1. Acute Stroke Research
A. Thrombectomy
6 to 24 Hours after Stroke Beneficial for Pts with a Mismatch between (large) Deficit
and (small) infarct.
Nogueira RG, et al. N Engl J Med. 2018 Jan 4;378(1):11-21.
BACKGROUND: The effect
of endovascular thrombectomy that is performed more than 6 hours after the
onset of ischemic stroke is uncertain. Patients with a clinical deficit that is
disproportionately severe relative to the infarct volume may benefit from late
thrombectomy.
METHODS: We enrolled
patients with occlusion of the intracranial internal carotid artery or proximal
middle cerebral artery who had last been known to be well 6 to 24 hours earlier
and who had a mismatch between the severity of the clinical deficit and the
infarct volume, with mismatch criteria defined according to age (less than 80
years or ≥80 years). Patients were randomly assigned to thrombectomy plus
standard care (the thrombectomy group) or to standard care alone (the control
group). The coprimary end points were the mean score for disability on the
utility-weighted modified Rankin scale (which ranges from 0 [death] to 10 [no symptoms
or disability]) and the rate of functional independence (a score of 0, 1, or 2
on the modified Rankin scale, which ranges from 0 to 6, with higher scores
indicating more severe disability) at 90 days.
RESULTS: A total of
206 patients were enrolled; 107 were assigned to the thrombectomy group and 99
to the control group. At 31 months, enrollment in the trial was stopped because
of the results of a prespecified interim analysis. The mean score on the
utility-weighted modified Rankin scale at 90 days was 5.5 in the thrombectomy
group as compared with 3.4 in the control group (adjusted difference [Bayesian
analysis], 2.0 points; 95% credible interval, 1.1 to 3.0; posterior probability
of superiority, greater than 0.999), and the rate of functional independence at
90 days was 49% in the thrombectomy group as compared with 13% in the control
group (adjusted difference, 33 percentage points; 95% credible interval, 24 to
44; posterior probability of superiority, greater than 0.999). The rate of
symptomatic intracranial hemorrhage did not differ significantly between the
two groups (6% in the thrombectomy group and 3% in the control group, P=0.50),
nor did 90-day mortality (19% and 18%, respectively; P=1.00).
CONCLUSIONS: Among
patients with acute stroke who had last been known to be well 6 to 24 hours
earlier and who had a mismatch between clinical deficit and infarct, outcomes
for disability at 90 days were better with thrombectomy plus standard care than
with standard care alone.
For a clever and
easy-to-follow video summary, see the Quick Take Summary here: http://www.nejm.org/doi/full/10.1056/NEJMoa1706442
Editorial Excerpt: A
New DAWN for Imaging-Based Selection in the Treatment of Acute Stroke
Two years ago, the
publication of the MR CLEAN trial (Multicenter Randomized Clinical Trial of
Endovascular Treatment for Acute Ischemic Stroke in the Netherlands),1 which
investigated endovascular mechanical thrombectomy for the treatment of acute
ischemic stroke, was called “a first step in the right direction.” Since then,
there have been five trials of thrombectomy for stroke that have shown positive
outcomes. A pooled analysis of these trials2 confirmed the efficacy of
thrombectomy that is performed within 6 hours after the onset of stroke in
patients with occlusion of a cerebral large vessel (intracranial internal
carotid artery or proximal middle cerebral artery).
The DAWN trial (DWI or
CTP Assessment with Clinical Mismatch in the Triage of Wake-Up and Late Presenting
Strokes Undergoing Neurointervention with Trevo), results of which are now
reported in the Journal,3 investigated the efficacy and safety of endovascular
thrombectomy that is performed 6 to 24 hours after the onset of stroke. The
trial was halted on the basis of results of a prespecified interim analysis,
which suggested a high probability of success. The trial included patients with
occlusion of a large cerebral vessel who presented between 6 and 24 hours after
the onset of stroke. Patients underwent successful thrombectomy, even though
the usually accepted window for stroke treatment is within 6 hours after the
first observation of symptoms. Furthermore, approximately 60% of the patients
had had their first stroke symptoms when they woke up, which meant that the
time of stroke onset was not known; this circumstance is currently a
contraindication to endovascular or thrombolytic treatment. However, patients
in the DAWN trial were selected specifically because they had a region of brain
that was poorly perfused but not yet infarcted. In essence, the usual 6-hour
time window for stroke treatment was replaced with a “tissue window.”
Some readers may
struggle with the Bayesian statistics and unusual primary end point that were
used in the DAWN trial. They should be assured that the positive outcome of the
trial was not due to complex statistical maneuvering or the use of an
unconventional end point, which involved a utility-weighted modification of the
usual Rankin scale. Even with the use of basic parametric statistics and an end
point that is typically used in stroke trials, the DAWN trial had strikingly
positive results….
…The DAWN trial gives
us hope that trials investigating the use of late intravenous thrombolysis that
require the presence of ischemic tissue might have positive outcomes. The
WAKE-UP trial (Efficacy and Safety of MRI-Based Thrombolysis in Wake-up Stroke;
ClinicalTrials.gov number, NCT01525290) required evidence of a small infarct
core on diffusion-weighted imaging and no evidence of an infarct on
fluid-attenuation inversion recovery imaging; this combination of findings
indicates that the onset of stroke symptoms (which were observed at awakening)
most likely occurred less than 4 hours earlier. The trial was terminated after
an interim analysis, but the results have not yet been reported. The ECASS-4
EXTEND trial (European Cooperative Acute Stroke Study 4: Extending the Time for
Thrombolysis in Emergency Neurological Deficits; EudraCT number,
2012-003609-80), which is investigating the mismatch between diffusion-weighted
MRI and perfusion MRI, and the EXTEND trial (Extending the Time for
Thrombolysis in Emergency Neurological Deficits; EudraCT number,
2014-002864-33), which uses an automated method that is based on perfusion CT,
are approaching their interim analyses. The results of the DEFUSE 3 trial
(Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke 3;
ClinicalTrials.gov number, NCT02586415), which investigated the use of
thrombectomy 6 to 16 hours after the patients were last known to be well,
should be reported soon.
These imaging-based
approaches represent a new “DAWN” for the selection of patients who are likely
to benefit from thrombectomy that is performed far longer after the onset of
stroke than current guidelines suggest, at least among patients who have severe
stroke, vascular occlusion, and penumbral tissue. However, the results of the
DAWN trial do not support a general liberalization of the time window for
thrombectomy or thrombolysis. Reducing the time from the onset of stroke to
treatment remains essential and results in the best outcomes. It is likely that
a limited proportion of patients with occlusion of a large vessel who present
late after the onset of stroke will have a small infarct core and a large
volume of tissue at risk, as did the patients in the DAWN trial. For those
patients, late thrombectomy works — but as of now, as far as we know, it works
only for them.
B. Detection
of Anterior Circulation Large Artery Occlusion in Ischemic Stroke Using Noninvasive
Cerebral Oximetry.
Flint AC, et al. Stroke. 2018 Jan 10 [Epub ahead of print]
BACKGROUND AND PURPOSE: Large artery occlusion (LAO) in
ischemic stroke requires recognition and triage to an endovascular stroke
treatment center. Noninvasive LAO detection is needed to improve triage.
METHODS: Prospective study to test whether noninvasive
cerebral oximetry can detect anterior circulation LAO in acute stroke.
Interhemispheric ΔBrSO2 in LAO was compared with controls.
RESULTS: In LAO stroke, mean interhemispheric ΔBrSO2 was
-8.3±5.8% (n=19), compared with 0.4±5.8% in small artery stroke (n=17),
0.4±6.0% in hemorrhagic stroke (n=14), and 0.2±7.5% in subjects without stroke
(n=19) (P less than 0.001).
Endovascular stroke treatment reduced the ΔBrSO2 in most LAO subjects (16/19).
Discrimination of LAO at a -3% ΔBrSO2 cut had 84% sensitivity and 70%
specificity. Addition of the G-FAST clinical score (gaze-face-arm-speech- time)
to the BrSO2 measure had 84% sensitivity and 90% specificity.
CONCLUSIONS: Noninvasive cerebral oximetry may help detect
LAO in ischemic stroke, particularly when combined with a simple clinical
scoring system.
2. Infectious Disease Corner
A.
Accuracy of the UA for UTI in Febrile Neonates less than
60 Days
Pediatrics. 2018 Jan
16. pii: e20173068. doi: 10.1542/peds.2017-3068. [Epub ahead of print]
Tzimenatos L, et al.;
Pediatric Emergency Care Applied Research Network (PECARN).
OBJECTIVES: Reports of
the test accuracy of the urinalysis for diagnosing urinary tract infections
(UTIs) in young febrile infants have been variable. We evaluated the test
characteristics of the urinalysis for diagnosing UTIs, with and without
associated bacteremia, in young febrile infants.
METHODS: We performed
a planned secondary analysis of data from a prospective study of febrile
infants ≤60 days old at 26 emergency departments in the Pediatric Emergency
Care Applied Research Network. We evaluated the test characteristics of the
urinalysis for diagnosing UTIs, with and without associated bacteremia, by
using 2 definitions of UTI: growth of ≥50 000 or ≥10 000 colony-forming units
(CFUs) per mL of a uropathogen. We defined a positive urinalysis by the
presence of any leukocyte esterase, nitrite, or pyuria (greater than 5 white
blood cells per high-power field).
RESULTS: Of 4147 infants
analyzed, 289 (7.0%) had UTIs with colony counts ≥50 000 CFUs/mL, including 27
(9.3%) with bacteremia. For these UTIs, a positive urinalysis exhibited
sensitivities of 0.94 (95% confidence interval [CI]: 0.91-0.97), regardless of
bacteremia; 1.00 (95% CI: 0.87-1.00) with bacteremia; and 0.94 (95% CI:
0.90-0.96) without bacteremia. Specificity was 0.91 (95% CI: 0.90-0.91) in all
groups. For UTIs with colony counts ≥10 000 CFUs/mL, the sensitivity of the
urinalysis was 0.87 (95% CI: 0.83-0.90), and specificity was 0.91 (95% CI:
0.90-0.92).
