1. ED Headache Management Studies
A. IV Prochlorperazine/Diphenhydramine
Beats IV Hydromorphone
Friedman BW, et al. Neurology
OBJECTIVE: To determine outcomes among patients with
migraine in the emergency department (ED) who receive IV hydromorphone vs IV
prochlorperazine + diphenhydramine.
METHODS: This study was conducted in 2 EDs in New York City.
Patients who met international criteria for migraine were eligible for
participation if they had not used an opioid within the previous month.
Clinicians, participants, investigators, and research personnel were blinded to
treatment. Patients were randomized in blocks of 4. Participants received
hydromorphone 1 mg or prochlorperazine 10 mg + diphenhydramine 25 mg.
Diphenhydramine was administered to prevent akathisia, a common side effect of
IV prochlorperazine. The primary outcome was sustained headache relief, defined
as achieving a headache level of mild or none within 2 hours of medication
administration and maintaining that level for 48 hours without the requirement
of rescue medication. A planned interim analysis was conducted once 48-hour
data were available for 120 patients.
RESULTS: The trial was halted by the data monitoring
committee after 127 patients had been enrolled. The primary outcome was
achieved in the prochlorperazine arm by 37 of 62 (60%) participants and in the
hydromorphone arm by 20 of 64 (31%) participants (difference 28%, 95%
confidence interval 12-45, number needed to treat 4, 95% confidence interval
2-9).
CONCLUSIONS: IV hydromorphone is substantially less
effective than IV prochlorperazine for the treatment of acute migraine in the
ED and should not be used as first-line therapy.
From the AAN Press Release: “While this study demonstrates
the overwhelming superiority of prochlorperazine over hydromorphone for initial
treatment of acute migraine, the results do not suggest that treatment with IV
opioids leads to long-term addiction,” Friedman said. “In addition, the results
should not be used to avoid the use of opioids for people who have not
responded well to anti-dopaminergic drugs.” https://www.aan.com/PressRoom/Home/PressRelease/1582
B. IV Prochlorperazine/Diphenhydramine Beats
IV Ketamine/Ondansetron
Zitek T, et al. Ann Emerg Med 2017 Oct 13 [Epub ahead of print].
Study objective
Intravenous subdissociative-dose ketamine has been shown to
be effective for pain management, but has not been specifically studied for
headaches in the emergency department (ED). For this reason, we designed a
study to compare standard treatment (prochlorperazine) with ketamine in
patients with benign headaches in the ED.
Methods
This study was a multicenter, double-blind, randomized,
controlled trial with a convenience sample of patients presenting to the ED
with benign headaches. Patients were randomized to receive either
prochlorperazine and diphenhydramine or ketamine and ondansetron. Patients'
headache severity was measured on a 100-mm visual analog scale (VAS) at 0, 15,
30, 45, and 60 minutes. Nausea, vomiting, anxiety, and the need for rescue
medications were also tracked. Patients were contacted at 24 to 48 hours
posttreatment to rate their satisfaction and to determine whether they were
still experiencing a headache.
Results
There were a total of 54 subjects enrolled. Two patients in
the ketamine group and one in the prochlorperazine group withdrew because of
adverse effects of the medications. In regard to the primary outcome, at 60
minutes, the prochlorperazine group had a mean improvement in VAS pain scores
of 63.5 mm compared with 43.5 mm in the ketamine group, corresponding to a
between-groups difference of 20.0 mm (95% confidence interval [CI] 2.8 to 37.2
mm) and a P value of .026. At 45 minutes, the prochlorperazine group had a mean
improvement in pain scores of 56.1 mm compared with 38.0 mm in the ketamine
group, a difference of 18.1 mm (95% CI 1.0 to 35.2 mm). At 24- to 48-hour
follow-up, the mean satisfaction score was 8.3 of 10 for prochlorperazine and
4.9 of 10 for ketamine, a difference of 3.4 (95% CI 1.2 to 5.6). There was not
a statistically significant difference in the percentage of patients who had a
headache at follow-up or in other secondary outcomes.
Conclusion
Prochlorperazine appears to be superior to ketamine for the
treatment of benign headaches in the ED.
C. IV Sodium valproate ties IV Dexamethasone
Karimi N, et al. Clin Exp Emerg Med 2017; 4(3): 138-145.
OBJECTIVE: Migraine headache is a chronic and disabling
condition in adults. Some studies have investigated the efficacy of sodium
valproate in the treatment of acute migraine, but the effectiveness and
tolerability of intravenous valproate as abortive therapy remains unclear. This
study aimed to evaluate the effects of sodium valproate and dexamethasone in
the treatment of acute migraine.
METHODS: We conducted a double-blind randomized clinical
trial including 90 patients aged 18 to 65 years with acute migraine headache
but no aura. Patients were randomized to receive intravenous dexamethasone (8
mg) or sodium valproate (400 mg) diluted into 4 mL of normal saline. The
primary outcome measure was pain relief after 0.5, 1, 3, or 6 hours after
administration. The secondary outcome criteria were the associated symptom
recovery, rate of headache recurrence after 24 hours, and medication side
effects. Pearson's chi square and the t-test were employed in the data
analysis.
RESULTS: Of the 90 patients, 80 were investigated. The
percentage of headache improvement at 0.5 hours after treatment was 55% and
67.5% in the sodium valproate and dexamethasone groups, respectively.
Before-treatment and 0.5 hour after treatment pain severity visual analog scale
scores were 9.05±0.90 and 3.8±3.09 in the sodium valproate group and 8.92±0.79
and 3.10±2.73 in the dexamethasone group, respectively. There were no
significant intergroup differences.
CONCLUSION: This randomized clinical trial showed that the
intravenous injection of sodium valproate 400 mg has similar effects to those
of dexamethasone for improving acute migraine headache.
D. Influence of greater occipital nerve
block on pain severity in migraine patients: A systematic review and
meta-analysis.
Tang Y, et al. Am J Emerg Med. 2017 Nov;35(11):1750-1754.
AIMS: Greater occipital nerve (GON) block may be a promising
approach to treat migraine. However, the results remained controversial. We
conducted a systematic review and meta-analysis to explore the efficacy of GON
block in migraine patients.
METHODS: PubMed, EMbase, Web of science, EBSCO, and Cochrane
library databases were systematically searched. Randomized controlled trials
(RCTs) assessing the efficacy of GON block versus placebo in migraine patients
were included. Two investigators independently searched articles, extracted
data, and assessed the quality of included studies. Meta-analysis was performed
using the random-effect model.
RESULTS: Six RCTs were included in the meta-analysis.
Overall, compared with control intervention in migraine patients, GON block
intervention was found to significantly reduce pain score (Std. mean
difference=-0.51; 95% CI=-0.81 to -0.21; P=0.0008), number of headache days
(Std. mean difference=-0.68; 95% CI=-1.02 to -0.35; P less than 0.0001), and
medication consumption (Std. mean difference=-0.35; 95% CI=-0.67 to -0.02;
P=0.04), but demonstrated no influence on duration of headache per four weeks
(Std. mean difference=-0.07; 95% CI=-0.41 to 0.27; P=0.70).
CONCLUSIONS: Compared to control intervention, GON block
intervention can significantly alleviate pain, reduce the number of headache
days and medication consumption, but have no significant influence on the
duration of headache per four weeks for migraine patients.
E. Validation of the Ottawa SAH Rule in
patients with acute headache.
However, with a specificity of only 13.6%, its impact on
imaging and lumbar puncture rates may be low.
Perry JJ, et al. CMAJ. 2017 Nov 13;189(45):E1379-E1385.
BACKGROUND: We previously derived the Ottawa Subarachnoid
Hemorrhage Rule to identify subarachnoid hemorrhage (SAH) in patients with acute
headache. Our objective was to validate the rule in a new cohort of consecutive
patients who visited an emergency department.
METHODS: We conducted a multicentre prospective cohort study
at 6 university-affiliated tertiary-care hospital emergency departments in
Canada from January 2010 to January 2014. We included alert, neurologically
intact adult patients with a headache peaking within 1 hour of onset. Treating
physicians in the emergency department explicitly scored the rule before
investigations were started. We defined subarachnoid hemorrhage as detection of
any of the following: subarachnoid blood visible upon computed tomography of
the head (from the final report by the local radiologist); xanthochromia in the
cerebrospinal fluid (by visual inspection); or the presence of erythrocytes
(> 1 × 106/L) in the final tube of cerebrospinal fluid, with an aneurysm or
arteriovenous malformation visible upon cerebral angiography. We calculated
sensitivity and specificity of the Ottawa SAH Rule for detecting or ruling out
subarachnoid hemorrhage.
RESULTS: Treating physicians enrolled 1153 of 1743 (66.2%)
potentially eligible patients, including 67 with subarachnoid hemorrhage. The
Ottawa SAH Rule had 100% sensitivity (95% confidence interval [CI] 94.6%-100%)
with a specificity of 13.6% (95% CI 13.1%-15.8%), whereas neuroimaging rates
remained similar (about 87%).
INTERPRETATION: We found that the Ottawa SAH Rule was
sensitive for identifying subarachnoid hemorrhage in otherwise alert and
neurologically intact patients. We believe that the Ottawa SAH Rule can be used
to rule out this serious diagnosis, thereby decreasing the number of cases
missed while constraining rates of neuroimaging.
