Friday, November 30, 2018

Lit Bits: Nov 30, 2018

From the recent medical literature...


1. Dr. Mel Herbert of EM-RAP Fame: “Emergency Physicians Have Superhero Status”
   
At the ACEP18 opening general session, ACEP's own Dr. Mel Herbert reminded us of the superhero nature of emergency medicine. His incredibly compelling speech was one of the most memorable moments in San Diego, and it is now available to watch online. The general session had some other "wow" moments, as well, with a unique forward-reverse video that you really need to watch until the end, and a short documentary on three of your peers that celebrates emergency medicine.


2.  Atrial Fibrillation Research

A. Cardioversion of AF in Obese Patients: Results from the Cardioversion-BMI RCT

Voskoboinik A, et al. J Cardiovasc Electrophysiol. 2018 Oct 29 [[Epub ahead of print]

AIMS:
Obesity is associated with higher electrical cardioversion (ECV) failure in persistent atrial fibrillation (PeAF). For ease-of-use many centers prefer patches over paddles. We assessed the optimum modality and shock vector, as well as safety and efficacy of the Manual Pressure Augmentation (MPA) technique.

METHODS:
Patients with obesity (BMI≥30) and PeAF undergoing ECV using a biphasic defibrillator were randomized into 1 of 4 arms by modality (adhesive patches or hand-held paddles) and shock vector (anteroposterior [AP] or anteroapical [AA]). If the first two shocks (100J, 200J) failed, then patients received a 200J shock using the alternative modality (patch or paddle). Shock vector remained unchanged. In an observational sub-study, 20 patients with BMI≥35 who failed ECV at 200J using both patches/paddles underwent a trial of MPA.

RESULTS:
In total, 125 patients were randomized between 7/2016-3/2018. First or second shock success was 43/63 (68.2%) for patches & 56/62 (90.3%) for paddles (p=0.002). There were 20 crossovers from patches to paddles (12/20 3rd shock success with paddles) and 6 crossovers from paddles to patches (3/6 3rd shock success with patches). Paddles successfully cardioverted 68/82 patients compared with 46/69 using patches (82.9% vs 66.7%; p=0.02). Shock vector did not influence 1st or 2nd shock success rates (82.0% AP vs 76.6% AA; p=0.46). MPA was successful in 16/20 (80%) who failed both patches/paddles, with 360J required in 6/7 cases.

CONCLUSION:
Routine use of adhesive patches at 200J is inadequate in obesity. Strategies that improve success include use of paddles, MPA and escalation to 360J.

B. Black Americans May Be Less Likely to Receive Newest Stroke-Preventing Drugs For AF

The New York Times (11/29) reports researchers found that “African-Americans are less likely than white people to get the newest stroke-preventing medicines for atrial fibrillation.” The findings were published in JAMA Cardiology. https://www.nytimes.com/2018/11/29/well/live/blacks-are-less-likely-than-whites-to-get-treatment-for-heart-disorder.html



3. Increasing safe outpt management for ED pts with PE: a controlled pragmatic trial.

Vinson DR and the KP CREST Network.  Ann Intern Med. 2018 Nov 13 [Epub ahead of print].

BACKGROUND:
Many low-risk patients with acute pulmonary embolism (PE) in the emergency department (ED) are eligible for outpatient care but are hospitalized nonetheless. One impediment to home discharge is the difficulty of identifying which patients can safely forgo hospitalization.

OBJECTIVE:
To evaluate the effect of an integrated electronic clinical decision support system (CDSS) to facilitate risk stratification and decision making at the site of care for patients with acute PE.

DESIGN:
Controlled pragmatic trial. (ClinicalTrials.gov: NCT03601676).

SETTING:
All 21 community EDs of an integrated health care delivery system (Kaiser Permanente Northern California).

PATIENTS:
Adult ED patients with acute PE.

INTERVENTION:
Ten intervention sites selected by convenience received a multidimensional technology and education intervention at month 9 of a 16-month study period (January 2014 to April 2015); the remaining 11 sites served as concurrent controls.

MEASUREMENTS:
The primary outcome was discharge to home from either the ED or a short-term (less than 24-hour) outpatient observation unit based in the ED. Adverse outcomes included return visits for PE-related symptoms within 5 days and recurrent venous thromboembolism, major hemorrhage, and all-cause mortality within 30 days. A difference-in-differences approach was used to compare pre-post changes at intervention versus control sites, with adjustment for demographic and clinical characteristics.

RESULTS:
Among 881 eligible patients diagnosed with PE at intervention sites and 822 at control sites, adjusted home discharge increased at intervention sites (17.4% pre- to 28.0% postintervention) without a concurrent increase at control sites (15.1% pre- and 14.5% postintervention). The difference-in-differences comparison was 11.3 percentage points (95% CI, 3.0 to 19.5 percentage points; P = 0.007). No increases were seen in 5-day return visits related to PE or in 30-day major adverse outcomes associated with CDSS implementation.

LIMITATION:
Lack of random allocation.

CONCLUSION:
Implementation and structured promotion of a CDSS to aid physicians in site-of-care decision making for ED patients with acute PE safely increased outpatient management.

PRIMARY FUNDING SOURCE:
Garfield Memorial National Research Fund and The Permanente Medical Group Delivery Science and Physician Researcher Programs.

KP DOR Spotlight: Many Patients with Blood Clots Can Go Home from ER Safely

Editorial: Stein PD, Hughes MJ. Mounting Evidence for Safe Home Treatment of Selected Patients With Acute Pulmonary Embolism. Ann Intern Med. 2018 Nov 13 [Epub ahead of print]. Subscription required: http://annals.org/aim/article-abstract/2714294/

Radecki: Computer Says: Discharge that Pulmonary Embolism! https://www.emlitofnote.com/?p=4329

4. ED Intubation Success with Succinylcholine Vs Rocuronium: A National Emergency Airway Registry Study

April MD, et al. Ann Emerg Med. 2018;72(6):645–653.

Background
Intubation is a critical procedure commonly performed in the emergency department (ED) setting. ED intubations typically entail rapid sequence intubation, with coadministration of a sedative agent and a paralytic medication.1 The 2 most commonly used rapid-acting paralytics in the ED setting are succinylcholine and rocuronium.2 ED providers have historically used succinylcholine for the majority of ED intubations.3 However, recent data have suggested the increasing use of rocuronium.1 Previous studies indicate that the time of onset may differ between rocuronium and succinylcholine.

Importance
Rapid achievement of ideal intubating conditions is important to facilitate rapid first-pass intubation success and to mitigate adverse events.4, 5 The differences in paralysis onset may influence intubation success rates between succinylcholine and rocuronium.2 Furthermore, although succinylcholine has more rapid onset than rocuronium, multiple contraindications exist to its use, many of which may not always be readily apparent during emergency intubation.6 Although the anesthesia literature suggests better conditions for rapid sequence intubation with succinylcholine than rocuronium,7 the best paralytic for ED rapid sequence intubation remains unknown.

Goals of This Investigation
The goal of this study was to compare first-pass intubation success and peri-intubation adverse events between rapid sequence intubation performed with succinylcholine versus rocuronium.

Abstract
Study objective
Although both succinylcholine and rocuronium are used to facilitate emergency department (ED) rapid sequence intubation, the difference in intubation success rate between them is unknown. We compare first-pass intubation success between ED rapid sequence intubation facilitated by succinylcholine versus rocuronium.

Methods
We analyzed prospectively collected data from the National Emergency Airway Registry, a multicenter registry collecting data on all intubations performed in 22 EDs. We included intubations of patients older than 14 years who received succinylcholine or rocuronium during 2016. We compared the first-pass intubation success between patients receiving succinylcholine and those receiving rocuronium. We also compared the incidence of adverse events (cardiac arrest, dental trauma, direct airway injury, dysrhythmias, epistaxis, esophageal intubation, hypotension, hypoxia, iatrogenic bleeding, laryngoscope failure, laryngospasm, lip laceration, main-stem bronchus intubation, malignant hyperthermia, medication error, pharyngeal laceration, pneumothorax, endotracheal tube cuff failure, and vomiting). We conducted subgroup analyses stratified by paralytic weight-based dose.

Results
There were 2,275 rapid sequence intubations facilitated by succinylcholine and 1,800 by rocuronium. Patients receiving succinylcholine were younger and more likely to undergo intubation with video laryngoscopy and by more experienced providers. First-pass intubation success rate was 87.0% with succinylcholine versus 87.5% with rocuronium (adjusted odds ratio 0.9; 95% confidence interval 0.6 to 1.3). The incidence of any adverse event was also comparable between these agents: 14.7% for succinylcholine versus 14.8% for rocuronium (adjusted odds ratio 1.1; 95% confidence interval 0.9 to 1.3). We observed similar results when they were stratified by paralytic weight-based dose.

Conclusion
In this large observational series, we did not detect an association between paralytic choice and first-pass rapid sequence intubation success or peri-intubation adverse events.