CONCLUSIONS: The
urinalysis is highly sensitive and specific for diagnosing UTIs, especially
with ≥50 000 CFUs/mL, in febrile infants ≤60 days old, and particularly for
UTIs with associated bacteremia.
B. Flu
presenting as myocarditis and as encephalitis.
Sellers SA, et al. The
hidden burden of influenza: A review of the extra- pulmonary complications of
influenza infection Influenza Other Respir Viruses. 2017 Sep;11(5):372-393.
Severe influenza
infection represents a leading cause of global morbidity and mortality.
Although influenza is primarily considered a viral infection that results in
pathology limited to the respiratory system, clinical reports suggest that
influenza infection is frequently associated with a number of clinical
syndromes that involve organ systems outside the respiratory tract.
A comprehensive MEDLINE literature review of
articles pertaining to extra-pulmonary complications of influenza infection,
using organ-specific search terms, yielded 218 articles including case reports,
epidemiologic investigations, and autopsy studies that were reviewed to
determine the clinical involvement of other organs.
The most frequently
described clinical entities were viral myocarditis and viral encephalitis. Recognition
of these extra-pulmonary complications is critical to determining the true
burden of influenza infection and initiating organ-specific supportive care.
C.
Pneumomediastinum Associated with Influenza A Infection
A previously healthy
33-year-old man presented to the emergency department with a 10-day history of
lethargy and feeling unwell. His temperature was 38.3°C, and he had
tachycardia, with an oxygen saturation of 85% while breathing 15 liters of
oxygen per minute through a nonrebreather mask. The physical examination was
notable for bronchial breath sounds in the left lower lung; no subcutaneous
emphysema was palpated. Chest radiography showed perihilar opacities in both
lungs with free air in the mediastinum (Panel A, arrows). Computed tomography
confirmed pneumomediastinum (Panel B, arrows) with enhanced interstitial
markings and lower-lobe opacities in both lungs, with greater severity in the
left lung. The throat swab was positive for influenza A (H1N1). The patient
received noninvasive ventilatory support and was treated with zanamivir for
influenza and piperacillin–tazobactam for bacterial superinfection. The pneumomediastinum
resolved without additional intervention, and the patient was discharged from
the hospital 15 days after presentation.
D. Necrotizing
Soft-Tissue Infections Review.
Stevens DL, Bryant AE. N Engl J Med. 2017 Dec
7;377(23):2253-2265.
Necrotizing fasciitis is a surgical diagnosis characterized
by friability of the superficial fascia, dishwater-gray exudate, and a notable
absence of pus. This and other necrotizing soft-tissue infections have multiple
causes, risk factors, anatomical locations, and pathogenic mechanisms, but all
such infections result in widespread tissue destruction, which may extend from
the epidermis to the deep musculature.
Necrotizing infections can occur after major traumatic
injuries, as well as after minor breaches of the skin or mucosa (e.g., tears,
abrasions, lacerations, or insect bites), varicella infection, nonpenetrating
soft-tissue injuries (e.g., muscle strain or contusion), or routine obstetrical
and gynecologic procedures; they can also occur in postsurgical and
immunocompromised patients.
Although necrotizing infections have common clinical
features, various entities have been defined, such as progressive bacterial
synergistic gangrene, synergistic necrotizing cellulitis, streptococcal
gangrene, gas gangrene (clostridial myonecrosis), and nonclostridial anaerobic
cellulitis. Subtle differences may distinguish one entity from another, but the
clinical approaches to diagnosis and treatment are similar.
In this review, we describe the clinical and laboratory
features of necrotizing fasciitis and other necrotizing soft-tissue infections.
We also discuss diagnostic pitfalls and recommended treatment approaches, as
well as the effect of delays in surgical intervention on mortality.
E. Herpes
Simplex Virus Infection in Infants Undergoing Meningitis Evaluation
Cruz AT, et al. Pediatrics. 2018 Jan 3 [Epub ahead of
print].
BACKGROUND: Although neonatal herpes simplex virus (HSV) is
a potentially devastating infection requiring prompt evaluation and treatment,
large-scale assessments of the frequency in potentially infected infants have
not been performed.
METHODS: We performed a retrospective cross-sectional study
of infants ≤60 days old who had cerebrospinal fluid culture testing performed in
1 of 23 participating North American emergency departments. HSV infection was
defined by a positive HSV polymerase chain reaction or viral culture. The
primary outcome was the proportion of encounters in which HSV infection was
identified. Secondary outcomes included frequency of central nervous system
(CNS) and disseminated HSV, and HSV testing and treatment patterns.
RESULTS: Of 26 533 eligible encounters, 112 infants had HSV
identified (0.42%, 95% confidence interval [CI]: 0.35%-0.51%). Of these, 90 (80.4%)
occurred in weeks 1 to 4, 10 (8.9%) in weeks 5 to 6, and 12 (10.7%) in weeks 7
to 9. The median age of HSV-infected infants was 14 days (interquartile range:
9-24 days). HSV infection was more common in 0 to 28-day-old infants compared
with 29- to 60-day-old infants (odds ratio 3.9; 95% CI: 2.4-6.2). Sixty-eight
(0.26%, 95% CI: 0.21%-0.33%) had CNS or disseminated HSV. The proportion of
infants tested for HSV (35%; range 14%-72%) and to whom acyclovir was
administered (23%; range 4%-53%) varied widely across sites.
CONCLUSIONS: An HSV infection was uncommon in young infants
evaluated for CNS infection, particularly in the second month of life.
Evidence-based approaches to the evaluation for HSV in young infants are
needed.
Ryan Radecki’s comments: http://www.emlitofnote.com/?p=4105
3. Addressing overuse in emergency medicine
A. Addressing
overuse in emergency medicine: evidence of a role for greater patient
engagement
Newton EH. Clin Exp
Emerg Med 2017; 4(4):189-200.
Overuse of health care
refers to tests, treatments, and even health care settings when used in
circumstances where they are unlikely to help. Overuse is not only wasteful, it
threatens patient safety by exposing patients to a greater chance of harm than
benefit. It is a widespread problem and has proved resistant to change. Overuse
of diagnostic testing is a particular problem in emergency medicine. Emergency
physicians cite fear of missing a diagnosis, fear of law suits, and perceived
patient expectations as key contributors.
However, physicians’
assumptions about what patients expect are often wrong, and overlook two of
patients’ most consistently voiced priorities: communication and empathy.
Evidence indicates that patients who are more fully informed and engaged in
their care often opt for less aggressive approaches. Shared decision making
refers to (1) providing balanced information so that patients understand their
options and the trade-offs involved, (2) encouraging them to voice their
preferences and values, and (3) engaging them—to the extent appropriate or
desired—in decision making. By adopting this approach to discretionary decision
making, physicians are better positioned to address patients’ concerns without
the use of tests and treatments patients neither need nor value.
Capsule Summary
What is already known
Overuse of health care
occurs on a wide scale and presents a threat to patient safety. Overuse of
diagnostic testing in particular is a problem in emergency medicine. Fear of
missing a diagnosis, fear of law suits, and perceived patient expectations are
among the explanations most frequently cited by emergency physicians.
What is new in the
current study
Shared decision
making–informing and engaging patients, and eliciting their preferences for
care–is an underutilized resource for tailoring medical care to the individual
patient. Evidence indicates that patients who engage in it often opt for less
aggressive approaches to care. Shared decision making has the potential to
reduce the delivery of care that may be neither beneficial to, nor desired by,
patients.
INTRODUCTION
A significant portion
of the medical care patients receive is of little or no benefit, or is as
likely to harm as help. According to a 2012 Institute of Medicine report,
unnecessary services, commonly referred to as overuse, comprise the single
largest source of waste in US health care—waste accounting for as much as 30
percent of all health care spending [1]. The implications of overuse for patient
safety are equally troubling. Tests, treatments, and even intensive health care
settings, used in circumstances where they are unlikely to help, expose
patients to unnecessary risk. This may involve direct harms, such as a
Clostridium difficile infection resulting from antibiotics prescribed for a
viral infection; or indirect harms, as when a computed tomography (CT) scan
performed for low-risk headache leads to false positive or clinically
unimportant findings, generating anxiety for the patient and the inconvenience
and risk of further testing or treatment.
Addressing overuse has
been identified as a national priority for US health care reform [2]. Recent
years have seen widespread calls for change [3,4], high-profile efforts to
raise physician awareness such as the Choosing Wisely initiative [5], dedicated
series in leading medical journals (JAMA Internal Medicine’s “Less is more,”
the BMJ’s “Too much medicine,” the Lancet’s “Right care”), and a rapidly
expanding research literature on the topic [6]. Yet in practice, progress has
been slow [7,8], even as physicians themselves acknowledge the problem [9,10].
This review will examine overuse in the context of emergency medicine (EM), and
emerging evidence of an underutilized mechanism for reducing it.
EXAMPLES OF OVERUSE IN
EM
Overuse takes
different forms in different specialties. Unnecessary invasive procedures
predominate in some; medications and screening tests in others. In EM, overuse
of diagnostic testing is the problem [11]. In a 2015 survey, over 85% of 435
emergency physicians (EPs) felt that too many diagnostic imaging tests were
being ordered in their own departments, and 97% felt that at least some (mean
22%) of the advanced imaging studies they themselves ordered were not medically
justified [9]. In 2014, the American College of Emergency Physicians, a
latecomer to Choosing Wisely, produced a list of 10 recognized sources of
overuse in EM to avoid (Table 1); advanced imaging, mainly CT, accounts for
half of these…
B. Don’t
just do something, stand there! The value and art of deliberate clinical
inertia
Keijzers G, et al. Emerg
Med Australas. 2018 Jan 12 [Epub ahead of print]
It can be difficult to
avoid unnecessary investigations and treatments, which are a form of low-value
care. Yet every intervention in medicine has potential harms, which may
outweigh the potential
benefits. Deliberate clinical inertia is the art of doing nothing as a positive
response. This paper provides suggestions on how to incorporate deliberate
clinical inertia into our daily clinical practice, and gives an overview of
current initiatives such as ‘Choosing Wisely’ and the ‘Right Care Alliance’.
