays in antibiotics are probably more accurately delays in
diagnosis, rather than logistics impacting timely delivery of antibiotics.
After all, even in those with LP prior to CT, only 41% received steroids plus
adequate antibiotics, so I expect the magnitude of effect seen here likely ties
more reliably to confounding individual patient factors not easily adjusted for
in a retrospective analysis.
That said, I do think the Swedes are doing the right thing –
the vast majority of CTs were unhelpful. Their guidelines for neuroimaging –
deep coma and/or lateralizing neurologic signs – will probably pick up any
relevant findings (like the subdural empyema in this series), and reduce waste
while obviating any possible delays in care.
Ryan’s blog: http://www.emlitofnote.com/?p=4038
The Swedish abstract: https://www.ncbi.nlm.nih.gov/pubmed/29020334
Their Conclusion: Adherence to Swedish guidelines in ABM (acute
bacterial meningitis) is associated with decreased mortality and increased
favorable outcome in contrast to adherence to ESCMID or IDSA recommendations.
Our findings support that impaired mental status and immunocompromised state
should not be considered indications for neuroimaging before LP in
patients with suspected ABM.
6. Ibutilide effectiveness and safety in the cardioversion of AF
and AFL in the community ED setting.
Vinson DR, et al, for the Pharm CAFÉ investigators of the
CREST Network. Ann Emerg Med. 2017 Sept 29 [Epub ahead of print].
Introduction
Background
and Importance
Restoration of sinus rhythm in patients with atrial
fibrillation (AF) reduces rhythm-related symptoms and functional impairment and
improves exercise tolerance and quality of life.1-3
Sinus restoration also has been shown to improve left ventricular function and
may delay the onset of persistent atrial dysrhythmia.4-8
Moreover, cardioversion of atrial fibrillation and atrial flutter (AFL;
combined, AF/FL) in the emergency department (ED) is associated with increased
patient satisfaction and reduced hospitalization and costs.9-11
Pharmacological cardioversion, though less effective than electrical
cardioversion (roughly 50% vs 90% successful), avoids the need for procedural
sedation and is thereby less resource intensive. Some medical centers begin with
a pharmacological approach and proceed to electrical cardioversion only as
needed,12
a practice also used in the community emergency setting.13
Ibutilide is among the leading recommended pharmacological
agents for the cardioversion of presumed recent-onset AF/FL,14-17
and it is particularly useful in the ED because of its rapid effect and minimal
impact on hemodynamics.18-21
Like other class III antidysrhythmics, however, ibutilide prolongs the QTc
interval, increasing risk for ventricular tachycardia (VT). The incidence of VT
in the trial data is concerning: up to 5% for sustained monomorphic VT and 4%
for polymorphic VT, although most of the latter is unsustained.22,
23
This risk generated a black box warning and is the reason that the standard
ibutilide dose of 2 mgs is divided into two half-doses of 1 mg each (or 0.01
mg/kg for patients less than 60 kg), separated by 10 minutes. The brief
observation period between half-doses allows for the assessment of both early
cardioversion and VT, which contraindicate the second half-dose.19,
20
VT nearly always occurs during or within 45 minutes of infusion,23
but given the half-life of ibutilide, U.S. and European cardiology societies
recommend continuous electrocardiographic (ECG) monitoring during and for 4
hours following administration.14,
16
The risk of ibutilide-induced VT can be reduced by excluding
patients with high-risk conditions, particularly congestive heart failure.20,
22, 24
Risk-reducing patient selection criteria have been integrated into trial
protocols to various degrees. Early trials included patients with significant
systolic dysfunction,20,
22, 25
but entry criteria have become stricter over time.26-28
Excluding patients with hypokalemia, hypomagnesemia, and prolonged QTc is
nearly universal.20,
21, 25, 26, 28-39
It is unclear, however, how commonly such patient selection criteria are
applied in unscripted community emergency medicine practice. The few studies
that have evaluated ibutilide in the ED have limited generalizability, being
single-center European studies, most of which are hampered by small sample
sizes.30,
35, 36, 40
This is one of the first multicenter studies to describe ibutilide use and
patient outcomes among U.S. community-based EDs.
Goals
of this Investigation
We undertook this multicenter retrospective cohort study to
improve understanding of ibutilide use in the real-world community ED setting.
Our aims were (1) to characterize patient selection; (2) to describe cardioversion
effectiveness of ibutilide at 90-minutes and 4-hours; (3) to analyze the
association of candidate predictor variables with cardioversion success; and
(4) to describe the 4-hour incidence of VT and other adverse events. The
results of this first report of the Pharm CAFÉ (Pharmacological Cardioversion
of Atrial Fibrillation/Flutter Effectiveness) Study may help inform the ED
management of AF/FL patients eligible for cardioversion.
Abstract
Study objective: Little is known about the use of ibutilide
for cardioversion in atrial fibrillation and flutter outside of clinical
trials. We seek to describe patient characteristics, ibutilide administration
patterns, cardioversion rates, and adverse outcomes in the community emergency
department (ED) setting. We also evaluate potential predictors of cardioversion
success.
Methods: Using a retrospective cohort of adults who received
ibutilide in 21 community EDs between January 2009 and June 2015, we gathered
demographic and clinical variables from electronic health records and
structured manual chart review. We calculated rates of cardioversion and
frequency of ventricular tachycardia within 4 hours and estimated adjusted odds
ratios (aOR) in a multivariate regression model for potential predictors of
cardioversion.
