1. Pediatric Corner
A. A Clinical Prediction Rule to Identify Febrile Infants 60
Days and Younger at Low Risk for Serious Bacterial Infection
Kuppermann N, and
PECARN. JAMA Pediatr 2019 Feb 19 [Epub ahead of print]
Key Points
Question Can clinical features and laboratory tests
identify febrile infants 60 days and younger at low risk for serious bacterial
infections?
Findings In a cohort of 1821 febrile infants 60 days
and younger, 170 (9.3%) had serious bacterial infections, and using recursive
partitioning analysis, we derived a low-risk prediction rule involving 3
variables: normal urinalysis, absolute neutrophil count ≤4090/μL, and serum
procalcitonin ≤1.71 ng/mL. The rule sensitivity was 97.7%, specificity was
60.0%, and negative predictive value was 99.6%; no infant with bacterial
meningitis was missed.
Meaning The urinalysis, absolute neutrophil count,
and serum procalcitonin levels may accurately identify febrile infants 60 days
and younger at low risk for serious bacterial infections.
Abstract
Importance In young febrile infants, serious bacterial
infections (SBIs), including urinary tract infections, bacteremia, and
meningitis, may lead to dangerous complications. However, lumbar punctures and
hospitalizations involve risks and costs. Clinical prediction rules using
biomarkers beyond the white blood cell count (WBC) may accurately identify
febrile infants at low risk for SBIs.
Objective To derive and validate a prediction rule to
identify febrile infants 60 days and younger at low risk for SBIs.
Design, Setting, and
Participants Prospective, observational
study between March 2011 and May 2013 at 26 emergency departments. Convenience
sample of previously healthy febrile infants 60 days and younger who were evaluated
for SBIs. Data were analyzed between April 2014 and April 2018.
Exposures Clinical and laboratory data (blood and
urine) including patient demographics, fever height and duration, clinical
appearance, WBC, absolute neutrophil count (ANC), serum procalcitonin, and urinalysis.
We derived and validated a prediction rule based on these variables using
binary recursive partitioning analysis.
Main Outcomes and
Measures Serious bacterial infection,
defined as urinary tract infection, bacteremia, or bacterial meningitis.
Results We derived the prediction rule on a random
sample of 908 infants and validated it on 913 infants (mean age was 36 days,
765 were girls [42%], 781 were white and non-Hispanic [43%], 366 were black
[20%], and 535 were Hispanic [29%]). Serious bacterial infections were present
in 170 of 1821 infants (9.3%), including 26 (1.4%) with bacteremia, 151 (8.3%)
with urinary tract infections, and 10 (0.5%) with bacterial meningitis; 16
(0.9%) had concurrent SBIs. The prediction rule identified infants at low risk
of SBI using a negative urinalysis result, an ANC of 4090/µL or less (to
convert to ×109 per liter, multiply by 0.001), and serum procalcitonin of 1.71
ng/mL or less. In the validation cohort, the rule sensitivity was 97.7% (95%
CI, 91.3-99.6), specificity was 60.0% (95% CI, 56.6-63.3), negative predictive
value was 99.6% (95% CI, 98.4-99.9), and negative likelihood ratio was 0.04
(95% CI, 0.01-0.15). One infant with bacteremia and 2 infants with urinary
tract infections were misclassified. No patients with bacterial meningitis were
missed by the rule. The rule performance was nearly identical when the outcome
was restricted to bacteremia and/or bacterial meningitis, missing the same
infant with bacteremia.
Conclusions and
Relevance We derived and validated an
accurate prediction rule to identify febrile infants 60 days and younger at low
risk for SBIs using the urinalysis, ANC, and procalcitonin levels. Once further
validated on an independent cohort, clinical application of the rule has the
potential to decrease unnecessary lumbar punctures, antibiotic administration,
and hospitalizations.
B. Diagnosis and Management of Kawasaki Disease
Sosa T, et al. JAMA
Pediatr. 2018 Jan 22 [Epub ahead of print]
Kawasaki disease (KD)
is an acute, self-limited vasculitis of medium-sized arteries that leads to
coronary artery aneurysms in approximately 25% of untreated patients. Timely
treatment with intravenous immunoglobulin (IVIG) has decreased this risk to 3% to
5%. Incomplete KD is a risk factor for delayed diagnosis and treatment, thus
increasing the risk for coronary artery abnormalities (CAAs). The American
Heart Association (AHA) guideline provides a diagnostic algorithm for suspected
cases of incomplete KD, which has retrospectively been shown to hasten
treatment.1,2 There remains a subset of children, particularly infants younger
than 6 months and adolescents, in whom the diagnosis is exceedingly
challenging. Once the diagnosis is made, the treatment of complete and
incomplete KD is identical. Intravenous immunoglobulin and acetylsalicylic acid
are the hallmarks of therapy. The use of adjunctive agents and strategies for
treatment of IVIG-resistant disease remains controversial.
C. Oral Ondansetron Ineffective in Nondehydrated Children
With Diarrhea and Associated Vomiting in EDs in Pakistan: A RCT
Freedman SB, et al.
Ann Emerg Med 2019;73(3):255-65.
Study objective
We determine whether
single-dose oral ondansetron administration to children with vomiting as a
result of acute gastroenteritis without dehydration reduces administration of
intravenous fluid rehydration.
Methods
In this 2-hospital,
double-blind, placebo-controlled, emergency department–based, randomized trial
conducted in Karachi Pakistan, we recruited children aged 0.5 to 5.0 years,
without dehydration, who had diarrhea and greater than or equal to 1 episode of
vomiting within 4 hours of arrival. Patients were randomly assigned (1:1),
through an Internet-based randomization service using a stratified
variable-block randomization scheme, to single-dose oral ondansetron or
placebo. The primary endpoint was intravenous rehydration (administration of
≥20 mL/kg of an isotonic fluid during 4 hours) within 72 hours of
randomization.
Results
Participant median age
was 15 months (interquartile range 10 to 26) and 59.4% (372/626) were male
patients. Intravenous rehydration use was 12.1% (38/314) and 11.9% (37/312) in
the placebo and ondansetron groups, respectively (odds ratio 0.98; 95% confidence
interval [CI] 0.60 to 1.61; difference 0.2%; 95% CI of the difference –4.9% to
5.4%). Bolus fluid administration occurred within 72 hours of randomization in
10.8% (34/314) and 10.3% (27/312) of children administered placebo and
ondansetron, respectively (odds ratio 0.95; 95% CI 0.56 to 1.59). A
multivariable regression model fitted with treatment group and adjusted for
antiemetic administration, antibiotics, zinc prerandomization, and vomiting
frequency prerandomization yielded similar results (odds ratio 0.91; 95% CI
0.55 to 1.53). There was no interaction between treatment group and age,
greater than or equal to 3 stools in the preceding 24 hours, or greater than or
equal to 3 vomiting episodes in the preceding 24 hours.
Conclusion
Oral administration of
a single dose of ondansetron did not result in a reduction in intravenous
rehydration use. In children without dehydration, ondansetron does not improve
clinical outcomes.
See the editorial for
interpretive help: https://www.annemergmed.com/article/S0196-0644(18)31360-X/fulltext
D. 8th-grade students can learn point of care ultrasound.
Kwon AS, et al. World J Emerg Med
2019;10(2):109–113.
BACKGROUND: Point-of-care ultrasound has gained widespread
use in developing countries due to decreased cost and improved telemedicine
capabilities. Ultrasound training, specifically image acquisition skills, is
occurring with more frequency in non-medical personnel with varying educational
levels in these underdeveloped areas. This study evaluates if students without
a high school education can be trained to acquire useful FAST images, and to
determine if an 8th grade student can teach peers these skills.
METHODS: The 8th grade students at a small middle school
were divided into two groups. One group received training by a certified
medical sonographer, while the other group received training by a peer 8th
grade student trainer who had previously received training by the sonographer.
After training, each student was independently tested by scanning the four FAST
locations. A blinded ultrasound expert evaluated these images and deemed each
image adequate or inadequate for clinical use.
RESULTS: Eighty video image clips were obtained. The
overall image adequacy rate was 74%. The splenorenal window had the highest
rate at 95%, followed by retrovesical at 90%, hepatorenal at 75%, and
subxiphoid cardiac at 35%. The adequacy rate of the sonographer-trained group was
78%, while the adequacy rate of the student-trained group was 70%. The
difference in image adequacy rate between the two groups was not significant
(P-value 0.459).
CONCLUSION: The majority of 8th graders obtained
clinically adequate FAST images after minimal training. Additionally, the
student-trained group performed as well as the sonographer-trained group.
Full-text (free): http://www.wjem.com.cn/default/articlef/index/id/675
E. Cool
Case: TXA for Post-tonsillectomy Bleeding
Schwarz W, et al. Nebulized
Tranexamic Acid Use for Pediatric Secondary Post-Tonsillectomy Hemorrhage. Ann
Emerg Med. 2019;73:269-71
Post-tonsillectomy
hemorrhage is a frequent occurrence in the emergency department, and management
of potentially life-threatening and ongoing bleeding by the emergency physician
is challenging. Limited evidence-based guidelines exist, and practice patterns
vary widely. We administered nebulized tranexamic acid to achieve hemostasis in
a pediatric patient with associated bleeding cessation prior to definitive
operative management.
F. Can the
Probiotic Lactobacillus reuteri Be Used to Treat Infant Colic?
Take-Home Message
The probiotic
Lactobacillus reuteri reduces the duration of crying and fussing in breastfed
infants with colic, although its use in formula-fed infants remains unclear.
2. Duration of ECG Monitoring of ED Patients with Syncope.
Thiruganasambandamoorthy
V, et al. Circulation. 2019 Jan 21 [Epub ahead of print]
BACKGROUND:
The optimal duration
of cardiac rhythm monitoring following emergency department (ED) presentation
for syncope is poorly described. We sought to describe the incidence and time
to arrhythmia occurrence to inform decisions regarding duration of monitoring
based on ED risk-stratification.
METHODS:
We conducted a
prospective cohort study enrolled adult (≥ 16 years) patients presenting within
24-hours of syncope at 6 EDs. We collected baseline characteristics, time of
syncope and ED arrival, and the Canadian Syncope Risk Score (CSRS) risk
category. We followed subjects for 30-days and our adjudicated primary outcome
was serious arrhythmic conditions (arrhythmias, interventions for arrhythmias
and unexplained death). After excluding patients with an obvious serious
condition on ED presentation and those with missing CSRS predictors, we used
Kaplan-Meier analysis to describe the time to serious arrhythmic outcomes.
