1. The HEART Score in Action
A. The HEART Score for Suspected ACS in U.S. EDs
Sharp AL, et
al. J Am Coll Cardiol. 2018 Oct 9;72(15):1875-1877.
Excerpts
We conducted a
prospective study of all suspected ACS ED encounters at 15 community hospitals.
Study sites were operated by Kaiser Permanente Southern California (KPSC). KPSC
is an integrated health system that, in May 2016, implemented decision support to
capture HEART scores and incorporate this tool into routine ED care. All ED
encounters for Kaiser
members (over 80%
of ED visits) with a prospective HEART score documented by the treating
emergency physician were included. Encounters were excluded if patients were less
than 18 years of age, died in the ED, transferred to another hospital, had a do
not resuscitate/hospice status, or had an ED acute myocardial infarction (MI)
diagnosis. All sites use the same troponin laboratory assay (Access AccuTnIþ3,
Beckman Coulter, Brea, California) to calculate the HEART score.
The primary
outcome was 30-day all-cause mortality or acute MI. The secondary outcome was
6-week major
adverse cardiac event rates, which also included any coronary revascularization
procedures. C-statistics were calculated for the HEART score’s ability to
predict the primary and secondary outcomes.
A total of
29,196 ED encounters met the study criteria, and most (59%) had low-risk (0 to
3) HEART scores (n = 16,703). The overall frequency of 30-day MI and death was
0.6%, with increasing frequencies related to higher HEART scores (Figure 1).
The percent of patients having an adverse event ranged from 0% (0 of 1,794) for
encounters with a HEART score of 0 to
11.1% (1 of 9)
for a HEART score of 10. ED encounters for patients with low-risk HEART scores
(0 to 3) had a primary event that occurred in 35 of 16,703 (0.2%; 95%
confidence interval [CI]: 0.1 to 0.3) for patients at low risk, 114 of 11,302
(1.0%; 95% CI: 0.8 to 1.2) for those at moderate to risk (4 to 6), and 36 of 1,191
(3.0%; 95% CI: 2.1 to 4.0) for those at high risk (7 to 10).
The
C-statistic describing the accuracy of the HEART score for the primary outcome
was 0.76 (95% CI: 0.72 to 0.79). In the sensitivity analysis including the ED
encounters for patients with an MI, the c-statistic was 0.88 (95% CI: 0.87 to
0.89). Likelihood ratios for low-risk, moderate-risk, and high-risk HEART scores
were 0.3, 1.6, and 4.9, respectively. The overall proportion of 6-week major
adverse cardiac events was 1.5%, with most events attributable to revascularization (234 of 448; 52.2%)
(C-statistic 0.78; 95% CI:0.77 to 0.80).
Our results
demonstrate that the majority of ED patients with suspected ACS fall below the
1% risk threshold of a 30-day adverse event. If a HEART score of 5 or below
were chosen as the low-risk threshold (about 1% 30-day MI or death risk) (5),
this would account for 89% of the ED encounters, representing a large number of
visits that might safely avoid hospitalization or noninvasive cardiac stress
testing.
For more on
the study’s context and design: Sharp AL, et al. Improving Emergency Department
Care for Low-Risk Chest Pain. NEJM Catal. 2018; Epub 2018 Apr 18.
Key
Takeaways from the NEJM article
- Adopting
an evidence-based clinical decision aid like the HEART score to risk-stratify
patients may improve the quality and efficiency of ED care for low-risk
patients with possible acute coronary syndrome (ACS).
- Patients
who have low-risk HEART scores are at extremely low risk for 30-day
adverse events, and below previously reported acceptable “miss rates.”
- A
large opportunity exists to avoid unwarranted hospital admissions and
noninvasive cardiac testing, which have not been shown to
improve outcomes for low-risk chest pain patients.
- Early engagement of thought leaders and frontline physicians through multiple modes of communication is vital to the success of a large-scale intervention like this.
B. Safely Identifying ED Pts with Acute CP for Early
Discharge: The HEART Pathway Accelerated Diagnostic Protocol
Mahler SA, et
al. Circulation. 2018 Sept 28 [Epub ahead of print]
Background:
The HEART Pathway is an accelerated diagnostic protocol (ADP) designed to
identify low-risk Emergency Department (ED) patients with chest pain for early
discharge without stress testing or angiography. The objective of this study
was to determine whether implementation of the HEART Pathway is safe (30 day
death and myocardial infarction rate less than 1% in low-risk patients) and
effective (reduces 30 day hospitalizations) in ED patients with possible acute
coronary syndrome (ACS).
Methods: A
prospective pre/post study was conducted at three US sites among 8,474 adult ED
patients with possible ACS. Patients included were greater than 21 years old, investigated for
possible ACS, and had no evidence of ST-segment elevation myocardial infarction
on electrocardiography. Accrual occurred for 12 months before and after HEART
Pathway implementation from November 2013- January 2016. The HEART Pathway ADP
was integrated into each site's electronic health record as an interactive
clinical decision support tool. Following ADP integration, ED providers
prospectively utilized the HEART Pathway to identify patients with possible ACS
as low-risk (appropriate for early discharge without stress testing or
angiography) or non-low-risk (appropriate for further in-hospital evaluation).
The primary safety and effectiveness outcomes, death and myocardial infarction
(MI) and hospitalization rates at 30 days, were determined from health records,
insurance claims, and death index data.
Results: Pre-
and post-implementation cohorts included 3713 and 4761 patients, respectively.
The HEART Pathway identified 30.7% as low-risk; 0.4% of these patients
experienced death or MI within 30 days. Hospitalization at 30 days was reduced
by 6% in the post- vs preimplementation cohort (55.6% vs 61.6%; aOR: 0.79,
95%CI: 0.71-0.87). During the index visit more MIs were detected in the
post-implementation cohort (6.6% vs 5.7%; aOR: 1.36, 95%CI:1.12-1.65). Rates of
death or MI during follow-up were similar (1.1% vs 1.3%; aOR: 0.88, 95% CI:
0.58-1.33).
Conclusions:
HEART Pathway implementation was associated with decreased hospitalizations,
increased identification of index visit MIs, and a very low death and MI rate
among low-risk patients. These findings support use of the HEART Pathway to
identify low-risk patients that can be safely discharged without stress testing
or angiography.
C.
Do all HEART Scores beat the same: evaluating the interoperator reliability of
the HEART Score.
Niven WGP, et
al. Emerg Med J. 2018 Sep 14 [Epub ahead of print]
Background
Patients presenting with chest pain represent a significant proportion of
attendances to the ED. The History, ECG, Age, Risk Factors and Troponin (HEART)
Score is validated for the risk stratification of suspected ischaemic chest
pain within the ED. The goal of this research was to establish the
interoperator reliability of the HEART Score as performed in the ED by
different grades of doctor and nurse.
Methodology
Patients with suspected ischaemic chest pain presenting to the ED of an inner
city, London Hospital, were recruited prospectively between January and May
2016. Patients that had been enrolled in the study were interviewed by
clinicians from four different categories: senior doctor, junior doctor, senior
nurse and junior nurse. Clinicians, blinded to other raters’ results,
calculated the HEART Scores for each patient with the assistance of a
pocket-sized HEART Score card. The intraclass correlation coefficient (ICC) was
calculated as the primary measure of reliability. 120 patients were required to
achieve a desired power of 80%.
Results 88
complete comparisons were obtained. There were no significant differences
between the distributions of HEART Scores for each clinician group (p=0.95).
The ICC for the overall HEART Score was 0.91 (95% CI 0.87 to 0.93). The ICC for
troponin and age were ‘1’, for ‘history’ 0.41 (95% CI 0.30 to 0.52), ‘ECG’ 0.64
(95% CI 0.54 to0.73) and ‘risk factors’ 0.84 (95% CI 0.79 to 0.89).
Conclusion
This study demonstrates very strong overall interoperator reliability between
the four groups of clinicians studied. This suggests that the HEART Score is
reproducible when used by different professional groups and grade of clinician.
2. Clinical Policy: Critical Issues in the Evaluation and
Management of ED Patients with Suspected Non–ST-Elevation ACS
Tomaszewski
CA, et al. Ann Emerg Med. 2018;72(5):e65–e106
Five Critical
Questions
1. In adult
patients without evidence of ST-elevation acute coronary syndrome, can initial
risk stratification be used to predict a low rate of 30-day major adverse
cardiac events?
Level A
recommendations: None specified.
Level B
recommendations
In adult
patients without evidence of ST-elevation ACS, the History, ECG, Age, Risk
factors, Troponin (HEART) score can be used as a clinical prediction instrument
for risk stratification. A low score (≤3) predicts a 30-day major adverse
cardiac event miss rate within a range of 0% to 2%.
Level C
recommendations
In adult
patients without evidence of ST-elevation ACS, other risk-stratification tools,
such as Thrombolysis in Myocardial Infarction (TIMI), can be used to predict a
rate of 30-day major adverse cardiac events.
2. In adult
patients with suspected acute non–ST-elevation ACS, can troponin testing within
3 hours of ED presentation be used to predict a low rate of 30-day major
adverse cardiac events?
Level A
recommendations: None specified.
Level B
recommendations: None specified.
Level C
recommendations
(1) In adult
patients with suspected acute non–ST-elevation ACS, conventional troponin
testing at 0 and 3 hours among low-risk ACS patients (defined by HEART score 0
to 3) can predict an acceptable low rate of 30-day major adverse cardiac
events.