Remind me, what is the Ottawa SAH Rule?
2. ED Analgesia Corner
A. Effect of a Single Dose of Oral
Opioid and Nonopioid Analgesics on Acute Extremity Pain in the ED: A Randomized
Clinical Trial.
Chang AK, et al. JAMA. 2017 Nov 7;318(17):1661-1667.
IMPORTANCE: The choice of analgesic to treat acute pain in
the emergency department (ED) lacks a clear evidence base. The combination of
ibuprofen and acetaminophen (paracetamol) may represent a viable nonopioid
alternative.
OBJECTIVES: To compare the efficacy of 4 oral analgesics.
DESIGN, SETTINGS, AND PARTICIPANTS: Randomized clinical
trial conducted at 2 urban EDs in the Bronx, New York, that included 416
patients aged 21 to 64 years with moderate to severe acute extremity pain
enrolled from July 2015 to August 2016.
INTERVENTIONS: Participants (104 per each combination
analgesic group) received 400 mg of ibuprofen and 1000 mg of acetaminophen; 5
mg of oxycodone and 325 mg of acetaminophen; 5 mg of hydrocodone and 300 mg of
acetaminophen; or 30 mg of codeine and 300 mg of acetaminophen.
MAIN OUTCOMES AND MEASURES: The primary outcome was the
between-group difference in decline in pain 2 hours after ingestion. Pain
intensity was assessed using an 11-point numerical rating scale (NRS), in which
0 indicates no pain and 10 indicates the worst possible pain. The predefined
minimum clinically important difference was 1.3 on the NRS. Analysis of
variance was used to test the overall between-group difference at P = .05 and
99.2% CIs adjusted for multiple pairwise comparisons.
RESULTS: Of 416 patients randomized, 411 were analyzed (mean
[SD] age, 37 [12] years; 199 [48%] women; 247 [60%] Latino). The baseline mean
NRS pain score was 8.7 (SD, 1.3). At 2 hours, the mean NRS pain score decreased
by 4.3 (95% CI, 3.6 to 4.9) in the ibuprofen and acetaminophen group; by 4.4
(95% CI, 3.7 to 5.0) in the oxycodone and acetaminophen group; by 3.5 (95% CI,
2.9 to 4.2) in the hydrocodone and acetaminophen group; and by 3.9 (95% CI, 3.2
to 4.5) in the codeine and acetaminophen group (P = .053). The largest
difference in decline in the NRS pain score from baseline to 2 hours was
between the oxycodone and acetaminophen group and the hydrocodone and
acetaminophen group (0.9; 99.2% CI, -0.1 to 1.8), which was less than the
minimum clinically important difference in NRS pain score of 1.3. Adverse
events were not assessed.
CONCLUSIONS AND RELEVANCE: For patients presenting to the ED
with acute extremity pain, there were no statistically significant or
clinically important differences in pain reduction at 2 hours among single-dose
treatment with ibuprofen and acetaminophen or with 3 different opioid and
acetaminophen combination analgesics. Further research to assess adverse events
and other dosing may be warranted.
B. A Randomized, Double-Blind,
Placebo-Controlled Trial of Naproxen With or Without Orphenadrine or Methocarbamol
for Acute Low Back Pain.
Friedman BW, et al. Ann Emerg Med. 2017 Oct 28 [Epub ahead
of print].
STUDY OBJECTIVE: In US emergency departments (EDs), patients
with low back pain are often treated with nonsteroidal anti-inflammatory drugs
and muscle relaxants. We compare functional outcomes among patients randomized
to a 1-week course of naproxen+placebo versus naproxen+orphenadrine or
naproxen+methocarbamol.
METHODS: This was a randomized, double-blind, comparative
effectiveness trial conducted in 2 urban EDs. Patients presenting with acute,
nontraumatic, nonradicular low back pain were enrolled. The primary outcome was
improvement on the Roland-Morris Disability Questionnaire (RMDQ) between ED
discharge and 1 week later. All patients were given 14 tablets of naproxen 500
mg, to be used twice a day, as needed for low back pain. Additionally, patients
were randomized to receive a 1-week supply of orphenadrine 100 mg, to be used
twice a day as needed, methocarbamol 750 mg, to be used as 1 or 2 tablets 3 times
per day as needed, or placebo. All patients received a standardized 10-minute
low back pain educational session before discharge.
RESULTS: Two hundred forty patients were randomized.
Baseline demographic characteristics were comparable. The mean RMDQ score of
patients randomized to naproxen+placebo improved by 10.9 points (95% confidence
interval [CI] 8.9 to 12.9). The mean RMDQ score of patients randomized to
naproxen+orphenadrine improved by 9.4 points (95% CI 7.4 to 11.5). The mean
RMDQ score of patients randomized to naproxen+methocarbamol improved by 8.1
points (95% CI 6.1 to 10.1). None of the between-group differences surpassed
our threshold for clinical significance. Adverse events were reported by 17%
(95% CI 10% to 28%) of placebo patients, 9% (95% CI 4% to 19%) of orphenadrine
patients, and 19% (95% CI 11% to 29%) of methocarbamol patients.
CONCLUSION: Among ED patients with acute, nontraumatic,
nonradicular low back pain, combining naproxen with either orphenadrine or
methocarbamol did not improve functional outcomes compared with
naproxen+placebo.
C. Use of Prophylactic Ondansetron with
IV Opioids in ED Patients: A Prospective Observational Pilot Study.
Culver MA, et al. J Emerg Med. 2017 Nov;53(5):629-634.
BACKGROUND: The current literature suggests that the
prophylactic use of antiemetics is ineffective at preventing nausea or vomiting
caused by opioids in the emergency department (ED). While there is no data
evaluating ondansetron's efficacy for preventing opioid-induced nausea and vomiting,
this practice remains common despite a lack of supporting evidence.
OBJECTIVES: This study aimed to identify if prophylactic
ondansetron administered with intravenous (IV) opioids prevents opioid-induced
nausea or vomiting.
METHODS: This prospective observational study was conducted
in the ED at two academic medical institutions. Patients were eligible for
enrollment if they were prescribed an IV opioid with or without IV ondansetron
and absence of baseline nausea. Patients' level of nausea was evaluated at
baseline, 5 min, and 30 min after an IV opioid was administered and then
observed for 2 hours.
RESULTS: One hundred thirty-three patients were enrolled,
with 90% of patients presenting with a chief complaint of pain. Sixty-four
(48.1%) patients received an IV opioid alone and 69 (51.9%) patients received
both IV ondansetron and an IV opioid. Twenty-three (17.3%) patients developed
nausea caused by opioid administration. One (0.75%) patient had an emetic event
and 3 (2.3%) patients required rescue antiemetics during their observation
period. Rate of nausea was similar between treatment groups 5 min after the
opioid was administered (p = 0.153). There was no statistical difference in
emesis, rescue medication requirements, or nausea severity between treatment
groups.
CONCLUSION: Our trial found that ondansetron did not appear
to be effective at preventing opioid-induced nausea or vomiting. These findings
and previous literature suggest prophylactic ondansetron should not be given to
ED patients who are receiving IV opioids.
D. Codeine still prescribed after
pediatric tonsil, adenoid removal despite warning
Although the rate of children who received codeine
prescriptions after tonsil or adenoid removal significantly declined after the
FDA issued a black box warning on the opioid in 2013, 5% continued to be
prescribed codeine in 2015, researchers reported in Pediatrics. The findings,
based on 2010 to 2015 private insurance claims data involving more than 360,000
youths across the US who underwent tonsillectomy, adenoidectomy or both, also
showed higher pediatric hydrocodone and oxycodone prescriptions months after
the FDA implemented its black box warning.
Getting
Doctors to Stop Prescribing Codeine To Kids Has Taken Years
Greta Jochim. NPR, Nov 16, 2017.
For years the Food and Drug Administration has been trying
to get doctors to quit prescribing codeine, an opioid painkiller, to children
after getting their tonsils or adenoids out.
But it can be hard to get clinicians to change their
prescribing habits, even when children have died and other less risky
medications are available.
In 2013, the FDA told providers that "codeine should
not be used for pain in children following these procedures." But in
December 2015, nearly three years later, 5 percent of children were being
prescribed the drug after surgery, according to a study published Thursday in
Pediatrics.
Some children are "ultra-metabolizers" of codeine,
causing their blood levels of medication to rise rapidly. That can depress
breathing and be deadly.
It's hard to know how an individual metabolizes codeine,
says Dr. Kao-Ping Chua, the paper's lead author and assistant professor in the
University of Michigan department of pediatrics and communicable diseases.
"You're basically rolling the dice when you prescribe codeine," he
says. "Codeine in general for children ought to be a zero event."
The remainder of the essay: https://www.npr.org/sections/health-shots/2017/11/16/564337003/getting-doctors-to-stop-prescribing-codeine-to-kids-has-taken-years
3. Is Sepsis Incidence and Mortality Changing in U.S. Hospitals?
Robust clinical data show that sepsis incidence and
sepsis-related mortality have remained stable.