The decision to ‘do nothing’ can be complex due to competing factors, and barriers
to implementation are highlighted. Several strategies to promote deliberate
clinical inertia are outlined, with an emphasis on shared decision-making. Preventing
medical harm must become one of the pillars of modern health care and the art
of not intervening, that is, deliberate clinical inertia, can be a novel
patient-centred quality indicator to promote harm reduction.
C. Does
Every ED Pt Need a Peripheral Line?
Peripheral Intravenous Cannula Insertion and Use in the ED: An Intervention Study.
Peripheral Intravenous Cannula Insertion and Use in the ED: An Intervention Study.
Hawkins T, et al. Acad
Emerg Med. 2018 Jan;25(1):26-32.
OBJECTIVES: The
objective was to examine cannulation practice and effectiveness of a multimodal
intervention to reduce peripheral intravenous cannula (PIVC) insertion in
emergency department (ED) patients.
METHODS: A prospective
before and after study and cost analysis was conducted at a single tertiary ED
in Australia. Data were collected 24 hours a day for 2 weeks pre- and post
implementation of a multimodal intervention. PIVC placement and utilization
within 24 hours were evaluated in all eligible patients.
RESULTS: A total of
4,173 participants were included in the analysis. PIVCs were placed in 42.1% of
patients' pre intervention and 32.4% post intervention, a reduction of 9.8%
(95% confidence interval [CI] = 6.8 to -12.72%). PIVC usage within 24 hours of
admission was 70.5% pre intervention and 83.4% post intervention, an increase
of 12.9% (95% CI = 8.8% to 17.0%). Sixty-six patients were observed in the ED
for cost analysis. The mean time per PIVC insertion was 15.3 (95% CI = 12.6 to
17.9) minutes. PIVC insertion cost, including staff time and consumables per
participant, was A$22.79 (95% CI = A$19.35 to A$26.23).
CONCLUSIONS: The
intervention reduced PIVC placement in the ED and increased the percentage of
PIVCs placed that were used. This program benefits patients and health services
alike, with potential for large cost savings.
D. Do We
Need All those CTPAs?
Association of Lower Diagnostic Yield With High Users of CT Pulmonary Angiogram
Association of Lower Diagnostic Yield With High Users of CT Pulmonary Angiogram
Chong J, et al. JAMA Intern Med. 2018 Jan 08
Comment: Pulmonary embolism (PE) can be life-threatening
and, when suspected, is usually investigated by computed tomographic pulmonary
angiogram (CTPA). Concerns related to overutilization and harmful ionizing
radiation have identified CTPA as an area in need of resource stewardship.1,2
The purpose of this study was to explore interphysician variability in CTPA
diagnostic yield and to identify any associated physician characteristics that
could inform an intervention to reduce overuse in our institution.
Methods: We retrospectively reviewed all CTPAs at an
academic teaching hospital in Montreal, Quebec, Canada, from September 2014 to
January 2016. Studies were classified as positive or negative; indeterminate
examinations, and those performed for chronic pulmonary emboli were excluded. A
total of 1394 examinations ordered by 182 physicians were included, of which
199 (14.3%) were positive and 1195 (85.7%) were negative. A multivariable
logistic regression analysis was performed to explore whether physician
specialty, years in practice, physician sex, or total numbers of studies ordered
per physician were associated with CTPA diagnostic yield. We used a generalized
estimating equations (GEE) approach to account for patients who underwent
repeated examinations over the study period.3 Statistical tests of hypothesis
were 2-sided with a significance of P ≤ .05. All analyses were performed using
SAS statistical software (version 9.4, SAS Institute Inc). The McGill
University Health Centre research ethics board approved this study.
Results: According to our analysis using GEE logistic
regression, the odds of a positive CTPA decreased as the total number of scans
ordered per physician increased (Table). For each additional 10 studies
ordered, the odds of a positive result decreased (odds ratio [OR], 0.76; 95%
CI, 0.73-0.79). Increasing patient age was associated with a higher diagnostic
yield (OR, 1.02 per year; 95% CI, 1.01-1.03). Physician years of experience
(OR, 1.01; 95% CI, 0.99-1.02; P = .39), physician sex (OR, 1.14; 95% CI,
0.79-1.63; P = .49), and studies originating from the emergency department (ER)
(OR, 1.11; 95% CI, 0.75-1.65; P = .60) did not show a statistically significant
association. When restricting the analysis to those studies performed by ER
physicians, 123 of 974 (12.6%) were positive, and the OR for positivity for
each additional 10 scans ordered decreased in a similar manner (OR, 0.74; 95%
CI, 0.71-0.78).
Discussion: Our institutional yield of positive CTPA was
14.3%, which is similar to prior reported studies.4- 6 However, closer
inspection demonstrated that there was substantial interphysician variability,
with individual positivity rates ranging between 0% to 33.3%. Our study
suggests that individual demographic features, such as specialty and
professional experience are not significantly associated with diagnostic yield;
however, physicians who ordered a greater volume of scans compared with their
peers had a markedly reduced diagnostic yield.
Limitations: Limitations of our study included its
retrospective design and the inadequate charting of parameters, which precluded
the derivation of a preexamination clinical probability score. In addition,
owing to limitations in data collection, we were unable to determine the
denominator of patients presenting with PE-related symptoms examined by each
physician. Notably, in the cohort of ER physicians shift allotment was
generally randomized and we did not observe any systematic biases.
Conclusions: Among physicians who ordered a greater number
of CTPA scans, we observed a statistically significant decrease in the
proportion of positive results. This association may reflect a fundamental
relationship between individual physician overutilization and decreasing
diagnostic yield, and is deserving of greater attention. Peer-relative rates of
utilization are easily quantified from electronic databases, and can identify
physicians most likely to benefit from individual performance feedback and
decision support tools. Based on these findings, our group has designed
automated yield monitoring and feedback, with the aim of closing the gap
between individual physician performance in our institution. We hope this will
translate to a substantial reduction in unnecessary CTPA scans along with the
associated complications that may occur owing to unnecessary radiation,
overdiagnosis, and overtreatment.
4. Top 10 ALiEM Clinical Posts in 2017
Here are the titles:
- Trick of the Trade: Sphenopalatine Ganglion Block for Treatment of Primary Headaches
- Update on the ED Management of Intracranial Hemorrhage: Not All Head Bleeds are the Same
- Epistaxis Management in the Emergency Department: A Helpful Mnemonic
- PECARN Pediatric Head Trauma: Official Visual Decision Aid for Clinicians
- PV Card: Laceration Repair and Sutures – A cheat sheet guide
- The Post-ROSC Checklist
- Trick of the Trade: Rapid Insertion of Orogastric Tube
- Top 8 Must-Know EM Pharmacotherapy Articles of 2016
- My EpiPen expired! Can I still use it?
- Trick of the Trade: Topical Treatment of Cannabinoid Hyperemesis Syndrome
5. Women in Medicine
A. How
Female Physicians Are Changing the Face of Emergency Medicine
On Dec 19, 2017.
EMCareers.org
What is the impact of
increasing numbers of women in medicine — and in emergency medicine
specifically?
It's a question that
is surprisingly under-explored, with most of the discussion centering simply on
how to redress gender imbalances which continue to exist in areas such as
leadership and pay. The number of students entering medical school in 2016 was
almost exactly equally divided between the genders (49.8 percent were women;
50.2 percent were men). And as older, mostly male physicians retire, medicine
will increasingly reflect that gender equality.
The most recent
numbers from the American Association of Medical Colleges show slightly more
than one in four active emergency medicine physicians are women. Meanwhile,
approximately 38 percent of new emergency medicine residents are women. This
means the percentage of women in emergency medicine will continue to rise for some
time.
Creating community for
women in emergency medicine
With that rise has
come the creation of communities specifically geared toward female EM
physicians. Organizations like ACEP's American Association of Women Emergency
Physicians, the Society for Academic Emergency Medicine's Academy for Women in
Academic Emergency Medicine and the Association of American Medical Colleges'
Group on Women in Medicine and Science are shaping the discussion. And the
FeminEM blog hosts the FeminEM Idea Exchange every October.
Meanwhile, vibrant
social networks like the Physician Moms Group continue to grow. These
organizations host conferences, publish newsletters, lead the development of
mentorship programs and support networks for female emergency physicians, and
more.
How women impact
emergency medicine
Dr. Chesney Fowler
wrote last year in The Shift that "a new generation of female physicians
is reshaping perceptions of our profession: what it takes to succeed, and
therefore what sorts of skills, temperaments and character types belong in our
field." Precisely which characteristics this new generation of women are
bringing to emergency medicine is a subject of debate, but loose consensus at
suggests agreement on at least one key attribute: a more collaborative decision-making
and leadership style.
"We are
tribe-like in the ways that we drive change and in the ways that we make
decisions, and we as a company are trying to garner that kind of energy on all
relevant fronts," said Dr. Patsy McNeil, East Director of Patient
Experience at US Acute Care Solutions, who is also involved in several company
initiatives to support gender diversity. The impact of women on emergency
medicine is overflowing into all kinds of hot-topic areas important to
physician groups now, including issues of wellness, work-life balance, career
progress, family and more.
USACS Southeast
President Dr. Linda Lawrence, a past president of ACEP and former Air Force
colonel, has also written extensively on how women in leadership roles tend to
bring a collaborative approach to their leadership and change management roles.
This is a quality that is sorely needed in emergency medicine and in healthcare
as a whole. The past stereotype — perhaps driven by pop culture — of a white,
male emergency doctor brusquely giving orders and taking charge in the ER has
given way to a more typically female-oriented way of collaborating with
colleagues to tackle the difficult, complex challenges of improving patient
care and making changes in healthcare. "Emergency medicine is a team
sport," Dr. Lawrence said.
Many physicians'
groups and health systems have recognized the need to step up their efforts to
recruit quality female physicians to their team. But it's those who are able to
harness the collaborative strengths that women tend to exhibit as leaders and
managers who will truly succeed as healthcare continues to change and evolve.
