1. Balanced Crystalloids Better than Saline in Both Critically and
Noncritically Ill Adults.
A. Balanced Crystalloids versus Saline in Critically Ill
Adults
Semler MW, et al;
SMART Investigators and the Pragmatic Critical Care Research Group.
N Engl J Med. 2018 Mar
1;378(9):829-839.
BACKGROUND: Both
balanced crystalloids and saline are used for intravenous fluid administration
in critically ill adults, but it is not known which results in better clinical
outcomes.
METHODS: In a
pragmatic, cluster-randomized, multiple-crossover trial conducted in five
intensive care units at an academic center, we assigned 15,802 adults to
receive saline (0.9% sodium chloride) or balanced crystalloids (lactated
Ringer’s solution or Plasma-Lyte A) according to the randomization of the unit
to which they were admitted. The primary outcome was a major adverse kidney
event within 30 days — a composite of death from any cause, new
renal-replacement therapy, or persistent renal dysfunction (defined as an
elevation of the creatinine level to ≥200% of baseline) — all censored at
hospital discharge or 30 days, whichever occurred first.
RESULTS: Among the
7942 patients in the balanced-crystalloids group, 1139 (14.3%) had a major
adverse kidney event, as compared with 1211 of 7860 patients (15.4%) in the
saline group (marginal odds ratio, 0.91; 95% confidence interval [CI], 0.84 to
0.99; conditional odds ratio, 0.90; 95% CI, 0.82 to 0.99; P=0.04). In-hospital
mortality at 30 days was 10.3% in the balanced-crystalloids group and 11.1% in
the saline group (P=0.06). The incidence of new renal-replacement therapy was
2.5% and 2.9%, respectively (P=0.08), and the incidence of persistent renal
dysfunction was 6.4% and 6.6%, respectively (P=0.60).
CONCLUSIONS: Among
critically ill adults, the use of balanced crystalloids for intravenous fluid
administration resulted in a lower rate of the composite outcome of death from
any cause, new renal-replacement therapy, or persistent renal dysfunction than
the use of saline.
B. In Noncritically Ill Adults in the ED
Self WH, et al. N Engl
J Med. 2018 Mar 1;378(9):819-828.
Background Comparative
clinical effects of balanced crystalloids and saline are uncertain,
particularly in noncritically ill patients cared for outside an intensive care
unit (ICU).
Methods We conducted a
single-center, pragmatic, multiple-crossover trial comparing balanced
crystalloids (lactated Ringer's solution or Plasma-Lyte A) with saline among
adults who were treated with intravenous crystalloids in the emergency
department and were subsequently hospitalized outside an ICU. The type of
crystalloid that was administered in the emergency department was assigned to
each patient on the basis of calendar month, with the entire emergency
department crossing over between balanced crystalloids and saline monthly
during the 16-month trial. The primary outcome was hospital-free days (days
alive after discharge before day 28). Secondary outcomes included major adverse
kidney events within 30 days - a composite of death from any cause, new
renal-replacement therapy, or persistent renal dysfunction (defined as an elevation
of the creatinine level to ≥200% of baseline) - all censored at hospital
discharge or 30 days, whichever occurred first.
Results A total of
13,347 patients were enrolled, with a median crystalloid volume administered in
the emergency department of 1079 ml and 88.3% of the patients exclusively
receiving the assigned crystalloid. The number of hospital-free days did not
differ between the balanced-crystalloids and saline groups (median, 25 days in
each group; adjusted odds ratio with balanced crystalloids, 0.98; 95%
confidence interval [CI], 0.92 to 1.04; P=0.41). Balanced crystalloids resulted
in a lower incidence of major adverse kidney events within 30 days than saline
(4.7% vs. 5.6%; adjusted odds ratio, 0.82; 95% CI, 0.70 to 0.95; P=0.01).
Conclusions Among
noncritically ill adults treated with intravenous fluids in the emergency
department, there was no difference in hospital-free days between treatment
with balanced crystalloids and treatment with saline.
2. Opioid-Induced "Likeability" and "Feeling
Good" Are Not Associated with Return Visits to an ED Among Migraine
Patients Administered IV Hydromorphone.
Friedman BW, et al. Headache.
2018 Mar 8 [Epub ahead of print].
BACKGROUND: Parenteral
opioids are used in more than 50% of emergency department (ED) visits for
migraine. Use of opioids for migraine has been associated with subsequent ED
visits, perhaps because of opioid-induced euphoria. In this study, we quantify
the extent to which nontherapeutic effects of opioids influence migraine
outcomes. We hypothesized that "feeling good" and medication
likeability would in fact be associated with receipt of opioids (rather than
relief of migraine pain) and that receipt of opioids (rather than relief of
migraine pain) would be associated with return visits to the ED.
METHODS: During an
ED-based clinical trial, migraine patients were randomized to receive
hydromorphone 1 mg or prochlorperazine 10 mg + diphenhydramine 25 mg IV. Thirty
minutes after medication administration, we asked, (1) How much did you like
the medication you received? and (2) How good did the medication make you feel?
Participants were asked to provide answers on a 0-10 scale. We also determined
0-10 pain scores at baseline and 1 hour and number of return visits for
headache during the subsequent month.
RESULTS: Sixty-three
patients received prochlorperazine and 64 hydromorphone. Prochlorperazine pain
scores improved by 6.8 (SD: 2.6), hydromorphone by 4.7 (SD: 3.3) (95%CI for
difference of 2.1: 1.0, 3.2). On the 0-10 likeability scale, prochlorperazine
patients reported a mean of 7.2 (SD: 2.8), hydromorphone 6.9 (SD: 2.9) (95% CI
for difference of 0.3: -0.7, 1.3). On the 0-10 feeling good scale,
prochlorperazine patients reported a mean of 7.5 (SD: 2.3), hydromorphone 6.8
(SD: 2.8) (95%CI: for difference of 0.7: -0.2, 1.6). In the hydromorphone
group, 8/57 (14%, 95%CI: 7, 26%) returned to the ED vs 5/63 (8%, 95%CI: 3,18%)
in the prochlorperazine group. In regression modeling, feeling good was
independently associated with pain relief (P less than .01) but not with
medication received (P = .67) or return visits (P = .12). Similarly, medication
likeability was independently associated with pain relief (P less than .01) but
not medication received (P = .12) or return visits (P = .16).
CONCLUSION: We did not
detect an association between hydromorphone and medication likeability, feeling
good, or return visits to the ED. Headache relief was associated with
medication likeability and feeling good.
3. Common antibiotics and their uncommon but worrisome risks
A. Fluoroquinolone use increases risk of aortic aneurysm and
dissection: nationwide cohort study.
Pasternak B, et al. BMJ.
2018 Mar 8;360:k678.
OBJECTIVE: To
investigate whether oral fluoroquinolone use is associated with an increased
risk of aortic aneurysm or dissection.
DESIGN: Nationwide
historical cohort study using linked register data on patient characteristics,
filled prescriptions, and cases of aortic aneurysm or dissection.
SETTING: Sweden, July
2006 to December 2013.
PARTICIPANTS: 360 088
treatment episodes of fluoroquinolone use (78%ciprofloxacin) and propensity
score matched comparator episodes of amoxicillin use (n=360 088).
MAIN OUTCOME MEASURES:
Cox regression was used to estimate hazard ratios for a first diagnosis of
aortic aneurysm or dissection, defined as admission to hospital or emergency
department for, or death due to, aortic aneurysm or dissection, within 60 days
from start of treatment.
RESULTS: Within the 60
day risk period, the rate of aortic aneurysm or dissection was 1.2 cases per
1000 person years among fluoroquinolone users and 0.7 cases per 1000 person
years among amoxicillin users. Fluoroquinolone use was associated with an
increased risk of aortic aneurysm or dissection (hazard ratio 1.66 (95%
confidence interval 1.12 to 2.46)), with an estimated absolute difference of 82
(95% confidence interval 15 to 181) cases of aortic aneurysm or dissection by
60 days per 1 million treatment episodes. In a secondary analysis, the hazard
ratio for the association with fluoroquinolone use was 1.90 (1.22 to 2.96) for
aortic aneurysm and 0.93 (0.38 to 2.29) for aortic dissection.
CONCLUSIONS: In a
propensity score matched cohort, fluoroquinolone use was associated with an
increased risk of aortic aneurysm or dissection. This association appeared to
be largely driven by aortic aneurysm.
Editorial: Possible
link with aortic pathology but the absolute risk appears very low
Do fluoroquinolone
antibiotics cause aortic pathology? In a linked article (doi:10.1136/bmj.k499),
Pasternak and colleagues report a population based study of the association
between outpatient treatment with fluoroquinolones (principally ciprofloxacin
and norfloxacin) and aortic aneurysms and dissection.1 Compared with patients
prescribed amoxicillin, those prescribed fluoroquinolones had a 66% increase in
the 60 day risk of aortic aneurysm or dissection (hazard ratio 1.66, 95%
confidence interval 1.12 to 2.46).
This is not the first
study to explore this question, but from a methodological perspective it is
arguably the strongest. Unlike in earlier studies,23 Pasternak and colleagues
used an active comparator (amoxicillin). This makes obvious sense, because
patients treated with antibiotics are systematically different from those who
are not. Other strengths included a large sample size, comprehensive prescription
data, and well balanced characteristics between groups at baseline, owing to
propensity score based matching…
B. Trimethoprim use for UTI and risk of adverse outcomes in
older patients: cohort study.
Crellin E, et al. BMJ.
2018 Feb 9;360:k341.
OBJECTIVE: To
determine if trimethoprim use for urinary tract infection (UTI) is associated
with an increased risk of acute kidney injury, hyperkalaemia, or sudden death
in the general population.
DESIGN: Cohort study.