RESULTS:
5,581 patients (mean
age 53.4 years, 54.5% females, 11.6% hospitalized) were available for analysis,
including 346 (6.2%) for whom the 30-day follow-up was incomplete and were
censored at the last follow-up time. 417 (7.5%) patients suffered serious
outcomes of which 207 (3.7%; 95% CI 3.3%, 4.2%) were arrhythmic (161
arrhythmias, 30 cardiac device implantations, 16 unexplained death). Overall,
4123 (73.9%) were classified as CSRS low-risk, 1062 (19.0%) medium and 396
(7.1%) high-risk. The CSRS accurately stratified subjects as low (0.4% risk for
30-day arrhythmic outcome), medium (8.7% risk) and high-risk (25.3% risk).
One-half of arrhythmic outcomes were identified within 2-hours of ED arrival in
low-risk and within 6-hours in medium and high-risk patients and the residual
risk after these cut-points were 0.2% for low-risk, 5.0% medium and 18.1%
high-risk patients. Overall, 91.7% of arrhythmic outcomes among medium and
high-risk patients including all ventricular arrhythmias were identified within
15-days. None of the low-risk patients suffered ventricular arrhythmia or
unexplained death while 0.9% medium-risk and 6.3% of high-risk patients
suffered them (p less than 0.0001).
CONCLUSIONS:
Serious underlying
arrhythmia was often identified within the first 2-hours of ED arrival for CSRS
low-risk patients, and within 6-hours for CSRS medium- and high-risk patients.
Outpatient cardiac rhythm monitoring for 15-days for selected medium-risk
patients and all high-risk patients discharged from the hospital should also be
considered.
3. MDCalc Launches EM Guideline Summaries
MDCalc, synonymous
with easy-to-use bedside tools for most emergency physicians, is now doing for
guidelines what it's been doing for medical calculators for over a decade.
Guidelines are
notoriously difficult to access-a report from the New England Health Institute
(NEHI) cited inconvenience as one of the primary barriers to regular use of
guideline recommendations by practicing physicians.
While most guidelines
are available online, limited searchability, and the fact that they're not
optimized for digital and mobile devices, makes them difficult for physicians
to use at the bedside.
4. Opioids and the Emergency Provider
A. What to do With Lazarus? Has it happened to you, yet?
Kline J. Acad Emerg
Med. Editor-in-Chief Pick of the Month. January 21, 2019
The civilian vehicle
that stops in front of the emergency department, briefly enough for the back
door to sling open. Out spills a crumpled, lifeless body. The dented drop-off
vehicle squeals away. You were walking out, just off shift, still talking with
a friend. You run over, with the triage nurse assistant and security guard who
just came out from triage, other patients staring on. You see the pale, apneic
body, the lifeless, pinpoint doll's eyes in mid-position. Three of you chuck
her on a stretcher. In to the resuscitation room.
"NEED NARCAN
NOW!"
If this were
television, you'd have added "STAT!"
Two nurses frantically
search for a vein, finding scars. Like a five-year-old on Christmas morning,
the respiratory therapist is now tearing the bag valve mask out of its plastic.
The chief who took over for you is drilling the tibia. You are looking for
access too, helping tear off clothes. The 2 percent of your brain not 100
percent preoccupied somehow registers a random touch of the patient's cold
fingers. "Like clammy tentacles of a sea creature," your 2 percent
bystander brain offers the other 98 percent, for no good reason.
The veteran nurse
says, "got it," and in goes 2 mg naloxone, then 2 more. The
respiratory therapist does a chin lift and applies the bag valve mask, someone
searches for the patient's identification, another gets a C-collar and the
chief checks the pupils. Nine professionals stop breathing, and one patient
starts to breathe. She coughs but does not vomit, and in 30 seconds she blinks,
then speaks: "Where the hell am I?"
In 60 minutes, she
wants to leave.
This vivid image plays
out daily in ED America. Narcan saves a life, and then the ED physicians argue
about how long we have to observe the patient. We discuss the patient's
capacity to decide, risk of false imprisonment, and possible bad things that
might happen if we let her go. Yet another blind sojourn in the evidence-free
zone. Every older physician has an apocryphal tale of something that warrants
admission...return of sedation, non-cardiogenic pulmonary edema.
This month's POTM from
Clemency et al rings in 2019 with evidence from 538 patients who received
prehospital naloxone, specifically elucidating the failure rate for patients
who are awake and alert with normal vital signs one hour after naloxone
administration. Among patients who met their rule (see paper to learn more), an
adverse event occurred in 13 (2.4 percent) of 538, but only one patient with a
presumed heroin overdose received a repeat dose of naloxone. Provider judgment
performed similarly.
Thanks to this
landmark paper by Clemency et al, we finally have evidence to make a decision.
The findings of the
study are discussed in the latest AEM podcast/SGEM Hop Review, "Wake Me Up
Before You Go-Go: Using the HOUR Rule."
Hospital Observation Upon Reversal (HOUR) With Naloxone: A
Prospective Clinical Prediction Rule Validation Study.
Clemency BM, et al. Acad
Emerg Med. 2019 Jan;26(1):7-15.
OBJECTIVE:
St. Paul's Early
Discharge Rule was derived to determine which patients could be safely
discharged from the emergency department after a 1-hour observation period
following naloxone administration for opiate overdose. The rule suggested that
patients could be safely discharged if they could mobilize as usual and had a
normal oxygen saturation, respiratory rate, temperature, heart rate, and
Glasgow Coma Scale score. Validation of the St. Paul's Early Discharge Rule is
necessary to ensure that these criteria are appropriate to apply to patients
presenting after an unintentional presumed opioid overdose in the context of
emerging synthetic opioids and expanded naloxone access.
METHODS:
In this prospective,
observational validation study, emergency medicine providers assessed patients
1 hour after administration of prehospital naloxone. Unlike in the derivation
study the threshold for normal oxygen saturation was set at 95% and patients
were not immediately discharged after a normal 1-hour evaluation. Patients were
judged to have a normal 1-hour evaluation if all six criteria of the rule were
met. Patients were judged to have an adverse event (AE) if they had one or more
of the preestablished AEs.
RESULTS:
A total of 538
patients received at least one administration of prehospital naloxone, were
transported to the study hospital, and had a 1-hour evaluation performed by a
provider. AEs occurred in 82 (15.4%) patients. The rule exhibited a sensitivity
of 84.1% (95% confidence interval [CI] = 76.2%-92.1%), a specificity of 62.1%
(95% CI = 57.6%-66.5%), and a negative predictive value of 95.6% (95% CI =
93.3%-97.9%). Only one patient with a normal 1-hour evaluation subsequently
received additional naloxone following a presumed heroin overdose.
CONCLUSION:
This rule may be used
to risk stratify patients for early discharge following naloxone administration
for suspected opioid overdose.
What’s the HOUR
decision rule?
One hour after the
administration of naloxone for presumed opioid overdose, patients can be safely
discharged from the ED if they meet all six criteria:
- Can mobilize as usual
- Have a normal O2 saturation (over 95%)
- Have a normal respiratory rate (over 10 and less than 20 breaths/min)
- Have a normal temperature (over 35.0 and less than 37.5°C)
- Have a normal heart rate (over 50 and less than 100 beats/min)
- Have a GCS score of 15
B. A Quality Framework for ED Treatment of
Opioid Use Disorder
Samuels EA, et al. Ann Emerg Med 2019;73(3):237–247.
Emergency clinicians are on the front lines of responding to
the opioid epidemic and are leading innovations to reduce opioid overdose
deaths through safer prescribing, harm reduction, and improved linkage to
outpatient treatment. Currently, there are no nationally recognized quality
measures or best practices to guide emergency department quality improvement
efforts, implementation science researchers, or policymakers seeking to reduce
opioid-associated morbidity and mortality. To address this gap, in May 2017,
the National Institute on Drug Abuse’s Center for the Clinical Trials Network
convened experts in quality measurement from the American College of Emergency
Physicians’ (ACEP’s) Clinical Emergency Data Registry, researchers in emergency
and addiction medicine, and representatives from federal agencies, including
the National Institute on Drug Abuse and the Centers for Medicare &
Medicaid Services. Drawing from discussions at this meeting and with experts in
opioid use disorder treatment and quality measure development, we developed a
multistakeholder quality improvement framework with specific structural,
process, and outcome measures to guide an emergency medicine agenda for opioid
use disorder policy, research, and clinical quality improvement.
C. IV subdissociative-dose ketamine
versus morphine for acute geriatric pain in the ED: A RCT
Motov S, et al. Am J Emerg Med. 2019;37(2):220–227.
STUDY OBJECTIVE:
We compare the analgesic efficacy and safety of
subdissociative intravenous-dose ketamine (SDK) versus morphine in geriatric
Emergency Department (ED) patients.
METHODS:
This was a prospective, randomized, double-blind trial
evaluating ED patients aged 65 and older experiencing moderate to severe acute
abdominal, flank, musculoskeletal, or malignant pain. Patients were randomized
to receive SDK at 0.3 mg/kg or morphine at 0.1 mg/kg by short intravenous
infusion over 15 min. Evaluations occurred at 15, 30, 60, 90, and 120 min.
Primary outcome was reduction in pain at 30 min. Secondary outcomes included
overall rates of adverse effects and incidence of rescue analgesia.
RESULTS:
Thirty patients per group were enrolled in the study. The
primary change in mean pain scores was not significantly different in the
ketamine and morphine groups: 9.0 versus 8.4 at baseline (mean difference 0.6;
95% CI -0.30 to 1.43) and 4.2 versus 4.4 at 30 min (mean difference -0.2; 95%
CI -1.93 to1.46). Patients in the SDK group reported higher rates of
psychoperceptual adverse effects at 15, 30, and 60 min post drug
administration. Two patients in the ketamine group and one in the morphine
group experienced brief desaturation episodes. There were no statistically
significant differences with respect to changes in vital signs and need for
rescue medication.
CONCLUSION:
SDK administered at 0.3 mg/kg over 15 min provides analgesic
efficacy comparable to morphine for short-term treatment of acute pain in the
geriatric ED patients but results in higher rates of psychoperceptual adverse
effects.
D. States move to require co-prescribing naloxone with
opioids
More states are
requiring physicians to prescribe or at least offer prescriptions for naloxone
when prescribing opioids for patients at a high risk of overdosing. The FDA is
considering if it should recommend naloxone co-prescribing nationally.
