Sunday, September 30, 2018

Lit Bits: Sept 30, 2018

From the recent medical literature...


1. AMI Corner

A. New Definition of Myocardial Infarction Established

The new guidelines are the 4-year work of a committee representing cardiologists and other healthcare professionals from the European Society of Cardiology, the American College of Cardiology, the American Heart Association, and the World Heart Federation.

The term acute MI should be used when there is acute myocardial injury with (1) detection of a rise and/or fall of cardiac troponin values with at least 1 value above the 99th percentile upper reference limit and (2) clinical evidence of acute myocardial ischaemia noted by at least 1 of the following:
  • Symptoms of myocardial ischaemia
  • New ischaemic electrocardiogram (ECG) changes
  • Development of pathological Q waves
  • Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality in a pattern consistent with an ischaemic etiology
  • Identification of a coronary thrombus by angiography or autopsy 


Thygesen K, Fourth Universal Definition of Myocardial Infarction (2018). J Am Coll Cardiol 2018 Aug 25 [Epub ahead of print].


B. Recent ESC Guidelines Reviewed by EM-RAP

Ibanez B, et al. 2017 ESC guidelines for the management of AMI in patients presenting with ST-segment elevation: The task force for the management of AMI in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018;39(2):119-177.


ED-specific Highlights from EM-RAP, September 2018
By Anand Swaminathan MD and Amal Mattu MD

1. A reduction in chest pain after nitroglycerin administration can be misleading and is not recommended as a diagnostic maneuver.

2. The criteria for diagnosis of ST elevation MI on ECG is more complex than just 1 mm of elevation in two contiguous leads.

“In the proper clinical context, ST-segment elevation (measured at the J-point) is considered suggestive of ongoing coronary artery acute occlusion in the following cases: at least two contiguous leads with ST-segment elevation ≥ 2.5 mm in men below 40 years, ≥2 mm in men ≥ 40 years, or ≥ 1.5 mm in women in leads V2–V3 and/or ≥ 1 mm in the other leads [in the absence of left ventricular (LV) hypertrophy or left bundle branch block LBBB)].”

3. Q waves on the ECG should not change reperfusion strategy.

4. Should we routinely look at additional leads to evaluate for right ventricular and posterior MI?

Not routinely, but selectively.

Example 1: “Isolated posterior MI. In AMI of the inferior and basal portion of the heart, often corresponding to the left circumflex territory, isolated ST-segment depression ≥ 0.5 mm in leads V1–V3 represents the dominant finding. These should be managed as a STEMI. The use of additional posterior chest wall leads [elevation V7–V9 ≥ 0.5 mm (≥1 mm in men, 40 years old)] is recommended to detect ST-segment elevation consistent with inferior and basal MI.”

Example 2: Right Ventricular MI. Get right-sided leads in pts with inferior STEMIs. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5267627/

5. The ECG diagnosis of acute myocardial infarction is difficult in the presence of a left bundle branch block but often possible if marked ST-segment abnormalities are present.

Use Scarbossa’s criteria, or Smith’s modified criteria. https://www.annemergmed.com/article/S0196-0644(12)01368-6/pdf

6. Patients with MI and right bundle branch block have a poor prognosis. It may be difficult to detect transmural ischemia in patients with chest pain and RBBB. A primary PCI strategy should be considered when persistent ischemic symptoms occur with RBBB.

7. Some patients with acute coronary occlusion may have an initial ECG without ST elevation.

“Non-diagnostic ECG. Some patients with an acute coronary occlusion may have an initial ECG without ST-segment elevation, sometimes because they are seen very early after symptom onset (in which case, one should look for hyper-acute T-waves, which may precede ST-segment elevation). It is important to repeat the ECG or monitor for dynamic ST-segment changes. In addition, there is a concern that some patients with acute occlusion of a coronary artery and ongoing MI, such as those with an occluded circumflex coronary artery,58,59 acute occlusion of a vein graft, or left main disease, may present without ST-segment elevation and be denied reperfusion therapy, resulting in a larger infarction and worse outcomes. Extending the standard 12-lead ECG with V7–V9 leads may identify some of these patients. In any case, suspicion of ongoing myocardial ischaemia is an indication for a primary PCI strategy even in patients without diagnostic ST-segment elevation.8,38,46–49Table 3 lists the atypical ECG presentations that should prompt a primary PCI strategy in patients with ongoing symptoms consistent with myocardial ischaemia.”

8. ST depression above 1 mm in eight or more surface leads, coupled with ST-segment elevation in aVR and/or V1, suggests multi-vessel ischemia or left main obstruction.

9. If the patient has a STEMI post-arrest, they should go to PCI.

C. The OMI Manifesto (Occlusion MI)

A collaboration by Dr. Smith’s ECG Blog and EMCrit
By Pendell Meyers, MD, Scott Weingart, MD, FCCM, and Stephen Smith, MD

The current guideline-recommended paradigm of acute MI management (“STEMI vs. NSTEMI”) is irreversibly flawed, and has prevented meaningful progress in the science of emergent reperfusion therapy over the past 25 years. Dr. Stephen Smith, my mentor and co-editor of this post, has been saying this much more eloquently for many years in his “STEMI/NSTEMI False Dichotomy” lecture series, but this bears repeating and needs to be reiterated as widely as possible.

Deciding which patients need emergent reperfusion therapy is complex, and our current criteria for doing so are not adequate to the task. The patients who benefit from emergent catheterization are those with acute coronary occlusion (ACO) or near occlusion, with insufficient collateral circulation, whose myocardium is at imminent risk of irreversible infarction without immediate reperfusion therapy. This is the anatomic substrate of the entity we are supposed to refer to as "STEMI." Unfortunately the term "STEMI" restricts our minds into thinking that ACO is diagnosed reliably and/or only by "STEMI criteria" and the ST segments. In reality, the STEMI criteria and widespread current performance under the current paradigm have unacceptable accuracy, routinely missing at least 25-30% of ACO in those classified as “NSTEMI”1-9 and generating a similar false positive rate of emergent cath lab activations.10-12…


D. Pre-activating the Cath Lab for STEMIs Improves Outcomes

Association Between Cardiac Catheterization Laboratory Pre-Activation and Reperfusion Timing Metrics and Outcomes in Patients With ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention: A Report From the ACTION Registry

Shavadia JS, et al. JACC Cardiovasc Interv. 2018;11(18):1837-1847.

Activating the cardiac catheterization laboratory at least 10 minutes before an ST-segment elevation MI (STEMI) patient arrived at the hospital was associated with less reperfusion delay – and possibly better in-hospital survival.


2. Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults with Out-of-Hospital Cardiac Arrest: A RCT

Wang HE, et al. JAMA 2018;320(8):769-778.

Key Points
Question  What is the effect of an initial airway management strategy using laryngeal tube insertion, compared with endotracheal intubation, on survival among adults with out-of-hospital cardiac arrest?

Findings  In this cluster-crossover randomized trial of 3004 adults with out-of-hospital cardiac arrest, 72-hour survival was 18.3% for laryngeal tube insertion and 15.4% for endotracheal intubation, a significant difference.

Meaning  A strategy of initial laryngeal tube insertion, compared with endotracheal intubation, was associated with greater likelihood of 72-hour survival, but given limitations in study design and findings, additional research is warranted.

Abstract
Importance  Emergency medical services (EMS) commonly perform endotracheal intubation (ETI) or insertion of supraglottic airways, such as the laryngeal tube (LT), on patients with out-of-hospital cardiac arrest (OHCA). The optimal method for OHCA advanced airway management is unknown.

Objective  To compare the effectiveness of a strategy of initial LT insertion vs initial ETI in adults with OHCA.

Design, Setting, and Participants  Multicenter pragmatic cluster-crossover clinical trial involving EMS agencies from the Resuscitation Outcomes Consortium. The trial included 3004 adults with OHCA and anticipated need for advanced airway management who were enrolled from December 1, 2015, to November 4, 2017. The final date of follow-up was November 10, 2017.

Interventions  Twenty-seven EMS agencies were randomized in 13 clusters to initial airway management strategy with LT (n = 1505 patients) or ETI (n = 1499 patients), with crossover to the alternate strategy at 3- to 5-month intervals.

Main Outcomes and Measures  The primary outcome was 72-hour survival. Secondary outcomes included return of spontaneous circulation, survival to hospital discharge, favorable neurological status at hospital discharge (Modified Rankin Scale score ≤3), and key adverse events.