5. Nonoperative Management of Uncomplicated Appendicitis Among Privately Insured Adults.

Sceats LA, et al. JAMA Surg. 2018 Nov 14. doi: 10.1001/jamasurg.2018.4282. [Epub ahead of print]

Introduction
Traditional surgical teaching states that acute appendicitis invariably progresses to gangrene and perforation if not undergoing surgery in a timely fashion.1-3 As such, urgent appendectomy has historically been considered the mainstay of treatment. However, appendectomy is not without risk; reported rates of postoperative complications range from 2% to 23%.4-6 In addition, long-term complications may occur, including incisional hernias and small-bowel obstructions.7-9 Due to sheer volume, appendectomy is the sixth leading cause of morbidity and mortality owing to emergency general surgery in the United States.10

Given the known risks associated with surgery, several randomized clinical trials have compared appendectomy with nonoperative antibiotic management for uncomplicated appendicitis.11-17 In the largest and most recent randomized trial, 73% of patients treated nonoperatively did not require appendectomy within 1 year of follow-up.14 For the patients with nonoperative treatment who eventually required surgery, the complication rate was no higher than for patients who initially underwent appendectomy. In combination with other existing randomized clinical trials and concordant with recent consensus guidelines,18 these data indicate that nonoperative management is a viable treatment option in most cases and imply that surgery is overused.

Despite randomization, these trials contain limitations that threaten the generalizability of their findings. Existing randomized clinical trials are relatively small, with a maximum follow-up of 2 years. Among the 2 existing studies that examined long-term outcomes of nonoperative management, one was a nonrandomized single-institution study confined to pediatric patients19; the other was regionally limited, unable to censor patients who left the cohort, and conducted a decade ago.20

To address these issues, we assessed nonoperative management of uncomplicated appendicitis using a large private insurance claims database. We hypothesized that (1) nonoperative management would be selected more often than appendectomy for patients deemed high-risk candidates for surgery; (2) nonoperative management would have comparable outcomes with appendectomy; and (3) the overall cost of nonoperative management would be less than that of appendectomy.

Key Points
Question  Is nonoperative management of appendicitis effective in a national retrospective cohort?

Findings  In a national cohort analysis of 58 329 patients with uncomplicated appendicitis, patients treated nonoperatively had higher rates of abscess (2.3% vs 1.3%) and readmission (all-cause, 4.6% vs 2.5%; appendicitis-associated, 2.6% vs 1.2%) and higher overall cost of care ($14 934 vs $14 186). The overall failure rate of nonoperative management was 3.9%.

Meaning  Although the overall failure rate of nonoperative management of appendicitis was very low, nonoperative management was associated with worse short-term outcomes compared with appendectomy.

Abstract
Importance  Health care professionals have shown significant interest in nonoperative management for uncomplicated appendicitis, but long-term population-level data are lacking.

Objective  To compare the outcomes of nonoperatively managed appendicitis against appendectomy.

Design, Setting, and Participants  This national retrospective cohort study used claims data from a private insurance database to compare patients admitted with uncomplicated appendicitis from January 1, 2008, through December 31, 2014, undergoing appendectomy vs nonoperative management. Coarsened exact matching was applied before multivariate analysis to reduce imbalance between groups. Data were analyzed from February 12 through May 1, 2018.

Exposures  Appendectomy (control arm) or nonoperative management (treatment arm).

Main Outcomes and Measures  Short-term primary clinical outcomes included emergency department visits, hospital readmission, abdominal abscess, and Clostridium difficile infections. Long-term primary clinical outcomes were small-bowel obstructions, incisional hernias, and appendiceal cancers. Nonoperative management failure was defined by hospital readmission with appendicitis diagnosis and an appendicitis-associated operation or procedure. Secondary outcomes included number of follow-up visits, length and cost of index hospitalization, and total cost of appendicitis-associated care. Covariates included age, sex, region, insurance plan type, admission year, and Charlson comorbidity index.

Results  Of 58 329 patients with uncomplicated appendicitis (52.7% men; mean [SD] age, 31.9 [16.5] years), 55 709 (95.5%) underwent appendectomy and 2620 (4.5%) underwent nonoperative management. Patients in the nonoperative management group were more likely to have appendicitis-associated readmissions (adjusted odds ratio, 2.13; 95% CI, 1.63-2.77; P less than .001) and to develop an abscess (adjusted odds ratio, 1.42; 95% CI, 1.05-1.92; P = .02). Patients in the nonoperative management group required more follow-up visits in the year after index admission (unadjusted mean [SD], 1.6 [6.3] vs 0.3 [1.4] visits; adjusted +1.11 visits; P  less than  .001) and had lower index hospitalization cost (unadjusted mean [SD], $11 502 [$9287] vs $13 551 [$10 160]; adjusted −$2117, P  less than  .001), but total cost of appendicitis care was higher when follow-up care was considered (unadjusted, $14 934 [$31 122] vs $14 186 [$10 889]; adjusted +$785; P = .003). During a mean (SD) of 3.2 (1.7) years of follow-up, failure of nonoperative management occurred in 101 patients (3.9%); median time to recurrence was 42 days (interquartile range, 8-125 days). Among the patients who experienced treatment failure, 44 did so within 30 days.

Conclusions and Relevance  According to results of this study, nonoperative management failure rates were lower than previously reported. Nonoperative management was associated with higher rates of abscess, readmission, and higher overall cost of care. These data suggest that nonoperative management may not be the preferred first-line therapy for all patients with uncomplicated appendicitis.


6. Lidocaine, Dripped on the Skin, Attenuates Procedural Pain

Wow! Too easy! Can’t wait to try it.

Patel BK et al. Comparison of Two Lidocaine Administration Techniques on Perceived Pain From Bedside Procedures: A RCT. Chest. 2018 Oct;154(4):773-780.

BACKGROUND:
Lidocaine is used to alleviate procedural pain but paradoxically increases pain during injection. Pain perception can be modulated by non-noxious stimuli such as temperature or touch according to the gate control theory of pain. We postulated that lidocaine dripped onto the skin prior to injection would cool or add the sensation of touch at the skin surface to reduce pain perception from the procedure.

METHODS:
A randomized clinical trial of patients referred to the procedure service from February 2011 through March 2015 was conducted. All patients received 1% subcutaneous lidocaine injection. Patients randomized to the intervention group had approximately 1 to 2 ml of lidocaine squirted onto the skin surface prior to subcutaneous lidocaine injection. Patients were blinded to the details of the intervention and were surveyed by a blinded investigator to document the primary outcome (severity of pain from the procedure) using a visual analog scale.

RESULTS:
A total of 481 patients provided consent and were randomized to treatment. There was a significant improvement in the primary outcome of procedural pain (control, 16.6 ± 24.8 mm vs 12.2 ± 19.4 mm; P = .03) with the intervention group as assessed by using the visual analog scale score. Pain scores were primarily improved for peripherally inserted central catheters (control, 18.8 ± 25.6 mm vs 12.2 ± 18.2 mm; P = .02) upon subgroup analysis.

CONCLUSIONS:
Bedside procedures are exceedingly common. Data regarding the severity of procedural pain and strategies to mitigate it are important for the informed consent process and patient satisfaction. Overall, pain reported from common bedside procedures is low, but pain can be further reduced with the addition of lidocaine onto the skin surface to modulate pain perception.

7. American Society of Hematology 2018 guidelines for diagnosis of VTE

Lim W, et al. Blood Advances 2018 2:3226-3256

These guidelines for PE diagnostics support the pathway advanced by the Amer College of Physician in 2015: Start with pre-test probability assessment: if low, assess the PERC; if moderate, use age-adjusted DD; if high, start with advanced imaging. Raja A, et al. Evaluation of Patients With Suspected Acute Pulmonary Embolism: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med. 2015; 163(9):701-11. http://annals.org/aim/fullarticle/2443959/

Background: Modern diagnostic strategies for venous thromboembolism (VTE) incorporate pretest probability (PTP; prevalence) assessment. The ability of diagnostic tests to correctly identify or exclude VTE is influenced by VTE prevalence and test accuracy characteristics.

Objective: These evidence-based guidelines are intended to support patients, clinicians, and health care professionals in VTE diagnosis. Diagnostic strategies were evaluated for pulmonary embolism (PE), deep vein thrombosis (DVT) of the lower and upper extremity, and recurrent VTE.

Methods: The American Society of Hematology (ASH) formed a multidisciplinary panel including patient representatives. The McMaster University GRADE Centre completed systematic reviews up to 1 October 2017. The panel prioritized questions and outcomes and used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess evidence and make recommendations. Test accuracy estimates and VTE population prevalence were used to model expected outcomes in diagnostic pathways. Where modeling was not feasible, management and accuracy studies were used to formulate recommendations.

Results: Ten recommendations are presented, by PTP for patients with suspected PE and lower extremity DVT, and for recurrent VTE and upper extremity DVT.

Conclusions: For patients at low (unlikely) VTE risk, using D-dimer as the initial test reduces the need for diagnostic imaging. For patients at high (likely) VTE risk, imaging is warranted. For PE diagnosis, ventilation-perfusion scanning and computed tomography pulmonary angiography are the most validated tests, whereas lower or upper extremity DVT diagnosis uses ultrasonography. Research is needed on new diagnostic modalities and to validate clinical decision rules for patients with suspected recurrent VTE.


