0. From BMJ’s Annual Light-hearted Christmas Issue
Preface: “If
2018 can be summed up by the Oxford Dictionaries word of the year—“toxic”—we
hope that generosity and compassion can serve as an antidote. We have a few
ideas for giving and sharing, inspired by the articles in this year’s festive
edition of the journal.
Abi Rimmer
asked several prominent doctors about moments of compassion that have helped to
brighten a busy and stressful day (https://www.bmj.com/content/363/bmj.k5136). We’re asking readers to share their own acts of
kindness: please do post a response to the article, or join us on social media
using #BMJchristmaskindness.
The Christmas
issue of The BMJ is a time for our more humorous authors to share their work.
Satirically minded readers should look out…
A. Surgeons are the best physician golfers
Koplewitz G,
et al. Golf habits among physicians and surgeons: observational cohort study. BMJ
2018;363:k4859
Objectives To
examine patterns of golfing among physicians: the proportion who regularly play
golf, differences in golf practices across specialties, the specialties with
the best golfers, and differences in golf practices between male and female
physicians.
Design
Observational study.
Setting
Comprehensive database of US physicians linked to the US Golfing Association
amateur golfer database.
Participants
41 692 US physicians who actively logged their golf rounds in the US Golfing
Association database as of 1 August 2018.
Main outcome
measures Proportion of physicians who play golf, golf performance (measured
using golf handicap index), and golf frequency (number of games played in
previous six months).
Results Among
1 029 088 physicians, 41 692 (4.1%) actively logged golf scores in the US
Golfing Association amateur golfer database. Men accounted for 89.5% of
physician golfers, and among male physicians overall, 5.5% (37 309/683 297)
played golf compared with 1.3% (4383/345 489) among female physicians. Rates of
golfing varied substantially across physician specialties. The highest
proportions of physician golfers were in orthopedic surgery (8.8%), urology
(8.1%), plastic surgery (7.5%), and otolaryngology (7.1%), whereas the lowest
proportions were in internal medicine and infectious disease (less than 3.0%).
Physicians in thoracic surgery, vascular surgery, and orthopedic surgery were
the best golfers, with about 15% better golf performance than specialists in
endocrinology, dermatology, and oncology.
Conclusions
Golfing is common among US male physicians, particularly those in the surgical
subspecialties. The association between golfing and patient outcomes, costs of
care, and physician wellbeing remain unknown.
B. Christmas, national
holidays, sport events, and time factors as triggers of acute myocardial
infarction: SWEDEHEART observational study 1998-2013
Mohammad MA,
et al. BMJ 2018;363:k4811
Objectives To
study circadian rhythm aspects, national holidays, and major sports events as
triggers of myocardial infarction….
Conclusions In
this nationwide real world study covering 16 years of hospital admissions for
myocardial infarction with symptom onset documented to the nearest minute,
Christmas, and Midsummer holidays were associated with higher risk of
myocardial infarction, particularly in older and sicker patients, suggesting a
role of external triggers in vulnerable individuals.
C. Holiday Weight Gain is Preventable
Mason F, et
al. Effectiveness of a brief behavioural intervention to prevent weight gain
over the Christmas holiday period: randomised controlled trial. BMJ
2018;363:k4867
Objective To
test the effectiveness of a brief behavioural intervention to prevent weight
gain over the Christmas holiday period…
Conclusion A
brief behavioural intervention involving regular self weighing, weight
management advice, and information about the amount of physical activity
required to expend the calories in festive foods and drinks prevented weight
gain over the Christmas holiday period.
D. Holiday Hospitalizations are Dangerous
Lapointe-Shaw L,
et al. Death and readmissions after hospital discharge during the December
holiday period: cohort study. BMJ 2018;363:k4481
Objective To
determine whether patients discharged from hospital during the December holiday
period have fewer outpatient follow-ups and higher rates of death or readmission
than patients discharged at other times….
Conclusions
Patients discharged from hospital during the December holiday period are less
likely to have prompt outpatient follow-up and are at higher risk of death or
readmission within 30 days.
E. Parachute use to prevent death and major trauma
when jumping from aircraft: RCT
Yeh RW, et al.
BMJ 2018;363:k5094
Objective To
determine if using a parachute prevents death or major traumatic injury when
jumping from an aircraft.
Design
Randomized controlled trial.
Setting
Private or commercial aircraft between September 2017 and August 2018.
Participants
92 aircraft passengers aged 18 and over were screened for participation. 23
agreed to be enrolled and were randomized.
Intervention
Jumping from an aircraft (airplane or helicopter) with a parachute versus an
empty backpack (unblinded).
Main outcome
measures Composite of death or major traumatic injury (defined by an Injury
Severity Score over 15) upon impact with the ground measured immediately after
landing.
Results
Parachute use did not significantly reduce death or major injury (0% for
parachute v 0% for control; P greater than 0.9). This finding was consistent across multiple
subgroups. Compared with individuals screened but not enrolled, participants
included in the study were on aircraft at significantly lower altitude (mean of
0.6 m for participants v mean of 9146 m for non-participants; P less than 0.001)
and lower velocity (mean of 0 km/h v mean of 800 km/h; P less than 0.001).
Conclusions
Parachute use did not reduce death or major traumatic injury when jumping from
aircraft in the first randomized evaluation of this intervention. However, the
trial was only able to enroll participants on small stationary aircraft on the
ground, suggesting cautious extrapolation to high altitude jumps. When beliefs
regarding the effectiveness of an intervention exist in the community,
randomized trials might selectively enroll individuals with a lower perceived
likelihood of benefit, thus diminishing the applicability of the results to
clinical practice.
1. The Additive Value of Pelvic Examinations to History in
Predicting STI for Young Female Patients with
Suspected Cervicitis or PID
Farrukh S,
Onogul B, et al. Ann Emerg Med. 2018 Dec;72(6):703-712.e1.
STUDY
OBJECTIVE:
We evaluate
the additive value of pelvic examinations in predicting sexually transmitted
infection for young female patients with suspected cervicitis or pelvic
inflammatory disease in a pediatric emergency department (ED).
METHODS:
This was a
prospective observational study of female patients aged 14 to 20 years who
presented to an urban academic pediatric ED with a complaint of vaginal
discharge or lower abdominal pain. Enrolled patients provided a urine sample
for chlamydia, gonorrhea, and trichomonas testing, which served as the
criterion standard for diagnosis. A practitioner (pediatric ED attending
physician, emergency medicine or pediatric resident, pediatric ED fellow, or
advanced practice provider) obtained a standardized history from the patient to
assess for cervicitis or pelvic inflammatory disease according to the Centers
for Disease Control and Prevention criteria. They then recorded the likelihood
of cervicitis or pelvic inflammatory disease on a 100-mm visual analog scale. The
same practitioner then performed a pelvic examination and again recorded the
likelihood of cervicitis or pelvic inflammatory disease on a visual analog
scale with this additional information. Using the results of the urine sexually
transmitted infection tests, the practitioner calculated and compared the test
characteristics of history alone and history with pelvic examination.
RESULTS:
Two hundred
eighty-eight patients were enrolled, of whom 79 had positive urine test results
for chlamydia, gonorrhea, or trichomonas, with a sexually transmitted infection
rate of 27.4% (95% confidence interval [CI] 22.6% to 32.8%). The sensitivity of
history alone in diagnosis of cervicitis or pelvic inflammatory disease was
54.4% (95% CI 42.8% to 65.5%), whereas the specificity was 59.8% (95% CI 52.8%
to 66.4%). The sensitivity of history with pelvic examination in diagnosis of
cervicitis or pelvic inflammatory disease was 48.1% (95% CI 36.8% to 59.5%),
whereas the specificity was 60.7% (95% CI 53.8% to 67.3%). The information from
the pelvic examination changed management in 71 cases; 35 of those cases
correlated with the sexually transmitted infection test and 36 did not.
CONCLUSION:
For young
female patients with suspected cervicitis or pelvic inflammatory disease, the
pelvic examination does not increase the sensitivity or specificity of
diagnosis of chlamydia, gonorrhea, or trichomonas compared with taking a
history alone. Because the test characteristics for the pelvic examination are
not adequate, its routine performance should be reconsidered.
2. Real World Evidence for Treatment of Hyperkalemia in the ED
(REVEAL–ED): A Multicenter, Prospective, Observational Study
Peacock WF, et al. J Emerg Med.
2018 Dec;55(6):741-750. doi:
BACKGROUND:
Contemporary emergency department (ED)
standard-of-care treatment of hyperkalemia is poorly described.
OBJECTIVE:
Our aim was to determine the treatment patterns of
hyperkalemia management in the ED.
METHODS:
This multicenter, prospective, observational study
evaluated patients aged ≥ 18 years with hyperkalemia (potassium [K+] level ≥
5.5 mmol/L) in the ED from October 25, 2015 to March 30, 2016. K+-lowering
therapies and K+ were documented at 0.5, 1, 2, and 4 h after initial ED
treatment. The primary end point was change in K+ over 4 h.
RESULTS:
Overall, 203 patients were enrolled at 14 U.S.-based
sites. The initial median K+ was 6.3 (interquartile range [IQR] 5.7-6.8) mmol/L
and median time to treatment was 2.7 (IQR 1.9-3.5) h post-ED arrival.
Insulin/glucose (n = 130; 64%) was frequently used to treat hyperkalemia;
overall, 43 different treatment combinations were employed within the first 4
h. Within 4 h, the median K+ for patients treated with medications alone
decreased from 6.3 (IQR, 5.8-6.8) mmol/L to 5.3 (4.8-5.7) mmol/L, while that
for patients treated with dialysis decreased from 6.2 (IQR 6.0-6.6) mmol/L to
3.8 (IQR 3.6-4.2) mmol/L. Hypoglycemia occurred in 6% of patients overall and
in 17% of patients with K+ greater than 7.0 mmol/L.
Hyperkalemia-related electrocardiogram changes were observed in 23% of all
patients; 45% of patients with K+ greater than 7.0 mmol/L
had peaked T waves or widened QRS. Overall, 79% were hospitalized; 3 patients
died.
CONCLUSIONS:
Hyperkalemia practice patterns vary considerably and,
although treatment effectively lowered K+, only dialysis normalized median K+
within 4 h.
Full-text
(free): https://www.jem-journal.com/article/S0736-4679(18)30923-5/fulltext
3. Cardiac Corner
A. Cancellation of the Cardiac Cath Lab
After Activation for STEMI
Lange DC, et
al. Circ Cardiovasc Qual Outcomes. 2018 Aug;11(8):e004464.
BACKGROUND:
Prehospital
ECG-based cardiac catheterization laboratory (CCL) activation for
ST-segment-elevation myocardial infarction reduces door-to-balloon times, but
CCL cancellations (CCLX) remain a challenging problem. We examined the reasons
for CCLX, clinical characteristics, and outcomes of patients presenting as
ST-segment-elevation myocardial infarction activations who receive emergent
coronary angiography (EA) compared with CCLX.
METHODS AND
RESULTS:
We reviewed
all consecutive CCL activations between January 1, 2012, and December 31, 2014
(n=1332). Data were analyzed comparing 2 groups stratified as EA (n=466) versus
CCLX (n=866; 65%). Reasons for CCLX included bundle branch block (21%),
poor-quality prehospital ECG (18%), non-ST-segment-elevation myocardial
infarction ST changes (18%), repolarization abnormality (13%), and arrhythmia
(8%). A multivariate logistic regression model using age, peak troponin, and
initial ECG findings had a high discriminatory value for determining EA versus
CCLX (C statistic, 0.985). CCLX subjects were older and more likely to be
women, have prior coronary artery bypass grafting, or a paced rhythm (P less
than 0.0001 for all). All-cause mortality did not differ between groups at 1
year or during the study period (mean follow-up, 2.186±1.167 years; 15.8% EA
versus 16.2% CCLX; P=0.9377). Cardiac death was higher in the EA group (11.8%
versus 3.0%; P less than 0.0001). After adjusting for clinical variables
associated with survival, CCLX was associated with an increased risk for
all-cause mortality during the study period (hazard ratio, 1.82; 95% CI,
1.28-2.59; P=0.0009).