Results: Among 361 patients, the median age was 61 years
(interquartile range 53 to 71 years) and most had recent-onset atrial
fibrillation and flutter (98.1%). Five percent of the cohort had a history of
heart failure. The initial QTc interval was prolonged (over 480 ms) in 29.4% of
patients, and 3.1% were hypokalemic (less than 3.5 mEq/L). The mean ibutilide
dose was 1.5 mg (SD 0.5 mg) and the rate of ibutilide-related cardioversion
within 4 hours was 54.8% (95% confidence interval [CI] 49.6% to 60.1%), 50.5%
for atrial fibrillation and 75.0% for atrial flutter. Two patients experienced ventricular
tachycardia (0.6%), both during their second ibutilide infusion. Age (in
decades) (aOR 1.3; 95% CI 1.1 to 1.5), atrial flutter (versus atrial
fibrillation) (aOR 2.7; 95% CI 1.4 to 5.1), and no history of atrial
fibrillation and flutter (aOR 2.0; 95% CI 1.2 to 3.1) were associated with
cardioversion.
Conclusion: The effectiveness and safety of ibutilide in
this community ED setting were consistent with clinical trial results despite
less stringent patient selection criteria.
Figure E2. Clinical decision aid for the use of ibutilide
for the cardioversion of atrial fibrillation or flutter.
Full-text available upon request.
7. Angioedema in the ED: a practical guide to differential
diagnosis and management.
Bernstein JA, et al. Int J Emerg Med. 2017 Dec;10(1):15.
BACKGROUND: Angioedema is a common presentation in the
emergency department (ED). Airway angioedema can be fatal; therefore, prompt
diagnosis and correct treatment are vital.
OBJECTIVE OF THE REVIEW: Based on the findings of two expert
panels attended by international experts in angioedema and emergency medicine,
this review aims to provide practical guidance on the diagnosis,
differentiation, and management of histamine- and bradykinin-mediated
angioedema in the ED.
REVIEW: The most common pathophysiology underlying
angioedema is mediated by histamine; however, ED staff must be alert for the
less common bradykinin-mediated forms of angioedema. Crucially,
bradykinin-mediated angioedema does not respond to the same treatment as
histamine-mediated angioedema. Bradykinin-mediated angioedema can result from
many causes, including hereditary defects in C1 esterase inhibitor (C1-INH),
side effects of angiotensin-converting enzyme inhibitors (ACEis), or acquired
deficiency in C1-INH. The increased use of ACEis in recent decades has resulted
in more frequent encounters with ACEi-induced angioedema in the ED; however,
surveys have shown that many ED staff may not know how to recognize or manage
bradykinin-mediated angioedema, and hospitals may not have specific medications
or protocols in place.
CONCLUSION: ED physicians must be aware of the different
pathophysiologic pathways that lead to angioedema in order to efficiently and
effectively manage these potentially fatal conditions.
Full-text (free): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5389952/
8. On Healthcare Delivery
A. The Best Health Care System in the
World: Which One Would You Pick?
By AARON E. CARROLL and AUSTIN FRAKT. New York Times. SEPT.
18, 2017
To better understand one of the most heated U.S. policy
debates, we created a tournament to judge which of these nations has the best
health system: Canada, Britain, Singapore, Germany, Switzerland, France,
Australia and the U.S.
“Medicare for all,” or “single-payer,” is becoming a
rallying cry for Democrats.
This is often accompanied by calls to match the health care
coverage of "the rest of the world." But this overlooks a crucial
fact: The “rest of the world” is not all alike.
The commonality is universal coverage, but wealthy nations
have taken varying approaches to it, some relying heavily on the government (as
with single-payer); some relying more on private insurers; others in between.
Experts don’t agree on which is best; a lot depends on
perspective. But we thought it would be fun to stage a small tournament.
We selected eight countries, representing a range of health
care systems, and established a bracket by randomly assigning seeds.
To select the winner of each matchup, we gathered a small
judging panel, which includes us:
Aaron Carroll, a health services researcher and professor of
pediatrics at Indiana University School of Medicine
Austin Frakt, director of the Partnered Evidence-Based
Policy Resource Center at the V.A. Boston Healthcare System; associate
professor with Boston University’s School of Public Health; and adjunct
associate professor with the Harvard T.H. Chan School of Public Health
and three economists and physician experts in health care
systems:
Craig Garthwaite, a health economist with Northwestern
University’s Kellogg School of Management
Uwe Reinhardt, a health economist with Princeton
University’s Woodrow Wilson School of Public and International Affairs
Ashish Jha, a physician with the Harvard T.H. Chan School of
Public Health and the director of the Harvard Global Health Institute
A summary of our worldviews on health care is at bottom.
So that you can play along at home and make your own picks,
we’ll describe each system along with our choices (the experts' selections will
decide who advances). When we cite hard data, they come from the Commonwealth
Fund’s International Country Comparison in 2017.
But enough talk. Let’s play….
The remainder of the essay (full-text free) is here:
B. The Key to Reducing Doctors’
Misdiagnoses: Researchers are finding new ways to make sure physicians make the
right call
By Laura Landro. The Wall Street Journal · September 12,
2017
Doctors are developing novel solutions to make sure they
come up with the right diagnoses.