8. Pediatric Research

A. Traumatic Brain Injury Among Children: New CDC Guidelines

Lumba-Brown A, et al. JAMA Pediatr. 2018;172(11):e182853.

Key Points
Question  Based on current evidence, what are best practices for diagnosis, prognosis, and management/treatment of pediatric mild traumatic brain injury (mTBI)?

Findings  Based on a previous systematic review of the literature, this guideline includes 19 sets of recommendations on diagnosis, prognosis, and management/treatment of pediatric mTBI. Each recommendation was assigned a level of obligation (ie, must, should, or may) based on confidence in the evidence.

Meaning  Clinical guidance for health care professionals is critical to improving health and safety of this vulnerable population; the recommendations represent current best practices and comprise the first evidence-based clinical guideline to date for diagnosing and managing pediatric mTBI in the United States.

Abstract
Importance  Mild traumatic brain injury (mTBI), or concussion, in children is a rapidly growing public health concern because epidemiologic data indicate a marked increase in the number of emergency department visits for mTBI over the past decade. However, no evidence-based clinical guidelines have been developed to date for diagnosing and managing pediatric mTBI in the United States.

Objective  To provide a guideline based on a previous systematic review of the literature to obtain and assess evidence toward developing clinical recommendations for health care professionals related to the diagnosis, prognosis, and management/treatment of pediatric mTBI.

Evidence Review  The Centers for Disease Control and Prevention (CDC) National Center for Injury Prevention and Control Board of Scientific Counselors, a federal advisory committee, established the Pediatric Mild Traumatic Brain Injury Guideline Workgroup. The workgroup drafted recommendations based on the evidence that was obtained and assessed within the systematic review, as well as related evidence, scientific principles, and expert inference. This information includes selected studies published since the evidence review was conducted that were deemed by the workgroup to be relevant to the recommendations. The dates of the initial literature search were January 1, 1990, to November 30, 2012, and the dates of the updated literature search were December 1, 2012, to July 31, 2015.

Findings  The CDC guideline includes 19 sets of recommendations on the diagnosis, prognosis, and management/treatment of pediatric mTBI that were assigned a level of obligation (ie, must, should, or may) based on confidence in the evidence. Recommendations address imaging, symptom scales, cognitive testing, and standardized assessment for diagnosis; history and risk factor assessment, monitoring, and counseling for prognosis; and patient/family education, rest, support, return to school, and symptom management for treatment.

Conclusions and Relevance  This guideline identifies the best practices for mTBI based on the current evidence; updates should be made as the body of evidence grows. In addition to the development of the guideline, CDC has created user-friendly guideline implementation materials that are concise and actionable. Evaluation of the guideline and implementation materials is crucial in understanding the influence of the recommendations.

The associated systematic review (subscription required): https://jamanetwork.com/journals/jamapediatrics/article-abstract/2698455


ED Implementation (subscription required): https://www.annemergmed.com/article/S0196-0644(18)30321-4/fulltext

B. Probiotics don't benefit children with gastroenteritis 

Two studies in The New England Journal of Medicine showed that youths with moderate-to-severe acute gastroenteritis who received Lactobacillus rhamnosus-L. helveticus combination probiotic or L. rhamnosus alone had a similar median duration of vomiting and diarrhea, as well as similar rates of adverse events, compared with those who were given placebo.



C. Emergency physicians, pediatricians, and nurses issue recommendations on emergency care for children

The American College of Emergency Physicians (ACEP), the American Academy of Pediatrics (AAP), and the Emergency Nurses Association (ENA) will publish the updated joint guidelines, “Pediatric Readiness in the Emergency Department,” that recommend ways health care providers can make sure every injured or critically ill child receives the best care possible.

The joint policy statement is published online in Annals of Emergency Medicine, represents a revision of the 2009 policy statement and highlights recent advances in pediatric emergency care that may be incorporated into all emergency departments that care for children. The statement (published Nov. 1 online) emphasizes the importance of evidence-based guidelines and includes additional recommendations for quality improvement plans focusing on children and disaster preparedness.

“The joint recommendations help improve and standardize care delivery for children of all ages in the emergency department, create best practice benchmarks for emergency departments and strengthen pediatric patient safety efforts,” said Vidor Friedman, MD, FACEP, president of ACEP.

According to the 2014 National Hospital Ambulatory Medical Care Survey, there were approximately 5,000 emergency departments in the United States. Of the more than 141 million emergency department visits, an estimated 20 percent were for children younger than 15 years. As many as 83 percent of children in need of emergency care go to a community emergency department versus a pediatric emergency department…


Pediatric Readiness in the Emergency Department

D. Do Low-Risk Febrile Infants Aged ≤60 Days Need a Lumbar Puncture?

It may be safe to forego LP in infants aged ≥29 days at low risk for invasive bacterial infection.

Aronson PL et al. Pediatrics 2018 Nov 13 [Epub ahead of print]

BJECTIVES: To evaluate the Rochester and modified Philadelphia criteria for the risk stratification of febrile infants with invasive bacterial infection (IBI) who do not appear ill without routine cerebrospinal fluid (CSF) testing.

METHODS:
We performed a case-control study of febrile infants ≤60 days old presenting to 1 of 9 emergency departments from 2011 to 2016. For each infant with IBI (defined as a blood [bacteremia] and/or CSF [bacterial meningitis] culture with growth of a pathogen), controls without IBI were matched by site and date of visit. Infants were excluded if they appeared ill or had a complex chronic condition or if data for any component of the Rochester or modified Philadelphia criteria were missing.

RESULTS:
Overall, 135 infants with IBI (118 [87.4%] with bacteremia without meningitis and 17 [12.6%] with bacterial meningitis) and 249 controls were included. The sensitivity of the modified Philadelphia criteria was higher than that of the Rochester criteria (91.9% vs 81.5%; P = .01), but the specificity was lower (34.5% vs 59.8%; P less than .001). Among 67 infants over 28 days old with IBI, the sensitivity of both criteria was 83.6%; none of the 11 low-risk infants had bacterial meningitis. Of 68 infants ≤28 days old with IBI, 14 (20.6%) were low risk per the Rochester criteria, and 2 had meningitis.

CONCLUSIONS:
The modified Philadelphia criteria had high sensitivity for IBI without routine CSF testing, and all infants over 28 days old with bacterial meningitis were classified as high risk. Because some infants with bacteremia were classified as low risk, infants discharged from the emergency department without CSF testing require close follow-up.

E. Causal Relationship Supported Between Childhood Obesity and Slipped Capital Femoral Epiphysis

Perry DC et al. Pediatrics 2018 Nov;142(5).

BACKGROUND: Slipped capital femoral epiphysis (SCFE) is believed to be associated with childhood obesity, although the strength of the association is unknown.

METHODS:
We performed a cohort study using routine data from health screening examinations at primary school entry (5-6 years old) in Scotland, linked to a nationwide hospital admissions database. A subgroup had a further screening examination at primary school exit (11-12 years old).

RESULTS:
BMI was available for 597 017 children at 5 to 6 years old in school and 39 468 at 11 to 12 years old. There were 4.26 million child-years at risk for SCFE. Among children with obesity at 5 to 6 years old, 75% remained obese at 11 to 12 years old. There was a strong biological gradient between childhood BMI at 5 to 6 years old and SCFE, with the risk of disease increasing by a factor of 1.7 (95% confidence interval [CI] 1.5-1.9) for each integer increase in BMI z score. The risk of SCFE was almost negligible among children with the lowest BMI. Those with severe obesity at 5 to 6 years old had 5.9 times greater risk of SCFE (95% CI 3.9-9.0) compared with those with a normal BMI; those with severe obesity at 11 to 12 years had 17.0 times the risk of SCFE (95% CI 5.9-49.0).

CONCLUSIONS:
High childhood BMI is strongly associated with SCFE. The magnitude of the association, temporal relationship, and dose response added to the plausible mechanism offer the strongest evidence available to support a causal association.

F. Everything is awesome: Don't forget the Lego

Tagg A, et al. J Paediatr Child Health. 2018 November 22 [Epub ahead of print]

What is already known on this topic
Children frequently ingest foreign objects.
Parents worry about transit times and complications from ingestion.

What this paper adds
A predefined object passes through adult patients in 1–3 days.
There were no complications in our subjects.
Parents should be counselled not to search for the object in stools as it is difficult to find.

Aim
Children frequently ingest coins (generally with minimal reported side effects); however, the ingestion of other items has been subject to less academic study. Parental concern regarding ingestion applies across a range of materials. In this study, we aimed to determine typical transit times for another commonly swallowed object: a Lego figurine head.