CONCLUSIONS:
In this study,
prehospital ECG without overreading or transmission lead to frequent CCLX. CCLX
subjects differ with regard to age, sex, risk factors, and comorbidities.
However, CCLX patients represent a high-risk population, with frequently
positive cardiac enzymes and similar short- and long-term mortality compared
with EA. Further studies are needed to determine how quality improvement
initiatives can lower the rates of CCLX and influence clinical outcomes.
B. European Resuscitation Council Guidelines for
Resuscitation: 2018 Update – Antiarrhythmic drugs for cardiac arrest
Soar J, et al.
Resuscitation 2018 Nov 26 [Epub ahead of print]
Abstract
This European
Resuscitation Council (ERC) Guidelines for Resuscitation 2018 update is focused
on the role of antiarrhythmic drugs during advanced life support for cardiac
arrest with shock refractory ventricular fibrillation/pulseless ventricular
tachycardia in adults, children and infants. This update follows the
publication of the International Liaison Committee on Resuscitation (ILCOR)
2018 International Consensus on Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care Science with Treatment Recommendations (CoSTR). The ILCOR
CoSTR suggests that any beneficial effects of amiodarone or lidocaine are similar.
This ERC update does not make any major changes to the recommendations for the
use of antiarrhythmic drugs during advanced life support for shock refractory
cardiac arrest.
Excerpt
We recommend
that amiodarone is given after three defibrillation attempts irrespective of
whether they are consecutive shocks or interrupted by CPR, or for recurrent
VF/pVT during cardiac arrest. An antiarrhythmic drug can be used in cases of a
primary shockable rhythm, or when a shockable rhythm follows a primary shockable
cardiac arrest. Give amiodarone 300 mg intravenously; a further dose of 150 mg
may be given after five defibrillation attempts. Lidocaine (100 mg) may be used
if amiodarone is not available or a local decision has been made to use
lidocaine instead of amiodarone. An additional bolus of lidocaine 50 mg may
also be given after five defibrillation attempts.
C. Evaluation of a novel cardioversion intervention
for AF: the Ottawa AF cardioversion
protocol
Ramirez FD, et
al. EP Europace. 2018 Dec 7 [Epub ahead of print]
Aims
Electrical cardioversion
is commonly performed to restore sinus rhythm in patients with atrial
fibrillation (AF), but it is unsuccessful in 10–12% of attempts. We sought to
evaluate the effectiveness and safety of a novel cardioversion protocol for
this arrhythmia.
Methods and
results
Consecutive
elective cardioversion attempts for AF between October 2012 and July 2017 at a
tertiary cardiovascular centre before (Phase I) and after (Phase II)
implementing the Ottawa AF cardioversion protocol (OAFCP) as an institutional
initiative in July 2015 were evaluated. The primary outcome was cardioversion
success, defined as ≥2 consecutive sinus beats or atrial-paced beats in
patients with implanted cardiac devices. Secondary outcomes were first shock
success, sustained success (sinus or atrial-paced rhythm on 12-lead
electrocardiogram prior to discharge from hospital), and procedural
complications. Cardioversion was successful in 459/500 (91.8%) in Phase I
compared with 386/389 (99.2%) in Phase II (P less than 0.001). This improvement
persisted after adjusting for age, body mass index, amiodarone use, and
transthoracic impedance using modified Poisson regression [adjusted relative
risk 1.08, 95% confidence interval (CI) 1.05–1.11; P less than 0.001] and when
analysed as an interrupted time series (change in level +9.5%, 95% CI
6.8–12.1%; P less than 0.001). The OAFCP was also associated with greater first
shock success (88.4% vs. 79.2%; P less than 0.001) and sustained success
(91.6% vs 84.7%; P=0.002). No serious complications occurred.
Conclusion
Implementing
the OAFCP was associated with a 7.4% absolute increase in cardioversion success
and increases in first shock and sustained success without serious procedural
complications. Its use could safely improve cardioversion success in patients
with AF.
About the
Ottawa AF protocol
The Ottawa AF
protocol prescribes the electrical energy dose, the electrode position and the
application of pressure to the electrodes the physician will use. The
individual elements of the protocol (energy dose, electrode position and
pressure application) are often used by physician in clinical practice but not
necessarily in the step by step order.
The Ottawa AF cardioversion
protocol consists of four sequential steps
1. 200 J shock
delivered using self-adhesive electrodes in an anteroposterior position*;
2. 200 J shock
delivered with self-adhesive electrodes in an anterolateral position with
manual force applied to the electrodes using standard, disconnected, handheld
defibrillation paddles (operator instructed to apply a force equivalent to a
‘push-up’)†;
3. 360 J shock
delivered with self-adhesive electrodes in an anterolateral position with the
same
prompt as in
Step 2;
4. Further
shock(s) at the treating physician’s discretion.
*Anterior electrode
placement was prescribed as immediately adjacent to the sternum, below the
right clavicle. Posterior electrode placement was prescribed as immediately to
the left of the spine, at the level of the heart.
† This was not in the protocol. But facilities that
don’t have paddle access can try Manual Pressure Augmentation (MPA): The MPA
technique is simple—apply manual force to the adhesive patches with gloved
hands for cardioversion during end-exhalation. MPA is safe, causing no injury
to the provider. See Voskoboinik A, et
al. Cardioversion of atrial fibrillation in obese patients: results from the
Cardioversion-BMI randomized controlled trial. J Cardiovasc Electrophysiol.
2018 Oct 29 [Epub ahead of print].
5. Pediatric Corner
A. Apneic oxygenation reduces hypoxemia during
endotracheal intubation in the pediatric ED
Vukovic AA, et
al. Am J Emerg Med. 2019;37(1):27-32.
Background
Apneic
oxygenation (AO) has been evaluated in adult patients as a means of reducing
hypoxemia during endotracheal intubation (ETI). While less studied in pediatric
patients, its practice has been largely adopted.
Objective
Determine
association between AO and hypoxemia in pediatric patients undergoing ETI.
Methods
Observational
study at an urban, tertiary children's hospital emergency department. Pediatric
patients undergoing ETI were examined during eras without (January 2011–June
2011) and with (August 2014–March 2017) apneic oxygenation. The primary outcome
was hypoxemia, defined as pulse oximetry (SpO2) less than 90%. The χ2 and
Wilcoxon rank-sum tests examined differences between cohorts. Multivariable
regression models examined adjusted associations between covariates and
hypoxemia.
Results
149 patients
were included. Cohorts were similar except for greater incidence of altered
mental status in those receiving AO (26% vs. 7%, p = 0.03). Nearly 50% of the
pre-AO cohort experienced hypoxemia during ETI, versus less than 25% in the AO
cohort. Median [IQR] lowest SpO2 during ETI was 93 (69, 99) for pre-AO and 100
[95, 100] for the AO cohort (p less than 0.001). In a multivariable logistic
regression model, hypoxemia during ETI was associated with AO (aOR 0.3, 95%
confidence interval [CI] 0.1–0.8), increased age (for 1 year, aOR 0.8, 95% CI 0.7–1.0),
lowest SpO2 before ETI (for 1% increase, aOR 0.9, 95% CI 0.8–1.0), and each
additional intubation attempt (aOR 4.0, 95% CI 2.2–7.2).
Conclusions
Apneic
oxygenation is an easily-applied intervention associated with decreases in
hypoxemia during pediatric ETI. Nearly 50% of children not receiving AO
experienced hypoxemia.
B. The Sonographic Appearance of Spinal Fluid at
Clinically Selected Interspaces in Sitting Versus Lateral Positions.
Vitberg YM, et
al. Pediatr Emerg Care. 2018;34(5):334-338.
OBJECTIVE:
Our objective
was to describe the sonographic appearance of fluid at clinically selected
interspinous spaces and see if additional interspaces could be identified as
suitable and safe targets for needle insertion. We also measured the
reproducibility of fluid measurements and assessed for positional differences.
METHODS:
A prospective
convenience sample of infants younger than 3 months was enrolled in the
pediatric emergency department. Excluded were clinically unstable infants or
those with spinal dysraphism. Infants were first held in standard lateral
lumbar puncture position. Pediatric emergency medicine (PEM) physicians marked
infants' backs at the level they would insert a needle using the landmark
palpation technique. A PEM sonologist imaged and measured the spinal fluid in 2
orthogonal planes at this marked level in lateral then sitting positions. Fluid
measurements were repeated by a second blinded PEM sonologist.
RESULTS:
Forty-six
infants were enrolled. Ultrasound verified the presence of fluid at the marked
level as determined by the landmark palpation technique in 98% of cases.
Ultrasound identified additional suitable spaces 1 space higher (82%) and 2
spaces higher (41%). Intraclass correlation coefficient of all measurements was
excellent (greater than 0.85), with differences noted for sitting versus
lateral position in mean area of fluid 0.34 mm versus 0.31 mm (difference,
0.03; 95% confidence interval [CI], 0.005-0.068), dorsal fluid pocket 0.23 mm
versus 0.15 mm (difference, 0.08; 95% CI, 0.031-0.123), and nerve root-to-canal
ratio 0.44 versus 0.51 (difference, 0.07; 95% CI, 0.004-0.117).
CONCLUSIONS:
Ultrasound can
verify the presence of fluid at interspaces determined by the landmark
palpation technique and identify additional suitable spaces at higher levels.
There were statistically greater fluid measurements in sitting versus lateral
positions. These novel fluid measurements were shown to be reliable.
Related: US
guidance for difficult LP in children: pearls and pitfalls.
Muthusami P,
et al. Pediatr Radiol. 2017;47(7):822-830
Pediatric
lumbar puncture can be challenging or unsuccessful for several reasons. At the
same time, the excellent sonographic window into the pediatric spine provides a
distinct opportunity for ultrasound-guided lumbar puncture. Minimal
cerebrospinal fluid and thecal displacement by subdural or epidural hematomas
are common after failed clinical attempts. Ultrasound is useful for determining
a safe infraconal level for subarachnoid access. Real-time guidance increases
not only the success rate but also the safety of diagnostic lumbar puncture and
injections for chemotherapy and myelography. In this article, we discuss clinical
and technical factors for ultrasound-guided pediatric lumbar puncture.
C. Pediatric Ingestions of Novel Antithrombotic
Agents Are Usually Not Dangerous
Among 638
“exploratory” ingestions over 10 years in four states there were no bleeding complications.
Levine M et
al. Exploratory Ingestions of Novel Anticoagulants and
Antiplatelets: What Is the Risk? Pediatr Emerg Care 2018 Nov 19 [Epub ahead of print]
BACKGROUND:
Historically, anticoagulants and antiplatelet agents
included warfarin and aspirin, respectively. In recent years, numerous novel
anticoagulants (eg, direct thrombin inhibitors and factor Xa inhibitors) as
well as the adenosine diphosphate receptor antagonists have increased
significantly. Little information on the bleeding risk after exploratory
ingestion of these agents is available. The primary purpose of this study is to
evaluate the bleeding risk of these agents after an exploratory ingestion in
children 6 years or younger.
METHODS:
This retrospective multicenter poison control center
study was conducted on calls between 2005 and 2014. The following agents were
included: apixaban, clopidogrel, dabigatran, edoxaban, prasugrel, rivaroxaban,
or ticagrelor. Bleeding characteristics and treatment rendered were recorded.
RESULTS:
A total of 638 cases were identified. Most cases
involved antiplatelet agents. No patient developed any bleeding complication.
The administration of charcoal was independent of the amount of drug ingested.
CONCLUSION:
Accidental, exploratory ingestions of these agents
seem well tolerated, with no patient developing bleeding complications.