SETTING: UK electronic
primary care records from practices contributing to the Clinical Practice
Research Datalink linked to the Hospital Episode Statistics database.
PARTICIPANTS: Adults
aged 65 and over with a prescription for trimethoprim, amoxicillin, cefalexin,
ciprofloxacin, or nitrofurantoin prescribed up to three days after a primary
care diagnosis of UTI between April 1997 and September 2015.
MAIN OUTCOME MEASURES:
The outcomes were acute kidney injury, hyperkalaemia, and death within 14 days
of a UTI treated with antibiotics.
RESULTS: Among a
cohort of 1 191 905 patients aged 65 and over, 178 238 individuals were
identified with at least one UTI treated with antibiotics, comprising a total
of 422 514 episodes of UTIs treated with antibiotics. The odds of acute kidney
injury in the 14 days following antibiotic initiation were higher following
trimethoprim (adjusted odds ratio 1.72, 95% confidence interval 1.31 to 2.24)
and ciprofloxacin (1.48, 1.03 to 2.13) compared with amoxicillin. The odds of
hyperkalaemia in the 14 days following antibiotic initiation were only higher
following trimethoprim (2.27, 1.49 to 3.45) compared with amoxicillin. However,
the odds of death within the 14 days following antibiotic initiation were not
higher with trimethoprim than with amoxicillin: in the whole population the
adjusted odds ratio was 0.90 (95% confidence interval 0.76 to 1.07) while among
users of renin-angiotensin system blockers the odds of death within 14 days of
antibiotic initiation was 1.12 (0.80 to 1.57). The results suggest that, for
1000 UTIs treated with antibiotics among people 65 and over, treatment with
trimethoprim instead of amoxicillin would result in one to two additional cases
of hyperkalaemia and two admissions with acute kidney injury, regardless of
renin-angiotensin system blockade. However, for people taking renin-angiotensin
system blockers and spironolactone treatment with trimethoprim instead of
amoxicillin there were 18 additional cases of hyperkalaemia and 11 admissions
with acute kidney injury.
CONCLUSION: Trimethoprim
is associated with a greater risk of acute kidney injury and hyperkalaemia
compared with other antibiotics used to treat UTIs, but not a greater risk of
death. The relative risk increase is similar across population groups, but the
higher baseline risk among those taking renin-angiotensin system blockers and
potassium-sparing diuretics translates into higher absolute risks of acute
kidney injury and hyperkalaemia in these groups.
C. FDA: Clarithromycin Risky for Patients With Heart Disease
March 01, 2018– On
Feb. 22, the FDA issued a safety announcement(www.fda.gov) on prescribing
clarithromycin (Biaxin) to patients with heart disease because of an increase
in the risk of cardiac and cerebrovascular events and even death that can occur
years later.
This recommendation is
based on the FDA's review of 10 years of followup data (www.ctu.dk) from the large
CLARICOR clinical trial(www.ncbi.nlm.nih.gov) involving short-term clarithromycin use in patients with
stable coronary heart disease. It was during that initial placebo-controlled
trial that these adverse events were first observed.
"As a result, we
have added a new warning about this increased risk of death in patients with
heart disease, and advised prescribers to consider using other antibiotics in
such patients," said the agency in its safety announcement. "We have
also added the study results to the clarithromycin drug labels. As part of
FDA's usual ongoing safety monitoring of drugs, we are continuing to monitor
safety reports in patients taking clarithromycin."
The remainder of the
AAFP Essay: https://www.aafp.org/news/health-of-the-public/20180301clarithromycin.html
4. Pediatric Corner
A. Development and Validation of a Novel Pediatric
Appendicitis Risk Calculator (pARC).
Kharbanda AB, and the KP CREST Network. Pediatrics. 2018 Mar
13 [Epub ahead of
print].
OBJECTIVES: We sought to develop
and validate a clinical calculator that can be used to quantify risk for
appendicitis on a continuous scale for patients with acute abdominal pain.
METHODS: The pediatric
appendicitis risk calculator (pARC) was developed and validated through
secondary analyses of 3 distinct cohorts. The derivation sample included visits
to 9 pediatric emergency departments between March 2009 and April 2010. The
validation sample included visits to a single pediatric emergency department
from 2003 to 2004 and 2013 to 2015. Variables evaluated were as follows: age,
sex, temperature, nausea and/or vomiting, pain duration, pain location, pain
with walking, pain migration, guarding, white blood cell count, and absolute
neutrophil count. We used stepwise regression to develop and select the best
model. Test performance of the pARC was compared with the Pediatric
Appendicitis Score (PAS).
RESULTS: The derivation
sample included 2423 children, 40% of whom had appendicitis. The validation
sample included 1426 children, 35% of whom had appendicitis. The final pARC
model included the following variables: sex, age, duration of pain, guarding,
pain migration, maximal tenderness in the right-lower quadrant, and absolute
neutrophil count. In the validation sample, the pARC exhibited near perfect
calibration and a high degree of discrimination (area under the curve: 0.85;
95% confidence interval: 0.83 to 0.87) and outperformed the PAS (area under the
curve: 0.77; 95% confidence interval: 0.75 to 0.80). By using the pARC, almost
half of patients in the validation cohort could be accurately classified as at less than 15% risk or ≥85%
risk for appendicitis, whereas only 23% would be identified as having a
comparable PAS of less than 3 or over 8.
CONCLUSIONS: In our validation
cohort of patients with acute abdominal pain, the pARC accurately quantified
risk for appendicitis.
Ps: An external
validation study of pARC is currently underway at Kaiser Permanente Northern California
B. A
Randomized Trial of High-Flow Oxygen Therapy in Infants with Bronchiolitis.
Franklin D, et al. N Engl J Med. 2018
Mar 22;378(12):1121-1131.
Background High-flow oxygen therapy through a nasal
cannula has been increasingly used in infants with bronchiolitis, despite
limited high-quality evidence of its efficacy. The efficacy of high-flow oxygen
therapy through a nasal cannula in settings other than intensive care units
(ICUs) is unclear.
Methods In this multicenter, randomized, controlled trial,
we assigned infants younger than 12 months of age who had bronchiolitis and a
need for supplemental oxygen therapy to receive either high-flow oxygen therapy
(high-flow group) or standard oxygen therapy (standard-therapy group). Infants in
the standard-therapy group could receive rescue high-flow oxygen therapy if
their condition met criteria for treatment failure. The primary outcome was
escalation of care due to treatment failure (defined as meeting ≥3 of 4
clinical criteria: persistent tachycardia, tachypnea, hypoxemia, and medical
review triggered by a hospital early-warning tool). Secondary outcomes included
duration of hospital stay, duration of oxygen therapy, and rates of transfer to
a tertiary hospital, ICU admission, intubation, and adverse events.
Results The analyses included 1472 patients. The
percentage of infants receiving escalation of care was 12% (87 of 739 infants)
in the high-flow group, as compared with 23% (167 of 733) in the
standard-therapy group (risk difference, -11 percentage points; 95% confidence
interval, -15 to -7; P less than 0.001). No
significant differences were observed in the duration of hospital stay or the
duration of oxygen therapy. In each group, one case of pneumothorax (less than 1% of infants)
occurred. Among the 167 infants in the standard-therapy group who had treatment
failure, 102 (61%) had a response to high-flow rescue therapy.
Conclusions Among infants with bronchiolitis who were
treated outside an ICU, those who received high-flow oxygen therapy had
significantly lower rates of escalation of care due to treatment failure than
those in the group that received standard oxygen therapy.
C. Early
Recurrence of First Unprovoked Seizures in Children is Common
Goldberg LR, et al. Acad
Emerg Med. 2018 Mar;25(3):275-282. doi: 10.1111/acem.13341. Epub 2017 Nov 28.
OBJECTIVES: The risk
of early seizure recurrences after first unprovoked seizures in children is
largely unknown. We aimed to determine the rate of seizure recurrence within 14
days of first unprovoked seizures in children and identify associated risk factors.
Secondarily, we aimed to determine the risk of recurrence at 48 hours and 4
months.
METHODS: We conducted
a secondary analysis of a multicenter cohort study of children 29 days to 18
years with first unprovoked seizures. Emergency department (ED) clinicians
completed standardized histories and physical examinations. The primary
outcome, recurrent seizure at 14 days, and the secondary outcomes, recurrence
at 48 hours and 4 months, were assessed by telephone follow-up and medical
record review. For each recurrence time point, we excluded those patients for
whom no seizure had recurred but chronic antiepileptic drugs had been
initiated.
RESULTS: A total of
475 patients were enrolled in the parent study. Of evaluable patients for this
secondary analysis, 26 of 392 (6.6%, 95% confidence interval [CI] = 4.4%-9.6%)
had recurrences within 48 hours of the incident seizures, 58 of 366 (15.8%, 95%
CI = 12.3%-20.0%) had recurrences within 14 days, and 107 of 340 (31.5%, 95% CI
= 26.6%-36.7%) had recurrences within 4 months. On logistic regression
analysis, age younger than 3 years was independently associated with a higher
risk of 14-day recurrence (adjusted odds ratio [OR] = 2.1, 95% CI = 1.2-3.7; p
= 0.01). Having had more than one seizure within the 24 hours prior to ED
presentation was independently associated with a higher risk of seizure
recurrence at 48 hours (adjusted OR = 4.3, 95% CI = 1.9-9.8; p less than
0.001).
CONCLUSIONS: Risk of
seizure recurrence 14 days after first unprovoked seizures in children is
substantial, with younger children at higher risk. Prompt completion of an
electroencephalogram and evaluation by a neurologist is appropriate for these
children.
D. Return
Visit Admissions May Not Indicate Quality of ED Care for Children
Sills MR, et al. Acad
Emerg Med. 2018 Mar;25(3):283-292.
