1. Pediatric Corner
A. Levetiracetam versus phenytoin for second-line treatment of
convulsive status epilepticus in children (ConSEPT): an open-label, multicentre
RCT
Dalziel
SR, et al. Lancet. 2019 Apr 17 [Epub ahead of print]
BACKGROUND:
Phenytoin
is the current standard of care for second-line treatment of paediatric
convulsive status epilepticus after failure of first-line benzodiazepines, but
is only effective in 60% of cases and is associated with considerable adverse
effects. A newer anticonvulsant, levetiracetam, can be given more quickly, is
potentially more efficacious, and has a more tolerable adverse effect profile.
We aimed to determine whether phenytoin or levetiracetam is the superior
second-line treatment for paediatric convulsive status epilepticus.
METHODS:
ConSEPT
was an open-label, multicentre, randomised controlled trial conducted in 13
emergency departments in Australia and New Zealand. Children aged between 3
months and 16 years, with convulsive status epilepticus that failed first-line
benzodiazepine treatment, were randomly assigned (1:1) using a
computer-generated permuted block (block sizes 2 and 4) randomisation sequence,
stratified by site and age (≤5 years, above 5 years), to receive 20 mg/kg
phenytoin (intravenous or intraosseous infusion over 20 min) or 40 mg/kg
levetiracetam (intravenous or intraosseous infusion over 5 min). The primary
outcome was clinical cessation of seizure activity 5 min after the completion
of infusion of the study drug. Analysis was by intention to treat. This trial
is registered with the Australian and New Zealand Clinical Trials Registry,
number ACTRN12615000129583.
FINDINGS:
Between
March 19, 2015, and Nov 29, 2017, 639 children presented to participating
emergency departments with convulsive status epilepticus; 127 were missed, and
278 did not meet eligibility criteria. The parents of one child declined to
give consent, leaving 233 children (114 assigned to phenytoin and 119 assigned
to levetiracetam) in the intention-to-treat population. Clinical cessation of
seizure activity 5 min after completion of infusion of study drug occurred in
68 (60%) patients in the phenytoin group and 60 (50%) patients in the
levetiracetam group (risk difference -9·2% [95% CI -21·9 to 3·5]; p=0·16). One
participant in the phenytoin group died at 27 days because of haemorrhagic
encephalitis; this death was not thought to be due to the study drug. There
were no other serious adverse events.
INTERPRETATION:
Levetiracetam
is not superior to phenytoin for second-line management of paediatric
convulsive status epilepticus.
B. First-Line Diagnostic Evaluation with MRI of Children Suspected
of Having Acute Appendicitis.
Mushtaq
R, et al. Radiology. 2019 Apr;291(1):170-177.
Background
Advances in abdominal MRI have enabled rapid, free-breathing imaging without
the need for intravenous or oral contrast material. The use of MRI as the
primary imaging modality for suspected appendicitis has not been previously
studied. Purpose To determine the diagnostic performance of MRI as the initial
imaging modality in children suspected of having acute appendicitis.
Materials
and Methods The study included consecutive patients 18 years of age and younger
presenting with acute abdominal pain at a tertiary care institution from
January 2013 through June 2016 who subsequently underwent an unenhanced MRI
examination as the primary diagnostic imaging modality. Electronic medical
records and radiology reports were retrospectively evaluated for the
feasibility and diagnostic performance of MRI, with surgical pathology and
follow-up electronic records as reference standards. Statistical analyses were
performed by using simple binomial proportions to quantify sensitivity,
specificity, and accuracy, and exact 95% confidence intervals (CIs) were
obtained.
Results
After exclusions, 402 patients (median age: 13 years; interquartile range
[IQR], 9-15 years; 235 female patients; 167 male patients) were included.
Sedation for MRI was required in 13 of 402 patients (3.2%; 95% CI: 1.7%, 5.5%).
The appendix was visualized in 349 of 402 patients (86.8%; 95% CI: 83.1%, 90%);
for the remaining patients, a diagnosis was provided on the basis of secondary
signs of appendicitis. The sensitivity, specificity, and accuracy of MRI as the
primary diagnostic imaging modality for the evaluation of acute appendicitis
were 97.9% (95 of 97; 95% CI: 92.8%, 99.8%), 99% (302 of 305; 95% CI: 97.2%,
99.8%), and 98.8% (397 of 402; 97.1%, 99.6%), respectively. Among patients with
negative findings for appendicitis at MRI, an alternate diagnosis was provided
in 113 of 304 patients (37.2%; 95% CI: 31.7%, 42.9%).
Conclusion When performed as the initial
imaging modality in children suspected of having acute appendicitis, MRI
examinations had high diagnostic performance for the diagnosis of acute
appendicitis and in providing alternative diagnoses.
C. Reconsidering the “Classic” Clinical History Associated with
Subluxations of the Radial Head.
Pirruccio
K, et al. West J Emerg Med. 2019;20(2).
Introduction:
The national burden of radial head subluxations in the United States (U.S.)
population is poorly defined, and non-classical injury mechanisms have been
increasingly reported in recent years. The purpose of this study is to report
historical national estimates and demographic characteristics of patients
presenting to U.S. emergency departments (ED) with subluxations of the radial
head.
Methods:
This cross-sectional, retrospective study analyzes the National Electronic
Injury Surveillance System (NEISS) database (2001-2017) to identify patients ≤
7 years of age presenting to U.S. EDs with subluxations of the radial head.
Results:
Linear regression (R2 = 0.65; P less than 0.01) demonstrated that the annual
number of patients presenting to U.S. EDs with subluxations of the radial head
increased significantly (P less than 0.001) between 2001 (N=13,247; confidence
interval [CI], 9,492-17,001) and 2010 (N=21,723; CI, 18,762-24,685), but did
not change significantly between 2010 and 2017 (R2 less than 0.01; P = 0.85).
It also demonstrated that 51.0% (CI, 45.3%-56.6%) of injuries were either
self-induced or spontaneous, whereas 36.8% (CI, 31.6%-42.0%) and 9.4% (CI,
8.0%-10.7%) were associated with parents/guardians or siblings, respectively.
The majority of injuries occurred in patients who were the age of one (33.5%;
CI, 32.1%-35.0%) and two (35.1%; CI, 33.7%-36.6%); females (57.8%; CI,
56.8%-58.9%) were more commonly injured than males.
Conclusion:
Although the national burden of radial head subluxations may be less than
previously reported, it still results in over 20,000 ED visits annually in the
U.S. Given that over half of such injuries are actually self-induced or
spontaneous, caretakers should be taught to recognize the clinical presentation
of radial head subluxation, since the classically described history of a
patient being lifted or pulled by the arm may simply have never occurred.
D. Long-Term Follow-Up of Infants After a Brief Resolved
Unexplained Event-Related Hospitalization.
Ari
A, et al. Pediatr Emerg Care. 2019 Apr 3 [Epub ahead of print]
OBJECTIVE:
A
brief resolved unexplained event (BRUE) in infancy is a common reason for
visiting the emergency department. However, little is known about the long-term
outcomes of such an event. This study evaluates future mortality, morbidity,
and/or developmental outcome after a BRUE.
METHODS:
A
single-center retrospective study performed in 2009 to 2013 included 87
hospitalized infants (less than 1 year old) fitting the American Academy of
Pediatrics' criteria of a lower-risk BRUE, with 2 exceptions: no time limit to
duration of episode and no age limit of ≥60 days. Hospitalized infants were
followed up for up to 5 years via a telephone questionnaire to assess mortality
rates, developmental delay, neurological/cardiovascular morbidity, and future
hospitalizations.