A flood of new initiatives by researchers, physicians,
health-care systems, nonprofits and malpractice insurers is yielding new
insights and approaches. These include sophisticated computer programs, some
that use artificial intelligence to help analyze and diagnose tough cases, and
others that scan records for errors such as missed test results and
appointments. Advanced technologies aren’t just bringing the processing power
of big data and machine learning to bear. They are also allowing more doctors
to share their knowledge—including lessons they’ve learned from their own diagnostic
mistakes.
Misdiagnoses are a leading cause of medical malpractice
suits in the U.S., and they don’t have simple causes or solutions. Most people
will experience at least one diagnostic error in their lifetime, sometimes with
“devastating consequences,” according to a landmark 2015 report by the National
Academies of Sciences, Engineering and Medicine.
For decades, inaccurate or delayed diagnosis has been “a
blind spot in the delivery of quality care,” said the report, which is broadly
credited in scientific circles with inspiring the recent multipronged push for
improvements.
“There is a huge opportunity to put knowledge and tools into
the hands of clinicians to help them make a better or more timely and accurate
diagnosis,” says Janet Corrigan, head of the patient-care program at the
nonprofit Gordon and Betty Moore Foundation, which is funding several projects
to improve the accuracy of medical diagnoses.
Here are some of the most promising efforts:
Spotting Mistakes
A Pennsylvania hospital is experimenting with the first
formal computerized program to track, measure and analyze doctors’ diagnostic
mistakes—sometimes as they are happening. The Safer Dx Learning Lab is being
implemented at Geisinger Medical Center, the flagship of Geisinger Health
System, based in Danville, Pa., which has 13 hospitals, a health plan and a medical
school. The project is funded by a Moore Foundation grant and is led by Hardeep
Singh, chief of health policy, quality and informatics at the Michael E.
DeBakey VA Medical Center and an associate professor at Baylor College of
Medicine in Houston.
Once fully installed, the system will scan electronic
medical records to identify patients who are experiencing potential or actual
diagnostic mistakes or delays, based on certain clinical criteria, such as
abnormal chest X-rays or CT scans for which there is no documented follow-up.
Flagged records will then be reviewed for confirmation, analysis and further
action.
For example, Geisinger will look at patients who return to
the ER unexpectedly within 48 hours after discharge, or a hospital patient who
was unexpectedly transferred to an intensive-care unit to see what happened and
why.
“Knowledge from systematically analyzing missed
opportunities in correct or timely diagnosis will inform improvements and
create a learning health system for diagnosis,” Dr. Singh says.
Dr. Singh’s research suggests doctors often miss common
conditions with significant potential for harm….
The remainder of the essay (full-text free) is here:
9. Video Laryngoscopy Helps Even Experienced Intubators
This systematic review finds that video laryngoscopy
improves outcomes, even for experts.
Pieters BMA, et al. Videolaryngoscopy vs. direct
laryngoscopy use by experienced anaesthetists in patients with known difficult
airways: a systematic review and meta-analysis. Anaesthesia. 2017 Sep 22 [Epub
ahead of print].
Experienced anaesthetists can be confronted with difficult
or failed tracheal intubations. We performed a systematic review and
meta-analysis to ascertain if the literature indicated if videolaryngoscopy
conferred an advantage when used by experienced anaesthetists managing patients
with a known difficult airway.
We searched PubMed, MEDLINE, Embase and the Cochrane central
register of controlled trials up to 1 January 2017. Outcome parameters
extracted from studies were: first-attempt success of tracheal intubation; time
to successful intubation; number of intubation attempts; Cormack and Lehane
grade; use of airway adjuncts (e.g. stylet, gum elastic bougie); and
complications (e.g. mucosal and dental trauma).
Nine studies, including 1329 patients, fulfilled the
inclusion criteria. First-attempt success was greater for all
videolaryngoscopes (OR 0.34 (95%CI 0.18-0.66); p = 0.001). Use of
videolaryngoscopy was associated with a significantly better view of the
glottis (Cormack and Lehane grades 1 and 2 vs. 3-4, OR 0.04 (95%CI 0.01-0.15);
p less than 0.00001). Mucosal trauma occurred less with the use of
videolaryngoscopy (OR 0.16 (95%CI 0.04-0.75); p = 0.02).
Videolaryngoscopy has added value for the experienced
anaesthetist, improving first-time success, the view of the glottis and
reducing mucosal trauma.
10. Images in Clinical Practice
Calcium Oxalate Crystals in Ethylene Glycol Toxicity
Acute Esophageal Necrosis
“Acrobatic” Lice
Pulmonary Foreign-Body Granulomatosis
Intraocular Infection with a Trematode
Middle-Aged Male With Right Neck Pain
Young Woman With Ankle Pain
Woman With Headache and Vertigo
Elderly Man With Bullous Eruption on the Feet
Elderly Man in Respiratory Arrest
Young Girl With Abdominal Pain
Child With Cough and Fever
Yellow Palms and Soles: Look Beyond the Eyes and Think
Beyond Hyperbilirubinemia
Small-Bowel Intussusception in a Pregnant Woman: A Case
Report
11. Comparison of outcomes for pediatric paraphimosis reduction
using topical anesthetic versus intravenous procedural sedation
Burstein B, et al. Am J Emerg Med. 2017;35:1391–1395.