Kaiser Health News: https://khn.org/news/more-states-say-doctors-must-offer-overdose-reversal-drug-along-with-opioids/
5. Edema Corner
A. External Validation of the MEESSI Acute Heart
Failure Risk Score: A Cohort Study
Wussler D, et al. Ann
Intern Med. 2019 Jan 29 [Epub ahead of print]
BACKGROUND:
The MEESSI-AHF
(Multiple Estimation of risk based on the Emergency department Spanish Score In
patients with AHF) score was developed to predict 30-day mortality in patients
presenting with acute heart failure (AHF) to emergency departments (EDs) in
Spain. Whether it performs well in other countries is unknown.
OBJECTIVE:
To externally validate
the MEESSI-AHF score in another country.
DESIGN:
Prospective cohort
study. (ClinicalTrials.gov: NCT01831115).
SETTING:
Multicenter
recruitment of dyspneic patients presenting to the ED.
PARTICIPANTS:
The external
validation cohort included 1572 patients with AHF.
MEASUREMENTS:
Calculation of the
MEESSI-AHF score using an established model containing 12 independent risk
factors.
RESULTS:
Among 1572 patients
with adjudicated AHF, 1247 had complete data that allowed calculation of the
MEESSI-AHF score. Of these, 102 (8.2%) died within 30 days. The score predicted
30-day mortality with excellent discrimination (c-statistic, 0.80). Assessment
of cumulative mortality showed a steep gradient in 30-day mortality over 6
predefined risk groups (0 patients in the lowest-risk group vs. 35 [28.5%] in
the highest-risk group). Risk was overestimated in the high-risk groups,
resulting in a Hosmer-Lemeshow P value of 0.022. However, after adjustment of
the intercept, the model showed good concordance between predicted risks and
observed outcomes (P = 0.23). Findings were confirmed in sensitivity analyses
that used multiple imputation for missing values in the overall cohort of 1572
patients.
LIMITATIONS:
External validation
was done using a reduced model. Findings are specific to patients with AHF who
present to the ED and are clinically stable enough to provide informed consent.
Performance in patients with terminal kidney failure who are receiving
long-term dialysis cannot be commented on.
CONCLUSION:
External validation of
the MEESSI-AHF risk score showed excellent discrimination. Recalibration may be
needed when the score is introduced to new populations.
B. Keeping nephrotic syndrome on the ED edema differential: A case report
Goodwin J, et al. World J Emerg Med
2019;10(2):116–118
Nephrotic syndrome is defined by the presence of
peripheral edema, heavy proteinuria (greater than 3.5 g/24h), and
hypoalbuminemia (less than 3 g/dL).[1] Nephrotic syndrome is relatively rare,
with an incidence of 3 new patients per 100,000 per year in adults.[1] Despite
being a known cause for new onset edema in patients at any age, nephrotic
syndrome is often neglected in considering differential diagnoses for this
presentation in primary care settings, and initial workups often focus on
ruling out cardiac and hepatic causes of edema.[1-3] In this case report, we
describe a 25-year-old male patient who presented to the emergency department
(ED) complaining of a 10-day history of anasarca. He was later diagnosed with
nephrotic syndrome secondary to minimal change disease. This case served as a
reminder to include the differential diagnosis of nephrotic syndrome early in
the workup of an adult with peripheral edema presenting to the ED.
CASE
A previously healthy 25-year-old male presented to the ED
with periorbital edema, as well as edema in his abdomen and lower extremities.
He had been prescribed an oral dose of furosemide 60 mg daily for his anasarca
by a family physician at a clinic five days prior. Laboratory investigations
were not performed. He felt that his symptoms have since been worsening. He
denied any recent shortness of breath or loss of consciousness. He reported an
allergy to kiwi with no known recent exposure and had not regularly taken medications
before the recently initiated diuretic.
On exam, he was not in any acute distress. His blood
pressure was 120/90 mmHg, his heart rate was 88 beats per minute, his
respiratory rate was 18 per minute, and his temperature was 37.3 °C. On
auscultation, he had normal S1 and S2 heart sounds, no S3 or S4, no murmurs,
and his lungs were clear bilaterally. His abdomen was soft and non-tender to
palpation. His legs had pitting edema up to his knees bilaterally.
Workup in the ED included chest radiographs and routine
blood work. Chest radiographs showed small bilateral pleural effusions. Routine
blood work showed a total protein of 45 g/L (normal range 64–83), serum albumin
of 9 g/L (normal range 35–50), platelet count of 420×109/L (normal range
150–350), and slightly elevated neutrophils at 71.0% (normal range 45.0–70.0).
A midstream urine culture is negative.
A urine dip was positive for significant proteinuria: the
urine contains greater than 10 g/L of protein (normal range, negative or
trace). It was straw colour, cloudy, contained 244 epithelial cells per low
power field (LPF) (normal range 0–100), had more than 100 hyaline casts per LPF
(normal range, 0–1), and contained 8 white blood cells per high power field
(HPF) (normal range 0–5). The urine microscopy showed 10 RBCs per HPF (normal
range 0–5). Finely granular and coarsely granular casts were also visible, with
50–100 finely granular casts counted per LPF and 0–2 coarsely granular casts
counted per LPF…
The rest of the case
and discussion (free): http://www.wjem.com.cn/default/articlef/index/id/677
6. Delayed endoscopy is associated with increased mortality in UGI
hemorrhage
Jeong N, et al. Am J
Emerg Med 2019;37:277-80.
Objectives
To determine the
association between delayed (over 24 h) endoscopy and hospital mortality in
patients with upper gastrointestinal hemorrhage (UGIH).
Methods
We retrospectively
analyzed all adult patients with UGIH who underwent endoscopy in a single
emergency room for 2 years. The primary exposure was defined as over 24 h from
the ED visit to the first endoscopy. The primary outcome was defined as all
cause hospital mortality. Secondary outcomes were intensive care unit admission
rate, ED length of stay, and hospital length of stay.
Results
Among 1101 patients
enrolled, 898 received endoscopy within 24 h (early group) and 203 received
endoscopy after 24 h (delayed group). The hospital mortality of early and delayed
group was 2.8% and 6.4%, respectively (unadjusted relative risk [RR] 2.30: 95%
CI, 1.20–4.42, p = 0.012). This was significant after adjusting covariates
including AIMS65 and Glasgow-Blatchford score (adjusted RR 2.23: 95% CI,
1.18–4.20, p = 0.013). Intensive care unit admission rate was not different
between two groups. ED and hospital length of stay were significantly longer in
delayed group.
Conclusions
Endoscopy performed
after 24 h was associated with increased hospital mortality in UGIH. Patients in
the delayed group stayed longer in the ED and in the hospital.
7. Fast Protocol for Treating Acute Ischemic Stroke Managed by
Emergency Physicians.
Heikkilä I, et al. Ann
Emerg Med. 2019 Feb;73(2):105-112.
Editor’s Capsule
Summary
What is already known
on this topic: Most stroke teams are led by neurologists, whereas emergency
physicians typically are the first to evaluate and treat patients with acute
neurologic deficits.
What question this
study addressed: What was the effect of a reorganization of the acute stroke
process to focus on emergency physicians guiding acute stroke care?
What this study adds
to our knowledge: Stroke patients were treated faster after the reorganization.
Although complications were similar before and after the change, the study was
not powered to confirm their equivalency.
How this is relevant
to clinical practice: With training and a well-defined protocol, emergency
physicians quickly treated patients with acute stroke.
STUDY OBJECTIVE:
Thrombolysis with
tissue plasminogen activator should occur promptly after ischemic stroke onset.
Various strategies have attempted to improve door-to-needle time. Our objective
is to evaluate a strategy that uses an emergency physician-based protocol when
no stroke neurologist is available.
METHODS:
This was a
retrospective before-after intervention analysis in an urban hospital.
Reorganization of the acute ischemic stroke treatment process was carried out
in 2013. We evaluated time delay, symptomatic intracerebral hemorrhage, and
clinical recovery of patients before and after the reorganization. We used
multivariable linear regression to estimate the change in door-to-needle time
before and after the reorganization.
RESULTS:
A total of 107
patients with comparable data were treated with tissue plasminogen activator in
2009 to 2012 (group 1) and 46 patients were treated during 12 months in 2013 to
2014 (group 2). Median door-to-needle time was 54 minutes before the
reorganization and 20 minutes after it (statistical estimate of difference 32
minutes; 95% confidence interval 26 to 38 minutes). After adjusting for several
potential cofounders in multivariable regression analysis, the only factor
contributing to a significant reduction in delay was group (after reorganization
versus before). Median onset-to-treatment times were 135 and 119 minutes,
respectively (statistical estimate of difference 23 minutes; 95% confidence
interval 6 to 39 minutes). The rates of symptomatic intracerebral hemorrhage
were 4.7% (5/107) and 2.2% (1/46), respectively (difference 2.5%; 95%
confidence interval -8.7% to 9.2%). Approximately 70% of treated patients were
functionally independent (modified Rankin Scale score 0 to 2) when treated
after the reorganization.
CONCLUSION:
Implementation of a
stroke protocol with emergency physician-directed acute care decreased both
door-to-needle time and onset-to-treatment time without increasing the rate of
symptomatic intracerebral hemorrhage.
8. Myths in Emergency Medicine
A. The Anti-Inflammatory Properties of NSAIDs
Klauer KM. ACEP Now. January
14, 2019
NSAIDs and the Anti-inflammatory
Myth
In the context of the
opioid crisis and seeking alternatives to their use, we are perhaps relying on
nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen more than ever.
Coupled with the belief that we should provide “prescription-strength” pain
relief (over 400 mg per dose of ibuprofen), we may be increasing risk to our
patients with no additional benefit. In recent years, the therapeutic ceiling
of NSAIDs has been recognized and discussed. Thus, ibuprofen 400 mg per dose
and 1,200 mg per day, regarded as over-the-counter doses with an excellent side
effect profile, provide maximal analgesic effect.1 At higher doses (eg, 2,400
mg per day), the risk of gastrointestinal, cardiovascular, renal, and hepatic
complications is greater.2
So why prescribe higher
doses? Many justify higher dosing by claiming the need to tap into the
anti-inflammatory dosage range. Although this hypothetical benefit may be
useful in chronic inflammatory conditions (eg, spondyloarthritis), most of the
patients we are prescribing NSAIDs for do not have such conditions. For
instance, we often presume there is an inflammatory component to most acute
injuries (eg, muscle strain or joint sprain). Has anyone actually tested
“inflammation” of a sprained joint? No such literature seems to be available.