(2) A single
high-sensitivity troponin result below the level of detection on arrival to the
ED, or negative serial high-sensitivity troponin result at 0 and 2 hours is
predictive of a low rate of major adverse cardiac events.
(3) In adult
patients with suspected acute non–ST-elevation ACS who are determined to be low
risk based on validated accelerated diagnostic pathways that include a
nonischemic ECG result and negative serial high-sensitivity troponin testing
results both at presentation and at 2 hours can predict a low rate of 30-day
major adverse cardiac events allowing for an accelerated discharge pathway from
the ED.
3. In adult
patients with suspected non–ST-elevation ACS in whom AMI has been excluded,
does further diagnostic testing (eg, provocative, stress test, computed
tomography [CT] angiography) for ACS prior to discharge reduce 30-day major
adverse cardiac events?
Level A
recommendations: None specified.
Level B
recommendations
Do not
routinely use further diagnostic testing (coronary CT angiography, stress
testing, myocardial perfusion imaging) prior to discharge in low-risk patients
in whom AMI has been ruled out to reduce 30-day major adverse cardiac events.
Level C
recommendations
Arrange
follow-up in 1 to 2 weeks for low-risk patients in whom myocardial infarction
has been ruled out. If no follow-up is available, consider further testing or
observation prior to discharge (Consensus recommendation).
4. Should
adult patients with acute non–STEMI receive immediate antiplatelet therapy in
addition to aspirin to reduce 30-day major adverse cardiac events?
Level A
recommendations: None specified.
Level B
recommendations: None specified.
Level C recommendations
P2Y12
inhibitors and glycoprotein IIb/IIIa inhibitors may be given in the ED or
delayed until cardiac catheterization.
Full-text
(free) of the full article: https://www.annemergmed.com/article/S0196-0644(18)30678-4/fulltext
Full-text
(free) of much shorter Executive Summary: https://www.annemergmed.com/article/S0196-0644(18)31310-6/fulltext
3. Cardiac Arrest Research
A. Studies Test Common Cardiac-Arrest Advanced Life
Support Practices
Ryan Radecki,
ACEP Now, 2018 Oct 16
There’s a big
difference between patients who are mostly dead and all dead. Mostly dead is,
by logical extension, slightly alive. Slightly alive we can work with.
However, this
leads to a question: Which application of the medical sciences is best for the
slightly alive?
Two important
questions have remained controversial for decades: the use of epinephrine in
cardiac arrest and the type of advanced airway management provided. This year
has brought to light several new studies concerning these topics, but they seem
to provide only minimal illumination…
Conclusion: “I
believe the current evidence favors conserving limited health care resources by
omitting epinephrine and using primarily SGA, if any airway is even needed.
However, it would be just as reasonable for a medical director to draw up
protocols using both epinephrine and ETI as it would be to omit both. At the
end of the day, we are a little closer to definitive answers, but we have many
new questions.”
Full-text
(free): https://www.acepnow.com/article/studies-test-common-cardiac-arrest-advanced-life-support-practices/
B. Always Stressed: Cardiac Arrest No Longer Peaks on
Monday Morning
For decades,
health experts believed that weekday mornings — especially Mondays — were prime
time for unexpected deaths and sudden cardiac arrests.
The reason,
they predicted, was due to the sudden surge of cortisol — known as the stress
hormone — we experience upon waking up. All that cortisol drives up our blood
pressure, heart rate, and blood sugar levels, and, consequently, would send
early risers off to the emergency room.
However, those
peak hours may now be a thing of the past.
Thanks to the
modern pressures of living and working in a fast-paced world, sudden cardiac
arrests are now more likely to occur at any time any day of the week, according
to a recent study published in Heart Rhythm.
HealthLine
article: https://www.healthline.com/health-news/sudden-cardiac-death-no-longer-linked-to-monday-morning
Unexpected
shift in circadian and septadian variation of sudden cardiac arrest: the Oregon
Sudden Unexpected Death Study.
Ni YM, et al. Heart
Rhythm. 2018 Sep 5 [Epub ahead of print]
BACKGROUND:
Earlier
studies have reported both early morning and Monday peaks in occurrence of
sudden cardiac arrest (SCA) in the community and appropriate defibrillator
shocks in patients with an implantable cardioverter-defibrillator (ICD).
However, a more recent analysis of ICD shocks reported absence of these peaks.
OBJECTIVE:
The purpose of
this study was to perform a contemporary evaluation of the circadian and
septadian variation of SCA in the general population.
METHODS:
The analysis
was performed from an ongoing, population-based study of SCA in a Northwestern
US community of approximately 1 million residents. To maximize accuracy, we
focused on consecutive patients who presented with witnessed SCA and were
attended by emergency medical services (EMS). The specific time of each SCA
event was determined based on the time of the 911 call to EMS.
RESULTS:
During
2002-2014, we identified 1535 patients age ≥18 years who suffered witnessed
SCA, with time of first EMS contact recorded. There was no morning (6 AM to 12
PM) peak, and we observed a nadir in SCA events during 12 AM to 6 AM, with only
13.9% of events occurring during this 6-hour block (P less than .0001). There
was no peak on Mondays, but a nadir was observed on Sundays that accounted for
only 11.3% of SCA events during the week (P = .004).
CONCLUSION:
in this
contemporary community-based study, we failed to observe the expected morning
peak or the Monday peak in SCA, duplicating recent findings in primary
prevention defibrillator patients. The significant public health implications
of these findings merit further investigation.
C. The effect of different target temperatures in
targeted temperature management on neurologically favorable outcome after
out-of-hospital cardiac arrest: A nationwide multicenter observational study in
Japan (the JAAM-OHCA registry).
Avoiding fever
is probably the most important factor.
Irisawa T, et
al. Resuscitation. 2018 Oct 11 [Epub ahead of print]
BACKGROUND:
It has been
insufficiently investigated whether neurological function after out-of-hospital
cardiac arrest (OHCA) would differ by 1 °C change in ordered target temperature
of 33-36 °C among patients undergoing targeted temperature management (TTM) in
the real-world setting.
METHODS:
This nationwide
hospital-based observational study (The Japanese Association for Acute
Medicine-OHCA Registry) conducted between June 2014 and December 2015 in Japan
included OHCA patients aged ≥18 years who were treated with TTM. The primary
outcome was one-month survival with neurologically favorable outcomes defined
by cerebral performance category 1 or 2. To investigate the effect of TTM by
1 °C change in ordered target temperature of 33-36 °C on each outcome, random
effects logistic regression analyses were performed.
RESULTS:
The final
analysis included 738 patients. The proportion of patients with neurologically
favorable outcome was 30.4% (7/23), 31.7% (175/552), 28.9% (11/38), and 30.4%
(38/125) in the 33 °C, 34 °C, 35 °C, and 36 °C groups, respectively. In the
multivariable logistic regression analysis, no group had a higher proportion of
neurologically favorable outcome compared with the 34 °C group (vs. 33 °C
group, adjusted odds ratio [AOR] 0.90; 95% confidence interval [CI] 0.25-3.12,
vs. 35 °C group, AOR 1.17; 95% CI 0.44-3.13, vs. 36 °C group, AOR 1.26; 95% CI
0.78-2.02).
CONCLUSIONS:
In this
population, we evaluated the difference in outcomes after adult OHCA patients
received TTM by 1 °C change in ordered target temperature of 33-36 °C and
demonstrated that there was no statistically significant difference in
neurologically favorable outcomes after OHCA irrespective of target
temperature.
D. Make it two: A case report of dual sequential
external defibrillation
Bell CR, et
al. CJEM. 2018 Sep;20(5):792-797.
Dual
sequential external defibrillation (DSED) is the process of near simultaneous
discharge of two defibrillators with differing pad placement to terminate
refractory arrhythmias. Previously used in the electrophysiology suite, this technique
has recently been used in the emergency department and prehospital setting for
out-of-hospital cardiac arrest (OHCA). We present a case of successful DSED in
the emergency department with neurologically intact survival to hospital
discharge after refractory ventricular fibrillation (RVF) and review the
putative mechanisms of action of this technique.
4. Factors Associated with ED Use by Patients With and Without
Mental Health Diagnoses
Niedzwiecki
MJ, et al. JAMA Netw Open. 2018;1(6):e183528.
Introduction
The rate of
visits to US emergency departments (EDs) continues to rise, and EDs
increasingly treat medically underserved patients.1 Because EDs are a high-cost
care setting, policymakers have concentrated on ways to reduce potentially
avoidable utilization.2,3 One area of focus has been on better understanding
the profile of frequent ED users, as they account for a disproportionate
percentage of ED visits and expenditures. In fact, 4% to 8% (15.7 million) of
frequent ED users account for 18% to 30% of total ED visits.4-6
Approximately
50% of frequent ED users have a mental health diagnosis,4 and this group has
higher rates of morbidity and mortality and incurs higher medical costs over
time.7-9 Additionally, frequent ED users often have many issues that
historically have been considered nonmedical, including homelessness, food
insecurity, and addiction.7 Nevertheless, up to 80% of patients with mental
illness seek care in medical—instead of behavioral care—settings, where they
often leave without treatment for mental illness.10 Given the potentially low
efficacy of ED-based treatment for mental illness, identifying characteristics
related to increased ED use among patients with mental illness is an important
step toward improving their health care access, quality, and costs.