RESULTS:
Most
infants (94%) who experienced a BRUE were hospitalized before 6 months of age.
No cases of mortality occurred. In terms of developmental outcome, 1 child
(1.15%) was diagnosed as having a global developmental delay and 12 (13.7%)
with a language delay, similar to prevalence rates by age in the United States.
Three children (3.4%) were diagnosed as having an autism spectrum disorder,
with higher prevalence rates than the global average. Simple febrile and
nonfebrile seizures were seen at a rate similar to the general population. None
of the children developed cardiovascular disease. Rehospitalization occurred in
22% of cases: 90% for common acute pediatric causes and 10% for recurrent
choking events secondary to gastroesophageal reflux disease.
CONCLUSIONS:
Low-risk
hospitalized infants younger than 1 year who experienced a BRUE seem to generally
have an excellent prognosis.
E. Managing the Frightened Child.
Krauss
BA, Krauss BS. Ann Emerg Med. 2019 Jan 12 [Epub ahead of print]
Introduction
Medical
encounters are often frightening for children and stressful for their families.
When children are afraid, they resist cooperating and responding to verbal
reasoning, inhibiting assessment and treatment.2, 3, 4 For children to
cooperate with physical examination and minor procedures, clinicians must first
establish a trusting relationship with them.5, 6 Although establishing trust is
fundamental to effective interactions with children, there is no systematic
approach to teaching this skill. This article describes and demonstrates a
practical approach to rapidly establishing trust with children in the emergency
department. We deconstruct the elements of clinician-child interactions and
elucidate the underlying principles and methods of an approach to establishing
trust. Our objective is to place a framework and a set of tools around what emergency
physicians are doing intuitively, to enhance effectiveness in their
interactions with children. Although what is described below is based on
established child development and nonverbal communication research, we have
developed much of the practical format and nomenclature presented.
F. Brushing Up on Measles for 2019
Remind
me, what does this look like? Here
are some photos from the CDC: https://www.cdc.gov/measles/about/photos.html
2. Marijuana Cases in the ED
A. Acute Illness Associated with Cannabis Use, by Route of
Exposure: An Observational Study
Pot
brownies and other cannabis "edibles" like gummy bears that are sold
online and where marijuana is legal may seem like harmless fun, but new
research indicates that edibles may be more potent and potentially more
dangerous than pot that is smoked or vaped. The new study analyzed thousands of
cannabis-triggered emergency room visits in the greater Denver area, and found
that edibles induced a disproportionate number of pot-related medical
crises.
Monte
AA, et al. Ann Intern Med. 2019 Mar 26 [Epub ahead of print]
Background:
Little
is known about the relative harms of edible and inhalable cannabis products.
Objective:
To
describe and compare adult emergency department (ED) visits related to edible
and inhaled cannabis exposure.
Design:
Chart
review of ED visits between 1 January 2012 and 31 December 2016.
Setting:
A
large urban academic hospital in Colorado.
Participants:
Adults
with ED visits with a cannabis-related International Classification of
Diseases, Ninth or 10th Revision, Clinical Modification (ICD-9-CM or
ICD-10-CM), code.
Measurements:
Patient
demographic characteristics, route of exposure, dose, symptoms, length of stay,
disposition, discharge diagnoses, and attribution of visit to cannabis.
Results:
There
were 9973 visits with an ICD-9-CM or ICD-10-CM code for cannabis use. Of these,
2567 (25.7%) visits were at least partially attributable to cannabis, and 238
of those (9.3%) were related to edible cannabis. Visits attributable to inhaled
cannabis were more likely to be for cannabinoid hyperemesis syndrome (18.0% vs.
8.4%), and visits attributable to edible cannabis were more likely to be due to
acute psychiatric symptoms (18.0% vs. 10.9%), intoxication (48% vs. 28%), and
cardiovascular symptoms (8.0% vs. 3.1%). Edible products accounted for 10.7% of
cannabis-attributable visits between 2014 and 2016 but represented only 0.32%
of total cannabis sales in Colorado (in kilograms of tetrahydrocannabinol) in
that period.
Limitation:
Retrospective
study design, single academic center, self-reported exposure data, and limited
availability of dose data.
Conclusion:
Visits
attributable to inhaled cannabis are more frequent than those attributable to
edible cannabis, although the latter is associated with more acute psychiatric
visits and more ED visits than expected.
B. Unintentional Pediatric Marijuana Exposures Prior to and After
Legalization and Commercial Availability of Recreational Marijuana in
Washington State
Thomas
AA, et al. J Emerg Med. 2019 Apr;56(4):398-404.
BACKGROUND:
Washington
State was one of the first states to legalize recreational marijuana. Increased
availability of marijuana may result in more unintentional pediatric exposure,
which often presents as altered mental status with unknown cause.
OBJECTIVES:
To
quantify unintentional pediatric marijuana exposures reported to the Washington
Poison Center (WAPC) prior to and after legalization and commercial
availability of recreational marijuana.
METHODS:
Data
were obtained from the WAPC database, toxiCALL®. Patients ≤ 9 years old with a
reported marijuana exposure between July 2010 and July 2016 were included in
the analysis. Patient and exposure characteristics were summarized and median
exposure frequencies were calculated for the periods prior to and after
legalization.
RESULTS:
There
were 161 cases meeting the inclusion criteria that occurred between July 2010
and July 2016. Of these, 130 (81%) occurred in the 2.5-year period after
legalization of recreational marijuana in January 2013. The median age of
exposed children was 2 years (range 0-9 years). Eighty-one percent of the
exposures occurred in the child's own home. The number of exposures per month
increased after recreational marijuana was legalized in November 2012, and increased
further once recreational marijuana shops were legally allowed to open in July
2014.
CONCLUSION:
Reported
unintentional pediatric marijuana exposure has increased in the state of
Washington since recreational marijuana was legalized. As marijuana becomes
more available, clinicians should be aware of the risk of unintentional
pediatric marijuana exposure, and this should inform lawmakers regarding
regulations around childhood exposure to marijuana.
C. Prenatal marijuana exposure tied to risk of childhood psychosis
3. ACS Research
A. Evaluation of Outpatient Cardiac Stress Testing After ED
Encounters for Suspected ACS.
Natsui
S, et al. Ann Emerg Med. 2019 Apr 5 [Epub ahead of print]
STUDY
OBJECTIVE:
Professional
guidelines recommend 72-hour cardiac stress testing after an emergency
department (ED) evaluation for possible acute coronary syndrome. There are
limited data on actual compliance rates and effect on patient outcomes. Our aim
is to describe rates of completion of noninvasive cardiac stress testing and
associated 30-day major adverse cardiac events.
METHODS:
We
conducted a retrospective analysis of ED encounters from June 2015 to June 2017
across 13 community EDs within an integrated health system in Southern
California. The study population included all adults with a chest pain
diagnosis, troponin value, and discharge with an order for an outpatient
cardiac stress test. The primary outcome was the proportion of patients who
completed an outpatient stress test within the recommended 3 days, 4 to 30 days,
or not at all. Secondary analysis described the 30-day incidence of major
adverse cardiac events.