D. Most Children Admitted To Non-Children’s Hospitals
With CAP May Not Receive Antibiotics In Accordance With Guidelines
Tribble AC, et
al. Comparison of Antibiotic Prescribing for Pediatric Community-Acquired
Pneumonia in Children’s and Non-Children’s Hospitals. JAMA Pediatr. 2018 Dec 10 [Epub ahead of print]
Pneumonia is
the most common indication for antibiotic use in hospitalized children.
National guidelines for community-acquired pneumonia (CAP) recommend
penicillin, amoxicillin, and ampicillin as first-line agents for children
hospitalized with CAP. Although use of these agents for CAP is increasing in
children’s hospitals, antibiotic prescribing trends for children admitted to
non-children’s hospitals, where 70% of hospitalized children receive care,4 are
unknown. We compared antibiotic prescribing for CAP between hospital types
before and after guideline publication in 2011. Four years after publication of
national pediatric CAP guidelines, only 27% of children admitted to
non-children’s hospitals received guideline-concordant therapy compared with
61% in children’s hospitals.
The reason for
these discrepancies in guideline-concordant prescribing is not known, the
authors write. "It is unlikely attributable to differences in patient
populations because we included only healthy children with uncomplicated CAP
and adjusted for potential confounders. Studies in children's hospitals have
suggested that local implementation efforts may be important in facilitating
guideline uptake. Non-children's hospitals likely have fewer resources to lead
pediatric-specific efforts, and care may be influenced by adult CAP
guidelines," they explain.
E.
Bacterial meningitis score inadequate in infants aged
0 to 60 days
Rees CA, et al. J Pediatric Infect Dis Soc. 2018 Dec 19 [Epub ahead of print]
A recent study found that the bacterial meningitis
score had high sensitivity but poor specificity when identifying bacterial
meningitis in infants aged 0 to 60 days.
“The bacterial meningitis score is a widely validated
clinical prediction rule for identifying children with [cerebrospinal fluid
(CSF)] pleocytosis who are very low risk for bacterial meningitis,” Chris A.
Rees, MD, MPH, clinical fellow in pediatric emergency medicine at Boston
Children’s Hospital, told Infectious Diseases in Children. “However, based on
the results of our study of 4,292 infants 60 days of age or younger with CSF
pleocytosis, the specificity of the bacterial meningitis score was too low for
this clinical prediction rule to be applied clinically in this age group.
F.
Prone positioning for children with severe bronchiolitis
The prone
position significantly decreases mortality in adults with severe acute
respiratory distress syndrome and improves oxygenation and may improve
respiratory mechanics and gas exchange in adults with chronic bronchitis. Prone
positioning has been proposed in infants with severe bronchiolitis. This
randomized cross-over study found that the prone position can decrease
inspiratory effort and the metabolic cost of breathing. Indicators of
inspiratory effort were lower in the prone position than the supine position,
and they decreased over time more efficiently in the prone position. All
mechanical, neural, and clinical measures showed that breathing was easier in
the prone position.
6. Clinical validation of a risk scale for serious outcomes
among patients with COPD managed in the ED
Stiell IG, et
al. CMAJ. 2018;190(48):E1406-E1413
BACKGROUND:
The Ottawa chronic obstructive pulmonary disease (COPD) Risk Scale (OCRS),
which consists of 10 criteria, was previously derived to identify patients in
the emergency department with COPD who were at high risk for short-term serious
outcomes. We sought to validate, prospectively and explicitly, the OCRS when
applied by physicians in the emergency department.
METHODS: We
conducted this prospective cohort study involving patients in the emergency
departments at 6 tertiary care hospitals and enrolled adults with acute
exacerbation of COPD from May 2011 to December 2013. Physicians evaluated
patients for the OCRS criteria, which were recorded on a data form along with
the total risk score. We followed patients for 30 days and the primary outcome,
short-term serious outcomes, was defined as any of death, admission to
monitored unit, intubation, noninvasive ventilation, myocardial infarction (MI)
or relapse with hospital admission.
RESULTS: We
enrolled 1415 patients with a mean age of 70.6 (SD 10.6) years and 50.2% were
female. Short-term serious outcomes occurred in 135 (9.5%) cases. Incidence of
short-term serious outcomes ranged from 4.6% for a total score of 0 to 100% for
a score of 10. Compared with current practice, an OCRS score threshold of
greater than 1 would increase sensitivity for short-term serious outcomes from
51.9% to 79.3% and increase admissions from 45.0% to 56.6%. A threshold of
greater than 2 would improve sensitivity to 71.9% with 47.9% of patients being
admitted.
INTERPRETATION:
In this clinical validation of a risk-stratification tool for COPD in the
emergency department, we found that OCRS showed better sensitivity for
short-term serious outcomes compared with current practice. This risk scale can
now be used to help emergency department disposition decisions for patients
with COPD, which should lead to a decrease in unnecessary admissions and in
unsafe discharges.
7. Emergency 'MacGyver' Tips for Physicians
Robert
Glatter, MD; Amy Faith Ho, MD. Medscape. December 03, 2018
Robert D.
Glatter, MD: A large part of being an emergency medicine physician is being a
problem solver, being innovative and resourceful, and trying to make the best
of a challenging clinical situation—often with the lack of complete information
or equipment. The spirit of what we do on a daily basis is reflected in the
character of a popular TV series, MacGyver, which aired decades ago but was
rebooted in 2016.
Dr Amy Ho fits
the bill of a problem solver, so much so that she came up with the concept of
what a character such as MacGyver would do if he didn't have exactly what he
needed to solve a problem—a topic of one of her past ACEP [American College of
Emergency Physicians] talks.
Dr Ho is a
recent graduate of the University of Chicago Emergency Medicine residency and
is newly clinical faculty and associate medical director at John Peter Smith
Hospital, a level-1 trauma center in Fort Worth, Texas. Welcome, Dr Ho.
Tip 1: Black
Tea Bags for Dental Extraction Bleeds
Tip 2: Speculum
for Peritonsillar Abscess Drainages
Tip 3: Makeshift
Eye Cannula
Tip 4: Dental
Floss for Stubborn Rings
Tip 5: Milk...
for capsaicin exposures (Pepper Spray)
Tip 6: Hot
Sauce for Cannabinoid Hyperemesis
8. Foregoing Surgery for Appendicitis? What Do Patients Prefer?
Hanson AL, et al. Patient Preferences for Surgery or Antibiotics for the Treatment of Acute Appendicitis. JAMA Surg. 2018;153(5):471-478.
Hanson AL, et al. Patient Preferences for Surgery or Antibiotics for the Treatment of Acute Appendicitis. JAMA Surg. 2018;153(5):471-478.
IMPORTANCE:
Studies have
compared surgical with nonsurgical therapy for acute uncomplicated
appendicitis, but none of these studies have a patient-centered perspective.
OBJECTIVES:
To evaluate
how patients might choose between surgical and nonsurgical therapy for acute
uncomplicated appendicitis and to identify targets to make antibiotic treatment
more appealing.
DESIGN,
SETTING, AND PARTICIPANTS:
This study
comprised an online survey and an in-person sensitivity analysis survey. For
the web survey, a convenience sample of 1728 respondents were asked to imagine
that they or their child had acute uncomplicated appendicitis, provided
information about laparoscopic and open appendectomy and antibiotic treatment
alone, and asked which treatment they might choose. The web survey was open
from April 17, 2016, through June 16, 2016, and was disseminated via email
link, a poster with a Quick Response code, and social media. For the
sensitivity analysis, 220 respondents were given the same scenario and options.
Those who chose surgery were asked whether certain factors influenced their
decision; each factor was incrementally improved during questioning about
whether respondents would consider switching to antibiotics. These participants
were recruited at public venues from June 3, 2016, to July 31, 2016. Web survey
data were analyzed from June 17, 2016, to September 21, 2017. Sensitivity
analysis data were analyzed from August 1, 2016, to September 21, 2017.
MAIN OUTCOMES
AND MEASURES:
Treatment
preferences.
RESULTS:
Among the 1728
web survey respondents, 1225 (70.9%) were female and 500 (28.9%) were male (3
[0.2%] either did not answer or responded as "gender fluid" within
the comments section of the survey), and most self-reported being between 50
and 59 years of age (391 [22.6%]) and being non-Hispanic white (1563 [90.5%]).
For themselves, 1482 respondents (85.8%) chose laparoscopic appendectomy, 84
(4.9%) chose open appendectomy, and 162 (9.4%) chose antibiotics alone. For
their child, 1372 respondents (79.4%) chose laparoscopic appendectomy, 106
(6.1%) open appendectomy, and 250 (14.5%) antibiotics alone. Respondents were
somewhat more likely to choose antibiotics for themselves if they had education
beyond college (105 [12.6%]; P less than .001), identified as other than
non-Hispanic white (24 [14.9%]; P less than. 001), or did not know anyone who
had previously been hospitalized (12 [15.8%]; P = .02), but they were less
likely to choose antibiotics if they were surgeons (11 [5.4%]; P = .008). Of
the 220 participants interviewed for the sensitivity analysis, 120 (54.5%) were
female and 100 (45.5%) were male, and most self-reported being between 18 and
24 years of age (53 [24.1%]) and being non-Hispanic white (204 [92.7%]). Their
responses suggested that improvements in the short- and long-term failure rate
of antibiotic treatment-rather than reductions in the duration of
hospitalization or antibiotic treatment-were more likely to increase the
desirability of choosing antibiotics.
CONCLUSIONS
AND RELEVANCE:
Most patients
may choose surgical intervention over antibiotics alone in treatment of acute
uncomplicated appendicitis, but a meaningful number may choose nonoperative
management. Therefore, from a patient-centered perspective, this option should
be discussed with patients, and future research could be directed at reducing
the failure and recurrence rates of antibiotic treatment for appendicitis.
9. Pneumothorax
A. A Systematic Review and
Meta-Analysis Comparing Pigtail Catheter and Chest Tube as the Initial
Treatment for Pneumothorax.
Chang SH, et
al. Chest. 2018 May;153(5):1201-1212.
BACKGROUND:
The optimal
initial treatment approach for pneumothorax remains controversial. This
systemic review and meta-analysis investigated the effectiveness of small-bore
pigtail catheter (PC) drainage compared with that of large-bore chest tube
(LBCT) drainage as the initial treatment approach for all subtypes of
pneumothorax.
METHODS:
PubMed and
Embase were systematically searched for observational studies and randomized
controlled trials published up to October 9, 2017, that compared PC and LBCT as
the initial treatment for pneumothorax. The investigative outcomes included
success rates, recurrence rates, complication rates, drainage duration, and
hospital stay.
RESULTS:
Of the 11
included studies (875 patients), the success rate was similar in the PC
(79.84%) and LBCT (82.87%) groups, with a risk ratio of 0.99 (95% CI, 0.93 to
1.05; I2 = 0%). Specifically, PC drainage was associated with a significantly
lower complication rate following spontaneous pneumothorax than LBCT drainage
(Peto odds ratio: 0.49 [95% CI, 0.28 to 0.85]; I2 = 29%). In the spontaneous
subgroup, PC drainage was associated with a significantly shorter drainage
duration (mean difference, -1.51 [95% CI, -2.93 to -0.09]) and hospital stay
(mean difference: -2.54 [95% CI, -3.16 to -1.92]; P less than .001) than the
LBCT group.
CONCLUSIONS:
Collectively,
results of the meta-analysis suggest PC drainage may be considered as the initial
treatment option for patients with primary or secondary spontaneous
pneumothorax. Ideally, randomized controlled trials are needed to compare PC vs
LBCT among different subgroups of patients with pneumothorax, which may
ultimately improve clinical care and management for these patients.
B.
Pneumothorax and Hemothorax in the Era of Frequent
Chest CT for the Evaluation of Adult Patients With Blunt
Trauma
Rodriguez RM, et al. Ann Emerg Med. 2019;73(1):58-65.