OBJECTIVE: The
objective was to test the hypothesis that in-hospital outcomes are worse among
children admitted during a return ED visit than among those admitted during an
index ED visit.
METHODS: This was a
retrospective analysis of ED visits by children age 0 to 17 to hospitals in
Florida and New York in 2013. Children hospitalized during an ED return visit
within 7 days were classified as "ED return admissions" (discharged
at ED index visit and admitted at return visit) or "readmissions"
(admission at both ED index and return visits). In-hospital outcomes for ED
return admissions and readmissions were compared to "index admissions
without return admission" (admitted at ED index visit without 7-day return
visit admission).
RESULTS: Among
1,886,053 index ED visits to 321 hospitals, 75,437 were index admissions
without return admission, 7,561 were ED return admissions, and 1,333 were
readmissions. ED return admissions had lower intensive care unit admission
rates (11.0% vs. 13.6%; adjusted odds ratio = 0.78; 95% confidence interval
[CI] = 0.71 to 0.85), longer length of stay (3.51 days vs. 3.38 days;
difference = 0.13 days; incidence rate ratio = 1.04; 95% CI = 1.02 to 1.07),
but no difference in mean hospital costs (($7,138 vs. $7,331; difference =
-$193; 95% CI = -$479 to $93) compared to index admissions without return
admission.
CONCLUSIONS: Compared
with children who experienced index admissions without return admission,
children who are initially discharged from the ED who then have a return visit
admission had lower severity and similar cost, suggesting that ED return visit
admissions do not involve worse outcomes than do index admissions.
E. Poverty, lack of vehicle access tied to pediatric
medication nonadherence
A study in Pediatrics showed that children living in areas
with the highest poverty quintile and those in the quintile with the highest
rate of homes without vehicle access were 60% and 77% more likely to have
unfilled prescriptions, respectively, compared with those in the low poverty
quintile and those in the quintile with the lowest rate of households without
vehicle access. Researchers also found that poverty and vehicle access had
significant, graded associations with primary medication nonadherence rates,
with the gradients seen across all medication classes.
5. Radial Arterial Lines Have a Higher Failure Rate than Femoral
Greer MR, et al. West
J Emerg Med 2018; 19(2)364-371.
Introduction: Arterial
lines are important for monitoring critically ill patients. They are placed
most commonly in either femoral or radial sites, though there is little
evidence to guide site preference.
Methods: This is an
ambispective, observational, cohort study to determine variance in failure rates
between femoral and radial arterial lines. This study took place from 2012 to
2016 and included all arterial lines placed in adult patients at a single
institution. Causes of line failure were defined as inaccuracy, blockage, site
issue, or accidental removal. The primary outcome was line failure by location.
Secondary outcomes included time to failure and cause of failure.
Results: We evaluated
272 arterial lines over both arms of the study. Fifty-eight lines eventually
failed (21.32%). Femoral lines failed less often in both retrospective (5.36%
vs 30.71%) and prospective (5.41% vs. 25.64%) arms. The absolute risk reduction
of line failure in the femoral site was 20.2% (95% confidence interval [3.7 -
36.2%]). Failures occurred sooner in radial sites compared to femoral.
Infection was not a significant cause of removal in our femoral cohort.
Conclusion: Femoral
arterial lines fail much less often then radial arterial lines. If placed
preferentially in the femoral artery, one line failure would be prevented for
every fourth line.
6. Ischemic Stroke After ED Discharge for Symptoms of Transient
Neurological Attack
Parikh NS, et al. The
Neurohospitalist. 2018 Feb 18 [Epub ahead of print].
Background and
Purpose: The significance of transient neurological attack (TNA) symptoms is
unclear. We sought to determine the risk of ischemic stroke after discharge
from the emergency department (ED) with a diagnosis consistent with symptoms of
TNA.
Methods: Using
administrative claims data, we identified patients discharged from EDs in New
York between 2006 and 2012 with a primary discharge diagnosis of a TNA symptom,
defined as altered mental status, generalized weakness, and sensory changes.
The primary outcome was ischemic stroke. We used Kaplan-Meier survival
statistics to calculate cumulative rates, and Cox regression to compare stroke
risk after TNA versus after transient ischemic attack (TIA; positive control)
or renal colic (negative control) while adjusting for demographics and vascular
risk factors.
Results: Of 499 369
patients diagnosed with a TNA symptom and discharged from the ED, 7756 were
hospitalized for ischemic stroke over a period of 4.7 (±1.9) years. At 90 days,
the cumulative stroke rate was 0.29% (95% confidence interval [CI]:
0.28%-0.31%) after TNA symptoms versus 2.08% (95% CI: 1.89%-2.28%) after TIA
and 0.03% (95% CI: 0.02%-0.04%) after renal colic. The hazard ratio (HR) of
stroke was higher after TNA than after renal colic (HR: 2.13; 95% CI:
1.90-2.40) but significantly lower than after TIA (HR: 0.47; 95% CI:
0.44-0.50). Compared to TIA, TNA was less strongly associated with stroke among
patients under 60 years of age compared to those over 60.
Conclusions: Patients
discharged from the ED with TNA symptoms faced a higher risk of ischemic stroke
than patients with renal colic, but the magnitude of stroke risk was low,
particularly compared to TIA.
7. Reviews in J Emerg Med
A. Hip Dislocations in the ED: A Review of Reduction
Techniques.
Gottlieb M. J Emerg Med. 2018
Mar;54(3):339-347.
BACKGROUND: Hip dislocations are
a common presentation in the Emergency Department (ED) and require urgent
reduction to reduce the risk of avascular necrosis. Over 90% of all
dislocations can successfully be reduced in the ED and there is evidence that
cases awaiting operative reduction result in significant delays.
DISCUSSION: While there is
limited data comparing specific techniques, the individual success rates of
most maneuvers range from 60-90%. Additionally, each technique has distinct
advantages and limitations associated with its use.
CONCLUSIONS: It is important for
Emergency Physicians to be familiar with several different reduction techniques
in case the initial reduction attempt is unsuccessful or patient
characteristics limit the use of certain maneuvers. This article reviews a
number of reduction techniques for hip dislocations, variations on these
techniques, and advantages and disadvantages for each approach.
Full-text
(subscription required): http://www.jem-journal.com/article/S0736-4679(17)31168-X/fulltext
B. Cannabinoid Hyperemesis Syndrome: Pathophysiology and
Treatment in the ED
Richards JR, et al. J Emerg Med. 2018
Mar;54(3):354-363.
BACKGROUND: Cannabinoid
hyperemesis syndrome (CHS) is a challenging clinical disorder. CHS patients
frequently present to the emergency department and may require treatment for
intractable emesis, dehydration, and electrolyte abnormalities. Thought to be a
variant of cyclic vomiting syndrome, CHS has become more prevalent with
increasing cannabis potency and use, as enabled by various states having
legalized the recreational use of cannabis.
OBJECTIVE: This aim of this
review is to investigate the pathophysiology of CHS and evaluate the published
literature on pharmacologic treatment in the emergency department. This
information may be helpful in providing evidence-based, efficacious antiemetic
treatment grounded in knowledge of antiemetic medications' mechanisms of
action, potentially precluding unnecessary tests, and reducing duration of
stay.
DISCUSSION: The endocannabinoid
system is a complex and important regulator of stress response and allostasis,
and it is occasionally overwhelmed from excessive cannabis use. Acute episodes
of CHS may be precipitated by stress or fasting in chronic cannabis users who
may have pre-existing abnormal hypothalamic-pituitary-adrenal axis feedback and
sympathetic nervous system response. The reasons for this may lie in the
physiology of the endocannabinoid system, the pathophysiology of CHS, and the
pharmacologic properties of specific classes of antiemetics and sedatives.
Treatment failure with standard antiemetics is common, necessitating the use of
mechanistically logical sedating agents such as benzodiazepines and
antipsychotics.
CONCLUSION: Despite the
increasing prevalence of CHS, there is a limited body of high-quality research.
Benzodiazepines and antipsychotics represent logical choices for treatment of
CHS because of their powerful sedating effects. Topical capsaicin holds promise
based on a totally different pharmacologic mechanism. Discontinuation of
cannabis use is the only assured cure for CHS.
C. Evidence-Based Review of Pharmacotherapy for Acute
Agitation. Part 1: Onset of Efficacy.
Zun LS. J Emerg Med. 2018
Mar;54(3):364-374.
BACKGROUND: The main goal of
antipsychotic medication in the management of acute agitation in the emergency
department is to rapidly induce calm without oversedation, enabling patients to
participate in their own care. However, there is a paucity of comparative
studies, particularly with newer fast-acting second-generation antipsychotic
agents.
OBJECTIVE OF THE REVIEW: This structured
evidence-based review compared the onset of efficacy of antipsychotic
treatments for acute agitation using data from randomized controlled trials
identified by a literature search of the PubMed database.
RESULTS: Based on findings
from 28 blinded randomized controlled trials, onset of efficacy was rapid and
generally observed at the first time point after intramuscular administration
of ziprasidone (15-30 min) or olanzapine (15-30 min), but was more likely to be
delayed with intramuscular haloperidol, even when combined with lorazepam
(30-60 min), and intramuscular aripiprazole (45-90 min). When administered
orally, rapid onset of efficacy was also consistently observed at the first
assessment time point with olanzapine (15-120 min), risperidone (30-120 min),
and sublingual asenapine (15 min). Significant effects were apparent for
inhaled loxapine within 10-20 min. Effects were apparent within approximately
5-10 min with i.v. droperidol. Onset of efficacy was typically more rapid with
second-generation antipsychotic agents than benzodiazepines, but data are
limited.
CONCLUSIONS: Although the patient
populations of trials included in this review do not truly reflect that of the
emergency department, the results provide useful information to emergency
physicians on the rapid efficacy of certain newer-generation antipsychotic
agents for the treatment of acutely agitated patients.