RESULTS:
During
the study period, 24,459 patients presented with a chest pain evaluation
requiring troponin analysis and stress test ordering from the ED. Of these, we
studied the 7,988 patients who were discharged home to complete diagnostic
testing, having been deemed appropriate by the treating clinicians for an
outpatient stress test. The stress test completion rate was 31.3% within 3 days
and 58.7% between 4 and 30 days, and 10.0% of patients did not complete the
ordered test. The 30-day rates of major adverse cardiac events were low (death
0.0%, acute myocardial infarction 0.7%, and revascularization 0.3%). Rapid
receipt of stress testing was not associated with improved 30-day major adverse
cardiac events (odds ratio 0.92; 95% confidence interval 0.55 to 1.54).
CONCLUSION:
Less
than one third of patients completed outpatient stress testing within the
guideline-recommended 3 days after initial evaluation. More important, the low
adverse event rates suggest that selective outpatient stress testing is safe.
In this cohort of patients selected for outpatient cardiac stress testing in a
well-integrated health system, there does not appear to be any associated
benefit of stress testing within 3 days, nor within 30 days, compared with
those who never received testing at all. The lack of benefit of obtaining
timely testing, in combination with low rates of objective adverse events, may
warrant reassessment of the current guidelines.
B. Misclassification of Myocardial Injury as Myocardial
Infarction: Implications for Assessing Outcomes in Value-Based Programs.
McCarthy
C, et al. JAMA Cardiol. 2019 Mar 17 [Epub ahead of print].
Key
Points
Question To what extent are patients with myocardial
injury being misclassified as having type 2 myocardial infarction (T2MI) and
what are the possible implications for 30-day readmission and mortality rates?
Findings This study used the new International
Statistical Classification of Diseases and Related Health Problems, Tenth
Revision code to identify 633 patients who were coded as having T2MI. After
strict adjudication, only 57% of patients met the criteria for T2MI and 42% had
myocardial injury; both groups had similar in-hospital mortality rates and
30-day mortality and readmission rates.
Meaning A substantial proportion of patients who are
coded as having T2MI actually have myocardial injury, which likely has
implications for hospital reimbursement under current policy programs.
Introduction
With
the widespread introduction of high-sensitivity troponin assays, the detection
of myocardial injury in hospitalized patients has become more frequent;
currently, the most common cause of troponin elevation may now be nonischemic
myocardial injury rather than acute myocardial infarction (MI).1 The detection
of abnormal troponin concentrations in the absence of ischemia has led to
confusion; this circumstance has frequently been labeled as “troponinemia,”
“troponinitis,” or incorrectly as a type 2 MI (T2MI; for which coronary
ischemia is a prerequisite). To address this confusion, the fourth universal
definition of MI distinguishes the various subtypes of MI from myocardial
injury.2 Specifically, myocardial injury is defined by at least 1 cardiac
troponin concentration above the 99th percentile upper reference limit.2
Myocardial infarction is a form of myocardial injury but requires clinical
evidence of acute myocardial ischemia. The most common subtypes are type 1 MI (T1MI;
characterized by plaque rupture, ulceration, erosion, or dissection resulting
in coronary thrombosis) and T2MI (infarction from myocardial oxygen
supply-demand mismatch in the absence of atherothrombosis).2
Currently,
as with other patients with acute MI, patients with T2MI are included in
several value-based programs, such as the Hospital Readmission Reduction
Program and the Hospital Value-Based Purchasing Program.3 To our knowledge, how
often patients with myocardial injury are being misclassified as T2MI is
unknown and may have implications for these programs. Since an International
Statistical Classification of Diseases and Related Health Problems, Tenth
Revision (ICD-10) code for T2MI was introduced in October 2017, there is an
opportunity to characterize patients who are coded as having T2MI…
Abstract
Importance Similar to other patients with acute
myocardial infarction, patients with type 2 myocardial infarction (T2MI) are
included in several value-based programs, including the Hospital Readmissions
Reduction Program and the Hospital Value-Based Purchasing Program. To our
knowledge, whether nonischemic myocardial injury is being misclassified as T2MI
is unknown and may have implications for these programs.
Objective To determine whether patients with
nonischemic myocardial injury are being miscoded as having T2MI and if this has
implications for 30-day readmission and mortality rates.
Design,
Settings, and Participants Using the new
International Statistical Classification of Diseases and Related Health
Problems, Tenth Revision code, we identified patients who were coded as having
T2MI between October 2017 and May 2018 at Massachusetts General Hospital.
Strict adjudication using the fourth universal definition of MI was then
applied.
Main
outcome and Measures Clinical
adjudication of T2MI and 30-day readmission and mortality rates as a function
of T2MI or nonischemic myocardial injury.
Results Of 633 patients, 369 (58.3%) were men and 514
(81.2%) were white. After strict adjudication, 359 (56.7%) had T2MI, 265
(41.9%) had myocardial injury, 6 (0.9%) had type 1 MI, and 3 (0.5%) had
unstable angina. Patients with T2MI had a higher prevalence of cardiovascular
comorbidities than those with myocardial injury. Patients with T2MI and
myocardial injury had high in-hospital mortality rates (10.6% and 8.7%,
respectively; P = .50). Of those discharged alive (563 [88.9%]), 30-day
readmission rates (22.7% vs 21.1%; P = .68) and mortality rates (4.4% vs 7.4%;
P = .14) were comparable among patients with T2MI and myocardial injury.
Conclusions
and Relevance A substantial percentage
of patients coded as having T2MI actually have myocardial injury. Both
conditions have high 30-day readmission and mortality rates. Including patients
with high-risk myocardial injury may have substantial implications for
value-based programs.
C. Cocaine Positivity in STEMI: A True or False Association.
Ifedili
I, et al. Perm J. 2019;23. pii: 18-048
INTRODUCTION
Among
the 250,000 patients who arrive at US Emergency Departments each year with
ST-elevation myocardial infarction (STEMI), a subpopulation will test positive
for cocaine use.1 The diagnosis of true STEMI in the setting of cocaine
positivity can be a challenge because more than 500,000 US Emergency Department
visits each year are related to symptoms and complications associated with cocaine
use and, in particular, cardiovascular symptoms,2 which usually necessitate an
electrocardiogram (ECG). A new ECG ST-segment elevation finding in a patient
with cardiovascular symptoms, especially chest pain and worsening shortness of
breath, usually triggers cardiac catheterization laboratory activation in
adherence with current guidelines.3 However, false activation of the cardiac
catheterization laboratory when treating the general population may be as high
as 36%.4 A US prospective observational study revealed a false STEMI rate of
11%,5 and this value may be higher in the cocaine-use setting considering the
prevalence of a true myocardial infarction is 0.7% to 6.0% for chest pain
presentations.2 False findings may occur because various mechanisms can cause
chest pain symptoms and cardiovascular complications.6 A better understanding
of the predictors of true STEMI in the cocaine-positive (CPos) population would
enable better-informed decisions between patients and physicians, leading to
optimal care and avoiding complications associated with unnecessary and
invasive coronary angiography. The aims of this study were to identify the
frequency and factors associated with true STEMI in patients with CPos findings
who present with suspected STEMI and to create a predictive model to help
classify those who may be more likely to experience a true positive STEMI….
ABSTRACT
INTRODUCTION:
Every
year, more than 500,000 US Emergency Department visits are associated with
cocaine use. People who use cocaine tend to have a lower incidence of true
ST-elevation myocardial infarction (STEMI).
OBJECTIVE:
To
identify the factors associated with true STEMI in patients with
cocaine-positive (CPos) findings.