Recent health
policy innovations have focused on patients with mental health conditions given
their complex needs and high cost burden.11,12 At the federal level, the Center
for Medicare & Medicaid Services has several initiatives currently
supporting states to provide more coordinated care and improved case management
for high-utilizing patients with public insurance. With California’s expansion
of its Medicaid program under the Affordable Care Act in 2014, a new set of
mental health benefits for Medicaid members with mild-to-moderate mental health
needs were added and delegated to Medicaid managed care plans.13 County mental
health plans, however, remain responsible for providing care to Medicaid
beneficiaries with severe mental health needs.
To help inform
such efforts, it is important to understand factors associated with increased
ED use among patients with mental health conditions and also to recognize how
these factors differ in patients without mental illness, if at all. To our
knowledge, no prior studies have examined how factors associated with increased
future ED utilization differ between patients with and without mental health
diagnoses and to what extent the severity of mental health needs is associated
with future ED usage. In our study, we used regression analysis to estimate
which medical and social factors are associated with future ED utilization and
how they differ between those with and without mental health diagnoses.
Abstract
Importance An association between frequent use of the
emergency department (ED) and mental health diagnoses is frequently documented
in the literature, but little has been done to more thoroughly understand why
mental illness is associated with increased ED use.
Objective To determine which factors were associated
with higher ED use in the near future among patients with and without mental
health diagnoses.
Design,
Setting, and Participants A
retrospective case-control study of all patients presenting to the ED in
California in 2013 using past ED data to predict future ED use. Data from
January 1, 2012, through December 31, 2014, from California’s Office of
Statewide Health Planning and Development were analyzed.
Main Outcomes
and Measures Factors associated with
higher ED use in the year following an index visit for patients with vs without
a mental health diagnosis.
Results Among the 3 446 338 individuals in the study
(accounting for 7 678 706 ED visits), 44.6% (1 537 067) were male; 31.6%
(1 089 043) were between the ages of 18 and 30 years, 40.3% (1 338 874) were
between the ages of 31 and 50 years, and 28.1% (968 421) were between the ages
of 51 and 64 years. The mean (SD) number of ED visits per patient per year was
1.69 (2.56), and 29.1% of patients (1 002 884) had at least 1 mental health
diagnosis. Previous hospitalization and high rates of lagged ED visits were
associated with higher future ED use. The severity of the mental health
diagnosis (mild, moderate, or severe) was associated with increased ED visits
(incidence rate ratio [IRR], 1.029; 95% CI, 1.02-1.04 for mild; IRR, 1.121; 95%
CI, 1.11-1.13 for moderate; and IRR, 1.226; 95% CI, 1.22-1.24 for severe).
Little evidence was found for interaction effects between mental health
diagnoses and other diagnoses in predicting increased future ED use.
Conclusions
and Relevance Certain classes of mental
health diagnoses were associated with higher ED use. The presence of a mental
illness diagnosis did not appear to interact with other patient-level factors
in a way that meaningfully altered associations with future ED use.
5. Brief Reviews by Ann Emerg Med
A. Is the Risk
of Bleeding Among Older Adults With Atrial Fibrillation Lower With Antiplatelet
Compared With Oral Anticoagulants?
“In
conclusion, antiplatelet agents are associated with the same risk of major
bleeding events as anticoagulants, and clinical evaluation for potential
bleeding complications should be commensurate with this equivalent risk.”
B. What Is the
Utility of Coronary Computed Tomography Angiography Compared With Standard of
Care for the Evaluation of Acute Chest Pain?
“Compared with
existing standards of care for the evaluation of acute chest pain, coronary
computed tomography (CT) angiography is associated with similar rates of major
adverse events, but higher rates of revascularization.”
C. Is Adenosine or an Intravenous Calcium Channel
Blocker More Effective for Treating Supraventricular Tachycardia?
“Among
patients presenting with supraventricular tachycardia, rates of reversion to
sinus rhythm and hypotension were similar between patients who were given
adenosine or calcium channel blockers.”
D. Does
Lidocaine Gel Decrease Procedural Pain for Pediatric Urethral Catheterization?
“Lidocaine gel
does not reduce the pain of transurethral bladder catheterization in children
younger than 4 years compared with nonanesthetic gel. Further study evaluating
lidocaine gel in patients older than 4 years is required.”
E. Is Hyperpronation More Effective Than Supination for Reduction of a Radial Head Subluxation?
“Hyperpronation has higher success rates than supination for reduction of radial head subluxation, according to low-quality evidence.”
Full-text (free): https://www.annemergmed.com/article/S0196-0644(18)30002-7/fulltext
See also Ballard DW, et al. Medically Clear: A New Twist on Nursemaids Elbow. Emerg Med News. 2017;39(5):13. https://journals.lww.com/em-news/fulltext/2017/05000/Medically_Clear__A_New_Twist_on_Nursemaid_s_Elbow.11.aspx
F. What if hyperpronation fails? What next?
Check out this
helpful treatment algorithm from Makin C et al
HP =
hyperpronation; SF = supination, flexion.
Start with the
affected elbow positioned between 70-90 degrees of flexion, then perform HP as
the initial maneuver of choice. Attempt reduction up to three times, with 10-15
minutes separating each attempt. Employ HP or SF for the second maneuver,
followed by the alternate for the third attempt. Obtain elbow x-rays of
children who fail to regain normal elbow function after three reduction
attempts. If the films are negative, immobilize the arm and arrange outpatient
follow-up with orthopedics or primary care. Note: If SF was performed for the
second maneuver, undertake HP for the third; and vice versa. Source: Used with
permission.
Makin CW, et
al. A literature-based algorithm for treatment of children with radial head
subluxation who fail to respond to initial hyperpronation [letter]. Am J Emerg
Med. 2017;35(9):1365-1367.
G. Among Patients with Intracerebral Hemorrhage, Is Intensive Blood Pressure Decreasing Associated With Improved Outcome?
“Intensive
blood pressure decreasing in patients with acute intracerebral hemorrhage does
not improve functional outcome or mortality.”
H. Is
Antibiotic Therapy Helpful for Preventing Infection After Acute Stroke?
“In patients
with acute ischemic or hemorrhagic stroke, prophylactic antibiotics reduce the
overall infection rate, but do not reduce the risk of pneumonia, death or
dependency.”
6. Be sure to get the name of the dog
Safder T. N
Engl J Med 2018;379:1299-1301.
Excerpts
During morning
rounds, I had presented a patient who was admitted for chest pain after walking
his dog. My attending had asked, “What was the name of his dog?”
I was stumped.
Worse, I didn’t know why we needed to know. Nowhere in the books or the studies
I’d read had a dog’s name contributed to the differential. But the attending
took us back to the patient’s bedside and asked. “Rocky,” the patient said. And
there followed a brief conversation that was more colorful than any other I’d
had with a patient that day. It led to a transformation I did not fully
appreciate at the time: there was an actual person behind that hospital-issued
gown.
Four years
later, I’m not sure anything I’ve carried from residency has been more useful
than that question….
…It is easy to
lose sight of yourself during residency, as you endure the countless hours
spent in windowless rooms entering data in electronic medical records or completing
administrative tasks or juggling a dozen other competing priorities. But if I
may offer one piece of advice to my new colleagues who don a long white coat
for the first time each July: Make sure to get the name of the dog.
7. Post-traumatic Strokes in Kids
A. Hyperdense Middle Cerebral Artery in a Boy with
Road Traffic Accident
A 6-year-old,
right-handed boy presented with acute onset encephalopathy, seizure, and right
hemiparesis following a road traffic accident. A non-contrast computed
tomography (CT) of the head ([Fig. 1]) showed a hypodensity at the left basal
ganglia and a hyperdense middle cerebral artery (MCA). A magnetic resonance
imaging (MRI) of the brain showed a left basal ganglia infract, and the MR
angiography showed attenuated left MCA ([Fig. 2]). The “hyperdense left MCA
sign” (HMCAS) was secondary to a post traumatic dissection and the resulting
thrombosis. The child was managed with anticoagulant therapy.
Full-text
(free): https://www.thieme-connect.com/DOI/DOI?10.1055/s-0038-1673629
B. Population-based study of ischemic stroke risk
after trauma in children and young adults.
Fox CK, et al.
Neurology. 2017 Dec 5;89(23):2310-2316.
OBJECTIVE:
To quantify
the incidence, timing, and risk of ischemic stroke after trauma in a population-based
young cohort.
METHODS:
We
electronically identified trauma patients (less than 50 years old) from a
population enrolled in a Northern Californian integrated health care delivery
system (1997-2011). Within this cohort, we identified cases of arterial
ischemic stroke within 4 weeks of trauma and 3 controls per case. A physician
panel reviewed medical records, confirmed cases, and adjudicated whether the
stroke was related to trauma. We calculated the 4-week stroke incidence and
estimated stroke odds ratios (OR) by injury location using logistic regression.