Results  Among 3004 enrolled patients (median [interquartile range] age, 64 [53-76] years, 1829 [60.9%] men), 3000 were included in the primary analysis. Rates of initial airway success were 90.3% with LT and 51.6% with ETI. Seventy-two hour survival was 18.3% in the LT group vs 15.4% in the ETI group (adjusted difference, 2.9% [95% CI, 0.2%-5.6%]; P = .04). Secondary outcomes in the LT group vs ETI group were return of spontaneous circulation (27.9% vs 24.3%; adjusted difference, 3.6% [95% CI, 0.3%-6.8%]; P = .03); hospital survival (10.8% vs 8.1%; adjusted difference, 2.7% [95% CI, 0.6%-4.8%]; P = .01); and favorable neurological status at discharge (7.1% vs 5.0%; adjusted difference, 2.1% [95% CI, 0.3%-3.8%]; P = .02). There were no significant differences in oropharyngeal or hypopharyngeal injury (0.2% vs 0.3%), airway swelling (1.1% vs 1.0%), or pneumonia or pneumonitis (26.1% vs 22.3%).

Conclusions and Relevance  Among adults with OHCA, a strategy of initial LT insertion was associated with significantly greater 72-hour survival compared with a strategy of initial ETI. These findings suggest that LT insertion may be considered as an initial airway management strategy in patients with OHCA, but limitations of the pragmatic design, practice setting, and ETI performance characteristics suggest that further research is warranted.


3. How the Availability of Observation Status Affects Emergency Physician Decision-making

Wright B, et al. Ann Emerg Med 2018;72(4):401-409.

Study objective
This study seeks to understand how emergency physicians decide to use observation services, and how placing a patient under observation influences physicians’ subsequent decisionmaking.

Methods
We conducted detailed semistructured interviews with 24 emergency physicians, including 10 from a hospital in the US Midwest, and 14 from 2 hospitals in central and northern England. Data were extracted from the interview transcripts with open coding and analyzed with axial coding.

Results
We found that physicians used a mix of intuitive and analytic thinking in initial decisions to admit, observe, or discharge patients, depending on the physician’s individual level of risk aversion. Placing patients under observation made some physicians more systematic, whereas others cautioned against overreliance on observation services in the face of uncertainty.

Conclusion
Emergency physicians routinely make decisions in a highly resource-constrained environment. Observation services can relax these constraints by providing physicians with additional time, but absent clear protocols and metacognitive reflection on physician practice patterns, this may hinder, rather than facilitate, decisionmaking.

4. An Outbreak of Synthetic Cannabinoid–Associated Coagulopathy in Illinois

Kelkar AH, et al. N Engl J Med 2018;379:1216-1223.

BACKGROUND
In March and April 2018, more than 150 patients presented to hospitals in Illinois with coagulopathy and bleeding diathesis. Area physicians and public health organizations identified an association between coagulopathy and synthetic cannabinoid use. Preliminary tests of patient serum samples and drug samples revealed that brodifacoum, an anticoagulant, was the likely adulterant.

METHODS
We reviewed physician-reported data from patients admitted to Saint Francis Medical Center in Peoria, Illinois, between March 28 and April 21, 2018, and included in a case series adult patients who met the criteria used to diagnose synthetic cannabinoid–associated coagulopathy. A confirmatory anticoagulant poisoning panel was ordered at the discretion of the treating physician.

RESULTS
A total of 34 patients were identified as having synthetic cannabinoid–associated coagulopathy during 45 hospitalizations. Confirmatory anticoagulant testing was performed in 15 of the 34 patients, and superwarfarin poisoning was confirmed in the 15 patients tested. Anticoagulant tests were positive for brodifacoum in 15 patients (100%), difenacoum in 5 (33%), bromadiolone in 2 (13%), and warfarin in 1 (7%). Common symptoms at presentation included gross hematuria in 19 patients (56%) and abdominal pain in 16 (47%). Computed tomography was performed to evaluate abdominal pain and revealed renal abnormalities in 12 patients. Vitamin K1 (phytonadione) was administered orally in all 34 patients and was also administered intravenously in 23 (68%). Red-cell transfusion was performed in 5 patients (15%), and fresh-frozen plasma infusion in 19 (56%). Four-factor prothrombin complex concentrate was used in 1 patient. One patient died from complications of spontaneous intracranial hemorrhage.

CONCLUSIONS
Our data indicate that superwarfarin adulterants of synthetic cannabinoids can lead to clinically significant coagulopathy. In our series, in most of the cases in which the patient presented with bleeding diathesis, symptoms were controlled with the use of vitamin K1 replacement therapy. The specific synthetic cannabinoid compounds are not known.

5. Ann Emerg Med Quick Reviews

A. Are Patients Receiving the Combination of Vancomycin and Piperacillin-Tazobactam at Higher Risk for Acute Renal Injury?

Take-Home Message
The combination of vancomycin and piperacillin-tazobactam increases the risk of acute kidney injury compared with vancomycin monotherapy, piperacillin-tazobactam monotherapy, or vancomycin plus cefepime or a carbapenem.


B. Are qSOFA Criteria Better Than the Systemic Inflammatory Response Syndrome Criteria for Diagnosing Sepsis and Predicting Inhospital Mortality?

Take-Home Message
Systemic inflammatory response syndrome (SIRS) criteria are more sensitive for diagnosing sepsis, while quick Sequential [Sepsis-related] Organ Failure Assessment (qSOFA) criteria are marginally more accurate for predicting inhospital mortality among patients identified with sepsis.


6. Chemotherapy Corner

A. New Immunotherapy Revolutionizes Cancer Care, but Guess Where Adverse Events End Up?

Ballard D, et al. Emerg Med News. 2018;40(9):29.

A 69-year-old man with a history of cancer presented to our ED on day four of taking Ceftin for pneumonia with a fever of 102.5°F and shortness of breath. He had a history of non-small cell
lung cancer after a wedge resection and hepatocellular carcinoma after a hepatectomy. His chest film was read as “patchy airspace disease over mid- and lower lung without improvement from prior,” and he was worked up, treated, and admitted for severe sepsis. Sounds like a fairly bread-and-butter emergency department case, right?

Of course, there was a twist, which emerged after a CT of the chest and bronchoscopy demonstrated diffuse ground glass opacity and tracheobronchitis, findings that resolved with high-dose prednisone. The diagnosis was not pneumonia but pneumonitis, a complication of the patient’s cancer treatment—pembrolizumab (Keytruda), last administered several months before presentation.

Pembrolizumab is one of the new-generation cancer treatments that deploys the patient’s immune system against cancer cells by removing the malignant cells’ ability to disguise themselves rather than killing them directly. These checkpoint inhibitors are revolutionizing
oncologic treatment, but are not a risk-free panacea. We all know where these patients are likely to be seen and evaluated when severe side effects emerge.

Be on the Lookout
Immunotherapy complications have been receiving some attention from scientific journals as well as the lay press this year. Actual data on adverse effect risk, especially for those
with a delayed presentation like our patient, remain limited….

For the rest of the essay, with references, and the poem below see here: https://journals.lww.com/em-news/Fulltext/2018/09000/Medically_Clear__New_Immunotherapy_Revolutionizes.15.aspx

Checkpoint Inhibitors in Rhyme
These meds can enhance our immunity
By promoting a state of disunity—
              Releasing the brakes,
              Raises the stakes,
With no guarantee of impunity.

The system is on the attack
Indifferent to who it might sack:
              Cancer? True;
              But other cells, too,
Will find themselves on the rack.

Events from these agents immune
Need not occur anytime soon;
              Post-med delays
              Can be hundreds of days—
Beware the long honeymoon…

B. Are We Being Misled About Precision Medicine?

Doctors and hospitals love to talk about the cancer patients they’ve saved, and reporters love to write about them. But deaths still vastly outnumber the rare successes.

By Liz Szabo, a health reporter for Kaiser Health News. New York Times, Sept 11, 2018


7. The Misunderstood Coagulopathy of Liver Disease: A Review for the Acute Setting.

Harrison MF. West J Emerg Med. 2018 Sep;19(5):863-871.