METHODS:
We
retrospectively analyzed 1144 consecutive patients with STEMI between 2008 and
2013. True STEMI was defined as having a culprit lesion on coronary angiogram.
Multivariate and univariate analyses were used to identify risk factors and
create a predictive model.
RESULTS:
A
total of 64 patients with suspected STEMI were CPos (mean age 53.1 ± 11.2
years; male = 80%). True STEMI was diagnosed in 34 patients. Patients with CPos
true STEMI were more likely to be uninsured than those with false STEMI (61.8%
vs 34.5%, p = 0.03) and have higher peak troponin levels (21.1 ng/mL vs 2.12
ng/mL, p = less than 0.01) with no difference in mean age between the 2 groups
(p = 0.24). In multivariate analyses, independent predictors of true STEMI in
patients with CPos findings included age older than 65 years (odds ratio [OR] =
19.3, 95% confidence iterval [CI] = 1.2-318.3), lack of health insurance (OR =
4.9, 95% CI = 1.2-19.6), and troponin level higher than 0.05 (OR = 24.0, 95% CI
= 2.6-216.8) (all p less than 0.05). A multivariate risk score created with a
C-statistic of 82% (95% CI = 71-93) significantly improved the identification
of patients with true STEMI.
CONCLUSION:
Among
those with suspected STEMI, patients with CPos findings had a higher incidence
of false STEMI. Older age, lack of health insurance, and troponin levels
outside of defined limits were associated with true STEMI in this group.
Full-text
(free): http://www.thepermanentejournal.org/issues/2019/spring/7015-myocardial-infarction.html
D. Some Kinds of Stress Really Do Contribute to ACS
Song
H, et al. Stress related disorders and risk of cardiovascular disease:
population based, sibling controlled cohort study. BMJ. 2019 Apr 10;365:l1255.
Objective
To assess the association between stress related disorders and subsequent risk
of cardiovascular disease.
Design
Population based, sibling controlled cohort study.
Setting
Population of Sweden.
Participants
136 637 patients in the Swedish National Patient Register with stress related
disorders, including post-traumatic stress disorder (PTSD), acute stress
reaction, adjustment disorder, and other stress reactions, from 1987 to 2013;
171 314 unaffected full siblings of these patients; and 1 366 370 matched
unexposed people from the general population.
Main
outcome measures Primary diagnosis of incident cardiovascular disease—any or
specific subtypes (ischaemic heart disease, cerebrovascular disease,
emboli/thrombosis, hypertensive diseases, heart failure, arrhythmia/conduction
disorder, and fatal cardiovascular disease)—and 16 individual diagnoses of
cardiovascular disease. Hazard ratios for cardiovascular disease were derived
from Cox models, after controlling for multiple confounders.
Results
During up to 27 years of follow-up, the crude incidence rate of any
cardiovascular disease was 10.5, 8.4, and 6.9 per 1000 person years among
exposed patients, their unaffected full siblings, and the matched unexposed
individuals, respectively. In sibling based comparisons, the hazard ratio for
any cardiovascular disease was 1.64 (95% confidence interval 1.45 to 1.84),
with the highest subtype specific hazard ratio observed for heart failure
(6.95, 1.88 to 25.68), during the first year after the diagnosis of any stress
related disorder. Beyond one year, the hazard ratios became lower (overall
1.29, 1.24 to 1.34), ranging from 1.12 (1.04 to 1.21) for arrhythmia to 2.02
(1.45 to 2.82) for artery thrombosis/embolus. Stress related disorders were
more strongly associated with early onset cardiovascular diseases (hazard ratio
1.40 (1.32 to 1.49) for attained age less than 50) than later onset ones (1.24
(1.18 to 1.30) for attained age ≥50; P for difference=0.002). Except for fatal
cardiovascular diseases, these associations were not modified by the presence
of psychiatric comorbidity. Analyses within the population matched cohort
yielded similar results (hazard ratio 1.71 (1.59 to 1.83) for any
cardiovascular disease during the first year of follow-up and 1.36 (1.33 to
1.39) thereafter).
Conclusion
Stress related disorders are robustly associated with multiple types of
cardiovascular disease, independently of familial background, history of
somatic/psychiatric diseases, and psychiatric comorbidity.
4. Infectious Disease
A. Perfusion Status vs Serum Lactate Levels on 28-Day Mortality
Among Pts with Septic Shock: The ANDROMEDA-SHOCK RCT
Hernandez
G, et al. JAMA. 2019 Feb 19;321(7):654-664.
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.
B. Most qSOFA-Positive Patients Do Not Have Sepsis
In
a database review, only 40% of admitted qSOFA-positive patients had a diagnosis
of infection on discharge, and only 13% had a diagnosis of sepsis.
Anand
V, et al. Epidemiology of qSOFA Criteria in Undifferentiated Patients and
Association with Suspected Infection and Sepsis. Chest. 2019 Apr 9 [Epub ahead
of print]
BACKGROUND:
The
role of Quick Sequential Organ Failure Assessment (qSOFA) criteria in sepsis
screening and management is controversial, particularly as they were derived
only in patients with suspected infection. We examined the epidemiology and
prognostic value of qSOFA in undifferentiated patients.
METHODS:
We
identified patients with ≥2 qSOFA criteria within 1 day of admission among all
adults admitted to 85 U.S. hospitals from 2012-2015 and assessed for suspected
infection using clinical cultures and antibiotics and sepsis using Sepsis-3
criteria. We also examined qSOFA's discrimination for in-hospital mortality in
patients with and without suspected infection using regression models.
RESULTS:
Of
1,004,347 hospitalized patients, 271,500 (27.0%) were qSOFA-positive on
admission. Compared to qSOFA-negative patients, qSOFA-positive patients were
older (median 65 vs 58 years), required ICU admission more often (28.5% vs
6.5%) and had higher mortality (6.7% vs 0.8%) (p less than 0.001 for all
comparisons). Sensitivities of qSOFA for suspected infection and sepsis were
41.3% (95% CI 41.1-41.5%) and 62.8% (95% CI 62.4-63.1%), respectively; positive
predictive values were 31.3% (95% CI 30.8-31.1%) and 17.4% (95% CI 17.2-17.5%).
The area under the receiver operating characteristic for mortality for qSOFA
was lower in patients with suspected infection versus those without (0.814 vs
0.875, p less than 0.001).
CONCLUSIONS:
Only
1 in 3 patients who are qSOFA-positive on admission have suspected infection
and 1 in 6 have sepsis. qSOFA also has low sensitivity for identifying
suspected infection and sepsis and its prognostic significance is not specific
to infection. More sensitive and specific tools for sepsis screening and
risk-stratification are needed.
C. Updated IDSA Guidelines for Managing Asymptomatic Bacteriuria
Jason
T. McMullan, MD, MS. Journal Watch. April 17, 2019
Source:
Nicolle LE et al. Clin Infect Dis 2019 Mar 21
Screening
for, or treating, asymptomatic bacteriuria is not recommended, except in
pregnant patients.
Sponsoring
Organization: Infectious Diseases Society of America (IDSA)
Background
and Objective
Nontreatment
of asymptomatic bacteriuria (ASB) is a priority in antimicrobial stewardship
initiatives. This update to the 2005 IDSA guidelines incorporates new evidence
and addresses additional populations, including children, patients with
neutropenia, recipients of solid organ transplants, and patients undergoing
nonurologic surgery.
Key
Recommendations
Screening
for, and then treating, asymptomatic bacteriuria is recommended for pregnant
women; 4 to 7 days of antibiotics is recommended for pregnant women with ASB.
