1. Clinical Trial of Fluid Infusion Rates for Pediatric DKA
Kuppermann
N, et al. N Engl J Med. 2018;378:2275-2287.
BACKGROUND
Diabetic
ketoacidosis in children may cause brain injuries ranging from mild to severe.
Whether intravenous fluids contribute to these injuries has been debated for
decades.
METHODS
We
conducted a 13-center, randomized, controlled trial that examined the effects
of the rate of administration and the sodium chloride content of intravenous
fluids on neurologic outcomes in children with diabetic ketoacidosis. Children
were randomly assigned to one of four treatment groups in a 2-by-2 factorial
design (0.9% or 0.45% sodium chloride content and rapid or slow rate of
administration). The primary outcome was a decline in mental status (two
consecutive Glasgow Coma Scale scores of less than 14, on a scale ranging from
3 to 15, with lower scores indicating worse mental status) during treatment for
diabetic ketoacidosis. Secondary outcomes included clinically apparent brain
injury during treatment for diabetic ketoacidosis, short-term memory during
treatment for diabetic ketoacidosis, and memory and IQ 2 to 6 months after
recovery from diabetic ketoacidosis.
RESULTS
A
total of 1389 episodes of diabetic ketoacidosis were reported in 1255 children.
The Glasgow Coma Scale score declined to less than 14 in 48 episodes (3.5%),
and clinically apparent brain injury occurred in 12 episodes (0.9%). No
significant differences among the treatment groups were observed with respect
to the percentage of episodes in which the Glasgow Coma Scale score declined to
below 14, the magnitude of decline in the Glasgow Coma Scale score, or the
duration of time in which the Glasgow Coma Scale score was less than 14; with
respect to the results of the tests of short-term memory; or with respect to
the incidence of clinically apparent brain injury during treatment for diabetic
ketoacidosis. Memory and IQ scores obtained after the children’s recovery from
diabetic ketoacidosis also did not differ significantly among the groups.
Serious adverse events other than altered mental status were rare and occurred
with similar frequency in all treatment groups.
CONCLUSIONS
Neither
the rate of administration nor the sodium chloride content of intravenous
fluids significantly influenced neurologic outcomes in children with diabetic
ketoacidosis.
Michelle
Lin at ALiEM summarize the trial and undertook an interview with Kuppermann and
Glaser, study co-authors, here: https://www.aliem.com/2018/06/pem-practice-changing-paper-clinical-trial-fluid-infusion-rates-pediatric-dka/
2. Effect of Use of a Bougie vs Endotracheal Tube and Stylet on
First-Attempt Intubation Success Among Pts with Difficult Airways Undergoing
Emergency Intubation: A Randomized Clinical Trial.
Driver
BE, et al. JAMA. 2018 Jun 5;319(21):2179-2189.
IMPORTANCE:
The
tracheal tube introducer, known as the bougie, is typically used to aid
tracheal intubation in poor laryngoscopic views or after intubation attempts
fail. The effect of routine bougie use on first-attempt intubation success is
unclear.
OBJECTIVE:
To
compare first attempt intubation success facilitated by the bougie vs the
endotracheal tube + stylet.
DESIGN,
SETTING, AND PATIENTS:
The
Bougie Use in Emergency Airway Management (BEAM) trial was a randomized
clinical trial conducted from September 2016 through August 2017 in the
emergency department at Hennepin County Medical Center, an urban, academic
department in Minneapolis, Minnesota, where emergency physicians perform all
endotracheal intubations. Included patients were 18 years and older who were
consecutively admitted to the emergency department and underwent emergency
orotracheal intubation with a Macintosh laryngoscope blade for respiratory
arrest, difficulty breathing, or airway protection.
INTERVENTIONS:
Patients
were randomly assigned to undergo the initial intubation attempt facilitated by
bougie (n = 381) or endotracheal tube + stylet (n = 376).
MAIN
OUTCOMES AND MEASURES:
The
primary outcome was first-attempt intubation success in patients with at least
1 difficult airway characteristic (body fluids obscuring the laryngeal view,
airway obstruction or edema, obesity, short neck, small mandible, large tongue,
facial trauma, or the need for cervical spine immobilization). Secondary
outcomes were first-attempt success in all patients, first-attempt intubation
success without hypoxemia, first-attempt duration, esophageal intubation, and
hypoxemia.
RESULTS:
Among
757 patients who were randomized (mean age, 46 years; women, 230 [30%]), 757
patients (100%) completed the trial. Among the 380 patients with at least 1
difficult airway characteristic, first-attempt intubation success was higher in
the bougie group (96%) than in the endotracheal tube + stylet group (82%)
(absolute between-group difference, 14% [95% CI, 8% to 20%]). Among all patients,
first-attempt intubation success in the bougie group (98%) was higher than the
endotracheal tube + stylet group (87%) (absolute difference, 11% [95% CI, 7% to
14%]). The median duration of the first intubation attempt (38 seconds vs 36
seconds) and the incidence of hypoxemia (13% vs 14%) did not differ
significantly between the bougie and endotracheal tube + stylet groups.
CONCLUSIONS
AND RELEVANCE:
In
this emergency department, use of a bougie compared with an endotracheal
tube + stylet resulted in significantly higher first-attempt intubation success
among patients undergoing emergency endotracheal intubation. However, these
findings should be considered provisional until the generalizability is
assessed in other institutions and settings.
Full-text
(free): https://emergencymedicinecases.com/wp-content/uploads/2018/05/jama_Driver_2018_oi_180054.pdf
See
also: EM Cases Episode 110 – Airway
Pitfalls Live from EMU 2018.
The
last decade has seen a torrent of literature and expert opinion on emergency
airway management. It is challenging to integrate all this new information into
a seamless flow when faced with a challenging airway situation. In this live
podcast recorded at North York General’s Emergency Medicine Update Conference
2018, Scott Weingart and Anton Helman put together the latest in emergency
airway management by outlining 6 common airway pitfalls: Failure to prepare for
failure, failure to position the patient properly, failure to optimize
oxygenation, failure to optimize hemodynamics, failure to consider an awake
intubation and failure to prepare for a cricothyrotomy…
3. Specific Viruses Tied to Asthma Treatment Failure in Kids
Veronica
Hackethal, MD. Medscape, June 04, 2018
Children
with moderate to severe asthma exacerbations who are also infected with
respiratory viruses, and especially respiratory syncytial virus, influenza, and
parainfluenza, are at increased risk of not responding to asthma treatments,
according to results published online today in Pediatrics.
The
results come from the largest study of its kind and suggest children with
moderate to severe asthma exacerbations may need a different workup and more
intense management.
About
60% to 80% of asthma exacerbations are triggered by respiratory pathogens, but
until now, researchers haven't known exactly which pathogens cause the problem.
"This
is the first time we've been able to disentangle the risk of non-response to
asthma treatment with the presence of specific viruses — specifically,
influenza and rhinovirus. The more than 20-per-cent higher absolute risk of
treatment failure in flu cases is very significant," senior author
Caroline Quach, MD, said in a press release. Quach is chair of the Quebec
Immunization Committee, chair of the National Advisory Committee on
Immunization of the Public Health Agency of Canada, and affiliated with McGill
University and the University of Montreal.
The
results also highlight the importance of prevention, using the influenza
vaccine. The authors encouraged easy access to vaccination at the point of care
in asthma, respiratory, and general pediatric clinics.
"These
kids should get their flu shot and they should get it systematically — it's
worth it," study coauthor Francine Ducharme, MD, from the University of
Montreal, Quebec, Canada, said in the news release.
"We
now know that if these kids get the flu the risks are very high that emergency
treatment for an asthma attack will fail," she added. "Instead of
having an overall 17-per-cent risk of treatment failure, with flu their risk
rises to almost 40 per cent."