8. Impact of a Shared Decision Making Intervention on Health
Care Utilization: A Secondary Analysis of the CP Choice Multicenter Randomized
Trial.
Schaffer JT, et al.
Acad Emerg Med. 2018 Mar;25(3):293-300.
BACKGROUND: Patients
at low risk for acute coronary syndrome are frequently admitted for observation
and cardiac testing, resulting in substantial burden and cost to the patient
and the health care system.
OBJECTIVES: The
purpose of this investigation was to measure the effect of the Chest Pain
Choice (CPC) decision aid on overall health care utilization as well as
utilization of specific services both during the index emergency department
(ED) visit and in the subsequent 45 days.
METHODS: This was a
planned secondary analysis of data from a pragmatic multicenter randomized
trial of shared decision making in adults presenting to the ED with chest pain
who were being considered for observation unit admission for cardiac stress
testing or coronary computed tomography angiography. The trial compared an intervention
group engaged in shared decision making facilitated by the CPC decision aid to
a control group receiving usual care. Hospital-level billing data were used to
measure utilization for the index ED visit and during the following 45 days.
Patients in both groups also were asked to keep a diary recording health care
utilization over the same 45-day period. Outcomes assessed included length of
time in the ED and observation, ED visits, office visits, hospitalizations,
testing, imaging, and procedures.
RESULTS: Of the 898
patients included in the original trial, we were able to contact 834 (92.9%)
patients for 45-day health care diary review. There was no difference in
patient-reported health care utilization between the study arms. Hospital-level
billing data were obtained for all 898 (100%) patients. During the initial ED
visit the length of stay (LOS) was similar, and there was no difference in the
frequency of observation unit admission between study arms. However, the mean
observation unit LOS was 95 minutes (95% confidence interval [CI] = 40.8-149.8)
shorter in the CPC arm and the mean number of tests was lower in the CPC arm
(decrease in 19.4 imaging studies per 100 patients, 95% CI = 15.5-23.3). When
evaluating the entire encounter and follow-up period, the intervention arm
underwent fewer tests (decrease in 125.6 tests per 100 patients, 95% CI =
29.3-221.6). More specifically, there were fewer advanced cardiac imaging tests
completed (25.8 fewer per 100 patients, 95% CI = 3.74-47.9) in the intervention
arm.
CONCLUSIONS: Shared
decision making in low-risk chest pain can lead to decreased diagnostic testing
without worsening outcomes measured over 45 days.
9. Endovascular treatment for acute ischaemic stroke in routine
clinical practice: prospective, observational cohort study (MR CLEAN Registry).
Jansen IGH, et al. BMJ.
2018 Mar 9;360:k949.
OBJECTIVE: To
determine outcomes and safety of endovascular treatment for acute ischaemic
stroke, due to proximal intracranial vessel occlusion in the anterior
circulation, in routine clinical practice.
DESIGN: Ongoing,
prospective, observational cohort study.
SETTING: 16 centres
that perform endovascular treatment in the Netherlands.
PARTICIPANTS: 1488
patients included in the Multicentre Randomised Controlled Trial of
Endovascular Treatment for Acute Ischaemic Stroke in the Netherlands (MR CLEAN)
Registry who had received endovascular treatment, including stent retriever
thrombectomy, aspiration, and all alternative methods for acute ischaemic
stroke within 6.5 hours from onset of symptoms between March 2014 and June
2016.
MAIN OUTCOME MEASURES:
The primary outcome was the modified Rankin Scale (mRS) score, ranging from 0
(no symptoms) to 6 (death) at 90 days after the onset of symptoms. Secondary
outcomes were excellent functional outcome (mRS score 0-1), good functional
outcome (mRS score 0-2), and favourable functional outcome (mRS score 0-3) at
90 days; score on the extended thrombolysis in cerebral infarction scale at the end of the
intervention procedure; National Institutes of Health Stroke Scale score 24-48
hours after intervention; and complications that occurred during intervention,
hospital admission, or three months' follow up period. Outcomes and safety
variables in the MR CLEAN Registry were compared with the MR CLEAN trial
intervention and control arms.
RESULTS: A
statistically significant shift was observed towards better functional outcome
in patients in the MR CLEAN Registry compared with the MR CLEAN trial
intervention arm (adjusted common odds ratio 1.30, 95% confidence interval 1.02
to 1.67) and the MR CLEAN trial control arm (1.85, 1.46 to 2.34). The
reperfusion rate, with successful reperfusion defined as a score of 2B-3 on the
extended thrombolysis in cerebral infarction score, was 58.7%, the same as for
patients in the MR CLEAN trial. Duration from onset of stroke to start of
endovascular treatment and from onset of stroke to successful reperfusion or
last contrast bolus was one hour shorter for patients in the MR CLEAN Registry.
Symptomatic intracranial haemorrhage occurred in 5.8% of patients in the MR
CLEAN Registry compared with 7.7% in the MR CLEAN trial intervention arm and
6.4% in the MR CLEAN trial control arm.
CONCLUSION: In routine
clinical practice, endovascular treatment for patients with acute ischaemic
stroke is at least as effective and safe as in the setting of a randomised
controlled trial.
10. Images in Clinical Practice
Hematometrocolpos in a Teenager
Lithium-Induced Nephropathy
Osgood–Schlatter Disease
Acute Angle-Closure Glaucoma
Meconium Ileus in a Neonate with Cystic Fibrosis
Ulnar-Artery Mycotic Aneurysm
A Male Teenager With Dysuria
Young Girl With Right Flank Pain
Young Boy With Fatigue and Weight Loss
A Cloudy Conical Cornea
Adult Male with Leg Swelling after a Fall Two Weeks Prior
Oculomotor Nerve Palsy Secondary to Cavernous Internal
Carotid Aneurysm
Child with Testicular Pain
Man with Total Knee Arthroplasty Now Unable to Extend the
Joint
Double Trouble: Massive Unruptured Aortic Aneurysms
Endophthalmitis and Mycotic Aneurysm: The Only Clues to
Underlying Endocarditis
The “Black-and-White Cookie” Sign – A Case Series of a Novel
Ultrasonographic Sign in Gastric Outlet Obstruction
Asymptomatic Hypotension in a Patient with Catheter-related
Right Atrial Thrombus
Isolated Dissection of the Superior Mesenteric Artery
Hemorrhagic bullous lesion
11. Renal Colic Research
A. Can low-dose of ketamine reduce the need for
morphine in renal colic? A double-blind RCT.
Abbasi S, et al. Am J Emerg Med. 2018
Mar;36(3):376-379.
BACKGROUND: The combination of
morphine with low doses of ketamine (MK) has been utilized in the Emergency
Department (ED) compared with morphine and placebo (MP) for the treatment of
acute pain in few studies. The purpose of this study was to compare the effect
of MP with MK for the treatment of severe pain with renal colic of patients who
had been referred to the ED.
METHODS: This study is a
double blind randomized clinical trial on patients with severe renal colic pain
who were referred to the ED. Patients were enrolled with pain severity of at
least 6 of the 10 visual analogue scales (VAS). Patients were divided into two
groups: Morphine 0.1mg/kg and placebo (MP group) and morphine 0.1mg/kg and
ketamine 0.15mg/kg (MK group). Pain of patients was studied in 10, 30, 60, 90,
and 120min after injection.
RESULTS: Totally, 106
patients were enrolled in study groups. Assessment of the average pain during
120min at 10 and 30min after the start in the drug, MK group was significantly
lower than the MP group (p=0.019 and p=0.003 respectively).
CONCLUSION: Given that
combinations of morphine with low doses of ketamine in patients with renal
colic pain causes more pain and morphine consumption reduction then this
combination is suggested as an alternative treatment that could be utilized in
patients with renal colic.
B. The accuracy and prognostic value of point‐of‐care US for
nephrolithiasis in the ED: A Systematic Review and Meta‐Analysis
Wong C, et al. Acad Emerg Med. 2018 Feb 10 [Epub ahead of
print]
INTRODUCTION: Point-of-care
ultrasound (POCUS) has been suggested as an initial investigation in the
management of renal colic. Our objectives were: 1) to determine the accuracy of
POCUS for the diagnosis of nephrolithiasis, and 2) to assess its prognostic
value in the management of renal colic.
METHODS: The review protocol
was registered to the PROSPERO database (CRD42016035331). An electronic
database search of MEDLINE, EMBASE, and PubMed was conducted utilizing subject
headings, keywords, and synonyms that address our research question.
Bibliographies of included studies and narrative reviews were manually
examined. Studies of adult emergency department patients with renal colic
symptoms were included. Any degree of hydronephrosis was considered a positive
POCUS finding. Accepted criterion standards were CT evidence of renal stone or
hydronephrosis, direct stone visualization, or surgical findings. Screening of
abstracts, quality assessment with the QUADAS-2 instrument, and data extraction
were performed by two reviewers, with discrepancies resolved by consensus with
a third reviewer. Test performance was assessed by pooled sensitivity and
specificity, calculated likelihood ratios, and a summary receiver operator
curve (SROC). The secondary objective of prognostic value was reported as a
narrative summary.
RESULTS: The electronic
search yielded 627 unique titles. After relevance screening, 26 papers
underwent full-text review, and 9 articles met all inclusion criteria. Of
these, 5 high-quality studies (N = 1773) were included in the meta-analysis for
diagnostic accuracy, and the remaining yielded data on prognostic value. The
pooled results for sensitivity and specificity were 70.2% (95% CI = 67.1% to
73.2%) and 75.4% (95% CI = 72.5% to 78.2%), respectively. The calculated
positive and negative likelihood ratios were 2.85 and 0.39. The SROC generated
did not show evidence of a threshold effect. Two of the studies in the
meta-analysis found that the finding of moderate or greater hydronephrosis
yielded a specificity of 94.4% (95% CI = 92.7% to 95.8%). Four studies
examining prognostic value noted a higher likelihood of a large stone when
positive POCUS findings were present. The largest randomized trial showed lower
cumulative radiation exposure and no increase in adverse events in those who
received POCUS investigation as the initial renal colic investigation.