STUDY OBJECTIVE:
Although traditional teachings in regard to
pneumothorax and hemothorax generally recommend chest tube placement and
hospital admission, the increasing use of chest computed tomography (CT) in
blunt trauma evaluation may detect more minor pneumothorax and hemothorax that
might indicate a need to modify these traditional practices. We determine the
incidence of pneumothorax and hemothorax observed on CT only and the incidence
of isolated pneumothorax and hemothorax (pneumothorax and hemothorax occurring
without other thoracic injuries), and describe the clinical implications of
these injuries.
METHODS:
This was a planned secondary analysis of 2
prospective, observational studies of adult patients with blunt trauma, NEXUS
Chest (January 2009 to December 2012) and NEXUS Chest CT (August 2011 to May
2014), set in 10 Level I US trauma centers. Participants' inclusion criteria
were older than 14 years, presentation to the emergency department (ED) within
6 hours of blunt trauma, and receipt of chest imaging (chest radiograph, chest
CT, or both) during their ED evaluation. Exposure(s) (for observational
studies) were that patients had trauma and chest imaging. Primary measures and
outcomes included the incidence of pneumothorax and hemothorax observed on CT
only versus on both chest radiograph and chest CT, the incidence of isolated
pneumothorax and hemothorax (pneumothorax and hemothorax occurring without
other thoracic injuries), and admission rates, hospital length of stay,
mortality, and frequency of chest tube placement for these injuries.
RESULTS:
Of 21,382 enrolled subjects, 1,064 (5%) had a
pneumothorax and 384 (1.8%) had a hemothorax. Of the 8,661 patients who
received both a chest radiograph and a chest CT, 910 (10.5%) had a
pneumothorax, with 609 (67%) observed on CT only; 319 (3.7%) had a hemothorax,
with 254 (80%) observed on CT only. Of 1,117 patients with pneumothorax,
hemothorax, or both, 108 (10%) had isolated pneumothorax or hemothorax.
Patients with pneumothorax observed on CT only had a lower chest tube placement
rate (30% versus 65%; difference in proportions [Δ] -35%; 95% confidence
interval [CI] -28% to 42%), admission rate (94% versus 99%; Δ 5%; 95% CI 3% to
8%), and median length of stay (5 versus 6 days; difference 1 day; 95% CI 0 to
2 days) but similar mortality compared with patients with pneumothorax observed
on chest radiograph and CT. Patients with hemothorax observed on CT had only a
lower chest tube placement rate (49% versus 68%; Δ -19%; 95% CI -31% to -5%)
but similar admission rate, mortality, and median length of stay compared with
patients with hemothorax observed on chest radiograph and CT. Compared with
patients with other thoracic injury, those with isolated pneumothorax or
hemothorax had a lower chest tube placement rate (20% versus 43%; Δ -22%; 95%
CI -30% to -13%), median length of stay (4 versus 5 days; difference -1 day;
95% CI -3 to 1 days), and admission rate (44% versus 97%; Δ -53%; 95% CI -62%
to -43%), with an admission rate comparable to that of patients without
pneumothorax or hemothorax (49%).
CONCLUSION:
Under current imaging protocols for adult blunt
trauma evaluation, most pneumothoraces and hemothoraces are observed on CT only
and few occur as isolated thoracic injury. The clinical implications (admission
rates and frequency of chest tube placement) of pneumothorax and hemothorax
observed on CT only and isolated pneumothorax or hemothorax are lower than
those of patients with pneumothorax and hemothorax observed on chest radiograph
and CT and of those who have other thoracic injury, respectively.
10. Images in Clinical Practice
Image Diagnosis: Thoracic Epidural Hematoma from a Fall
Requiring Emergent Decompressive Laminectomy and Hematoma Evacuation
Parvovirus B19 Infection
Amebic Liver Abscess
Laryngocele
Lead Toxicity from a Retained Bullet
Coronary-Artery Occlusion from Kawasaki’s Disease
Man With a Pruritic Rash
Woman With Nausea and Vomiting
Middle-Aged Man With Rash (HSP in Adult)
Young Man With Acute Chest Pain
Man With Acute Respiratory Distress
Elderly Man With Weight Loss and Groin Masses
Young Male With Abdominal Pain
Pneumoparotitis
11. New Research on Soft Tissue Infections
A. Abscess Incision and Drainage With
or Without US: A Randomized Controlled Trial.
Gaspari RJ, et al. Ann Emerg Med. 2019;73(1):1-7.
STUDY OBJECTIVE:
We hypothesize that clinical failure rates will be lower in
patients treated with point-of-care ultrasonography and incision and drainage
compared with those who undergo incision and drainage after physical
examination alone.
METHODS:
We performed a prospective randomized clinical trial of
patients presenting with a soft tissue abscess at a large, academic emergency
department. Patients presenting with an uncomplicated soft tissue abscess
requiring incision and drainage were eligible for enrollment and randomized to
treatment with or without point-of-care ultrasonography. The diagnosis of an
abscess was by physical examination, bedside ultrasonography, or both. Patients
randomized to the point-of-care ultrasonography group had an incision and
drainage performed with bedside ultrasonographic imaging of the abscess.
Patients randomized to the non-point-of-care ultrasonography group had an
incision and drainage performed with physical examination alone. Comparison
between groups was by comparing means with 95% confidence intervals. The
primary outcome was failure of therapy at 10 days, defined as a repeated
incision and drainage, following a per-protocol analysis. Multivariate analysis
was performed to control for study variables. Our study was designed to detect
a clinically important difference between groups, which we defined as a 13%
difference.
RESULTS:
A total of 125 patients were enrolled, 63 randomized to the
point-of-care ultrasonography group and 62 to physical examination alone. After
loss to follow-up and misallocation, 54 patients in the ultrasonography group
and 53 in the physical examination alone group were analyzed. The overall
failure rate for all patients enrolled in the study was 10.3%. Patients who
were evaluated with ultrasonography were less likely to fail therapy and have
repeated incision and drainage, with a difference between groups of 13.3% (95%
confidence interval 0.0% to 19.4%). Abscess locations were predominantly torso
(21%), buttocks (21%), lower extremity (18%), and axilla or groin (16%). There
was no difference in baseline characteristics between groups relative to
abscess size, duration of symptoms before presentation, percentage with
cellulitis, and treatment with antibiotics.
CONCLUSION:
Patients with soft tissue abscesses who were undergoing
incision and drainage with point-of-care ultrasonography demonstrated less
clinical failure compared with those treated without point-of-care
ultrasonography.
B. Systemic Antibiotics for the
Treatment of Skin and Soft Tissue Abscesses: A Systematic Review and
Meta-Analysis
Ann Emerg Med. 2019;72(1):8-16.
STUDY OBJECTIVE:
The addition of antibiotics to standard incision and
drainage is controversial, with earlier studies demonstrating no significant benefit.
However, 2 large, multicenter trials have recently been published that have
challenged the previous literature. The goal of this review was to determine
whether systemic antibiotics for abscesses after incision and drainage improve
cure rates.
METHODS:
PubMed, the Cumulative Index of Nursing and Allied Health
Literature, Scopus, the Cochrane Database of Systematic Reviews, the Cochrane
Central Register of Controlled Trials, and bibliographies of selected articles
were assessed for all randomized controlled trials comparing adjuvant
antibiotics with placebo in the treatment of drained abscesses, with an outcome
of treatment failure assessed within 21 days. Data were dual extracted into a
predefined worksheet and quality analysis was performed with the Cochrane Risk
of Bias tool.
RESULTS:
Four studies (n=2,406 participants) were identified. There
were 89 treatment failures (7.7%) in the antibiotic group and 150 (16.1%) in
the placebo group. The calculated risk difference was 7.4% (95% confidence
interval [CI] 2.8% to 12.1%), with an odds ratio for clinical cure of 2.32 (95%
CI 1.75 to 3.08) in favor of the antibiotic group. There was also a decreased
incidence of new lesions in the antibiotic group (risk difference -10.0%, 95%
CI -12.8% to -7.2%; odds ratio 0.32, 95% CI 0.23 to 0.44), with a minimally
increased risk of minor adverse events (risk difference 4.4%, 95% CI 1.0% to
7.8%; odds ratio 1.29, 95% CI 1.06 to 1.58).
CONCLUSION:
The use of systemic antibiotics for skin and soft tissue
abscesses after incision and drainage resulted in an increased rate of clinical
cure. Providers should consider the use of antibiotics while balancing the risk
of adverse events.
Full-text (free): https://www.annemergmed.com/article/S0196-0644(18)30142-2/fulltext
C. Is Loop Drainage Technique More
Effective for Treatment of Soft Tissue Abscess Compared With Conventional
Incision and Drainage?
Take-Home Message
Loop drainage technique may be associated with lower failure
rate than conventional incision and drainage in treatment of skin and soft
tissue abscesses, but data are limited. Further randomized controlled trial
data are required.
Full-text (free): https://www.annemergmed.com/article/S0196-0644(18)30123-9/fulltext
D. What Is the Accuracy of Physical
Examination, Imaging, and the LRINEC Score for the Diagnosis of Necrotizing
Soft Tissue Infection?
Take-Home Message
Computed tomography (CT) has superior sensitivity compared
with radiography for the diagnosis of necrotizing soft tissue infection,
although different imaging findings have various diagnostic test characteristics.
No single element of the physical examination, radiography, or the Laboratory
Risk Indicator for Necrotizing Fasciitis (LRINEC) score has sufficient
sensitivity to exclude necrotizing soft tissue infection.
Full-text (free): https://www.annemergmed.com/article/S0196-0644(18)30560-2/fulltext
E. Identification of risk factors for
failure in patients with skin and soft tissue infections
Cieri B, et al. Am J Emerg Med. 2019;37(1):48–52.
Purpose
The purpose was to determine significant predictors of
treatment failure of skin and soft tissue infections (SSTI) in the inpatient
and outpatient setting.
Methods
A retrospective chart review of patients treated between
January 1, 2005 to July 1, 2016 with ICD-9 or ICD-10 code of cellulitis or
abscess. The primary outcome was failure defined as an additional prescription
or subsequent hospital admission within 30 days of treatment. Risk factors for
failure were identified through multivariate logistic regression.
Results
A total of 541 patients were included. Seventeen percent
failed treatment. In the outpatient group, 24% failed treatment compared to 9%
for inpatients. Overweight/obesity (body mass index (BMI) greater than 25 kg/m2)
was identified in 80%, with 15% having a BMI greater than 40 kg/m2. BMI, heart
failure, and outpatient treatment were determined to be significant predictors
of failure. The unit odds ratio for failure with BMI was 1.04 (95% [Cl] = 1.01
to 1.1, p = 0.0042). Heart failure increased odds by 2.48 (95% [Cl] = 1.3 to
4.7, p = 0.0056). Outpatients were more likely to fail with an odds ratio of
3.36.
Conclusion
Patients with an elevated BMI and heart failure were found
to have increased odds of failure with treatment for SSTIs. However, inpatients
had considerably less risk of failure than outpatients. These risk factors are
important to note when making the decision whether to admit a patient who
presents with SSTI in the emergency department. Thoughtful strategies are
needed with this at-risk population to prevent subsequent admission.
F. Identification of Clinical
Characteristics Associated With High-Level Care Among Patients With Skin and
Soft Tissue Infections
Mower WR, et al. Ann Emerg Med. 2018 Nov 9 [Epub ahead of
print]
STUDY OBJECTIVE:
Serious adverse outcomes associated with skin and soft
tissue infections are uncommon, and current hospitalization rates appear
excessive. It would be advantageous to be able to differentiate between
patients who require high-level inpatient services and those who receive little
benefit from hospitalization. We sought to identify characteristics associated
with the need for high-level inpatient care among emergency department patients
presenting with skin and soft tissue infections.
METHODS:
We conducted a nonconcurrent review of existing records to
identify emergency department (ED) patients treated for skin and soft tissue
infections. For each case, we recorded the presence or absence of select
criteria and whether the patient needed high-level care, defined as ICU
admission, operating room surgical intervention, or death as the primary
outcome. We applied recursive partitioning to identify the principal criteria
associated with high-level care.