Background
Paraphimosis is an acute urologic emergency requiring urgent
manual reduction, frequently necessitating procedural sedation (PS) in the
pediatric population. The present study sought to compare outcomes among
pediatric patients undergoing paraphimosis reduction using a novel topical
anesthetic (TA) technique versus PS.
Methods
We performed a retrospective analysis of all patients less
than 18 years old, presenting to a tertiary pediatric ED requiring analgesia for
paraphimosis reduction between October 2013 and September 2016. The primary
outcome was reduction first attempt success; secondary outcomes included
Emergency Department length of stay (ED LOS), adverse events and return visits.
Dichotomous outcomes were analyzed by Chi-square testing and multivariate
linear regression was used to compare continuous variables.
Results
Forty-six patients were included; 35 underwent reduction
using TA, 11 by PS. Patient age and duration of paraphimosis at ED presentation
did not differ between groups. There was no difference in first attempt success
between TA (32/35, 91.4%) and PS groups (9/11, 81.8%; p = 0.37). Mean ED LOS
was 209 min shorter for TA patients (148 min vs. 357 min, p = 0.001) and
remained significantly shorter after controlling for age and duration of
paraphimosis (adjusted mean difference −198 min, p = 0.003). There were no
return visits or major adverse events in either group, however, among
successful reduction attempts, PS patients more frequently experienced minor
adverse events (7/9 vs. 0/32, p less than 0.001).
Conclusions
Paraphimosis reduction using TA was safe and effective.
Compared to PS, TA was associated with a reduced ED LOS and fewer adverse
events. TA could potentially allow more timely reduction with improved patient
experience and resource utilization.
12. Prevalence of PE in patients presenting with syncope. A
systematic review and meta-analysis.
Oqab Z, et al. Am J Emerg Med. 2017 Sep 14 [Epub ahead of
print]
BACKGROUND: Syncope is a common clinical presentation and
establishing an etiology is often challenging. Pulmonary embolism (PE) has been
thought to be an uncommon cause but a recent report suggested otherwise.
OBJECTIVE: To establish the prevalence of PE in patients
presenting with syncope to the emergency department (ED) and in hospitalized
patients.
METHODS: We systematically searched Medline, CINAHL, EMBASE,
LILACS and Web of Science with relevant keywords and MeSH headings for syncope
and PE. Inclusion criteria were patients presenting with syncope to ED or
hospitalized due to syncope, and etiologies including PE.
RESULTS: Of 1329 titles and abstracts, 12 (other than
Prandoni et al.) met inclusion criteria. Nine studies included 6608 ED patients
and 3 included 975 hospitalized patients. The mean age was 62 (95% CI 54-69)
for ED patients and 67 (95% CI 64-70) for hospitalized. The pooled estimate of
PE prevalence in ED syncope patients was 0.8% (95% CI 0.5-1.3%, I2=0%). The
pooled estimate of PE prevalence in hospitalized patients was 1.0% (95% CI
0.5-1.9%, I2=0). In contrast, the prevalence of PE in Prandoni et al. were 3.8%
and 17.3% for ED and hospitalized patients respectively, both significantly
higher than in other relevant studies (p less than 0.0001).
CONCLUSION: The estimated prevalence of PE in patients
presenting with syncope is low. The Prandoni et al. estimates are significantly
higher, suggesting a possible site effect, accrual bias, or investigation
strategy. These and the prognostic impact of higher PE prevalence require
understanding before changes in practice.
13. Firearm-Related Injury and Death — A U.S. Health Care Crisis
in Need of Health Care Professionals
Taichman DB, et al. N Engl J Med 2017 October 9 [Epub ahead
of print].
What would happen if on one day more than 50 people died and
over 10 times that many were harmed by an infectious disease in the United
States? Likely, our nation’s esteemed and highly capable public health
infrastructure would gear up to care for those harmed and study the problem.
There would be a rush to identify the cause, develop interventions, and refine
them continually until the threat is eliminated or at least contained. In light
of the risks to public health (after all, over 500 people have been harmed
already!), health care professionals would sound the alarm. We would demand
funding. We would go to conferences to learn what is known and what we should
do. We would form committees at our institutions to plan local responses to
protect our communities. The United States would spend millions or more in
short order to assure public safety, and no elected officials would conceive of
getting in the way. Rather, they would compete to be calling the loudest for
the funds and focus required to protect our people. Americans should be proud
of our prowess at and commitment to addressing public health crises.
Yet, here we are again with another editorial about the
public health crisis of firearm-related injury and death following what used to
be unthinkable, this time a mass murder and casualties at a concert in Las
Vegas. We’ve written it all before. The staggering numbers killed annually. The
numbers left permanently disabled. The families left to cope with the loss of
loved ones or to care for those broken but not killed by a bullet. As health
care professionals, we seem powerless. This public health crisis seems beyond
the reach of our tools.
Is there really nothing health care professionals can do? We
think there is a lot. We need to each ask ourselves what we have done to apply
our knowledge and skills to help address the problem since the moment of
silence that followed the last mass shooting. More silence is not the answer.
Have we demanded funding to adequately study the problem and test solutions?