Rhee C, et al. CDC Prevention Epicenter Program. Incidence and
Trends of Sepsis in US Hospitals Using Clinical vs Claims Data, 2009-2014.
JAMA. 2017 Oct 3;318(13):1241-1249.
Estimates from claims-based analyses suggest that the
incidence of sepsis is increasing and mortality rates from sepsis are
decreasing. However, estimates from claims data may lack clinical fidelity and
can be affected by changing diagnosis and coding practices over time.
OBJECTIVE: To estimate the US national incidence of sepsis
and trends using detailed clinical data from the electronic health record (EHR)
systems of diverse hospitals.
DESIGN, SETTING, AND POPULATION: Retrospective cohort study
of adult patients admitted to 409 academic, community, and federal hospitals
from 2009-2014.
EXPOSURES: Sepsis was identified using clinical indicators
of presumed infection and concurrent acute organ dysfunction, adapting Third
International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)
criteria for objective and consistent EHR-based surveillance.
MAIN OUTCOMES AND MEASURES: Sepsis incidence, outcomes, and
trends from 2009-2014 were calculated using regression models and compared with
claims-based estimates using International Classification of Diseases, Ninth
Revision, Clinical Modification codes for severe sepsis or septic shock. Case-finding
criteria were validated against Sepsis-3 criteria using medical record reviews.
RESULTS: A total of 173 690 sepsis cases (mean age, 66.5
[SD, 15.5] y; 77 660 [42.4%] women) were identified using clinical criteria
among 2 901 019 adults admitted to study hospitals in 2014 (6.0% incidence). Of
these, 26 061 (15.0%) died in the hospital and 10 731 (6.2%) were discharged to
hospice. From 2009-2014, sepsis incidence using clinical criteria was stable
(+0.6% relative change/y [95% CI, -2.3% to 3.5%], P = .67) whereas incidence
per claims increased (+10.3%/y [95% CI, 7.2% to 13.3%], P less than .001).
In-hospital mortality using clinical criteria declined (-3.3%/y [95% CI, -5.6%
to -1.0%], P = .004), but there was no significant change in the combined
outcome of death or discharge to hospice (-1.3%/y [95% CI, -3.2% to 0.6%],
P = .19). In contrast, mortality using claims declined significantly (-7.0%/y
[95% CI, -8.8% to -5.2%], P less than .001), as did death or discharge to
hospice (-4.5%/y [95% CI, -6.1% to -2.8%], P less than .001). Clinical
criteria were more sensitive in identifying sepsis than claims (69.7% [95% CI,
52.9% to 92.0%] vs 32.3% [95% CI, 24.4% to 43.0%], P less than .001), with
comparable positive predictive value (70.4% [95% CI, 64.0% to 76.8%] vs 75.2%
[95% CI, 69.8% to 80.6%], P = .23).
CONCLUSIONS AND RELEVANCE: In clinical data from 409
hospitals, sepsis was present in 6% of adult hospitalizations, and in contrast
to claims-based analyses, neither the incidence of sepsis nor the combined
outcome of death or discharge to hospice changed significantly between
2009-2014. The findings also suggest that EHR-based clinical data provide more
objective estimates than claims-based data for sepsis surveillance.
4. Methemoglobinemia Due to Antifreeze Ingestion
Farkas AN, et al. N Engl J Med 2017; 377:1993-199.
Ingestion of antifreeze that contains ethylene glycol
produces acidosis, nephropathy, coma, and cardiovascular collapse.1 Previously,
minimal increases in methemoglobin levels (to as high as 6%; normal value, less
than 1.0% or 1.5%, depending on the assay) after ingestion of antifreeze have
been reported,2 with no known cause. We report a case of antifreeze ingestion
that resulted in clinically significant methemoglobinemia caused by an
identified agent.
Our patient, a 62-year-old man with a history of depression,
presented to an emergency department 5 hours after ingesting antifreeze (Fleet
Charge SCA Precharged Coolant/Antifreeze [Peak]). The bottle was recovered by
paramedics. He had an arterial pH of 7.14 (normal range, 7.35 to 7.45), a serum
bicarbonate level of 11 mmol per liter (normal range, 22 to 28), an osmolar gap
of 167 mOsm per kilogram (normal value, less than 10), an anion gap of 17 mmol
per liter (normal range, 3 to 11), and obtundation requiring intubation and
mechanical ventilation. He was initially treated with intravenous sodium
bicarbonate and fomepizole. Despite receiving mechanical ventilation, the
patient had persistent pulse oximetry readings of 88% with the ventilator set
to a fraction of inspired oxygen of 100% and a positive end-expiratory pressure
of 15 cm of water. When his venous blood appeared brown in color despite an
arterial partial pressure of oxygen of 502 mm Hg, the patient’s methemoglobin
level was tested and found to be 32.2%. The methemoglobinemia was successfully
treated with methylene blue, and hemodialysis resolved the ethylene glycol
poisoning with a favorable outcome.
On the basis of the patient’s history and the results of
urine gas chromatography–mass spectroscopy testing, no substance known to cause
methemoglobinemia was present. The safety data sheet for the product that the
patient ingested indicated a mixture of ethylene glycol (90 to 97%), diethylene
glycol, water, and denatonium benzoate. Because only substances that comprise
more than 1% of a given product are required by the Occupational Safety and
Health Administration Hazard Communication Standard to be reported on the
safety data sheet, a manufacturer’s representative was contacted directly for
further information. He disclosed the presence of nitrite (0.27%) and nitrate
(0.08%) in the product. Nitrites and nitrates are used as anticorrosion agents
in antifreeze3 but are not universally included in all formulations, which may
explain why methemoglobinemia has not been consistently observed after
antifreeze ingestion.
On the basis of the concentration of ethylene glycol
reported to be in the product, the patient’s serum level of ethylene glycol at
5 hours after ingestion (835 mg per deciliter), and the patient’s body weight
(64 kg), we estimate that the ingested volume of antifreeze potentially
exceeded 400 ml. This would contain the equivalent of 1.8 g of sodium nitrite,
a toxic dose given that only 300 mg of medicinal sodium nitrite induces
methemoglobinemia in the treatment of cyanide poisoning.4
In conclusion, methemoglobinemia should be considered after
a massive ingestion of antifreeze. More importantly, clinicians should be aware
of the fact that because of the reporting limits allowed by the law, clinically
significant poisons may not be listed on safety data sheets.
5. Bacteremia in Febrile Infants Aged 60 Days and Younger.
A. Epidemiology of Bacteremia in
Febrile Infants Aged 60 Days and Younger.
Powell EC, et al. Ann Emerg Med. 2017 Oct 6 [Epub ahead of
print]
STUDY OBJECTIVE: To describe the current epidemiology of
bacteremia in febrile infants 60 days of age and younger in the Pediatric
Emergency Care Applied Research Network (PECARN).
METHODS: We conducted a planned secondary analysis of a
prospective observational study of febrile infants 60 days of age and younger
presenting to any of 26 PECARN emergency departments (2008 to 2013) who had blood
cultures obtained. We excluded infants with significant comorbidities or
critically ill appearance. The primary outcome was prevalence of bacteremia.
RESULTS: Of 7,335 screened infants, 4,778 (65.1%) had blood
cultures and were enrolled. Of these patients, 84 had bacteremia (1.8%; 95%
confidence interval [CI] 1.4% to 2.2%). The prevalence of bacteremia in infants
aged 28 days or younger (47/1,515) was 3.1% (95% CI 2.3% to 4.1%); in infants
aged 29 to 60 days (37/3,246), 1.1% (95% CI 0.8% to 1.6%). Prevalence differed
by week of age for infants 28 days of age and younger (0 to 7 days: 4/156,
2.6%; 8 to 14 days: 19/356, 5.3%; 15 to 21 days: 15/449, 3.3%; and 22 to 28
days: 9/554, 1.6%). The most common pathogens were Escherichia coli (39.3%; 95%
CI 29.5% to 50.0%) and group B streptococcus (23.8%; 95% CI 16.0% to 33.9%).
Bacterial meningitis occurred in 19 of 1,515 infants 28 days of age and younger
(1.3%; 95% CI 0.8% to 2.0%) and 5 of 3,246 infants aged 29 to 60 days (0.2%;
95% CI 0.1% to 0.4%). Of 84 infants with bacteremia, 36 (42.9%; 95% CI 32.8% to
53.5%) had urinary tract infections (E coli 83%); 11 (13.1%; 95% CI 7.5% to
21.9%) had bacterial meningitis.
CONCLUSION: The prevalence of bacteremia and meningitis
among febrile infants 28 days of age and younger is high and exceeds that
observed in infants aged 29 to 60 days. E coli and group B streptococcus are
the most common bacterial pathogens.
B. Accuracy of CBC Counts to Identify
Febrile Infants 60 Days or Younger With Invasive Bacterial Infections.
Cruz AT, et al. PECARN. JAMA Pediatr. 2017 Nov
6;171(11):e172927.
IMPORTANCE: Clinicians often risk stratify young febrile
infants for invasive bacterial infections (IBIs), defined as bacteremia and/or
bacterial meningitis, using complete blood cell count parameters.