RESULTS:
We identified 2,923 patients, including 84 experiencing high-level
events. Recursive partitioning identified 6 variables associated with
high-level outcomes: abnormal computed tomography, magnetic resonance imaging,
or ultrasonographic imaging result; systemic inflammatory response syndrome;
history of diabetes; previous infection at the same location; older than 65
years; and an infection involving the hand. One or more of these variables were
present in all 84 patients requiring high-level care.
CONCLUSION:
A limited number of simple clinical characteristics appear
to be able to identify skin and soft tissue infection patients who require
high-level inpatient services. Further research is needed to determine whether
patients who do not exhibit these criteria can be safely discharged from the
ED.
11. Physician Prescribing Performance Comparisons Reduces
Opioids Prescribing
A. Reduction of opioid prescribing
through the sharing of individual physician opioid prescribing practices.
Boyle KL, et al. Am J Emerg Med. 2019;37(1):118-122.
BACKGROUND:
Drug overdoses are the most common cause of accidental death
in the United States, with the majority being attributed to opioids. High per
capita opioid prescribing is correlated with higher rates of opioid abuse and
death. We aimed to determine the impact of sharing individual prescribing data
on the rates of opioid prescriptions written for patients discharged from the
emergency department (ED).
METHODS:
This was a pre-post intervention at a single community ED.
We compared opioid prescriptions written on patient discharge before and after
an intervention consisting of sharing individual and comparison prescribing
data. Clinicians at or over one standard deviation above the mean were notified
via standard template electronic communication.
RESULTS:
For each period, we reported the median number of monthly
prescriptions written by each clinician, accounting for the total number of
patient discharges. The pre-intervention median was 12.5 prescriptions per 100
patient discharges (IQR 10-19) compared to 9 (IQR 6-11) in the
post-intervention period (p less than 0.001). This
represents a 28% reduction in the overall rate of opioid prescriptions written
per patient discharged. Using interrupted time series analysis for monthly
rates, this was associated with a reduction in opioid prescriptions, showing a
decrease of almost 9 prescriptions for every 100 discharges over the 6 months
of the study (p = 0.032).
CONCLUSION:
Our study demonstrates the sharing of individual opioid
prescribing data was associated with a reduction in opioid prescribing at a
single institution.
B. Quality Improvement Initiative to
Decrease Variability of Emergency Physician Opioid Analgesic Prescribing.
Burton JH, et al. West J Emerg Med. 2016 May;17(3):258-63.
INTRODUCTION:
Addressing pain is a crucial aspect of emergency medicine.
Prescription opioids are commonly prescribed for moderate to severe pain in the
emergency department (ED); unfortunately, prescribing practices are variable.
High variability of opioid prescribing decisions suggests a lack of consensus
and an opportunity to improve care. This quality improvement (QI) initiative
aimed to reduce variability in ED opioid analgesic prescribing.
METHODS:
We evaluated the impact of a three-part QI initiative on ED
opioid prescribing by physicians at seven sites. Stage 1: Retrospective
baseline period (nine months). Stage 2: Physicians were informed that opioid
prescribing information would be prospectively collected and feedback on their
prescribing and that of the group would be shared at the end of the stage
(three months). Stage 3: After physicians received their individual opioid
prescribing data with blinded comparison to the group means (from Stage 2) they
were informed that individual prescribing data would be unblinded and shared
with the group after three months. The primary outcome was variability of the
standard error of the mean and standard deviation of the opioid prescribing
rate (defined as number of patients discharged with an opioid divided by total
number of discharges for each provider). Secondary observations included mean
quantity of pills per opioid prescription, and overall frequency of opioid
prescribing.
RESULTS:
The study group included 47 physicians with 149,884 ED
patient encounters. The variability in prescribing decreased through each stage
of the initiative as represented by the distributions for the opioid
prescribing rate: Stage 1 mean 20%; Stage 2 mean 13% (46% reduction, p less than 0.01), and Stage 3
mean 8% (60% reduction, p less than 0.01). The mean
quantity of pills prescribed per prescription was 16 pills in Stage 1, 14 pills
in Stage 2 (18% reduction, p less than 0.01), and 13
pills in Stage 3 (18% reduction, p less than 0.01). The group
mean prescribing rate also decreased through each stage: 20% in Stage 1, 13% in
Stage 2 (46% reduction, p less than 0.01), and 8% in
Stage 3 (60% reduction, p less than 0.01).
CONCLUSION:
ED physician opioid prescribing variability can be decreased
through the systematic application of sharing of peer prescribing rates and
prescriber specific normative feedback.
12. Nonanesthetic Effects of Ketamine: A Review Article.
Eldufani J, et al. Am J Med. 2018 Dec;131(12):1418-1424.
Ketamine, considered a dissociative anesthetic medication,
has a variety of pharmacologic effects including sedation, analgesia,
bronchodilation, and nervous system stimulation. Ketamine appears to have
particular mechanisms that are potentially involved during analgesic induction,
including enhancing of descending inhibition and anti-inflammatory effects.
This drug has potential in clinical practice for the management of chronic
pain, cognitive function, depression, acute brain injury, and disorders of the
immune system.
13. Bleeding Research
A. New Score Predicts Low-Risk Lower GI
Bleeding
The SHA2PE score accurately identified patients who did not
require intervention.
Hreinsson JP et al. The SHA2PE score: a new score for lower
gastrointestinal bleeding that predicts low-risk of hospital-based
intervention. Scand J Gastroenterol 2018 Nov 20
OBJECTIVES:
Lower gastrointestinal bleeding (LGIB) risk scores have
mainly focused on identifying high-risk patients. A risk score aimed at
predicting which patients will not require hospital-based intervention may
reduce unnecessary hospital admissions. The aim of the current study was to
develop such a risk score.
MATERIAL AND METHODS:
A retrospective, population-based study that included
patients presenting to the emergency room (ER) with LGIB from 2010 to 2013.
Hospital-based intervention was defined as blood transfusion, endoscopic
hemostasis, arterial embolization or surgery. The study cohort was split into
train (70%) and test (30%) data. Train data were used to produce a multiple
logistic regression model and a risk score that was validated on the test data.
RESULTS:
Overall, 581 patients presented 625 times to the ER, mean
age 61 (±22), males 49%. Of train data patients, 72% did not require
hospital-based intervention. Independent predictors of low-risk patients (did
not require hospital-based intervention) were systolic pressure ≥100mmHg (Odds
ratio [OR] 4.9), hemoglobin greater than 12g/dL (OR 103), hemoglobin
10.5-12.0g/dL (OR 19), no antiplatelets (OR 3.7), no anticoagulants (OR 2.2),
pulse ≤100 (OR 2.9), and visible bleeding in the ER (OR 3.8). When validating
the score on the test data, only 2% were wrongly predicted to be low-risk, the
negative predictive value was 96% and the area under curve was 0.83.
CONCLUSIONS:
A new risk score has been developed for LGIB that may help
identify low-risk patients in the ER that can be managed in an outpatient
setting, thereby lowering unnecessary hospital admissions.
B. Comparison of the National Early
Warning Score+Lactate score with the pre-endoscopic Rockall,
Glasgow-Blatchford, and AIMS65 scores in patients with upper GIB
Kim D, et al. Clin Exp Emerg Med 2018; 5(4): 219-229.
What is already known
Recently, the serum lactate level has been shown to be a
significant predictor of mortality in upper gastrointestinal bleeding (UGIB).
However, the traditional risk scores that are currently used for UGIB do not
contain the serum lactate level as one of their components.
What is new in the current study
The National Early Warning Score+Lactate score showed better
discriminative performance than the pre-endoscopic Rockall score and comparable
discriminative performance to the Glasgow-Blatchford score and albumin,
international normalized ratio, altered mental status, systolic blood pressure,
age older than 65 years score for the composite of in-hospital death, intensive
care unit admission, and requiring red blood cell transfusion of ≥5 packs
within 24 hours.
Objective
We compared the predictive value of the National Early
Warning Score+Lactate (NEWS+L) score with those of other parameters such as the
pre-endoscopic Rockall score (PERS), Glasgow-Blatchford score (GBS), and
albumin, international normalized ratio, altered mental status, systolic blood
pressure, age older than 65 years score (AIMS65) among patients with upper
gastrointestinal bleeding (UGIB).
Methods
We conducted a retrospective study of patients with UGIB
during 2 consecutive years. The primary outcome was the composite of
in-hospital death, intensive care unit admission, and the need for ≥5 packs of
red blood cell transfusion within 24 hours.
Results
Among 530 included patients, the composite outcome occurred
in 59 patients (19 in-hospital deaths, 13 intensive care unit admissions, and
40 transfusions of ≥5 packs of red blood cells within 24 hours). The area under
the receiver operating characteristic curve of the NEWS+L score for the
composite outcome was 0.76 (95% confidence interval, 0.70 to 0.82), which
demonstrated a significant difference compared to PERS (0.66, 0.59–0.73,
P=0.004), but not to GBS (0.70, 0.64–0.77, P=0.141) and AIMS65 (0.76,
0.70–0.83, P=0.999). The sensitivities of NEWS+L scores of 3 (n=34, 6.4%), 4
(n=92, 17.4%), and 5 (n=171, 32.3%) were 100%, 98.3%, and 96.6%, respectively,
while the sensitivity of an AIMS65 score of 0 (n=159, 30.0%) was 91.5%.
Conclusion
The NEWS+L score showed better discriminative performance
than the PERS and comparable discriminative performance to the GBS and AIMS65.
The NEWS+L score may be used to identify low-risk patients among patients with
UGIB.
Full-text (free): https://www.ceemjournal.org/journal/view.php?doi=10.15441/ceem.17.268
C. PPIs may reduce OAC-induced UGI
Bleeding by One-third
Ray WA, et al. Association of Oral Anticoagulants and Proton
Pump Inhibitor Cotherapy With Hospitalization for Upper Gastrointestinal Tract
Bleeding. JAMA. 2018;320(21):2221-2230.
Key Points
Question Are
anticoagulant drug choice and proton pump inhibitor (PPI) cotherapy associated
with the risk of upper gastrointestinal tract bleeding in Medicare
beneficiaries?
Findings During
754 389 person-years of anticoagulation treatment with apixaban, dabigatran,
rivaroxaban, and warfarin, the risk of hospitalization for upper
gastrointestinal tract bleeding was highest for rivaroxaban. The use of PPI
cotherapy (264 447 person-years) was associated with a significantly lower
overall risk of gastrointestinal bleeding for all anticoagulants (incidence
rate ratio, 0.66).
Meaning Drug choice
and PPI cotherapy may be important during oral anticoagulant treatment,
particularly for patients with elevated risk of gastrointestinal bleeding.
Abstract
Importance
Anticoagulant choice and proton pump inhibitor (PPI) cotherapy could
affect the risk of upper gastrointestinal tract bleeding, a frequent and
potentially serious complication of oral anticoagulant treatment.
Objectives To compare
the incidence of hospitalization for upper gastrointestinal tract bleeding in
patients using individual anticoagulants with and without PPI cotherapy, and to
determine variation according to underlying gastrointestinal bleeding risk.
Design, Setting, and Participants Retrospective cohort study in Medicare
beneficiaries between January 1, 2011, and September 30, 2015.
Exposures Apixaban,
dabigatran, rivaroxaban, or warfarin with or without PPI cotherapy.
Main Outcomes and Measures
Hospitalizations for upper gastrointestinal tract bleeding: adjusted
incidence and risk difference (RD) per 10 000 person-years of anticoagulant
treatment, incidence rate ratios (IRRs).