Screening
and treatment is not recommended in the following populations: infants and
children; healthy nonpregnant women of any age; elderly persons living
independently or in a long-term care facility; patients with diabetes; renal
transplant recipients beyond 1 month after surgery; any nonrenal solid organ
transplant recipients; patients with spinal cord injury; and patients with
indwelling urinary catheters of any duration.
No
recommendation is made for high-risk afebrile neutropenic patients due to lack
of evidence.
Observation
is preferred over antimicrobial treatment for cognitively impaired adults who
experience a fall and are found to have bacteriuria without signs of infection.
COMMENT
These
guidelines reinforce that the risks associated with treatment of asymptomatic
bacteriuria generally outweigh the benefits, even in populations generally
considered fragile. Notably, symptomatic patients are not covered by these
recommendations.
IDSA
guideline full-text (free): https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciy1121/5407612
5. RCT Comparing Procedural Amnesia and Respiratory
Depression Between Moderate and Deep Sedation with Propofol in the ED
Schick
A, et al. Acad Emerg Med. 2019 Apr;26(4):364-374.
OBJECTIVES:
The
objective was to determine if there is a difference in procedural amnesia and
adverse respiratory events (AREs) between the target sedation levels of
moderate (MS) and deep (DS) procedural sedation.
METHODS:
This
was a prospective, randomized clinical trial of consenting adult patients
planning to undergo DS with propofol between March 5, 2015, and May 24, 2017.
Patients were randomized to a target sedation level of MS or DS using the
American Society of Anesthesiologist's definitions. Drug doses, vital signs,
observer's assessment of alertness/sedation (OAAS) score, end-tidal CO2 (ETCO2
), and the need for supportive airway maneuvers (SAMs; bag-valve mask use,
repositioning, and stimulation to induce respirations) were monitored
continuously. A standardized image was shown every 30 seconds starting 3
minutes before the procedure continuing until the patient had returned to
baseline after the procedure. Recall and recognition of images were assessed 10
minutes after the sedation. Subclinical respiratory depression (RD) was defined
as SaO2 ≤ 91%, change in ETCO2 ≥ 10 mm Hg, or absent ETCO2 at any time. The
occurrence of RD with a SAM was defined as an ARE. Patient satisfaction, pain,
and perceived recollection and physician assessment of procedure difficulty
were collected using visual analog scales (VASs). Data were analyzed with
descriptive statistics and Wilcoxon rank-sum test.
RESULTS:
A
total of 107 patients were enrolled: 54 randomized to target MS and 53 to DS.
Of the patients randomized to target MS, 50% achieved MS and 50% achieved DS.
In the target DS group, 77% achieved DS and 23% achieved MS. The median total
propofol dose (mg/kg) was lower in the MS group: MS 1.4 (95% confidence
interval [CI] = 1.3-1.6, IQR = 1) versus DS 1.8 (95% CI = 1.6-2.0, IQR = 0.9).
There were no differences in median OAAS during the procedure (MS 2.4 and DS
2.8), lowest OAAS (MS 2 and DS 2), percentage of images recalled (MS 4.7% vs.
DS 3.8%, p = 0.73), or percentage of images recognized (MS 61.1% vs. DS 55%, p
= 0.52). In the MS group, 41% patients had any AREs compared to 42% in the DS
group (p = 0.77, 95% CI difference = -0.12 to 0.24). The total number of AREs
was 23% lower in the MS group (p = 0.01, 95% CI = -0.41 to -0.04). There was no
difference in patient-reported pain, satisfaction, or recollection VAS scores.
Provider's rating of procedural difficulty and procedural success were similar
in both groups.
CONCLUSIONS:
Targeting
MS or DS did not reliably result in the intended sedation level. Targeting MS,
however, resulted in a lower rate of total AREs and fewer patients had multiple
AREs with no difference in procedural recall. As seen in previous reports,
patients who achieved MS had less AREs than those who achieved DS. Our study
suggests that a target of MS provides adequate amnesia with less need for
supportive airway interventions than a target level of DS, despite the fact
that it often does not result in intended sedation level.
6. Orthopedic Surgeon Pays $400K to Keep Son Out of
Ophthalmology Residency: A twist in the college cheating scandal
by
Gomer Blog Team. March 21, 2019. Disclaimer: This post is from GomerBlog, a
satirical site about healthcare.
Inspired
by the recent college admissions cheating scandal, orthopedic surgeon Brock
Hammersley took matters into his own hands when his son ranked only
ophthalmology residencies in the ACGME Match.
"I
couldn't believe it when I saw his rank list! Ophthalmology Harvard,
Ophthalmology Mass. Eye and Ear, Ophthalmology Duke, Ophthalmology
Tinyhandsville!" Hammersley fumed to GomerBlog.
"You
think you're raising your kids right. You start taking them to the gym as soon
as they can walk, pay for the best bicep-building trainers starting when
they're 3, buy them their own mallet at 4, power tools at 5. You know, trying
to do everything you can to make sure they're started down the right path. Then
one day -- BAM! It all blows up in your face and they apply to do a residency
without power tools where they sit down for every surgery! They sit down to do
surgery!"
"So,
I did what any caring parent would do, I sat him down and chewed his ass.
'Listen here, Brock Jr., I know some of your friends have chosen alternative
career paths, but I want something better for you. Please tell me you somehow
accidentally put random p's and h's in your poor attempt to spell orthopedics,
and we can get back to playing beer pong with your mother and sister.'"
Hammersley
stopped as tears were forming in his eyes at this point, "Then he looks me
in the eyes and said the six words every parent fears the most: 'I really want
to do ophthalmology.'"
"After
all the sacrifices we made for him, he insults our family like this. I felt
helpless until I heard what that loving mother Lori Loughlin did for her kids,
and I got an idea."
Hammersley
then proceeded to call the American Academy of Ophthalmology president, Dr.
George A. Williams, and offered a $400,000 "donation" to the Beaumont
Eye Institute. "The study of some sort of eyeball stuff was the pretense,
but Dr. Williams wouldn't promise to 'guide' the match results for Brock
Jr.," Hammersley recalled.
"Fortunately,
I was able to pull a few strings elsewhere -- greased with the 400 G's -- and
what do you know, Brock Jr. matched ortho at my alma mater, the University of
Michigan! The Lord really does work in mysterious ways!"
7. Trauma Track
A. Observing pneumothoraces: The 35-millimeter rule is safe for
both blunt and penetrating chest trauma.
Bou
Zein Eddine S, et al. J Trauma Acute Care Surg. 2019 Apr;86(4):557-564.
BACKGROUND:
As
more pneumothoraxes (PTX) are being identified on chest computed tomography
(CT), the empiric trigger for tube thoracostomy (TT) versus observation remains
unclear. We hypothesized that PTX measuring 35 mm or less on chest CT can be
safely observed in both penetrating and blunt trauma mechanisms.
METHODS:
A
retrospective review was conducted of all patients diagnosed with PTX by chest
CT between January 2011 and December 2016. Patients were excluded if they had
an associated hemothorax, an immediate TT (TT placed before the initial chest
CT), or if they were on mechanical ventilation. Size of PTX was quantified by
measuring the radial distance between the parietal and visceral
pleura/mediastinum in a line perpendicular to the chest wall on axial imaging
of the largest air pocket. Based on previous work, a cutoff of 35 mm on the
initial CT was used to dichotomize the groups. Failure of observation was
defined as the need for a delayed TT during the first week. A univariate
analysis was performed to identify predictors of failure in both groups, and
multivariate analysis was constructed to assess the independent impact of PTX
measurement on the failure of observation while controlling for demographics
and chest injuries.