RESULTS:
From 1,308,009
trauma encounters, we confirmed 52 trauma-related ischemic strokes. The 4-week
stroke incidence was 4.0 per 100,000 encounters (95% confidence interval [CI]
3.0-5.2). Trauma was multisystem in 26 (50%). In 19 (37%), the stroke occurred
on the day of trauma, and all occurred within 15 days. In 7/28 cases with
cerebrovascular angiography at the time of trauma, no abnormalities were
detected. In unadjusted analyses, head, neck, chest, back, and abdominal
injuries increased stroke risk. Only head (OR 4.1, CI 1.1-14.9) and neck (OR
5.6, CI 1.03-30.9) injuries remained associated with stroke after adjusting for
demographics and trauma severity markers (multisystem trauma, motor vehicle
collision, arrival by ambulance, intubation).
CONCLUSIONS:
Stroke risk is
elevated for 2 weeks after trauma. Onset is frequently delayed, providing an
opportunity for stroke prevention during this period. However, in one-quarter
of stroke cases with cerebrovascular angiography at the time of trauma, no
vascular abnormality was detected.
8. More Pediatric Research
A. Predicting Escalated Care in Infants
with Bronchiolitis.
Freire G, et al. Pediatrics. 2018 Sep;142(3).
BACKGROUND AND OBJECTIVES:
Early risk stratification of infants with bronchiolitis
receiving airway support is critical for focusing appropriate therapies, yet
the tools to risk categorize this subpopulation do not exist. Our objective was
to identify predictors of "escalated care" in bronchiolitis. We
hypothesized there would be a significant association between escalated care
and predictors in the emergency department. We subsequently developed a risk
score for escalated care.
METHODS:
We conducted a retrospective cohort study of previously
healthy infants aged less
than 12 months with bronchiolitis. Our primary outcome was
escalated care (ie, hospitalization with high-flow nasal cannula, noninvasive
or invasive ventilation, or intensive care admission). The predictors evaluated
were age, prematurity, day of illness, poor feeding, dehydration, apnea, nasal
flaring and/or grunting, respiratory rate, oxygen saturation, and retractions.
RESULTS:
Of 2722 patients, 261 (9.6%) received escalated care.
Multivariable predictors of escalated care were oxygen saturation less than 90% (odds ratio
[OR]: 8.9 [95% confidence interval (CI) 5.1-15.7]), nasal flaring and/or
grunting (OR: 3.8 [95% CI 2.6-5.4]), apnea (OR: 3.0 [95% CI 1.9-4.8]),
retractions (OR: 3.0 [95% CI 1.6-5.7]), age ≤2 months (OR: 2.1 [95% CI
1.5-3.0]), dehydration (OR 2.1 [95% CI 1.4-3.3]), and poor feeding (OR: 1.9
[95% CI 1.3-2.7]). One of 217 (0.5%) infants without predictors received
escalated care. The risk score ranged from 0 to 14 points, with the estimated
risk of escalated care from 0.46% (0 points) to 96.9% (14 points). The area
under the curve was 85%.
CONCLUSIONS:
We identified variables measured in the emergency department
predictive of escalated care in bronchiolitis and derived a risk score to
stratify risk of this outcome. This score may be used to aid management and
disposition decisions.
B. Point-of-Care US Assessment of
Bladder Fullness for Female Pts Awaiting Radiology-Performed Transabdominal
Pelvic US in a Pediatric ED Saved Time: A RCT
Dessie A, et al. Ann Emerg Med. 2018 Nov;72(5):571-580. doi:
STUDY OBJECTIVE:
Radiology-performed transabdominal pelvic ultrasound, used
to evaluate female patients with suspected pelvic pathology in the pediatric
emergency department (ED), is often delayed by the need to fill the bladder. We
seek to determine whether point-of-care ultrasound assessment of bladder
fullness can predict patient readiness for transabdominal pelvic ultrasound
more quickly than patient sensation of bladder fullness.
METHODS:
We performed a randomized controlled trial of female
patients aged 8 to 18 years who required transabdominal pelvic ultrasound in a
pediatric ED. Patients were randomized to usual care or point-of-care
ultrasound and then assessed every 30 minutes for subjective bladder fullness
(0 to 4 ordinal scale) and qualitative bladder fullness by point-of-care
ultrasound. Patients were sent for pelvic ultrasound when they reported 3 or 4
on the subjective fullness scale (usual care) or a large bladder was visualized
(point-of-care ultrasound). Primary outcome was time from enrollment to
completion of pelvic ultrasound. Secondary outcome was success rate of pelvic
ultrasound on first attempt.
RESULTS:
One hundred twenty patients were randomized and 117 had
complete outcomes (59 usual care, 58 point-of-care ultrasound). Kaplan-Meier
curves differed between groups (P less than .001). Median time
to successful completion of pelvic ultrasound was 139 minutes (usual care) and
87.5 minutes (point-of-care ultrasound), with difference in medians 51.5
minutes (95% confidence interval [CI] 23.4 to 77.2 minutes). All point-of-care
ultrasound patients had successful transabdominal pelvic ultrasound on the
first attempt compared with 84.7% in the usual care group, with difference
-15.3% (95% Bayesian credible interval -5.3% to -25.0%). Weighted κ for
interrater agreement was 0.83 (95% CI 0.79 to 0.87).
CONCLUSION:
Point-of-care ultrasound assessment of bladder fullness
decreases time to transabdominal pelvic ultrasound and improves first-attempt
success rate for female patients in the pediatric ED.
C. Paediatric traumatic cardiac arrest:
the development of an algorithm to guide recognition, management and decisions
to terminate resuscitation.
Vassallo J, et al. Emerg Med J. 2018 Nov;35(11):669-674.
INTRODUCTION:
Paediatric traumatic cardiac arrest (TCA) is a high acuity,
low frequency event. Traditionally, survival from TCA has been reported as low,
with some believing resuscitation is futile. Within the adult population, there
is growing evidence to suggest that with early and aggressive correction of
reversible causes, survival from TCA may be comparable with that seen from
medical out-of-hospital cardiac arrests. Key to this survival has been the
adoption of a standardised approach to resuscitation. The aim of this study
was, by a process of consensus, to develop an algorithm for the management of
paediatric TCA for adoption in the UK.
METHODS:
A modified consensus development meeting of UK experts
involved in the management of paediatric TCA was held. Statements discussed at
the meeting were drawn from those that did not reach consensus
(positive/negative) from a linked three-round online Delphi study. 19
statements relating to the diagnosis, management and futility of paediatric TCA
were initially discussed in small groups before each participant anonymously
recorded their agreement with the statement using 'yes', 'no' or 'don't know'.
In keeping with our Delphi study, consensus was set a priori at 70%. Statements
reaching consensus were included in the proposed algorithm.
RESULTS:
41 participants attended the meeting. Of the 19 statements
discussed, 13 reached positive consensus and were included in the algorithm. A
single statement regarding initial rescue breaths reached negative consensus
and was excluded. Consensus was not reached for five statements, including the
use of vasopressors and thoracotomy for haemorrhage control in blunt trauma.
CONCLUSION:
In attempt to standardise our approach to the management of
paediatric TCA and to improve outcomes, we present the first consensus-based
algorithm specific to the paediatric population. While this algorithm was
developed for adoption in the UK, it may be applicable to similar healthcare
systems internationally.
9. Effect of Early Sustained Prophylactic Hypothermia on
Neurologic Outcomes Among Patients with Severe Traumatic Brain Injury: The
POLAR Randomized Clinical Trial
Cooper DJ, et al; for the POLAR Trial Investigators and the
ANZICS Clinical Trials Group. JAMA. Published online October 24, 2018.
Key Points
Question Does early
prophylactic hypothermia improve long-term neurologic outcomes in patients with
severe traumatic brain injury?
Findings In this
randomized clinical trial that included 511 adults, the proportion of patients
with favorable neurologic outcomes at 6 months was 48.8% after hypothermia vs
49.1% after normothermia, a difference that was not statistically significant.
Meaning These
findings do not support the use of early prophylactic hypothermia in patients
with severe traumatic brain injury.
Abstract
Importance After
severe traumatic brain injury, induction of prophylactic hypothermia has been
suggested to be neuroprotective and improve long-term neurologic outcomes.
Objective To
determine the effectiveness of early prophylactic hypothermia compared with
normothermic management of patients after severe traumatic brain injury.
Design, Setting, and Participants The Prophylactic Hypothermia Trial to Lessen
Traumatic Brain Injury–Randomized Clinical Trial (POLAR-RCT) was a multicenter
randomized trial in 6 countries that recruited 511 patients both
out-of-hospital and in emergency departments after severe traumatic brain
injury. The first patient was enrolled on December 5, 2010, and the last on
November 10, 2017. The final date of follow-up was May 15, 2018.
Interventions There
were 266 patients randomized to the prophylactic hypothermia group and 245 to
normothermic management. Prophylactic hypothermia targeted the early induction
of hypothermia (33°C-35°C) for at least 72 hours and up to 7 days if
intracranial pressures were elevated, followed by gradual rewarming.
Normothermia targeted 37°C, using surface-cooling wraps when required.
Temperature was managed in both groups for 7 days. All other care was at the
discretion of the treating physician.
Main Outcomes and Measures
The primary outcome was favorable neurologic outcomes or independent
living (Glasgow Outcome Scale–Extended score, 5-8 [scale range, 1-8]) obtained
by blinded assessors 6 months after injury.