Results There were
1 643 123 patients with 1 713 183 new episodes of oral anticoagulant treatment
included in the cohort (mean [SD] age, 76.4 [2.4] years, 651 427 person-years
of follow-up [56.1%] were for women, and the indication was atrial fibrillation
for 870 330 person-years [74.9%]). During 754 389 treatment person-years
without PPI cotherapy, the adjusted incidence of hospitalization for upper
gastrointestinal tract bleeding (n = 7119) was 115 per 10 000 person-years (95%
CI, 112-118). The incidence for rivaroxaban (n = 1278) was 144 per 10 000
person-years (95% CI, 136-152), which was significantly greater than the
incidence of hospitalizations for apixaban (n = 279; 73 per 10 000
person-years; IRR, 1.97 [95% CI, 1.73-2.25]; RD, 70.9 [95% CI, 59.1-82.7]),
dabigatran (n = 629; 120 per 10 000 person-years; IRR, 1.19 [95% CI, 1.08-1.32];
RD, 23.4 [95% CI, 10.6-36.2]), and warfarin (n = 4933; 113 per 10 000
person-years; IRR, 1.27 [95% CI, 1.19-1.35]; RD, 30.4 [95% CI, 20.3-40.6]). The
incidence for apixaban was significantly lower than that for dabigatran (IRR,
0.61 [95% CI, 0.52-0.70]; RD, −47.5 [95% CI,−60.6 to −34.3]) and warfarin (IRR,
0.64 [95% CI, 0.57-0.73]; RD, −40.5 [95% CI, −50.0 to −31.0]). When
anticoagulant treatment with PPI cotherapy (264 447 person-years; 76 per 10 000
person-years) was compared with treatment without PPI cotherapy, risk of upper
gastrointestinal tract bleeding hospitalizations (n = 2245) was lower overall
(IRR, 0.66 [95% CI, 0.62-0.69]) and for apixaban (IRR, 0.66 [95% CI,
0.52-0.85]; RD, −24 [95% CI, −38 to −11]), dabigatran (IRR, 0.49 [95% CI,
0.41-0.59]; RD, −61.1 [95% CI, −74.8 to −47.4]), rivaroxaban (IRR, 0.75 [95%
CI, 0.68-0.84]; RD, −35.5 [95% CI, −48.6 to −22.4]), and warfarin (IRR, 0.65
[95% CI, 0.62-0.69]; RD, −39.3 [95% CI, −44.5 to −34.2]).
Conclusions and Relevance
Among patients initiating oral anticoagulant treatment, incidence of
hospitalization for upper gastrointestinal tract bleeding was the highest in
patients prescribed rivaroxaban, and the lowest for patients prescribed
apixaban. For each anticoagulant, the incidence of hospitalization for upper
gastrointestinal tract bleeding was lower among patients who were receiving PPI
cotherapy. These findings may inform assessment of risks and benefits when
choosing anticoagulant agents.
D. Effect of low and moderate dose
FEIBA to reverse major bleeding in patients on direct oral anticoagulants.
Dager WE, et al. Thromb Res. 2018 Nov 16;173:71-76.
OBJECTIVE:
Management of acute, major or life threatening bleeding in
the presence of direct acting oral anticoagulants (DOAC) is unclear. In the
absence of a specific antidote, or in situations where there is a need for
adjunctive therapy, the ideal prothrombin complex concentrate and dose is
unclear. The goal of our study was to evaluate the outcomes of our reduced
dosing strategy with FEIBA in patients experiencing a DOAC-related bleeding
event.
DESIGN:
Retrospective analysis of patients treated with FEIBA for a
DOAC-related bleeding event.
SETTING:
Academic medical center PATIENTS: Consecutive patients
between May 2011 and April 2017 receiving FEIBA for a DOAC-related bleed
INTERVENTIONS: None MEASUREMENTS & MAIN RESULTS: Of the 64 patients
included in this analysis, 38 patients received low dose FEIBA (mean
10.0 ± 3.6 units/kg) and 26 received moderate dose (mean 24.3 ± 2.1 units/kg)
FEIBA; an additional dose was requested in 6 patients. Six dabigatran patients
received idarucizumab. 30 day event rates included 5 thromboembolic events (8%)
and 9 (14%) patients expired. Follow-up CT-imaging for ICH,
endoscopy/colonoscopy, or interventional radiology exams did not reveal any
clinically concerning active bleeding or hematoma expansion except in 2 ICH
patients with slight expansion between imaging sessions.
CONCLUSIONS:
Low (less
than 20 units/kg) to moderate (20-30 units/kg) doses of FEIBA,
with the option for a repeat dose, may be an effective management strategy for
obtaining hemostasis in DOAC-related major bleeding events.
Remind me, what does FEIBA stand for? Factor eight inhibitor
bypassing activity. How does it work? FEIBA: mode of action: https://www.ncbi.nlm.nih.gov/pubmed/15385040
14. Associations of ICU Capacity Strain with Disposition and
Outcomes of Patients with Sepsis Presenting to the ED
Anesi GL, et al. Ann Am Thorac Soc. 2018
Nov;15(11):1328-1335.
RATIONALE:
Intensive care unit (ICU) capacity strain refers to the
potential limits placed on an ICU's ability to provide high-quality care for
all patients who may need it at a given time. Few studies have investigated how
fluctuations in ICU capacity strain might influence care outside the ICU.
OBJECTIVES:
To determine whether ICU capacity strain is associated with
initial level of inpatient care and outcomes for emergency department (ED)
patients hospitalized for sepsis.
METHODS:
We performed a retrospective cohort study of patients with
sepsis admitted from the ED to a medical ward or ICU at three hospitals within
the University of Pennsylvania Health System between 2012 and 2015. Patients
were excluded if they required life support therapies, defined as invasive or
noninvasive ventilatory support or vasopressors, at the time of admission. The
exposures were four measures of ICU capacity strain at the time of the ED
disposition decision: ICU occupancy, ICU turnover, ICU census acuity, and ward
occupancy. The primary outcome was the decision to admit to a ward or to an
ICU. Secondary analyses assessed the association of ICU capacity strain with
in-hospital outcomes, including mortality.
RESULTS:
Among 77,142 hospital admissions from the ED, 3,067 patients
met the study's eligibility criteria. The ICU capacity strain metrics varied
between and within study hospitals over time. In unadjusted analyses, ICU
occupancy, ICU turnover, ICU census acuity, and ward occupancy were all
negatively associated with ICU admission. In the fully adjusted model including
patient-level covariates, only ICU occupancy remained associated with ICU
admission (odds ratio, 0.87; 95% confidence interval, 0.79-0.96; P = 0.005),
such that a 10% increase in ICU occupancy (e.g., one additional patient in a
10-bed ICU) was associated with a 13% decrease in the odds of ICU admission.
Among the subset of patients admitted initially from the ED to a medical ward,
ICU occupancy at the time of admission was associated with increased odds of
hospital mortality (odds ratio, 1.61; 95% confidence interval, 1.21-2.14;
P = 0.001).
CONCLUSIONS:
The odds that patients in the ED with sepsis who do not
require life support therapies will be admitted to the ICU are reduced when
those ICUs experience high occupancy but not high levels of other previously
explored measures of capacity strain. Patients with sepsis admitted to the
wards during times of high ICU occupancy had increased odds of hospital
mortality.
15. Online physician ratings fail to predict actual performance
on measures of quality, value, and peer review.
Daskivich TJ, et al. J Am Med Inform Assoc. 2018 Apr
1;25(4):401-407.
OBJECTIVE:
Patients use online consumer ratings to identify
high-performing physicians, but it is unclear if ratings are valid measures of
clinical performance. We sought to determine whether online ratings of
specialist physicians from 5 platforms predict quality of care, value of care,
and peer-assessed physician performance.
MATERIALS AND METHODS:
We conducted an observational study of 78 physicians
representing 8 medical and surgical specialties. We assessed the association of
consumer ratings with specialty-specific performance scores (metrics including
adherence to Choosing Wisely measures, 30-day readmissions, length of stay, and
adjusted cost of care), primary care physician peer-review scores, and
administrator peer-review scores.
RESULTS:
Across ratings platforms, multivariable models showed no
significant association between mean consumer ratings and specialty-specific
performance scores (β-coefficient range, -0.04, 0.04), primary care physician
scores (β-coefficient range, -0.01, 0.3), and administrator scores
(β-coefficient range, -0.2, 0.1). There was no association between ratings and
score subdomains addressing quality or value-based care. Among physicians in
the lowest quartile of specialty-specific performance scores, only 5%-32% had
consumer ratings in the lowest quartile across platforms. Ratings were
consistent across platforms; a physician's score on one platform significantly
predicted his/her score on another in 5 of 10 comparisons.
DISCUSSION:
Online ratings of specialist physicians do not predict
objective measures of quality of care or peer assessment of clinical
performance. Scores are consistent across platforms, suggesting that they
jointly measure a latent construct that is unrelated to performance.
CONCLUSION:
Online consumer ratings should not be used in isolation to
select physicians, given their poor association with clinical performance.
16. Critical EMS Research
A. EMS Use Among Patients Receiving
Involuntary Psychiatric Holds and the Safety of an Out-of-Hospital Screening
Protocol to “Medically Clear” Psychiatric Emergencies in the Field, 2011 to
2016
Trivedi TK, et al. Ann Emerg Med. 2019;73(1):42-51.
STUDY OBJECTIVE:
Patients with acute psychiatric emergencies who receive an
involuntary hold often spend hours in the emergency department (ED) because of
a deficit in inpatient psychiatric beds. One solution to address the lack of
prompt psychiatric evaluation in the ED has been to establish regional
stand-alone psychiatric emergency services. However, patients receiving
involuntary holds still need to be screened and evaluated to ensure that their
behavior is not caused by an underlying and life-threatening nonpsychiatric
illness. Although traditional regional emergency medical services (EMS) systems
depend on the medical ED for this function, a field-screening protocol can
allow EMS to directly transport a substantial portion of patients to a
stand-alone psychiatric emergency service. The purpose of this investigation is
to describe overall EMS use for patients receiving involuntary holds, compare
patients receiving involuntary holds with all EMS patients, and evaluate the
safety of field medical clearance of an established field-screening protocol in
Alameda County, CA.
METHODS:
We obtained data for all EMS encounters between November 1,
2011, and November 1, 2016, using Alameda County's standardized data set. After
unique patient identification, we describe the data at the patient level and at
the encounter level. At the patient level, we compare "involuntary hold
patients" (≥1 involuntary hold during the study period) with those who
were "never held." Additionally, we assess the safety of
out-of-hospital medical clearance by calculating the rate of failed diversion,
defined as retransport of a patient to a medical ED within 12 hours of
transport to the psychiatric emergency services by EMS.
RESULTS:
Of the 541,731 total EMS encounters in Alameda County during
the study period, 10% (N=53,887) were identified as involuntary hold
encounters. Of these involuntary hold patient encounters, 41% (N=22,074)
resulted in direct transport of the patient to the stand-alone psychiatric
emergency service for evaluation; 0.3% (N=60) failed diversion and required
retransport within 12 hours. At the patient level, Alameda County EMS
encountered 257,625 unique patients, and 10% (N=26,283) had at least one
encounter for an involuntary hold during the study period. These
"involuntary hold patients" were substantially younger, more likely
to be men, and less likely to be insured. Additionally, they had higher overall
EMS use: "involuntary hold patients" accounted for 24% of all
encounters (N=128,003); 53,887 of these encounters were for involuntary holds,
whereas an additional 74,116 were for other reasons. Similarly, 4% of
"involuntary hold patients" had 20 or more encounters, whereas only
0.4% of "never held" patients were in this category. Last, the 7% of
"involuntary hold patients" (N=1,907) who received greater than or
equal to 5 involuntary holds during the study period accounted for 39% of all
involuntary holds and 9% of all EMS encounters.
CONCLUSION:
Ten percent of all EMS encounters were for involuntary
psychiatric holds. With an EMS-directed screening protocol, 41% of all such
patient encounters resulted in direct transport of the patient to the
psychiatric emergency service, bypassing medical clearance in the ED. Overall,
only 0.3% of these patients required retransport to a medical ED within 12
hours of arrival to psychiatric emergency services. We found that 24% of all
EMS encounters in Alameda County were attributable to "involuntary hold
patients," reinforcing the importance of the effects of mental illness on
EMS use.