RESULTS:
Of
the 1,767 chest trauma patients screened, 832 (47%) had PTX, and of those
meeting inclusion criteria, 257 (89.0%) were successfully observed until
discharge. Of those successfully observed, 247 (96%) patients had a measurement
of 35 mm or less. The positive predictive value for 35 mm as a cutoff was 90.8%
to predict successful observation. In the univariant analyses, rib fractures (p
= 0.048), Glasgow Coma Scale (p = 0.012), and size of the PTX (≤35 mm or over 35
mm) (P less than 0.0001) were associated with failed observation. In
multivariate analysis, PTX measuring 35 mm or less was an independent predictor
of successful observation (odds ratio, 0.142; 95% confidence interval,
0.047-0.428)] for the combined blunt and penetrating trauma patients.
CONCLUSION:
A
35-mm cutoff is safe as a general guide with only 9% of stable patients failing
initial observation regardless of mechanism.
B. Guidelines for the Management of Pediatric Severe Traumatic
Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines
Kochanek
P, et al. Pediatr Crit Care Med 2019;20(35):S1–S82.
Severe
Traumatic Brain Injury in Infants, Children, and Adolescents in 2019: Some
Overdue Progress, Many Remaining Questions, and Exciting Ongoing Work in the
Field of Traumatic Brain Injury Research
In
order to promote the highest standards of care and improve overall rates of
survival and recovery following traumatic brain injury (TBI), a panel of
pediatric critical care, neurosurgery, and other pediatric experts published "Guidelines
for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition:
Update of the Brain Trauma Foundation Guidelines."
Published in the March 2019 issue of Pediatric Critical Care Medicine, these updated guidelines include results from nearly 50 research studies and a range of treatment recommendations for healthcare providers, including intracranial monitoring and the use of hypertonic saline to reduce acute brain swelling.
An executive summary is also available, along with an associated article, "Management of Pediatric Severe Traumatic Brain Injury," which describes an algorithm designed to guide first- and second-tier therapies for infants and children with severe TBI.
Published in the March 2019 issue of Pediatric Critical Care Medicine, these updated guidelines include results from nearly 50 research studies and a range of treatment recommendations for healthcare providers, including intracranial monitoring and the use of hypertonic saline to reduce acute brain swelling.
An executive summary is also available, along with an associated article, "Management of Pediatric Severe Traumatic Brain Injury," which describes an algorithm designed to guide first- and second-tier therapies for infants and children with severe TBI.
METHODS
The
methods for developing these guidelines were organized in two phases: a
systematic review, assessment, and synthesis of the literature; and use of that
product as the foundation for evidence-based recommendations. These guidelines
are the product of the two-phased, evidence-based process.
Based
on almost 2 decades of collaboration, the team of clinical investigators and
methodologists is grounded in and adheres to the fundamental principles of
evidence-based medicine to derive recommendations, and is committed to
maintaining the distinction between evidence and consensus. It is important
that this distinction is clear to promote transparency and inspire innovative
future research that will expand the evidence base for TBI care.
Because
these guidelines only provide recommendations based on available evidence, most
often they do not provide direction for all phases of clinical care. Ideally,
clinically useful protocols begin with evidence-based guidelines, and then use
clinical experience and consensus to fill the gaps where evidence is
insufficient. The goal is to use the evidence and the evidence-based
recommendations as the backbone to which expertise and consensus can be added
to produce protocols appropriate to specific clinical environments.
Guidelines
(free): https://journals.lww.com/pccmjournal/Fulltext/2019/03001/Guidelines_for_the_Management_of_Pediatric_Severe.1.aspx
Executive
summary (free): https://journals.lww.com/pccmjournal/Fulltext/2019/03000/Guidelines_for_the_Management_of_Pediatric_Severe.9.aspx
C. Buddy Taping Is as Effective as Plaster Immobilization for
Adults with an Uncomplicated Neck of Fifth Metacarpal Fracture. A RCT
Pellatt
R, et al. Ann Emerg Med. 2019 Mar 7 [Epub ahead of print]
STUDY
OBJECTIVE:
We
compare buddy taping with plaster casting for uncomplicated fifth metacarpal
(boxer's) fractures. We hypothesize buddy taping will give superior functional
outcomes at 12 weeks, defined as a 10-point difference on the Shortened
Disabilities of the Arm, Shoulder and Hand (quickDASH) score.
[What is uncomplicated? “minimally displaced, closed, isolated
injuries, with a fracture angulation up to 70 degrees”]
METHODS:
This
randomized controlled trial included patients aged 18 to 70 years, with
uncomplicated boxer's fractures in 2 hospitals in Queensland, Australia. The
intervention consisted of buddy taping of the ring and little fingers on the
affected side, in which the control group received plaster casting. Primary
outcome was hand function as measured by quickDASH score (0 to 100, with 0
indicating no disability) at 12 weeks. Secondary outcomes measured at 3, 6, and
12 weeks included time off work and activities, pain, satisfaction, and the
EuroQol 5-Dimension 3-Level score (measure of overall health).
RESULTS:
Ninety-seven
patients with primary endpoint data were available for analysis, 48 in the
buddy taping group and 49 in the plaster group. At 12 weeks, median quickDASH
scores were the same for both groups (buddy 0, interquartile range [IQR] 0 to
2.3; plaster 0, IQR 0 to 4; difference 0; 95% confidence interval of the
difference 0 to 0). Patients in the buddy taping group missed a median 0 days
(IQR 0 to 7) of work compared with the plaster group's 2 days (IQR 0 to 14).
Other secondary outcome measures were the same in both groups.
CONCLUSION:
We
found that patients with boxer's fractures who were randomized to buddy taping
had functional outcomes similar to those of patients randomized to plaster cast
at 12 weeks. We advocate a minimal intervention such as buddy taping for uncomplicated
boxer's fractures.
8. Full Study Report of Andexanet Alfa for Bleeding
Associated with Factor Xa Inhibitors
Connolly
SJ, et al. N Engl J Med. 2019 Apr 4;380(14):1326-1335
BACKGROUND
Andexanet
alfa is a modified recombinant inactive form of human factor Xa developed for
reversal of factor Xa inhibitors.
METHODS
We
evaluated 352 patients who had acute major bleeding within 18 hours after
administration of a factor Xa inhibitor. The patients received a bolus of
andexanet, followed by a 2-hour infusion. The coprimary outcomes were the
percent change in anti–factor Xa activity after andexanet treatment and the
percentage of patients with excellent or good hemostatic efficacy at 12 hours
after the end of the infusion, with hemostatic efficacy adjudicated on the
basis of prespecified criteria. Efficacy was assessed in the subgroup of
patients with confirmed major bleeding and baseline anti–factor Xa activity of
at least 75 ng per milliliter (or ≥0.25 IU per milliliter for those receiving
enoxaparin).
RESULTS
Patients
had a mean age of 77 years, and most had substantial cardiovascular disease.
Bleeding was predominantly intracranial (in 227 patients [64%]) or
gastrointestinal (in 90 patients [26%]). In patients who had received apixaban,
the median anti–factor Xa activity decreased from 149.7 ng per milliliter at
baseline to 11.1 ng per milliliter after the andexanet bolus (92% reduction;
95% confidence interval [CI], 91 to 93); in patients who had received
rivaroxaban, the median value decreased from 211.8 ng per milliliter to 14.2 ng
per milliliter (92% reduction; 95% CI, 88 to 94). Excellent or good hemostasis
occurred in 204 of 249 patients (82%) who could be evaluated. Within 30 days,
death occurred in 49 patients (14%) and a thrombotic event in 34 (10%).