The international normalized ratio (INR) represents a clinical tool to assess the effectiveness of vitamin-K antagonist therapy. However, it is often used in the acute setting to assess the degree of coagulopathy in patients with hepatic cirrhosis or acute liver failure. This often influences therapeutic decisions about invasive procedures or the need for potentially harmful and unnecessary transfusions of blood product. This may not represent a best-practice or evidence-based approach to patient care.

The author performed a review of the literature related to the utility of INR in cirrhotic patients using several scientific search engines. Despite the commonly accepted dogma that an elevated INR in a cirrhotic patient corresponds with an increased hemorrhagic risk during the performance of invasive procedures, the literature does not support this belief. Furthermore, the need for blood-product transfusion prior to an invasive intervention is not supported by the literature, as this practice increases the risk of complications associated with a patient's hospital course. Many publications ranging from case studies to meta-analyses refute this evidence and provide examples of thrombotic events despite elevated INR values. Alternative methods, such as thromboelastogram, represent alternate means of assessing in vivo risk of hemorrhage in patients with acute or chronic liver disease in real-time in the acute setting.


8. Does Point-of-Care US Improve Clinical Outcomes in ED Patients with Undifferentiated Hypotension? An International RCT from the SHoC-ED Investigators

Atkinson PR, et al. Ann Emerg Med. 2018;72(4):478-489.

Study objective
Point-of-care ultrasonography protocols are commonly used in the initial management of patients with undifferentiated hypotension in the emergency department (ED). There is little published evidence for any mortality benefit. We compare the effect of a point-of-care ultrasonography protocol versus standard care without point-of-care ultrasonography for survival and clinical outcomes.

Methods
This international, multicenter, randomized controlled trial recruited from 6 centers in North America and South Africa and included selected hypotensive patients (systolic blood pressure less than 100 mm Hg or shock index over 1) randomized to early point-of-care ultrasonography plus standard care versus standard care without point-of-care ultrasonography. Diagnoses were recorded at 0 and 60 minutes. The primary outcome measure was survival to 30 days or hospital discharge. Secondary outcome measures included initial treatment and investigations, admissions, and length of stay.

Results
Follow-up was completed for 270 of 273 patients. The most common diagnosis in more than half the patients was occult sepsis. We found no important differences between groups for the primary outcome of survival (point-of-care ultrasonography group 104 of 136 patients versus standard care 102 of 134 patients; difference 0.35%; 95% binomial confidence interval [CI] –10.2% to 11.0%), survival in North America (point-of-care ultrasonography group 76 of 89 patients versus standard care 72 of 88 patients; difference 3.6%; CI –8.1% to 15.3%), and survival in South Africa (point-of-care ultrasonography group 28 of 47 patients versus standard care 30 of 46 patients; difference 5.6%; CI –15.2% to 26.0%). There were no important differences in rates of computed tomography (CT) scanning, inotrope or intravenous fluid use, and ICU or total length of stay.

Conclusion
To our knowledge, this is the first randomized controlled trial to compare point-of-care ultrasonography to standard care without point-of-care ultrasonography in undifferentiated hypotensive ED patients. We did not find any benefits for survival, length of stay, rates of CT scanning, inotrope use, or fluid administration. The addition of a point-of-care ultrasonography protocol to standard care may not translate into a survival benefit in this group.


Editorial: But It Makes Sense Physiologically…

9. Discriminatory value of the ascending aorta diameter in suspected acute type A aortic dissection.

Mark DG, et al. Acad Emerg Med. 2018 Aug 9 [Epub ahead of print].

INTRO: Proximal thoracic aortic dissections (Stanford classification Type A) occur with an incidence of 4 per 100,000 person-years and an observed average mortality of 25%. While patients with specific structural and genetic diseases are at higher risk for type A aortic dissection (TAAD), prospective registries have found that the majority of cases occur in patients without these known predispositions, but with similar resultant mortality rates.1 Unfortunately patients with acute TAAD have highly variable clinical presentations2,3, leaving clinicians to rely on gestalt and the liberal use of advanced imaging modalities, in particular high-dose computed tomography (CT) angiography, magnetic resonance imaging (MRI) and transesophageal echocardiography (TEE), all of which have reported sensitivities for TAAD around 98%.4 Given the highly morbid consequences of misdiagnosis, very low (i.e. less than 2%) testing thresholds are commonly promoted with correspondingly low diagnostic yields.5,6 However, despite liberal screening recommendations, rates of initial misdiagnosis range from 14 to 31%.7,8 As such, TAADs represent a high-risk diagnostic clinical challenge.

Fortunately, there are anatomic factors that may reliably identify at-risk patients and direct more appropriate use of advanced imaging. Analysis of one single-center (177 patients)9 and one multicenter registry (591 patients)1 of patients with acute TAAD revealed that only 5 to 10% of patients in these studies had maximal ascending aorta (AscAo) diameters less than 4.0 cm. Conversely, nearly all healthy men and women have maximal AscAo diameters less than 4.0 cm (upper 95th percentiles between 3.8-4.2 cm and 3.4-3.9 cm, respectively).10 Along these lines, predictive models using age, gender and body surface area (BSA) have been developed to further refine population norms for AscAo diameters.10-13 Using normalized measures based on these models might significantly improve the discriminative ability of an AscAo diameter to detect TAAD, as opposed to using a single raw threshold diameter.

We hypothesized that, among emergency department (ED) patients undergoing CT angiography to rule-out TAAD, the use of AscAo measurements (as measured on non-contrast CT images) would allow for excellent discrimination between patients with and without TAAD, allowing for determination of a threshold with 100% sensitivity for TAAD as well as clinically useful specificity. We additionally hypothesized that normalization of these AscAo measurements for patient age, gender and BSA would further improve predictive performance. Identification of such thresholds might allow for accurate TAAD risk stratification using AscAo measurements obtained by transthoracic echocardiography (TTE) or non-contrast CT, the latter being relevant for patients with contraindications to intravenous contrast or non-diagnostic CT angiography. 

ABSTRACT
OBJECTIVE: To determine if ascending aorta (AscAo) diameters measured by non-contrast computed tomography (CT) allow for meaningful discrimination between patients with and without type A aortic dissection (TAAD), ideally with 100% sensitivity.

METHODS: Retrospective analysis of cases of TAAD, as well as controls undergoing evaluation for TAAD with CT aortography, presenting to 21 emergency departments within an integrated health system between 2007 and 2015. AscAo diameters were determined using axial non-contrast CT images at the level of the right main pulmonary artery by two readers. AscAo diameters were additionally normalized for age, sex and body surface area (assessed by a Z-score, which is the number of standard deviations between the observed and expected AscAo diameters). Overall model discrimination was assessed using the area under the receiver operating characteristic curve (AUC). Comparative discrimination was assessed using both the change in area under the receiver operating characteristic curve (∆AUC) and the continuous net reclassification index (NRI).

RESULTS: 230 cases of TAAD and 325 controls were included in the study. The median age for cases and controls was 65 and 62 years, and the median AscAo diameters were 50 mm and 35 mm, respectively. The raw and normalized AscAo diameters demonstrated similarly excellent discrimination (AUCs of 0.96 versus 0.97, respectively, ∆AUC = 0.01, p = 0.09) and an NRI of 0.30 (95% CI 0.13-0.47), both indicating small incremental improvements in classification with the use of the normalized AscAo measures. A raw AscAo diameter of 34 mm and a normalized Z-score of 1.84 both yielded 100% sensitivity for TAAD, with respective specificities of 35% (95% CI 29.6% - 40.2%) and 67% (95% CI 61.7% - 72.2%).

CONCLUSIONS: Nearly all patients with TAAD appear to have enlarged AscAo diameters as measured by non-contrast CT, whereas most patients with suspected but absent TAAD have relatively normal AscAo diameters. Both raw and normalized AscAo measures provided relatively comparable discriminatory value. If validated, these data may be useful in adjudicating risk among patients with suspected TAAD in whom a gold-standard test is unavailable, non-diagnostic or contraindicated.

10. Images in Clinical Practice

Mycoplasma pneumoniae–Associated Mucositis

Congenital Cytomegalovirus Infection

Tuberculosis of the Finger

Tuberculous Peritonitis

Glandular Tularemia

Black Hairy Tongue

Adolescent With Chest Pain and Dyspnea

Child With Autism and a Limp

Man With Sudden Lower Leg Numbness

Young Boy With Lateral Foot Pain

11. Infectious Disease

A. Five-Year Follow-up of Antibiotic Therapy for Uncomplicated Acute Appendicitis in the APPAC RCT.

Saliminen P, et al. JAMA. 2018 Sep 25;320(12):1259-1265.