Respiratory Viruses
and Treatment Failure in Children with Asthma Exacerbation
Merckx
J, et al. Pediatrics 2018 June 04 [Epub ahead of print]
OBJECTIVES:
Respiratory pathogens commonly trigger pediatric asthma exacerbations, but
their impact on severity and treatment response remains unclear.
METHODS:
We performed a secondary analysis of the Determinants of Oral Corticosteroid
Responsiveness in Wheezing Asthmatic Youth (DOORWAY) study, a prospective
cohort study of children (aged 1–17 years) presenting to the emergency
department with moderate or severe exacerbations. Nasopharyngeal specimens were
analyzed by RT-PCR for 27 respiratory pathogens. We investigated the
association between pathogens and both exacerbation severity (assessed with the
Pediatric Respiratory Assessment Measure) and treatment failure (hospital
admission, emergency department stay over 8 hours, or relapse) of a
standardized severity-specific treatment. Logistic multivariate regressions
were used to estimate average marginal effects (absolute risks and risk
differences [RD]).
RESULTS:
Of 958 participants, 61.7% were positive for ≥1 pathogen (rhinovirus was the
most prevalent [29.4%]) and 16.9% experienced treatment failure. The presence
of any pathogen was not associated with higher baseline severity but with a
higher risk of treatment failure (20.7% vs 12.5%; RD = 8.2% [95% confidence
interval: 3.3% to 13.1%]) compared to the absence of a pathogen. Nonrhinovirus
pathogens were associated with an increased absolute risk (RD) of treatment failure
by 13.1% (95% confidence interval: 6.4% to 19.8%), specifically, by 8.8% for
respiratory syncytial virus, 24.9% for influenza, and 34.1% for parainfluenza.
CONCLUSIONS:
Although respiratory pathogens were not associated with higher severity on
presentation, they were associated with increased treatment failure risk,
particularly in the presence of respiratory syncytial virus, influenza, and
parainfluenza. This supports influenza prevention in asthmatic children,
consideration of pathogen identification on presentation, and exploration of
treatment intensification for infected patients at higher risk of treatment
failure.
4. Systematic Reviews from Acad Emerg Med.
A. Excited Delirium: A Systematic Review.
Gonin
P, et al. Acad Emerg Med. 2018;25(5):552-565.
OBJECTIVE:
We
aimed to clarify the definition, epidemiology, and pathophysiology of excited
delirium syndrome (ExDS) and to summarize evidence-based treatment
recommendations.
METHODS:
We
conducted a systematic literature search of MEDLINE, Ovid, Web of Knowledge,
and Cochrane Library for articles published to March 18, 2017. We also searched
the gray literature (Google Scholar) and official police or medical expert
reports to complete specific epidemiologic data. Search results and full-text
articles were independently assessed by two investigators and agreements
between reviewers assessed with K statistics. We classified articles by study
type, setting, and evidence level.
RESULTS:
After
reviewing the title and abstract of 3,604 references, we fully reviewed 284
potentially relevant references, from which 66 were selected for final review.
Six contributed to the definition of ExDS, 24 to its epidemiology, 38 to its
pathophysiology, and 27 to its management. The incidence of ExDS varies widely
with medical or medicolegal context. Mortality is estimated to be as much as
8.3% to 16.5%. Patients are predominantly male. Male sex, young age,
African-American race, and being overweight are independent risk factors.
Pathophysiology hypotheses mostly implicate dopaminergic pathways. Most cases
occur with psychostimulant use or among psychiatric patients or both. Proposed
treatments are symptomatic, often with rapid sedation with benzodiazepines or
antipsychotic agents. Ketamine is suggested as an alternative.
CONCLUSION:
The
overall quality of studies was poor. A universally recognized definition is
lacking, remaining mostly syndromic and based on clinical subjective criteria.
High mortality rate may be due to definition inconsistency and reporting bias.
Our results suggest that ExDS is a real clinical entity that still kills people
and that has probably specific mechanisms and risk factors. No comparative
study has been performed to conclude whether one treatment approach is
preferable to another in the case of ExDS.
B. Homelessness and Emerg Med: A Review of the
Literature
Salhi
BA, et al. Acad Emerg Med. 2018;25(5):577-593.
OBJECTIVES:
We
aimed to synthesize the available evidence on the demographics, prevalence,
clinical characteristics, and evidence-based management of homeless persons in
the emergency department (ED). Where appropriate, we highlight knowledge gaps
and suggest directions for future research.
METHODS:
We
conducted a systematic literature search following databases: PubMed, Ovid, and
Google Scholar for articles published between January 1, 1990, and December 31,
2016. We supplemented this search by cross-referencing bibliographies of the
retrieved publications. Peer-reviewed studies written in English and conducted
in the United States that examined homelessness within the ED setting were
included. We used a qualitative approach to synthesize the existing literature.
RESULTS:
Twenty-eight
studies were identified that met the inclusion criteria. Based on our study
objectives and the available literature, we grouped articles examining homeless
populations in the ED into four broad categories: 1) prevalence and sociodemographic
characteristics of homeless ED visits, 2) ED utilization by homeless adults, 3)
clinical characteristics of homeless ED visits, and 4) medical education and
evidence-based management of homeless ED patients.
CONCLUSION:
Homelessness
may be underrecognized in the ED setting. Homeless ED patients have distinct
care needs and patterns of ED utilization that are unmet by the current
disease-oriented and episodic models of emergency medicine. More research is
needed to determine the prevalence and characteristics of homelessness in the
ED and to develop evidence-based treatment strategies in caring for this
vulnerable population.
C. Protocolized Laboratory Screening for the Medical
Clearance of Psychiatric Patients in the ED: A Systematic Review.
Conigliaro
A, et al. Acad Emerg Med. 2018;25(5):566-576.
OBJECTIVE:
Emergency
department (ED) patients with psychiatric chief complaints undergo medical
screening to rule out underlying or comorbid medical illnesses prior to
transfer to a psychiatric facility. This systematic review attempts to
determine the clinical utility of protocolized laboratory screening for the
streamlined medical clearance of ED psychiatric patients by determining the
clinical significance of individual laboratory results.
METHODS:
We
searched PubMed, Embase, and Scopus using the search terms "emergency
department, psychiatry, diagnostic tests, laboratories, studies, testing,
screening, and clearance" up to June 2017 for studies on adult psychiatric
patients. This systematic review follows the recommendations of Meta-analysis
of Observational Studies in Epidemiology (MOOSE) statement. The quality of each
study was rated according to the Newcastle-Ottawa quality assessment scale.
RESULTS:
Four
independent reviewers identified 2,847 publications. We extracted data from
three studies (n = 629 patients). Included studies defined an abnormal test
result as any laboratory result that falls out of the normal range. A
laboratory test result was deemed as "clinically significant" only
when patient disposition or treatment plan was changed because of that test
result. Across the three studies the prevalence of clinically significant
results were low (0.0%-0.4%).
CONCLUSIONS:
The
prevalence of clinically significant laboratory test results were low,
suggesting that according to the available literature, routine laboratory
testing does not significantly change patient disposition. Due to the paucity
of available research on this subject, we could not determine the clinical
utility of protocolized laboratory screening tests for medical clearance of
psychiatric patients in the ED. Future research on the utility of routine
laboratory testing is important in a move toward shared decision making and
patient-centered health care.
5. Physicians Experience Highest Suicide Rate of Any Profession
Pauline
Anderson. Medscape. May 07, 2018
NEW
YORK — With one completed suicide every day, US physicians have the highest
suicide rate of any profession. In addition, the number of physician suicides
is more than twice that of the general population, new research shows.
A
systematic literature review of physician suicide shows that the suicide rate
among physicians is 28 to 40 per 100,000, more than double that in the general
population.
Physicians
who die by suicide often suffer from untreated or undertreated depression or
other mental illnesses, a fact that underscores the need for early
intervention, study investigator Deepika Tanwar, MD, Psychiatric Program,
Harlem Hospital Center, New York City, told Medscape Medical News.