OBJECTIVE: To estimate the accuracy of individual complete
blood cell count parameters to identify febrile infants with IBIs.
DESIGN, SETTING, AND PARTICIPANTS: Planned secondary
analysis of a prospective observational cohort study comprising 26 emergency
departments in the Pediatric Emergency Care Applied Research Network from 2008
to 2013. We included febrile (≥38°C), previously healthy, full-term infants
younger than 60 days for whom blood cultures were obtained. All infants had
either cerebrospinal fluid cultures or 7-day follow-up.
MAIN OUTCOMES AND MEASURES: We tested the accuracy of the
white blood cell count, absolute neutrophil count, and platelet count at
commonly used thresholds for IBIs. We determined optimal thresholds using
receiver operating characteristic curves.
RESULTS: Of 4313 enrolled infants, 1340 (31%; 95% CI, 30% to
32%) were aged 0 to 28 days, 2412 were boys (56%), and 2471 were white (57%).
Ninety-seven (2.2%; 95% CI, 1.8% to 2.7%) had IBIs. Sensitivities were low for
common complete blood cell count parameter thresholds: white blood cell count
less than 5000/µL, 10% (95% CI, 4% to 16%) (to convert to 109 per liter,
multiply by 0.001); white blood cell count ≥15 000/µL, 27% (95% CI, 18% to
36%); absolute neutrophil count ≥10 000/µL, 18% (95% CI, 10% to 25%) (to convert
to × 109 per liter, multiply by 0.001); and platelets less than 100 × 103/µL,
7% (95% CI, 2% to 12%) (to convert to × 109 per liter, multiply by 1). Optimal
thresholds for white blood cell count (11 600/µL), absolute neutrophil count
(4100/µL), and platelet count (362 × 103/µL) were identified in models that had
areas under the receiver operating characteristic curves of 0.57 (95% CI,
0.50-0.63), 0.70 (95% CI, 0.64-0.76), and 0.61 (95% CI, 0.55-0.67),
respectively.
CONCLUSIONS AND RELEVANCE: No complete blood cell count
parameter at commonly used or optimal thresholds identified febrile infants 60
days or younger with IBIs with high accuracy. Better diagnostic tools are
needed to risk stratify young febrile infants for IBIs.
6. ACEP Clinical Policy: ED Management of Patients Needing
Reperfusion Therapy for Acute STEMI
Promes SB, et al. Ann Emerg Med 2017;70:724-39.
Ischemic heart disease is the leading cause of death in the
world. More than half a million patients present to emergency departments
across the United States each year with ST-segment elevation myocardial
infarctions.1 Timely reperfusion is critical to saving myocardium at risk.
Multiple studies have been conducted that demonstrate that improved care
processes are linked to improved survival in patients having an acute
myocardial infarction.
This clinical policy from the American College of Emergency
Physicians addresses key issues in reperfusion for patients with acute
ST-segment elevation myocardial infarction. A writing subcommittee conducted a
systematic review of the literature to derive evidence-based recommendations to
answer the following clinical questions:
(1) In adult patients having an ST-segment elevation
myocardial infarction, are there patients for whom treatment with fibrinolytic
therapy decreases the incidence of major adverse cardiac events when
percutaneous coronary intervention is delayed?
(2) In adult patients having an ST-segment elevation
myocardial infarction, does transfer to a percutaneous coronary intervention
center decrease the incidence of major adverse cardiac events?
(3) In adult patients undergoing reperfusion therapy, should
opioids be avoided to prevent adverse outcomes?
Evidence was graded and recommendations were made based on
the strength of the available data.
7. ED Care Delivery
A. EDs deliver 47.7% of US medical care
Marcozzi D, et al. Trends in the Contribution of Emergency
Departments to the Provision of Health Care in the USA. Int J Health Serv 2017
Oct 17 [Epub ahead of print].
Abstract
Traditional approaches to assessing the health of
populations focus on the use of primary care and the delivery of care through
patient-centered homes, managed care resources, and accountable care
organizations. The use of emergency departments (EDs) has largely not been
given consideration in these models. Our study aimed to determine the contribution
of EDs to the health care received by Americans between 1996 and 2010 and to
compare it with the contribution of outpatient and inpatient services using
National Ambulatory Medical Care Survey and National Hospital Discharge Survey
databases. We found that EDs contributed an average of 47.7% of the medical
care delivered in the United States, and this percentage increased steadily
over the 14-year study period. EDs are a major source of medical care in the
United States, especially for vulnerable populations, and this contribution
increased throughout the study period. Including emergency care within health
reform and population health efforts would prove valuable to supporting the
health of the nation.
B. How one Las Vegas ED saved hundreds
of lives after the worst mass shooting in U.S. history
The night that Stephen Paddock opened fire on thousands of
people at a Las Vegas country music concert, nearby Sunrise Hospital received
more than 200 penetrating gunshot wound victims. Dr. Kevin Menes was the
attending in charge of the ED that night, and thanks to his experience
supporting a local SWAT team, he'd thought ahead about how he might mobilize
his department in the event of a mass casualty incident.
EP Monthly (free): http://epmonthly.com/article/not-heroes-wear-capes-one-las-vegas-ed-saved-hundreds-lives-worst-mass-shooting-u-s-history/
8. Comparing the success rates of standard and modified Valsalva
maneuvers to terminate PSVT: A randomized controlled trial.
Çorbacıoğlu ŞK, et al. Am J Emerg Med. 2017
Nov;35(11):1662-1665.
PURPOSE: The study aimed to detect whether modified Valsalva
maneuver (VM) is more effective than the standard VM in terminating paroxysmal
supraventricular tachycardia (PSVT).
METHODOLOGY: This randomized controlled trial was conducted
in the emergency department of a training and research hospital between Dec. 1,
2015 and Dec. 31, 2016. Participants were divided into two groups, randomly
assigned standard VM or modified VM, as the first treatment with
two-dimensional permutation blocks; in the order of arrival of the patients. In
both groups; the determined procedure for standard or modified VM was repeated
up to three times in patients whose PSVT did not convert to sinus rhythm. In
both groups; if the maneuver was unsuccessful after three attempts,
anti-arrhythmic medication was administered. The primary outcome was defined to
compare the success rate of achieving sinus rhythm after standard VM or
modified VM.
RESULTS: Fifty-six patients were randomized to modified or
standard VM with 28 patients in each treatment arm. Three of 28 patients
(10.7%) in VM group and 12 of 28 patients (42.9%) in modified VM group were
returned to sinus rhythm after intervention (p=0.007). The number of patients
who needed rescue treatment was lower in the modified VM group - 16 (57.1%) of
28 versus 25 (89.3%) of 28 in the standard VM group (p=0.007).
CONCLUSION: This study suggests that modified VM therapy was
more effective than standard VM for terminating PSVT. The modified VM therapy
also indirectly reduced the need for anti-arrhythmic medication and indirectly
caused fewer side effects.
What
is the modified Valsalva?
From the original study: “The modified Valsalva manoeuvre (intervention) was termed “lying down with leg lift Valsalva” (video). Participants performed the standardised strain in the same semi-recumbent position but immediately at the end of the strain, were laid flat and had their legs raised by a member of staff to 45° for 15 s. Participants were then returned to the semi-recumbent position for a further 45 s before re-assessment of cardiac rhythm, initially by 3-lead ECG. If sinus rhythm was not restored, participants were invited to undertake one further attempt at the allocated Valsalva manoeuvre.”
From the original study: “The modified Valsalva manoeuvre (intervention) was termed “lying down with leg lift Valsalva” (video). Participants performed the standardised strain in the same semi-recumbent position but immediately at the end of the strain, were laid flat and had their legs raised by a member of staff to 45° for 15 s. Participants were then returned to the semi-recumbent position for a further 45 s before re-assessment of cardiac rhythm, initially by 3-lead ECG. If sinus rhythm was not restored, participants were invited to undertake one further attempt at the allocated Valsalva manoeuvre.”
Appelboam A, et al. Postural modification to the standard
Valsalva manoeuvre for emergency treatment of SVT (REVERT): a RCT. Lancet 2015 Oct
31;386(10005):1747-53.
Full-text (free): http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)61485-4/fulltext
9. New International CPR Guidelines
Olasveengen TM et al. 2017 International Consensus on
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With
Treatment Recommendations Summary.
Resuscitation 2017;121:201–214.
Journal Watch Summary
Quality cardiopulmonary resuscitation (CPR) has become the
central factor in improving outcomes of cardiac arrest. ILCOR has moved from a
5-year cycle for releasing guidelines to a continuous process of conducting
systematic reviews and annual publication of recent results. These guidelines
focus on the key issue of when to give ventilations during CPR.
Although questions remain about the optimal role of
ventilations in CPR, several things are clear: (1) Use a 30:2 ratio of
compressions:ventilations when possible and appropriate; (2) don't withhold
compressions if the rescuer can't or won't give rescue breaths; and (3) once an
endotracheal tube is in place, don't pause to give breaths.
JW Review: https://www.jwatch.org/na45519/2017/11/21/updated-international-guidelines-ventilation-during-cpr
10. Images in Clinical Practice
Acute constipation and vomiting with the “coffee bean” sign
Decompression Sickness
A 42-year-old man presented to the emergency department with
skin changes, arthralgias, and vomiting after scuba diving. He was treated for
decompression sickness.