Results Among 511
patients who were randomized, 500 provided ongoing consent (mean age, 34.5
years [SD, 13.4]; 402 men [80.2%]) and 466 completed the primary outcome
evaluation. Hypothermia was initiated rapidly after injury (median, 1.8 hours
[IQR, 1.0-2.7 hours]) and rewarming occurred slowly (median, 22.5 hours [IQR,
16-27 hours]). Favorable outcomes (Glasgow Outcome Scale–Extended score, 5-8)
at 6 months occurred in 117 patients (48.8%) in the hypothermia group and 111
(49.1%) in the normothermia group (risk difference, 0.4% [95% CI, –9.4% to
8.7%]; relative risk with hypothermia, 0.99 [95% CI, 0.82-1.19]; P = .94). In
the hypothermia and normothermia groups, the rates of pneumonia were 55.0% vs
51.3%, respectively, and rates of increased intracranial bleeding were 18.1% vs
15.4%, respectively.
Conclusions and Relevance
Among patients with severe traumatic brain injury, early prophylactic
hypothermia compared with normothermia did not improve neurologic outcomes at 6
months. These findings do not support the use of early prophylactic hypothermia
for patients with severe traumatic brain injury.
Full-text (free): https://jamanetwork.com/journals/jama/fullarticle/2710778
10. Images in Clinical Practice
Necrotizing Fasciitis Requires Rapid Diagnosis and Treatment
Man With Painless Erythematous Lesions on the Toes
Young Woman With Thigh Wound and Rash
Woman With a Groin Mass
Pregnant Woman With Sudden Right Abdominal Pain
Woman With Headache and Amnesia
Man With Coughing and Chest Tightness
Nail Changes During Chemo
Atrial Myxoma
Radial Fracture Due to Parathyroid Carcinoma
11. Fluoroquinolone Antibiotics: FDA Requires Labeling Changes
Due to Low Blood Sugar Levels and Mental Health Side Effects
BACKGROUND:
Fluoroquinolone antibiotics are approved to treat certain serious bacterial
infections, and have been used for more than 30 years. They work by killing or
stopping the growth of bacteria that can cause illness. Without treatment, some
infections can spread and lead to serious health problems.
Most
fluoroquinolone antibiotic drug labels include a warning that blood sugar
disturbances, including high blood sugar and low blood sugar and depending on
the fluoroquinolone antibiotic class, a range of mental health side effects are
already described under Central Nervous System Effects in the Warnings and
Precautions section of the drug label, which differed by individual drug.
RECOMMENDATION:
The new label changes will add that low blood sugar levels, also called
hypoglycemia, can lead to coma and the new label will also make the mental
health side effects more prominent and more consistent across the systemic
fluoroquinolone drug class. The mental health side effects to be added to or
updated across all the fluoroquinolones are:
- disturbances in attention
- disorientation
- agitation
- nervousness
- memory impairment
- serious disturbances in mental abilities called delirium.
FDA continues
to monitor and evaluate the safety and effectiveness of medicines after we
approve them and they go on the market. In the case of fluoroquinolones, we
reviewed reports of cases submitted to FDA and the published medical literature
of apparently healthy patients who experienced serious changes in mood,
behavior, and blood sugar levels while being treated with systemic
fluoroquinolones.
FDA Warning: https://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm612979.htm
Discussion by
James Roberts, Emerg Med News. 2018;40(10):26-7. https://journals.lww.com/em-news/Fulltext/2018/10000/InFocus__Fluoroquinolone_Side_Effects_Just_Got.12.aspx
12. A simple clinical assessment may be superior to systematic
triage in prediction of mortality in the ED
Iverson AKS, et al. Emerg Med J. 2018 Oct 16 [Epub ahead of
print]
OBJECTIVE:
To compare the Danish Emergency Process Triage (DEPT) with a
quick clinical assessment (Eyeball triage) as predictors of short-term
mortality in patients in the emergency department (ED).
METHODS:
The investigation was designed as a prospective cohort study
conducted at North Zealand University Hospital. All patient visits to the ED
from September 2013 to December 2013 except minor injuries were included. DEPT
was performed by nurses. Eyeball triage was a quick non-systematic clinical
assessment based on patient appearance performed by phlebotomists. Both triage
methods categorised patients as green (not urgent), yellow, orange or red (most
urgent). Primary analysis assessed the association between triage level and
30-day mortality for each triage method. Secondary analyses investigated the
relation between triage level and 48-hour mortality as well as the agreement
between DEPT and Eyeball triage.
RESULTS:
A total of 6383 patient visits were included. DEPT was
performed for 6290 (98.5%) and Eyeball triage for 6382 (~100%) of the patient
visits. Only patients with both triage assessments were included. The hazard
ratio (HR) for 48-hour mortality for patients categorised as yellow was 0.9
(95% CI 0.4 to 1.9) for DEPT compared with 4.2 (95% CI 1.2 to 14.6) for Eyeball
triage (green is reference). For orange the HR for DEPT was 2.2 (95% CI 1.1 to
4.4) and 17.1 (95% CI 5.1 to 57.1) for Eyeball triage. For red the HR was 30.9
(95% CI 12.3 to 77.4) for DEPT and 128.7 (95% CI 37.9 to 436.8) for Eyeball
triage. For 30-day mortality the HR for patients categorised as yellow was 1.7
(95% CI 1.2 to 2.4) for DEPT and 2.4 (95% CI 1.6 to 3.5) for Eyeball triage.
For orange the HR was 2.6 (95% CI 1.8 to 3.6) for DEPT and 7.6 (95% CI 5.1 to
11.2) for Eyeball triage, and for red the HR was 19.1 (95% CI 10.4 to 35.2) for
DEPT and 27.1 (95% CI 16.9 to 43.5) for Eyeball triage. Agreement between the
two systems was poor (kappa 0.05).
CONCLUSION:
Agreement between formalised triage and clinical assessment
is poor. A simple clinical assessment by phlebotomists is superior to a
formalised triage system to predict short-term mortality in ED patients.
13. Oxygen therapy for acutely ill medical patients: an
international clinical practice guideline
Siemieniuk RAC, et al. BMJ 2018;363:k4169
What you need to know
- It is a longstanding cultural norm to provide supplemental oxygen to sick patients regardless of their blood oxygen saturation
- A recent systematic review and meta-analysis has shown that too much supplemental oxygen increases mortality for medical patients in hospital
- For patients receiving oxygen therapy, aim for peripheral capillary oxygen saturation (SpO2) of ≤96% (strong recommendation)
- For patients with acute myocardial infarction or stroke, do not initiate oxygen therapy in patients with SpO2 ≥90% (for ≥93% strong recommendation, for 90-92% weak recommendation)
- A target SpO2 range of 90-94% seems reasonable for most patients and 88-92% for patients at risk of hypercapnic respiratory failure; use the minimum amount of oxygen necessary
14. Which Syncope Patients Need an Echo?
Probst MA, et al. Predictors of Clinically Significant
Echocardiography Findings in Older Adults with Syncope: A Secondary Analysis. J
Hosp Med. 2018 Sep 26:E1-E7. [Epub ahead of print]
BACKGROUND:
Syncope is a common reason for visiting the emergency
department (ED) and is associated with significant healthcare resource
utilization.
OBJECTIVE:
To develop a risk-stratification tool for clinically
significant findings on echocardiography among older adults presenting to the
ED with syncope or nearsyncope.
DESIGN:
Prospective, observational cohort study from April 2013 to
September 2016.
SETTING:
Eleven EDs in the United States.
PATIENTS:
We enrolled adults (60 years and older) who presented to the
ED with syncope or near-syncope who underwent transthoracic echocardiography
(TTE).
MEASUREMENTS:
The primary outcome was a clinically significant finding on
TTE. Clinical, electrocardiogram, and laboratory variables were also collected.
Multivariable logistic regression analysis was used to identify predictors of
significant findings on echocardiography.
RESULTS:
A total of 3,686 patients were enrolled. Of these, 995 (27%)
received echocardiography, and 215 (22%) had a significant finding on
echocardiography. Regression analysis identified five predictors of significant
finding: (1) history of congestive heart failure, (2) history of coronary
artery disease, (3) abnormal electrocardiogram, (4) high-sensitivity troponin-T
over 14 pg/mL, and 5) N-terminal pro B-type natriuretic peptide over 125 pg/mL.
These five variables make up the ROMEO (Risk Of Major Echocardiography findings
in Older adults with syncope) criteria. The sensitivity of a ROMEO score of zero
for excluding significant findings on echocardiography was 99.5% (95% CI:
97.4%-99.9%) with a specificity of 15.4% (95% CI: 13.0%-18.1%).
CONCLUSIONS:
If validated, this risk-stratification tool could help
clinicians determine which syncope patients are at very low risk of having
clinically significant findings on echocardiography.
15. Association of COLD Weather With Day-to-Day Incidence of MI:
A SWEDEHEART Nationwide Observational Study
Key Points
Question Is the
incidence of myocardial infarction affected by different weather conditions?
Findings In this
nationwide population-based study, a higher incidence of myocardial infarction
in Sweden was observed at days with low air temperature, low atmospheric air
pressure, high wind velocity, and shorter sunshine duration.
Meaning This study
adds to knowledge on the role of weather as potential trigger of myocardial
infarction.
16. Pulmonary Embolism Corner
A. Determinants and prognostic
implication of diagnostic delay in patients with a first episode of PE
Goyard C, et al. Thromb Res. 2018 Aug 26 [Epub ahead of
print]
Signs and symptoms of pulmonary embolism (PE) are not
specific and this can lead to a diagnostic delay. Little is known about the
determinants of this delay and its prognostic implication.