Furthermore, such injuries are self-limited, which begs the question, Is it the
anti-inflammatory property of the NSAID that improved the patient’s symptoms,
or simply the analgesic effect and time?
A Cochrane database
review from 2015 compared NSAIDs to other analgesics for acute soft-tissue
injuries. It concluded, “There is generally low- or very low-quality but
consistent evidence of no clinically important difference in analgesic efficacy
between NSAIDs and other oral analgesics.”3 This review implies that if acute
inflammation does exist with such injuries, either NSAIDs do not provide a
clinically significant benefit in reducing inflammation or inflammation is not
a significant contributor to symptoms of those injured.
Continuing with this
theme are two additional Cochrane reviews. The first evaluated NSAIDs for the
treatment of acute gout. One would suspect clear benefit from NSAIDs in a
condition widely accepted as inflammatory in nature. After reviewing 23 trials,
the authors concluded that limited evidence existed to support NSAID use for
the treatment of acute gout.4 The second reviewed the same but for
spondyloarthritis. NSAIDs were efficacious based on several functional scoring
tools, and there was a trend toward reduced radiographic spinal progression.5
Thus, NSAIDs most likely provide benefit in chronic inflammatory conditions.
The concept of the
anti-inflammatory effect of NSAIDs is largely a physiologic argument. If we
believe NSAIDs reduce inflammation and other mechanisms of bone healing, we are
forced to subscribe to the belief of some of our orthopedic colleagues that
NSAIDs impede fracture healing. Many articles have been published citing these
hypothetical concerns about inhibited fracture healing and studying animal models
suggesting the same.
“Prostaglandins (PGs)
are autocrine and paracrine lipid mediators produced by several cell types
capable of mediating either a stimulatory or resorptive role depending on the
physiological or pathological conditions. Administration of prostaglandins in animal
models has shown to increase cortical and trabecular mass and cause
hyperostosis in infants.”6
“The activity of
prostaglandins in bone tissue is defined by maintaining bone turnover balance
and its reactions to humoral mediators and mechanical stress. A balanced
osteoblast and osteoclast activity guarantees bone turnover equilibrium. PGE2
takes part in all processes of trauma response, including homeostasis,
inflammation and healing, and plays a key role in bone physiology.”7
However, at the end of
the day, many articles have noted the lack of evidence confirming such an
effect, particularly with short-term NSAID use.8
“What’s in a name?
That which we call a rose by any other name would smell as sweet.” —William
Shakespeare
Names do not define
the subject. However, they can shape our thinking. Nonsteroidal
anti-inflammatory drugs have claimed their anti-inflammatory properties merely
by their name. However, the outcome benefit achieved for acutely injured
patients is just as likely from their analgesic effects alone. Higher doses
seem to add more risk without additional benefit.
B. Catheter-Directed Therapy for PE: Built on Fallacy?
Mondie C. Emerg Med
News 2019;41(2):1,14
Tissue plasminogen
activator has a notoriously checkered past within emergency medicine, and its
controversial use continues with the advent of targeted therapy for pulmonary
embolism. Catheter-directed administration of tPA for PE is gaining traction,
and the development of multidisciplinary PE Response Teams are popularizing and
advocating this therapy. (Chest 2016;150[2]:384.) The evidence for this
treatment strategy, however, raises concerns about its early adoption.
Catheter-directed
therapy (CDT) for PE involves placing a special catheter directly into the
pulmonary artery, into or adjacent to the clot, followed by a continuous
infusion of tPA. The thought is that by infusing the tPA directly into the
pulmonary circulation, significantly lower doses can be used to achieve
thrombolysis and to mitigate the risk of hemorrhage. Some of these catheters
are specially equipped to provide ultrasound pulsations that are said to
provide mechanical force to expose fibrin and improve tPA efficacy. The former
is termed catheter-directed thrombolysis, the latter ultrasound-assisted
catheter-directed thrombolysis. (Chest 2016;150[2]:384; Circulation
2014;129[4]:479; http://bit.ly/2CbgjUY; Chest 2015;148[3]:667; J Vasc Interv
Radiol 2018;29[3]:293; http://bit.ly/2Ggqqfd.)
Proponents of this
therapy tout reduced doses of thrombolytics and decreased major bleeding events
as compelling reasons to adopt this groundbreaking therapy. Several studies
have evaluated its feasibility and efficacy for various forms of PE, but only
one randomized controlled trial has been done comparing catheter-directed
thrombolysis to standard care. The remainder of the literature consists largely
of cohort studies with no control groups and no patient-oriented outcomes…
The remainder of the
essay: https://journals.lww.com/em-news/Fulltext/2019/02000/News__Catheter_Directed_Therapy_for_PE_Built_on.3.aspx
9. Partial Oral Therapy for Osteomyelitis and Endocarditis — Is
It Time?
A. Partial Oral versus Intravenous Antibiotic Treatment of
Endocarditis
Iverson K, et al. N
Engl J Med 2019; 380:415-424
BACKGROUND
Patients with
infective endocarditis on the left side of the heart are typically treated with
intravenous antibiotic agents for up to 6 weeks. Whether a shift from
intravenous to oral antibiotics once the patient is in stable condition would
result in efficacy and safety similar to those with continued intravenous
treatment is unknown.
METHODS
In a randomized,
noninferiority, multicenter trial, we assigned 400 adults in stable condition
who had endocarditis on the left side of the heart caused by streptococcus,
Enterococcus faecalis, Staphylococcus aureus, or coagulase-negative
staphylococci and who were being treated with intravenous antibiotics to
continue intravenous treatment (199 patients) or to switch to oral antibiotic
treatment (201 patients). In all patients, antibiotic treatment was
administered intravenously for at least 10 days. If feasible, patients in the
orally treated group were discharged to outpatient treatment. The primary
outcome was a composite of all-cause mortality, unplanned cardiac surgery,
embolic events, or relapse of bacteremia with the primary pathogen, from the
time of randomization until 6 months after antibiotic treatment was completed.
RESULTS
After randomization,
antibiotic treatment was completed after a median of 19 days (interquartile
range, 14 to 25) in the intravenously treated group and 17 days (interquartile
range, 14 to 25) in the orally treated group (P=0.48). The primary composite
outcome occurred in 24 patients (12.1%) in the intravenously treated group and
in 18 (9.0%) in the orally treated group (between-group difference, 3.1
percentage points; 95% confidence interval, −3.4 to 9.6; P=0.40), which met
noninferiority criteria.
CONCLUSIONS
In patients with
endocarditis on the left side of the heart who were in stable condition,
changing to oral antibiotic treatment was noninferior to continued intravenous
antibiotic treatment.
B. Oral versus Intravenous Antibiotics for Bone and Joint
Infection
Li H-K, et al. N Engl
J Med 2019; 380:425-436.
BACKGROUND
The management of
complex orthopedic infections usually includes a prolonged course of
intravenous antibiotic agents. We investigated whether oral antibiotic therapy
is noninferior to intravenous antibiotic therapy for this indication.
METHODS
We enrolled adults who
were being treated for bone or joint infection at 26 U.K. centers. Within 7
days after surgery (or, if the infection was being managed without surgery,
within 7 days after the start of antibiotic treatment), participants were
randomly assigned to receive either intravenous or oral antibiotics to complete
the first 6 weeks of therapy. Follow-on oral antibiotics were permitted in both
groups. The primary end point was definitive treatment failure within 1 year
after randomization. In the analysis of the risk of the primary end point, the
noninferiority margin was 7.5 percentage points.
RESULTS
Among the 1054
participants (527 in each group), end-point data were available for 1015
(96.3%). Treatment failure occurred in 74 of 506 participants (14.6%) in the
intravenous group and 67 of 509 participants (13.2%) in the oral group. Missing
end-point data (39 participants, 3.7%) were imputed. The intention-to-treat
analysis showed a difference in the risk of definitive treatment failure (oral
group vs. intravenous group) of −1.4 percentage points (90% confidence interval
[CI], −4.9 to 2.2; 95% CI, −5.6 to 2.9), indicating noninferiority.
Complete-case, per-protocol, and sensitivity analyses supported this result.
The between-group difference in the incidence of serious adverse events was not
significant (146 of 527 participants [27.7%] in the intravenous group and 138
of 527 [26.2%] in the oral group; P=0.58). Catheter complications, analyzed as
a secondary end point, were more common in the intravenous group (9.4% vs.
1.0%).
CONCLUSIONS
Oral antibiotic
therapy was noninferior to intravenous antibiotic therapy when used during the
first 6 weeks for complex orthopedic infection, as assessed by treatment
failure at 1 year.
10. Images in Clinical Practice
Sporotrichosis
Pituitary Hyperplasia from Primary Hypothyroidism
Heart of Gold
Thrombus in Transit
Oral and Genital Ulcers in Behçet’s Disease
Adult Intussusception from Peutz–Jeghers Syndrome
Abdominal Pain After a Football Game
Young Woman With Chest and Back Pain
Middle Aged Male With Acute Abdominal Pain
Man With Left Upper Quadrant Pain
11. “Worst Headache of Life” in a Migraineur: Marginal Value of ED
CT Scanning
Sahraian S, et al. JACR 2019 Jan 17 [Epub ahead of print]
Purpose
The ACR Appropriateness Criteria recommend performing
noncontrast head CT (NCCT) for patients with sudden severe headache (“worst
headache of life” [WHOL] or “thunderclap headache” [TCH]). The aim of this
study was to assess the value of NCCT scanning in patients with known migraine
histories and WHOL or TCH. The hypothesis was that there would be little
utility in performing emergency department (ED) NCCT scans in migraineurs
without other red flags, even if they had WHOL or TCH.
Methods
The ED NCCT scans of all patients reporting WHOL or TCH who
had established diagnoses of migraine were retrospectively reviewed over a
5-year period. Patients without known intracranial pathology, cancer, or immunocompromising
disease or recent head trauma were included as the main study group. For
comparison, patients with any of those factors were included as the comparison
group. Scans were graded as (1) normal, (2) minor unimportant findings, (3)
findings requiring intervention or follow-up, or (4) critical.