Have we participated in such studies? Have we mobilized forces at our
institutions to plan strategies to lower the risks in our communities? Have we
talked to our patients about gun safety and effectively challenged policies
that would enforce our silence on this matter? Some of our colleagues have. We
should be proud of them, but they need all of our help. And so do our patients.
Here’s a short list of how health care professionals can use
our skills and voices to fight the threat that firearms present to health in
the United States…
14. Henry Ford HEART Score Randomized Trial: Rapid Discharge of
Patients Evaluated for Possible MI
Frisoli TM, et al. Circ Cardiovasc Qual Outcomes. 2017
Oct;10(10).
BACKGROUND: Hospital evaluation of patients with chest pain
is common and costly. The HEART score risk stratification tool that merges
troponin testing into a clinical risk model for evaluation emergency department
patients with possible acute myocardial infarction (AMI) has been shown to
effectively identify a substantial low-risk subset of patients possibly safe
for early discharge without stress testing, a strategy that could have
tremendous healthcare savings implications.
METHOD AND RESULTS: A total of 105 patients evaluated for
AMI in the emergency departments of 2 teaching hospitals in the Henry Ford
Health System (Detroit and West Bloomfield, MI), between February 2014 and May
2015, with a modified HEART score ≤3 (which includes cardiac troponin I less
than 0.04 ng/mL at 0 and 3 hours) were randomized to immediate discharge (n=53)
versus management in an observation unit with stress testing (n=52). The
primary end points were 30-day total charges and length of stay. Secondary end
points were all-cause death, nonfatal AMI, rehospitalization for evaluation of
possible AMI, and coronary revascularization at 30 days. Patients randomized to
early discharge, compared with those who were admitted for observation and
cardiac testing, spent less time in the hospital (median 6.3 hours versus 25.9
hours; P less than 0.001) with an associated reduction in median total charges
of care ($2953 versus $9616; P less than 0.001). There were no deaths, AMIs, or
coronary revascularizations in either group. One patient in each group was lost
to follow-up.
CONCLUSIONS: Among patients evaluated for possible AMI in
the emergency department with a modified HEART score ≤3, early discharge
without stress testing as compared with transfer to an observation unit for
stress testing was associated with significant reductions in length of stay and
total charges, a finding that has tremendous potential national healthcare
expenditure implications.
15. Point-of-care US in the ED
A. Diagnostic Accuracy of US for
Identifying Shoulder Dislocations and Reductions: A Systematic Review of the
Literature.
Gottlieb M, et al. West J Emerg Med. 2017 Aug;18(5):937-942.
INTRODUCTION: Patients with shoulder dislocations commonly
present to the emergency department. Ultrasound has the potential to save time,
radiation exposure, healthcare costs, and possible need for re-sedation. We
conducted this systematic review to compare the diagnostic accuracy of
ultrasound compared with plain radiography in the assessment of shoulder
dislocations.
METHODS: We searched PubMed, Scopus, the Cochrane Database
of Systematic Reviews, and the Cochrane Central Register of Controlled Trials
for relevant trials. Primary data and test characteristics were obtained for
all included studies. We used QUADAS-2 to assess study quality. Meta-analysis
was not performed due to significant heterogeneity.
RESULTS: Four studies met our inclusion criteria, comprising
531 assessments with 202 dislocations. Most studies had a sensitivity of 100%
for identifying dislocations. One study demonstrated a sensitivity of 54%, and
another had only one dislocation that was misidentified. All studies were 100%
specific for detecting dislocation.
CONCLUSION: Ultrasound may be considered as an alternative
diagnostic method for the detection of shoulder dislocation and reduction, but
further studies are necessary before routine use.
Full-text (free): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5576631/
B. ED point-of-care ultrasonography
improves time to pericardiocentesis for clinically significant effusions
Alpert EA, et al. Clin Exp Emerg Med 2017; 4(3): 128-132.
Objective
Our objective was to determine the utility of point-of-care
ultrasound (POCUS) to identify and guide treatment of tamponade or clinically
significant pericardial effusions in the emergency department (ED).
Methods
This was a retrospective cohort study of non-trauma patients
who were diagnosed with large pericardial effusions or tamponade by the ED
physician using POCUS. The control group was composed of those patients later
diagnosed on the medical wards or incidentally in the ED by other means such as
a computed tomography. The following data were abstracted from the patient’s
file: demographics, medical background, electrocardiogram results, chest
radiograph readings, echocardiogram results, and patient outcomes.
Results
There were 18 patients in the POCUS arm and 55 in the
control group. The POCUS arm had a decreased time to pericardiocentesis (11.3
vs. 70.2 hours, P=0.055) as well as a shorter length of stay (5.1 vs. 7.0 days,
P=0.222). A decreased volume of pericardial fluid was drained (661 vs. 826 mL,
P=0.139) in the group diagnosed by POCUS.
Conclusion
This study suggests that POCUS may effectively identify
pericardial effusions and guide appropriate treatment, leading to a decreased
time to pericardiocentesis and decreased length of hospital stay. Pericardial
tamponade or a large pericardial effusion should be considered in all patients
presenting to the ED with clinical, radiographic, or electrocardiographic signs
of cardiovascular compromise.