"It's
very surprising" that the suicide rate among physicians is higher than
among those in the military, which is considered a very stressful occupation,
Tanwar told Medscape Medical News.
The
findings were presented here at the American Psychiatric Association (APA) 2018
annual meeting.
Stigma,
Access to Lethal Means
Using
MEDLINE and PubMed, the investigators conducted a systematic literature review
of physician suicide that included articles published in peer-reviewed journals
during the past 10 years.
The
review showed that the physician suicide rate was 28 to 40 per 100,000; in the
general population, the overall rate was 12.3 per 100,000.
The
results also showed that although female physicians attempt suicide far less
often than women in the general population, the completion rate for female
physicians exceeds that of the general population by 2.5 to 4 times and equals
that of male physicians.
Experts
are trying to understand why physician suicide rates are so high, said Tanwar.
She pointed out that their review shows that some of the most common diagnoses
were mood disorders, alcoholism, and substance abuse.
One
study showed that depression affects an estimated 12% of male physicians and up
to 19.5% of female physicians, a prevalence that is on par with that of the
general population.
Depression
is more common in medical students and residents, with 15% to 30% screening
positive for depressive symptoms.
6. Feeding Children Honey After They Swallow A Small Battery Can
Prevent Serious Injury
Anfang
RR, et al. pH‐neutralizing esophageal irrigations as a novel mitigation
strategy for button battery injury. Laryngoscope 2018 June 7 [Epub ahead of
print].
Objectives/Hypothesis
Ingestion
of button batteries (BB) can rapidly lead to caustic esophageal injury in
infants and children, resulting in significant morbidity and mortality. To
identify novel mitigation strategies, we tested common weakly acidic household
beverages, viscous liquids, and Carafate® for their ability to act as
protective esophageal irrigations until endoscopic removal of the BB.
Study
Design
Cadaveric
and live animal model.
Methods
Apple
juice, orange juice, Gatorade®, POWERADE®, pure honey, pure maple syrup, and
Carafate® were screened using a 3 V lithium (3 V‐CR2032) BB on cadaveric
porcine esophagus. The most promising in vitro options were tested against a
saline control in live American Yorkshire piglets with anode‐facing placement
of the BB on the posterior wall of the proximal esophagus for 60 minutes. BB
voltage and tissue pH were measured before battery placement and after removal.
The 10 mL irrigations occurred every 10 minutes from t = 5 minutes. Gross and
histologic assessment was performed on the esophagus of piglets euthanized
7 ± 0.5 days following BB exposure.
Results
Honey
and Carafate® demonstrated to a significant degree the most protective effects
in vitro and in vivo. Both neutralized the tissue pH increase and created more
localized and superficial injuries; observed in vivo was a decrease in both
full‐thickness injury (i.e., shallower depths of necrotic and granulation
tissue) and outward extension of injury in the deep muscle beyond surface ulcer
margins (P less than .05).
Conclusions
Ingestion
of honey in the household setting and Carafate® in the clinical setting has the
potential to reduce injury severity and improve patient outcomes.
7. Adjunct Ketamine Improves Delirium Tremens Management
Pizon
AF, et al. Adjunct Ketamine Use in the Management of Severe Ethanol Withdrawal.
Crit Care Med. 2018 May 8 [Epub ahead of print].
OBJECTIVES:
Ketamine offers a plausible mechanism with favorable kinetics in treatment of
severe ethanol withdrawal. The purpose of this study is to determine if a
treatment guideline using an adjunctive ketamine infusion improves outcomes in
patients suffering from severe ethanol withdrawal.
DESIGN:
Retrospective observational cohort study.
SETTING:
Academic tertiary care hospital.
PATIENTS:
Patients admitted to the ICU and diagnosed with delirium tremens by Diagnostic
and Statistical Manual of Mental Disorders V criteria.
INTERVENTIONS:
Pre and post guideline, all patients were treated in a symptom-triggered
fashion with benzodiazepines and/or phenobarbital. Postguideline, standard
symptom-triggered dosing continued as preguideline, plus, the patient was
initiated on an IV ketamine infusion at 0.15-0.3 mg/kg/hr continuously until
delirium resolved. Based upon withdrawal severity and degree of agitation, a
ketamine bolus (0.3 mg/kg) was provided prior to continuous infusion in some
patients.
MEASUREMENTS
AND MAIN RESULTS: A total of 63 patients were included (29 preguideline; 34
postguideline). Patients treated with ketamine were less likely to be intubated
(odds ratio, 0.14; p less than 0.01; 95% CI, 0.04-0.49) and had a decreased ICU
stay by 2.83 days (95% CI, -5.58 to -0.089; p = 0.043). For ICU days outcome,
correlation coefficients were significant for alcohol level and total
benzodiazepine dosing. For hospital days outcome, correlation coefficients were
significant for patient age, aspartate aminotransferase, and alanine
aminotransferase level. Regression revealed the use of ketamine was associated
with a nonsignificant decrease in hospital stay by 3.66 days (95% CI, -8.40 to
1.08; p = 0.13).
CONCLUSIONS:
Mechanistically, adjunctive therapy with ketamine may attenuate the
demonstrated neuroexcitatory contribution of N-methyl-D-aspartate receptor
stimulation in severe ethanol withdrawal, reduce the need for excessive
gamma-aminobutyric acid agonist mediated-sedation, and limit associated
morbidity. A ketamine infusion in patients with delirium tremens was associated
with reduced gamma-aminobutyric acid agonist requirements, shorter ICU length
of stay, lower likelihood of intubation, and a trend toward a shorter
hospitalization.
8. And Here’s Why CTCA Is Useless
In the Emergency
Department, that is, at least.
By
Ryan Radecki. EM Lit of Note. June 6,
2018
A
few years ago, there were several major studies evaluating the safety of a CT
coronary angiogram-based study for the evaluation of chest pain in the
Emergency Department. These studies consistently found the CTCA is sensitive
for coronary artery plaque – and, thus, patients with troponin-negative chest
pain syndromes and clear coronary arteries could be discharged from the ED.
The
constant challenge, however, has been specificity – not only with respect to
whether the CT can accurately detect stenoses, but the clinical relevance of
the stenoses. Non-obstructive, moderate, and high-grade stenoses detected on
CTCA all trigger further evaluation – either non-invasive or invasive, with
subsequent interventions of uncertain clinical value.
This
small propensity-matched study from a cohort of 25,251 patients undergoing CTCA
picked out 234 pairs of patients, matching those who had an acute coronary
syndrome during follow-up with those who did not. And, yes, those with ≥50% or
≥70% stenosis were more likely to suffer an ACS, but not my much. The vast
majority – 62% – of those with an ACS in follow-up had non-obstructive coronary
disease. Indeed, just over half of patients with an ACS even had their culprit
lesion identified on the initial CTCA. The degree of stenosis was mildly
predictive of future ACS, but plaque burden between those who suffered an event
and those who did not was similar. The most predictive feature, however, was
composition of non-obstructive plaque, including fibrofatty features and
necrotic core.
This
is why CTCA is unhelpful in the Emergency Department. It does, yes, accurately
detect patients without coronary disease – but this target “low-risk”
population already has such a low pretest likelihood of poor outcome the added
value is nil. Then, the “true positives” from these studies – stenoses and
interventions – are not equivalent to ACS prevented.
Friends
don’t let friends do CTCA in the ED – it doesn’t add value or prevent adverse
outcomes.
Reference:
Chang HJ, et al. Coronary Atherosclerotic Precursors of Acute Coronary
Syndromes. J Am Coll Cardiol. 2018 Jun 5;71(22):2511-2522. http://www.onlinejacc.org/content/71/22/2511
9. Should We Anticoagulate Patients with Isolated Subsegmental PE?
Ali
S. Raja, MD, MBA, MPH. Journal Watch
Not
necessarily, and without evidence to guide us, patients and physicians need to
decide together.