We conducted a retrospective analysis of a prospective
cohort involving 514 patients with a first episode of PE. The diagnostic delay
was defined as a time from first symptom onset to diagnosis of more than 3 days,
corresponding of the median time in the population. Multivariable logistic
regression analysis was performed to identify determinants of diagnostic delay.
Prognostic implication was measured as the occurrence of 30-day all-cause
mortality, haemodynamic collapse or recurrent PE.
A total of 240 (47%) among 514 patients had a time from
first symptom to diagnosis more than 3 days. Previous deep vein thrombosis (OR
0.55, 95% Confidence Interval (CI), 0.32-0.93), immobilization (OR 0.52, 95%
CI, 0.28-0.96), surgery (OR 0.31, 95% CI, 0.16-0.62), chest pain (OR 0.58, 95%
CI, 0.39-0.86), syncope (OR 0.48, 95% CI, 0.23-1.01), dyspnea (OR 2.48, 95% CI,
1.57-3.91) and hemoptysis (OR 3.57, 95% CI, 1.40-9.07) were associated with
diagnostic delay. Twenty-two patients (4.3%, 95%CI, 2.8-6.5) experienced an
outcome event within 30 days. Among them, 15 patients (6.2% 95%CI, 3.7-10.3)
had a diagnostic delay and 7 (2.6%, 95% CI 1.1-5.4) did not (p = 0.039).
In this cohort, diagnostic delay is associated with the
absence of major risk factors for PE or clinical features such as chest pain or
syncope and the presence of dyspnea or hemoptysis. Diagnostic delay is
associated with a worse 30-day prognosis.
B. ED patient satisfaction with
treatment of low-risk pulmonary embolism.
Simon LE, et al. West J Emerg Med. 2018 Oct 18 [Epub ahead of print].
Introduction: Many emergency department (ED) patients with
acute pulmonary embolism (PE) who meet low-risk criteria may be eligible for a
short length of stay (LOS) (less than 24 hours), with
expedited discharge home either directly from the ED or after a brief observation
or hospitalization. We describe the association between expedited discharge and
site of discharge on care satisfaction and quality of life (QOL) among patients
with low-risk PE (PE Severity Index [PESI] Classes I-III).
Methods: This phone survey was conducted from September 2014
through April 2015 as part of a retrospective cohort study across 21 community
EDs in Northern California. We surveyed low-risk patients with acute PE,
treated predominantly with enoxaparin bridging and warfarin. All eligible
patients were called 2-8 weeks after their index E D visit. PE-specific,
patient-satisfaction questions addressed overall care, discharge instruction
clarity, and LOS. We scored physical and mental QOL using a modified version of
the validated Short Form Health Survey. Satisfaction and QOL were compared by
LOS. For those with expedited discharge, we compared responses by site of
discharge: ED vs. hospital, which included ED-based observation units. We used
chi-square and Wilcoxon rank-sum tests as indicated.
Results: Survey response rate was 82.3% (424 of 515 eligible
patients). Median age of respondents was 64 years; 47.4% were male. Of the 145
patients (34.2%) with a LOS less than 24 hours, 65
(44.8%) were discharged home from the ED. Of all patients, 8 9.6% were
satisfied with their overall care and 94.1% found instructions clear. Sixty-six
percent were satisfied with their LOS, whereas 17.5% would have preferred a
shorter LOS and 16.5% a longer LOS. There were no significant differences in
satisfaction between patients with LOS less than 24 hours vs. ≥24
hours (p above 0.13 for all). Physical QOL scores were significantly higher for
expedited-discharge patients (p=0.01). Patients with expedited discharge home
from the ED vs. the hospital had no significant difference in satisfaction (p above
0.20 for all) or QOL (p above 0.19 for all).
Conclusion: ED patients with low-risk PE reported high
satisfaction with their care in follow-up surveys. Expedited discharge (less than 24 hours) and site
of discharge were not associated with differences in patient satisfaction.
C. Diagnosis of PE During Pregnancy: A
Multicenter Prospective Management Outcome Study.
Righini M, et al. Ann Intern Med. 2018 Oct 23 [Epub ahead of
print].
BACKGROUND:
Data on the optimal diagnostic management of pregnant women
with suspected pulmonary embolism (PE) are limited, and guidelines provide
inconsistent recommendations on use of diagnostic tests.
OBJECTIVE:
To prospectively validate a diagnostic strategy in pregnant
women with suspected PE.
DESIGN:
Multicenter, multinational, prospective diagnostic
management outcome study involving pretest clinical probability assessment,
high-sensitivity D-dimer testing, bilateral lower limb compression
ultrasonography (CUS), and computed tomography pulmonary angiography (CTPA).
(ClinicalTrials.gov: NCT00740454).
SETTING:
11 centers in France and Switzerland between August 2008 and
July 2016.
PATIENTS:
Pregnant women with clinically suspected PE in emergency
departments.
INTERVENTION:
Pulmonary embolism was excluded in patients with a low or
intermediate pretest clinical probability and a negative D-dimer result. All
others underwent lower limb CUS and, if results were negative, CTPA. A
ventilation-perfusion (V/Q) scan was done if CTPA results were inconclusive.
Pulmonary embolism was excluded if results of the diagnostic work-up were
negative, and untreated pregnant women had clinical follow-up at 3 months.
MEASUREMENTS:
The primary outcome was the rate of adjudicated venous
thromboembolic events during the 3-month follow-up.
RESULTS:
441 women were assessed for eligibility, and 395 were
included in the study. Among these, PE was diagnosed in 28 (7.1%) (proximal
deep venous thrombosis found on ultrasound [n = 7], positive CTPA result [n =
19], and high-probability V/Q scan [n = 2]) and excluded in 367 (clinical
probability and negative D-dimer result [n = 46], negative CTPA result [n =
290], normal or low-probability V/Q scan [n = 17], and other reason [n = 14]).
Twenty-two women received extended anticoagulation during follow-up, mainly for
previous venous thromboembolic disease. The rate of symptomatic venous
thromboembolic events was 0.0% (95% CI, 0.0% to 1.0%) among untreated women
after exclusion of PE on the basis of negative results on the diagnostic
work-up.
LIMITATION:
There were several protocol deviations, reflecting the
difficulty of performing studies in pregnant women with suspected PE.
CONCLUSION:
A diagnostic strategy based on assessment of clinical
probability, D-dimer measurement, CUS, and CTPA can safely rule out PE in
pregnant women.
D. Postpartum venous thromboembolism
readmissions in the United States
Wen T, et al. Am J Obstet Gynecol. 2018
Oct;219(4):401.e1-401.e14.
BACKGROUND:
There are limited data on when postpartum readmissions for
thromboembolism occur after delivery hospitalizations on a population basis in
the United States.
OBJECTIVE:
We sought to characterize risk factors for and timing of
postpartum venous thromboembolism readmission after delivery hospitalization
discharge.
STUDY DESIGN:
The Healthcare Cost and Utilization Project Nationwide
Readmissions Database for calendar years 2013 and 2014 was used to perform a
retrospective cohort study evaluating risk for readmission for venous
thromboembolism within 60 days of discharge from a delivery hospitalization.
Risks for deep vein thrombosis and pulmonary embolism were individually
assessed. Obstetric, medical, demographic, and hospital factors associated with
postpartum readmission for venous thromboembolism were analyzed. Risk was
characterized as odds ratios with 95% confidence intervals. Both unadjusted and
adjusted analyses were performed. Adjusted analyses included relevant
obstetric, medical, demographic, and hospital factors within logistic
regression models.
RESULTS:
From Jan. 1 through Oct. 31 in 2013 and 2014, 6,269,641
delivery hospitalizations were included in the analysis. In all, 2975 cases of
readmission for any venous thromboembolism were identified (4.7 per 10,000
delivery hospitalizations) including 1170 cases of deep vein thrombosis and
1805 cases of pulmonary embolism. In all, 69.6% of readmissions for any venous
thromboembolism occurred within the first 20 days of discharge vs 22.3% and
8.0% at 21-40 and 41-60 days after discharge. Median times to readmission were
12.7, 14.0, and 11.7 days for venous thromboembolism, deep vein thrombosis, and
pulmonary embolism, respectively. Women readmitted for any venous
thromboembolism were more likely to have a history of venous thromboembolism
(4.2% vs 0.3%, P less than .01),
to have had a cesarean delivery (54.4% vs 32.4%, P less than .01), to have a thrombophilia (1.8% vs
0.4%, P less than
.01), to have had a longer delivery hospitalization of greater than 3 days for
vaginal delivery and greater than 4 days for cesarean (18.0% vs 6.6%, P less than .01), to have been diagnosed with
gestational hypertension or preeclampsia (19.7% vs 8.2%, P less than .01), and to have had postpartum
hemorrhage with transfusion (2.6% vs 0.5%, P less than .01). These factors retained
significance in adjusted models. History of venous thromboembolism and
hemorrhage with transfusion were associated with the largest odds of
readmission (odds ratio, 9.5; 95% confidence interval, 6.6-13.6, and odds
ratio, 3.6; 95% confidence interval, 2.4-5.5, respectively). Other factors
associated with increased odds included thrombophilia (odds ratio, 2.0; 95%
confidence interval, 1.2-3.5), cesarean delivery (odds ratio, 2.0; 95%
confidence interval, 1.8-2.3), longer delivery hospitalization (odds ratio,
1.8; 95% confidence interval, 1.5-2.2), and preeclampsia or gestational
hypertension (odds ratio, 2.0; 95% confidence interval, 1.6-2.4).