Full-text (free): http://www.ceemjournal.org/journal/view.php?doi=10.15441/ceem.16.169
C. Annals Lit Reviews on ED Ultrasound
C1.
What Is the Utility of Ultrasonography for the Identification of Skin and Soft
Tissue Infections in the ED?
Take-Home Message
Point-of-care ultrasonographic examination of skin and soft
tissue infections enhances the ability to differentiate abscesses from
cellulitis.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(17)30096-3/fulltext
C2.
Can Abdominal US Be Used to Accurately Diagnose Acute Appendicitis?
Take-Home Message
Although abdominal ultrasonography alone may not identify
all cases of acute appendicitis, it still has a place in the diagnostic
algorithm, especially when patient and sonographer characteristics are
favorable.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(17)30188-9/fulltext
C3.
Is Bedside Ultrasonography Rapid and Accurate for Confirmation of Central
Venous Catheter Position and Exclusion of Pneumothorax Compared with Chest
Radiograph?
Take-Home Message
Ultrasonography is faster than chest radiography for
confirming correct central venous catheter placement and ruling out
pneumothorax. However, it is less accurate for ruling out malposition, and
chest radiography should be obtained in cases of suspected malposition.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(17)30587-5/fulltext
16. Alcohol, marijuana, and opioid use disorders: 5-Year
patterns and characteristics of ED encounters.
Bahorik AL, et al. Subst Abus. 2017 Jul 19 [Epub ahead of
print]
BACKGROUND: Changes in substance use patterns stemming from
opioid misuse, ongoing drinking problems, and marijuana legalization may result
in new populations of patients with substance use disorders (SUDs) using
emergency department (ED) resources. This study examined ED admission trends in
a large sample of patients with alcohol, marijuana, and opioid use disorders in
an integrated health system.
METHODS: In a retrospective design, electronic health record
(EHR) data identified patients with ≥1 of 3 common SUDs in 2010 (n = 17,574;
alcohol, marijuana, or opioid use disorder) and patients without SUD (n =
17,574). Logistic regressions determined odds of ED use between patients with
SUD versus controls (2010-2014); mixed-effect models examined 5-year
differences in utilization; moderator models identified subsamples for which
patients with SUD may have a greater impact on ED resources.
RESULTS: Odds of ED use were higher at each time point
(2010-2014) for patients with alcohol (odds ratio [OR] range: 5.31-2.13, Ps less
than .001), marijuana (OR range: 5.45-1.97, Ps less than .001), and opioid (OR
range: 7.63-4.19, Ps less than .001) use disorders compared with controls; odds
decreased over time (Ps less than .001). Patients with opioid use disorder were
at risk of high ED utilization; patients were 7.63 times more likely to have an
ED visit in 2010 compared with controls and remained 5.00 (average) times more
likely to use ED services. ED use increased at greater rates for patients with
alcohol and opioid use disorders with medical comorbidities relative to
controls (Ps less than .045).
CONCLUSIONS: ED use is frequent in patients with SUDs who
have access to private insurance coverage and integrated medical services. ED
settings provide important opportunities in health systems to identify patients
with SUDs, particularly patients with opioid use disorder, to initiate
treatment and facilitate ongoing care, which may be effective for reducing
excess medical emergencies and ED encounters.
17. Pelvic Exam for Vaginal Bleeding or Abdominal Pain in Early
Pregnancy
A two-center, randomized study suggests that this common
practice adds no benefit.
Linden JA, et al. Is the Pelvic Examination Still Crucial in
Patients Presenting to the Emergency Department With Vaginal Bleeding or
Abdominal Pain When an Intrauterine Pregnancy Is Identified on Ultrasonography?
A Randomized Controlled Trial. Ann Emerg Med. 2017 Sep 19 [Epub ahead of print].
STUDY OBJECTIVE: We determine whether omitting the pelvic
examination in emergency department (ED) evaluation of vaginal bleeding or
lower abdominal pain in ultrasonographically confirmed early intrauterine
pregnancy is equivalent to performing the examination.
METHODS: We conducted a prospective, open-label, randomized,
equivalence trial in pregnant patients presenting to the ED from February 2011
to November 2015. Patients were randomized to no pelvic examination versus
pelvic examination. Inclusion criteria were aged 18 years or older, English
speaking, vaginal bleeding or lower abdominal pain, positive β-human chorionic
gonadotropin result, and less than 16-week intrauterine pregnancy by
ultrasonography. Thirty-day record review and follow-up call assessed for
composite morbidity endpoints (unscheduled return, subsequent admission,
emergency procedure, transfusion, infection, and alternate source of symptoms).
Wilcoxon rank sum tests were used to assess patient satisfaction and throughput
times.
RESULTS: Only 202 (of a planned 720) patients were enrolled,
despite extension of the study enrollment period. The composite morbidity
outcome was experienced at similar rates in the intervention (no pelvic
examination) and control (pelvic examination) groups (19.6% versus 22.0%;
difference -2.4%; 90% confidence interval [CI] -11.8% to 7.1%). Patients in the
intervention group were less likely to report feeling uncomfortable or very
uncomfortable during the visit (11.2% versus 23.7%; difference -12.5; 95% CI
-23.0% to -2.0%).