Full-text (free): https://www.annemergmed.com/article/S0196-0644(18)31158-2/fulltext
B. Long-Term Outcomes of
Out-of-Hospital Cardiac Arrest Care Improved at Regionalized Centers
Elmer J, et al. Ann Emerg Med. 2019;73(1):29-39.
STUDY OBJECTIVE:
It is unknown whether regionalization of postarrest care by
interfacility transfer to cardiac arrest receiving centers reduces mortality.
We seek to evaluate whether treatment at a cardiac arrest receiving center,
whether by direct transport or early interfacility transfer, is independently
associated with long-term outcome.
METHODS:
We performed a retrospective cohort study including adults
resuscitated from out-of-hospital cardiac arrest in southwestern Pennsylvania
and neighboring Ohio, West Virginia, and Maryland, which includes approximately
5.7 million residents in urban, suburban, and rural counties. Patients were
treated by 1 of 78 ground emergency medical services agencies or 2 air medical
transport agencies between January 1, 2010, and November 30, 2014. Our primary
exposures of interest were interfacility transfer to a cardiac arrest receiving
center within 24 hours of arrest or any treatment at a cardiac arrest receiving
center regardless of transfer status. Our primary outcome was vital status,
assessed through December 31, 2014, with National Death Index records. We used
unadjusted and adjusted survival analyses to test the independent association
of cardiac arrest receiving center care, whether through direct or
interfacility transport, on mortality.
RESULTS:
Overall, 5,217 cases were observed for 3,629 person-years,
with 3,865 total deaths. Most patients (82%) were treated at 42 non-cardiac
arrest receiving centers with median annual volume of 17 cases (interquartile
range 1 to 53 cases per center annually), whereas 18% were cared for at cardiac
arrest receiving centers receiving at least 1 interfacility transfer per month.
In adjusted models, treatment at a cardiac arrest receiving center was
independently associated with reduced hazard of death compared with treatment
at a non-cardiac arrest receiving center (adjusted hazard ratio 0.84; 95%
confidence interval 0.74 to 0.94). These effects were unchanged when analysis
was restricted to patients brought from the scene to the treating hospital. No
other hospital characteristic, including total out-of-hospital cardiac arrest
patient volume and cardiac catheterization capabilities, independently
predicted outcome.
CONCLUSION:
Both early interfacility transfer to a cardiac arrest
receiving center and direct transport to a cardiac arrest receiving center from
the scene are independently associated with reduced mortality.
17. Misdiagnosis of Cerebral Vein Thrombosis in the ED
Liberman AL, et al. Stroke. 2018;49(6):1504-1506.
BACKGROUND AND PURPOSE:
Rates of cerebral venous thrombosis (CVT) misdiagnosis in
the emergency department and outcomes associated with misdiagnosis have been
underexplored.
METHODS:
Using administrative data, we identified adults with CVT at
New York, California, and Florida hospitals from 2005 to 2013. Our primary
outcome was probable misdiagnosis of CVT, defined as a treat-and-release
emergency department visit for headache or seizure within 14 days before CVT.
In addition, logistic regression was used to compare rates of clinical outcomes
in patients with and without probable CVT misdiagnosis. We performed a
confirmatory study at 2 tertiary care centers.
RESULTS:
We identified 5966 patients with CVT in whom 216 (3.6%; 95%
confidence interval [CI], 1.1%-4.1%) had a probable misdiagnosis of CVT. After
adjusting for demographics, risk factors for CVT, and the Elixhauser
comorbidity index, probable CVT misdiagnosis was not associated with
in-hospital mortality (odds ratio, 0.14; 95% CI, 0.02-1.05), intracerebral
hemorrhage (odds ratio, 0.97; 95% CI, 0.57-1.65), or unfavorable discharge
disposition (odds ratio, 0.90; 95% CI, 0.61-1.32); a longer length of hospital
stay was seen among misdiagnosed patients with CVT (odds ratio, 1.62; 95% CI,
1.04-2.50). In our confirmatory cohort, probable CVT misdiagnosis occurred in 8
of 134 patients with CVT (6.0%; 95% CI, 2.6%-11.4%).
CONCLUSIONS:
In a large, heterogeneous multistate cohort, probable
misdiagnosis of CVT occurred in 1 of 30 patients but was not associated with
the adverse clinical outcomes included in our study.
18. Helpful Reviews from Ann Emerg Med
A. Should Adults With Mild Head Injury
Who Are Receiving Direct Oral Anticoagulants Undergo CT Scanning? A Systematic
Review
Conclusion
There are limited data available to characterize the risk of
adverse outcome in patients receiving direct oral anticoagulants after mild
traumatic brain injury. A sufficiently powered prospective cohort study is
required to validly define this risk, identify clinical features predictive of
adverse outcome, and inform future head injury guidelines.
Full-text (free): https://www.annemergmed.com/article/S0196-0644(18)30652-8/fulltext
But until better studies roll in, I’m inclined to get the scan.
B. What Physiologic Parameters Are
Indicative of Severe Injury in Trauma?
Take-Home Message
Pulse rate, systolic blood pressure, shock index,
respiratory rate, and lactate demonstrate poor sensitivity but high specificity
for predicting severe injury among trauma patients. No parameter in isolation
is able to adequately predict the risk of severe injury.
Full-text (free): https://www.annemergmed.com/article/S0196-0644(18)30545-6/fulltext
19. Pain Control Research
A. Gentle stroking may curb pain in babies
UK researchers found that infants who were gently stroked at
an optimal speed of 3 cm per second during blood tests had 40% reduced
pain-related brain activity, compared with controls who weren't stroked. The
findings in Current Biology may help explain the benefits of massages, kangaroo
care and other touch-based practices for babies, said researcher Rebeccah
Slater.
BBC News: https://www.bbc.com/news/health-46591640
B. Opioids for Chronic Noncancer Pain:
A Systematic Review and Meta-analysis.
Busse JW, et al. JAMA. 2018 Dec 18;320(23):2448-2460.
IMPORTANCE:
Harms and benefits of opioids for chronic noncancer pain
remain unclear.
OBJECTIVE:
To systematically review randomized clinical trials (RCTs)
of opioids for chronic noncancer pain.
DATA SOURCES AND STUDY SELECTION:
The databases of CENTRAL, CINAHL, EMBASE, MEDLINE, AMED, and
PsycINFO were searched from inception to April 2018 for RCTs of opioids for
chronic noncancer pain vs any nonopioid control.
DATA EXTRACTION AND SYNTHESIS:
Paired reviewers independently extracted data. The analyses
used random-effects models and the Grading of Recommendations Assessment,
Development and Evaluation to rate the quality of the evidence.
MAIN OUTCOMES AND MEASURES:
The primary outcomes were pain intensity (score range, 0-10
cm on a visual analog scale for pain; lower is better and the minimally
important difference [MID] is 1 cm), physical functioning (score range, 0-100
points on the 36-item Short Form physical component score [SF-36 PCS]; higher
is better and the MID is 5 points), and incidence of vomiting.
RESULTS:
Ninety-six RCTs including 26 169 participants (61% female;
median age, 58 years [interquartile range, 51-61 years]) were included. Of the
included studies, there were 25 trials of neuropathic pain, 32 trials of
nociceptive pain, 33 trials of central sensitization (pain present in the
absence of tissue damage), and 6 trials of mixed types of pain. Compared with
placebo, opioid use was associated with reduced pain (weighted mean difference
[WMD], -0.69 cm [95% CI, -0.82 to -0.56 cm] on a 10-cm visual analog scale for
pain; modeled risk difference for achieving the MID, 11.9% [95% CI, 9.7% to
14.1%]), improved physical functioning (WMD, 2.04 points [95% CI, 1.41 to 2.68
points] on the 100-point SF-36 PCS; modeled risk difference for achieving the
MID, 8.5% [95% CI, 5.9% to 11.2%]), and increased vomiting (5.9% with opioids
vs 2.3% with placebo for trials that excluded patients with adverse events
during a run-in period). Low- to moderate-quality evidence suggested similar
associations of opioids with improvements in pain and physical functioning
compared with nonsteroidal anti-inflammatory drugs (pain: WMD, -0.60 cm [95%
CI, -1.54 to 0.34 cm]; physical functioning: WMD, -0.90 points [95% CI, -2.69
to 0.89 points]), tricyclic antidepressants (pain: WMD, -0.13 cm [95% CI, -0.99
to 0.74 cm]; physical functioning: WMD, -5.31 points [95% CI, -13.77 to 3.14
points]), and anticonvulsants (pain: WMD, -0.90 cm [95% CI, -1.65 to -0.14 cm];
physical functioning: WMD, 0.45 points [95% CI, -5.77 to 6.66 points]).
CONCLUSIONS AND RELEVANCE:
In this meta-analysis of RCTs of patients with chronic
noncancer pain, evidence from high-quality studies showed that opioid use was
associated with statistically significant but small improvements in pain and
physical functioning, and increased risk of vomiting compared with placebo.
Comparisons of opioids with nonopioid alternatives suggested that the benefit
for pain and functioning may be similar, although the evidence was from studies
of only low to moderate quality.
20. Night shift preparation, performance, and perception: are
there differences between emergency medicine nurses, residents, and faculty?
Richards JR, et al. Clin Exp Emerg Med. 2018;5(4): 40-248.
OBJECTIVE:
Determine differences between faculty, residents, and nurses
regarding night shift preparation, performance, recovery, and perception of
emotional and physical health effects.
METHODS:
Survey study performed at an urban university medical center
emergency department with an accredited residency program in emergency
medicine.
RESULTS:
Forty-seven faculty, 37 residents, and 90 nurses completed
the survey. There was no difference in use of physical sleep aids between
groups, except nurses utilized blackout curtains more (69%) than residents (60%)
and faculty (45%). Bedroom temperature preference was similar. The routine use
of pharmacologic sleep aids differed: nurses and residents (both 38%) compared
to faculty (13%). Residents routinely used melatonin more (79%) than did
faculty (33%) and nurses (38%). Faculty preferred not to eat (45%), whereas
residents (24%) preferred a full meal. The majority (greater than 72%) in all
groups drank coffee before their night shift and reported feeling tired despite
their routine, with 4:00 a.m. as median nadir. Faculty reported a higher rate
(41%) of falling asleep while driving compared to residents (14%) and nurses
(32%), but the accident rate (3% to 6%) did not differ significantly. All had
similar opinions regarding night shift-associated health effects. However, faculty
reported lower level of satisfaction working night shifts, whereas nurses
agreed less than the other groups regarding increased risk of drug and alcohol
dependence.
CONCLUSION:
Faculty, residents, and nurses shared many characteristics.
Faculty tended to not use pharmacologic sleep aids, not eat before their shift,
fall asleep at a higher rate while driving home, and enjoy night shift work
less.
Full-text (free): https://www.ceemjournal.org/journal/view.php?number=180
21. Directing Low-risk Patients Safely to Appropriate non-ED Venues
21. Directing Low-risk Patients Safely to Appropriate non-ED Venues
A. Tele-triage outcomes for patients with chest pain: comparing physicians
and registered nurses.
Sax DR, et al. Health Affairs. 2018;37(12):1997-2004.
We took advantage of a change in protocol in an integrated
delivery system’s telephone consultation service—routing callers complaining of
chest pain to physicians instead of registered nurses, whenever feasible—to
explore whether tele-triage outcomes differed by staffing type.
Comparing outcomes of 11,315 physician-directed calls to
those of an equal number of nurse-directed calls in 2013, we found that the
physician-directed calls were briefer (eight minutes versus thirteen minutes),
produced fewer ED referrals (10 percent versus 16 percent), and resulted in
higher patient adherence to the providers’ site-of-care recommendation (86
percent versus 82 percent). Mortality rates at seven days were low for both
physician- and nurse-directed calls (0.1 percent). We suspect that providers’
immediate access to callers’ comprehensive electronic health records and
patients’ rapid access to outpatient care likely contributed to the program’s
success.