Takotsubo Cardiomyopathy
A 61-year-old woman with hypertension and hypothyroidism
presented to the emergency department with acute onset of severe chest pain.
She reported multiple recent stressors, including the death of her dog. An
electrocardiogram showed ST-segment elevation in the anterolateral leads.
Emergency coronary angiography revealed normal coronary arteries.
Molluscum Contagiosum in a Patient with Atopic Dermatitis
“Popeye” Sign
Falciform Ligament Sign
Compartment Syndrome
HIV Infection Manifesting as Proximal White Onychomycosis
Button Magnets in the Nasal Cavity
Congenital Diaphragmatic Hernia
Woman With Swelling of the Left Breast
Adolescent Male With Abdominal Pain
Newborn With a Rash
Woman With Headache and Neck Swelling
Elderly Woman With Chest Pain and Cough (Hampton’s Hump)
Man With Blunt Abdominal Trauma
Child With a Serpinginous Structure in the Bowel
You Traveled the World and All You Got
Was Ascariasis
Seven-Year-Old Girl With Forehead Swelling
Female With Neck Pain
Male With Sudden Left Eye Vision Loss
Young Woman With a Blue, Painful and Swollen Arm
Male With Left Lower Quadrant Pain
Elderly Female With Dyspnea
Young Woman With Eye Pressure
Child With Generalized Weakness and Anorexia
Elderly Woman With Atrial Fibrillation
11. Lumbar Puncture Before CT in Patients with Bacterial
Meningitis
Sweden’s LP-first strategy was associated with less
mortality and more favorable outcomes.
Glimåker M, et al. Lumbar puncture performed promptly or
after neuroimaging in adult bacterial meningitis: A prospective national cohort
study evaluating different guidelines.
Clin Infect Dis. 2017 Sep 9 [Epub ahead of print].
INTRODUCTION: Acute bacterial meningitis (ABM) is a
life-threatening disease. Despite modern treatment and intensive care, the
mortality is still 10%–30%, and the risk of persistent neurologic or hearing
deficit is high [1–3]. Early adequate treatment is pivotal to achieve a
favorable outcome [1, 4]. Lumbar puncture (LP) is the basis of ABM diagnosis and,
in clinical practice, LP and cerebrospinal fluid (CSF) analyses are often
decisive to start correct antibiotics and corticosteroids in meningitis dosages
[4, 5].
It is recommended that, in certain situations with suspected
increased intracranial pressure (ICP) and cerebral mass lesion, the clinician
should refrain from prompt LP and instead first perform computed tomography
(CT) of the brain, as it is argued that LP may increase the risk of brain
herniation [6–8]. However, firm evidence that LP may cause herniation is
lacking, and the natural course of ABM or brain abscess may itself result in
herniation [6, 9, 10]. Furthermore, it is shown that cerebral CT is poor at
predicting the risk of herniation in ABM [11–13]. Guidelines differ as to when
to perform neuroimaging before LP in patients with suspected bacterial
meningitis. Table 1 shows the recommendations in the current Swedish, European
Society for Clinical Microbiology and Infectious Diseases (ESCMID), and
Infectious Diseases Society of America (IDSA) guidelines. The Swedish
guidelines are the most liberal regarding prompt LP since impaired mental
status and new-onset seizures were omitted as indications for CT before LP
after the revision in 2009 [14]. The ESCMID guidelines were revised in 2016 when
the level of consciousness indicating CT before LP was lowered from Glasgow
Coma Scale score (GCS) less than 12 to less than 10 [8]. IDSA guidelines from
2004 are the most conservative regarding prompt LP by recommending CT before LP
if abnormal mental status (GCS less than 15) is observed [7]. In contrast to
the Swedish recommendations, both the ESCMID and IDSA guidelines recommend CT
before LP in cases with severely immunocompromised state or new-onset seizures.
ABSTRACT
BACKGROUND: Early treatment is pivotal for favourable
outcome in acute bacterial meningitis (ABM). Lumbar puncture (LP) is the
diagnostic key. The aim was to evaluate the effect on outcome of adherence to
European Society of Clinical Microbiology and Infectious Diseases (ESCMID),
Infectious Diseases Society of America (IDSA), and Swedish guidelines regarding
neuroimaging before LP.
METHODS: The cohort comprised 815 adult ABM patients in
Sweden registered prospectively between 2008-2015. Primary endpoint was
in-hospital mortality and secondary endpoint was favorable outcome at 2-6
months follow-up.
RESULTS: Indications for neuroimaging before LP existed in
7%, 32% and 65% according to Swedish, ESCMID and IDSA guidelines, respectively.
The adjusted odds ratio (aOR) was 0.48 (95% CI: 0.26-0.89) for mortality and
1.52 (1.08-2.12) for favorable outcome if Swedish guidelines were followed.
ESCMID guideline adherence resulted in aOR of 0.68 (0.38-1.23) for mortality
and 1.05 (0.75-1.47) for favorable outcome. Following IDSA recommendations
resulted in aOR of 1.09 (0.61-1.95) for mortality and 0.59 (0.42-0.82) for
favorable outcome. Performing prompt vs. neuroimaging preceded LP was associated
with aOR of 0.37 (0.18-0.76) for mortality and 2.12 (CI: 1.49-3.03) for
favorable outcome. The beneficial effect of prompt LP was observed regardless
of mental status and immunosuppression.
CONCLUSION: Adherence to Swedish guidelines in ABM 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.
The Swedish Guidelines discussed here: Glimåker M ,
Johansson B , Bell M et al. Early lumbar puncture in adult bacterial
meningitis—rationale for revised guidelines. Scand J Infect Dis 2013;
45:657–63. https://www.ncbi.nlm.nih.gov/pubmed/23808722
12. Cannabinoid Hyperemesis Syndrome: Public Health Implications
and a Novel Model Treatment Guideline
Lapoint J, et al. West J Emerg Med 2017 Nov 8 [Epub ahead of
print].
Introduction: Cannabinoid hyperemesis syndrome (CHS) is an
entity associated with cannabinoid overuse. CHS typically presents with
cyclical vomiting, diffuse abdominal pain, and relief with hot showers.
Patients often present to the emergency department (ED) repeatedly and undergo
extensive evaluations including laboratory examination, advanced imaging, and
in some cases unnecessary procedures. They are exposed to an array of
pharmacologic interventions including opioids that not only lack evidence, but
may also be harmful.This paper presents a novel treatment guideline that
highlights the identification and diagnosis of CHS and summarizes treatment
strategies aimed at resolution of symptoms, avoidance of unnecessary opioids,
and ensuring patient safety.
Methods: The San Diego Emergency Medicine Oversight
Commission in collaboration with the County of San Diego Health and Human
Services Agency and San Diego Kaiser Permanente Division of Medical Toxicology
created an expert consensus panel to establish a guideline to unite the ED
community in the treatment of CHS.
Results: Per the consensus guideline, treatment should focus
on symptom relief and education on the need for cannabis cessation. Capsaicin
is a readily available topical preparation that is reasonable to use as
first-line treatment. Antipsychotics including haloperidol and olanzapine have
been reported to provide complete symptom relief in limited case studies.
Conventional antiemetics including antihistamines, serotonin antagonists,
dopamine antagonists and benzodiazepines may have limited effectiveness.
Emergency physicians should avoid opioids if the diagnosis of CHS is certain
and educate patients that cannabis cessation is the only intervention that will
provide complete symptom relief.
Conclusion: An expert consensus treatment guideline is
provided to assist with diagnosis and appropriate treatment of CHS. Clinicians
and public health officials should identity and treat CHS patients with
strategies that decrease exposure to opioids, minimize use of healthcare
resources, and maximize patient safety.
13. Annal Emerg Med Brief Reviews
A. What Elements of the History,
Examination, Laboratory Testing, or Point-of-Care Ultrasonography Are Most
Useful in the Diagnosis of Acute Appendicitis in Children?
Take-Home Message
In children with suspected appendicitis, history, physical
examination, laboratory results, and the Pediatric Appendicitis Score cannot
safely rule in or rule out the diagnosis. A positive ultrasonographic result,
with sonography performed by a qualified provider, is diagnostic.
B. What Is the Utility of End-Tidal
Capnography for Procedural Sedation and Analgesia in the ED?
Take-Home Message
The addition of capnography to standard monitoring in
emergency department (ED) procedural sedation and analgesia does not appear to
reduce the rate of clinically significant adverse events.
C. Are Nonsteroidal Anti-inflammatory
Drugs Efficacious in Relieving Biliary Colic Pain?
Take-Home Message
Nonsteroidal anti-inflammatory drugs are beneficial in
managing biliary colic pain compared with placebo. No difference was found in
pain relief when nonsteroidal anti-inflammatory drugs were compared with
opioids.
D. Is Antiplatelet Therapy an
Independent Risk Factor for Traumatic ICH in Patients With Mild Traumatic Brain
Injury?
Take-Home Message
Antiplatelet therapy appears to increase the risk for
intracranial bleeding in patients with traumatic brain injury compared with
those receiving warfarin or no antiplatelet therapy; however, this may not
apply to aspirin monotherapy.