CONCLUSION: Although there was only a small difference
between the percentage of patients experiencing the composite morbidity
endpoint in the 2 study groups (2.4%), the resulting 90% CI was too wide to
conclude equivalence. This may have been due to insufficient power. Patients
assigned to the pelvic examination group reported feeling uncomfortable more
frequently.
18. Loperamide-Induced Torsades de Pointes: A Case Series
Katz KD, et al. J Emerg Med 2017;53:339-44.
Background
Loperamide is an over-the-counter, inexpensive,
antidiarrheal opioid that can produce life-threatening toxicity at high
concentrations.
Case Report 1
A 28-year-old man with a history of depression and substance
abuse disorder (SUD) presented to the emergency department (ED) with shortness
of breath and lightheadedness. He ingested large amounts of loperamide daily.
The patient's initial electrocardiogram (ECG) demonstrated sinus rhythm, right
axis deviation, undetectable PR interval, QRS 168 ms, and QTc 693 ms. He was
administered intravenous sodium bicarbonate and magnesium sulfate and admitted
to the intensive care unit, eventually developing Torsades de Pointes (TdP). He
was given lidocaine and isoproterenol infusions, and an external pacemaker was
placed. He was discharged in stable condition on hospital day (HD) 16.
Case Report 2
A 39-year-old woman with a history of hepatitis C,
depression, and SUD was transported to the ED after reported seizure-like
activity. The patient experienced TdP in the ED and admitted to ingesting large
amount of loperamide daily. An ECG demonstrated sinus rhythm, right axis
deviation, PR interval 208 ms, QRS interval 142 ms, and QTc 687 ms. She was
administered intravenous magnesium, sodium bicarbonate, and isoproterenol.
After intensive care unit admission, the patient experienced no further TdP and
was discharged on HD 6.
Why Should an Emergency Physician Be Aware of This?
Emergency physicians should proceed with caution when
treating patients with loperamide toxicity. Even in asymptomatic patients and
drug discontinuance, obtain consultation with a medical toxicologist, promptly
treat ECG abnormalities aggressively, and admit all patients for further
monitoring.
19. On Falls in the Elderly
One out of three adults ages 65 and older falls at least
once a year, which can lead to moderate to severe injuries, including
fractures, decreased mobility and even death.
A. Revisit, Subsequent Hospitalization,
Recurrent Fall, and Death Within 6 Months After a Fall Among Elderly ED Pts
Sri-On J, et al. Ann Emerg Med. 2017 Oct;70(4):516-521.e2.
Introduction
Background
Fall and fall-related injuries are a major public health
problem and a leading cause of morbidity and mortality among elderly patients.1
Fall-related death rates have increased among older persons worldwide.
Furthermore, serious injuries after a fall, such as hip fractures, subdural
hematomas, serious soft tissue injury, and head injury, occur in 5% to 11% of
older individuals.2
Importance
The emergency department (ED) is often the first place where
patients with fall-related injuries receive care. Approximately 2.4 million
older adults visit the ED each year, and more than 28% of these patients are
admitted to the hospital.3 Overall, 16% of elderly ED patients experience
adverse events within 30 days of discharge, and 27% experience adverse events
within 90 days.4 One study found that indoor falls, hospital admissions, and a
Barthel Index of activities of daily living less than or equal to 18 were
associated with increased 1- and 3-year mortality rates after patients visited
the ED.5 A recently published large database study identified that male sex and
comorbidities increased ED revisit and death within 1 year.6 However, to our
knowledge there is no ED-based study that examines how risk factors according
to recent geriatric ED guidelines predict recurrent falls, as well as
subsequent ED visits, subsequent hospitalizations, and death, after a visit to
the ED for a fall among older adult patients.
Goals of This Investigation
The objective of this study was to determine the risk during
6 months and specific risk factors for recurrent falls, ED revisits, subsequent
hospitalizations, and death within 6 months after an older adult ED fall visit.
Abstract
STUDY OBJECTIVE: We seek to describe the risk during 6
months and specific risk factors for recurrent falls, emergency department (ED)
revisits, subsequent hospitalizations, and death within 6 months after a
fall-related ED presentation.
METHODS: This was a secondary analysis of a retrospective
cohort of elderly fall patients who presented to the ED from one urban teaching
hospital. We included patients aged 65 years and older who had an ED fall visit
in 2012. We examined the frequency and risk factors of adverse events
(composite of recurrent falls, ED revisits, subsequent hospitalization, and
death, selected a priori) at 6 months.
RESULTS: Our study included 350 older adults. Adverse events
steadily increased, from 7.7% at 7 days, 21.4% at 30 days, and 50.3% at 6
months. Within 6 months, 22.6% of patients had at least one recurrent fall,
42.6% revisited the ED, 31.1% had subsequent hospitalizations, and 2.6% died.
In multivariable logistic regression analysis, psychological or sedative drug
use predicted recurrent falls, ED revisits, subsequent hospitalizations, and
adverse events.
CONCLUSION: More than half of fall patients had an adverse
event within 6 months of presenting to the ED after a fall. The risk during 6
months of these adverse events increased with psychological or sedative drug
use. Larger future studies should confirm this association and investigate
methods to minimize recurrent falls through management of such medications.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(17)30659-5/fulltext
B. Task force draft recommendations
cover falls, fractures
A US Preventive Services Task Force draft recommendation
statement gave a "B" recommendation to using exercise to prevent
falls in community-dwelling older adults and said physicians may selectively
offer multifactorial interventions based on individual patient assessments.