IMPORTANCE:
Short-term results support antibiotics as an alternative to surgery for treating uncomplicated acute appendicitis, but long-term outcomes are not known.

OBJECTIVE:
To determine the late recurrence rate of appendicitis after antibiotic therapy for the treatment of uncomplicated acute appendicitis.

DESIGN, SETTING, AND PARTICIPANTS:
Five-year observational follow-up of patients in the Appendicitis Acuta (APPAC) multicenter randomized clinical trial comparing appendectomy with antibiotic therapy, in which 530 patients aged 18 to 60 years with computed tomography-confirmed uncomplicated acute appendicitis were randomized to undergo an appendectomy (n = 273) or receive antibiotic therapy (n = 257). The initial trial was conducted from November 2009 to June 2012 in Finland; last follow-up was September 6, 2017. This current analysis focused on assessing the 5-year outcomes for the group of patients treated with antibiotics alone.

INTERVENTIONS:
Open appendectomy vs antibiotic therapy with intravenous ertapenem for 3 days followed by 7 days of oral levofloxacin and metronidazole.

MAIN OUTCOMES AND MEASURES:
In this analysis, prespecified secondary end points reported at 5-year follow-up included late (after 1 year) appendicitis recurrence after antibiotic treatment, complications, length of hospital stay, and sick leave.

RESULTS:
Of the 530 patients (201 women; 329 men) enrolled in the trial, 273 patients (median age, 35 years [IQR, 27-46]) were randomized to undergo appendectomy, and 257 (median age, 33 years, [IQR, 26-47]) were randomized to receive antibiotic therapy. In addition to 70 patients who initially received antibiotics but underwent appendectomy within the first year (27.3% [95% CI, 22.0%-33.2%]; 70/256), 30 additional antibiotic-treated patients (16.1% [95% CI, 11.2%-22.2%]; 30/186) underwent appendectomy between 1 and 5 years. The cumulative incidence of appendicitis recurrence was 34.0% (95% CI, 28.2%-40.1%; 87/256) at 2 years, 35.2% (95% CI, 29.3%-41.4%; 90/256) at 3 years, 37.1% (95% CI, 31.2%-43.3%; 95/256) at 4 years, and 39.1% (95% CI, 33.1%-45.3%; 100/256) at 5 years. Of the 85 patients in the antibiotic group who subsequently underwent appendectomy for recurrent appendicitis, 76 had uncomplicated appendicitis, 2 had complicated appendicitis, and 7 did not have appendicitis. At 5 years, the overall complication rate (surgical site infections, incisional hernias, abdominal pain, and obstructive symptoms) was 24.4% (95% CI, 19.2%-30.3%) (n = 60/246) in the appendectomy group and 6.5% (95% CI, 3.8%-10.4%) (n = 16/246) in antibiotic group (P  less than  .001), which calculates to 17.9 percentage points (95% CI, 11.7-24.1) higher after surgery. There was no difference between groups for length of hospital stay, but there was a significant difference in sick leave (11 days more for the appendectomy group).

CONCLUSIONS AND RELEVANCE:
Among patients who were initially treated with antibiotics for uncomplicated acute appendicitis, the likelihood of late recurrence within 5 years was 39.1%. This long-term follow-up supports the feasibility of antibiotic treatment alone as an alternative to surgery for uncomplicated acute appendicitis.

B. Risk of Bacterial Coinfections in Febrile Infants 60 Days Old and Younger with Documented Viral Infections.

Mahajan P, et al. J Pediatr. 2018 Sep 6 [Epub ahead of print]

OBJECTIVE:
To determine the risk of serious bacterial infections (SBIs) in young febrile infants with and without viral infections.

STUDY DESIGN:
Planned secondary analyses of a prospective observational study of febrile infants 60 days of age or younger evaluated at 1 of 26 emergency departments who did not have clinical sepsis or an identifiable site of bacterial infection. We compared patient demographics, clinical, and laboratory findings, and prevalence of SBIs between virus-positive and virus-negative infants.

RESULTS:
Of the 4778 enrolled infants, 2945 (61.6%) had viral testing performed, of whom 1200 (48.1%) were virus positive; 44 of the 1200 had SBIs (3.7%; 95% CI, 2.7%-4.9%). Of the 1745 virus-negative infants, 222 had SBIs (12.7%; 95% CI, 11.2%-14.4%). Rates of specific SBIs in the virus-positive group vs the virus-negative group were: UTIs (33 of 1200 [2.8%; 95% CI, 1.9%-3.8%] vs 186 of 1745 [10.7%; 95% CI, 9.2%-12.2%]) and bacteremia (9 of 1199 [0.8%; 95% CI, 0.3%-1.4%] vs 50 of 1743 [2.9%; 95% CI, 2.1%-3.8%]). The rate of bacterial meningitis tended to be lower in the virus-positive group (0.4%) than in the viral-negative group (0.8%); the difference was not statistically significant. Negative viral status (aOR, 3.2; 95% CI, 2.3-4.6), was significantly associated with SBI in multivariable analysis.

CONCLUSIONS:
Febrile infants ≤60 days of age with viral infections are at significantly lower, but non-negligible risk for SBIs, including bacteremia and bacterial meningitis.

C. Pip/Tazo combo raises death risk in patients with tough-to-treat infections

A study published in the Journal of the American Medical Association indicated that the two-drug combo of piperacillin and tazobactam, used to treat bloodstream infections induced by ceftriaxone-resistant Escherichia coli or Klebsiella pneumoniae, could not be proved noninferior to the broad-spectrum antibiotic meropenem. Study findings showed that all-cause mortality rates at 30 days were 12.3% for those in the piperacillin/tazobactam group versus 3.7% in the meropenem group, with researchers concluding that use of the combo as a substitute for treating these infections should not be considered.


12. Can Mobile Integrated Health Care Paramedics Safely Conduct Medical Clearance of Behavioral Health Patients in a Pilot Project? A Report of the First 1000 Consecutive Encounters.

Mackey KE, Qiu C. Prehosp Emerg Care. 2018 Aug 23 [Epub ahead of print]

BACKGROUND:
Mental health patients wait lengthy periods in emergency departments for disposition. This delay is secondary to the process of medical clearance and then placement in an appropriate psychiatric specialty center. ACEP clinical policy questions the necessity of laboratory investigation for medical clearance and favors history and physical exam to determine safe disposition to mental health facilities. This manuscript explores if specially trained paramedics can effectively employ triage algorithms to determine proper disposition of patients suffering an acute mental health crisis in a 9-1-1 system.

METHODS:
Six paramedics working for AMR in Stanislaus County, California underwent 180 hours of specialized training to become Mobile Integrated Healthcare Paramedics (MIHPs). Their training detailed the use of two algorithms designed to identify patients that require evaluation in an emergency department versus those that can be triaged directly to a licensed mental health facility. Patients aged 18-59 with a suspected mental health crisis who are encountered via the 9-1-1 system, law enforcement or who walk in to the mental health facility for treatment were eligible. All patients in the study were evaluated with the well person algorithm (WPA). Those that passed the WPA were evaluated using the mental health clearance algorithm (MCHA). MIHPs directed patients to either the ED or the mental health facility based upon the evaluation results of the WPA and MHCA.

RESULTS:
1006 patients were evaluated between September 2015 and December 2017. 404 patients failed one or more components of the WPA or MHCA. 326 patients passed both the WPA and the MHCA, but were ultimately transported to a local emergency department, most often because of lack of available psychiatric beds in the community. 276 patients were transported directly to a psychiatric facility. Of these, 10 returned to the emergency department within 6 hours, but none of the 10 were admitted for a previously unidentified medical or traumatic condition.

CONCLUSION:
Specially trained paramedics can effectively employ triage algorithms to screen and select patients experiencing an acute mental health crisis for transport directly to psychiatric treatment facilities.

13. A Multicenter Program to Implement the Canadian C-Spine Rule by ED Triage Nurses

Stiell IG, et al. Ann Emerg Med 2018;72(4):333-341.