Results
Two hundred twenty-four patients with the chief symptom of
WHOL or TCH and a history of migraine who underwent ED NCCT were studied. In
the main study group, no patients had grade 4 imaging findings (0%), one had a
false-positive grade 3 finding (0.8%), and there were no cases of subarachnoid
hemorrhage (0%). In the comparison group, six patients had grade 4 imaging
findings (6.5%) and three had grade 3 findings (3.3%).
Conclusions
NCCT in known migraineurs with WHOL or TCH who do not have
intracranial pathology, cancer, immunocompromising disease, or recent head
trauma yielded no critical findings. Therefore, the value of scanning these
patients is questionable.
12. California Hospitals Strive to Comply With New Homeless
Patient Laws, But Say Lack Of Resources Makes It Tough
Sammy Caiola. Cap Public Rado. January 21, 2019
Earlier this month, Dr. Aimee Moulin at the UC Davis
emergency department treated a homeless man who was experiencing some foot
pain. It was raining, and the waiting room was crowded with car crash patients
and flu cases.
She did the usual exam and prescribed Ibuprofen. But with
California’s SB 1152 in effect as of Jan. 1 she had to take extra steps,
including teaming up with another staffer to check in with local shelters about
available beds. It took a couple of hours.
“It was just sort of hard finding all the resources to make
the calls to all the shelters, then we couldn’t find a bed, and then figuring
out transportation,” she said. “It just took a couple hours to finish up with
all that, which would have been an otherwise very simple visit. We just don’t
quite have the systems in place.”
Physicians across the state are grappling with the new law,
which requires hospitals to offer homeless patients a meal, clothing and other
services before sending them to a residence or a social services provider that
has agreed to take them. It was designed to address “patient dumping,” a phrase
homeless advocates use to describe hospitals discharging patients to the
streets without adequate planning.
But hospitals say there’s been confusion about how to
interpret and implement the law. Peggy Wheeler, Vice President of Rural Health
and Governance for the California Hospital Association, which originally
opposed the policy, said she’s been receiving “any number of questions” from
members trying to comply.
California requires hospitals to make arrangements for all
departing patients, but most go home with a family member. Wheeler said
emergency department staff already screen for homeless patients, and now it’s
just a matter of documenting that resources were offered.
Under the new law, hospital staff must offer a ride to a
desired location less than 30 miles or 30 minutes away. If the patient wants to
return to a tent, a car or another location they call a residence, the hospital
can send them there with a bus ticket or a ride-share service. If they have
nowhere to go, the hospital must confirm a bed for them.
This comes after media reports about patients who said they
were sent to shelters that couldn't take them. In a survey from the Sacramento
Regional Coalition to End Homelessness, service organizations reported patients
arriving in hospital gowns, without wheelchairs or other supplies needed for
recovery.
There are other requirements, such as asking about
vaccinations, infectious disease screenings, health insurance enrollment
information and a follow-up care referrals.
At UC Davis, Moulin said these extra tasks can increase
waiting times, or result in hospitals holding patients longer than usual to
avoid an unlawful discharge.
“You would like to find a bed,” she said. “I’d love for
people not to be homeless. We all want to provide the services, and it’s just
hard when they’re not there.”
The rest of the essay: http://www.capradio.org/articles/2019/01/21/california-hospitals-strive-to-comply-new-homeless-patient-laws-but-say-lack-of-resources-makes-it-tough/
13. Two ED Scribe Studies
A. Impact of scribes on EM doctors’
productivity and patient throughput: multicentre randomised trial
Walker K, et al. BMJ 2019;364:l121
OBJECTIVES:
To evaluate the changes in productivity when scribes were
used by emergency physicians in emergency departments in Australia and assess
the effect of scribes on throughput.
DESIGN:
Randomised, multicentre clinical trial.
SETTING:
Five emergency departments in Victoria used Australian
trained scribes during their respective trial periods. Sites were broadly
representative of Australian emergency departments: public (urban, tertiary,
regional referral, paediatric) and private, not for profit.
PARTICIPANTS:
88 physicians who were permanent, salaried employees working
more than one shift a week and were either emergency consultants or senior
registrars in their final year of training; 12 scribes trained at one site and
rotated to each study site.
INTERVENTIONS:
Physicians worked their routine shifts and were randomly
allocated a scribe for the duration of their shift. Each site required a
minimum of 100 scribed and non-scribed shifts, from November 2015 to January
2018.
MAIN OUTCOME MEASURES:
Physicians' productivity (total patients, primary patients);
patient throughput (door-to-doctor time, length of stay); physicians'
productivity in emergency department regions. Self reported harms of scribes
were analysed, and a cost-benefit analysis was done.
RESULTS:
Data were collected from 589 scribed shifts (5098 patients)
and 3296 non-scribed shifts (23 838 patients). Scribes increased physicians'
productivity from 1.13 (95% confidence interval 1.11 to 1.17) to 1.31 (1.25 to
1.38) patients per hour per doctor, representing a 15.9% gain. Primary
consultations increased from 0.83 (0.81 to 0.85) to 1.04 (0.98 to 1.11)
patients per hour per doctor, representing a 25.6% gain. No change was seen in
door-to-doctor time. Median length of stay reduced from 192 (interquartile
range 108-311) minutes to 173 (96-208) minutes, representing a 19 minute
reduction (P less than 0.001).
The greatest gains were achieved by placing scribes with senior doctors at
triage, the least by using them in sub-acute/fast track regions. No significant
harm involving scribes was reported. The cost-benefit analysis based on productivity
and throughput gains showed a favourable financial position with use of
scribes.
CONCLUSIONS:
Scribes improved emergency physicians' productivity,
particularly during primary consultations, and decreased patients' length of
stay. Further work should evaluate the role of the scribe in countries with
health systems similar to Australia's.
B. Impact of Medical Scribes on Provider
Efficiency in the Pediatric ED.
Addesso LC, et al. Acad Emerg Med 2019;26(2):174-182. https://onlinelibrary.wiley.com/doi/10.1111/acem.13544
14. Low-dose Mag Sulfate Vs High Dose in the Early Management of
Rapid A Fib: Randomized Controlled Double-blind Study (LOMAGHI Study).
Bouida W, et al. Acad Emerg Med. 2019 Feb;26(2):183-191.
OBJECTIVES:
We aim to determine the benefit of two different doses
magnesium sulfate (MgSO4 ) compared to placebo in rate control of rapid atrial
fibrillation (AF) managed in the emergency department (ED).
METHODS:
We undertook a randomized, controlled, double-blind clinical
trial in three university hospital EDs between August 2009 and December 2014.
Patients over
18 years with rapid AF (over
120 beats/min) were enrolled and randomized to 9 g of intravenous MgSO4
(high-dose group, n = 153), 4.5 g of intravenous MgSO4 (low-dose group, n =
148), or serum saline infusion (placebo group, n = 149), given in addition to
atrioventricular (AV) nodal blocking agents. The primary outcome was the
reduction of baseline ventricular rate (VR) to 90 beats/min or less or
reduction of VR by 20% or greater from baseline (therapeutic response).
Secondary outcome included resolution time (defined as the elapsed time from
start of treatment to therapeutic response), sinus rhythm conversion rate, and
adverse events within the first 24 hours.
RESULTS:
At 4 hours, therapeutic response rate was higher in low- and
high-MgSO4 groups compared to placebo group; the absolute differences were,
respectively, 20.5% (risk ratio [RR] = 2.31, 95% confidence interval [CI] =
1.45-3.69) and +15.8% (RR = 1.89, 95% CI = 1.20-2.99). At 24 hours, compared to
placebo group, therapeutic response difference was +14.1% (RR = 9.74, 95% CI =
2.87-17.05) with low-dose MgSO4 and +10.3% (RR = 3.22, 95% CI = 1.45-7.17) with
high-dose MgSO4 . The lowest resolution time was observed in the low-dose MgSO4
group (5.2 ± 2 hours) compared to 6.1 ± 1.9 hours in the high-dose MgSO4 group
and 8.4 ± 2.5 hours in the placebo group. Rhythm control rate at 24 hours was
significantly higher in the low-dose MgSO4 group (22.9%) compared to the
high-dose MgSO4 group (13.0%, p = 0.03) and the placebo group (10.7%). Adverse
effects were minor and significantly more frequent with high-dose MgSO4 .
CONCLUSIONS:
Intravenous MgSO4 appears to have a synergistic effect when
combined with other AV nodal blockers resulting in improved rate control.
Similar efficacy was observed with 4.5 and 9 g of MgSO4 but a dose of 9 g was
associated with more side effects.
15. FDA Clears Novel Eye Tracking Test to Detect Concussion
Megan Brooks. Medscape Medical News. January 08, 2019
The US Food and Drug Administration (FDA) will allow
marketing of EyeBOX (Oculogica), the first noninvasive, baseline-free test to
help diagnose concussion.
The company plans to market the device for use in children
ages 5 and older and adults up to 67 years of age, starting with a pilot launch
for select, qualified sites.
EyeBOX uses eye-tracking to provide objective information
that helps clinicians assess patients who have a suspected concussion with a
simple, 4-minute test that does not require a baseline test.
In many situations, a baseline concussion assessment is not
feasible, particularly when evaluating trauma patients in the emergency
department. Baseline tests can also be "gamed" or memorized so that
athletes and military personnel can pass a subsequent test. EyeBOX’s unique
eye-tracking algorithm enables it to be baseline-free, the company announced.
"Eye-tracking will change the practice of emergency
care for concussion and will greatly assist a large number of patients. The
result will be more consistent and objective diagnoses of concussion in the
emergency room and clinic, and eventually on the [playing] field," Robert
Spinner, MD, chair of the department of neurological surgery at Mayo Clinic in
Rochester, Minnesota, said in a statement.
EyeBOX was evaluated in a clinical trial known as DETECT,
which enrolled 282 patients at six clinical sites in the US and compared the
EyeBOX results to a clinical reference standard for concussion in patients
presenting to emergency departments and sports medicine clinics with suspected
head injury.
The study showed that the EyeBOX had high sensitivity to the
presence of concussion and that a negative EyeBOX result is consistent with a
lack of concussion, the company said.
"Oculogica’s extensive clinical research and validation
have shown we can provide an objective assessment to healthcare providers when
evaluating patients with suspected mild traumatic brain injury," Rosina
Samadani, PhD, founder and CEO of Oculogica, said in the statement.
16. A Case-Control Study of Sonographic Maximum Ovarian Diameter
as a Predictor of Ovarian Torsion in ED Females with Pelvic Pain.