Important Links
Number of Female
Medical School Enrollees Reaches 10-Year High: https://news.aamc.org/press-releases/article/applicant-enrollment-2016/
B. For a
fascinating historical perspective, see the BBC’s documentary: The Ascent of
Women
A groundbreaking
four-part documentary series originally created for BBC2 in the UK that charts
the role of women in society over the course of 10,000 years. Dr. Amanda Foreman’s landmark series is the
first ever documentary to present the history of women from the dawn of
civilisation to the modern day. The
Ascent of Woman argues that the history of women isn’t a straight line from
Eve’s apple to Margaret Sanger’s Pill. Instead, over the past ten thousand
years it has veered wildly between extremes of freedom and oppression,
inclusion and exclusion.
The reason is that the
status of women is a barometer of a society’s tolerance, fairness and
openness.
A poor record on
women’s rights goes hand-in-hand with low economic output and high levels of
violence. Amanda argues that for the
next economic cycle to be the age of full participation, there has to be a
woman-led revolution that unleashes the potential of all individuals.
At stake are the goals
of autonomy, authority and agency for all women.
C. Sexual Harassment in Medicine — #MeToo
Jagsi
R. N Engl J Med 2018 Jan 18;378(3):209-211
he
news is filled with stories of celebrities who have engaged in egregious sexual
misconduct. A recent poll suggested that more than half of U.S. women have
experienced “unwanted and inappropriate sexual advances” at some point in their
lives.1 Because I led a study of workplace sexual harassment in medicine,2 I
was not surprised when reporters contacted me for comments on the recent
disclosures. When a secretary filling in for my usual assistant relayed one
reporter’s request, she told me she presumed the story was about my personal
experience of sexual harassment. Disturbed, I leapt to correct her
misapprehension: I was being sought out as a scholarly expert, not a victim.
Then I wondered why it seemed so urgent to make that distinction…
Reference
2 above: Jagsi R. Sexual Harassment and Discrimination Experiences of Academic
Medical Faculty. JAMA. 2016 May 17; 315(19): 2120–2121.
6. Adjunctive Glucocorticoid Therapy in Patients with Septic Shock
Venkatesh B, et al. N
Engl J Med. 2018 Jan 19 [Epub ahead of print].
Background: Whether
hydrocortisone reduces mortality among patients with septic shock is unclear.
Methods: We randomly
assigned patients with septic shock who were undergoing mechanical ventilation
to receive hydrocortisone (at a dose of 200 mg per day) or placebo for 7 days
or until death or discharge from the intensive care unit (ICU), whichever came
first. The primary outcome was death from any cause at 90 days.
Results: From March
2013 through April 2017, a total of 3800 patients underwent randomization.
Status with respect to the primary outcome was ascertained in 3658 patients
(1832 of whom had been assigned to the hydrocortisone group and 1826 to the
placebo group). At 90 days, 511 patients (27.9%) in the hydrocortisone group
and 526 (28.8%) in the placebo group had died (odds ratio, 0.95; 95% confidence
interval [CI], 0.82 to 1.10; P=0.50). The effect of the trial regimen was
similar in six prespecified subgroups. Patients who had been assigned to
receive hydrocortisone had faster resolution of shock than those assigned to
the placebo group (median duration, 3 days [interquartile range, 2 to 5] vs. 4
days [interquartile range, 2 to 9]; hazard ratio, 1.32; 95% CI, 1.23 to 1.41; P
less than 0.001). Patients in the hydrocortisone group had a shorter duration
of the initial episode of mechanical ventilation than those in the placebo
group (median, 6 days [interquartile range, 3 to 18] vs. 7 days [interquartile
range, 3 to 24]; hazard ratio, 1.13; 95% CI, 1.05 to 1.22; P less than 0.001),
but taking into account episodes of recurrence of ventilation, there were no
significant differences in the number of days alive and free from mechanical
ventilation. Fewer patients in the hydrocortisone group than in the placebo
group received a blood transfusion (37.0% vs. 41.7%; odds ratio, 0.82; 95% CI,
0.72 to 0.94; P=0.004). There were no significant between-group differences
with respect to mortality at 28 days, the rate of recurrence of shock, the
number of days alive and out of the ICU, the number of days alive and out of
the hospital, the recurrence of mechanical ventilation, the rate of
renal-replacement therapy, and the incidence of new-onset bacteremia or
fungemia.
Conclusions: Among
patients with septic shock undergoing mechanical ventilation, a continuous
infusion of hydrocortisone did not result in lower 90-day mortality than
placebo.
7. In the Balance: NEJM Interactive Case
Opener: A 71-year-old
man presented to the emergency department with a 3-day history of changes in
mental status. His partner noted that the patient had become more irritable
than usual and was behaving as if other people were in the room with him when
no one else was present. The patient had also had several episodes of uncontrollable
laughter for no apparent reason…
8. Safety of cardioversion in AF lasting less than 48 h without
post-procedural anticoagulation in patients at low cardioembolic risk.
Tampieri A, et al. Intern
Emerg Med. 2018 Jan;13(1):87-93
Currently, there is no
unified consensus on short-term anticoagulation after cardioversion of atrial
fibrillation lasting less than 48 h in low-cardioembolic-risk patients. The aim
of this study is to evaluate the rate of transient ischemic attacks, stroke and
death in this subset of patients after cardioversion without post-procedural
anticoagulation.
In a prospective
observational study, patients with recent-onset AF undergoing cardioversion
attempts in the Emergency Department were evaluated over the past 3 years.
Inclusion criteria were conversion to sinus rhythm, low thromboembolic risk
defined by a CHA2DS2VASc score of 0-1 points for males (0-2 points for females
aged over 65 years), and hospital discharge without anticoagulant treatment.
Patients with severe valvular heart disease, underlying systemic causes of AF,
and those discharged with anticoagulant therapy were excluded. The main
outcomes measured were TIA, stroke and death at thirty days' follow-up after
discharge.
During the study
period, 218 successful cardioversions, obtained both electrically and
pharmacologically, were performed on 157 patients. One hundred and eleven patients
were males (71%), the mean age was 55.2 years (±standard deviation 10.7), 99
patients (63%) reported a CHA2DS2VASc score of 0, and the remaining 58 (37%)
had a risk profile of 1 point. Of these, latter 8 were females (5%) older than
65 years (risk score 2 points). At the thirty days outcome, none of the 150
enrolled patients who completed a follow-up visit has reported TIA or stroke,
nor died, in the overall 211 successful cardioversions evaluated. In our study,
the rate of thromboembolic events after cardioversion of recent-onset AF of
less than 48 h duration, in patients with a 0-1 CHA2DS2VASc risk profile
(females 0-2), appeared to be extremely low even in absence of post-procedural
anticoagulation.
These findings seem to
confirm data from previous studies, and suggest that routine post-procedural
short-term anticoagulation may be considered as an overtreatment in this very
low-risk subset of patients.
9. NEJM Journal Watch EM Top Stories of 2017
Richard D. Zane, MD,
FAAEM.
December 29, 2017
A
perspective on the most important research in the field from the past year
Dear
Readers,
We
are pleased to present our top 10 stories for 2017. These not only represent
the most important articles from the past year but also seem to parallel the
current political climate. We have learned that care coordination improves
outcomes as well as saves money, guns and bullets are not good for the human condition,
following guidelines saves lives (and money), math and facts matter, dogma is
indeed fallible, and, lastly, access to healthcare is good and not bad.
Our NEJM
Journal Watch Emergency Medicine Top Stories of 2017 are:
- Early Catheterization After
Cardiac Arrest in Patients Without STEMI or Shockable Rhythms
- Opioid Prescribing by Emergency
Physicians and Long-Term Use in Older Patients
- Unexpected Death After Discharge
from Emergency Departments
- Improving Outcomes from
Out-of-Hospital Cardiac Arrest
- Evidence-Based Clinical Decision
Support Decreases Use of Imaging
- The HEART Score Is Safe to Use in
the Emergency Department
- Sepsis Mortality Increases with
Delays in Treatment
- Firearm Deaths and Injuries Among
U.S. Children
- Want to Reduce Avoidable Emergency
Department Visits by High-Utilizers?
- Give Tranexamic Acid Early for
Severe Hemorrhage from Trauma or Childbirth
We
hope you enjoy reading these stories, and we look forward to bringing you more
in 2018.
All
the best.
10. Images in Clinical Practice
Pneumomediastinum Associated with Influenza A Infection
Rib Fracture Associated with Bordetella pertussis Infection
Iris Abscess
Identify and Treat Lisfranc Injuries
11. Ideal Cricoid Pressure Is Biomechanically Impossible During
Laryngoscopy.
Trethewy CE, et al. Acad Emerg Med. 2018 Jan;25(1):94-98.
OBJECTIVE: This study was a prospective, randomized
controlled trial of rapid sequence intubation (RSI) with cricoid pressure (CP)
within the emergency department (ED). The primary aim of the study was to
examine the link between ideal CP and the incidence of aspiration.
METHOD: Patients greater than 18 years of age undergoing RSI in the
ED of two hospitals in New South Wales, Australia, were randomly assigned to
receive measured CP using weighing scales to target the ideal CP range
(3.060-4.075 kg) or control CP where the weighing scales were used, but the CP
operator was blinded to the amount of CP applied during the RSI. A data logger
recorded all CP delivered during each RSI. Immediately after intubation,
tracheal and esophageal samples were taken and underwent pepsin analysis.
RESULTS: Fifty-four RSIs were analyzed (25 measured/29
control). Macroscopic contamination of the larynx at RSI was observed in 14
patients (26%). During induction (0-50 seconds), both groups delivered in-range
CP. During intubation (51-223 seconds), laryngoscopy was associated with a
reduction in mean CP below 3.060 kg in both groups. When compared, there was no
statistically significant difference between the groups. For 11 patients,
pepsin was detected in the oropharyngeal sample, while three were positive for
tracheal pepsin. Seven patients (four control/three measured) were treated for
clinical aspiration during hospitalization. As a result of the finding that
neither group could maintain ideal range CP during laryngoscopy, the trial was
abandoned.