Methods
Six paediatric health‐care professionals were recruited to swallow a Lego head. Previous gastrointestinal surgery, inability to ingest foreign objects and aversion to searching through faecal matter were all exclusion criteria. Pre‐ingestion bowel habit was standardised by the Stool Hardness and Transit (SHAT) score. Participants ingested a Lego head, and the time taken for the object to be found in the participants stool was recorded. The primary outcome was the Found and Retrieved Time (FART) score.

Results
The FART score averaged 1.71 days. There was some evidence that females may be more accomplished at searching through their stools than males, but this could not be statistically validated.

Conclusions
A toy object quickly passes through adult subjects with no complications. This will reassure parents, and the authors advocate that no parent should be expected to search through their child's faeces to prove object retrieval.


Radecki’s comments: https://www.emlitofnote.com/?p=4335

G. Limitations of Using Pediatric Respiratory Illness Readmissions to Compare Hospital Performance


9. Clinical Tips from the EM News Journals

A. How to Effectively Block an Acutely Fractured Distal Radius

Luftig J, et al. ACEP Now

Distal radius fractures (commonly called Colles’ or Smith’s fractures) are often encountered in the emergency department, with options for analgesia revolving around either a hematoma block, intravenous opioids, or procedural sedation, particularly for closed reduction. A novel single-injection nerve block technique known as the retroclavicular approach to the infraclavicular region (RAPTIR) may be the ideal method for excellent pain control, allowing for nearly painless closed reduction and lasting analgesia.1,2


B. No Reason Not to Use TXA for Critical GI Bleeds

TXA deserves a permanent place in EPs’ armamentarium against GI bleeds because multiple trials have proven its ability to save lives and disproven the feared complications.

Pescatore R. Emerg Med News. 2018; 40(11):1,9-9.

The application of evidence-based medicine is at its easiest after large trials and rigorous analyses have been popularized and widely disseminated. The evidence-based clinician must juggle online resources, academic manuscripts, and trade journals, but ultimately can remain current through the cornucopia of open-access educational resources available to the modern emergency medicine physician.

A true test of bedside Bayesianism, however, comes when we are presented with clinical conundrums not yet thoroughly vetted and extensively analyzed by contemporary emergency medicine educators. It is when no clear answer exists that we are forced to faithfully apply the best available knowledge to answer critical questions in real time. As methodical skepticism in emergency medicine continues to permeate and propel our evidence-based culture, it is crucial that we not abdicate our underlying responsibility to do what we think is best for the patient in front of us…

Consider the patient dying of a gastrointestinal bleed. It's no rarity—tens of thousands of these patients pass through our doors annually. Emergency medicine residents cut their procedural teeth in resuscitation bays full of GI bleeders and almost every EP has a story about that time he put a Blakemore in. We often lament how little we have to offer these patients while awaiting reticent gastroenterologists…

Curiously, one medication has remained inexplicably absent from our routine resuscitation of the critically ill GI bleeder. Tranexamic acid, or TXA, recently championed in trauma and publicized for every bleeding source from epistaxis (EMN 2018;40[4]:1; http://bit.ly/2Qq5Iux) to abnormal uterine bleeding (EMN 2018;40[3]:5; http://bit.ly/2N7MAmW), often sits unused in the pharmacy as the blood bank is emptied and our patients deteriorate. Despite strong physiologic justification for its use and a level of clinical evidence that should sate even the strictest of EBM evangelists, TXA has yet to find permanent purchase in the GI bleed armamentarium…


10. Images in Clinical Practice

Hemolacria — Crying Blood

Parinaud’s Oculoglandular Syndrome in Cat Scratch Disease

Cast of the Right Bronchial Tree

Nail Pitting in Psoriasis

Pneumococcal Bacteremia and Meningitis

Portal Venous Gas

Ingestion of Lead-Contaminated Packs of Opium

Burton’s Line from Chronic Lead Intoxication

Miliary Metastases in Non–Small-Cell Lung Cancer

Man With Abdominal Pain and Bilious Emesis

Woman With Neck Pain

Elderly Woman With Abdominal Pain

Man With Left-Sided Neck Pain

Woman With Foreign Body on Her Tongue

11. Psychiatric Emergencies for Clinicians: ED Management of Hypercalcemia

Alfaraj DN, et al. J Emerg Med. 2018;55:688-692.

Clinical Scenario
A 55-year-old male with a medical history notable for diabetes mellitus and lung cancer was brought to the emergency department via emergency medical services for lethargy and confusion that started a few hours earlier. His family reported that his medications included tramadol 50 mg three times a day as needed for pain and glyburide 5 mg twice a day. A review of systems was taken from his family members, which was positive for nausea, abdominal pain, polyuria, polydipsia, and a recent renal stone. The vital signs included temperature of 37.1°C, blood pressure of 110/60 mm Hg, heart rate of 120 beats/min, respiratory rate of 22 breaths/min, and oxygen saturation rate of 97% on room air. A fingerstick glucose level was 185 mg/dL and an electrocardiogram was initially reported as unremarkable, although a short QT interval was noted. On physical examination, the patient was not oriented to person, place, or time, and appeared dehydrated with dry mucous membranes. Pupils were equal, round, and reactive to light. Other physical examination findings were unremarkable. A basic metabolic panel eventually resulted with a calcium level of 15 mg/dL.


12. Ann Emerg Med Quick Reviews

A. Can the HEART Score Rule Out ACS in the ED?

Take-Home Message
Patients presenting to the emergency department (ED) with possible acute coronary syndrome and a HEART score of 0 to 3 are at low risk for a subsequent major adverse cardiac event.


B. In Patients With STEMI, Which Fibrinolytic Agent Is the Safest and Most Effective?

Take-Home Message
In patients with ST-segment elevation myocardial infarction (STEMI), when percutaneous coronary intervention is not an option, reperfusion therapy with the fibrinolytic agents tenecteplase, reteplase, or accelerated alteplase (90 minutes of infusion) plus parenteral anticoagulation has better overall safety and efficacy than other regimens.


C. What Is the Best Imaging Study to Rule Out PE in Pregnancy?

Take-Home Message
Both computed tomography (CT) pulmonary angiography and lung scintigraphy (ie, ventilation-perfusion scan) are appropriate imaging options for exclusion of pulmonary embolism during pregnancy.


D. Is High-Flow Nasal Cannula More Effective Than Conventional Oxygen Therapy for Preventing Escalation of Respiratory Support in Patients With Acute Respiratory Failure?

Take-Home Message
High-flow nasal cannula and conventional oxygen therapy demonstrate similar results in the treatment of acute respiratory failure in regard to rates of respiratory support escalation, intubation, mortality, and ICU transfer, although it may decrease the need for escalation of respiratory support and intubation among patients with acute respiratory failure who are undergoing treatment for greater than or equal to 24 hours.


E. Are Shorter Courses of Corticosteroids as Effective as Longer Courses in Acute Exacerbations of COPD?

In patients with acute chronic obstructive pulmonary disease exacerbation, short-term corticosteroids (less than 7 days) have similar rates of treatment failure, relapse, and medication adverse effects compared with longer-term corticosteroid therapy.


13. Cozy Down in Cannabis Corner

A. Risk for DKA in Diabetic Cannabis Users

Thomas L. Schwenk, MD, Journal Watch, 2018 Nov 15 reviewing Akturk HK et al. JAMA Intern Med 2018 Nov 5

Among adults with type 1 diabetes, cannabis users were more likely to be hospitalized for ketoacidosis than were nonusers.

Some reports suggest excess risk for diabetic ketoacidosis (DKA) in cannabis users with type 1 diabetes. This retrospective cohort study took place at a diabetes treatment center in Colorado, where recreational and medical marijuana are legal. Researchers asked 450 adults with type 1 diabetes (mean age, 35; mean duration of diabetes, 19 years) about cannabis use and hospitalization for DKA in the previous year; 30% of these patients were cannabis users, half used the substance at least twice weekly, and half had used cannabis for longer than 3 years. About 40% were considered to have possibly hazardous levels of use or cannabis use disorders.

Based on patients' reports of hospitalization for ketoacidosis (validated by medical record review), cannabis use was associated with greater likelihood of DKA than was nonuse (odds ratio, 1.98).

COMMENT
These findings, based on self-reported data, are sufficiently intriguing to warrant further research. A larger prospective cohort study could be used to confirm the findings and examine whether cannabis-associated risk for DKA is dose-dependent.


B. Cannabis Use, Sex, and Mental Health Symptoms Across the Lifespan

Associations with psychotic, depressive, and anxious symptoms were found in both adolescents and adults, with stronger findings in females.

Leadbeater BJ, et al. Addiction 2018 Oct 1 [Epub ahead of print]

AIMS:
We tested the age-varying associations of cannabis use (CU) frequency and disorder (CUD) with psychotic, depressive and anxiety symptoms in adolescent and adult samples. Moderating effects of early onset (≤ 15 years) and sex were tested.

DESIGN:
Time-varying effect models were used to assess the significance of concurrent associations between CU and CUD and symptoms of psychosis, depression and anxiety at each age.

SETTING AND PARTICIPANTS:
Adolescent data (V-HYS; n = 662) were collected from a randomly recruited sample of adolescents in Victoria, British Columbia, Canada during a 10-year period (2003-13). Adult cross-sectional data (NESARC-III; n = 36 309) were collected from a representative sample from the United States (2012-13).