CONCLUSION: Point-of-care
ultrasound has modest diagnostic accuracy for diagnosing nephrolithiasis. The
finding of moderate or severe hydronephrosis is highly specific for the
presence of any stone, and the presence of any hydronephrosis is suggestive of
a larger (greater than 5mm) stone in those
presenting with renal colic.
12. Acute Amnestic Syndrome Associated with Fentanyl
Overdose
Between 2012 and 2016, a total of 14 patients in
Massachusetts with a history of substance use had an acute anterograde amnestic
syndrome that lasted for months (or longer in some patients); this amnestic
syndrome was characterized by a hyperintense signal involving both hippocampi
on magnetic resonance imaging diffusion-weighted sequences.1 The patients were
also variably observed to have deficits in other cognitive domains, including
orientation and attention. Thirteen of these 14 patients had a positive
toxicologic test for opioids or had a history of opioid use, but none underwent
testing for synthetic opioids such as fentanyl. Although synthetic opioids are
currently often combined with heroin, they are not typically identified on
routine assays for morphine, heroin metabolites, or oxycodone.2…
…Potential mechanisms
of fentanyl-related hippocampal injury include cerebral ischemia1 or hypoxemia
as a result of overdose4 or excitotoxicity, since fentanyl and its analogues
have been shown to induce neuronal hypermetabolism and acute neuronal damage in
the hippocampus of rats.5 Expanded toxicologic screening for fentanyl and its
analogues should be considered in patients with a history of substance use who
present with this amnestic syndrome.
For the full-text
(free), link here: http://www.nejm.org/doi/full/10.1056/NEJMc1716355
13. Brief Reviews from Ann Emerg Med
A. Can Multidetector CT Rule Out Left Atrial Thrombus in
Patients With Atrial Fibrillation?
Take-Home Message
Multidetector computed
tomography (CT) is a sensitive test to detect left atrial thrombus in patients
with atrial fibrillation.
B. What Factors Predict Fluid Responsiveness in
Hemodynamically Unstable Patients?
Take-Home Message
Passive leg raising is
useful in predicting fluid responsiveness, whereas other elements of the
physical examination have limited predictive value.
C. Which Compression-to-Ventilation Ratio Yields Better
Cardiac Arrest Outcomes?
Take-Home Message
Continuous
compressions with asynchronous ventilations and a compression-to-ventilation
ratio of 30:2 resulted in improved outcomes in adults in cardiopulmonary arrest,
whereas either 30:2 or 15:2 improved outcomes in children.
D. What Elements Suggest Infectious Mononucleosis?
Take-Home Message
In teens and young
adults (less than 26 years) with sore throat, the likelihood of mononucleosis
is increased with lymphadenopathy (posterior cervical, axillary, or inguinal),
palatine petechiae, splenomegaly, and atypical lymphocytosis.
E. How Accurate Is Rapid Antigen Testing for Group A
Streptococcus in Children With Pharyngitis?
Take-Home Message
Children with negative
results on rapid antigen testing may be discharged without antibiotics or
further testing.
F. Update: Can Newer Rapid Influenza Tests Rule Out Disease?
Take-Home Message
Although newer rapid
influenza tests have improved our ability to rule out disease, they are still
better at ruling in influenza. Change in management should be considered before
testing.
G. What Is the Utility of Physical Examination,
Ankle-Brachial Index, and Ultrasonography for the Diagnosis of Arterial Injury
in Patients With Penetrating Extremity Trauma?
Take-Home Message
Among patients with
penetrating extremity trauma, the combination of normal physical examination
result (no hard or soft signs) and normal systolic blood pressure index
(brachial-brachial, brachial-wrist, or ankle-brachial, depending on injury
location) results in sufficiently low probability of arterial injury to obviate
the need for computed tomography (CT) angiography. A lack of consensus is
present in regard to hard and soft signs. An abnormal ultrasonographic result
should prompt treatment without necessitating confirmatory CT angiography.
H. Does Administration of Hypertonic Solutions Improve
Mortality in Hemorrhagic Shock Compared With Isotonic Solutions?
Take-Home Message
Hypertonic solutions
offer no survival benefit compared with isotonic solutions in traumatic
hemorrhagic shock.
14. On Pulmonary Embolism
A. Deciding Whether to Anticoagulate a Patient with Isolated
Subsegmental PE?
A systematic review
found no evidence for or against anticoagulation in these patients.
Bariteau A et al. Systematic
review and meta-analysis of outcomes of patients with subsegmental pulmonary
embolism with and without anticoagulation treatment. Acad Emerg Med 2018 Mar 2 [Epub
ahead of print]
BACKGROUND: This
systematic review addresses the controversy over the decision to anticoagulate
patients with subsegmental pulmonary embolism (SSPE).
METHODS: We searched
Ovid MEDLINE, PubMed, Embase, the Cochrane Library, Scopus, Web of Science,
ClinicalTrials . gov, Google Scholar and bibliographies in March 2017. Two
authors reviewed and retained papers with symptomatic patients who underwent
computerized tomographic pulmonary angiography and had sufficient information
to determine SSPE, decision to treat (or not) with systemic anticoagulation,
and outcomes of bleeding, VTE recurrence and death. Papers were assessed for
selection and publication bias and heterogeneity, with Eggers and the
inconsistency indexes (I2 ).
RESULTS: From 1512
papers screened, we included 14 studies comprising 15,563 patients for
full-length review and analysis. Pooled data demonstrated I2 = 99% with an
Eggers P less than 0.001, suggesting significant publication bias. The pooled
prevalence of SSPE was 4.6% (95% CI = 1.8 to 8.5%). The frequency of bleeding
in SSPE patients treated with anticoagulation (N= 589) was 8.1% (95% CI = 2.8
to 15.8%), with no available bleeding data in untreated patients (N=126). The
frequency of VTE recurrence within 90 days was 5.3% (95% CI = 1.6 to 10.9%) for
treated vs. 3.9% (95% CI = 4.8 to 13.4%) for untreated, while the frequency of
death was 2.1% (95% CI = 3.4 to 5.2%) for treated vs. 3.0% (95% CI = 2.8 to
8.6%) for untreated.
CONCLUSION: This
systematic review highlights the lack of any clinical trial to make a clear
inference about harm or benefit of anticoagulation for SSPE. Comparison of
pooled data from uncontrolled outcome studies shows no increase in VTE
recurrence or death rates for patients who were not anticoagulated. These data
suggest clinical equipoise for decision to anticoagulate or not anticoagulate
patients with SSPE. However, this inference is limited by small numbers,
imprecision and the lack of a controlled clinical trial.
B. Ruling out PE
in Patients with High Pretest Probability
Ahkter M, et al. West
J Emerg Med. 2018 Mar 08 [Epub ahead of print].
Introduction: The
American College of Emergency Physicians guidelines recommend more aggressive
workup beyond imaging alone in patients with a high pretest probability (PTP)
of pulmonary embolism (PE). However, the ability of multiple tests to safely
rule out PE in high PTP patients is not known. We sought to measure the ability
of negative computed tomography pulmonary angiography (CTPA) along with
negative D-dimer to rule out PE in these high-risk patients.
Methods: We analyzed
data from a previous prospective observational study conducted in 12 emergency
departments (ED). Wells score criteria were entered by providers before final
PE testing. PE was diagnosed by imaging on the index ED visit, or within 45
days, demonstrating either PE ordeep vein thrombosis (DVT), or if the patient
died of PE during the 45-day, follow-up period. Testing threshold was set at
1.8%.
Results: A total of
7,940 patients were enrolled and tested for PE, and 257 had high PTP (Wells greater
than 6). Sixteen of these high-risk patients had negative CTPA and negative
D-dimer, of whom two were positive for PE (12.5% [95% confidence interval
2.2%-40.0%]). One of these patients had a DVT on CT venogram and the other was
diagnosed at follow-up.
Conclusion: Our
analysis suggests that in patients with high PTP of PE, neither negative CTPA
by itself nor a negative CTPA plus a negative D-dimer are sufficient to rule
out PE. More aggressive workup strategies may be required for these patients.
C. Trends and Variation in the Utilization and Diagnostic
Yield of Chest Imaging for Medicare Patients With Suspected PE in the ED
Venkatesh AK, et al. AJR
Am J Roentgenol. 2018 Mar;210(3):572-577.
OBJECTIVE: The purpose
of this study is to assess trends and variation in chest CT utilization in the
emergency department (ED) and its diagnostic yield for suspected pulmonary
embolism (PE) among a national sample of Medicare beneficiaries. The
relationship between hospital and provider characteristics is also discussed.
MATERIALS AND METHODS:
We conducted an observational analysis of Medicare beneficiaries evaluated in
the ED for suspected PE from 2000 to 2009. Standard Medicare analytic files
representing a 20% sample of fee-for-service beneficiaries were linked to the
American Hospital Association Annual Survey of Hospitals, American Medical
Association Physician Masterfile, Medicare Physician Identification and
Eligibility Registry, and Dartmouth Atlas Project to calculate geographic- and
physician-level chest CT utilization (i.e., the proportion of ED visits
involving chest CT examination for suspected PE) and diagnostic yield (i.e.,
the proportion of chest CT examinations with a positive PE diagnosis).