20. NEJM Interactive Case: 26-year-old ED pt with one week of
worsening pleuritic CP
Solomon CG, et al. N Engl J Med 2017; 377:e1
A 26-year-old woman presented to the emergency department
with a 1-week history of worsening pleuritic chest pain. She recalled the
development of a dull, substernal ache several days after a 5-hour flight home
from Puerto Rico, where she had spent 3 weeks hiking in national parks and
exploring several caves.
The ache progressed over the ensuing days to a constant,
stabbing pain that worsened with deep inspiration and coughing. She had not
taken any medication for the pain. The patient reported no fevers, chills,
shortness of breath, wheezing, sputum production, hemoptysis, weight loss,
night sweats, leg swelling, or diarrhea and no changes in appetite or urinary
habits. She had no history of venous thromboembolism, cancer, or environmental
or drug allergies and did not use oral contraceptives…
Because of the patient’s pleurisy and recent long-distance
air travel, emergency department physicians considered the possibility that she
may have a pulmonary embolism. Which one of the following tests should be
performed to evaluate for pulmonary embolism?
The rest of the interactive is available (free) here: http://www.nejm.org/doi/full/10.1056/NEJMimc1616026
21. Micro Bits
A. Lifestyle Medicine: A Brief Review of Its Dramatic
Impact on Health and Survival.
Bodai BI, et al.
Perm J. 2018;22:17-025.
B. Reversing the New Oral Anticoagulants Not as
Complicated as You Think
Rodos A, et al.
Emerg Med New 2017;39(10):14-15.
Full-text: http://journals.lww.com/em-news/Fulltext/2017/10000/Special_Report__Reversing_the_New_Oral.4.aspx
Youths who took ibuprofen for pain relief after undergoing
minor outpatient orthopedic surgery had similarly reduced pain scores but
significantly fewer adverse effects such as drowsiness, nausea, dizziness,
vomiting and constipation compared with those who took oral morphine, according
to a study in the Canadian Medical Association Journal. However, the findings
showed that neither drug provided complete pain relief, prompting researchers
to suggest further studies on better treatments.
Abstract: http://www.cmaj.ca/content/189/40/E1252
D. Coordination Program Reduced Acute Care Use And
Increased Primary Care Visits Among Frequent Emergency Care Users
E. CDC finds suicide rates on the rise, particularly in
rural areas
CDC researchers
found that suicide rates in the US rose by over 20% from 2001 to 2015, translating
to 500,000 lost lives during that period, and suicide rates were higher in
rural areas than urban areas. Suicide was the 10th leading cause of death by
2015, men were five times more likely to commit suicide than women, and risk
was highest among working-age adults.
F. Survey: 87.3% of patients want to avoid antibiotic for
RTI
A study in the
Journal of the American Board of Family Medicine found 87.3% of patients
surveyed wanted to avoid taking antibiotics for respiratory tract infections,
but 64% who saw a physician for an RTI received one. The survey of 737 adult
patients showed 63.1% were very or somewhat willing to have venous blood drawn
and 79% were very or somewhat willing to have a point-of-care fingerstick test
to determine if they needed an antibiotic.
Full-text (free): http://www.jabfm.org/content/30/5/645.full
G. The Importance of Breakfast in Atherosclerosis
Disease: Insights From the PESA Study
Conclusion
Skipping breakfast is associated with an increased odds of prevalent
noncoronary and generalized atherosclerosis independently of the presence of
conventional CV risk factors.
H. Bed bugs love your stinky laundry. Here’s how to keep
them away
On the surface,
bed bugs seem ill-equipped for world domination: They can’t fly, jump, or swim;
they can survive only on blood; and the world’s foremost apex
predators—humans—want them all dead. Yet the parasitic arthropods have recently
undergone what scientists are calling a “rapid global expansion,” taking over
new territories and growing in number and range. And according to a new study,
their globetrotting is made possible in part by an unusual form of
transportation: our stinky laundry.
Essay: http://www.sciencemag.org/news/2017/09/bed-bugs-love-your-stinky-laundry-here-s-how-keep-them-away
I. Physicians see more fulfillment in work than
retirement
A growing number
of physicians nearing retirement age are choosing not to step back. According
to a CompHealth survey, they believe they can find more fulfillment with the
social interactions of their practice and continuing to help patients.
J. CDC reports record high STD cases in the US in 2016
New cases of
sexually transmitted diseases such as chlamydia, gonorrhea and syphilis in the
US reached a record high of more than 2 million in 2016, more than 1.6 million
of which were from chlamydia, according to a CDC report. Data also showed that
syphilis prevalence among newborns increased by 28% between 2015 and 2016.
K. Youth football may boost behavioral, cognitive
problems in adulthood
Children who
played tackle football before age 12 were two times more likely to develop
problems with behavioral regulation, executive function and apathy, and had an
increased likelihood of elevated depression scores in adulthood, compared with
those who played at age 12 or older, researchers reported in Nature's
Translational Psychiatry. The findings also showed similar health risks for
those who gave up the sport before high school and those who continued in high
school and college.
L. Global Causes of Death, By the Numbers
Cardiovascular
disease reigns; U.S life expectancy flatlines