MEASUREMENTS:
Mental health symptoms were assessed using self-report measures of diagnostic symptoms. CU was based on frequency of past-year use. Past-year CUD was based on DSM-5 criteria.

FINDINGS:
For youth in the V-HYS, CU was associated with psychotic symptoms following age 22 [b = 0.13, 95% confidence interval (CI) = 0.002, 0.25], with depressive symptoms from ages 16-19 and following age 25 (b = 0.17, 95% CI = 0.003, 0.34), but not with anxiety symptoms. CUD was associated with psychotic symptoms following age 23 (b = 0.51, 95% CI = 0.01, 1.01), depressive symptoms at ages 19-20 and following age 25 (b = 0.71, 95% CI = 0.001, 1.42) and anxiety symptoms ages 26-27 only. For adults in the NESARC-III, CU was associated with mental health symptoms at most ages [e.g. psychotic symptoms; age 18 (b = 0.22, 95% CI = 0.10, 0.33) to age 65 (b = 0.36, 95% CI = 0.16, 0.56)]. CUD was associated with all mental health symptoms across most ages [e.g. depressive symptoms; age 18 (b = 0.96, 95% CI = 0.19, 1.73) to age 61 (b = 1.11, 95% CI = 0.01, 2.21)]. Interactions with sex show stronger associations for females than males in young adulthood [e.g.

V-HYS:
CUD × sex interaction on psychotic symptoms significant after age 26 (b = 1.12, 95% CI = 0.02, 2.21)]. Findings were not moderated by early-onset CU.

CONCLUSIONS:
Significant associations between cannabis use (CU) frequency and disorder (CUD) and psychotic and depressive symptoms in late adolescence and young adulthood extend across adulthood, and include anxiety.

14. New Flu Drug Offers Convenience, Fast Activity, and a Novel Mechanism — at a Price

Paul E Sax, MD. J Watch ID Blog. October 28th, 2018

New Flu Drug Offers Convenience, Fast Activity, and a Novel Mechanism — at a Price

Last week, the FDA approved a new drug for treatment of influenza, baloxavir marboxil (Xofluza).

The drug is indicated for treatment of symptomatic influenza in patients 12 years of age or older. As with existing treatments, it should be started within 48 hours of symptom onset.

In a comparative clinical trial in otherwise healthy outpatients, baloxavir and oseltamivir (commonly known as Tamiflu) comparably reduced the duration of flu symptoms — both on average by about 36 hours. Each treatment was more effective if started within 24 hours of symptom onset.

Baloxavir differs from oseltamivir in several ways, some of them potentially important:

Treatment is a single dose. Patients receive 40 mg if their weight is between 40 and 80 kg, and 80 mg (two pills) if 80 kg or more. As every primary care clinician knows, oseltamivir is 75 mg twice daily for 5 days.

Side effects ascribed to the treatment occurred less frequently in those randomized to baloxavir vs oseltamivir — specifically, 3.9% and 8.4% for baloxavir and oseltamivir, respectively (p=0.009). The side effects table from the study indicate that GI-related side effects (especially nausea) were numerically more common with oseltamivir. In clinical practice, this is the most commonly encountered problem with the drug, which can be diminished (but not eliminated) when oseltamivir is taken with food. The incidence of severe adverse events did not differ between arms.

Baloxavir lowered influenza viral loads in respiratory secretions faster than oseltamivir. The clinical significance of this faster antiviral action is unclear. Might this make patients less contagious more quickly? Or could this translate to a clinical benefit in very immunocompromised hosts, or in the most severe cases? A study in “high risk” adults demonstrated a faster recovery time compared to oseltamivir if the infecting virus was influenza B; outcomes in influenza A were similar. A different clinical trial of the drug in hospitalized patients is about to start.

The mechanism of action is different. Unlike the neuraminidase inhibitors (oseltamivir, et al), baloxavir blocks influenza replication through inhibition of viral endonuclease (see the fine video below). It’s the first flu drug with this mechanism of action. The good news is that baloxavir should retain activity against neuraminidase-resistant strains, which periodically emerge and could be a substantial global threat.

Baloxavir treatment selects for resistance. This excellent accompanying editorial to the above-cited phase 3 trial describes the resistance concerns in more detail. Will this resistance limit the usefulness of the drug? Or will the impaired replication capacity of resistance variants make them less transmissible?

Oseltamivir is generic, and cheap. A 5-day course costs around $50. Payers have undoubtedly negotiated a much lower price. (That stuff is kept secret from us patients and clinicians, remember.) Baloxavir will cost $150, regardless of the dose, with coupons available to lower the price.

My colleague Ken Freedberg, whose research focus is cost-effectiveness, often jokes that he’s frequently the last to speak at a conference since the topic of cost is so often considered secondary to the “scientific” parts of the program.

Please note, Ken, that I meant no offense by putting cost last in the bulleted list above.

Especially since with baloxavir, it’s probably this very point — cost — that will limit use of the drug, at least initially. Insurance plans are not eager (an understatement) to add new treatments to their formularies that cost more than existing options unless they are clearly more effective, or safer, or preferably both.

With baloxavir, while it seems to have some advantages over osteltamivir in these metrics, we’re not quite there yet.

In the meantime, we can make fun of the brand name —Xofluza! — which, if you say it loudly and quickly, kind of sounds like someone sneezing.


15. Why Do We Recommend a Sodium-Restricted Diet for HF Patients?

A systematic review reveals the paucity of data behind this recommendation.

Mahtani KR, et al. Reduced Salt Intake for Heart Failure: A Systematic Review. JAMA Intern Med. 2018 Nov 5 [Epub ahead of print]

IMPORTANCE:
Recent estimates suggest that more than 26 million people worldwide have heart failure. The syndrome is associated with major symptoms, significantly increased mortality, and extensive use of health care. Evidence-based treatments influence all these outcomes in a proportion of patients with heart failure. Current management also often includes advice to reduce dietary salt intake, although the benefits are uncertain.

OBJECTIVE:
To systematically review randomized clinical trials of reduced dietary salt in adult inpatients or outpatients with heart failure.

EVIDENCE REVIEW:
Several bibliographic databases were systematically searched, including the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, and CINAHL. The methodologic quality of the studies was evaluated, and data associated with primary outcomes of interest (cardiovascular-associated mortality, all-cause mortality, and adverse events, such as stroke and myocardial infarction) and secondary outcomes (hospitalization, length of inpatient stay, change in New York Heart Association [NYHA] functional class, adherence to dietary low-salt intake, and changes in blood pressure) were extracted.

FINDINGS:
Of 2655 retrieved references, 9 studies involving 479 unique participants were included in the analysis. None of the studies included more than 100 participants. The risks of bias in the 9 studies were variable. None of the included studies provided sufficient data on the primary outcomes of interest. For the secondary outcomes of interest, 2 outpatient-based studies reported that NYHA functional class was not improved by restriction of salt intake, whereas 2 studies reported significant improvements in NYHA functional class.

CONCLUSIONS AND RELEVANCE:
Limited evidence of clinical improvement was available among outpatients who reduced dietary salt intake, and evidence was inconclusive for inpatients. Overall, a paucity of robust high-quality evidence to support or refute current guidance was available. This review suggests that well-designed, adequately powered studies are needed to reduce uncertainty about the use of this intervention.

From the editorial:
We have long treated the dictum to restrict sodium intake in heart failure as a pillar of best practices and a sacrosanct edict that populates the core database for all physicians treating cardiovascular disease. Guidelines have mandated empirical thresholds that are to be respected, and consensus statements from leading organizations further make the case for sodium restriction as a basic tenet of good cardiovascular care.1 However, like many other dogmatic statements that were fully embedded in cardiovascular medicine—for example, suppression of premature ventricular contractions, avoidance of β-blockers in left ventricular dysfunction, and use of hormone replacement therapy in women at risk for cardiovascular disease—the time has now come for sodium restriction in heart failure to be critically reevaluated. There is simply too much uncertainty for a conviction we hold as truth. At a minimum, rigorous testing in well-performed randomized clinical trials is needed. There should be only 1 goal: valid evidence leading to a much more informed position, actionable guidelines, and personalized implementation.

16. Immunotherapy: What side effects can you expect?

While immunotherapy is a boon for cancer treatment, it's not always benign

Phyllis Maguire, Today’s Hospitalist.  July 2018

IMMUNOTHERAPY has not only transformed how many cancers are treated, but it’s also changed how oncologists think of cancer.

“We always thought of cancer as a sumo wrestler suppressing the immune system and that it was the failure of the immune system to detect cancer that led to metastatic disease,” said Yelena Y. Janjigian, MD, who presented an oncology update at this year’s Society of Hospital Medicine conference.

But with immune checkpoint inhibitors, “the sumo wrestler is now the immune system, suppressing cancer as the little guy.” This treatment bonanza, however, has come with one major misperception, said Dr. Janjigian, who is chief of the GI oncology service at New York’s Memorial Sloan Kettering Cancer Center: the idea that immunotherapies are benign.

