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.
Watch all
three videos here. https://www.acep.org/life-as-a-physician/celebrating-emergency-physicians#sm.000jhg0xh189zfqbzqy1es95kj613
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
JAMA Cardiol
Full-text: https://jamanetwork.com/journals/jamacardiology/fullarticle/2716303
Reuters News: https://www.reuters.com/article/us-health-heart-race/racial-disparities-seen-in-u-s-heart-rhythm-treatment-idUSKCN1NY2CD
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/
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…
The remainder of the essay: http://newsroom.acep.org/Emergency-Physicians-Pediatricians-and-Nurses-Issue-Recommendations-on-Emergency-Care-for-Children
Pediatric
Readiness in the Emergency Department
Full-text (free) in Ann Emerg Med: https://www.annemergmed.com/article/S0196-0644(18)31167-3/fulltext
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.
Full-text (free) in https://onlinelibrary.wiley.com/doi/full/10.1111/jpc.14309
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
The essay
(free): https://www.acepnow.com/article/how-to-effectively-block-an-acutely-fractured-distal-radius/
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…
The rest of
the essay here (free): https://journals.lww.com/em-news/Fulltext/2018/11000/What_to_D_O___No_Reason_Not_to_Use_TXA_for.3.aspx
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.
The remainder of the essay (free): https://www.todayshospitalist.com/immunotherapy-side-effects/
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
Affirmed in the 2018 TGs: http://www.jshbps.jp/modules/en/index.php?content_id=47
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…
The rest (for free): https://www.nejm.org/doi/full/10.1056/NEJMp1809698
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.