The
widespread use of computed tomography (CT) pulmonary angiography has
facilitated the rapid diagnosis of pulmonary embolism (PE), but sometimes the
only CT abnormality is the presence of one or several subsegmental emboli. Are
these findings clinically important, and is it necessary to anticoagulate
patients with subsegmental emboli? A recent meta-analysis forces us to think
carefully about the management of these patients.
The
meta-analysis included 14 observational studies involving 15,563 symptomatic
patients (NEJM JW Emerg Med Apr 2018 and Acad Emerg Med 2018 Mar 2; [e-pub]).
All patients underwent CT pulmonary angiography for suspected PE and had at
least 30 days of follow-up to assess rates of recurrent PE or deep venous
thrombosis (DVT) and bleeding complications. In the pooled population, the
prevalence of subsegmental PE was 4.6%. Among those with subsegmental PE, there
were no significant differences between anticoagulated patients and
nonanticoagulated patients in incidence of recurrent PE/DVT (5.3% and 3.9%,
respectively) or death (2.1% and 3.0%). However, administration or withholding
of anticoagulation was not randomized, and the incidence of bleeding was only
reported for anticoagulated patients (8.1%). Notably, most of the studies did
not provide information regarding the presence of concurrent DVT at the time of
PE diagnosis, so we don't know whether these subsegmental emboli were truly
isolated or not. The one study that included only patients with isolated
subsegmental PE (i.e., without detectable DVT) showed no difference in
recurrent PE/DVT between patients who were and were not anticoagulated.
To
put these findings in perspective, some background information is worth
considering. Prior to 20 years ago, PE was usually diagnosed by
ventilation-perfusion lung scanning. The landmark 1990 PIOPED study suggested
that patients with subsegmental perfusion defects who were not anticoagulated
had benign clinical outcomes (JAMA 1990; 263:2753). In the 1990s, CT pulmonary
angiography became available, and a 2011 study found that — although the
incidence of diagnosed PE doubled between 1993 and 2006 — mortality associated
with PE remained the same, suggesting that we might be overdiagnosing PE and
possibly overtreating clinically benign cases (NEJM JW Gen Med Jun 15 2011 and
Arch Intern Med 2011; 171:831). In addition, a recent study found that roughly
one quarter of CT pulmonary angiograms initially interpreted as positive might
actually have been false-positive scans, owing in part to various scanning
artifacts; in that study, a majority of false-positive readings involved
subsegmental locations. Yet another often-overlooked question is whether some
subsegmental “emboli” actually represent in situ thrombosis within the
pulmonary artery — as has been postulated, for example, in patients with sickle
cell disease (NEJM JW Gen Med Dec 15 2011 and Am J Respir Crit Care Med 2011;
184:1022).
What
do guidelines say about anticoagulating patients with subsegmental PE? The 2016
guideline from the American College of Chest Physicians suggests “clinical
surveillance over anticoagulation” for patients with subsegmental PE who have
no more-proximal pulmonary artery involvement, no proximal leg DVT, and low
risk for recurrent venous thromboembolism (Chest 2016; 149:315). In contrast,
the guideline suggests “anticoagulation over clinical surveillance” for
patients deemed at high risk for recurrent venous thromboembolism. The authors
acknowledge that the quality of the evidence is low, and that bleeding risk and
patient preferences should play a role. Guidelines from the European Society of
Cardiology state that decisions to treat patients with isolated subsegmental PE
and no proximal DVT “should be made on an individual basis, taking into account
the clinical probability [of PE] and the bleeding risk” (Eur Heart J 2014;
35:3033). And finally, just three months ago, the American College of Emergency
Physicians issued a “Clinical Policy” on management of PE and DVT that included
the following statement: “Given the lack of evidence, anticoagulation treatment
decisions for patients with subsegmental PE without associated DVT should be
guided by individual patient risk profiles and preferences”
(https://www.acep.org/Clinical---Practice-Management/ACEP-Current-Clinical-Policies/#sm.00008dvwz2c45fo2vyb19oa7admy7).
The authors acknowledge that this is a “Level C” recommendation, based on
consensus and not randomized trials.
Wrap
Up
Clinicians
have a strong intuitive desire to anticoagulate all patients with PE; action is
often favored over inaction. But treatment is not without risk, and severe
intracranial and gastrointestinal bleeding complications are especially
regrettable if the original indications for anticoagulation were marginal or
uncertain. Potential bleeding complications should obviously be discussed with
all PE patients who receive anticoagulation, regardless of PE size and
location. However, for patients with isolated subsegmental PE — especially
those we believe to be at high risk for bleeding — we should be willing to
consider observation rather than treatment (after excluding concurrent DVT). In
my view, not anticoagulating is not only as safe as, but perhaps even safer
than, anticoagulation in selected patients with isolated subsegmental PE. In
these cases, patient preferences should be an important element of the shared decision-making
process.
10. Images in Clinical Practice
Tinea Capitis in a Newborn
Retinal Vasculitis in Takayasu’s Arteritis
Severe Vulvovaginal Varicosities in Pregnancy
Pemberton’s Sign in a Patient with a Goiter
Left Main Coronary Artery Aneurysm
Thumbprinting in Ischemic Colitis
Macroglossia in Light-Chain Amyloidosis
11. A Sacred Cow Slaughtered: Eliminating the Glasgow Coma Scale
from Trauma Field Triage
Journal Watch. Daniel J. Pallin, MD, MPH reviewing Hopkins E
et al. Ann Emerg Med 2018 May 2
A large two-center validation study provides good evidence
that “patient does not follow commands” is just as predictive as the
more-complex Glasgow Coma Scale.
A signature contribution of modern prehospital care has been
to regionalize trauma care. Under regionalization, severely injured patients
are not transported to the nearest hospital — instead, they go to the region's
designated trauma center (they are “up-triaged”). But how do prehospital
personnel decide? They use the CDC's Guidelines for Field Triage of Injured
Patients. These guidelines direct prehospital personnel to up-triage when a
patient has a Glasgow Coma Scale (GCS) score of less than 14
or meets one of the other numerous criteria for up-triage.
Because the GCS is a hassle for paramedics to learn and
calculate, investigators have proposed using instead a simpler triage tool: if
an injured person is not following commands, up-triage. Now investigators
report on a two-center validation study comparing the predictive value of this
dichotomous triage tool with that of the full GCS. This analysis of nearly
48,000 trauma patients found that “patient does not follow commands” had the
same predictive value as GCS less than 14
for all studied trauma outcomes, with slightly superior positive likelihood
ratios (e.g., those for mortality, 2.37 vs. 2.13) offsetting slightly inferior
negative ones (e.g., those for mortality, 0.25 vs. 0.24).
COMMENT
Take a look at the Field Triage Guidelines linked above.
They could stump a rocket scientist (or a brain surgeon, for that matter). To
minimize time in the field, the expert panel that owns these guidelines should
simplify them. The first step? Eliminate the Glasgow Coma Scale, and instead
just up-triage if the patient is not following commands.
CDC Guidelines 2011: https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6101a1.htm
Hopkins’ abstract: Ann Emerg Med. 2018 May 2 [Epub ahead of
print].
Study objective
Out-of-hospital personnel worldwide calculate the 13-point
Glasgow Coma Scale (GCS) score as a routine part of field trauma triage. We
wish to independently validate a simpler binary assessment to replace the GCS
for this task.
Methods
We analyzed trauma center registries from Loma Linda
University Health (2003 to 2015) and Denver Health Medical Center (2009 to
2015) to compare the binary assessment “patient does not follow commands” (ie,
GCS motor score less
than 6) with GCS score less than or equal to 13 for the
prediction of 5 trauma outcomes: emergency intubation, clinically significant
brain injury, need for neurosurgical intervention, Injury Severity Score
greater than 15, and mortality. As a secondary analysis, we similarly evaluated
3 other measures simpler than the GCS: GCS motor score less than 5, Simplified
Motor Score, and the “alert, voice, pain, unresponsive” scale.