“Side effects can be severe and even deadly.”

In reality, “side effects can be severe and even deadly,” she said. “Patients may not be getting the alopecia or neuropathy they do with chemo, but they’re getting rashes, colitis and pneumonitis.” As she explains to her patients, “Immunotherapy takes the brakes off the immune system, so it disables the checks and balances we normally have to prevent autoimmune effects.”

The good news is most of these toxicities are reversible, said Dr. Janjigian—”if you treat them aggressively and quickly.”

Toxicity profiles
The FDA has approved six immune checkpoint blocking antibodies that target either the CTLA-4 receptor or the PD-1 receptor and its ligand PD-L1. According to Dr. Janjigian, these agents “are now FDA-approved for multiple cell tumor malignancies, so you will be seeing them more and more.”

The one that targets CTL-4—ipilimumab (Yervoy)— is approved for melanoma, although it’s being tested in several GI trials. As for therapies targeting PD-1 receptors, there’s nivolumab (Opdivo), which is manufactured by Bristol Myers Squibb, or “its Merck counterpart, penbrolizumab (Keytruda), the drug that cured Jimmy Carter of metastatic melanoma of the brain,” she pointed out. “These are the Coke and Pepsi of PD-1 inhibitors, and they have very similar effectiveness profiles.”

Their toxicities are also similar. The other approved agents—atezolizumab, avelumab and durvalumab— all target PD-L1 and are not used as often.

The side effects of these drugs vary, but “generally the patients who are actually responding to therapy are the ones who develop effects,” said Dr. Janjigian.


Related EM articles
Simmons D, et al. The Most Recent Oncologic Emergency: What EPs Need to Know About the Potential Complications of Immune Checkpoint Inhibitors. Cureus. 2017;9(10):e1774.  (full-text free) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5729030/  

El Majzoub I, et al. Adverse Effects of Immune Checkpoint Therapy in Cancer Pts Visiting the ED of a Comprehensive Cancer Center. Ann Emerg Med. 2018 Jun 4 [Epub]. https://www.ncbi.nlm.nih.gov/pubmed/29880440

Pallin DJ, et al.  Immune-related AEs in Cancer Pts. Acad Emerg Med. 2018;25(7):819-827. https://www.ncbi.nlm.nih.gov/pubmed/29729100

Hryniewiecki AT, et al. Management of Immune Checkpoint Inhibitor Toxicities: A Review and Clinical Guideline for EPs. J Emerg Med. 2018;55(4):489-502. https://www.ncbi.nlm.nih.gov/pubmed/30120013

Ballard DW, et al. Medically Clear: New Immunotherapy Revolutionizes Cancer Care but Guess Where Adverse Events End Up? (full-text free) https://journals.lww.com/em-news/Fulltext/2018/09000/Medically_Clear__New_Immunotherapy_Revolutionizes.15.aspx

17. On Gun Violence

A. Gun-Related Deaths Increasing After Decade-Long Decline, CDC Report Says.


B. Reducing Firearm Injuries and Deaths in the United States: A Position Paper From the American College of Physicians



C. How to Stop Mass Shootings

Garen J. Wintemute, MD, MPH. N Engl J Med 2018;379:1193-1196.

Two policies exist today that if properly designed, widely enacted, and adequately implemented would likely have saved these lives and could potentially save many more in the future. Their benefits would extend far beyond reducing the incidence of mass shootings…


D. THIS IS OUR LANE: An Open Letter to the NRA from American Healthcare Professionals

Dear National Rifle Association,

On Wednesday night (11/7/2018), in response to a position paper released by the American College of Physicians (ACP) “Reducing Firearm Injuries and Death in the United States”, your organization published the statement “Someone should tell self-important anti-gun doctors to stay in their lane.”

On that same day, the CDC published new data indicating that the death toll from gun violence in our nation continues to rise. As we read your demand for us doctors to stay in our lane, we awoke to learn of the 307th mass shooting in 2018 with another 12 innocent lives lost to an entirely preventable cause of death–gun violence….


18. Rotating night shift work and adherence to unhealthy lifestyle in predicting risk of type 2 diabetes: results from two large US cohorts of female nurses

Shan Z, et al. BMJ. 2018 Nov 21;363:k4641.

OBJECTIVES:
To prospectively evaluate the joint association of duration of rotating night shift work and lifestyle factors with risk of type 2 diabetes risk, and to quantitatively decompose this joint association to rotating night shift work only, to lifestyle only, and to their interaction.

DESIGN:
Prospective cohort study.

SETTING:
Nurses' Health Study (1988-2012) and Nurses' Health Study II (1991-2013).

PARTICIPANTS:
143 410 women without type 2 diabetes, cardiovascular disease, or cancer at baseline.

EXPOSURES:
Rotating night shift work was defined as at least three night shifts per month in addition to day and evening shifts in that month. Unhealthy lifestyles included current smoking, physical activity levels below 30 minutes per day at moderate to vigorous intensity, diet in the bottom three fifths of the Alternate Healthy Eating Index score, and body mass index of 25 or above.

MAIN OUTCOME MEASURES:
Incident cases of type 2 diabetes were identified through self report and validated by a supplementary questionnaire.

RESULTS:
During 22-24 years of follow-up, 10 915 cases of incident type 2 diabetes occurred. The multivariable adjusted hazard ratios for type 2 diabetes were 1.31 (95% confidence interval 1.19 to 1.44) per five year increment of duration of rotating night shift work and 2.30 (1.88 to 2.83) per unhealthy lifestyle factor (ever smoking, low diet quality, low physical activity, and overweight or obesity). For the joint association of per five year increment rotating night shift work and per unhealthy lifestyle factor with type 2 diabetes, the hazard ratio was 2.83 (2.15 to 3.73) with a significant additive interaction (P for interaction less than 0.001). The proportions of the joint association were 17.1% (14.0% to 20.8%) for rotating night shift work alone, 71.2% (66.9% to 75.8%) for unhealthy lifestyle alone, and 11.3% (7.3% to 17.3%) for their additive interaction.

CONCLUSIONS:
Among female nurses, both rotating night shift work and unhealthy lifestyle were associated with a higher risk of type 2 diabetes. The excess risk of rotating night shift work combined with unhealthy lifestyle was higher than the addition of risk associated with each individual factor. These findings suggest that most cases of type 2 diabetes could be prevented by adhering to a healthy lifestyle, and the benefits could be greater in rotating night shift workers.


19. Derivation and validation of a practical Bedside Score for the diagnosis of cholecystitis.

Yeh DD, et al. Am J Emerg Med. 2019;37(1):61-66.

OBJECTIVE:
We sought to develop a practical Bedside Score for the diagnosis of cholecystitis and test its accuracy against the Tokyo Guidelines (TG13).

METHODS:
We conducted a retrospective study of 438 patients undergoing urban, academic Emergency Department (ED) evaluation of RUQ pain. Symptoms, physical signs, ultrasound signs, and labs were scoring system candidates. A random split-sample approach was used to develop and validate a new clinical score. Multivariable regression analysis using development data was conducted to identify predictors of cholecystitis. Cutoff values were chosen to ensure positive/negative predictive values (PPV, NPV) of at least 0.95. The score was externally validated in 80 patients at a different hospital undergoing RUQ pain evaluation.

RESULTS:
230 patients (53%) had cholecystitis. Five variables predicted cholecystitis and were included in the scores: gallstones, gallbladder thickening, clinical or ultrasonographic Murphy's sign, RUQ tenderness, and post-prandial symptoms. A clinical prediction score was developed. When dichotomized at 4, overall accuracy for acute cholecystitis was 90% for the development cohort, 82% and 86% for the internal and external validation cohorts; TG13 accuracy was 62%-79%.

CONCLUSIONS:
A clinical prediction score for cholecystitis demonstrates accuracy equivalent to TG13. Use of this score may streamline work-up by decreasing the need for comprehensive ultrasound evaluation and CRP measurement and may shorten ED length of stay.



Remind me, what are the Tokyo Guidelines from 2013/2018?