Study objective
The Canadian C-Spine Rule has been widely applied by emergency physicians to safely reduce use of cervical spine imaging. Our objective is to evaluate the clinical effect and safety of real-time Canadian C-Spine Rule implementation by emergency department (ED) triage nurses to remove cervical spine immobilization.

Methods
We conducted this multicenter, 2-phase, prospective cohort program at 9 hospital EDs and included alert trauma patients presenting with neck pain or with cervical spine immobilization. During phase 1, ED nurses were trained and then had to demonstrate competence before being certified. During phase 2, certified nurses were empowered by a medical directive to “clear” the cervical spine of patients, allowing them to remove cervical spine immobilization and to triage to a less acute area. The primary outcomes were clinical effect (cervical spine clearance by nurses) and safety (missed clinically important cervical spine injuries).

Results
In phase 1, 312 nurses evaluated 3,098 patients. In phase 2, 180 certified nurses enrolled 1,408 patients (mean age 43.1 years, women 52.3%, collision 56.5%, and cervical spine injury 1.1%). In phase 2 and for the 806 immobilized ambulance patients, the primary outcome of immobilization removal by nurses was 41.1% compared with 0% before the program. The primary safety outcome of cervical spine injuries missed by nurses was 0. Time to discharge was reduced by 26.0% (3.4 versus 4.6 hours) for patients who had immobilization removed. In only 1.3% of cases did nurses indicate their discomfort with applying the Canadian C-Spine Rule.

Conclusion
We clearly demonstrated that ED triage nurses can successfully implement the Canadian C-Spine Rule, leading to more rapid and comfortable management of patients without any threat to patient safety. Widespread adoption of this approach should improve care and comfort for trauma patients, and could decrease length of stay in our very crowded EDs.


14. Thrombophilia Testing and Venous Thrombosis

Connors JM. N Engl J Med 2017;377:1177-1187.

Summary: “Most patients with venous thromboembolism do not require thrombophilia testing, since the results will not affect management. Testing may be considered in younger patients with weak provoking factors, a strong family history, or recurrence at a young age.”

Ordering thrombophilia tests is easy; determining whom to test and how to use the results is not. Although inherited and acquired thrombophilias are acknowledged to increase the risk of venous thromboembolism (VTE), the majority of patients with VTE should not be tested for thrombophilia.

Data showing the clinical usefulness and benefits of testing are limited or nonexistent, as are data supporting the benefit of primary or secondary VTE prophylaxis based on thrombophilia status alone. Testing for inherited thrombophilia is controversial, with some arguing that these tests should never be performed.

No validated testing guidelines have been published. The American College of Chest Physicians does not give guidance on thrombophilia testing in its ninth edition of clinical practice guidelines for antithrombotic therapy or its 2016 VTE update,1,2 whereas the American Society of Hematology’s 2013 Choosing Wisely campaign recommends not testing for thrombophilia in adults with VTE who have major transient risk factors.3 According to the most comprehensive guide, Clinical Guidelines for Testing for Heritable Thrombophilia, published by the British Committee for Standards in Haematology, “It is not possible to give a validated recommendation as to how such patients (and families) should be selected” for testing.4 Although similar guidelines advise limiting testing to a narrow range of specific clinical situations and patients, the recommendations are not uniform.5-9 These recommendations have been developed in response to indiscriminate testing practices and misconceptions regarding the role of thrombophilia status in the management of VTE.

Patients with inherited thrombophilia can often be identified by coagulation experts on the basis of the patient’s personal and family history of VTE, even without knowledge of test results…

Full-text (subscription required): https://www.nejm.org/doi/full/10.1056/NEJMra1700365

15. Low-dose Ketamine for Pain Reduction

A. Slow Infusion of Low-dose Ketamine Reduces Bothersome Side Effects Compared to Intravenous Push: A Double-blind, Double-dummy, Randomized Controlled Trial.

Clattenburg EJ, et al.  Acad Emerg Med. 2018 Sep;25(9):1048-1052.

OBJECTIVE:
We compared the analgesic efficacy and incidence of side effects when low-dose (0.3 mg/kg) ketamine (LDK) is administered as a slow infusion (SI) over 15 minutes versus an intravenous push (IVP) over 1 minute.

METHODS:
This was a prospective, randomized, double-blind, double-dummy, placebo-controlled trial of adult ED patients presenting with moderate to severe pain (numerical rating scale [NRS] score ≥ 5). Patients received 0.3 mg/kg ketamine administered either as a SI or a IVP. Our primary outcome was the proportion of patients experiencing any psychoperceptual side effect over 60 minutes. A secondary outcome was incidence of moderate or greater psychoperceptual side effects. Additional outcomes included reduction in pain NRS scores at 60 minutes and percent maximum summed pain intensity difference (%SPID).

RESULTS:
Fifty-nine participants completed the study. A total of 86.2% of the IVP arm and 70.0% of the SI arm experienced any side effect (difference = 16.2%, 95% confidence interval [CI] = -5.4 to 37.8). We found a large reduction in moderate or greater psychoperceptual side effects with SI administration-75.9% reported moderate or greater side effects versus 43.4% in the SI arm (difference = 32.5%, 95% CI = 7.9 to 57.1). Additionally, the IVP arm experienced more hallucinations (n = 8, 27.6%) than the SI arm (SI n = 2, 6.7%, difference = 20.9%, 95% CI = 1.8 to 43.4). We found no significant differences in analgesic efficacy. At 60 minutes, the mean %SPID values in the IVP and SI arms were 39.9 and 33.5%, respectively, with a difference of 6.5% (95% CI = -5.8 to 18.7).

CONCLUSION:
Most patients who are administered LDK experience a psychoperceptual side effect regardless of administration via SI or IVP. However, patients receiving LDK as a SI reported significantly fewer moderate or greater psychoperceptual side effects and hallucinations with equivalent analgesia.

B. Continuous Intravenous Sub-Dissociative Dose Ketamine Infusion for Managing Pain in the ED

Motov S, et al. West J Emerg Med. 2018;19(3):559-566.

INTRODUCTION:
Our objective was to describe dosing, duration, and pre- and post-infusion analgesic administration of continuous intravenous sub-dissociative dose ketamine (SDK) infusion for managing a variety of painful conditions in the emergency department (ED).

METHODS:
We conducted a retrospective chart review of patients aged 18 and older presenting to the ED with acute and chronic painful conditions who received continuous SDK infusion in the ED for a period over six years (2010-2016). Primary data analyses included dosing and duration of infusion, rates of pre- and post-infusion analgesic administration, and final diagnoses. Secondary data included pre- and post-infusion pain scores and rates of side effects.

RESULTS:
A total of 104 patients were enrolled in the study. Average dosing of SDK infusion was 11.26 mg/hr, and the mean duration of infusion was 135.87 minutes. There was a 38% increase in patients not requiring post-infusion analgesia. The average decrease in pain score was 5.04. There were 12 reported adverse effects, with nausea being the most prevalent.

CONCLUSION:
Continuous intravenous SDK infusion has a role in controlling pain of various etiologies in the ED with a potential to reduce the need for co-analgesics or rescue analgesic administration. There is a need for more robust, prospective, randomized trials that will further evaluate the analgesic efficacy and safety of this modality across a wide range of pain syndromes and different age groups in the ED.


16. The Search for Satisfaction Often Lies Beyond the ED

Combating the grind of the daily shift can be overcome by branching out

By MICHAEL SILVERMAN, MD, Emergency Physicians Monthly. Aug 24, 2018

Dear Director,

I’m an experienced emergency physician but I’m looking for more than just seeing patients.  What ideas do you have for me?

I think the first few years after residency are about learning and mastering your craft as a physician, and enjoying the new free time and financial freedom you have as an attending.  At some point in a physician’s career, I advise them to diversify a little and look for something outside of just clinical shifts. We generally all went to residency with a passion for emergency medicine, and throughout residency, we developed areas of interest that we focused on.

However, over the years, the daily grind of shift world combined with increasing family responsibilities can erode at this passion and leave us just doing the shifts and wondering what else is out there. Being a full-time clinician can be very fulfilling, but many people look to a little diversity to help prevent burnout. As we look to diversify your career a touch, ideally you can bring your expertise to an area of medicine you’re passionate about.