Budhram G, et al. Acad Emerg Med. 2019 Feb;26(2):152-159.
BACKGROUND:
Color and power Doppler ultrasound are commonly used in the
evaluation of ovarian torsion but are unreliable. Because normal-sized ovaries
are unlikely to cause torsion, maximum ovarian diameter (MOD) could
theoretically be used as a screening test in the ED. Identification of MOD
values below which torsion is unlikely would be of benefit to providers
interpreting radiology department or point-of-care pelvic ultrasound.
OBJECTIVES:
The objective was to determine if sonographic MOD can be
used as a screening tool to rule out torsion in selected patients.
METHODS:
Via a retrospective case-control study spanning a 14-year
period, we examined the ultrasound characteristics of patients with torsion and
age-matched controls, all presenting to the emergency department with lower
abdominal pain and receiving a radiology department pelvic ultrasound for
"rule-out torsion." Standardized data collection forms were utilized.
Distributions of MOD were compared and sensitivity, specificity, and likelihood
ratios were calculated for multiple cutoffs.
RESULTS:
We identified 92 cases of surgically confirmed ovarian
torsion and selected 92 age-matched controls. In postmenarchal patients the
sensitivity, specificity, positive likelihood ratio, and negative likelihood
ratio of 3- and 5-cm MODs were 100% (96%-100%), 30% (20%-41%), 1.4 (1.3-1.7),
and 0 and 91% (83%-97%), 92% (83%-97%), 11.2 (5.5-22.9), and 0.09 (0.04-0.19),
respectively. The 5-cm MOD, however, excluded an additional 52 of 84 (62%)
postmenarchal patients.
CONCLUSIONS:
A threshold MOD of 5 cm on pelvic ultrasound may be useful
to rule out ovarian torsion in postmenarchal females presenting with lower
abdominal and pelvic pain.
17. Sepsis Research
A. Early Use of Norepinephrine in
Septic Shock Resuscitation (CENSER): A Randomized Trial
Permpikul C, et al. Am J Respir Crit Care Med. 2019 Feb 1 [Epub
ahead of print]
RATIONALE:
Recent retrospective evidence suggests the efficacy of early
norepinephrine administration during resuscitation; however, prospective data
to support this assertion are scarce.
OBJECTIVES:
To conduct a Phase II trial evaluating the hypothesis that
early low-dose norepinephrine in adults sepsis with hypotension increases shock
control by six hours compared with standard care.
METHODS:
This single-center, randomized, double-blind,
placebo-controlled clinical trial was conducted at Siriraj Hospital, Bangkok,
Thailand. The study enrolled 310 adults diagnosed with sepsis with hypotension.
The patients were randomly divided into two groups: early norepinephrine
(n=155) and standard treatment (n=155). The primary outcome was shock control
rate (defined as achievement of mean arterial blood pressure over 65mmHg, with urine flow over 0.5mL/kg/h for 2 consecutive hours, or
decreased serum lactate over
10% from baseline) by 6 hours after diagnosis.
MEASUREMENTS AND MAIN RESULTS:
The patients in both groups were well matched in background
characteristics and disease severity. Median time from emergency room arrival
to norepinephrine administration was significantly shorter in early
norepinephrine group (93 vs.192min;P less than 0.001). Shock control rate by 6 hours
was significantly higher in early norepinephrine group (118/155[76.1%]
vs.75/155[48.4%];P less than
0.001). 28 day mortality was not different between groups:
24/155(15.5%) in the early norepinephrine group versus 34/155(21.9%) in the
standard treatment group (P=0.15). The early norepinephrine group was
associated with lower incidences of cardiogenic pulmonary edema (22/155[14.4%]
vs. 43/155[27.7%]; P=0.004) and new-onset arrhythmia (17/155[11%] vs.
31/155[20%]; P=0.03).
CONCLUSIONS:
Early norepinephrine was significantly associated with
increased shock control by 6 hours. Further studies are needed before this
approach is introduced in clinical resuscitation practice.
B. Association of Corticosteroid
Treatment With Outcomes in Adult Patients With Sepsis: A Systematic Review and
Meta-analysis
Fang F, et al. JAMA Intern Med. 2019;179(2):213-223.
Introduction
Sepsis is defined as a life-threatening host response to
infection that may culminate in organ failure and death.1-3 The incidence of
sepsis is 535 cases per 100 000 person-years. The in-hospital mortality in the
presence of sepsis ranges from 30% to 45%.4-6 Concomitant with early
hemodynamic and respiratory support and appropriate antibiotic administration,
since the mid-20th century, corticosteroids have been used as adjuvant therapy
in the context of sepsis.7,8 Although evaluated in numerous randomized clinical
trials (RCTs), both the safety and efficacy of corticosteroids remains
controversial.7,8 Various systematic reviews and meta-analyses have either
confirmed9,10 or refuted11-13 any survival benefit. A recent Cochrane
meta-analysis suggested that low-dose corticosteroids may be associated with
reduced mortality in patients with sepsis.9 In parallel, an additional
systematic review concluded that there is no beneficial effect of high-dose or
low-dose corticosteroids for treatment of sepsis.11 The conclusions of both
reviews emphasized low9 or very low11 certainty in the evidence, limited by
risk of bias,11 inconsistency,9,11 imprecision,9,11 and publication bias.9
Because of the low quality of available evidence, current clinical practice
guidelines provide only a weak recommendation for the use of hydrocortisone in
patients with septic shock if adequate fluid resuscitation and treatment with
vasopressors have not restored hemodynamic stability.8
In 2018, 2 large RCTs14,15 reported comprehensive analyses
of the uses of corticosteroids in patients with sepsis. These trials included
more than 5000 combined patients, a larger sample than all the previous RCTs.
The 2 trials yielded different results. In the Activated Protein C and
Corticosteroids for Human Septic Shock (APROCCHSS) trial, hydrocortisone plus
fludrocortisone given at low doses reduced 90-day mortality among patients with
septic shock.14 In the Adjunctive Corticosteroid Treatment in Critically Ill
Patients with Septic Shock (ADRENAL) trial, a continuous infusion of
hydrocortisone in patients undergoing mechanical ventilation did not result in
lower mortality compared with patients receiving a placebo.15 These 2 trials had
significant differences in the severity of illness (mortality in the control
group, 28.8% vs 49.1%), the type of administered corticosteroids
(hydrocortisone plus fludrocortisone vs hydrocortisone), method of drug
administration (intermittent boluses vs continuous), and associated medical
conditions when sepsis developed (in patient after a surgical admission vs
patients with pneumonia).
The uncertainty about the efficacy of corticosteroids among
patients with sepsis has resulted in a wide variation in clinical practice.16
This finding was the impetus for this systematic review and meta-analysis of
the literature on the efficacy and safety of corticosteroid administration in
patients with sepsis.
Key
Points
Question Are
corticosteroids associated with a reduction in 28-day mortality in patients
with sepsis?
Findings In this
systematic review and meta-analysis of 37 randomized clinical trials that
included 9564 patients with sepsis, administration of corticosteroids was
associated with reduced 28-day mortality. Corticosteroids were also
significantly associated with increased shock reversal at day 7 and
vasopressor-free days and with decreased intensive care unit length of stay,
the Sequential Organ Failure Assessment score at day 7, and time to resolution
of shock.
Meaning The findings
suggest that administration of corticosteroid treatment in patients with sepsis
is associated with significant improvement in health care outcomes and thus
with reduced 28-day mortality.
Abstract
Importance Although
corticosteroids are widely used for adults with sepsis, both the overall
benefit and potential risks remain unclear.
Objective To conduct
a systematic review and meta-analysis of the efficacy and safety of
corticosteroids in patients with sepsis.
Data Sources and Study Selection MEDLINE, Embase, and the Cochrane Central
Register of Controlled Trials were searched from inception until March 20,
2018, and updated on August 10, 2018. The terms corticosteroids, sepsis, septic
shock, hydrocortisone, controlled trials, and randomized controlled trial were
searched alone or in combination. Randomized clinical trials (RCTs) were
included that compared administration of corticosteroids with placebo or
standard supportive care in adults with sepsis.
Data Extraction and Synthesis Meta-analyses were conducted using a
random-effects model to calculate risk ratios (RRs) and mean differences (MDs)
with corresponding 95% CIs. Two independent reviewers completed citation
screening, data abstraction, and risk assessment.
Main Outcomes and Measures
Twenty-eight–day mortality.
Results This
meta-analysis included 37 RCTs (N = 9564 patients). Eleven trials were rated as
low risk of bias. Corticosteroid use was associated with reduced 28-day
mortality (RR, 0.90; 95% CI, 0.82-0.98; I2 = 27%) and intensive care unit (ICU)
mortality (RR, 0.85; 95% CI, 0.77-0.94; I2 = 0%) and in-hospital mortality (RR,
0.88; 95% CI, 0.79-0.99; I2 = 38%). Corticosteroids were significantly
associated with increased shock reversal at day 7 (MD, 1.95; 95% CI, 0.80-3.11)
and vasopressor-free days (MD, 1.95; 95% CI, 0.80-3.11) and with ICU length of
stay (MD, −1.16; 95% CI, −2.12 to −0.20), the sequential organ failure
assessment score at day 7 (MD, −1.38; 95% CI, −1.87 to −0.89), and time to
resolution of shock (MD, −1.35; 95% CI, −1.78 to −0.91). However,
corticosteroid use was associated with increased risk of hyperglycemia (RR,
1.19; 95% CI, 1.08-1.30) and hypernatremia (RR, 1.57; 95% CI, 1.24-1.99).
Conclusions and Relevance
The findings suggest that administration of corticosteroids is
associated with reduced 28-day mortality compared with placebo use or standard
supportive care. More research is needed to associate personalized medicine
with the corticosteroid treatment to select suitable patients who are more
likely to show a benefit.
C. Effect of a Resuscitation Strategy
Targeting Peripheral Perfusion Status vs Serum Lactate Levels on 28-Day
Mortality Among Patients With Septic Shock: The ANDROMEDA-SHOCK RCT
Hernandez G, et al. JAMA. 2019;321(7):654-664.
Key
Points
Question Does the use
of a resuscitation strategy targeting normalization of capillary refill time,
compared with a strategy targeting serum lactate levels, reduce mortality among
patients with septic shock?
Findings In this
randomized clinical trial of 424 patients with early septic shock, 28-day
mortality was 34.9% in the peripheral perfusion–targeted resuscitation group
compared with 43.4% in the lactate level–targeted resuscitation group, a
difference that did not reach statistical significance.