Table 1. TG18/TG13 diagnostic criteria for acute cholecystitis
A. Local signs of inflammation etc.
(1) Murphy's sign, (2) RUQ mass/pain/tenderness
B. Systemic signs of inflammation etc.
(1) Fever, (2) elevated CRP, (3) elevated WBC count
C. Imaging findings
Imaging findings characteristic of acute cholecystitis
Suspected diagnosis: one item in A + one item in B
Definite diagnosis: one item in A + one item in B + C
  • The TG13 diagnostic criteria of acute cholecystitis was judged from numerous validation studies as useful indicators in clinical practice and adopted as TG18 diagnostic criteria without any modification
  • Acute hepatitis, other acute abdominal diseases, and chronic cholecystitis should be excluded
  • CRP C‐reactive protein, RUQ right upper abdominal quadrant, WBC white blood cell

More on the Tokyo Guidelines 2013 (TG13): https://onlinelibrary.wiley.com/toc/18686982/20/1


20. Diagnostic Imaging in EM: How Much Is Too Much?

Baloescu C, et al. Ann Emerg Med. 2018;72(6): 637–643

Introduction
Few topics are as pertinent to the current emergency medicine climate as the debate surrounding the overuse of diagnostic imaging. Use of advanced diagnostic imaging has increased in the United States exponentially since the advent of computed tomography (CT) and magnetic resonance imaging (MRI). CT use has increased from 3 million scans in 1980 to greater than 60 million in 2005, and is still increasing.1 Although this growth stretches across the care continuum, it includes the emergency department (ED). Overall, CT use during ED visits increased 330%, from 3.2% of encounters in 1996 to 13.9% in 2007.2

This subject incorporates intertwined issues, including the reliability of history and physical examination findings, special or high-risk ED populations, fear of litigation, physician risk aversion, public opinion, patient satisfaction, reimbursement, timing pressures, and physician experience, to name just a few.

Given the topic’s complexity, it is not surprising that a plethora of views has been circulating in both the medical literature and the popular press…


21. Lit Reviews from EM Journals

A. US for the Confirmation of Endotracheal Tube Intubation: A Systematic Review and Meta-Analysis

Gottlieb M, et al. Ann Emerg Med. 2018;72(6):627-636.

Study objective
Intubation is routinely performed in the emergency department, and rapid, accurate confirmation is essential to avoid potentially serious adverse outcomes. The number of studies assessing ultrasonography for the verification of endotracheal tube placement has expanded rapidly in recent years. We performed this systematic review and meta-analysis to determine the sensitivity and specificity of transtracheal ultrasonography for the verification of endotracheal tube location.

Methods
PubMed, the Cumulative Index of Nursing and Allied Health, Scopus, Latin American and Caribbean Health Sciences Literature database, the Cochrane databases, and bibliographies of selected articles were assessed for all prospective and randomized controlled trials evaluating the accuracy of transtracheal ultrasonography for identifying endotracheal tube location. Data were dual extracted into a predefined worksheet and quality analysis was performed with the Quality Assessment of Diagnostic Accuracy Studies–2 tool. Data were summarized and a meta-analysis was performed with subgroup analyses by location, specialty, experience, transducer type, and technique. Time to confirmation was assessed as a secondary outcome.

Results
This systematic review identified 17 studies (n=1,595 patients). Overall, transtracheal ultrasonography was 98.7% sensitive (95% confidence interval [CI] 97.8% to 99.2%) and 97.1% specific (95% CI 92.4% to 99.0%), with a positive likelihood ratio of 34.4 (95% CI 12.7 to 93.1) and a negative likelihood ratio of 0.01 (95% CI 0.01 to 0.02). Subgroup analyses did not demonstrate a significant difference by location, provider specialty, provider experience, transducer type, or technique. Mean time to confirmation was 13.0 seconds.

Conclusion
Transtracheal sonography is rapid to perform, with an acceptable degree of sensitivity and specificity for the confirmation of endotracheal intubation. Ultrasonography is a valuable adjunct and should be considered when quantitative capnography is unavailable or unreliable.

B. Management of HF in the ED Setting: An Evidence-Based Review of the Literature.

Long B, et al. J Emerg Med. 2018;55:635-46.

BACKGROUND:
Acute heart failure (AHF) is a common presentation to the emergency department (ED), with the potential to cause significant morbidity and mortality. It is important to tailor treatments to the appropriate type of heart failure.

OBJECTIVES:
This review provides an evidence-based summary of the current ED management of acute heart failure.

DISCUSSION:
Heart failure can present along a spectrum, especially in acute exacerbation. Treatment should focus on the underlying disease process, with guidelines focusing primarily on blood pressure and hemodynamic status. Treatment of patients with mild AHF exacerbations often focuses on intravenous diuretics. Patients with AHF with flash pulmonary edema should receive nitroglycerin and noninvasive positive pressure ventilation, with consideration of an angiotensin-converting enzyme inhibitor, while monitoring for hypotension. Patients with hypotensive AHF should receive emergent specialty consultation and an initial fluid bolus of 250-500 mL, followed by initiation of inotropic agents with or without vasopressors. Dobutamine is the inotrope of choice in these patients, with norepinephrine recommended if blood pressure support is needed. If noninvasive positive pressure ventilation is required, providers should monitor closely for acute decompensation. Mechanical circulatory support devices may be considered as a bridge to further therapeutic intervention. High-output heart failure can be managed acutely with vasoconstricting agents, with focus on treating the underlying etiology. Disposition is not always straightforward, and several risk scores may assist in this decision.

CONCLUSION:
AHF is a condition that requires rapid assessment and management. Understanding the appropriate management strategy can allow for more targeted treatment and improved outcomes.

C. Malpractice in EM—A Review of Risk and Mitigation Practices for the EM Provider

Ferguson B, et al. J Emerg Med. 2018;55:659-665.

BACKGROUND:
Malpractice in emergency medicine is of high concern for medical providers, the fear of which continues to drive decision-making. The body of evidence evaluating risk specific to emergency physicians is disjointed, and thus it remains difficult to derive cohesive themes and strategies for risk minimization.

OBJECTIVE:
This review evaluates the state of malpractice in emergency medicine and summarizes a concise approach for the emergency physician to minimize risk.

DISCUSSION:
The environment of the emergency department (ED) represents moderate overall malpractice risk and yields a heavy burden in finance and time. Key areas of relatively high litigation occurrence include missed acute myocardial infarction, missed fractures/foreign bodies, abdominal pain/appendicitis, wounds, intracranial bleeding, aortic aneurysm, and pediatric meningitis. Mitigation of risk is best accomplished through constructive communication, intelligent documentation, utilization of clinical practice guidelines and generalizable diagnoses, careful management of discharge against medical advice, and establishing follow-up for diagnostic studies ordered while in the ED (especially x-ray studies). Communication breakdown seems to be more predictive of malpractice litigation than injury experienced.

CONCLUSIONS:
There are consistent diagnoses that are associated with increased litigation incidence. A combination of mitigation approaches may assist providers in mitigation of malpractice risk.

D. Ketamine for Rapid Sedation of Agitated Patients in the Prehospital and Emergency Department Settings: A Systematic Review and Proportional Meta-Analysis.

Mankowitz SL, et al. J Emerg Med. 2018;55:670-681.

BACKGROUND:
Rapid tranquilization of agitated patients can prevent injuries and expedite care. Whereas antipsychotics and benzodiazepines are commonly used for this purpose, ketamine has been suggested as an alternative.

OBJECTIVE:
The aim of this systematic review is to determine the safety and effectiveness of ketamine to sedate prehospital and emergency department (ED) patients with undifferentiated agitation.

METHODS:
Studies and case series of patients receiving ketamine for agitation were included. Studies were excluded if ketamine was used for analgesia, procedural sedation, asthma, or induction. Information sources included traditional and gray literature.

RESULTS:
The initial search yielded 1176 results from 14 databases. After review of titles and abstracts, 32 studies were reviewed and 18 were included in the analysis, representing 650 patient encounters. The mean dose of ketamine was 315 mg (SD 52) given intramuscularly, with adequate sedation achieved in 7.2 min (SD 6.2, range 2-500). Intubation occurred in 30.5% of patients (95% confidence interval [CI] 27.0-34.1%). In the majority of those patients, ketamine was administered by paramedics during ground transport and the patient was intubated on ED arrival. When ketamine was administered in the ED, the intubation rate was 1.8% (95% CI 0.0-4.4%); in air medical transport, the rate was 4.9% (95% CI 0.0-10.3%). Other reported side effects included: vomiting, 5.2% (2.3-8.1%); hypertension, 12.1% (5.7-18.6%); emergence reactions, 3.5% (1.4-5.6%); transient hypoxia, 1.8% (0.1-3.6%) and laryngospasm, 1.3% (0.3-2.3%).

CONCLUSIONS:
Ketamine provides rapid sedation for undifferentiated agitated patients and is associated with higher intubation rates when used by ground Emergency Medical Services paramedics, compared with ED or air medical transport patients. Other side effects are common but usually self-limiting.

22. Micro Bits

A. Cleveland Clinic lists top medical innovations for 2019

The Cleveland Clinic has announced its list of 10 medical innovations expected to transform health care next year, with alternative therapies for pain and artificial intelligence leading the way. Also on the list are 3D-printed patient-specific products, innovations in robotic surgery, and percutaneous replacement and repair of mitral and tricuspid valves.


B. Vitamin D, omega-3 supplements do not prevent cancer or heart disease

(CNN)Vitamin D and omega-3 supplements do not prevent cancer or heart disease, a new study finds, the latest in the years-long debate over their benefits.

The trial enrolled more than 25,000 Americans of various ethnicities who were over the age of 50 and had no history of cancer, heart attack, stroke or other forms of heart disease.

Participants were randomly assigned a daily dose of vitamin D, omega-3 or a placebo. After more than five years, no significant heart disease or cancer difference was seen between those taking supplements and those taking a placebo.