In the hospital

I got into administration because I wanted to help more than one patient at a time. But the personal benefit to me as a medical director is that I’ve really enjoyed getting to know the docs from different specialties throughout the hospital.  I’ve done this by working side by side with them on committees, as we worked through clinical issues, and by just spending time in the doctor’s lounge.   Even as an attending physician, given your training and skill set, there are numerous committees and projects throughout the hospital that could benefit from your experience and expertise…

Out of the Hospital

There are numerous opportunities outside of your hospital where you can apply your experience.  These range from volunteering with your professional organization to high hourly compensation for legal reviews.

I’ve been involved with my state chapter of ACEP on and off for over 20 years.  I’ve really enjoyed the people I’ve met and the networking it’s allowed me. It’s also been a great opportunity to represent my colleagues.  State chapters usually work to improve patient care throughout your state via advocacy and representing you to your state government.  Most state chapters also provide some educational benefits to the members.  Malpractice and balanced billing are popular topics for us, but I’ve also seen colleagues become experts and then testify before lawmakers on the impact of psychiatric boarders and issues involving pediatric emergency medicine in the community hospital. Some of these opportunities will pique your interest and remind you why you went into EM. There is a huge need for docs to advocate for our specialty and our patients at the local, state and federal levels….


17. Poor Accuracy of Height (of Fall) Estimation Among Bystanders.

Carey S, et al. West J Emerg Med. 2018 Sep;19(5):813-819.

INTRODUCTION:
High-risk mechanisms in trauma usually dictate certain treatment and evaluation in protocolized care. A 10-15 feet (ft) fall is traditionally cited as an example of a high-risk mechanism, triggering trauma team activations and costly work-ups. The height and other details of mechanism are usually reported by lay bystanders or prehospital personnel. This small observational study was designed to evaluate how accurate or inaccurate height estimation may be among typical bystanders.

METHODS:
This was a blinded, prospective study conducted on the grounds of a community hospital. Four panels with lines corresponding to varying heights from 1-25 ft were hung within a building structure that did not have stories or other possibly confounding factors by which to judge height. The participants were asked to estimate the height of each line using a multiple-choice survey-style ballot. Participants were adult volunteers composed of various hospital and non-hospital affiliated persons, of varying ages and genders. In total, there were 96 respondents.

RESULTS:
For heights equal to or greater than 15 ft, less than 50% of participants of each job description were able to correctly identify the height. When arranged into a scatter plot, as height increased, the likelihood to underestimate the correct height was evident, having a strong correlation coefficient (R=+0.926) with a statistically significant p value = less than 0.001.

CONCLUSION:
The use of vertical height as a predictor of injury severity is part of current practice in trauma triage. This data is often an estimation provided by prehospital personnel or bystanders. Our small study showed bystanders may not estimate heights accurately in the field. The greater the reported height, the less likely it is to be accurate. Additionally, there is a higher likelihood that falls from greater than 15 ft may be underestimated.


18. How events in emergency medicine impact doctors' psychological well-being.

Howard L, et al. Emerg Med J. 2018 Oct;35(10):595-599.

Background Emergency medicine is a high-pressured specialty with exposure to disturbing events and risk. We conducted a qualitative study to identify which clinical events resulted in emotional disruption and the impact of these events on the well-being of physicians working in an ED.

Methods We used the principles of naturalistic inquiry to conduct narrative interviews with physicians working in the ED at Central Manchester University Hospitals NHS Foundation Trust, between September and October 2016. Participants were asked, ‘Could you tell me about a time when an event at work has continued to play on your mind after the shift in which it occurred was over?’ Data were analysed using framework analysis. The study had three a priori themes reported here. Other emergent themes were analysed separately.

Results We interviewed 17 participants. Within the first a priori theme (‘clinical events’) factors associated with emotional disruption included young or traumatic deaths, patients or situations that physicians could relate to, witnessing the impact of death on relatives, the burden of responsibility (including medical error) and conflict in the workplace. Under theme 2 (psychological and physical effects), participants reported substantial upset leading to substance misuse, sleep disruption and neglecting their own physical needs through preoccupation with caring. Within theme 3 (impact on relationships), many interviewees described becoming withdrawn from personal relationships following clinical events, while others described feeling isolated because friends and family were non-medical.

Conclusions Clinical events encountered in the ED can affect a physician’s psychological and physical well-being. For many participants these effects were negative and long lasting.


19. IM Midazolam, Olanzapine, Ziprasidone, or Haloperidol for Treating Acute Agitation in the ED

Klein L, et al. Ann Emerg Med 2018;72(4):374-85.

Study objective
Agitation in the emergency department (ED) can pose a threat to patient and provider safety; therefore, treatment is indicated. The purpose of this study is to compare haloperidol, olanzapine, midazolam, and ziprasidone to treat agitation.

Methods
This was a prospective observational study of consecutive patients receiving intramuscular medication to treat agitation in the ED. Medications were administered according to an a priori protocol in which the initial medication given was predetermined in the following 3-week blocks: haloperidol 5 mg, ziprasidone 20 mg, olanzapine 10 mg, midazolam 5 mg, and haloperidol 10 mg. The primary outcome was the proportion of patients adequately sedated at 15 minutes, assessed with the Altered Mental Status Scale.

Results
Seven hundred thirty-seven patients were enrolled (median age 40 years; 72% men). At 15 minutes, midazolam resulted in a greater proportion of patients adequately sedated (Altered Mental Status Scale less than 1) compared with ziprasidone (difference 18%; 95% confidence interval [CI] 6% to 29%), haloperidol 5 mg (difference 30%; 95% CI 19% to 41%), haloperidol 10 mg (difference 28%; 95% CI 17% to 39%), and olanzapine (difference 9%; 95% CI –1% to 20%). Olanzapine resulted in a greater proportion of patients adequately sedated at 15 minutes compared with haloperidol 5 mg (difference 20%; 95% CI 10% to 31%), haloperidol 10 mg (difference 18%; 95% CI 7% to 29%), and ziprasidone (difference 8%; 95% CI –3% to 19%). Adverse events were uncommon: cardiac arrest (0), extrapyramidal adverse effects (2; 0.3%), hypotension (5; 0.5%), hypoxemia (10; 1%), and intubation (4; 0.5%), and occurred at similar rates in each group.

Conclusion
Intramuscular midazolam achieved more effective sedation in agitated ED patients at 15 minutes than haloperidol, ziprasidone, and perhaps olanzapine. Olanzapine provided more effective sedation than haloperidol. No differences in adverse events were identified.

20. Association Between Physical Therapy in the ED and ED Revisits for Older Adult Fallers: A Nationally Representative Analysis

Lesser A, et al. J Am Geriatr Soc. 2018 Aug 21  [Epub ahead of print]

OBJECTIVES:
To determine whether providing physical therapy (PT) services in the emergency department (ED) improves outcomes for older adults who fall.

DESIGN:
We used Medicare claims data to examine differences in recurrent fall-related ED revisit rates of older adults who presented to the ED for a ground-level fall and whether they received PT services in the ED. Our logistic regression model controlled for age, sex, Medicaid eligibility, acute injury, and certain known chronic comorbidities associated with risk of falling.

SETTING:
We analyzed national 2012-13 Medicare claims data for individuals aged 65 and older.

PARTICIPANTS:
This was a claims-based analysis. We defined an index visit as any ED claim that included an International Classification of Diseases, Ninth Revision, Clinical Modification E-Code indicating a ground-level fall. Visits resulting in admission were excluded, as were claims associated with an individual who died during follow-up; 17,975 of the 560,277 claims for eligible outpatient index visits included revenue center codes for PT services.

MEASUREMENTS:
We calculated the proportion of index visits associated with a fall-related ED revisit within 30 and 60 days and assessed differences in these proportions between individuals who did and did not receive PT services in the ED.

RESULTS:
Receiving PT services in the ED during an index visit for a ground-level fall was associated with a significantly lower likelihood of a fall-related ED revisit within 30 days (odds ratio (OR)=0.655, p less than .001) and 60 days (OR=0.684, p less than .001).

CONCLUSION:
Expanding PT services in the ED may reduce future fall-related ED use of older adults. Additional analyses could assess characteristics of individuals receiving PT in the ED and follow-up PT use after discharge.


21. LVADs in Emergency Medicine

A. Left Ventricular Assist Device Management in the ED

Trinquero P, et al. West J Emerg Med. 2018 Sep;19(5):834-841.