Meaning These
findings do not support the use of a peripheral perfusion–targeted
resuscitation strategy in patients with septic shock.
Abstract
Importance Abnormal
peripheral perfusion after septic shock resuscitation has been associated with
organ dysfunction and mortality. The potential role of the clinical assessment
of peripheral perfusion as a target during resuscitation in early septic shock
has not been established.
Objective To
determine if a peripheral perfusion–targeted resuscitation during early septic
shock in adults is more effective than a lactate level–targeted resuscitation
for reducing mortality.
Design, Setting, and Participants Multicenter, randomized trial conducted at 28
intensive care units in 5 countries. Four-hundred twenty-four patients with
septic shock were included between March 2017 and March 2018. The last date of
follow-up was June 12, 2018.
Interventions
Patients were randomized to a step-by-step resuscitation protocol aimed
at either normalizing capillary refill time (n = 212) or normalizing or
decreasing lactate levels at rates greater than 20% per 2 hours (n = 212),
during an 8-hour intervention period.
Main Outcomes and Measures
The primary outcome was all-cause mortality at 28 days. Secondary
outcomes were organ dysfunction at 72 hours after randomization, as assessed by
Sequential Organ Failure Assessment (SOFA) score (range, 0 [best] to 24
[worst]); death within 90 days; mechanical ventilation–, renal replacement
therapy–, and vasopressor-free days within 28 days; intensive care unit and
hospital length of stay.
Results Among 424
patients randomized (mean age, 63 years; 226 [53%] women), 416 (98%) completed
the trial. By day 28, 74 patients (34.9%) in the peripheral perfusion group and
92 patients (43.4%) in the lactate group had died (hazard ratio, 0.75 [95% CI,
0.55 to 1.02]; P = .06; risk difference, −8.5% [95% CI, −18.2% to 1.2%]).
Peripheral perfusion–targeted resuscitation was associated with less organ
dysfunction at 72 hours (mean SOFA score, 5.6 [SD, 4.3] vs 6.6 [SD, 4.7]; mean
difference, −1.00 [95% CI, −1.97 to −0.02]; P = .045). There were no
significant differences in the other 6 secondary outcomes. No protocol-related
serious adverse reactions were confirmed.
Conclusions and Relevance
Among patients with septic shock, a resuscitation strategy targeting
normalization of capillary refill time, compared with a strategy targeting
serum lactate levels, did not reduce all-cause 28-day mortality.
18. Does Increased Access to Primary Care Reduce EM Visits? Ah,
not necessarily.
Science
Trumps Empiricism (Humans Are Bad at Math)
Jeff Kline, Editor-in-chief, Acad Emerg Med writes: February's
pick of the month, (Access to Federally Qualified Health Centers and Emergency
Department Use Among Uninsured and Medicaid-insured Adults: California, 2005 to
2013 by Nath, et al.), shows the importance of "showing your work"
when it comes to imagined math in health policy. This paper explores the errant
public perception that more primary care equals fewer unecessary emergency
department visits. I chose this paper because it shows that the make-believe
reality created by our puny human brains so often get trounced by actual data.
I mean, of course, every educated voter knows the health services mathematical
equation: more money ($9 billion as pointed out by Nath, et al.) for more
Federally Qualified Health Centers (FQHCs) and therefore more primary care
access = fewer of those low income patients with their trifling complaints
inhabiting my emergency department. But humans are so bad at math. From
2008-2013 (for your slide deck, please copy Table 2), Nath, et al., found no
mathematical relationship between the density of FQHCs and emergency department
visits for either Medicaid or uninsured patients. This finding prompts
difficult questions about what taxpayers are getting for their billions, and
the underlying why behind Table 2. For more on the why, please read on to the
narrative that follows by Dr. Zachary F. Meisel.
Narrative Summary
Zachary F. Meisel, MD, associate professor of emergency
medicine at the Perelman School of Medicine at the University of Pennsylvania,
places the EIC Pick into perspective in the emergency setting:
I have a physician friend who, not long ago, served as the
chief medical officer for a cluster of Federally Qualified Health Centers in a
large city. She spoke about two of them in vastly different ways. One was a
beautiful new construction, but staffed with grumpy, burned-out providers who
would go the minimum distance for their patients. The other was grungy and
falling apart, but was directed by one of her favorite doctors. As you might
expect, the first was (despite the gleaming facility) widely disparaged in the
community and underused. The other was overflowing with patients willing to
wait to be seen in the crumbing building by the beloved staff. When I reflect
on Nath and colleagues' counterintuitive and important study, showing that
increased access to these primary care clinics does not translate into lower
rates of emergency department use, I am not surprised. People have real (and
legitimate) reasons for seeking care where they go, especially Medicaid
enrollees who are sicker than others. I often think about an excellent study
published six years ago called "Understanding Why Patients Of Low
Socioeconomic Status Prefer Hospitals Over Ambulatory Care." The authors
found that patients perceive the hospital (and the ED) to be more accessible,
and of higher quality than ambulatory care. Maybe the paternalistic approach to
keeping patients out of the ED – which assumes that patients don't know what is
best for them – is misguided.
19. Acute Dizziness: A Newer Approach
Gurley KL, et al. Semin Neurol 2019; 39(01): 027-040
Dizziness is a common chief complaint with an extensive
differential diagnosis that includes both benign and serious conditions.
Physicians must distinguish the majority of patients who suffer from
self-limiting conditions from those with serious illnesses that require acute
treatment. The preferred approach to the diagnosis of an acutely dizzy patient
emphasizes different aspects of the history to guide a focused physical
examination, with the goal of differentiating benign peripheral vestibular
conditions from dangerous posterior circulation strokes. Currently, misdiagnoses are frequent and diagnostic testing costs are
high. This partly relates to use of an outdated diagnostic paradigm. This
commonly used traditional approach relies on dizziness “symptom quality” or
“type” (vertigo, presyncope, disequilibrium) to guide inquiry. It does not
distinguish benign from dangerous causes and is inconsistent with current best
evidence.
A
better approach categorizes patients into three groups based on timing and
triggers. Each category has its own differential diagnosis and
targeted bedside approach: (1) acute vestibular syndrome, where bedside
physical examination differentiates vestibular neuritis from stroke; (2)
spontaneous episodic vestibular syndrome, where associated symptoms help
differentiate vestibular migraine from transient ischemic attack; and (3)
triggered episodic vestibular syndrome, where the Dix-Hallpike and supine roll
test help differentiate benign paroxysmal positional vertigo from posterior
fossa structural lesions. The “timing and triggers” diagnostic approach for the
acutely dizzy derives from current best evidence and offers the potential to
reduce misdiagnosis while simultaneously decreasing diagnostic test overuse,
unnecessary hospitalization, and incorrect treatments.
Full-text (free): https://www.thieme-connect.com/products/ejournals/html/10.1055/s-0038-1676857#N71089
20. Two HEART Studies
A. Prognostic Accuracy of the HEART
Score for Prediction of Major Adverse Cardiac Events in Patients Presenting with
Chest Pain: A Systematic Review and Meta-analysis.
Fernando SM, et al. Acad Emerg Med. 2019 Feb;26(2):140-151.
OBJECTIVE:
The HEART score has been proposed for emergency department
(ED) prediction of major adverse cardiac events (MACE). We sought to summarize
all studies assessing the prognostic accuracy of the HEART score for prediction
of MACE in adult ED patients presenting with chest pain.
METHODS:
We searched MEDLINE, PubMed, EMBASE, Scopus, Web of Science,
and the Cochrane Database of Systematic Reviews from inception through May 2018
and included studies using the HEART score for the prediction of short-term
MACE in adult patients presenting to the ED with chest pain. The main outcome
was short-term (i.e., 30-day or 6-week) incidence of MACE. We secondarily
evaluated the prognostic accuracy of the HEART score for prediction of
mortality and myocardial infarction (MI). Where available, accuracy of the
Thrombolysis in Myocardial Infarction (TIMI) score was determined.
RESULTS:
We included 30 studies (n = 44,202) in analysis. A HEART
score above the low-risk threshold (≥4) had a sensitivity of 95.9% (95%
confidence interval [CI] = 93.3%-97.5%) and specificity of 44.6% (95% CI =
38.8%-50.5%) for MACE. A high-risk HEART score (≥7) had a sensitivity of 39.5%
(95% CI = 31.6%-48.1%) and specificity of 95.0% (95% CI = 92.6%-96.6%) for
MACE, whereas a TIMI score above the low-risk threshold (≥2) had a sensitivity
of 87.8% (95% CI = 80.2%-92.8%) and specificity of 48.1% (95% CI = 38.9%-57.5%)
for MACE. A high-risk TIMI score (≥6) was 2.8% sensitive (95% CI = 0.8%-9.6%),
but 99.6% (95% CI = 98.5%-99.9%) specific for MACE. A HEART score ≥ 4 had a sensitivity
of 95.0% (95% CI = 87.2%-98.2%) for prediction of mortality and 97.5% (95% CI =
93.7%-99.0%) for prediction of MI.
CONCLUSIONS:
The HEART score has excellent performance for prediction of
MACE (particularly mortality and MI) in chest pain patients and should be the
primary clinical decision instrument used for the risk stratification of this
patient population.
B. HEART Score Risk Stratification of
Low-Risk CP Patients in the ED: A Systematic Review and Meta-Analysis
Laureano-Phillips J, et al. Ann Emerg Med. 2019. In press.
Study objective
The objectives of this systematic review and meta-analysis
are to appraise the evidence in regard to the diagnostic accuracy of a low-risk
History, ECG, Age, Risk Factors, and Troponin (HEART) score for prediction of
major adverse cardiac events in emergency department (ED) patients. These
included 4 subgroup analyses: by geographic region, the use of a modified
low-risk HEART score (traditional HEART score [0 to 3] in addition to negative
troponin results), using conventional versus high-sensitivity troponin assays
in the HEART score, and a comparison of different post–ED-discharge patient
follow-up intervals.
Methods
We searched MEDLINE, EBSCO, Web of Science, and Cochrane
Database for studies on the diagnostic performance of low-risk HEART scores to
predict major adverse cardiac events among ED chest pain patients. Two
reviewers independently screened articles for inclusion, assessed the quality
of studies with both an adapted Quality Assessment of Diagnostic Accuracy
Studies version 2 tool and an internally developed tool that combined
components of the Quality in Prognostic Studies; Checklist for Critical
Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling
Studies; and Grading of Recommendations Assessment, Development and Evaluation.