CONCLUSION: Laryngoscopy provides a counter force to CP,
which is negated to facilitate tracheal intubation. The concept that a static
3.060 to 4.075 kg CP could be maintained during laryngoscopy and intubation was
rejected by our study. Whether a lower CP range could prevent aspiration during
RSI was not explored by this study.
12. Glucagon for Hypoglycemia Is Underprescribed and
Underutilized
Kahn PA et al. Ann Intern Med 2017 Dec 26
All emergency medical technicians, from basic to paramedic,
should be allowed to use glucagon, and we should be prescribing it from the
emergency department.
Background: Patients receiving insulin or certain oral
hypoglycemic agents are at increased risk for hypoglycemia, which results in
more than 100 000 emergency department visits incurring approximately $120
million in costs annually (1). Although not all of these visits can be
prevented, glucagon use could reduce the number and severity of hypoglycemic
episodes requiring emergency medical attention and hospitalization. Data from
the National EMS Information System's public-release research data sets (2)
between 2013 and 2015 and from Medicare Part D (3) claims from 2014 suggest
that glucagon is underutilized in the prehospital setting and underprescribed
in the outpatient setting. Despite its effectiveness, it is not allowed to be
administered by most emergency medical services (EMS) personnel; however,
family members do so routinely.
Objective: To understand glucagon use and availability in
the prehospital and outpatient setting.
Methods: We included cases from the National EMS Information
System in which glucagon was administered. Response times longer than 60
minutes were eliminated as probable errors. Medicare Part D data from 2014 were
filtered, retaining only those cases in which glucagon was prescribed. State
EMS offices were contacted to review protocols for glucagon administration and
blood glucose testing. Data from the National EMS Information System between
2013 and 2015 and from the Centers for Medicare & Medicaid Services data
warehouse were analyzed in Alteryx, version 11 (Alteryx), and Tableau, version
10.2.1 (Tableau Software).
Findings: Across all states, glucagon was administered in 89
263 cases in the prehospital setting between 2013 and 2015. Dispatchers
correctly coded only 44.67% of the calls as a “diabetic problem.” The patient
experienced adverse effects in 3944 of the events in which glucagon was
administered.
In most states, paramedics are the only members of EMS who
carry and administer glucagon (Figure). However, nationally there are 198 200
providers of basic emergency medicine compared with 61 121 paramedics;
therefore, the dispatched responder may be unable to treat hypoglycemia with
glucagon 3 out of 4 times (4). The mean EMS response time to calls in which
glucagon was administered was 15.34 minutes (SD, 11.50).
Hypoglycemia is a substantial burden on the health care
system. Among persons aged 65 years or older, hypoglycemic events occur at an
estimated rate of 5.01 per 100 person-years (5). Inpatient admissions for hypoglycemia cost an average of $18
961, and emergency department visits cost an average of $1487 (both adjusted
for inflation). The total cost to Medicare Part D for glucagon prescriptions
was $5 044 593 (adjusted for inflation) with an average cost of $212 per
prescription for these 23 423 prescriptions. Approximately 11.6 million
Medicare beneficiaries in 2014 had diabetes (5), yet only 0.2% were prescribed
glucagon.
Discussion: Our data did not allow for precise review of
crew composition; however, the lack of nationwide protocols permitting
providers of basic emergency medicine, who comprise 76% of all EMS responders,
to carry and use glucagon (or even to check blood glucose levels in some
states) probably impedes optimal care of hypoglycemic patients. These
restrictions are even more surprising given that glucagon is routinely
administered by family members and adverse effects were not serious and most
typically included nausea.
Emergency medical service response times to episodes of
hypoglycemia are crucial in the diabetes chain of survival. The average
response time of more than 15 minutes suggests that policy changes may be
needed, because such a delay coupled with policies preventing basic emergency
medicine providers from administering glucagon may increase patients' risk for
neurologic sequelae, death, or both. Further complicating care, dispatchers
correctly coded only 44.67% of calls as a “diabetic problem,” potentially
increasing the likelihood of dispatching providers who cannot administer this
agent to patients with hypoglycemia.
Despite the favorable safety profile of glucagon, it is
infrequently prescribed in the outpatient setting. The average cost to Medicare
for a glucagon prescription is $212. Patients who filled glucagon prescriptions
had fewer hypoglycemia-related emergency department visits, suggesting that
providing this agent to patients may effectively reduce prehospital
hypoglycemic complications (1).
All emergency personnel should have access to glucagon along
with training to safely administer this agent to minimize unintended treatment
accidents. Ensuring access is an important opportunity to reduce morbidity,
mortality, and health care costs. Diabetes specialists should work with
emergency medical personnel to design curricula for the safe and effective use
of glucagon nationwide.
13. News on the Opioid Front
A. Prescription Opioid Cough and Cold
Medicines Restricted to Adult Use
By Kelly Young. Journal Watch, January 12, 2018.
Prescription cough and cold medications containing opioids
like codeine and hydrocodone will no longer be indicated for patients under age
18, the FDA announced on Thursday.
The FDA instructed parents whose children are currently
taking these medicines to talk with their clinician about alternative
treatments. In addition, parents should read the labels of over-the-counter
cough and cold medicines because codeine is still being sold in some states.
In 2017, the FDA added a contraindication to prescription
codeine products for pain and cough in children younger than age 12 because
certain patients are at risk for ultra-rapid metabolism of the drug. An expert
roundtable subsequently determined that the risks for opioid cough and cold
products generally outweighed the benefits in all children.
For adults, opioid-containing cough and cold medicines will
come with an updated boxed warning cautioning users about the risks for misuse,
abuse, addiction, overdose, death, and slowed or difficult breathing.
FDA News Release: https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm592109.htm
B. Association between Electronic
Medical Record Implementation of Default Opioid Prescription Quantities and
Prescribing Behavior in Two EDs
Delgado MK, et al. J Gen Intern Med. 2018 Jan 16 [Epub ahead
of print].
INTRODUCTION: Larger quantities of opioid tablets for
initial prescriptions are associated with transition to continued use.1 Default
options, or conditions that are set in place unless an alternative is actively
chosen, have been shown to influence behavior in many contexts, including
increasing the rates of prescribing generic versus brand-name drugs to over 98%
in primary care.2,3 Leveraging default options in electronic medical record
(EMR) prescribing orders thus represents a promising approach to guide
clinicians towards prescribing smaller quantities of opioid tablets, thus
reducing continued use, misuse, and diversion.
In 2015, the emergency departments (EDs) of the Hospital of
the University of Pennsylvania (HUP, annual volume 68,000) and Penn
Presbyterian Medical Center (PMC, annual volume 41,000) adopted a new EMR
(Epic, Verona, WI) to replace a homegrown EMR (EMTRAC). EMTRAC required the
clinician to enter the number of tablets for opioid prescriptions. Since the
implementation of the new EMR, when a clinician types in an ED discharge opioid
prescription order, a preference list appears with a default quantity of 10
tablets displayed first. The clinician can “opt out” by selecting a quantity of
20 tablets, which is displayed second, by modifying either of these orders, or
by clicking on “Database Lookup,” where a new health system default of 28 tabs
is displayed, as well as manual entry options. We evaluated the effect on
prescribing behavior associated with the implementation of an EMR opioid
default supply quantity for our most common opioid discharge prescription in
two EDs.
METHODS: Using EMR data from October 1, 2014, to June 29, 2015,
we compared weekly prescribing patterns in discharge quantities supplied for
oxycodone 5 mg/acetaminophen 325 mg (Oxy/APAP) between the pre-intervention
period (weeks 1–22 for HUP and 1–26 for PMC) and the post-intervention period
(weeks 23–41 for HUP and 27–41 for PMC). Using a staggered roll-out, two time
periods were constructed: (1) 4 weeks prior to HUP ED default implementation
(weeks 19–22), and (2) 4 weeks after HUP ED default implementation/PMC no
change (weeks 23–26). We used two-way analysis of variance to test for
differences in the mean and median number of tablets supplied per week and
chi-square tests to determine differences in proportions of prescription
quantities.
RESULTS: During the 41-week period, 3264 prescriptions for
Oxy/APAP were written across the two EDs. After the default implementation,
there was no change in the mean number of Oxy/APAP tablets prescribed per week
across the two EDs (p = 0.42), but the median number decreased by a small
amount, from 11.3 to 10 (p = 0.004) in the HUP ED and 12.6 to 10.9 (p less than 0.001) in the PMC ED (Fig. 1). However,
there was a marked increase across the two EDs in the proportion of
prescriptions written for 10 tablets (from 20.6% to 43.3%, an increase of
22.8%; Fig. 2), and this increase was even higher when comparing the 4 weeks
after implementation in the HUP ED relative to the control period in the PMC ED
(27.8% [95% CI 17.4–37.5%], p less than 0.001). The proportion of prescriptions
written for 20 tablets, the second listed option in the preference list,
actually decreased by 6.7%, as did prescriptions for 11–19 tablets (13.3%) and less than 10 tablets (5%). Finally, there was a
small increase in the proportion of prescriptions written for greater than 20 tabs (2.3%), 50.0% of which were for
the system-wide default of 28 tablets, compared to 4% in the pre-intervention
period (p less than 000.1).
The clinician could “opt out” by selecting a quantity of 20
tablets, which was displayed second, by modifying either of these orders, or by
clicking on “Database Lookup,” where a health system default of 28 tabs was
displayed, as well as manual entry options.
DISCUSSION: We found that implementation of an EMR default
of 10 tablets versus no default was associated with a strong increase in the
proportion of prescriptions written for 10 tablets. However, given that
baseline quantities prescribed were already low and were consistent with ED
guidelines,4 there was no clinically significant reduction in the overall
quantity supplied. A potential unintended consequence of this intervention was
a small reduction in prescriptions written for less than the default option of
10 tablets. This suggests that future efforts to set default quantities should
start with the lowest baseline prescription. One other study on ED defaults
found that the change from a 15-tablet default to no default resulted in an
increase in the quantity supplied.5 In conclusion, deploying EMR defaults that
include lower-than-baseline default opioid quantities for acute pain is
potentially a widely scalable approach for changing prescribing behavior, while
still preserving clinician autonomy.