The prevalence of patients living with a left ventricular assist device (LVAD) is rapidly increasing due to improvements in pump technology, limiting the adverse event profile, and to expanding device indications. To date, over 22,000 patients have been implanted with LVADs either as destination therapy or as a bridge to transplant. It is critical for emergency physicians to be knowledgeable of current ventricular assist devices (VAD), and to be able to troubleshoot associated complications and optimally treat patients with emergent pathology. Special consideration must be taken when managing patients with VADs including device inspection, alarm interpretation, and blood pressure measurement. The emergency physician should be prepared to evaluate these patients for cerebral vascular accidents, gastrointestinal bleeds, pump failure or thrombosis, right ventricular failure, and VAD driveline infections. Early communication with the VAD team and appropriate consultants is essential for emergent care for patients with VADs.


B. Analysis of Patients with Ventricular Assist Devices Presenting to an Urban ED

McKillip RP, et al. West J Emerg Med 2018 Sept 10 [Epub ahead of print]

Introduction: Left ventricular assist device (LVAD) insertion is an increasingly common intervention for patients with advanced heart failure; however, published literature on the emergency department (ED) presentation of this population is limited. The objective of this study was to characterize ED presentations of patients with LVADs with a focus on device-specific complications to inform provider education and preparation initiatives.

Methods: This was a retrospective chart review of all patients with LVADs followed at an urban academic medical center presenting to the ED over a five-year period (July 1, 2009, to June 30, 2014). Two abstractors reviewed 45 randomly selected charts to standardize the abstraction process and establish a priori categories for reason for presentation to the ED. Remaining charts were then divided evenly for review by one of the two abstractors. Primary outcomes for this study were (1) frequency of and (2) reason for presentation to the ED by patients with LVADs.

Results: Of 349 patients with LVADs identified, 143 (41.0%) had ED encounters during the study period. There were 620 total ED encounters, (range 1 to 32 encounters per patient, median=3, standard deviation=5.3). Among the encounters, 431 (69.5%) resulted in admission. The most common reasons for presentation were bleeding (e.g., gastrointestinal, epistaxis) (182, 29.4%); infection (127, 20.5%); heart failure exacerbation (68, 11.0%); pain (56, 9.0%); other (45, 7.3%); and arrhythmias (40, 6.5%). Fifty-two encounters (8.4%) were device-specific; these patients frequently presented with abnormal device readings (37, 6.0%). Interventions for device-specific presentations included anticoagulation regimen adjustment (16/52, 30.8%), pump exchange (9, 17.3%), and hardware repair (6, 11.5%). Pump thrombosis occurred in 23 cases (3.7% of all encounters). No patients required cardiopulmonary resuscitation or died in the ED.

Conclusion: This is the largest study known to the investigators to report the rate of ED presentations of patients with LVADs and provide analysis of device-specific presentations. In patients who do have device-specific ED presentations, pump thrombosis is a common diagnosis and can present without device alarms. Specialized LVAD education and preparation initiatives for ED providers should emphasize the recognition and management of the most common and critical conditions for this patient population, which have been identified in this study as bleeding, infection, heart failure, and pump thrombosis.


22. Comparison of the Safety Planning Intervention with Follow-up vs Usual Care of Suicidal Patients Treated in the ED.

Stanley B, et al. JAMA Psychiatry. 2018 Sep 1;75(9):894-900.

A simple suicide intervention that worked

IMPORTANCE:
Suicidal behavior is a major public health problem in the United States. The suicide rate has steadily increased over the past 2 decades; middle-aged men and military veterans are at particularly high risk. There is a dearth of empirically supported brief intervention strategies to address this problem in health care settings generally and particularly in emergency departments (EDs), where many suicidal patients present for care.

OBJECTIVE:
To determine whether the Safety Planning Intervention (SPI), administered in EDs with follow-up contact for suicidal patients, was associated with reduced suicidal behavior and improved outpatient treatment engagement in the 6 months following discharge, an established high-risk period.

DESIGN, SETTING, AND PARTICIPANTS:
Cohort comparison design with 6-month follow-up at 9 EDs (5 intervention sites and 4 control sites) in Veterans Health Administration hospital EDs. Patients were eligible for the study if they were 18 years or older, had an ED visit for a suicide-related concern, had inpatient hospitalization not clinically indicated, and were able to read English. Data were collected between 2010 and 2015; data were analyzed between 2016 and 2018.

INTERVENTIONS:
The intervention combines SPI and telephone follow-up. The SPI was defined as a brief clinical intervention that combined evidence-based strategies to reduce suicidal behavior through a prioritized list of coping skills and strategies. In telephone follow-up, patients were contacted at least 2 times to monitor suicide risk, review and revise the SPI, and support treatment engagement.

MAIN OUTCOMES AND MEASURES:
Suicidal behavior and behavioral health outpatient services extracted from medical records for 6 months following ED discharge.

RESULTS:
Of the 1640 total patients, 1186 were in the intervention group and 454 were in the comparison group. Patients in the intervention group had a mean (SD) age of 47.15 (14.89) years and 88.5% were men (n = 1050); patients in the comparison group had a mean (SD) age of 49.38 (14.47) years and 88.1% were men (n = 400). Patients in the SPI+ condition were less likely to engage in suicidal behavior (n = 36 of 1186; 3.03%) than those receiving usual care (n = 24 of 454; 5.29%) during the 6-month follow-up period. The SPI+ was associated with 45% fewer suicidal behaviors, approximately halving the odds of suicidal behavior over 6 months (odds ratio, 0.56; 95% CI, 0.33-0.95, P = .03). Intervention patients had more than double the odds of attending at least 1 outpatient mental health visit (odds ratio, 2.06; 95% CI, 1.57-2.71; P  less than .001).

CONCLUSIONS AND RELEVANCE:
This large-scale cohort comparison study found that SPI+ was associated with a reduction in suicidal behavior and increased treatment engagement among suicidal patients following ED discharge and may be a valuable clinical tool in health care settings.

23. CT for Minor Head Injury in Kids and Adults

A. Effect of the Head CT Choice Decision Aid in Parents of Children with Minor Head Trauma: A Cluster Randomized Trial

Hess EP, et al. JAMA Network Open. 2018;1(5):e182430.

Key Points
Question  What is the effect of a decision aid in parents of children with minor head trauma?

Findings  In this cluster randomized trial of 172 clinicians caring for 971 children at intermediate risk of traumatic brain injury, the Head Computed Tomography Choice decision aid increased parental knowledge, decreased decisional conflict, and increased engagement. The intervention did not reduce the emergency department computed tomography rate but safely decreased 7-day health care utilization.

Meaning  Use of a decision aid in parents of children with minor head trauma had no effect on the emergency department computed tomography rate, but improved decisional quality and safely decreased downstream health care utilization.

Abstract
Importance  The Pediatric Emergency Care Applied Research Network prediction rules for minor head trauma identify children at very low, intermediate, and high risk of clinically important traumatic brain injuries (ciTBIs) and recommend no computed tomography (CT) for those at very low risk. However, the prediction rules provide little guidance in the choice of home observation or CT in children at intermediate risk for ciTBI.

Objective  To compare a decision aid with usual care in parents of children at intermediate risk for ciTBI.

Design, Settings, and Participants  This cluster randomized trial was conducted in 7 geographically diverse US emergency departments (EDs) from April 1, 2014, to September 30, 2016. Eligible participants were emergency clinicians, children ages 2 to 18 years with minor head trauma at intermediate risk for ciTBI, and their parents.

Interventions  Clinicians were randomly assigned (1:1 ratio) to shared decision-making facilitated by the Head CT Choice decision aid or to usual care.

Main Outcomes and Measures  The primary outcome, selected by parent stakeholders, was knowledge of their child’s risk for ciTBI and the available diagnostic options. Secondary outcomes included decisional conflict, parental involvement in decision-making, the ED CT rate, 7-day health care utilization, and missed ciTBI.