Results
In this analysis of 47,973 trauma patients, we found that
the binary assessment “patient does not follow commands” was essentially
identical to GCS score less than or equal to 13 for the prediction of all 5
trauma outcomes, with slightly superior positive likelihood ratios (eg, those
for mortality 2.37 versus 2.13) offsetting slightly inferior negative ones (eg,
those for mortality 0.25 versus 0.24) and its graphic depiction of sensitivity
versus specificity superimposing the GCS prediction curve. We found similar
results for the 3 other simplified measures.
Conclusion
In this 2-center external validation, we confirmed that a
simple binary assessment—“patient does not follow commands”—could effectively
replace the more complicated GCS for field trauma triage.
12. Clopidogrel and Aspirin in Acute Ischemic Stroke and
High-Risk TIA
Johnston SC, et al. N Engl J Med. 2018 May 16 [Epub ahead of
print]
Background Combination antiplatelet therapy with clopidogrel
and aspirin may reduce the rate of recurrent stroke during the first 3 months
after a minor ischemic stroke or transient ischemic attack (TIA). A trial of
combination antiplatelet therapy in a Chinese population has shown a reduction
in the risk of recurrent stroke. We tested this combination in an international
population.
Methods In a randomized trial, we assigned patients with
minor ischemic stroke or high-risk TIA to receive either clopidogrel at a
loading dose of 600 mg on day 1, followed by 75 mg per day, plus aspirin (at a
dose of 50 to 325 mg per day) or the same range of doses of aspirin alone. The
dose of aspirin in each group was selected by the site investigator. The
primary efficacy outcome in a time-to-event analysis was the risk of a
composite of major ischemic events, which was defined as ischemic stroke,
myocardial infarction, or death from an ischemic vascular event, at 90 days.
Results A total of 4881 patients were enrolled at 269
international sites. The trial was halted after 84% of the anticipated number
of patients had been enrolled because the data and safety monitoring board had
determined that the combination of clopidogrel and aspirin was associated with
both a lower risk of major ischemic events and a higher risk of major
hemorrhage than aspirin alone at 90 days. Major ischemic events occurred in 121
of 2432 patients (5.0%) receiving clopidogrel plus aspirin and in 160 of 2449
patients (6.5%) receiving aspirin plus placebo (hazard ratio, 0.75; 95%
confidence interval [CI], 0.59 to 0.95; P=0.02), with most events occurring
during the first week after the initial event. Major hemorrhage occurred in 23
patients (0.9%) receiving clopidogrel plus aspirin and in 10 patients (0.4%)
receiving aspirin plus placebo (hazard ratio, 2.32; 95% CI, 1.10 to 4.87;
P=0.02).
Conclusions In patients with minor ischemic stroke or
high-risk TIA, those who received a combination of clopidogrel and aspirin had
a lower risk of major ischemic events but a higher risk of major hemorrhage at
90 days than those who received aspirin alone.
Editorial:
What is the take-home message for the clinician?
The evidence from the SAMMPRIS, CHANCE, and POINT trials is
that the combination of aspirin plus clopidogrel reduces the chance of
recurrent ischemic stroke during the high-risk period in the first few weeks
after a TIA or noncardioembolic ischemic stroke. However, to conform to the results of the POINT trial, if dual therapy
is used, it should be confined to the first 3 weeks after a TIA or minor stroke
and then transitioned to monotherapy. If patient follow-up and adherence to
therapy are not reliable, then dual therapy perhaps should not be considered.
Dual therapy may also not be advisable in patients with an uncertain diagnosis
of TIA, who either would have been excluded from the trial or did not benefit.
Finally, patients who are at increased risk for bleeding, such as those with
cerebral microbleeding or a history of brain or systemic bleeding, were
excluded from this trial and may not be appropriate candidates for such dual
therapy. The POINT trial has provided useful data to help us further
personalize our efforts in preventing recurrent stroke.
Full-text (free): https://www.nejm.org/doi/full/10.1056/NEJMe1806043
13. Safety of Lumbar Puncture Performed on Dual Antiplatelet
Therapy.
Carabenciov ID, et al. Mayo Clin Proc. 2018
May;93(5):627-629., Hawkes MA2, Hocker S2.
Practice guidelines generally recommend delaying lumbar
puncture (LP) in patients on dual antiplatelet therapy, with these
recommendations often citing an increased risk of hemorrhagic complications,
specifically the development of epidural hematomas. However, no data exist
about the risks of performing an LP in the setting of dual antiplatelet therapy
and conclusions are often based on data from spinal anesthesia literature.
We reviewed the medical records of 100 patients who
underwent LP while taking dual antiplatelet therapy. We recorded the number of
traumatic and bloody cerebrospinal fluid results as well as the presence of any
complications occurring within 3 months of the procedure. Complications
requiring imaging or hospitalization were considered serious.
The most common complication was back pain, which was
reported by 2 patients, only 1 of which was ultimately found to be attributable
to the procedure. No serious complications occurred. Cerebrospinal fluid
analysis was consistent with a traumatic LP, defined as having at least 100 red
blood cells per microliter, in 8% of cases. Bloody LP, defined as having 1000
red blood cells per microliter, occurred in 4% of cases. The percentage of
traumatic or bloody LPs was within the range reported previously for LPs
performed in any setting.
Although this is a small study and additional review is
necessary, performing LPs in the setting of dual antiplatelet therapy may not
pose an increased risk of serious complications.
14. Effectiveness of a Specialized Brief Intervention for
At-risk Drinkers in an ED: Short-term Results of a RCT
Bruguera P, et al.. Acad Emerg Med. 2018;25(5):517-525.
BACKGROUND:
Screening, Brief Intervention, and Referral to Treatment
(SBIRT) programs have been developed, evaluated, and shown to be effective,
particularly in primary care and general practice. Nevertheless, effectiveness
of SBIRT in emergency departments (EDs) has not been clearly established.
OBJECTIVE:
We aimed to evaluate the feasibility and efficacy of an
SBIRT program conducted by highly specialized professionals in the ED of a
tertiary hospital.
METHODS:
We conducted a randomized controlled trial to study the
feasibility and efficacy of an SBIRT program conducted by alcohol specialists
for at-risk drinkers presenting to the ED, measured with the three-item version
of the Alcohol Use Disorder Identification Test (AUDIT-C). Patients were
randomized to two groups, with the control group receiving two leaflets-one
regarding alcohol use and the other giving information about the study
protocol. The intervention group received the same leaflets as well as a brief
motivational intervention on alcohol use and, where appropriate, a referral to
specialized treatment. The primary outcomes were the proportion of at-risk
alcohol use measured by AUDIT-C scale and the proportion of patients attending
specialized treatment at 1.5 months.
RESULTS:
Of 3,027 patients presenting to the ED, 2,044 (67%) were
potentially eligible to participate, 247 (12%) screened positive for at-risk
drinking, and 200 agreed to participate. Seventy-two percent of the
participating sample were men, and the mean (±SD) age was 43 (±16.7) years.
Follow-up rates were 76.5%. At 1.5 months, the intervention group showed
greater reductions in alcohol consumption and fewer patients continuing with
at-risk alcohol use (27.8% vs. 48.1%; p = 0.01). The SBIRT program also
increased the probability of attending specialized treatment, compared to the
control condition (23% vs. 9.8%, p = 0.0119)
CONCLUSION: The SBIRT program in the ED was found to be
feasible and effective in identifying at-risk drinkers, reducing at-risk
alcohol use, and increasing treatment for alcohol problems.