CONCLUSION:
While the majority of events occurred within 20 days of
discharge, risk factors other than thrombophilia and prior venous
thromboembolism were generally associated with modestly increased odds of
events, and only a small proportion of readmissions occurred among women with
thrombophilia and prior events. Our data demonstrate both the challenging
nature and urgent need for further research to determine which clinical
practices and interventions may reduce risk for venous thromboembolism
readmissions on a population basis.
17. More patients go to ED but fewer admitted to hospital
A study in JAMA Internal Medicine showed an 18.4% increase
in annual emergency department visits from 2006 through 2014, while admission
rates from the ED decreased 9.8%. Researchers said the lower hospitalization
rate may reflect efforts to reduce admissions, but Mitchell Katz wrote in an
accompanying editorial that it may show more people with nonemergency
conditions go to the ED due to a lack of access to timely primary care.
Abstract
Hospital-based care accounts for approximately one-third of
US health expenditures, and increasingly, most hospitalizations originate from
emergency departments (ED).1-3 Value-based payment programs have focused on
decreasing avoidable ED visits and hospitalizations. We describe trends in ED
visits and admission rates among US acute care hospitals from January 1, 2006,
through December 31, 2014.
Full-text (subscription required): https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2706174
18. The clinical and cost-effectiveness of corticosteroid
injection versus night splints for carpal tunnel syndrome (INSTINCTS trial): an
open-label, parallel group, randomised controlled trial
Chesterton LS, et al. Lancet. 2018 Oct
20;392(10156):1423-1433.
The injection was better, the “treatment of choice”
BACKGROUND:
To our knowledge, the comparative effectiveness of commonly
used conservative treatments for carpal tunnel syndrome has not been evaluated
previously in primary care. We aimed to compare the clinical and
cost-effectiveness of night splints with a corticosteroid injection with
regards to reducing symptoms and improving hand function in patients with mild
or moderate carpal tunnel syndrome.
METHODS:
We did this randomised, open-label, pragmatic trial in
adults (≥18 years) with mild or moderate carpal tunnel syndrome recruited from
25 primary and community musculoskeletal clinics and services. Patients with a
new episode of idiopathic mild or moderate carpal tunnel syndrome of at least 6
weeks' duration were eligible. We randomly assigned (1:1) patients (permutated
blocks of two and four by site) with an online web or third party telephone
service to receive either a single injection of 20 mg methylprednisolone
acetate (from 40 mg/mL) or a night-resting splint to be worn for 6 weeks.
Patients and clinicians could not be masked to the intervention. The primary
outcome was the overall score of the Boston Carpal Tunnel Questionnaire (BCTQ)
at 6 weeks. We used intention-to-treat analysis, with multiple imputation for
missing data, which was concealed to treatment group allocation. The trial is
registered with the European Clinical Trials Database, number 2013-001435-48,
and ClinicalTrial.gov, number NCT02038452.
FINDINGS:
Between April 17, 2014, and Dec 31, 2016, 234 participants
were randomly assigned (118 to the night splint group and 116 to the
corticosteroid injection group), of whom 212 (91%) completed the BCTQ at 6
weeks. The BCTQ score was significantly better at 6 weeks in the corticosteroid
injection group (mean 2·02 [SD 0·81]) than the night splint group (2·29 [0·75];
adjusted mean difference -0·32; 95% CI -0·48 to -0·16; p=0·0001). No adverse
events were reported.
INTERPRETATION:
A single corticosteroid injection shows superior clinical effectiveness
at 6 weeks compared with night-resting splints, making it the treatment of
choice for rapid symptom response in mild or moderate carpal tunnel syndrome
presenting in primary care.
Full-text (free): https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31572-1/fulltext
19. Learning Empathy from My ’97 Camry
Cuneo NC. N Engl J Med 2018;379:1596-7.
There was an improbable air of intrigue about the black 1997
Camry I’d inherited from my mother. As I packed it for my trip to Baltimore to
begin medical school, I began rediscovering its quirks — the spattering of
orange paint across the front bumper, the elaborate crack in the vanity mirror
(from which an occasional shard would still fall). Its incongruous rear spoiler
served only as a weighty, ostentatious hazard to those who dared access the
trunk.
Before long, I became immersed in the day-to-day struggles
of the first year of medical school. First, we were taught how to practice
empathy by following clever mnemonics. Then we got to apply these skills on
so-called standardized patients. One, a 30-year-old who looked like he’d just
run a marathon, scolded me for not offering to assist him as he got down from
the exam table. Another bemoaned my failure to inquire about his dog during a
time-limited visit in which I was supposed to disclose a terminal diagnosis. At
one point I got dinged for unprofessional behavior for resting my arm on a sink
during an encounter with an elderly woman with whom I felt I was actually
starting to connect. With every faux interaction I felt myself being forced to
shed another layer of authenticity, and I quickly grew to dread the whole tedious
charade. Were these just bad actors, or was I fundamentally flawed in my
inability to connect with them? Was this really the best way to learn how to be
a good doctor?
Thankfully, in January we graduated to interacting with real
patients when we were paired with community physicians for one afternoon each
week at clinics around the city. Mine was across town, more than 30 minutes
away, and I became newly grateful for the Camry’s service. I eagerly jumped
into eliciting exhaustive histories and performing detailed exams on the
generous few patients who’d acquiesce. My visits with patients quickly evolved
into confessionals, as I harnessed the power of my own naiveté. A young woman
sheepishly disclosed the office affair at the root of her anxiety. A middle-aged
man tearfully admitted to picking up a cocaine habit. Often their revelations
were more mundane: a patient struggling with alcoholism had fallen off the
wagon again; another with poorly controlled diabetes was skipping doses of
insulin.
More quickly than I expected, a certain cynicism began to
creep into my thoughts. As my relationships with individual patients grew, so
did my frustrations with their indiscretions. Why didn’t she call weeks ago,
when her medications first ran out? I’d wonder, scanning through a hypertensive
patient’s alarming vital signs. If only he’d been more adherent to begin with,
I’d lament, identifying worsening signs of lipodystrophy in a patient with HIV
who’d been relegated to a third-line drug regimen. I bit my tongue as a woman
expounded on her newly discovered “chronic Lyme disease,” which she
self-diagnosed after perusing an online forum. The embracing acceptance I’d
cultivated began to break down.
And then it started happening…
20. Hypertensive Issues
A. The Characteristics and Outcomes of
Patients Who Make an ED Visit for Hypertension After Use of a Home or Pharmacy
Blood Pressure Device
Atzema CL, et al. Ann Emerg Med 2018;72(5):534-43.
What is already known on this topic
Emergency department (ED) visits for asymptomatic
hypertension are common. Public awareness campaigns and the wide availability
of home sphygmomanometers will likely increase their numbers.
What question this study addressed
The authors measured hospitalizations among adults evaluated
for hypertension in the ED after abnormal home measurement, pharmacy
measurement, or physician referral during a 12-month period in 5 EDs in
Ontario.
What this study adds to our knowledge
Despite markedly abnormal presenting blood pressure (median
182/97 mm Hg), only 7% of patients required admission. Patients referred by
their physicians were admitted 4-fold more than those in the home or pharmacy
groups (12% versus 3%).
How this is relevant to clinical practice
Patients with elevated home or pharmacy blood pressure
measurements and no signs of target-organ damage rarely need emergency ED
treatment or hospitalization and should first be evaluated by a primary care
clinician.
Editorial: Asymptomatic and Under Pressure: https://www.annemergmed.com/article/S0196-0644(18)31324-6/fulltext
(subscription required)
B. Effect of Intranasal
Vasoconstrictors on Blood Pressure: A Randomized, Double-Blind,
Placebo-Controlled Trial.
Bellew SD, et al. J Emerg Med. 2018 Oct;55(4):455-464.
BACKGROUND:
Treatment for epistaxis includes application of intranasal
vasoconstrictors. These medications have a precaution against use in patients
with hypertension. Given that many patients who present with epistaxis are
hypertensive, these warnings are commonly overridden by clinical necessity.
OBJECTIVE:
Our aim was to determine the effects of intranasal
vasoconstrictors on blood pressure.
METHODS:
We conducted a single-center, randomized, double-blind,
placebo-controlled trial from November 2014 through July 2016. Adult patients
being discharged from the emergency department (ED) at Mayo Clinic (Rochester,
Minnesota) were recruited. Patients were ineligible if they had a
contraindication to study medications, had a history of hypertension, were
currently taking antihypertensive or antidysrhythmic medications, or had nasal
abnormalities, such as epistaxis. Subjects were randomized to one of four study
arms (phenylephrine 0.25%; oxymetazoline 0.05%; lidocaine 1% with epinephrine
1:100,000; or bacteriostatic 0.9% sodium chloride [saline]). Blood pressure and
heart rate were measured every 5 min for 30 min.
RESULTS:
Sixty-eight patients were enrolled in the study; of these,
63 patients completed the study (oxymetazoline, n = 15; phenylephrine, n = 20;
lidocaine with epinephrine, n = 11; saline, n = 17). We did not observe any
significant differences in mean arterial pressure over time between
phenylephrine and saline, oxymetazoline and saline, or lidocaine with
epinephrine and saline. The mean greatest increases from baseline in mean
arterial pressure, systolic and diastolic blood pressure, and heart rate for
each treatment group were also not significantly different from the saline
group.