Results  A total of 172 clinicians caring for 971 children (493 decision aid; 478 usual care) with minor head trauma at intermediate risk for ciTBI were enrolled. The patient mean (SD) age was 6.7 (7.1) years, 575 (59%) were male, and 253 (26%) were of nonwhite race. Parents in the decision aid arm compared with the usual care arm had greater knowledge (mean [SD] questions correct: 6.2 [2.0] vs 5.3 [2.0]; mean difference, 0.9; 95% CI, 0.6-1.3), had less decisional conflict (mean [SD] decisional conflict score, 14.8 [15.5] vs 19.2 [16.6]; mean difference, −4.4; 95% CI, −7.3 to −2.4), and were more involved in CT decision-making (observing patient involvement [OPTION] scores: mean [SD], 25.0 [8.5] vs 13.3 [6.5]; mean difference, 11.7; 95% CI, 9.6-13.9). Although the ED CT rate did not significantly differ (decision aid, 22% vs usual care, 24%; odds ratio, 0.81; 95% CI, 0.51-1.27), the mean number of imaging tests was lower in the decision aid arm 7 days after injury. No child had a missed ciTBI.

Conclusions and Relevance  Use of a decision aid in parents of children at intermediate risk of ciTBI increased parent knowledge, decreased decisional conflict, and increased involvement in decision-making. The intervention did not significantly reduce the ED CT rate but safely decreased health care utilization 7 days after injury.

Full-text (free): https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2703135

Radecki’s critique: https://www.emlitofnote.com/?p=4298

B. External validation of CT decision rules for minor head injury: prospective, multicentre cohort study in the Netherlands

Foks KA, et al. BMJ 2018;362:k3527

OBJECTIVE:
To externally validate four commonly used rules in computed tomography (CT) for minor head injury.

DESIGN:
Prospective, multicentre cohort study.

SETTING:
Three university and six non-university hospitals in the Netherlands.

PARTICIPANTS:
Consecutive adult patients aged 16 years and over who presented with minor head injury at the emergency department with a Glasgow coma scale score of 13-15 between March 2015 and December 2016.

MAIN OUTCOME MEASURES:
The primary outcome was any intracranial traumatic finding on CT; the secondary outcome was a potential neurosurgical lesion on CT, which was defined as an intracranial traumatic finding on CT that could lead to a neurosurgical intervention or death. The sensitivity, specificity, and clinical usefulness (defined as net proportional benefit, a weighted sum of true positive classifications) of the four CT decision rules. The rules included the CT in head injury patients (CHIP) rule, New Orleans criteria (NOC), Canadian CT head rule (CCHR), and National Institute for Health and Care Excellence (NICE) guideline for head injury.

RESULTS:
For the primary analysis, only six centres that included patients with and without CT were selected. Of 4557 eligible patients who presented with minor head injury, 3742 (82%) received a CT scan; 384 (8%) had a intracranial traumatic finding on CT, and 74 (2%) had a potential neurosurgical lesion. The sensitivity for any intracranial traumatic finding on CT ranged from 73% (NICE) to 99% (NOC); specificity ranged from 4% (NOC) to 61% (NICE). Sensitivity for a potential neurosurgical lesion ranged between 85% (NICE) and 100% (NOC); specificity from 4% (NOC) to 59% (NICE). Clinical usefulness depended on thresholds for performing CT scanning: the NOC rule was preferable at a low threshold, the NICE rule was preferable at a higher threshold, whereas the CHIP rule was preferable for an intermediate threshold.

CONCLUSIONS:
Application of the CHIP, NOC, CCHR, or NICE decision rules can lead to a wide variation in CT scanning among patients with minor head injury, resulting in many unnecessary CT scans and some missed intracranial traumatic findings. Until an existing decision rule has been updated, any of the four rules can be used for patients presenting minor head injuries at the emergency department. Use of the CHIP rule is recommended because it leads to a substantial reduction in CT scans while missing few potential neurosurgical lesions.


Related: Around One In Six American Adults Have Been Knocked Unconscious By Head Injury: NEJM: https://www.nejm.org/doi/full/10.1056/NEJMc1808550

Related: Concussion Rate Plummets In Ivy League Football After Kickoff Change:

24. Micro Bits

A. Psychological distress may increase odds of heart trouble

UK and Australian researchers found that women ages 45 and older with high or very high levels of psychological distress were 44% more likely to have a stroke and 18% more likely to have a heart attack, compared with those with low levels of psychological distress. The findings in Circulation: Cardiovascular Quality and Outcomes also showed a 30% increased likelihood of heart attack among men ages 45 to 79 with high or very high psychological distress, but the association was weaker among those ages 80 and older.


B. Study Shows Physicians, Nurses How They Talk to Each Other

Authors See Broad Utility in Model of Recording Medical Setting Interactions



C. Conflicting Beliefs Shouldn't Hinder Patient Care

Kim came to my office for a followup regarding hormone replacement therapy, but when I asked how she was tolerating the medication, Kim -- a transgender female -- said she had been unable to fill her prescription. A pharmacist told her he could not do so, but did not explain why and did not refer her elsewhere.

Kim's story sounded familiar because there have been other, high-profile stories of patients being refused prescribed medications this summer.


D. Interventions to improve patient flow in ED: an umbrella review

Conclusions Overall, the evidence supporting the interventions to improve patient flow is weak. Only the fast track intervention had moderate evidence to support its use but correlation/clustering was not taken into consideration in the RCTs examining the intervention. Failure to consider the correlation of the data in the primary studies could result in erroneous conclusions of effectiveness.


E. Survey Finds One in Three U.S. Teens Texts While Driving

Scary!


F. My mother was in unbearable pain, but the ER staff didn’t seem to believe her

…Furthermore, pain experienced by women is often treated differently than that of men. Studies have shown that in men and women reporting similar levels of pain, women were less likely to receive any pain medication and less likely to receive opiate medications. In addition, women waited longer to receive such medications. Similarly, women are nearly twice as likely as men to receive an “emotional or mental diagnosis” compared with one for a physical ailment when showing the same symptoms.

Yet pain does not discriminate. Pain makes you vulnerable. Pain is the great equalizer.

Washington Post: https://wapo.st/2InCh8T

G. Teens Who Get Too Little Sleep May Be More Likely To Engage In Risky Behaviors, Study Indicates.


H. Semi-Automatic Rifles Make Active Shooters More Deadly, Research Indicates.

Researchers have found that “active shooters with semi-automatic rifles wound and kill twice as many people as those using non-automatic weapons.”


I. Aspirin Not so Hot for Primary Prevention of Cardiovascular Events

Allan S. Brett, MD. Journal Watch. September 6, 2018

Two new studies push the pendulum away from aspirin prophylaxis.

…In sum, among nondiabetic patients with CV risk factors, aspirin conferred no benefit and was associated with slight harm. Among diabetic patients, the tradeoff between small probabilities of benefit and harm was a close call. Notably, a large proportion of patients in both studies were taking statins and antihypertensive drugs, and only a small proportion were current smokers. Thus, one could reasonably conclude that these studies examined the incremental benefit of aspirin, added to other standard preventive interventions.


J. USPSTF Recommends Intensive Behavioral Intervention for Obesity


K. E-cigarette use increases MI risk

A study in the American Journal of Preventive Medicine found daily e-cigarette use may nearly double the risk for myocardial infarction, and using both e-cigarettes and conventional cigarettes daily increased the risk fivefold. Senior author Stanton Glantz said patients should be reminded that e-cigarettes do not actually help with smoking cessation, although they are promoted as smoking cessation devices.


L. Southern Diet Called Single Biggest Factor in HTN Racial Disparities: Higher incidence among blacks also associated with other social, clinical factors


M. Updated car seat guidance

The American Academy of Pediatrics' updated policy on childhood passenger safety recommends basing car safety seat usage on height and weight instead of largely on age. Family physicians should be aware of these recommendations and discuss auto safety with parents and caregivers.


N. WHO: One in 20 deaths globally related to alcohol use

The World Health Organization found more than 1 in 20 deaths globally in 2016 was related to alcohol, with 28% due to traffic accidents, self-harm, violence and other injuries. The report found more than 75% of the deaths were among men.


O. Irregular bedtimes increase health risks, study says

An analysis of sleeping patterns for almost 2,000 adults found those who had irregular bedtimes had higher body mass index and blood pressure, as well as higher levels of blood sugar and HbA1C, compared with those who had more regular sleeping patterns, according to a study published in Scientific Reports. People with irregular sleep patterns also had a higher risk of heart attack, stroke, depression and stress.


P. Patient-Identified Needs Related to Seeking a Diagnosis in the ED


Q. Medical Expulsive Therapy No Longer Recommended for Ureterolithiasis

Radecki in ACEP Now. Aug 29, 2018


R. ADHD May Affect One in Ten Children
U.S. prevalence jumped to 10%, up from 6% two decades ago