RESULTS: Of 2.5
million ED visits, 2.5% (n = 164,274) included chest CT for suspected PE; 6.2%
visits (n = 10,121) resulted in positive findings for PE. Between 2000 and
2009, chest CT utilization increased fivefold. Geographic variation in CT
utilization (median, 2.38%; interquartile range [IQR], 1.91-2.92%) and
diagnostic yield (median, 6.31%; IQR, 5.11-7.66%) was observed between 306
hospital referral regions. Physician use of imaging was explained by greater
experience (lower utilization and higher yield) and emergency medicine board
certification (lower utilization and equivalent yield).
CONCLUSION: CT
utilization in the ED for suspected PE has steadily risen, whereas diagnostic
yields have declined over time. Wide variation in practice is observed at the
physician and geographic levels and is explained by several physician and
hospital characteristics. Taken together, our findings suggest a substantial
inefficiency of chest CT use and substantial opportunities for improvement.
15. From Journal Watch
A. Should EMS Drive Longer to Get to a Cardiac Center for
Patients with Cardiac Arrest?
Daniel M. Lindberg, MD
reviewing Cournoyer A et al. Resuscitation 2018 Feb 2
This study suggests
that up to 14 minutes of extra driving time is worth it.
Patients who are
successfully resuscitated after out of hospital cardiac arrest (OHCA)
frequently require percutaneous coronary intervention (PCI), but emergency
medical services (EMS) transfer time also predicts outcomes. So, should EMS
choose a longer transport time to bring patients to a PCI center?
These authors used a
registry of all OHCA in Montreal to compare outcomes according to transport
times and type of center. EMS protocols at the time of the study (2010–2015)
required that OHCA patients be transported to the nearest of the region's 20
hospitals, of which 7 were PCI centers.
Of nearly 5000 adult
patients with OHCA who were transported to a hospital, 48% were transported to
a PCI center and 52% to a non-PCI center. Patients transported to a PCI center
had higher rates of prehospital return of spontaneous circulation and initially
shockable rhythms. Survival to hospital discharge was significantly higher in
patients transported to PCI centers (20% vs. 11%). Multivariable modeling suggested
that a 14-minute increase in transport time would be offset by the benefits of
transfer to a PCI center.
COMMENT
While we could quibble
with a precise estimate of 14 minutes, these results make sense: it is probably
worth a small increase in transport time to get to a PCI center. EMS
dispatchers should estimate travel time, and recommend transport to a PCI
center when the delay is less than 10–15 minutes.
B. Migraine Is Associated with Excess Stroke and Venous
Thromboembolism Risk
Paul S. Mueller, MD,
MPH, FACP reviewing Adelborg K et al. BMJ 2018 Jan 31.
In a cohort study,
several other adverse cardiovascular outcomes also were more common.
Prior research has
suggested an association between migraine and myocardial infarction and stroke
(NEJM JW Gen Med Sep 15 2006 and JAMA 2006; 296:283; NEJM JW Gen Med Jun 1 2007
and JAMA Intern Med 2007; 167:795; NEJM JW Gen Med Oct 15 2010 and BMJ 2010;
341:3659). In this nationwide study, researchers in Denmark determined risks
for adverse cardiovascular outcomes among 51,000 patients with migraine (but
without known cardiovascular disease) who were compared with age- and
sex-matched controls from the general population.
Median age at
diagnosis of migraine was 35, and 71% of patients were women. After as long as
19 years of follow-up, migraine was associated with significantly higher
relative risks for ischemic stroke (hazard ratio, 2.26), hemorrhagic stroke
(HR, 1.94), venous thromboembolism (HR, 1.59), myocardial infarction (HR,
1.49), and atrial fibrillation or flutter (HR, 1.25); peripheral artery disease
and heart failure occurred at similar rates in both groups. However, absolute
risks for these outcomes were low: For example, cumulative incidence of
myocardial infarction per 1000 people was 25 for migraine patients and 17 for
the general population. The associations were stronger in patients with aura
than in patients without aura and stronger in women than in men.
COMMENT
In this study,
migraine was associated with excess risk for adverse cardiovascular outcomes.
However, given the young age of the study population, absolute risks were low.
Whether treatment that reduces migraine frequency and more aggressive
cardiovascular prevention strategies in patients with migraine (e.g., lower
threshold for prescribing aspirin) mitigate cardiovascular risk is unknown.
C. Young People Who Self-Harm Face Striking Increase in
Suicide Risk
By Amy Orciari Herman.
Edited by Susan Sadoughi, MD
Teens who self-harm
are nearly 50 times more likely to commit suicide in the following year
compared with their non-self-harming peers, a Pediatrics study finds.
Using Medicaid data,
researchers studied over 32,000 young people with clinical diagnoses of intentional
self-harm. During the year after self-harm, 48 committed suicide.
Compared with
population-based controls, adolescents aged 12–17 who self-harmed were 46 times
more likely to commit suicide, and young adults aged 18–24 were 19 times more
likely. Suicide risk was particularly high for males, American Indians/Alaska
Natives, and those who used violent self-harm methods.
Of note, the risk for
repeated self-harm was 100 times higher than the risk for suicide.
The researchers
conclude, "Clinical priority should be given to ensuring the safety of
young people after self-harm, which may include treating underlying psychiatric
disorders, restricting access to lethal means, fortifying psychosocial
supports, and close monitoring for emerging suicidal symptoms."
16. Pulmonary Corner
A. Effect of Bag-Mask Ventilation vs Endotracheal
Intubation During CPR on Neurological Outcome After Out-of-Hospital
Cardiorespiratory Arrest: A RCT.
Jabre P, et al. JAMA.
2018 Feb 27;319(8):779-787. doi: 10.1001/jama.2018.0156.
IMPORTANCE: Bag-mask
ventilation (BMV) is a less complex technique than endotracheal intubation
(ETI) for airway management during the advanced cardiac life support phase of
cardiopulmonary resuscitation of patients with out-of-hospital
cardiorespiratory arrest. It has been reported as superior in terms of
survival.
OBJECTIVES: To assess
noninferiority of BMV vs ETI for advanced airway management with regard to
survival with favorable neurological function at day 28.
DESIGN, SETTINGS, AND
PARTICIPANTS: Multicenter randomized clinical trial comparing BMV with ETI in
2043 patients with out-of-hospital cardiorespiratory arrest in France and
Belgium. Enrollment occurred from March 9, 2015, to January 2, 2017, and
follow-up ended January 26, 2017.
INTERVENTION: Participants
were randomized to initial airway management with BMV (n = 1020) or ETI
(n = 1023).
MAIN OUTCOMES AND
MEASURES: The primary outcome was favorable neurological outcome at 28 days
defined as cerebral performance category 1 or 2. A noninferiority margin of 1%
was chosen. Secondary end points included rate of survival to hospital
admission, rate of survival at day 28, rate of return of spontaneous
circulation, and ETI and BMV difficulty or failure.
RESULTS: Among 2043
patients who were randomized (mean age, 64.7 years; 665 women [32%]), 2040
(99.8%) completed the trial. In the intention-to-treat population, favorable
functional survival at day 28 was 44 of 1018 patients (4.3%) in the BMV group
and 43 of 1022 patients (4.2%) in the ETI group (difference, 0.11% [1-sided
97.5% CI, -1.64% to infinity]; P for noninferiority = .11). Survival to
hospital admission (294/1018 [28.9%] in the BMV group vs 333/1022 [32.6%] in
the ETI group; difference, -3.7% [95% CI, -7.7% to 0.3%]) and global survival
at day 28 (55/1018 [5.4%] in the BMV group vs 54/1022 [5.3%] in the ETI group;
difference, 0.1% [95% CI, -1.8% to 2.1%]) were not significantly different.
Complications included difficult airway management (186/1027 [18.1%] in the BMV
group vs 134/996 [13.4%] in the ETI group; difference, 4.7% [95% CI, 1.5% to
7.9%]; P = .004), failure (69/1028 [6.7%] in the BMV group vs 21/996 [2.1%] in
the ETI group; difference, 4.6% [95% CI, 2.8% to 6.4%]; P less than .001),
and regurgitation of gastric content (156/1027 [15.2%] in the BMV group vs
75/999 [7.5%] in the ETI group; difference, 7.7% [95% CI, 4.9% to 10.4%]; P less
than .001).
CONCLUSIONS AND
RELEVANCE: Among patients with out-of-hospital cardiorespiratory arrest, the
use of BMV compared with ETI failed to demonstrate noninferiority or
inferiority for survival with favorable 28-day neurological function, an
inconclusive result. A determination of equivalence or superiority between
these techniques requires further research.
B. Lung ultrasound: a useful tool in the assessment of the
dyspnoeic patient in the ED. Fact or fiction?
Wimalasena Y, et al. Emerg Med J. 2018
Apr;35(4):258-266.
Patients with respiratory distress present a frequent and challenging
dilemma for emergency physicians (EPs). The accurate diagnosis and treatment of
the underlying pathology is vitally important in these sick patients to ensure
the best outcome and minimise harm from unnecessary treatments. Within the last
decade, studies have shown lung ultrasonography (LU) to be valuable in the
accurate diagnosis of a variety of lung pathologies, including cardiogenic
pulmonary oedema, pleural effusion, pneumothorax, haemothorax and pneumonia.
However, despite advances in techniques and the evidence for the use of LU in
the diagnosis of respiratory pathology, it remains poorly understood and rarely
used by EPs. This clinical review article provides an overview of LU and its
relevance as a diagnostic aid to the detection of respiratory pathology in the
Emergency Department (ED).
17. Amal Mattu’s Favorite Articles from 2017
The 2017 calendar year
had many outstanding articles focused on high-risk topics that directly relate
to emergency medicine clinical practice. As in past years, I solicited my
colleagues for their opinions on the best and most useful journal publications
of the year. I received dozens of selections to consider that ranged from
deadly conditions, such as myocardial infarction and stroke, to more benign
everyday conditions, such as pharyngitis.