CONCLUSIONS:
Intranasal vasoconstrictors did not significantly increase
blood pressure in patients without a history of hypertension. Our findings
reinforce the practice of administering these medications to patients who
present to the ED with epistaxis, regardless of high blood pressure.
21. Beta-blocker use does not increase need for additional doses
of epinephrine in anaphylaxis
Prior evidence suggests that beta-blocker use may predispose
patients to more severe anaphylaxis. This is a retrospective observational
study of emergency department patients at Mayo Clinic Hospital, Rochester,
Minn., with anaphylaxis (n=789). Compared to non-users, those on beta-blockers
were not at statistically higher risk to have needed more than one dose of
epinephrine (p=.56) nor to have received any epinephrine (p=.17). The authors
concluded that beta-blocker use may not be clinically significant with regard
to epinephrine responsiveness.
White JL, et al. Patients Taking β-Blockers Do Not Require
Increased Doses of Epinephrine for Anaphylaxis. J Allergy Clin Immunol Pract. 2018
Sep - Oct;6(5):1553-1558.e1.
22. A systematic review and meta-analysis of outpatient
treatment for acute diverticulitis.
van Dijk ST, et al. Int J Colorectal Dis. 2018;33(5):505-512.
BACKGROUND:
The shift from routine antibiotics towards omitting
antibiotics for uncomplicated acute diverticulitis opens up the possibility for
outpatient instead of inpatient treatment, potentially reducing the burden of
one of the most common gastrointestinal diseases in the Western world.
PURPOSE:
Assessing the safety and cost savings of outpatient
treatment in acute colonic diverticulitis.
METHODS:
PubMed and EMBASE were searched for studies on outpatient
treatment of colonic diverticulitis, confirmed with computed tomography or
ultrasound. Outcomes were readmission rate, need for emergency surgery or
percutaneous abscess drainage, and healthcare costs.
RESULTS:
A total of 19 studies with 2303 outpatient treated patients
were included. These studies predominantly excluded patients with comorbidity
or immunosuppression, inability to tolerate oral intake, or lack of an adequate
social network. The pooled incidence rate of readmission for outpatient
treatment was 7% (95%CI 6-9%, I2 48%). Only 0.2% (2/1288) of patients underwent
emergency surgery, and 0.2% (2/1082) of patients underwent percutaneous abscess
drainage. Only two studies compared readmission rates outpatients that had
similar characteristics as a control group of inpatients; 4.5% (3/66) and 6.3%
(2/32) readmissions in outpatient groups versus 6.1% (4/66) and 0.0% (0/44)
readmissions in inpatient groups (p = 0.619 and p = 0.174, respectively). Average
healthcare cost savings for outpatient compared with inpatient treatment ranged
between 42 and 82%.
CONCLUSION:
Outpatient treatment of uncomplicated diverticulitis
resulted in low readmission rates and very low rates of complications.
Furthermore, healthcare cost savings were substantial. Therefore, outpatient
treatment of uncomplicated diverticulitis seems to be a safe option for most
patients.
Full-text (free): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5899114/
23. Management of Bleeding in Patients Taking Oral Anticoagulants
Anderson I, et al. JAMA. 2018;319(19):2032-2033.
Opening lines…
More than 6 million people in the United States take OACs.1
The most common indications for OACs are atrial fibrillation and treatment or
prevention of venothromboembolism.1 Hemorrhage and its related morbidity and
mortality are the primary risks associated with these agents.2 A meta-analysis
of 13 randomized clinical trials involving 102 707 adults showed major bleeding
case-fatality rates of 7.57% with DOACs and 11.05% with warfarin.2 With the
approval of 4 DOACs since 2010, management of OAC-associated bleeding has
become more complex.
Summary, courtesy of Emerg Med Abstracts, Sept 2018
SUMMARY
The American College of Cardiology put together an Expert
Consensus Decision Pathway on Management of Bleeding in Patients on Oral
Anticoagulants.
For patients treated with an oral anticoagulant (OAC) who
experience either life-threatening bleeding or major bleeding at a critical
site, management should include at least temporarily discontinuing the OAC,
local therapy, supportive measures, and, when appropriate, administering a
reversal agent.
- For warfarin, 5 to 10 mg of intravenous Vitamin K and 4-factor prothrombin complex concentrate (4F-PCC).
- For dabigatran, intravenous idarucizumab (first line) or intravenous 4F-PCC (second line), or finally dialysis.
- For rivaroxaban and all FXa Inhibitors, intravenous 4F-PCC; these patients can’t be dialyzed.
24. Micro Bits
A.
The CDC Offers Guidance to Parents, Kids, and Docs on ED Concussion Management
Including educational apps for kids
Blast Off into Concussion Safety with CDC HEADS UP Rocket
Blades!
The brain safety game for kids 6-8. Available in the App
Store. Through a futuristic world of galactic racing adventures children can
learn the benefits of playing it safe and smart!
The app aims to teach children:
the different ways the brain can get hurt during sports
activities.
how important it is to tell a coach, parent, or other adult
when an injury occurs.
the importance of taking time to rest and recover if they
have a concussion.
B.
Exposure to air pollution increases short-term risk of ischemic stroke
C.
Real-Time Patient–Provider Video Telemedicine Integrated with Clinical Care
D.
Aspirin for Primary Prevention?
1. ASA in the healthy elderly person causes bleeding without
benefits
2. ASA in the diabetic patient causes a balance of benefits
and harms
F.
Association of Cardiorespiratory Fitness With Long-term Mortality Among Adults
Undergoing Exercise Treadmill Testing
Life expectancy increases as aerobic fitness improves with
no upper limit of benefit at any age.
G.
Aspirin Prophylaxis After Total Knee Arthroplasty
May be as effective as anticoagulation in preventing DVTs.
Journal Watch: https://www.jwatch.org/na47786/2018/10/25/aspirin-prophylaxis-after-total-knee-arthroplasty
H.
Rivaroxaban Approved to Prevent CV Events in Patients with CAD or PAD
Journal Watch: https://www.jwatch.org/fw114671/2018/10/15/rivaroxaban-approved-prevent-cv-events-patients-with-cad
I.
Does Drinking Additional Water Prevent Recurrent UTI?
That depends on baseline intake. “Conclusions and
Relevance Increased water intake is an
effective antimicrobial-sparing strategy to prevent recurrent cystitis in
premenopausal women at high risk for recurrence who drink low volumes of fluid
daily (drinking less than 1.5 L of fluid daily).
J.
Seven-Day Metronidazole Course for Trichomoniasis
Trichomoniasis is the most common non-viral sexually
transmitted infection in the world. WHO estimates that 143 million new cases of
trichomoniasis among young women occur each year. 1 Trichomoniasis could cause
serious adverse health effects, including increased risk for HIV acquisition,
preterm birth, pelvic inflammatory disease, urethritis, vaginitis, and
cervicitis. 2 Currently, the US Centers for Disease Control and Prevention
(CDC) and WHO recommend single-dose metronidazole (2 g single dose) or
tinidazole as first-line treatment. 2 However, mounting evidence shows that a
7-day dose of metronidazole (500 mg twice daily) might result in fewer
treatment failures among women.
This RCT found that women treated for 7 days had fewer
treatment failures than those who received a single dose.
Lancet Infect Dis abstract: https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(18)30423-7/fulltext
K.
Low systolic blood pressure associated with falls
A cross-sectional study was performed to identify fall
injuries among medically treated hypertensive individuals within one US health
system and evaluate the association between low minimum and mean systolic blood
pressure (SBP) and serious falls/syncope after adjustment for demographics,
comorbidities, and medications. Results showed both minimum and mean SBP less
than 110 mmHg were associated with serious falls and syncope.
L.
The Problem With Probiotics
There are potential harms as well as benefits, and a lot of
wishful thinking and imprecision in the marketing of products containing them.
M.
Analysis of a Commercial Insurance Policy to Deny Coverage for ED Visits With
Nonemergent Diagnoses
JAMA Netw Open (full-text free): https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2707430
N.
Preventive Dental Care Associated with Fewer ED, Hospital Visits
Treating dental care like a population health management
issue may help reduce avoidable ED visits and hospitalizations.
Health IT Analytics: https://healthitanalytics.com/news/preventive-dental-care-associated-with-fewer-ed-hospital-visits
O.
Scribes Lessen FPs' Administrative Burden, Researchers Find
P.
EDs See More Patients, Fewer Inpatient Admissions
Q.
Dementia Risk Lower for Afib Patients on Blood Thinners
Study shows atrial fibrillation tied overall to faster
cognitive decline, dementia
R. Death or debt? National Estimates of Financial Toxicity
in Persons with Newly-Diagnosed Cancer
Among persons newly diagnosed with cancer, a sizable
percentage of individuals depleted their life assets within two years following
diagnosis. Worsening cancer, requirement of continued treatment, socioeconomic
factors, and clinical characteristics increased the odds of asset depletion. As
large financial burdens have been found to adversely affect access to care and
outcomes, approaches to mitigate these effects among vulnerable groups remain
of key importance.
S.
Why I Dance with My Patients: Joy is contagious