Lead researcher Dr. JoAnn E. Manson, chief of the Division of Preventive Medincine at the Brigham and Women's Hospital and professor at Harvard Medical School, said the study distinguishes itself because it is the world's largest randomized trial of its kind.


C. Women’s Health

C1. Why Bystanders Are Less Likely to Give CPR to Women

MONDAY, Nov. 5, 2018 (HealthDay News) -- Some bystanders may avoid performing CPR on women because they fear hurting them, or even being accused of sexual assault, preliminary research suggests.


C2. Risk factors for MI are more potent in women, finds study


BMJ Editorial: Let’s acknowledge the biggest killer of women (and men): https://blogs.bmj.com/bmj/2018/11/08/lets-acknowledge-the-biggest-killer-of-women-and-men/

D. Getting Rid of Stupid Stuff (in the EHR)

Melinda Ashton, M.D. N Engl J Med 2018; 379:1789-1791

any health care organizations are searching for ways to engage employees and protect against burnout, and involvement in meaningful work has been reported to serve both functions. According to Bailey and Madden, it is easy to damage employees’ sense of meaningfulness by presenting them with pointless tasks that lead them to wonder, “Why am I bothering to do this?”1 An increase in administrative tasks has resulted in less time for the activity that clinicians find most important: interacting with patients. Some commentators have recently suggested that it may not be the electronic health record (EHR) per se that leads to burnout, but rather the approach to documentation that has been adopted in the United States.2

Although my health system, like most in the United States, cannot magically eliminate the documentation required for billing and regulatory compliance, my colleagues and I had reason to believe that there might be some documentation tasks that could be eliminated. Our EHR was adopted more than 10 years ago, and since then we have made a number of additions and changes to meet various identified needs. We decided to see whether we could reduce some of the unintended burden imposed by our EHR and launched a program called “Getting Rid of Stupid Stuff.” Starting in October 2017, we asked all employees to look at their daily documentation experience and nominate anything in the EHR that they thought was poorly designed, unnecessary, or just plain stupid. The first thought we shared as we kicked off this effort was, “Stupid is in the eye of the beholder. Everything that we might now call stupid was thought to be a good idea at some point.”

We thought we would probably receive nominations in three categories: documentation that was never meant to occur and would require little consideration to eliminate or fix; documentation that was needed but could be completed in a more efficient or effective way with newer tools or better understanding; and documentation that was required but for which clinicians did not understand the requirement or the tools available to them…


E. CDC reports record-low smoking rates in the US

Fourteen percent of US adults smoked cigarettes in 2017, down from 15.5% in 2016 and the lowest rate since tracking began, while the smoking rate among adults ages 18 to 24 declined from 13% in 2016 to 10% in 2017, according to a study in the CDC's Morbidity and Mortality Weekly Report. Full implementation of comprehensive smoke-free laws, increased tobacco taxes and raising the legal smoking age to 21 could further decrease smoking rates, said Campaign for Tobacco-Free Kids President Matthew Myers.


F. Triple therapy in the management of COPD: systematic review and meta-analysis


G. Many parents save, share antibiotics

A study presented at the American Academy of Pediatrics' annual meeting found 48.2% of parents reported saving unused antibiotics, and 73% of had given them to siblings, unrelated children and unrelated adults. The findings should prompt clinicians "to do a better job of telling our patients that proper disposal of antibiotics is a really important practice," said researcher Dr. Ruth Milanaik.
       

H. Clotting risk is long-lasting for childhood cancer survivors

Pediatric cancer survivors have a 25 times increased risk of developing venous thromboembolism within five years of their diagnosis as those in the general population, and an increased risk is sustained through the patient's life, researchers reported in the Journal of Clinical Oncology. Increased odds of VTE were seen among those treated with cisplatin, osteosarcoma survivors who received limb-sparing treatments, and women who were underweight or obese.


I. Exercise Guideline Update Gets Mostly Positive Reviews: HHS recommendations now encourage even brief activity

Even two minutes of any physical activity -- taking the stairs, walking the dog or carrying out the trash -- can add up to significant health benefits, such as improved blood pressure, enhanced brain function and reduced risk of cancer and weight gain, according to the updated physical activity guidelines published in the Journal of the American Medical Association. The guidelines also recommend at least three hours of physical activity daily for children up to age 5 and at least 60 minutes of moderate to vigorous activity for those ages 6 to 17, while pregnant and postpartum women should engage in at least 150 minutes of moderate-intensity exercise weekly.

Revised U.S. Department of Health and Human Services (HHS) recommendations on physical activity drew largely positive feedback from cardiologists and others in preventive medicine.

Key changes from the first edition released in 2008 -- announced Monday at the American Heart Association meeting in Chicago and published online in JAMA – included…


JAMA Physical Activity Guidelines for America: https://jamanetwork.com/journals/jama/fullarticle/2712935

J. More US counties report cancer as leading cause of death

The percentage of US counties reporting cancer as the top cause of mortality rose from 21% in 2003 to 41% in 2015, while the percentage that listed heart disease as the leading cause dropped from 79% to 59% during the same period, according to a study in the Annals of Internal Medicine. Mortality for both diseases dropped during the study period, but cancer mortality fell more slowly.


K. What you need to know: Homeless discharge law

As you might have heard, SB 1152 (Hernandez) was signed by Governor Brown. When introduced, this bill would have made it nearly impossible to discharge a homeless patient from your ED. We worked extensively with the author’s office and sponsors to amend the bill and California ACEP was able to obtain a number of amendments to limit the number of requirements on treating physicians as well as soften the impact on your emergency department.

Please read the requirements carefully as the rumors you are hearing from colleagues and others may be from a previous version of the bill, not what in fact became law. Unfortunately, even with the amendments the bill will still impact your emergency department. SB 1152 Requirements. https://californiaacep.site-ym.com/page/Legislation_Implementation

L. Study Finds 43 Percent Higher Risk Of Pedestrian Deaths On Halloween Night


M. Increased screen time tied to lower pediatric mental well-being

A study in the journal Preventive Medicine Reports showed that children and adolescents with at least seven hours of screen time daily had a more than twofold increased likelihood of being diagnosed with anxiety or depression compared with those with an hour of daily screen time. The findings also showed reduced emotional stability, increased distractibility and difficulty in making friends, as well as greater inability to finish tasks among those with longer daily screen times.


N. Neisseria gonorrhoeae — Rising Infection Rates, Dwindling Treatment Options

NEJM Excerpt
Nevertheless, as the history of this organism has proven, progression of resistance of N. gonorrhoeae is an ever-present concern, and we are facing the real danger of multidrug-resistant, nearly untreatable gonorrhea. There is still no effective preventive vaccine against this organism to assist us with disease control. To avoid untreatable cases of this high-incidence infection, we need to advance diagnostic technology and develop treatments with different mechanisms of action. Development of new and effective treatments is also an urgent matter of health equity, given that minority racial or ethnic groups are overrepresented among patients with gonorrhea in the United States and that men who have sex with men and young people are also at the leading edge of increased gonorrhea incidence.


O. The Social Media Index as an Indicator of Quality for EM Blogs: A METRIQ Study


P. Researchers Find Surrogates Are Often Wrong About What Patients Would Want


Q. Delayed transition from crib to bed linked to better sleep outcomes

A study in Sleep Medicine showed that young children ages 18 months to 36 months who slept in cribs had earlier parent-reported bedtimes and sleep times, reduced bedtime resistance and sleep disturbances, and prolonged nightly sleep, compared with those who slept in beds.

R. Many adults skip care due to poor health insurance literacy

A study in JAMA Network Open found that many patients remain unaware that many preventive health care services are covered by health insurers at no cost, and those with low health insurance literacy were more likely to postpone or skip preventive health care services due to costs. The findings, based on survey data from 506 insured adults, suggest some people may be missing out on health care due to their belief that they can't afford it, even when it may be free, said lead study author Renuka Tipirneni.


S. ICU survivors are at increased risk of depression

And depression in ICU survivors was linked with a higher risk of death in the next two years, researchers found. More than half of former ICU patients reported symptoms of psychological disorders, including anxiety, depression and post-traumatic stress disorder, according to the study published in Critical Care. 


T. Woman sues hospital for resuscitating her


U. The ED Is Healthcare's One-Night Stand. Are We Ready to Address It?


V. Maternal omega-3 intake in pregnancy may lower adverse birth outcomes

Women who took omega-3 supplements during pregnancy were 42% less likely to give birth before 34 weeks' gestation and 11% less likely to give birth prior to 37 weeks' gestation, researchers reported in the Cochrane Database of Systematic Reviews. The findings also associated omega-3 supplementation during gestation to 10% and 25% reduced odds of low infant birth weight and perinatal death, respectively.


W. ACC/AHA 2018 Guideline on the Management of Blood Cholesterol


X. US life expectancy falls for 3rd straight year

Average life expectancy for Americans was 78.6 years in 2017, modestly lower than the 78.7 average the year before and the third consecutive year of decline. The last time the US experienced declining life expectancy over multiple years was in the 1960s.