I narrowed the
selections to articles that provided (1) practical, immediately useful
recommendations and (2) would help critically ill patients in the emergency
department (ED). Given the space limitations, I again have chosen only three
articles.
A. Lung-Protective
Ventilation Initiated in the ED (LOV-ED): A Quasi-Experimental, Before-After
Trial
B. Severe
Hyperkalemia: Can the ECG Risk-Stratify for Short-Term Adverse Events?
C. Use of NTG by bolus
prevents ICU admission in patients with acute hypertensive heart failure
18. On ECG Interpretation
A. Self-Management of an Inferior STEMI
Lee F, et al. N Engl J
Med. 2018 Mar 8;378(10):960-962.
A 44-year-old man
presented with severe chest pain and dizziness to the nursing post where he
worked in Coral Bay, Australia, more than 1000 km from Perth and 150 km from
the next nearest medical facility. He was the only nurse on duty when the
symptoms occurred. Since no other medical personnel were available, he
performed and emailed his own electrocardiograms to an emergency physician by
means of the Emergency Telehealth Service (ETS). The first electrocardiogram
showed complete heart block, right bundle-branch block, hyperacute T waves in
the inferior leads, and reciprocal ST-segment depression in the anterolateral
leads (Figure 1A). The second electrocardiogram, obtained 50 minutes later,
showed sinus tachycardia with 2 mm of inferior ST-segment elevation (Figure
1B).
He self-cannulated
both antecubital fossae for intravenous access and self-administered aspirin,
clopidogrel, sublingual nitroglycerin, intravenous heparin, and opiates.
Preparations were made for thrombolysis with tenecteplase, with real-time video
interaction with the ETS. He attached his own defibrillator pads and prepared
adrenaline, atropine, and amiodarone. After thrombolysis, there was resolution
of his ST-segment elevation and symptoms….
B. ECG Predictors of Cardiac Arrhythmias in Older Adults With
Syncope.
Nishijima DK, et al. Ann
Emerg Med. 2018;71(4):452–461.e3
STUDY OBJECTIVE: Cardiac
arrhythmia is a life-threatening condition in older adults who present to the
emergency department (ED) with syncope. Previous work suggests the initial ED
ECG can predict arrhythmia risk; however, specific ECG predictors have been
variably specified. Our objective is to identify specific ECG abnormalities
predictive of 30-day serious cardiac arrhythmias in older adults presenting to
the ED with syncope.
METHODS: We conducted
a prospective, observational study at 11 EDs in adults aged 60 years or older
who presented with syncope or near syncope. We excluded patients with a serious
cardiac arrhythmia diagnosed during the ED evaluation from the primary
analysis. The outcome was occurrence of 30-day serous cardiac arrhythmia. The
exposure variables were predefined ECG abnormalities. Independent predictors
were identified through multivariate logistic regression. The sensitivities and
specificities of any predefined ECG abnormality and any ECG abnormality
identified on adjusted analysis to predict 30-day serious cardiac arrhythmia
were also calculated.
RESULTS: After
exclusion of 197 patients (5.5%; 95% confidence interval [CI] 4.7% to 6.2%)
with serious cardiac arrhythmias in the ED, the study cohort included 3,416
patients. Of these, 104 patients (3.0%; 95% CI 2.5% to 3.7%) had a serious
cardiac arrhythmia within 30 days from the index ED visit (median time to
diagnosis 2 days [interquartile range 1 to 5 days]). The presence of nonsinus
rhythm, multiple premature ventricular conductions, short PR interval,
first-degree atrioventricular block, complete left bundle branch block, and Q
wave/T wave/ST-segment abnormalities consistent with acute or chronic ischemia
on the initial ED ECG increased the risk for a 30-day serious cardiac
arrhythmia. This combination of ECG abnormalities had a similar sensitivity in
predicting 30-day serious cardiac arrhythmia compared with any ECG abnormality
(76.9% [95% CI 67.6% to 84.6%] versus 77.9% [95% CI 68.7% to 85.4%]) and was
more specific (55.1% [95% CI 53.4% to 56.8%] versus 46.6% [95% CI 44.9% to
48.3%]).
CONCLUSION: In older
ED adults with syncope, approximately 3% receive a diagnosis of a serious
cardiac arrhythmia not recognized on initial ED evaluation. The presence of
specific abnormalities on the initial ED ECG increased the risk for 30-day
serious cardiac arrhythmias
19. Do patients with blunt thoracic aortic injury
present to hospital with unstable vital signs? A systematic review and
meta-analysis.
Bade-Boon J, et al. Emerg Med J. 2018
Apr;35(4):231-237.
BACKGROUND: Blunt thoracic
aortic injury (BTAI) is an uncommon diagnosis, usually developing as a
consequence of high-impact acceleration-deceleration mechanisms. Timely
diagnosis may enable early resuscitation and reduction of shear forces,
essential to prevent worsening of the injury prior to definitive management.
Death is commonly due to haemorrhagic shock, but clinical features may be
absent until sudden and massive haemorrhage.
OBJECTIVES: The aim of this
systematic review was to determine the proportion of patients with BTAI who
present with unstable vital signs.
METHODS: Manuscripts were
identified through a search of MEDLINE, EMBASE and the Cochrane Library
databases, focusing on subject headings and keywords related to the aorta and
trauma. Mechanisms of injury, haemodynamic status and mortality from the
included manuscripts were reviewed. Meta-analysis of presenting haemodynamic
status among a select group of similar papers was conducted.
RESULTS: Nineteen studies
were included, with five selected for meta-analysis. Most reported cases of
BTAI (80.0%-100%) were caused by road traffic incidents, with mortality
consistently higher among initially unstable patients. There was statistically
significant heterogeneity among the included studies (P less than 0.01). The pooled proportion
of patients with haemodynamic instability in the setting of BTAI was 48.8% (95%
CI 8.3 to 89.4).
CONCLUSIONS: Normal vital signs
do not rule out aortic injury. A high degree of clinical suspicion and liberal
use of imaging is necessary to prevent missed or delayed diagnoses.
20. Antibiotics for simple skin abscesses: the new
evidence in perspective.
Frazee B. Emerg Med J. 2018
Apr;35(4):277-278.
Two studies, both published in New England Journal of
Medicine in the last 2 years, go a long way in answering, once and for all,
whether antibiotics are beneficial after incision and drainage (I&D) of
simple skin abscesses. This is an age-old question in emergency medicine and
one that grew more urgent with the emergence of community-associated
methicillin-resistant Staphylococcus aureus (CA-MRSA) in the late 1990s and
early 2000s. While CA-MRSA can cause serious invasive infections, it
predominantly causes skin and soft tissue abscesses, mostly simple furuncles in
young, healthy patients. Between 1997 and 2005, for example, ED visits for skin
and soft tissue infections rose more than 50%, with 59% of culturable
infections due to MRSA.1 Do all these furuncles we are now seeing really require
a prescription for MRSA-active antibiotics?
‘A strategy of routinely treating all skin abscesses with
adjunctive antibiotics seems perfectly justified’.
There have been many studies over the last 40 years
examining the benefit of adjunctive antibiotics (in addition to I&D) for
simple skin abscesses, though most are small and low quality. A 2013
meta-analysis, which pooled the results of the 12 highest quality studies and
focused in particular on MRSA infections, found no evidence of benefit with antibiotics.2
The 2014 Infectious Disease Society of America (IDSA) guidelines on skin and
soft tissue infection treatment emphasise that providing good surgical drainage
is the most important treatment for uncomplicated skin abscesses.3 The
guidelines recommend reserving adjunctive antibiotics for complicated
infections, defined as those with fever or toxicity, greater than 5 cm of
surrounding cellulitis, or occurring in an immunocompromised host. Nonetheless,
in an international poll of physicians who were given a hypothetical case of an
uncomplicated skin abscess that had undergone I&D, only 31% voted for
withholding adjunctive antibiotics. Respondents from North America were much
more likely to give antibiotics than those from Europe.4
It was in this setting—with a recent increase in CA-MRSA
skin abscesses, a lack of quality evidence on the benefit of antibiotics and
wide variation in practice—that in 2009, with funding from the U.S. National
Institutes of Health, two large, multicentre, randomised controlled trials were
undertaken to investigate the effect of off-patent antibiotics on uncomplicated
skin abscesses.
The first to be published was by Talan et al, in 2016.5 It
enrolled 1247 subjects 12 years of age or older with simple cutaneous abscesses
(eg, less than 1% were febrile)
that yielded pus on surgical exploration and were treated as outpatients.
Subjects were randomized…
Full-text (free): http://emj.bmj.com/content/35/4/277.long
21. Effect of Opioid vs Nonopioid Medications on Pain-Related
Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain:
The SPACE RCT.
Krebs EE, et al. JAMA.
2018 Mar 6;319(9):872-882.
IMPORTANCE: Limited
evidence is available regarding long-term outcomes of opioids compared with
nonopioid medications for chronic pain.
OBJECTIVE: To compare
opioid vs nonopioid medications over 12 months on pain-related function, pain
intensity, and adverse effects.
DESIGN, SETTING, AND
PARTICIPANTS: Pragmatic, 12-month, randomized trial with masked outcome
assessment. Patients were recruited from Veterans Affairs primary care clinics
from June 2013 through December 2015; follow-up was completed December 2016.
Eligible patients had moderate to severe chronic back pain or hip or knee
osteoarthritis pain despite analgesic use. Of 265 patients enrolled, 25
withdrew prior to randomization and 240 were randomized.
INTERVENTIONS: Both
interventions (opioid and nonopioid medication therapy) followed a
treat-to-target strategy aiming for improved pain and function. Each
intervention had its own prescribing strategy that included multiple medication
options in 3 steps. In the opioid group, the first step was immediate-release
morphine, oxycodone, or hydrocodone/acetaminophen. For the nonopioid group, the
first step was acetaminophen (paracetamol) or a nonsteroidal anti-inflammatory
drug. Medications were changed, added, or adjusted within the assigned
treatment group according to individual patient response.
