Thursday, March 22, 2018

Lit Bits: Mar 22, 2018

From the recent medical literature...


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…

The remainder requires subscription: http://www.bmj.com/content/360/bmj.k988

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."



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.


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


Mattu’s discussion: Medscape (requires registration): https://www.medscape.com/viewarticle/891270

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…


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.


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….


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.


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