15. Patients on Opioids OK with Lower Doses
ROBERT PREIDT, HealthDay Reporter. June 8, 2018
Even patients who have taken high doses of opioid
painkillers for long periods of time aren't unhappy with their care when their
doctor lowers their dose, new research suggests.
The study included nearly 2,500 patients with chronic pain
who had been on high doses of opioids for at least six straight months. The
researchers compared patient satisfaction scores between those whose opioid
dose was reduced to the recommended level for at least 30 days and those who
stayed on high doses.
The study found that 86 percent of patients in the
reduced-dose group remained satisfied with their care, and that the likelihood
of a favorable satisfaction rating was higher when opioid doses were reduced by
a patient's regular primary care doctor rather than another doctor.
"Physicians are often concerned they will receive lower
satisfaction scores if they reduce opioids for patients who are accustomed to
high opioid doses to manage chronic pain," said study author Dr. Adam
Sharp, from Kaiser Permanente's Southern California department of research
& evaluation.
"This study showed that following current
recommendations and reducing opioids for chronic pain did not result in lower
satisfaction scores," he added in a Kaiser Permanente news release.
"If you are a physician, you should do the right thing
and you should feel comfortable you will not receive lower patient satisfaction
scores. Our results should reassure physicians and help promote use of
recommended guidelines," Sharp said.
"Even if you are in the small subset of physicians
reducing opioids for people who are not your regular patients, there is still
only a small difference in overall patient satisfaction," he noted.
Sharp said high doses of opioids for chronic pain are more
likely to hurt than benefit patients, and that patients "should be
reassured that your physician wants to follow guidelines designed to improve
your health and well-being."
So, he concluded, "At times, your doctor may be helping
you most by prescribing less."
Sharp AL, Shen E, Wu YL, Wong A, Menchine M, Kanter MH, Gould MK. Satisfaction with
Care After Reducing Opioids for Chronic Pain. Am J Manag Care. 2018;24(6):e196-e199.
Full-text (free): http://www.ajmc.com/journals/issue/2018/2018-vol24-n6/satisfaction-with-care-after-reducing-opioids-for-chronic-pain
16. Readmissions are down, unless you consider rise in
OBSERVATION stays
John Cummins. Health Leaders. MAY 31, 2018.
When the rising numbers of non-admitted patients held for
observation is factored in, declines in readmissions disappear. Are hospitals
trying to skirt readmissions penalties, or are there valid reasons for the
increase in observational status?A study out today in the New England Journal
of Medicine suggests that the much-ballyhooed reduction in hospital
readmissions in recent years all but disappears when researchers factor in the
increase in non-admitted patients being kept for observational stays.
Study co-author Brad Wright, an associate professor of
Health Management and Policy at University of Iowa in Iowa City, spoke with
HealthLeaders Media on the subject.
The following is an edited transcript.
HLM: Does your study mean we've made no progress in lowering
readmissions?
Wright: Yes, more or less. There is still a very small
reduction in readmissions but yeah, you're reading that correctly. But that is
only when we include observation in both components of the calculation. That is
not just looking at people who were hospitalized who bounced back and now we
are putting them all on observation. That takes away some of the reduction in
readmissions but not all of it. It's when you also include the observation
stays as initial index events. That's where the wipe out happens.
HLM: Are hospitals gaming the system?
Wright: I hesitate to say that. It's difficult to say that
from the claims data. It could happen, but more than likely what we are seeing
is simply the result of two different things. One being the increase in the use
of observations, which is happening for a host of reasons alongside the
readmissions reduction program. The argument we are making is not that
hospitals are somehow purposely and malevolently gaming the system. It's just a
confluence of events and these are the implications.
HLM: If it's not gaming, how else could this be explained?
Wright: One piece, and this is gaming of another sort, is
audits from Medicare contractors. If they are denying payments for shorter
inpatient stays that they think are inappropriate and should have been handled
as observations, hospitals obviously don’t want to forego payment. So, there is
pressure to put more patients in observation. From the clinical side, you've
given physicians a space where, as technology has improved, patients who would
have at one time been handled in the inpatient setting can now be handled
appropriately in an outpatient observation setting. The other piece is that you create a space
for physicians to ensure patient safety. Patients in the past would have been
discharged home. You now have created an avenue for them to be kept in the
hospital to rule out potentially life-threatening causes for whatever is going
out with them.
HLM: Given your findings, has this effort to reduce readmissions
been a big waste of time?
Wright…
Full-text (free): https://www.healthleadersmedia.com/clinical-care/readmissions-are-down-unless-you-consider-rise-observation-stays
NEJM editorial (subscription required): https://www.nejm.org/doi/full/10.1056/NEJMp1800732
17. Tranexamic acid for hyperacute primary IntraCerebral
Haemorrhage (TICH-2): an international randomised, placebo-controlled, phase 3
superiority trial
Sprigg N, et al. Lancet. 2018;391(10135): 2107–2115.
BACKGROUND:
Tranexamic acid can prevent death due to bleeding after
trauma and post-partum haemorrhage. We aimed to assess whether tranexamic acid
reduces haematoma expansion and improves outcome in adults with stroke due to
intracerebral haemorrhage.
METHODS:
We did an international, randomised placebo-controlled trial
in adults with intracerebral haemorrhage from acute stroke units at 124
hospital sites in 12 countries. Participants were randomly assigned (1:1) to
receive 1 g intravenous tranexamic acid bolus followed by an 8 h infusion of 1
g tranexamic acid or a matching placebo, within 8 h of symptom onset.
Randomisation was done centrally in real time via a secure website, with
stratification by country and minimisation on key prognostic factors. Treatment
allocation was concealed from patients, outcome assessors, and all other
health-care workers involved in the trial. The primary outcome was functional
status at day 90, measured by shift in the modified Rankin Scale, using ordinal
logistic regression with adjustment for stratification and minimisation
criteria. All analyses were done on an intention-to-treat basis. This trial is
registered with the ISRCTN registry, number ISRCTN93732214.
FINDINGS:
We recruited 2325 participants between March 1, 2013, and
Sept 30, 2017. 1161 patients received tranexamic acid and 1164 received
placebo; the treatment groups were well balanced at baseline. The primary
outcome was assessed for 2307 (99%) participants. The primary outcome,
functional status at day 90, did not differ significantly between the groups
(adjusted odds ratio [aOR] 0·88, 95% CI 0·76-1·03, p=0·11). Although there were
fewer deaths by day 7 in the tranexamic acid group (101 [9%] deaths in the
tranexamic acid group vs 123 [11%] deaths in the placebo group; aOR 0·73,
0·53-0·99, p=0·0406), there was no difference in case fatality at 90 days (250
[22%] vs 249 [21%]; adjusted hazard ratio 0·92, 95% CI 0·77-1·10, p=0·37).
Fewer patients had serious adverse events after tranexamic acid than after
placebo by days 2 (379 [33%] patients vs 417 [36%] patients), 7 (456 [39%] vs
497 [43%]), and 90 (521 [45%] vs 556 [48%]).
INTERPRETATION:
Functional status 90 days after intracerebral haemorrhage
did not differ significantly between patients who received tranexamic acid and
those who received placebo, despite a reduction in early deaths and serious
adverse events. Larger randomised trials are needed to confirm or refute a
clinically significant treatment effect.
Full-text (free): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5976950/
18. World’s First Airport ER Opens At DFW International.
The
Dallas Morning News (6/7, Ortega, 1.05M) reports Dallas Fort Worth
International Airport “is now home to what’s being touted as the first airport
emergency room in the world,” sporting an 8,160-square-foot facility “pitched
by Texas company Code 3 ER and Urgent Care in 2015 and approved by the
airport’s board in 2016.” Open Friday, the facility “has CT scanners, a full
lab, a pharmacy, and X-ray and ultrasound machines.”