Reduction in anti–factor Xa activity was not predictive of hemostatic efficacy
overall but was modestly predictive in patients with intracranial hemorrhage.
CONCLUSIONS
In
patients with acute major bleeding associated with the use of a factor Xa
inhibitor, treatment with andexanet markedly reduced anti–factor Xa activity,
and 82% of patients had excellent or good hemostatic efficacy at 12 hours, as
adjudicated according to prespecified criteria.
9. Pearls and Myths in the Evaluation of Patients
with Suspected Acute PE
Stüssi-Helbling
M, et al. Am J Med. 2019 Jan 31 [Epub ahead of print]
Significant
improvement has been achieved in diagnostic accuracy, validation of probability
scores, and standardized treatment algorithms for patients with suspected acute
pulmonary embolism. These developments have provided the tools for a safe and
cost-effective management for most of these patients. In our experience,
however, the presence of medical myths and ongoing controversies seem to hinder
the implementation of these tools in everyday clinical practice. This review
provides a selection of such dilemmas and controversies and discusses the
published evidence beyond them. By doing so, we try to overcome these dilemmas
and suggest pragmatic approaches guided by the available evidence and current
guidelines.
MYTH:
THE CLINICAL ASSESSMENT (“CLINICAL GESTALT”) IS INFERIOR TO STANDARDIZED
PREDICTION
SCORES (“CLINICAL DECISION RULES”)
MYTH:
THE OUTCOME OF PATIENTS HAS IMPROVED DUE TO MORE FREQUENT DETECTION OF
PULMONARY EMBOLISM
MYTH:
PULMONARY EMBOLISM CANNOT BE SAFELY RULED OUT WITHOUT D-DIMER TESTING OR CTA
MYTH:
PATIENTS WITH A SYNCOPAL EVENT SHOULD BE TESTED FOR THE PRESENCE OF PULMONARY
EMBOLISM
MYTH:
THE LOCALIZATION AND EXTENT OF VASCULAR OBSTRUCTION IS AN INDICATOR OF
HEMODYNAMIC
COMPROMISE (SEVERITY OF DISEASE)
MYTH:
THE ELECTROCARDIOGRAM HAS NO ROLE IN ACUTE PULMONARY EMBOLISM
MYTH:
ECHOCARDIOGRAPHY AND CARDIAC BIOMARKERS ARE PART OF THE ROUTINE
EVALUATION
IN STABLE PATIENTS WITH PULMONARY EMBOLISM
MYTH:
THROMBOPHILIA SCREENING SHOULD BE PERFORMED IN PATIENTS WITH UNPROVOKED
PULMONARY EMBOLISM
MYTH:
ALL PATIENTS WITH PULMONARY EMBOLISM SHOULD BE TREATED AS INPATIENTS
10. Images in Clinical Practice
Disseminated
Cysticercosis
Pneumatosis
Cystoides Intestinalis with Pneumoperitoneum
Disseminated
Gonococcal Infection
Thrombotic
Thrombocytopenic Purpura
Traumatic
Iridodialysis
Diffuse
Subcutaneous Emphysema
Rhinosporidiosis
Tungiasis
11. FDA Gives Go Ahead to Novel Device That Treats
Carbon Monoxide Poisoning
By
Kristin J. Kelley. Journal Watch EM. March 18, 2019
Edited
by Susan Sadoughi, MD, and André Sofair, MD, MPH
The
FDA late last week approved marketing for a device (ClearMate) that can be used
in emergency departments to treat patients for carbon monoxide poisoning.
The
device will help minimize treatment delays for patients with the most severe
cases of exposure, who need to be treated in hyperbaric chambers. The agency
notes that only 60 medical centers in the country have these units.
ClearMate
delivers 100% oxygen, plus a combination of oxygen and carbon dioxide, which
forces the patient to breathe faster and expel the carbon monoxide quickly.
Marketing authorization was based on data from multiple studies (of 100
patients total) in which the device eliminated carbon monoxide faster than
treatment with only 100% oxygen but no faster than hyperbaric oxygen. No
complications related to the device were reported.
LINK(S):
FDA news release (free): https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm633533.htm
12. Migraine Research
A. The Efficacy and Safety of Prochlorperazine in Patients with
Acute Migraine: A Systematic Review and Meta‐Analysis
Golikhatir
I, et al. Headache. 2019 Apr 16. doi: 10.1111/head.13527. [Epub ahead of print]
OBJECTIVE:
The
aim of this review was to evaluate the efficacy and safety of prochlorperazine
(PCP) in patients with acute migraine headache in the emergency department
(ED).
METHODS:
Electronic
databases (Medline, Scopus, Web of Science, and Cochrane) were searched for
randomized clinical trials that investigated the effect of PCP on headache
relief. The outcomes were the number of patients without headache or with
reduced headache severity, the number of adverse events, and the need for
rescue analgesia.
RESULTS:
From
450 citations, 11 studies (n = 771) with 15 comparison arms met the inclusion
criteria. Overall, PCP was more effective than placebo (OR = 7.23; 95% CI =
3.82-3.68), metoclopramide (OR = 2.89; 95% CI = 1.42-5.86), and other active
comparators (OR = 3.70; 95% CI = 2.41-5.67) for headache relief. The odds ratio
of experiencing adverse events with PCP compared with placebo was 5.79 (95% CI
= 2.43-13.79). When PCP compared with other active comparators, no statistical
difference was found regarding the overall number of adverse events (OR = 1.88;
95% CI = 0.99-3.59). However, PCP significantly increased the odds of
akathisia/dystonia (OR = 2.55; 95% CI = 1.03-6.31). The request for rescue
analgesia was significantly lower in the PCP group compared with other groups
(16% vs 84%; OR = 0.16; 95% CI = 0.09-27).
CONCLUSIONS:
For
adult patients with acute migraine, PCP could effectively abort the acute
attack and reduce the request for rescue analgesia in the ED. However, compared
with placebo, PCP could increase the risk of adverse events.
B. Migraine Treatment in Pregnant Women Presenting to Acute Care:
A Retrospective Observational Study.
Hamilton
KT, et al. Headache. 2019 Feb;59(2):173-179.
OBJECTIVE:
To
assess the acute treatment of pregnant women presenting to a hospital with
migraine.
BACKGROUND:
Migraine
is a common problem in pregnancy; however, migraine treatment is challenging in
pregnant women for fears of medication teratogenicity and lack of data in this
population. To date, no study has directly explored physician practices for
treatment of acute migraine in pregnant women.
METHODS:
We
conducted a retrospective chart review of medication administration for
pregnant women who presented to an acute care setting with a migraine attack
and received neurology consultation between 2009 and 2014.