MAIN OUTCOMES AND
MEASURES: The primary outcome was pain-related function (Brief Pain Inventory
[BPI] interference scale) over 12 months and the main secondary outcome was
pain intensity (BPI severity scale). For both BPI scales (range, 0-10; higher
scores = worse function or pain intensity), a 1-point improvement was
clinically important. The primary adverse outcome was medication-related
symptoms (patient-reported checklist; range, 0-19).
RESULTS: Among 240
randomized patients (mean age, 58.3 years; women, 32 [13.0%]), 234 (97.5%)
completed the trial. Groups did not significantly differ on pain-related function
over 12 months (overall P = .58); mean 12-month BPI interference was 3.4 for
the opioid group and 3.3 for the nonopioid group (difference, 0.1 [95% CI, -0.5
to 0.7]). Pain intensity was significantly better in the nonopioid group over
12 months (overall P = .03); mean 12-month BPI severity was 4.0 for the opioid
group and 3.5 for the nonopioid group (difference, 0.5 [95% CI, 0.0 to 1.0]).
Adverse medication-related symptoms were significantly more common in the
opioid group over 12 months (overall P = .03); mean medication-related symptoms
at 12 months were 1.8 in the opioid group and 0.9 in the nonopioid group
(difference, 0.9 [95% CI, 0.3 to 1.5]).
CONCLUSIONS AND
RELEVANCE: Treatment with opioids was not superior to treatment with nonopioid
medications for improving pain-related function over 12 months. Results do not
support initiation of opioid therapy for moderate to severe chronic back pain
or hip or knee osteoarthritis pain.
22. Steroids for Septic Shock: Are These RCTs Contradictory?
A. Adjunctive Glucocorticoid Therapy Unhelpful 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.
B. Hydrocortisone
plus Fludrocortisone for Adults with Septic Shock
Annane E, et al. N
Engl J Med. 2018;
BACKGROUND
Septic shock is
characterized by dysregulation of the host response to infection, with
circulatory, cellular, and metabolic abnormalities. We hypothesized that
therapy with hydrocortisone plus fludrocortisone or with drotrecogin alfa
(activated), which can modulate the host response, would improve the clinical
outcomes of patients with septic shock.
METHODS
In this multicenter,
double-blind, randomized trial with a 2-by-2 factorial design, we evaluated the
effect of hydrocortisone-plus-fludrocortisone therapy, drotrecogin alfa
(activated), the combination of the three drugs, or their respective placebos.
The primary outcome was 90-day all-cause mortality. Secondary outcomes included
mortality at intensive care unit (ICU) discharge and hospital discharge and at
day 28 and day 180 and the number of days alive and free of vasopressors,
mechanical ventilation, or organ failure. After drotrecogin alfa (activated)
was withdrawn from the market, the trial continued with a two-group parallel
design. The analysis compared patients who received hydrocortisone plus
fludrocortisone with those who did not (placebo group).
RESULTS
Among the 1241
patients included in the trial, the 90-day mortality was 43.0% (264 of 614
patients) in the hydrocortisone-plus-fludrocortisone group and 49.1% (308 of
627 patients) in the placebo group (P=0.03). The relative risk of death in the
hydrocortisone-plus-fludrocortisone group was 0.88 (95% confidence interval,
0.78 to 0.99). Mortality was significantly lower in the hydrocortisone-plus-fludrocortisone
group than in the placebo group at ICU discharge (35.4% vs. 41.0%, P=0.04),
hospital discharge (39.0% vs. 45.3%, P=0.02), and day 180 (46.6% vs. 52.5%,
P=0.04) but not at day 28 (33.7% and 38.9%, respectively; P=0.06). The number
of vasopressor-free days to day 28 was significantly higher in the
hydrocortisone-plus-fludrocortisone group than in the placebo group (17 vs. 15
days, P less than 0.001), as was the number of organ-failure–free days (14 vs.
12 days, P=0.003). The number of ventilator-free days was similar in the two
groups (11 days in the hydrocortisone-plus-fludrocortisone group and 10 in the
placebo group, P=0.07). The rate of serious adverse events did not differ
significantly between the two groups, but hyperglycemia was more common in hydrocortisone-plus-fludrocortisone
group.
CONCLUSIONS
In this trial
involving patients with septic shock, 90-day all-cause mortality was lower
among those who received hydrocortisone plus fludrocortisone than among those
who received placebo.
23. Micro Bits
A. Association of
Varicose Veins With Incident Venous Thromboembolism and Peripheral Artery
Disease
B. Television Format
and Children’s Executive Function
Theories regarding the
impact of media on development can largely be grouped into content-based and
content-independent categories.1 Content-based theories argue that the impact
of media on aspects of development differs depending on content. For example,
media that involve prosocial themes (eg, helping) may positively impact
children’s behavior, whereas media that involve violence have the potential to
negatively impact behavior. Content-independent theories argue that many of the
impacts of media occur irrespective of the content children are exposed to. For
example, irrespective of content, viewing media may displace other activities
(eg, reading) that positively contribute to children’s intellectual
development. A third theory that contains both content-based and
content-independent elements is based on media form. Briefly, form-based
theories argue that specific features of media may negatively impact children’s
behavior. Although form-based theories are generally classified as
content-independent,1 many forms commonly intersect with certain types of
content.
Concerns regarding
form have largely focused on the pace of media (ie, the frequency of scene
changes or cuts) and the impact pacing may have on aspects of executive
function (EF). EF comprises a number of skills, including self-regulation,
working memory, and problem solving. Empirical investigations of the potential
link between pace and EF can be traced back …
C. Prices, not
utilization, explain high health care spending in US
An analysis of data
from 2013 to 2016 comparing 11 high-income nations showed the US spends almost
twice as much as other wealthy countries on health care, but it had the lowest
life expectancy and highest infant death rates of the group. The study, published
in the Journal of the American Medical Association, found utilization of care
in the US is similar to that of other countries, but administrative costs and
prices for prescription drugs and medical services are substantially higher in
the US.
NY Times: https://www.nytimes.com/2018/03/13/upshot/united-states-health-care-resembles-rest-of-world.html
Study title: Health
Care Spending in the United States and Other High-Income Countries.
CONCLUSIONS AND
RELEVANCE: The United States spent approximately twice as much as other
high-income countries on medical care, yet utilization rates in the United
States were largely similar to those in other nations. Prices of labor and
goods, including pharmaceuticals, and administrative costs appeared to be the
major drivers of the difference in overall cost between the United States and
other high-income countries. As patients, physicians, policy makers, and
legislators actively debate the future of the US health system, data such as
these are needed to inform policy decisions.
D. Frequency and
Magnitude of Co-payments Exceeding Prescription Drug Costs
E. Suicide: The
Leading Cause of Violent Death
Kuehn N. JAMA.
2018;319(10):973.
Suicide was the
leading cause of violent death in the United States accounting for 14 834
(65.6%) of violent deaths in 2014, according to a recent report from the CDC.
F. Characterizing
Kaiser Permanente Southern California’s Experience With the California End of
Life Option Act in the First Year of Implementation
G. Kick Butts Day,
March 21: Campaign for Tobacco-Free Kids Initiative
H. ER Goddess: Nagging
Means ‘We Love You’
Simons SS. Emerg Med News.
2018;40(3):22
To our children,
No matter how old you
get or how far away you go, we will always worry about you with a neurosis
unique to EP parents. Raising kids these days is stressful enough without
nightmares at work planting extra seeds of angst. Constantly seeing bad
outcomes makes us more aware of worst-case scenarios. Being an EP means
harboring an incessant fear that these worst-case scenarios will happen to you.
We're not so neurotic
that we worry when we see once-in-a-career cases. We've never imagined you
being injured by a killer whale or while knitting….
The rest of the essay:
https://journals.lww.com/em-news/Fulltext/2018/03000/ER_Goddess__Nagging_Means__We_Love_You_.14.aspx
I. What are the most
dangerous animals? Sharks? Lions? Snakes?
People killed by
animals were most often attacked by bees, hornets and dogs, a new analysis
finds.
J. Women more likely
to have mental stress-induced myocardial ischemia
After myocardial
infarction, women had about twice the rate of mental stress-induced myocardial
ischemia and ischemia with conventional stress, compared with men, according to
a study in the special Go Red for Women issue of the journal Circulation.
"Microvascular dysfunction and peripheral vasoconstriction with mental
stress are implicated in MSIMI among women but not among men, perhaps reflecting
women's proclivity toward ischemia because of microcirculatory
abnormalities," researchers wrote.
K. AMA report shows
34% of physicians have had a liability claim
An American Medical
Association report found 34% of physicians have had a medical liability claim
filed against them, with the likelihood of getting sued increasing with age.
AMA President David Barbe said even though most claims are dropped or
dismissed, the cost of litigation still extracts a significant toll at a time
when the US health care system is trying to reduce unnecessary costs.
Article: https://wire.ama-assn.org/practice-management/1-3-physicians-has-been-sued-age-55-1-2-hit-suit
L. Early childhood TBI may increase later odds of ADHD
A study in JAMA Pediatrics showed that young children with
severe traumatic brain injury at ages 3 to 7 had a 3.6 times increased
likelihood of developing attention-deficit/hyperactivity disorder when they
reached middle school, compared with those who had orthopedic injuries at the
same age, but those with mild or moderate TBI did not have an increased ADHD
risk. The findings also showed an increased ADHD risk among those whose mothers
had lower educational attainment and those with TBI who lived in dysfunctional
families.
M. Hunger Pangs Quashed With Percutaneous Nerve Freezing: Reduced weight, appetite 90 days after cryoablation in
pilot study