19. FDA says don't use OTC teething products that contain
benzocaine
Over-the-counter teething products that contain benzocaine
pose a "serious risk to infants and children" and offer no benefit,
according to an FDA warning. Teething gels, sprays, ointments, solutions and
lozenges that contain benzocaine could cause the fatal blood condition
methemoglobinemia, the FDA said, and the agency is asking manufacturers to stop
marketing the products for pediatric use.
What can we do when our children have symptoms of teething?
Here’s what the American Academy of Pediatrics recommends:
Here’s what the American Academy of Pediatrics recommends:
How to ease your baby’s discomfort: Teething occasionally
may cause mild irritability, crying, a low-grade temperature (but not over 101
degrees Fahrenheit or 38.3 degrees Celsius), excessive drooling, and a desire
to chew on something hard. More often, the gums around the new teeth will swell
and be tender. Try gently rubbing or massaging the gums with one of your
fingers. Teething rings are helpful, too, but they should be made of firm
rubber. (The teethers that you freeze tend to get too hard and can cause more
harm than good.) Pain relievers and medications that you rub on the gums are
not necessary or useful since they wash out of the baby’s mouth within minutes.
Some medication you rub on your child’s gums can even be harmful if too much is
used and the child swallows an excessive amount. Stay away from teething
tablets that contain the plant poison belladonna and gels with benzocaine.
Belladonna and benzocaine are marketed to numb your child's pain, but the FDA
has issued warnings against both due to potential side effects. If your child
seems particularly miserable or has a fever higher than 101 degrees Fahrenheit
(38.3 degrees Celsius), it’s probably not because she’s teething, and you
should consult your pediatrician.
20. Immune Checkpoint Inhibitors, the Most Recent Onc Emergency:
What Emergency Physicians Need to Know
Simmons D, Lang E. Cureus. 2017 Oct 13;9(10):e1774.
Immune checkpoint inhibitors targeting cytotoxic
T-lymphocyte associated protein 4 (CTLA-4) and programmable cell death protein
1 (PD-1)/PD-L1 have shown antitumor activity in cancers such as melanoma,
non-small cell lung cancer, renal cell carcinoma, and urothelial cancer.
Certain checkpoint inhibitors have been approved for use in Canada, and are
becoming a mainstay in the treatment of melanoma and other malignancies.
These drugs have a unique side effect profile and are known
to cause immune-related adverse events (irAEs). These adverse events often
appear to originate from an infectious etiology, when in fact they result from
the enhanced immune response caused by immune checkpoint therapy. IrAEs are
primarily treated with corticosteroids, which suppress the overactive immune
response that is secondary to the treatment. IrAEs can occur in any organ
system, but adverse events in the skin, gastrointestinal, endocrine, and
pulmonary systems are among the most common. As an emergency physician, one
must be familiar with these drugs and their adverse events in order to identify
patients presenting with irAE and treat them accordingly.
This paper provides a brief introduction to immune
checkpoint inhibitors, discusses the most common irAEs relevant to emergency
physicians, and gives suggestions on how to manage patients presenting to the
emergency department (ED) suffering from irAEs.
Full-text (free): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5729030/
See also Pallin DJ, et al. Immune-related Adverse Events in
Cancer Patients. Acad Emerg Med 2018 May 05 [Epub ahead of print].
The U.S. Food and Drug Administration has approved immune
checkpoint inhibitors and chimeric antigen receptor T cells (CAR-T cells) as
immunotherapy strategies for cancer. These
therapies cause a wide variety of adverse events, which mimic other disease
states and may emerge months after completion of treatment. This is important
because ascertaining a past medical history of cancer treatment within the past
year becomes necessary for many presentations. This narrative review
summarizes the biology, pathophysiology, and adverse events associated with
checkpoint inhibitors and CAR-T cells and provides a rational approach to
management. Proper treatment begins with heightened awareness, rapid diagnosis,
and discussion with the patient's oncologist. Treatment of these adverse
effects requires only corticosteroids, infliximab, tocilizumab, or fluids or
vasopressors when clinically indicated.
21. Docs who under-estimate their opioid prescribing can reduce
their prescribing when presented with the data: A RCT
Michael SS, et al. Acad Emerg Med. 2018;25(5):482-493.
OBJECTIVE:
Little is known about accuracy of provider self-perception
of opioid prescribing. We hypothesized that an intervention asking emergency
department (ED) providers to self-identify their opioid prescribing practices
compared to group norms-and subsequently providing them with their actual
prescribing data-would alter future prescribing compared to controls.
METHODS:
This was a prospective, multicenter randomized trial in
which all attending physicians, residents, and advanced practice providers at
four EDs were randomly assigned either to no intervention or to a brief
data-driven intervention during which providers were: 1) asked to self-identify
and explicitly report to research staff their perceived opioid prescribing in
comparison to their peers and 2) then given their actual data with peer group norms
for comparison. Our primary outcome was the change in each provider's
proportion of patients discharged with an opioid prescription at 6 and 12
months. Secondary outcomes were opioid prescriptions per hundred total
prescriptions and normalized morphine milligram equivalents prescribed. Our
primary comparison stratified intervention providers by those who
underestimated their prescribing and those who did not underestimate their
prescribing, both compared to controls.
RESULTS:
Among 109 total participants, 51 were randomized to the
intervention, 65% of whom underestimated their opioid prescribing. Intervention
participants who underestimated their baseline prescribing had larger-magnitude
decreases than controls (Hodges-Lehmann difference = -2.1 prescriptions per
hundred patients at 6 months [95% confidence interval {CI} = -3.9 to -0.5] and
-2.2 per hundred at 12 months [95% CI = -4.8 to -0.01]). Intervention
participants who did not underestimate their prescribing had similar changes to
controls.
CONCLUSIONS:
Self-perception of prescribing was frequently inaccurate.
Providing clinicians with their actual opioid prescribing data after querying
their self-perception reduced future prescribing among providers who
underestimated their baseline prescribing. Our findings suggest that guideline
and policy interventions should directly address the potential barrier of
inaccurate provider self-awareness.
22. Micro Bits
A.
Providing Bias-Free Patient Care is a Journey — Take Your First Steps Today
Unconscious Bias in Clinical Practice is a FREE ACEP-sponsored
online course to help you learn about the physiologic basis of unconscious
bias, discover the negative effects of unconscious bias in clinical scenarios,
and employ strategies to minimize the negative effects of unconscious bias in
clinical care.
B.
Diagnostic accuracy of point-of-care BNP testing for chronic HF in ambulatory care:
systematic review and meta-analysis
C.
Report shows link between obesity, cancer
A World Cancer Research Fund report showed an association between
obesity and an increased risk of 12 cancers, including breast, esophagus,
gallbladder, kidney and liver cancers. The report also recommends being
physically active; limiting consumption of fast food, high-fat products, red
and processed meats, alcohol and sugar; and eating a diet rich in beans, fruit,
whole grains and vegetables to reduce cancer risks.
D.
Research Finds Acupuncture Effective for Chronic Pain
May 21, 2018 — A new meta-analysis published in the Journal
of Pain has found that acupuncture is effective for the treatment of chronic
pain, which may have implications for the way family physicians treat patients
with this condition.
E.
As Paroxysmal Afib Burden Rises, So Does Stroke Risk: Some 'low-risk' patients
may need preventive treatment, data suggest
A greater burden of even intermittent atrial fibrillation
(Afib, or AF) was associated with a significantly higher stroke risk and could
warrant anticoagulation, according to a retrospective study of continuous
ambulatory heart monitoring data.
Compared with paroxysmal Afib patients with the lowest
burden, those in the highest tertile had a more than threefold risk (adjusted
hazard ratio 3.13; 95% CI 1.5-6.56) after adjusting for ATRIA stroke risk
score, reported researchers led by Alan Go, MD, of Kaiser Permanente Northern
California in Oakland.
F.