See also editorial by the co-authors in the NEJM this week (link
below).
From
the Press Release: In a new perspective published in the
New England Journal of Medicine, Mitesh S. Patel, MD, MBA, MS, an assistant
professor of Medicine and Health Care Management and director of the Penn
Medicine Nudge Unit, and co-authors argue that "opportunities for
effective nudges abound in health care because choice architectures guide our
behavior whether we know it or not ... Though there is some common sense
involved in creating effective nudges, expertise is also required—for
identifying promising targets, designing both the conceptual approach and the
technical implementation, managing the politics and process of obtaining
stakeholder buy-in, and evaluating impact." Given the value of its
applications, the authors argue that nudges are a small investment and say most
health systems would be "well served" by supporting the development
of internal nudge units, which have improved government policies around the
world.
The new data informs a larger study known as REDUCE, an
acronym for "Randomized trial of EHR Defaults and Using social Comparison
Feedback to Effectively decrease opioid prescription pill
burden."
14. Safety of Giving Pressors through Peripheral Lines
A. Complications from Administration of
Vasopressors Through Peripheral Venous Catheters: An Observational Study.
Medlej K, et al. J Emerg Med. 2018 Jan;54(1):47-53.
BACKGROUND: The placement of a central venous catheter for
the administration of vasopressors is still recommended and required by many
institutions because of concern about complications associated with peripheral
administration of vasopressors.
OBJECTIVE: Our aim was to determine the incidence of
complications from the administration of vasopressors through peripheral venous
catheters (PVC) in patients with circulatory shock, and to identify the factors
associated with these complications.
METHODS: This was a prospective, observational study
conducted in the emergency department (ED) of a tertiary care medical center.
Patients presenting to the ED with circulatory shock and in whom a vasopressor
was started through a PVC were included. Research fellows examined the i.v.
access site for complications twice daily during the period of peripheral
vasopressor administration, then daily up to 48 h after treatment
discontinuation or until the patient expired.
RESULTS: Of the 55 patients that were recruited, 3 (5.45%
overall, 6% of patients receiving norepinephrine) developed complications; none
were major. Two developed local extravasation and one developed local
thrombophlebitis. All three complications occurred during the vasopressor
infusion, none in the 48 h after discontinuation, and none required any medical
or surgical intervention. Two of the three complications occurred in the hand,
and all occurred in patients receiving norepinephrine and with 20-gauge
catheters.
CONCLUSIONS: The incidence of complications from the
administration of vasopressors through a PVC is small and did not result in
significant morbidity in this study. Larger prospective studies are needed to
better determine the factors that are associated with these complications, and
identify patients in whom this practice is safe.
B. Safety of the Peripheral
Administration of Vasopressor Agents.
Lewis T, et al. J Intensive Care Med. 2017 Jan 1 [Epub ahead
of print]
Vasopressors are an integral component of the management of
septic shock and are traditionally given via a central venous catheter (CVC)
due to the risk of tissue injury and necrosis if extravasated. However, the
need for a CVC for the management of septic shock has been questioned, and the
risk of extravasation and incidence of severe injury when vasopressors are
given via a peripheral venous line (PVL) remains poorly defined.
We performed a retrospective chart review of 202 patients
who received vasopressors through a PVL. The objective was to describe the
vasopressors administered peripherally, PVL size and location, the incidence of
extravasation events, and the management of extravasation events. The primary
vasopressors used were norepinephrine and phenylephrine. The most common PVL
sites used were the forearm and antecubital fossa. The incidence of
extravasation was 4%. All of the events were managed conservatively; none required
an antidote or surgical management. Vasopressors were restarted at another
peripheral site in 88% of the events. The incidence of extravasation was
similar to prior studies.
The use of a PVL for administration of vasopressors can be
considered in patients with a contraindication to a CVC.
C. A systematic review of extravasation
and local tissue injury from administration of vasopressors through peripheral IV
catheters and CVCs.
Loubani OM, et al. J
Crit Care. 2015 Jun;30(3):653.e9-17., Green RS2.
PURPOSE: The aim of this study was to collect and describe
all published reports of local tissue injury or extravasation from vasopressor
administration via either peripheral intravenous (IV) or central venous
catheter.
METHODS: A systematic search of Medline, Embase, and
Cochrane databases was performed from inception through January 2014 for
reports of adults who received vasopressor intravenously via peripheral IV or
central venous catheter for a therapeutic purpose. We included primary studies
or case reports of vasopressor administration that resulted in local tissue
injury or extravasation of vasopressor solution.
RESULTS: Eighty-five articles with 270 patients met all
inclusion criteria. A total of 325 separate local tissue injury and extravasation
events were identified, with 318 events resulting from peripheral vasopressor
administration and 7 events resulting from central administration. There were
204 local tissue injury events from peripheral administration of vasopressors,
with an average duration of infusion of 55.9 hours (±68.1), median time of 24
hours, and range of 0.08 to 528 hours. In most of these events (174/204,
85.3%), the infusion site was located distal to the antecubital or popliteal
fossae.
CONCLUSIONS: Published data on tissue injury or
extravasation from vasopressor administration via peripheral IVs are derived
mainly from case reports. Further study is warranted to clarify the safety of
vasopressor administration via peripheral IVs.
15. Non-operative management of appendicitis: insights from the
literature and from patients
A. Conservative treatment versus
surgery for uncomplicated appendicitis in children: a systematic review and
meta-analysis.
Kessler U, et al. Arch Dis Child. 2017 Dec;102(12):1118-1124.
OBJECTIVES: To compare conservative treatment with index
admission appendicectomy in children with acute uncomplicated appendicitis.
DESIGN: Systematic review and meta-analysis.
DATA SOURCES: Medline, Embase and the Cochrane Library
(CENTRAL) from 1950 to 18 February 2017.
ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Studies that
assessed both appendicectomy and non-operative management of acute
uncomplicated appendicitis in children of less than 18 years of age. Endpoints
were postintervention complications, readmission and efficacy (successful
outcome of the initial therapy).
RESULTS: Five studies met the inclusion criteria
(conservative treatment n=189; surgical intervention n=253). Compared with
patients undergoing index admission appendicectomy, conservative treatment
showed a reduced treatment efficacy (relative risk 0.77, 95% CI 0.71 to 0.84; p less than 0.001) and an increased readmission
rate (relative risk 6.98, 95% CI 2.07 to 23.6; p less than 0.001), with a comparable rate of
complications (relative risk 1.07, 95% CI 0.26 to 4.46). Exclusion of patients
with faecoliths improved treatment efficacy in conservatively treated patients.
One study was randomised, with the remaining four comprising cohorts assembled
by patient or physician choice. Different antibiotic regimens were used between
investigations. Follow-up varied from 1 to 4 years.
CONCLUSIONS: Conservative treatment was less efficacious and
was associated with a higher readmission rate. Index admission appendicectomy
should in the present still be considered to be the treatment of choice for the
management of uncomplicated appendicitis in children.
Editorial: Non-operative management of
uncomplicated acute appendicitis in children: where is the evidence?
Rollins KE, et al. Arch Dis Child. 2017
Dec;102(12):1099-1100.
Appendicitis is the most common emergency condition in
children, with a lifetime incidence of 7% to 8%. Appendicectomy has been the
mainstay of treatment of acute appendicitis in both adults and children for
over 100 years, with the laparoscopic approach being favoured in recent times.
However, in addition to the need for general anaesthetia, there are potential
risks and complications associated with the procedure. Moreover, in children,
surgical procedures are associated frequently with both physiological and
psychological stress for the patient and their parents, as well as having an
economic impact. The management of uncomplicated acute appendicitis, in both
adults and children, is currently in a state of significant flux. Evidence from
a number of randomised controlled trials and case-controlled series have been
combined in systematic reviews and meta-analyses, and in the adult literature
the role of primary antibiotic therapy for the management of uncomplicated
acute appendicitis is becoming supported increasingly.1 Surgery is generally
regarded as a more effective initial treatment option than antibiotic therapy
due to the largely unknown long-term risk of recurrent appendicitis following
non-operative management. However, in adults, surgery is associated with
greater complication rates and increased incidence of readmission than primary
antibiotic therapy.1 Nevertheless, antibiotic therapy is not recommended
currently as the first-line treatment strategy.2
Within the field of paediatrics, the evidence base for
non-operative treatment is limited, with just one randomised controlled trial3
investigating its role in acute non-perforated appendicitis. However, this was
a pilot study, which was underpowered to detect differences between the
treatment arms. This study3 found that 92% of those treated non-operatively had
initial resolution of symptoms, with just 5% developing recurrent appendicitis
at 1-year follow-up, suggesting it to be a safe and feasible treatment
strategy. The literature to date in children has been summarised succinctly in
a systematic review and meta-analysis by Kessler et al 4 examining five studies
comparing appendicectomy with non-operative management of uncomplicated acute
appendicitis. The authors4 have demonstrated a reduced treatment efficacy (OR
0.77, 95% CI 0.71 to 0.84, p less than 0.001), increased readmission rate (OR
6.98, 95% CI 2.07 to 23.6, p less than 0.001) and an equivalent complication
rate (relative risk 1.07, 95% CI 0.26 to 4.46) for antibiotic therapy when
compared with appendicectomy, and thus conclude ‘conservative management was
less efficacious, and … index admission appendicectomy should for the present
still be considered to be the treatment of choice for the management of
uncomplicated appendicitis in children’. This study4 somewhat contradicts
another recent meta-analysis5 on the topic. However, in the latter study,5 the
criteria for inclusion were somewhat broader, including four studies that
reported outcomes in children undergoing non-operative treatment without a
comparator group, thus representing lower quality evidence, which may be
subject to a number of biases. The current study4 represents the best evidence
to date of the role of antibiotic therapy as the primary treatment modality for
acute uncomplicated appendicitis in children. However, the evidence presented4
cannot be classed as high quality because only one randomised controlled study,
three prospective cohort studies and one retrospective cohort study were
included.
A particular flaw within the adult literature surrounds the
length of follow-up after the initial treatment period, with the majority of
studies following patients up for only 1 year.1 However, this meta-analysis4
includes studies with variable follow-up of between 1 and 4 years, a factor
which is likely to be more important with children who may have an increased
risk of developing recurrent appendicitis during their lifetime.