14. The Science of Performance Under Stress and of Wellness
during Residency (and beyond)
A. Psychological Skills to Improve
Emergency Care Providers' Performance Under Stress.
Lauria MJ, Weingart SD, et al. Ann Emerg Med. 2017
Dec;70(6):884-890.
Stress experienced by emergency medical providers during the
resuscitation of critically ill or injured patients can cause cognitive and
technical performance to deteriorate. Psychological skills training offers a
reasonable and easily implemented solution to this problem. In this article, a
specific set of 4 performance-enhancing psychological skills is introduced:
breathe, talk, see, and focus. These skills comprise breathing techniques,
positive self-talk, visualization or mental practice, and implementing a focus
"trigger word." The evidence supporting these concepts in various
domains is reviewed and specific methods for adapting them to the environment
of resuscitation and emergency medicine are provided.
B. Strategies to Enhance Wellness in
Emergency Medicine Residency Training Programs.
Ross S, et al. Ann Emerg Med. 2017 Dec;70(6):891-897.
Physician wellness is important at all stages of training,
and resident depression and suicide has recently gained national attention as a
critical problem in residencies across all specialties.9, 10 Despite this, many
emergency medicine residencies have little to no devoted time to address
wellness in their educational curricula. Residencies have begun to implement
wellness activities, which range from rotations in wellness and leadership to
wellness retreats, but so far those efforts have been insufficient to stave off
the presence of depression and burnout in residency training.11, 12, 13 Here we
discuss strategies to improve wellness during emergency medicine residency.
Strategies include both interventions at the level of the individual resident
and the emergency medicine residency training community.
15. OB/GYN Corner
A. Is the Pelvic Examination Still
Crucial in Patients Presenting to the ED with Vaginal Bleeding or Abdominal
Pain When an IUP Is Identified on US? A RCT
Linden JA, et al. Ann Emerg Med. 2017 Dec;70(6):825-834.
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.
Editor’s Capsule Summary
What is already known on this topic
It is unknown whether pelvic examinations enhance the
management of first-trimester vaginal bleeding or lower abdominal pain.
What question this study addressed
This randomized controlled trial compared patient morbidity,
satisfaction, and length of stay among 220 patients presenting to 2 emergency
departments (EDs) with lower abdominal pain or vaginal bleeding and a confirmed
first-trimester intrauterine pregnancy, who were randomized to no pelvic
examination (versus standard care of a pelvic examination).
What this study adds to our knowledge
Although the study did not reach target recruitment numbers,
it shows similar composite morbidity endpoints and substantially higher
satisfaction among patients randomized to no pelvic examination compared with
those receiving one.
How this is relevant to clinical practice
This study provides the best available evidence supporting
omission of pelvic examinations from ED evaluation of women with confirmed
intrauterine pregnancy and first-trimester bleeding or lower abdominal pain.
B. Update: UTI Diagnosis and Treatment
Gupta K, et al. Ann Intern Med. 2017;167:ITC49-ITC64.
This narrative review provides an update of the evidence
regarding diagnosis and treatment of urinary tract infections (UTIs). Key
points include:
- Clinicians should not screen for or treat asymptomatic bacteriuria, except in pregnant patients or those undergoing invasive urinary procedures that will induce mucosal bleeding (e.g., transurethral resection of the prostate).
- Although UTI can be diagnosed clinically, urine culture should be done in patients in whom the diagnosis is uncertain, in pregnant women, and in men with suspected UTI. Urine culture is also indicated when pyelonephritis or complicated infection is suspected and in cases of relapse or treatment failure.
- Antibiotic choice depends on the classification of the disease. Fluoroquinolones should not be used to treat uncomplicated cystitis based on safety and stewardship concerns but may be used to treat pyelonephritis and complicated infections (e.g., structural abnormalities of the urinary tract or immunocompromised host). Resistance is common in many areas.
Bonus: Symptomatic
treatment of uncomplicated lower urinary tract infections in the ambulatory
setting: randomised, double blind trial
C. What Antibiotic Regimen Is Most
Efficacious in Treating Pelvic Inflammatory Disease?
Take-Home Message
Outcomes do not differ between the various antibiotics
currently recommended by Centers for Disease Control and Prevention (CDC)
guidelines for pelvic inflammatory disease, although most studies are at
unclear or high risk of bias.
16. Does This Patient Have Acute Mountain Sickness? The Rational
Clinical Examination Systematic Review
Meier D, et al. JAMA.
2017;318(18):1810-1819.
Key Points
Question What is the
best instrument to use for diagnosing acute mountain sickness (AMS)?
Findings In a
systematic review of studies assessing the accuracy of existing AMS diagnostic
instruments, the visual analog scale for the overall feeling of sickness at
altitude (VAS[O]) score, the Acute Mountain Sickness-Cerebral score (AMS-C), and
the clinical functional score (CFS) had similar testing characteristics for
diagnosing AMS as did a reference standard (the Lake Louise Questionnaire Score
[LLQS] using ≥5 to indicate a positive test result).
Meaning Although
these instruments emphasize different clinical features, they all performed
similarly for establishing a diagnosis of AMS. The clinical functional score is
the simplest instrument to use for diagnosing AMS because it relies on a single
question and emphasizes functional limitations resulting from AMS.
17. Oral Anticoagulant Corner
A. Dabigatran Reversal with Idarucizumab
Yip L, et al. N Engl J Med 2017; 377:1690-1692
Data provided by Pollack and colleagues (Aug. 3 issue)1
suggest a dissociation between the normalization of the coagulation profile and
the establishment of effective hemostasis after the administration of
idarucizumab in patients with uncontrolled bleeding. The median time to the
cessation of bleeding was 2.5 hours among patients with nonintracranial
hemorrhage. In analyses reported separately, the median time to the cessation
of bleeding was 3.5 hours among patients with gastrointestinal bleeding and 4.5
hours among those with nonintracranial and nongastrointestinal bleeding.2 The
median time to the cessation of bleeding was 11.4 hours when intracranial
hemorrhage was included in the analysis involving patients with serious
bleeding.3 Should clinicians rely solely on idarucizumab and hope that their
patients do not die from uncontrolled hemorrhage while waiting for hemostasis
to be established?
A reasonable approach would be to administer blood-component
therapy (e.g., prothrombin complex concentrate and activated prothrombin
complex concentrate) — a bridge between the normalization of the coagulation
profile and the establishment of hemostasis, according to in vitro and
preclinical data4,5 — in addition to idarucizumab. It can be reasonably argued
that the establishment of effective hemostasis with blood-component and
idarucizumab therapy outweighs the risk of thrombotic adverse events among
patients with serious hemorrhaging. The effectiveness and need for further
blood-component and idarucizumab therapy may be assessed by serial clinical
assessments and a serial profile of clotting times.
B. OACs Tied to Less Dementia in
Patients with Atrial Fibrillation
By Amy Orciari Herman. Journal Watch News.
Oral anticoagulation in patients with atrial fibrillation is
associated with reduced risk for dementia, according to a retrospective study
in the European Heart Journal.
Using data from Swedish health registries, researchers
studied over 440,000 adults with diagnosed atrial fibrillation and no history
of dementia. Over 40% of the patients were using vitamin K antagonists at
baseline, and 3% were using novel oral anticoagulants (NOACs). During
follow-up, about 6% of the cohort developed dementia (1.73 diagnoses per 100
patient-years).
In a matched cohort analysis, patients who'd received oral
anticoagulants at baseline had a 29% lower risk for dementia than those who
hadn't received oral anticoagulants. Earlier treatment initiation appeared more
beneficial. The protective effect didn't seem to differ between NOACs and
warfarin.
The researchers speculate that oral anticoagulation may
"protect against small emboli which [cause] microinfarctions that
eventually lead to cognitive deterioration." They conclude: "Our
findings regarding dementia protection may provide a second argument for
initiation of treatment among untreated AF-patients. Since the time from
diagnosis to start of treatment appears to be an independent risk factor, early
initiation of treatment is desirable in order to preserve cognitive
function."
C. When Anticoagulants Become a Bloody
Mess
Lai S, et al. Ann Emerg Med 2017;70:949–952.
Annals Case
Imagine just another busy day in your emergency department
(ED) when an elderly gentleman presents with a simple, straightforward
mechanical fall. Sounds easy. Subsequent head computed tomography shows a
traumatic subdural hemorrhage and now his care is a little more complicated.
Then you discover his history of atrial fibrillation and, as recommended by his
CHA2DS2-VASc score,1 he is in fact receiving an oral anticoagulant. Of course
he has no previous records or medication list on hand and cannot recall the
name of his mystery anticoagulant. Now this simple case is very, very
complicated. Anticoagulation reversal for his unknown anticoagulant is
needed…and fast. Could he be receiving a non–vitamin K oral anticoagulant
(NOAC)? How do we reverse these agents?
Helpful
discussion section is located in this middle section (see full-text below)
Case Conclusion
Take 1: Fortunately for us and our patient, a family member
shows up and reports he last took his dabigatran 6 hours ago. You cleverly
order idarucizumab, and a concerned neurosurgeon takes the patient up to the
ICU. After giving yourself a hearty and deserved pat on the back, on to the
next patient!