New Biologics for Asthma: monoclonal antibodies against type 2 inflammation
NEJM editorial: https://www.nejm.org/doi/full/10.1056/NEJMe1806037
The AP (5/17,
Stobbe) says that on Thursday, CDC officials released their annual report on
safe swimming that advises people with diarrhea to stay out of pools, hot tubs,
and water playgrounds. The report highlights outbreaks of stomach bugs from
2000 through 2014 that were linked to swimming or bathing in treated
recreational water spots. According to the report, “in an average year, there
were 15 such outbreaks and about 1,800 related illnesses. Overall, a third were
tied to hotels.” Cryptosporidium caused most of the outbreaks.
On its website, ABC
News (5/17, Strachan, 2.58M) reports that “over half of the
cases were due to a parasite called Cryptosporidium, which causes
gastrointestinal symptoms, like diarrhea, with the infection beginning when
contaminated water is ingested.” Some strains of Cryptosporidium can survive in
chlorinated water for over a week. Between 2000 and 2007, outbreaks related to
Cryptosporidium increased by about 25 percent per year.
CNN (5/17,
Scutti, 80.64M) says on its website that during the 15-year period examined in the
report, a total of 493 outbreaks linked to treated recreational water were
reported in 46 states and Puerto Rico.
H.
CDC: Suicide rate rising in US
The average annual rate of suicide among individuals ages 10
and older in the US rose by 25% between 1999 and 2016, increasing by a low of
6% in Delaware to over 57% in North Dakota, according to a CDC Vital Signs
report. Contributing factors include social isolation, poor access to mental
health care, misuse of drugs and alcohol, and gun ownership; and common
precursors include termination of a relationship, financial problems, substance
abuse and eviction.
I.
Pediatric adenoid, tonsil removal tied to disease risk in adulthood
People who had adenoid or tonsil removal before age 10 were
two to three times as likely to develop upper respiratory tract diseases and
had increased odds of developing allergic and infectious diseases through age
30, researchers reported in JAMA Otolaryngology -- Head & Neck Surgery. The
findings also found a 2% increase in absolute risk of infectious diseases
following adenotonsillectomy.
Full-text in JAMA: https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/2683621
J.
A fresh look at shortsightedness
We want you to read The BMJ, but perhaps it should carry a
health warning. Research published this week includes a worrying finding: more
study worsens eyesight (doi:10.1136/bmj.k2022). Each year spent in education
raised myopic refractive error by an average −0.27 dioptres, the researchers
found.
K.
FDA Approves Lokelma for Hyperkalemia
Troy Brown, RN. May 18, 2018
The US Food and Drug Administration (FDA) has approved
sodium zirconium cyclosilicate (Lokelma, AstraZeneca) — a medication that
rapidly restores normal potassium levels — for adults with hyperkalemia.
Formerly known as ZS-9, the drug is a
"highly-selective, oral potassium-removing agent," the company
explains in a company news release.
"We are pleased by today's FDA approval of Lokelma as
it enables us to help address a long-standing clinical need with a new medicine
that offers rapid and sustained treatment for adults with hyperkalemia. The
consequences of hyperkalemia can be very serious and it's reassuring for
treating physicians that Lokelma has demonstrated lowering of potassium levels
in patients with chronic kidney disease, heart failure, diabetes and those
taking [renin-angiotensin-aldosterone system (RAAS)] inhibitors," Sean
Bohen, MD, PhD, executive vice president, Global Medicines Development, and
chief medical officer, AstraZeneca, said in the news release.
The FDA considered data from three double-blind,
placebo-controlled trials and two open-label trials. The onset of action was at
1 hour and the median time until patients achieved normal serum potassium
levels was 2.2 hours. Most (92%) patients reached normal potassium levels
within 48 hours from baseline. The treatment effect continued for as long as 12
months, according to the company.
L.
FDA Approves AI-Based Software for Wrist Fracture Detection
The US Food and Drug Administration (FDA) approved
computer-aided detection and diagnostic software called OsteoDetect to speed
the diagnosis of wrist fractures in adults, the agency announced yesterday.
OsteoDetect, from Imagen, in New York City, uses an
artificial-intelligence algorithm to detect fractures in the distal radius by analyzing
standard x-ray images. The software then marks the image for further review by
a clinician.
M.
Task force report highlights 22% decrease in opioid Rx
The American Medical Association Opioid Task Force's 2018
report found more than a 22% decrease in opioid prescriptions between 2013 and
2017, and a decrease for the fifth year in a row. Prescriptions for naloxone
more than doubled, from 3,500 weekly to 8,000 in 2017, and treatment capacity
increased 42% in the past 12 months.
N.
Study finds links between breastfeeding, gut microbiome, weight
The gut microbiome in breastfed babies differs from that of
babies fed mostly formula, and breastfed babies are less likely than their
formula-fed peers to develop obesity, suggesting that obesity starts early and
is linked to gut bacteria. The study, published in the Journal of Pediatrics,
found an association between a proliferation of certain gut bacteria and
healthy weight, and revealed that occasional formula feeding does not raise the
risk of overweight.
O.
Research finds variation in personal
health care access, quality worldwide
The Healthcare Access and Quality index varied significantly
across 195 countries, territories and subnational locations, from a high of
97.1 in Iceland to a low of 18.6 in the Central African Republic, according to
a study in The Lancet. Researchers analyzed the Global Burden of Diseases,
Injuries, and Risk Factors Study 2016 and found that "alongside
initiatives to strengthen public health programs, the pursuit of universal
health coverage hinges upon improving both access and quality worldwide, and
thus requires adopting a more comprehensive view -- and subsequent provision --
of quality health care for all populations."
P.
Complex regional pain syndrome: Signs and symptoms
Complex regional pain syndrome may develop as a complication
after limb trauma or lesions of the peripheral nervous system. Typical features
are continuing pain, sensory, vasomotor, sudomotor, motor and trophic changes
as well as edema. This article provides a retrospective analysis of 1,043 CRPS
patients in comparison with 421 patients suffering from other pain disorders.
The results could potentially facilitate a more reliable and earlier diagnosis
of CRPS, a better differentiation from other pain disorders, and ultimately in
a more targeted and effective therapy.
Q.
Suicide Rates Spike Across United States, Says CDC
June 12, 2018 08:43 am Chris Crawford – In 2016, nearly
45,000 Americans age 10 or older took their own lives -- a figure that reflects
the unfortunate fact that suicide rates in the country have risen nearly 30
percent since 1999. That's the word from a pair of reports the CDC released
June 7; that timing, unhappily, coincided with the high-profile suicides of
Kate Spade on June 5 and Anthony Bourdain on June 8.
R.
Antiplatelet Restart May Be OK after Brain Bleed
Functional independence, quality of life similar in mild to moderate
ICH
Restarting antiplatelet therapy in patients with mild to
moderate intracerebral hemorrhage (ICH) is not associated with worse functional
outcomes, a retrospective analysis suggests.
Patients who had mild to moderately severe ICH had no difference
in functional independence outcomes or health-related quality of life metrics
whether or not they resumed antiplatelet therapy, reported Ching-Jen Chen, MD,
of the University of Virginia in Charlottesville and colleagues in Neurology.
"In patients with intracerebral hemorrhage who were on
antiplatelet therapy, clinicians are often faced with the decision of whether
or not to restart antiplatelet therapy at the time of discharge," Chen
said.
"Although antiplatelet use after ICH is associated with
decreased incidence of ischemic cardiovascular events without an elevated risk
of recurrent ICH, functional outcomes and health-related quality of life
measures in these circumstances remained unclear," he told MedPage Today.
"These measures may not be accurately portrayed by incidences of ischemic
cardiovascular events or recurrent ICH alone."
The effectiveness of antiplatelet therapy in preventing
primary and secondary ischemic events has led to wider use which, despite
overall benefits, may elevate the risk of spontaneous ICH. For patients who
survive an initial hemorrhagic stroke, a second ICH is linked to further
morbidity and mortality.