The histopathological entity of neuroimmune appendicitis
remains an important consideration in the management of uncomplicated acute
appendicitis.6 This condition is associated with neuroproliferation in the
mucosal layer of the appendix as well as increased immunoreactivity to
substance P and vasoactive intestinal peptide in the setting of a
histologically normal appendix. Following an episode of acute abdominal
inflammation, changes in enteric neurotransmitters may be seen, which can alter
the perception of visceral pain within the gut and manifest as either repeated
bouts of acute or chronic abdominal pain. The diagnosis of neuroimmune
appendicitis cannot be made prior to appendicectomy as grossly the appendix
appears normal and the presenting symptoms and signs often mirror those of
uncomplicated acute appendicitis. Thus, non-operative treatment of a child with
acute right iliac fossa pain with suspected uncomplicated acute appendicitis
may result in chronic right iliac fossa pain due to a missed neuroimmune
appendicitis or postinflammatory irritable bowel syndrome. It was suggested
previously that the appendix had an immunomodulatory role in the
gastrointestinal tract, and several studies suggested an inverse relationship
between appendicectomy and the incidence of inflammatory bowel disease (IBD).
However, a recent systematic review7 has found limited and poor quality data on
the association, with most studies finding no firm relationship between appendicectomy
or the diagnosis of appendicitis and subsequent IBD.
It is also interesting to compare the current meta-analysis4
with that published by Huang et al 8 in May 2017. Both meta-analyses review
five studies, with four of these being identical between the two studies. The
latter meta-analysis8 includes a prospective study of non-operative management
of children with uncomplicated acute appendicitis associated with an
appendicolith,9 with the study being halted early due to an unacceptably high
failure rate (60% at median follow-up of 4.7 months). Overall, this
meta-analysis8 found non-operative management to be successful in 90.5% (n=152
of 168) at 1-month follow-up and concludes that ‘antibiotics as the initial
treatment for p(a)ediatric patients with uncomplicated appendicitis may be
feasible and effective’. However, when recurrence of appendicitis at 1-year
follow-up was considered, 26.8% (45 patients) underwent a subsequent
appendicectomy. In the current meta-analysis,4 one additional retrospective study
that considered the cost of the two treatment strategies was included and the
previously detailed study of children with an appendicolith was not,9 as the
authors chose to exclude studies that only included groups with a potentially
worse outcome (such as in patients with appendicoliths only). This
meta-analysis4 considered treatment efficacy rates but did not stipulate the
time point for inclusion of data in the forest plot, making this difficult to
interpret and compare with meta-analyses performed previously. The stated
treatment efficacy in this meta-analysis4 was 74% (n=140/18) for non-operative
management versus 98% (n=249/253) in the appendicectomy group.
Studies have generally accepted 20% as an acceptable
non-inferiority margin for the non-operative management of uncomplicated acute
appendicitis, but there is no threshold agreed universally for accepted
efficacy of non-operative management.
In due course, further high-quality evidence for the role of
non-operative management of uncomplicated acute appendicitis will be provided
by several studies including the APPY (appendectomy versus non-operative
treatment for acute non-perforated appendicitis in children) study,10 a
multicentre, non-inferiority randomised controlled trial that has begun recruitment
of participants, as well as the CONTRACT study (CONservative TReatment of
Appendicitis in Children a randomised controlled Trial), which has also started
recruitment. It is hoped that evidence from these studies will bring some
clarity to a wholly understudied topic and inform the care of approximately
12 000 children under 18 years of age undergoing emergency appendicectomies per
year in England,11 and many more worldwide.
B. Patient Preferences for Surgery or
Antibiotics for the Treatment of Acute Appendicitis
Hanson AL, et al. JAMA Surg. 2018 Jan 10 [Epub ahead of
print].
Question Which
treatment will patients with uncomplicated acute appendicitis choose when
presented with both surgical and nonsurgical options, and what might make
nonsurgical antibiotic therapy a more appealing option?
Findings In a survey
of 1728 participants, most respondents chose laparoscopic appendectomy over
open appendectomy and antibiotics alone as a treatment option for acute
appendicitis, while a sensitivity analysis involving 220 individuals
demonstrated that antibiotics alone was more appealing when short-term failure
or long-term recurrence rates were decreased.
Meaning Patients
should be presented with all viable treatment options, including antibiotics
alone, while future research on antibiotic treatment for appendicitis should
focus on improving failure rates.
16. Patient perspectives on how physicians communicate
diagnostic uncertainty: An experimental vignette study.
Bhise V, et al. Int J Qual Health Care. 2018 Jan 10 [Epub
ahead of print]
OBJECTIVE: We evaluated the effects of three different
strategies for communicating diagnostic uncertainty on patient perceptions of
physician competence and visit satisfaction.
DESIGN/SETTING: Experimental vignette-based study design
involving pediatric cases presented to a convenience sample of parents living
in a large US city.
PARTICIPANTS/INTERVENTION(S): Three vignettes were
developed, each describing one of three different ways physicians communicated
diagnostic uncertainty to parents-(i) explicit expression of uncertainty ('not
sure' about diagnosis), (ii) implicit expression of uncertainty using broad
differential diagnoses and (iii) implicit expression of uncertainty using 'most
likely' diagnoses. Participants were randomly assigned to one of the three
vignettes and then answered a 37-item web-based questionnaire.
MAIN OUTCOME MEASURE(S): Outcome variables included
parent-perceived technical competence of physician, trust and confidence, visit
satisfaction and adherence to physician instructions. Differences between the
three groups were compared using analysis of variance, followed by individual
post hoc analyses with Bonferroni correction.
RESULTS: Seventy-one participants completed the vignette
questions. Demographic characteristics and scores on activation (parent
activation measure [PAM]) and intolerance to uncertainty were similar across
the three groups. Explicit expression of uncertainty was associated with lower
perceived technical competence, less trust and confidence, and lower patient
adherence as compared to the two groups with implicit communication. These
latter two groups had comparable outcomes.
CONCLUSION: Parents may react less negatively in terms of
perceived competence, physician confidence and trust, and intention to adhere
when diagnostic uncertainty is communicated using implicit strategies, such as
using broad differential diagnoses or most likely diagnoses. Evidence-based
strategies to communicate diagnostic uncertainty to patients need further
development.
17. Decreasing ED Walkout Rate and Boarding Hours by Improving
Inpatient Length of Stay
Artenstein AW, et al. West J Emerg Med. 2017
Oct;18(6):982-992.
INTRODUCTION: Patient progress, the movement of patients
through a hospital system from admission to discharge, is a foundational
component of operational effectiveness in healthcare institutions. Optimal
patient progress is a key to delivering safe, high-quality and high-value
clinical care. The Baystate Patient Progress Initiative (BPPI), a
cross-disciplinary, multifaceted quality and process improvement project, was
launched on March 1, 2014, with the primary goal of optimizing patient progress
for adult patients.
METHODS: The BPPI was implemented at our system's tertiary
care, academic medical center, a high-volume, high-acuity hospital that serves
as a regional referral center for western Massachusetts. The BPPI was
structured as a 24-month initiative with an oversight group that ensured
collaborative goal alignment and communication of operational teams. It was
organized to address critical aspects of a patient's progress through his
hospital stay and to create additional inpatient capacity. The specific goal of
the BPPI was to decrease length of stay (LOS) on the inpatient adult Hospital
Medicine service by optimizing an interdisciplinary plan of care and promoting
earlier departure of discharged patients. Concurrently, we measured the effects
on emergency department (ED) boarding hours per patient and walkout rates.
RESULTS: The BPPI engaged over 300 employed clinicians and
non-clinicians in the work. We created increased inpatient capacity by
implementing daily interdisciplinary bedside rounds to proactively address
patient progress; during the 24 months, this resulted in a sustained rate of
discharge orders written before noon of more than 50% and a decrease in
inpatient LOS of 0.30 days (coefficient: -0.014, 95% CI [-0.023, -0.005] P less than 0.005). Despite the increase in ED
patient volumes and severity of illness over the same time period, ED boarding
hours per patient decreased by approximately 2.1 hours (coefficient: -0.09; 95%
CI [-0.15, -0.02] P = 0.007). Concurrently, ED walkout rates decreased by
nearly 32% to a monthly mean of 0.4 patients (coefficient: 0.4; 95% CI [-0.7,
-0.1] P= 0.01).
CONCLUSION: The BPPI realized significant gains in patient
progress for adult patients by promoting earlier discharges before noon and
decreasing overall inpatient LOS. Concurrently, ED boarding hours per patient
and walkout rates decreased.
18. Thoracic Aortic Dissection without CP?
Fan KL, et al. Clinical
profile of patients of acute aortic dissection presenting to the ED without
chest pain. Am J Emerg Med. 2017 Apr;35(4):599-601.
Though the clinical manifestation of acute aortic dissection
(AAD) is diverse, chest pain remains a common presentation. The incidence of
chest pain is 83% and 71% in Stanford type A and type B dissection respectively
[1]. In the emergency departments (ED), chest pain is also a common presenting
complaint [2]. The primary responsibility of clinicians in the ED when managing
a patient with chest pain is to recognize and exclude life-threatening causes.
AAD is certainly one of them. However, studies have shown that possibly 16% to
38% of patients with AAD were misdiagnosed at the ED [3,4].
19. Two Pediatric Interventions Failed the RCT Test
A. A RCT of a Single Dose Furosemide to
Improve Respiratory Distress in Moderate to Severe Bronchiolitis.
Williamson K, et al. J Emerg Med. 2018 Jan;54(1):40-46.
BACKGROUND: Bronchiolitis is one of the most common
disorders of the lower respiratory tract in infants. While historically
diuretics have been used in severe bronchiolitis, no studies have looked
directly at their early use in children in the emergency department.
OBJECTIVE: The primary objective of this study was to
determine whether a single early dose of a diuretic in infants with moderate to
severe bronchiolitis would improve respiratory distress. Secondary objectives
examined whether it reduced the use of noninvasive ventilation and hospital
length of stay.