Pooled sensitivity, specificity, positive predictive value, negative predictive
value, and positive and negative likelihood ratios were calculated.
Results
There were 25 studies published from 2010 to 2017, with a
total of 25,266 patients included in the final meta-analysis, of whom 9,919
(39.3%) were deemed to have low-risk HEART scores (0 to 3). Among patients with
low-risk HEART scores, short-term major adverse cardiac events (30 days to 6
weeks) occurred in 2.1% of the population (182/8,832) compared with 21.9% of
patients (3,290/15,038) with non–low-risk HEART scores (4 to 10). For patients
with HEART scores of 0 to 3, the pooled sensitivity of short-term major adverse
cardiac event predictions was 0.96 (95% confidence interval [CI] 0.93 to 0.98),
specificity was 0.42 (95% CI 0.36 to 0.49), positive predictive value was 0.19
(95% CI 0.14 to 0.24), negative predictive value was 0.99 (95% CI 0.98 to
0.99), positive likelihood ratio was 1.66 (95% CI 1.50 to 1.85), and negative
likelihood ratio was 0.09 (95% CI 0.06 to 0.15). Subgroup analysis showed that
lower short-term major adverse cardiac events occurred among North American
patients (0.7%), occurred when modified low-risk HEART score was used (0.8%),
or occurred when high-sensitivity troponin was used for low-risk HEART score
calculations (0.8%).
Conclusion
In this meta-analysis, despite its use in different patient
populations, the troponin type used, and timeline of follow-up, a low-risk
HEART score had high sensitivity, negative predictive value, and negative
likelihood ratio for predicting short-term major adverse cardiac events,
although risk of bias and statistical heterogeneity were high.
21. Addressing Medicine’s Bias Against Patients Who Are
Overweight
Rubin R. JAMA Intern Med. February 20, 2019
According to her obituary, Ellen Maud Bennett had felt
unwell for a few years before her death in May 2018.
But the physicians Bennett consulted couldn’t see past the
extra pounds she carried. If she’d only lose weight, she’d feel better, they
told her.
Finally, a physician must have suspected another reason for
her malaise, because Bennett was diagnosed with advanced-stage cancer just days
before her death at age 64 years.
Bennett, a costume designer for stage and screen who lived
in Victoria, British Columbia, expressed a final plea in her obituary: “Ellen’s
dying wish was that women of size make her death matter by advocating strongly
for their health and not accepting that fat is the only relevant health issue.”
Whether Bennett’s prognosis would have been less dire if
she’d been diagnosed earlier isn’t known. But, given the tales told by scores
of strangers from around the world who posted their condolences, Bennett’s health
care encounters epitomized that of many overweight and obese individuals.
“There is not a single patient with significant obesity who
has not experienced weight bias, whether it’s comments from doctors or nurses,
the way waiting rooms are set up, or privacy issues,” said Yoni Freedhoff, MD,
an obesity specialist at the University of Ottawa. “Weight bias is ubiquitous
in society as a whole. Doctors are part of society.”
Weight appears to be the last acceptable bias, because,
unlike most other characteristics or conditions, it is one over which
individuals are perceived as having control. Losing weight and keeping it off
should be (not eating) a piece of cake, this line of thinking goes. And yet,
nearly three-quarters of US adults ages 20 years or older are overweight or
obese, according to the US Centers for Disease Control and Prevention.
“Our country has placed a huge emphasis on personal
responsibility for body weight,” said Rebecca Puhl, PhD, deputy director of the
Rudd Center for Food Policy and Obesity at the University of Connecticut. But,
Puhl said, that “really oversimplifies the complex causes of obesity and of
weight loss and of weight regain.”
“Many healthcare providers hold strong negative attitudes
and stereotypes about people with obesity,” concluded the authors of a 2015
review of the empirical literature on weight bias in health care. “There is
considerable evidence that such attitudes influence person-perceptions,
judgment, interpersonal behavior, and decision-making.”
The rest of the essay (free): https://jamanetwork.com/journals/jama/fullarticle/2725893
The 2015 review (free): “Impact of weight bias and stigma on quality of care and outcomes for patients with obesity” https://onlinelibrary.wiley.com/doi/full/10.1111/obr.12266
The 2015 review (free): “Impact of weight bias and stigma on quality of care and outcomes for patients with obesity” https://onlinelibrary.wiley.com/doi/full/10.1111/obr.12266
22. Micro Bits
A.
Eating and Drinking at ED Workstations is Permissible
Caring about our members’ well-being, ACEP worked with The
Joint Commission to clarify that emergency staff can eat at an ED work station
during their shifts.
B.
Five Ways Sleep Is Good for Your Relationships
New research highlights how sleep benefits our social lives.
Greater Good Science Center (at UC Berkeley): https://greatergood.berkeley.edu/article/item/five_ways_sleep_is_good_for_your_relationships
C.
‘I Had No Idea I Was Having a Heart Attack’: For Women, Cardiac Arrests Are
Unseen Killers
A retired cardiac-care nurse didn’t recognize her own
symptoms, which are different for women. Neither did the first responders. It’s
a problem that can have fatal consequences.
D.
Is It Time to Stop Addressing Physicians as 'Dr.'?
Blog posting at MedPage Today: https://www.medpagetoday.com/blogs/wiredpractice/78026
E.
Effect of breakfast on weight and energy intake: systematic review and
meta-analysis of randomised controlled trials
F.
Three week versus six week immobilisation for stable Weber B type ankle
fractures: randomised, multicentre, non-inferiority clinical trial
G.
Exercising might inspire healthy food choices
People who start exercising regularly might subsequently
make more healthful food choices, according to a study published in the
International Journal of Obesity. Researchers found that college students who
stuck with an exercise program began eating nutritious foods more frequently
and unhealthful foods less frequently than they had before starting the exercise
regimen.
H.
US spends $8.3B on unnecessary ED visits for chronic diseases
A Premier study found that about 30% of emergency department
visits among patients with chronic illnesses probably could have been prevented
and handled in a less costly outpatient setting, and those unneeded ED visits
amounted to $8.3 billion in additional spending. The findings, based on an analysis
of 24 million ED visits at 747 hospitals, showed 60% of those visits involved
asthma, diabetes, hypertension, chronic obstructive pulmonary disease, heart
failure or behavioral health conditions.
https://www.modernhealthcare.com/article/20190207/TRANSFORMATION03/190209949
I.
6 Ideas That Physicians Need To Explain Better To Patients
J.
How One Woman Changed What Doctors Know About Heart Attacks
The story of SCAD underscores how much doctors still don’t
understand, including about heart disease in women.
K.
Uninsured rate under Trump surges to highest level since Obamacare began
L.
Expired Medications May Remain Effective, Study Indicates.
Reuters (2/20, Crist) reports that research suggests “even
medicines that are years past their expiration date and haven’t always been
kept in strict climate-controlled conditions may still retain their original
potency.” The tested “drugs included atropine, which is used to treat certain
types of pesticide or nerve agent poisonings; nifedipine, a calcium channel
blocker that relaxes the heart and blood vessels in cases of high blood
pressure and chest pain; flucloxacillin, an antibiotic in the penicillin family;
bendroflumethiazide, a diuretic used to treat hypertension; and naproxen, a
nonsteroidal anti-inflammatory (NSAID) painkiller.” The study was published in
Wilderness & Environmental Medicine.
M.
Fluconazole use during pregnancy linked to adverse outcomes
Women who received fluconazole doses of up to 150 mg and
more than 150 mg for yeast infections during pregnancy had a more than twofold
and more than threefold increased miscarriage risk, respectively, compared with
those who didn't take fluconazole during pregnancy, according to a study in the
Canadian Medical Association Journal. Researchers also found an 81% increased
likelihood of cardiac defects among infants whose mothers took higher
fluconazole doses during the first trimester of pregnancy.
N.
Legionnaires’ Disease Cases Up Over Fivefold Since 2000, Data Show.
USA Today (2/19, Alltucker, 12.61M) reports that “nearly
7,500 people contracted Legionnaires’ disease in 2017, a more than fivefold
increase in the number of cases since 2000, according to the Centers for
Disease Control and Prevention.” However, “federal health officials said that increasing
reports of the once-mysterious disease can be explained by better awareness,
improved testing and an aging population more susceptible to Legionnaires’.”
O.
CDC releases first video on vaccinations for children
The CDC has released the first video in its How Vaccines
Work series, aimed at giving parents information on vaccine-related issues. The
resource includes a link to a CDC page on what to expect during a child's first
office visit for a vaccination.
P.
WHO spotlights 10 health threats for 2019
The World Health Organization's 10 biggest global health
threats for 2019 include vaccine hesitancy, drug-resistant bacteria, climate
change and air pollution, a global flu pandemic, and sustained humanitarian
crises. Also on the list are risks related to outbreaks of high-threat
pathogens, nontransmissible disease, dengue, HIV and the unmet needs for
primary care.
Q.
Dr. Google Is a Liar
Fake news threatens our democracy. Fake medical news
threatens our lives.
By Haider Warraich. NY Times. Dec 16, 2018
It started during yoga class. She felt a strange pull on her
neck, a sensation completely foreign to her. Her friend suggested she rush to
the emergency room. It turned out that she was having a heart attack.
She didn’t fit the stereotype of someone likely to have a
heart attack. She exercised, did not smoke, watched her plate. But on reviewing
her medical history, I found that her cholesterol level was sky high. She had
been prescribed a cholesterol-lowering statin medication, but she never picked
up the prescription because of the scary things she had read about statins on
the internet. She was the victim of a malady fast gearing up to be a modern
pandemic — fake medical news.
While misinformation has been the object of great attention
in politics, medical misinformation might have an even greater body count. As
is true with fake news in general, medical lies tend to spread further than
truths on the internet — and they have very real repercussions.
Numerous studies have shown that the benefits of statins far
outweigh the risks, especially for people at high risk of heart disease. But
they have been targeted online by a disparate group that includes paranoid
zealots, people selling alternative therapies and those who just want clicks.
Innumerable web pages and social media posts exaggerate rare risks and drum up
unfounded claims, from asserting that statins cause cancer to suggesting that
low cholesterol is actually bad for health. Even stories simply weighing the
risks versus benefits of statins, a 2016 study found, were associated with
patients’ stopping the cholesterol-lowering drugs — which is associated with a
spike in heart attacks…