Our findings suggest that tele-triage can be used to safely
and effectively manage an emergent complaint, and that physicians’ expertise
may bring additional efficiency to the process.
KP Spotlight: https://spotlight.kaiserpermanente.org/kaiser-permanente-tele-triage-of-chest-pain-safely-reduces-emergency-room-visits/
B. No clear evidence that diverting
patients from EDs curbs overcrowding
November 27, 2018, British Medical Journal
There's no clear evidence that diverting patients, who are
not seriously ill, away from emergency departments, in a bid to curb
overcrowding, is either safe or effective, reveals research published online in
Emergency Medicine Journal.
Given the considerable costs of providing alternative
sources of care, there is remarkably little good quality evidence to back this
approach, conclude the researchers. Redirecting low need patients from
emergency care departments to alternative sources of care, has been proposed as
a potential solution to tackling the overcrowding that often occurs in these
facilities.
But it isn't clear whether this strategy actually works or is
safe. The researchers therefore systematically reviewed and pooled the data
from 15 relevant studies, evaluating the impact of redirecting patients to
alternative sources of care before reaching, or once in, an emergency care
department.
No strong evidence emerged to either back or refute the
safety and effectiveness of this strategy, the data analysis showed. What's
more, the proportion of patients suitable for diversion was relatively low and
a considerable proportion of those who were suitable didn't want to use
alternative sources of care either.
Redirecting patients to alternative sources of care was
twice as common among those who had already reached an emergency care
department. But compared with those who weren't redirected, doing this before
the patient reached hospital didn't cut the proportion transferred to emergency
care. Nor did it stop them subsequently using emergency care services: their
patterns of use didn't differ from those of patients who weren't redirected.
While only three studies looked at the costs involved, none
found any difference in total healthcare spend between patients who were
diverted away from emergency care departments and those who weren't.
The overall quality of the published evidence was not particularly
good. This included varying definitions of low need; limited information on the
outcomes of patients given standard care; the numbers of patients willing and
able to accept alternative sources of care; or the costs involved.
"Despite the clear resource implications for
implementing [emergency department] diversion strategies, including training
and hiring additional staff, costs of implementing the diversion strategies
were infrequently reported," they write.
All this makes it difficult to draw definitive conclusions,
they caution, concluding: "At this time there is insufficient evidence to
recommend the implementation of diversion protocols as effective and safe
strategies to address emergency department overcrowding."
And in a linked podcast in discussion with the journal's
editor, Professor Ellen Weber, lead author, Dr. Brian Rowe, University of
Alberta, isn't convinced 'the juice is worth the squeeze.'
"I am not sure the efforts involved in doing diversion
are really worth all the costs, time, and surveillance," he says. And not
all emergency department patients are the same, although the diversionary
strategies to date tend to assume that they are, he says.
Surveys in Canada indicate that patients have often tried
many other options before coming to an emergency department, or that they are
there because the health system has failed them, he suggests. What's more, he
adds, patients like the 'one-stop shop' service provided by hospitals, and
younger patients often don't register with a family doctor, leaving them with
few other options.
EMJ Abstract by Rowe BH et al: https://www.ncbi.nlm.nih.gov/pubmed/30510034
22. FDA warns fluoroquinolones can cause fatal aortic dissection
Drugs commonly used to treat upper respiratory infection,
urinary tract infections should not be prescribed to patients already at risk.
Maggie Fox. NBC News. Dec. 20, 2018
Certain antibiotics can cause painful and sometimes fatal
damage to the body’s main artery, the Food and Drug Administration said
Thursday.
Fluoroquinolone antibiotics might raise the risk of an aortic dissection, and people who are already at risk
should be cautious about taking those antibiotics, the FDA said.
“A U.S. Food and Drug Administration (FDA) review found that
fluoroquinolone antibiotics can increase the occurrence of rare but serious
events of ruptures or tears in the main artery of the body, called the aorta.
These tears, called aortic dissections, or ruptures of an aortic aneurysm can
lead to dangerous bleeding or even death,” the FDA said in a statement.
“Fluoroquinolones should not be used in patients at
increased risk unless there are no other treatment options available. People at
increased risk include those with a history of blockages or aneurysms (abnormal
bulges) of the aorta or other blood vessels, high blood pressure, certain
genetic disorders that involve blood vessel changes, and the elderly.”
The FDA said the new risk guidance will be added to the
labels and prescribing information of fluoroquinolone drugs. The agency has
already warned that the powerful drugs should only be used when absolutely
necessary because they can cause other side effects involving tendons, muscles,
joints, nerves and the central nervous system…
The rest of the essay: https://www.nbcnews.com/health/health-news/fda-warns-some-antibiotics-can-cause-serious-heart-damage-n950606
23. Micro Bits
A.
Free Medication-Assisted Treatment (MAT) Training
8 hours of training on medication-assisted treatment (MAT)
is required to obtain a waiver from the Drug Enforcement Agency to prescribe
buprenorphine, one of three medications approved by the FDA for the treatment
of opioid use disorder. Providers Clinical Support System (PCSS) offers free
waiver training for physicians to prescribe medication for the treatment of
opioid use disorder. PCSS uses three formats in training on MAT:
- Live
eight-hour training
- “Half
and Half” format, which involves 3.75 hours of online training and 4.25
hours of face-to-face training.
- Live
training (provided in a webinar format) and an online portion that must be
completed after participating in the full live training webinar
Trainings are open to all practicing physicians. Residents
may take the course and apply for their waiver when they receive their DEA
license. For upcoming trainings consult the MAT Waiver Training Calendar.
For more information on PCSS, click here. Please email Sam Shahid
for more information on MAT training.
B.
Nearly 20 Percent Of Older Adults Taking Medications That Could Increase Risks
Of Auto Accidents
AAA Study: http://aaafoundation.org/medication-use-in-older-adult-drivers-findings-from-the-aaa-longroad-study/
C.
Restaurants are (generally) bad for your health
C1. Measured energy content of frequently purchased
restaurant meals: multi-country cross sectional study
Roberts SB, et
al. BMJ 2018;363:k4864
Objective To
measure the energy content of frequently ordered meals from full service and
fast food restaurants in five countries and compare values with US data…
Conclusion
Very high dietary energy content of both full service and fast food restaurant
meals is a widespread phenomenon that is probably supporting global obesity and
provides a valid intervention target.
C2: (Over)eating out at major UK restaurant chains:
observational study of energy content of main meals
Robinson E, et
al. BMJ 2018;363:k4982.
D.
Prominent Doctors Aren’t Disclosing Their Industry Ties in Medical Journal
Studies. And Journals Are Doing Little to Enforce Their Rules
The dean of Yale’s medical school, the incoming president of
a prominent cancer group and the head of a Texas cancer center are among
leading medical figures who have not accurately disclosed their relationships
with drug companies.
ProPublica: https://www.propublica.org/article/prominent-doctors-industry-ties-disclosures-medical-journal-studies/amp
E.
Epinephrine Auto-Injector Appears Safe in Paediatric Patients Weighing Less
Than 15 kg
F.
Heart Group: Statins' Benefits "Greatly Outweigh" Their Risks
For most patients who meet criteria for statin therapy, the
benefits "greatly outweigh" the risks, according to a new scientific
statement from the American Heart...
J Watch: https://www.jwatch.org/fw114850/2018/12/10/heart-group-statins-benefits-greatly-outweigh-their-risks
G.
ERs can be loud, hectic and even dangerous for the elderly. Here’s how
hospitals are trying to fix that.
In 2005, when physician Kevin Biese was a medical resident
in Boston, a 92-year-old woman with a urinary tract infection arrived by
ambulance at a hospital emergency room. Her behavior — confusion and lethargy —
suggested she also was suffering from hypoactive delirium, a cognitive
disorder.
She was alone, without family or friends. The doctors
decided to admit her, but a bed wasn’t yet available. So she had to wait. “She
spent 24 hours on a cot in the hallway,” Biese recalls. “She came in during the
day on a Thursday and was still there Friday morning. I got mad.”
The emergency care system should “not allow that to happen
to those who deserve the most respect in our society,” he says.
Nobody enjoys a trip to the ER. But it can be especially
difficult — sometimes even dangerous — for the elderly. Many emergency
health-care settings are frenzied and noisy, with glaring lights and slippery
floors, often without handrails. Cots and gurneys are hard on fragile bodies. Privacy
is scarce….
H.
68% of patients have at least one social determinant of health
Improving social determinants for patients can have strong
positive effects on the patient's health and decreased costs for the healthcare
system.
Sixty-eight percent of US patients reported challenges
associated with at least one social determinant of health -- such as financial
or food insecurity -- and most have not discussed the issue with their health
care professional, according to a Waystar survey. Patients covered by Medicare
and Medicaid were more likely than those with commercial coverage to be
affected by three or more social determinants, and although patients often
decline assistance, they may be more receptive to offers of help after speaking
with a physician or nurse, rather than an insurer.
I.
Hospital Beds Get Digital Upgrade
A leading manufacturer is embedding sensors in the low-tech
product to monitor vital signs of patients
J.
Women's Preventive Services Initiative creates well-woman chart
The Women's Preventive Services Initiative, overseen by an
advisory panel that includes the American Academy of Family Physicians (AAFP),
has created a social media kit to help raise awareness of its well-woman chart,
which outlines preventive care recommendations for women from adolescence to
maturity. There also is a frequently asked questions document that describes
well-woman visits and how the chart can be used during these encounters.
K.
FDA Approves New Drug for Traveler's Diarrhea (Rifampin, aka Aemcolo)
L.
Why Do Patients Withhold Information?
Survey respondents report embarrassment, fear of being
judged by clinicians
M.
Teen suicide attempts related to popular television show
Suicide contagion is a known phenomenon among teens. This
study suggests a temporal correlation between the release of the popular
Netflix series "13 Reasons Why" and admissions to a tertiary
children's hospital for self-harm with attempt to die and suicidal ideation.
N.
Assessing Your Risk of Burnout
The Maslach Burnout Inventory (MBI) is recognized as the
leading measure of burnout validated by more than 35 years of extensive
research. The assessment is designed to help you gain an understanding of how
you feel about your work experiences and determine whether you are at risk of
burnout
Scoring the items of the abbreviated MBI: https://www.integration.samhsa.gov/about-us/MaslachScoringAbbreviated.pdf
O.
Anxiety, depression equal smoking in predicting poor health
Anxiety and depression predict higher rates of almost all
illnesses and somatic symptoms, equaling obesity and smoking in predicting poor
health, researchers reported in Health Psychology. People with anxiety and
depression had a 65% higher risk of developing a heart condition, a 64% greater
likelihood of stroke and 50% higher risk for high blood pressure, compared with
people who did not have anxiety and depression.
P.
Stethoscopes carry broad range of bacteria, even after cleaning
In a recent study, researchers analyzed the DNA of bacterial
populations found on 40 stethoscopes in one hospital's intensive care unit,
including 20 reusable scopes used by practitioners and 20 disposable
stethoscopes used in patient rooms. Of the 20 disposable stethoscopes, half
were clean and unused. Researchers swabbed stethoscopes both before and after
they were cleaned via different methods. Stethoscopes used by practitioners had
the highest bacterial contamination levels, although researchers detected
significant contamination on all 40 scopes. The stethoscopes contained a broad
range of bacteria, including pathogens responsible for healthcare-associated
infections.
Q.
Successful treatment of central retinal artery occlusion using hyperbaric
oxygen therapy
Full-text (free): https://www.ceemjournal.org/journal/view.php?number=205
R.
Why Hospitals Should Let You Sleep
Frequent disruptions are more than just annoying for patients.
They can also cause harm.