Take 2: But what if this family member reported rivaroxaban
taken 7 hours ago instead? Well, we are outside the 2-hour last ingestion
window for activated charcoal, rivaroxaban does not currently have an antidote
available, and it is not dialyzable. Here, you cleverly order PCC or aPCC and
consider tranexamic acid, after which a concerned neurosurgeon takes the
patient up to the ICU. Time for another hearty and deserved pat on the back,
and on to the next patient!
D. ACEP Policy: Reversal of Non–Vitamin
K Antagonist Oral Anticoagulants (NOACs) in the Presence of Major
Life-Threatening Bleeding
This offers a helpful, up-to-date review.
E. A Crazy Case Report
Agosti S, et al. Successful Intravenous Thrombolysis for
Ischemic Stroke After Reversal of Dabigatran Anticoagulation With Idarucizumab:
A Case Report. J Med Case Rep. 2017; 11: 224.
18. Shared Decisionmaking in the ED: A Guiding Framework for
Clinicians
Probst MA, et al. Ann Emerg Med. 2017;70:688–695.
Shared decisionmaking has been proposed as a method to
promote active engagement of patients in emergency care decisions. Despite the
recent attention shared decisionmaking has received in the emergency medicine
community, including being the topic of the 2016 Academic Emergency Medicine
Consensus Conference, misconceptions remain in regard to the precise meaning of
the term, the process, and the conditions under which it is most likely to be
valuable. With the help of a patient representative and an interaction
designer, we developed a simple framework to illustrate how shared
decisionmaking should be approached in clinical practice.
We believe it should be the preferred or default approach to
decisionmaking, except in clinical situations in which 3 factors interfere.
These 3 factors are lack of clinical uncertainty or equipoise, patient
decisionmaking ability, and time, all of which can render shared decisionmaking
infeasible. Clinical equipoise refers to scenarios in which there are 2 or more
medically reasonable management options. Patient decisionmaking ability refers
to a patient’s capacity and willingness to participate in his or her emergency
care decisions. Time refers to the acuity of the clinical situation (which may
require immediate action) and the time that the clinician has to devote to the
shared decisionmaking conversation. In scenarios in which there is only one
medically reasonable management option, informed consent is indicated, with
compassionate persuasion used as appropriate. If time or patient capacity is
lacking, physician-directed decisionmaking will occur. With this framework as
the foundation, we discuss the process of shared decisionmaking and how it can
be used in practice. Finally, we highlight 5 common misconceptions in regard to
shared decisionmaking in the ED. With an improved understanding of shared
decisionmaking, this approach should be used to facilitate the provision of
high-quality, patient-centered emergency care.
19. Choking on a Foreign Body: A Physiological Study of the
Effectiveness of Abdominal Thrust Manoeuvres to Increase Thoracic Pressure
Pavitt MJ, et al. Thorax. 2017;72(6):576-578.
Abstract
The Heimlich manoeuvre is a well-known intervention for the
management of choking due to foreign body airway occlusion, but the evidence
base for guidance on this topic is limited and guidelines differ. We measured
pressures during abdominal thrusts in healthy volunteers. The angle at which
thrusts were performed (upthrust vs circumferential) did not affect
intrathoracic pressure. Self-administered abdominal thrusts produced similar
pressures to those performed by another person. Chair thrusts, where the subject
pushed their upper abdomen against a chair back, produced higher pressures than
other manoeuvres. Both approaches should be included in basic life support
teaching….
Conclusion
The key to diagnosing complete airway obstruction is a
conscious subject, in the process of eating, who is unable to breathe at all,
nor to speak. Autoadministered thrusts appear as physiologically effective as
first-aider-administered ones to generate expulsive intrathoracic pressures,
and chair thrusts appear to be the most physiologically effective. We advise
that everyone with complete airway obstruction should, in the first instance,
either autoadminister abdominal thrusts or perform a chair thrust. The various
manoeuvres should be more widely taught in schools, first aid courses, to staff
in restaurants and publicised as widely as possible. We would like to see
suitable notices in eating places.
20. Corticosteroids for treatment of sore throat: systematic
review and meta-analysis of randomised trials
Sadeghirad B, et al. BMJ. 2017 Sep 20;358:j3887.
Objective To estimate the benefits and harms of using
corticosteroids as an adjunct treatment for sore throat.
Design Systematic review and meta-analysis of randomised
control trials.
Data sources Medline, Embase, Cochrane Central Register of
Controlled Trials (CENTRAL), trial registries up to May 2017, reference lists
of eligible trials, related reviews.
Study selection Randomised controlled trials of the addition
of corticosteroids to standard clinical care for patients aged 5 or older in
emergency department and primary care settings with clinical signs of acute
tonsillitis, pharyngitis, or the clinical syndrome of sore throat. Trials were
included irrespective of language or publication status.
Review methods Reviewers identified studies, extracted data,
and assessed the quality of the evidence, independently and in duplicate. A
parallel guideline committee (BMJ Rapid Recommendation) provided input on the
design and interpretation of the systematic review, including the selection of
outcomes important to patients. Random effects model was used for
meta-analyses. Quality of evidence was assessed with the GRADE approach.
Results 10 eligible trials enrolled 1426 individuals.
Patients who received single low dose corticosteroids (the most common
intervention was oral dexamethasone with a maximum dose of 10 mg) were twice as
likely to experience pain relief after 24 hours (relative risk 2.2, 95%
confidence interval 1.2 to 4.3; risk difference 12.4%; moderate quality
evidence) and 1.5 times more likely to have no pain at 48 hours (1.5, 1.3 to
1.8; risk difference 18.3%; high quality). The mean time to onset of pain
relief in patients treated with corticosteroids was 4.8 hours earlier (95%
confidence interval −1.9 to −7.8; moderate quality) and the mean time to
complete resolution of pain was 11.1 hours earlier (−0.4 to −21.8; low quality)
than in those treated with placebo. The absolute pain reduction at 24 hours
(visual analogue scale 0-10) was greater in patients treated with
corticosteroids (mean difference 1.3, 95% confidence interval 0.7 to 1.9;
moderate quality). Nine of the 10 trials sought information regarding adverse
events. Six studies reported no adverse effects, and three studies reported few
adverse events, which were mostly complications related to disease, with a
similar incidence in both groups.
Conclusion Single low dose corticosteroids can provide pain
relief in patients with sore throat, with no increase in serious adverse
effects. Included trials did not assess the potential risks of larger
cumulative doses in patients with recurrent episodes of acute sore throat.
21. 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; 377:2090-2091.
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.
Educate yourself. Read the background materials and
proposals for sensible firearm legislation from health care professional
organizations. Make a phone call and write a letter to your local, state, and
federal legislators to tell them how you feel about gun control. Now. Don’t
wait. And do it again at regular intervals. Attend public meetings with these
officials and speak up loudly as a health care professional. Demand answers,
commitments, and follow-up. Go to rallies. Join, volunteer for, or donate to
organizations fighting for sensible firearm legislation. Ask candidates for
public office where they stand and vote for those with stances that mitigate
firearm-related injury.
Meet with the leaders at your own institutions to discuss
how to leverage your organization’s influence with local, state, and federal
governments. Don’t let concerns for perceived political consequences get in the
way of advocating for the well-being of your patients and the public. Let your
community know where your institution stands and what you are doing. Tell the
press.
Educate yourself about gun safety. Ask your patients if
there are guns at home. How are they stored? Are there children or others at
risk for harming themselves or others? Direct them to resources to decrease the
risk for firearm injury, just as you already do for other health risks. Ask if
your patients believe having guns at home makes them safer, despite evidence
that they increase the risk for homicide, suicide, and accidents.
Don’t be silent. We don’t need more moments of silence to
honor the memory of those who have been killed. We need to honor their memory
by preventing a need for such moments. As health care professionals, we don’t throw
up our hands in defeat because a disease seems to be incurable. We work to
incrementally and continuously reduce its burden. That’s our job.
Will yet another commentary about the ravages of
firearm-related harm change anything? Probably not — our journals have
published far too many following prior firearm-enabled catastrophes. The only
thing that will change the world for the better is a group of people who
believe that they can change the world. With regard to firearm-related injury
and death, let’s each be part of that group.
22. Ultrasound in Emerg Med
A. Ultrasound-guided central venous
catheter placement: a structured review and recommendations for clinical
practice.
Saugel B, et al. Crit Care. 2017 Aug 28;21(1):225. doi:
10.1186/s13054-017-1814-y.
The use of ultrasound (US) has been proposed to reduce the
number of complications and to increase the safety and quality of central
venous catheter (CVC) placement. In this review, we describe the rationale for
the use of US during CVC placement, the basic principles of this technique, and
the current evidence and existing guidelines for its use. In addition, we
recommend a structured approach for US-guided central venous access for
clinical practice. Static and real-time US can be used to visualize the anatomy
and patency of the target vein in a short-axis and a long-axis view. US-guided
needle advancement can be performed in an "out-of-plane" and an
"in-plane" technique.