METHODS: Patients diagnosed with clinical bronchiolitis were
enrolled at a tertiary care, academic children's hospital over a 3-year period.
This was a double-blind, randomized controlled trial in which subjects were
randomly assigned to either furosemide or placebo. Respiratory rate and oxygen
saturation at the time of medication delivery and at 2 and 4 h
post-intervention were recorded, as well as other data. Exact logistic
regression was used to examine associations.
RESULTS: There were 46 subjects enrolled and randomized.
There was no difference in respiratory rates, measured as a decrease of ≥ 25%,
at both 2 and 4 h after intervention between furosemide and placebo groups
(odds ratios 1.13 and 1.13, respectively). There was also no difference in
oxygen saturation, intensive care unit admission rate, or hospital length of
stay between groups.
CONCLUSIONS: While theoretically a single dose of a diuretic
to reduce lung fluid would improve respiratory distress in children with
bronchiolitis, our randomized controlled medication trial showed no difference
in outcomes.
B. A Randomized Double-Blind Trial
Comparing the Effect on Pain of an Oral Sucrose Solution vs. Placebo in
Children 1 to 3 Months Old Undergoing Simple Venipuncture.
Gouin S, et al. J Emerg Med. 2018 Jan;54(1):33-39.
BACKGROUND: Few clinical trials evaluating the efficacy of
oral sweet solutions for procedures in the emergency department (ED) have been
published.
OBJECTIVES: To compare the efficacy of an oral sucrose
solution vs. a placebo in reducing pain in infants undergoing venipuncture
without cannulation.
METHODS: A randomized, double-blinded clinical trial was
conducted in a pediatric ED. Infants 1 to 3 months old were randomly allocated
to receive 2 mL of 88% sucrose or 2 mL of placebo, 2 min prior to venipuncture.
The outcome measures were the difference in pain levels as assessed by the
Face, Legs, Activity, Cry and Consolability Pain Scale (FLACC) and Neonatal
Infant Pain Scale (NIPS) scores, crying time, and variations in heart rate.
RESULTS: Eighty-two participants were recruited. Data were
analyzed for 38 patients from each group (excluding protocol deviations). The
mean difference in FLACC scores 1 min post venipuncture compared with baseline
was 2.84 ± .64 (sucrose) vs. 2.71 ± .62 (placebo) (p = 0.98). For the NIPS
score, it was 2.32 ± .47 (sucrose) vs. 1.63 ± .49 (placebo) (p = 0.60). The
difference in the median crying time was not statistically significant between
the two groups: 63.0 ± 3 (sucrose) vs. 48.5 ± 5 s (placebo) (p = 0.17). No
significant difference was found in participants' heart rates 1 min post venipuncture
compared with baseline: 33 ± 6 (sucrose) vs. 24 ± 5 beats per minute (placebo)
(p = 0.44).
CONCLUSIONS: In infants 1 to 3 months of age undergoing
simple venipuncture, administration of an oral sweet solution did not
statistically decrease pain scores, and participants' heart rate variations and
crying time were not significantly changed.
20. Oxygen Therapy in Suspected AMI: Points of Clarification
21. Migraine Management Reminder
(1) Antidopaminergics are
First Line and (2) Co-administer Adjunct Diphenhydramine when Giving
Prochlorperazine but not (correcting an EM-RAP misstatement)
A.
InFocus: The Best Three Treatments for Migraine
Roberts JR. Emerg Med
News. 2018;40:12–14.
Can you guess?
https://journals.lww.com/em-news/Fulltext/2018/01000/InFocus__The_Best_Three_Treatments_for_Migraine.8.aspx
https://journals.lww.com/em-news/Fulltext/2018/01000/InFocus__The_Best_Three_Treatments_for_Migraine.8.aspx
B. Prochlorperazine, Metoclopramide,
and Diphenhydramine for Acute Migraine Headache: A Correction to the Lin
Session, EM-RAP, November 2017.
Lin M, et al. Acad Life Emerg Med. 2018 Jan 10 [Epub]
The 2016 American Headache Society (AHS) released
recommendations on managing adults with acute migraine headaches.1 In the
November 2017 EM:RAP LIN Sessions podcast episode that I recorded, I realized
that I overgeneralized several statements about anti-dopaminergic agents and
the use of concurrent diphenhydramine for akathisia risk reduction. So I wanted
to clarify things and share a deeper-dive on the topic…
The post (full-text, free): https://www.aliem.com/2018/01/prochlorperazine-metoclopramide-diphenhydramine-acute-migraine-headache/
22. Micro Bits
A.
Comparing Facebook Users and Facebook Non-Users: Relationship between
Personality Traits and Mental Health Variables – An Exploratory Study
Brailovskaia J, et al. PLoSOne December 1, 2016
B.
Toxic Alcohols
Jeffrey A. Kraut, M.D., and Michael E. Mullins, M.D.
N Engl J Med 2018; 378:270-280January 18, 2018DOI:
10.1056/NEJMra1615295
Poisonings by the toxic alcohols (methanol, ethylene glycol,
isopropanol, diethylene glycol, and propylene glycol) are potentially fatal.
This review summarizes the mechanisms of toxicity, methods of diagnosis, and
current recommendations for treatment.
C.
Health care becomes biggest source of US jobs
Health care has passed manufacturing and retail to become,
for the first time, the biggest source of jobs in the US. An aging US
population, the stability provided by public health program funding, and an
industry sector that's more resistant to globalization and automation were
factors leading to the rise of the health care job sector.
D. Dangers of Energy Drinks for Kids (CMAJ Open)
Tachycardia, insomnia among adverse effects; more common
than in coffee drinkers
E.
Guideline: Experts recommend a single dose of oral steroids for pain relief in
acute sore throat
Aertgeerts B,
Agoritsas T, Siemieniuk RA, et al. Corticosteroids for sore throat: a
clinical practice guideline. BMJ. 2017;358:j4090. 28931507
To review evidence and provide recommendations for the use
of corticosteroids in patients with acute sore throat.
What you need to know:
- Sore throat is one of the most common reasons for primary care appointments, and international guidance varies about whether to use corticosteroids to treat it, but a trial published in April 2017 suggested that costicosteroids might be effective
- We make a weak recommendation to use a single dose of oral corticosteroids, in those presenting with acute sore throat, after performing a systematic review of the new evidence in this rapid recommendation publication package
- The recommendation is weak and shared decision making is needed because corticosteroids did not help all patient reported outcomes and patients’ preferences varied substantially
- Steroids somewhat reduced the severity and duration of pain by one day, but time off school or work was unchanged. Harm seems unlikely with one steroid dose.
- The treatment is inexpensive and likely to be offered in the context of a consultation that would have taken place anyway
Full-text (free): http://www.bmj.com/content/358/bmj.j4090.long
F.
Study links social jet lag to adiposity measures in children
Social jet lag, or going to bed and waking up later on
weekends than on weekdays, was associated with a higher body fat percentage,
fat mass index, body mass index and waist-to-hip ratio in children, compared
with maintaining a constant bedtime, researchers reported in Childhood Obesity.
One hour of social jet lag was linked to a 3% increase in body fat, the study
showed.
G. Increased Risk of Fibrinolysis Shutdown Associated with
Tranexamic Acid
H.
The Hospital Gown Gets a Modest Redesign
As 2018 dawns and with it the new tax plan, the future of
health care for many individuals remains uncertain. But there is at least one
type of improvement in coverage Americans can look forward to: the end of the
dreaded exposed rear end, that hospital cliché created by back-tying gowns that
has been immortalized in movies including “Something’s Gotta Give” (courtesy of
a medicated Jack Nicholson stumbling down the hallway) to “Yes Man” (Jim Carrey
this time, spotted on the back of a motorcycle). The fashion world has woken up
to a new dressing opportunity.
In partnership with students from Parsons School of Design,
Care and Wear, a “healthwear company” (it specializes in medical wearables),
has created a new kimono-inspired hospital gown that opens in the front, has a
shielding pleat in the back, replaces five types of gowns with one, and allows
for partial exposure through the use of ties and snaps.
I.
Interest in the Ketogenic Diet Grows for Weight Loss and Type 2 Diabetes
J.
Horizons in Heart Failure Research
Collins SP, et al. What's Next for Acute Heart Failure
Research? Acad Emerg Med. 2018 Jan;25(1):85-93.
Abstract
Each year over one million patients with acute heart failure
(AHF) present to a United States emergency department (ED). The vast majority
are hospitalized for further management. The length of stay and high
postdischarge event rate in this cohort have changed little over the past
decade. Therapeutic trials have failed to yield substantive improvement in
postdischarge outcomes; subsequently, AHF care has changed little in the past
40 years. Prior research studies have been fragmented as either “inpatient” or
“ED-based.” Recognizing the challenges in identification and enrollment of ED
patients with AHF, and the lack of robust evidence to guide management, an AHF
clinical trials network was developed. This network has demonstrated, through
organized collaboration between cardiology and emergency medicine, that many of
the hurdles in AHF research can be overcome. The development of a network that
supports the collaboration of acute care and HF researchers, combined with the
availability of federally funded infrastructure, will facilitate more efficient
conduct of both explanatory and pragmatic trials in AHF. Yet many important
questions remain, and in this document our group of emergency medicine and cardiology
investigators have identified four high-priority research areas.
Questions
1 1. Does Early Bolus Vasodilator Use Improve Symptoms in
Patients With Hypertensive AHF?
2 2. Can Utilization of Objective Targets of Decongestion
Lead to Improve Clinical Outcomes?
3 3. Can Use of Noninvasive Physiologic Monitoring
Facilitate ED Care and Safe Discharge?
4 4. Do All AHF Patients With a Troponin Elevation Absent
Suspected Acute Coronary Syndrome Require Admission to the Hospital?
K. Physician says reframing can help reduce work-related stress
Physicians can use the technique of "reframing" to
reduce their work-based stress and make difficult situations easier to handle,
says Jay Winner, M.D, a family physician in Santa Barbara, Calif. Reframing is
thinking about a situation from a different perspective, such as calling time
spent doing administrative work as "patient care done via the
computer."