There is clear evidence that US offers gains in safety and
quality during CVC placement in the internal jugular vein. For the subclavian
and femoral veins, US offers small gains in safety and quality. Based on the
available evidence from clinical studies, several guidelines from medical
societies strongly recommend the use of US for CVC placement in the internal
jugular vein. Data from survey studies show that there is still a gap between
the existing evidence and guidelines and the use of US in clinical practice.
For clinical practice, we recommend a six-step systematic
approach for US-guided central venous access that includes assessing the target
vein (anatomy and vessel localization, vessel patency), using real-time US
guidance for puncture of the vein, and confirming the correct needle, wire, and
catheter position in the vein. To achieve the best skill level for CVC
placement the knowledge from anatomic landmark techniques and the knowledge
from US-guided CVC placement need to be combined and integrated.
B. The role for US in hypotension and
in cardiac arrest
International Federation for Emergency Medicine Consensus
Statement: Sonography in hypotension and cardiac arrest (SHoC): An international
consensus on the use of point of care ultrasound for undifferentiated
hypotension and during cardiac arrest
Atkinson P, et al. CJEM 2017 Nov;19(6):459-470.
The International Federation for Emergency Medicine (IFEM)
Ultrasound Special Interest Group (USIG) was tasked with development of a
hierarchical consensus approach to the use of point of care ultrasound (PoCUS)
in patients with hypotension and cardiac arrest.
The IFEM USIG invited 24 recognized international leaders in
PoCUS from emergency medicine and critical care to form an expert panel to
develop the sonography in hypotension and cardiac arrest (SHoC) protocol. The
panel was provided with reported disease incidence, along with a list of
recommended PoCUS views from previously published protocols and guidelines.
Using a modified Delphi methodology the panel was tasked with integrating the
disease incidence, their clinical experience and their knowledge of the medical
literature to evaluate what role each view should play in the proposed SHoC
protocol.
Consensus on the SHoC protocols for hypotension and cardiac
arrest was reached after three rounds of the modified Delphi process. The final
SHoC protocol and operator checklist received over 80% consensus approval. The
IFEM-approved final protocol, recommend Core, Supplementary, and Additional
PoCUS views. SHoC-hypotension core views consist of cardiac, lung, and inferior
vena vaca (IVC) views, with supplementary cardiac views, and additional views
when clinically indicated. Subxiphoid or parasternal cardiac views, minimizing
pauses in chest compressions, are recommended as core views for SHoC-cardiac
arrest; supplementary views are lung and IVC, with additional views when
clinically indicated. Both protocols recommend use of the “4 F” approach:
fluid, form, function, filling.
An international consensus on sonography in hypotension and
cardiac arrest is presented. Future prospective validation is required.
23. Pushing Back on Push Dose Pressors?
Genes N. EP Monthly. Nov 20, 2017
A quick and easy life-saving solution, or an unjustifiable
risk to patients?
As a resident, I was fortunate to regularly hear Scott
Weingart speak at our Wednesday conference. So to me, bolus-dose vasopressors
(or as Scott coined them, push-dose pressors) have just always been a useful
thing to have nearby.
Say you have a crashing peri-intubation patient with a low
MAP. Wouldn’t it be comforting to know that you can boost the blood pressure
for your procedure quickly, albeit temporarily, while a drip is set up? We’ve
had pre-filled syringes close at hand in our resuscitation bay for years, and
push-dose pressors have bailed me out of at least a few tense situations. There
are times when waiting for pressure-bagged fluids to exert an effect, or
waiting for a drip to get set up isn’t in the patient’s best interest.
I just assumed that everyone else agreed. I didn’t realize
that other specialties, and some of our own colleagues, would look upon EPs
using push-dose pressors with suspicion – unnecessary at best, and too risky to
recommend.
But that’s the perception that AJEM’s Letters to the Editor
section gave this summer, with echoes across the EM social media world…
24. Micro Bits
A. Laptops in the Classroom Hinder Learning. Imagine
their Effect during Meetings.
B. Regular Walking, Even if Minimal, Tied to Lower Death
Risk
Researchers found
that adults who did moderate-intensity walking for 120 minutes or less per week
were at a reduced likelihood of dying prematurely from all causes, compared
with inactive individuals, while higher levels of walking were tied to a 20%
lower mortality risk. The findings in the American Journal of Preventive
Medicine, based on data on more than 139,000 adults enrolled in the Cancer
Prevention Study II Nutrition Cohort, showed that the age-standardized overall
death rate among those who walked less than the recommended amount of physical
activity was 2,851 per 100,000, compared with 4,293 per 100,000 among inactive
participants.
C. Mood might influence vaccine efficacy among seniors,
study suggests
Researchers who
monitored the psychological and physical health of 138 people ages 65 to 85
found that those whose moods were more positive had higher serum levels of
antibodies to H1N1 four and 16 weeks after vaccination than those whose moods
were more negative. The findings -- reported in Brain, Behavior, and Immunity
-- suggest that although many factors that could influence vaccine efficacy are
out of patients' control, a positive outlook on the day of inoculation might
benefit, health psychologist Kavita Vedhara said.
D. Pregnant Women Should Still Get The Flu Vaccine,
Doctors Advise
E. Coffee consumption and health: umbrella review of
meta-analyses of multiple health outcomes
Drinking three to
four cups of coffee a day is associated with health benefits across a range of
diseases and conditions. A review published in The BMJ this week identified 201
meta-analyses of observational research and 17 meta-analyses of interventional
research and found that coffee consumption was more often associated with
benefit than harm over various health outcomes
F. Thanks a Lot! New Reasons Not to Eat Cookie Dough
Spoiler alert.
If you are already
elbow-deep in holiday cake and cookie batter, you may just want to take your
chances and stop reading here.
But to become
wiser and safer, though indisputably annoyed, step away from that bowl and read
on.
Tasting uncooked
foods made with flour can make you dangerously ill, according to a study
published Wednesday in The New England Journal of Medicine. The report, which
recounts the detective work that led to a recall of more than 10 million pounds
of flour in the summer of 2016, confirms that a type of E. coli bacteria
previously discovered lurking in wet environments like hamburger meat and leafy
vegetables can also thrive in arid hosts.
“We’re not trying
to ruin people’s holidays but we want them to be aware of the risks,” said
Samuel J. Crowe, the lead author of the study and an epidemiologist…
G. Updated AHA guidelines lower threshold for
hypertension
New guidelines
from the American Heart Association and 10 other medical groups reduce the
hypertension threshold from 140 mm Hg systolic over 90 mm Hg to 130 over 80,
meaning 46% of US adults would be diagnosed with high blood pressure. The
guidelines, published in the Journal of the American College of Cardiology and
in Hypertension, call for patients already being treated for high blood
pressure to work toward the lower goal and for adults to address early
hypertension with lifestyle changes rather than medication.
Journal Watch summary and commentary : https://www.jwatch.org/na45488/2017/11/16/new-multisociety-hypertension-guideline-released
A Visual Guide to the New Blood Pressure
Guidelines : The ACC/AHA 2017 recommendations -- in color and by the
numbers
What the new
guidelines mean for Kaiser Permanente, and what can be learned
H. During Pregnancy, Side Sleeping Better For Baby
(British Journal of Obstetrics and Gynaecology): Supine sleeping tied to
stillbirth risk
I. FDA approves the first pill that can alert your doctor
when you swallow it
The Food and Drug
Administration has approved the first pill embedded with a sensor that can
alert a patient’s physician or caregiver when it’s been ingested, the agency
announced on Monday.
The Japanese drug
maker Otsuka Pharmaceutical won the approval for an upgraded version of
Abilify, the antipsychotic drug first approved 15 years ago to treat
schizophrenia, bipolar disorder, and depression. Otsuka collaborated with
Proteus Digital Health, the Silicon Valley company that designed the futuristic
sensor technology.
The new product,
which will be sold as Abilify MyCite, can be swallowed just like any other
pill. When that happens, the ingestible sensor inside it sends a message to a
patch worn by the patient, which then transmits the information to a mobile app
that the patient can monitor. If a patient opts to allow it, the patient’s
caregivers and doctor can access the data online, too…
J. Vegetarianism Linked to Depression : Maybe from
Vit Deficiency ?
K. Readmission reduction program leads to higher
mortality rates in HF Pts
The Hospital
Readmissions Reduction Program has led to fewer patient readmissions but an
increase in 30-day and one-year mortality rates for Medicare beneficiaries
hospitalized with heart failure, researchers reported in JAMA Cardiology. Study
co-author Gregg Fonarow, M.D., said while reducing preventable readmissions is
important, it must be done in concert with "strong efforts to ensure
patient safety and to reduce preventable deaths."
L. Offering Influenza Vaccine to All Pediatric Emergency
Department Patients May Be Cost
In a computerized
simulation, this strategy prevented an estimated 27 influenza cases per 1000
patients.
M. Does Acetaminophen Exposure In Utero Increase Risk for
ADHD? FREE
Jenny Radesky, MD
reviewing Ystrom E et al. Pediatrics 2017 Nov Wolraich ML. Pediatrics 2017 Nov
A large dataset analysis
adjusted for multiple confounders indicates that acetaminophen use for ≥29 days
during in pregnancy doubles the risk for ADHD in offspring.