RESULTS:
We
identified 72 pregnant women with migraine who were treated with pain
medications. Fifty-one percent (37/72) were in the third trimester of
pregnancy, 39% (28/72) in the second trimester, and 10% (7/72) in the first
trimester. Thirty-two percent (23/72) had not tried any acute medications at
home before coming to the hospital, and 47% (34/72) presented in status
migrainosus. Patients received treatment in the hospital for a median of 23
hours (interquartile range = 5-45 hours). The most common medications
prescribed were metoclopramide in 74% (53/72) of patients (95% confidence
interval [CI] 62-82%) and acetaminophen in 69% (50/72) of patients (95% CI
58-79%). Metoclopramide was administered along with diphenhydramine in 81%
(44/53) of patients (95% CI 71-91%). Acetaminophen was the most frequent
medicine administered first (53%, 38/72). Patients were often treated with
butalbital (35%, 25/72) or opioids (30%, 22/72), which were used as second- or
third-line treatments in 29% of patients (20/72). Thirty-eight percent (27/72)
received an intravenous (IV) fluid bolus, 24% received IV magnesium (17/72),
and 6% (4/72) had peripheral nerve blocks performed.
CONCLUSIONS:
While
the majority of pregnant women with acute migraine received medications
considered relatively safe in pregnancy, there was variation in treatment
choice and sequence. Some acute medications considered potentially hazardous
for fetal health and less effective for migraine (opioids and butalbital) were
used frequently, whereas other treatments that may have low teratogenic risk
(nerve blocks, IV fluid boluses, and triptans) were used less or not at all.
These results indicate a need for developing guidelines and protocols to
standardize acute treatment of migraine in pregnancy.
13. Better Living: Happiness at Work and Developing
your Passion
A. Happiness of Work
You
don’t need to change everything about your job to see major benefits. A few
changes here and there can be all you need.
Tim Herrera. NY Times. April 7, 2019
Do
you like what you do?
Now,
I don’t mean that in the broad sense of wondering whether you’re on the right career
path. I mean on a day-to-day basis, if you thought about every single task your
job entails, could you name the parts that give you genuine joy? What about the
tasks you hate?
It’s
an odd question. We don’t often step back to ask whether the small, individual
components of our job actually make us happy.
But
maybe we should. As many as a third of
United States workers say they don’t feel engaged at work. The reasons vary
widely, and everyone’s relationship with work is unique. But there are small
ways to improve any job, and those incremental improvements can add up to major
increases in job satisfaction.
A study
from the Mayo Clinic found that physicians who spend about 20 percent of their
time doing “work they find most meaningful are at dramatically lower risk for
burnout.” But here’s what’s fascinating: Anything beyond that 20 percent has a
marginal impact, as “spending 50 percent of your time in the most meaningful
area is associated with similar rates of burnout as 20 percent.”
In
other words: You don’t need to change everything about your job to see
substantial benefits. A few changes here and there can be all you need.
“When
you look at people who are thriving in their jobs, you notice that they didn’t
find them, they made them,” said Ashley Goodall, senior vice president of
leadership and team intelligence at Cisco and co-author of the book “Nine
Lies About Work.”
“We’re
told in every commencement speech that if you find a job you love you’ll never
work a day in your life. But the verb is wrong,” he said, adding that
successful people who love their jobs take “the job that was there at the
beginning and then over time they transform the contents of that job.”
Executive Leadership
and Physician Well-being: Nine Organizational Strategies to Promote Engagement
and Reduce Burnout
Shanafelt
TD, et al. Mayo Clin Proc. 2017;92(1):129-146
These
are challenging times for health care executives. The health care field is
experiencing unprecedented changes that threaten the survival of many health
care organizations. To successfully navigate these challenges, health care
executives need committed and productive physicians working in collaboration
with organization leaders. Unfortunately, national studies suggest that at
least 50% of US physicians are experiencing professional burnout, indicating
that most executives face this challenge with a disillusioned physician
workforce. Burnout is a syndrome characterized by exhaustion, cynicism, and
reduced effectiveness. Physician burnout has been shown to influence quality of
care, patient safety, physician turnover, and patient satisfaction.
Although
burnout is a system issue, most institutions operate under the erroneous
framework that burnout and professional satisfaction are solely the
responsibility of the individual physician. Engagement is the positive antithesis of burnout and is characterized
by vigor, dedication, and absorption in work. There is a strong business
case for organizations to invest in efforts to reduce physician burnout and
promote engagement. Herein, we summarize 9 organizational strategies to promote
physician engagement and describe how we have operationalized some of these
approaches at Mayo Clinic. Our experience demonstrates that deliberate,
sustained, and comprehensive efforts by the organization to reduce burnout and
promote engagement can make a difference. Many effective interventions are
relatively inexpensive, and small investments can have a large impact.
Leadership and sustained attention from the highest level of the organization
are the keys to making progress.
B. Why ‘Find Your Passion’ Is Such Terrible Advice
Prepare
for a hard truth: We’re pretty bad at most things when we first try them.
Stephanie
Lee. NY Times. April 21, 2019
Are
you passionate about your work? Fulfilled in every aspect of your career?
If
yes, congratulations! You’ve done what we all strive for but rarely achieve.
As
for the rest of us, there’s hope: Part of why we haven’t found our passion yet
is that we tend to give up quickly on new things. The reason? Prepare for a
hard truth: We’re pretty bad at most things when we first try them.
People
“often assume that their own interest or passion just needs to be ‘found’ or
revealed. Once revealed, it will be in a fully formed state,” said Paul A.
O’Keefe, an assistant professor of psychology at Yale-NUS College in Singapore.
Nonsense, of course, he said.
“By
that logic, pursuing one’s passion should come with boundless motivation and
should be relatively easy,” he said.
Dr.
O’Keefe was part of a team that published a study in 2018 that examined how two
different “implicit theories of interest” impacted how people approach new
potential passions. One, the fixed theory, says that our interests are
relatively fixed and unchanging, while the other, the growth theory, suggests
our interests are developed over time and not necessarily innate to our
personality.
In
other words: Do we truly find our passions, or develop them over time? (You can
probably guess where this is going.)
The
researchers found that people who hold a fixed theory had less interest in
things outside of their current interests, were less likely to anticipate
difficulties when pursuing new interests, and lost interest in new things much
quicker than people who hold a growth theory. In essence, people with a growth
mind-set of interest tend to believe that interests and passions are capable of
developing with enough time, effort and investment.
“This
comes down to the expectations people have when pursuing a passion,” Dr.
O’Keefe said. “Someone with a fixed mind-set of interest might begin their
pursuit with lots of enthusiasm, but it might diminish once things get too
challenging or tedious.”
The
rest of the essay: https://www.nytimes.com/2019/04/21/smarter-living/why-find-your-passion-is-such-terrible-advice.html
The source
study:
O'Keefe PA, et al. Implicit Theories of Interest: Finding Your Passion or
Developing It? Psychol Sci. 2018 Oct;29(10):1653-1664.
People
are often told to find their passion, as though passions and interests are
preformed and must simply be discovered. This idea, however, has hidden
motivational implications. Five studies examined implicit theories of
interest-the idea that personal interests are relatively fixed (fixed theory)
or developed (growth theory). Whether assessed or experimentally induced, a
fixed theory was more likely to dampen interest in areas outside people's
existing interests (Studies 1-3). Individuals endorsing a fixed theory were
also more likely to anticipate boundless motivation when passions were found,
not anticipating possible difficulties (Study 4). Moreover, when it became
difficult to engage in a new interest, interest flagged significantly more for
people induced to hold a fixed rather than a growth theory of interest (Study
5). Urging people to find their passion may lead them to put all their eggs in
one basket but then to drop that basket when it becomes difficult to carry.
14. On Stroke
A. Post-Thrombolysis Recanalization in Stroke Referrals for
Thrombectomy
Seners
P, et al. Stroke. 2018 Dec;49(12):2975–2982.
Background
and Purpose—
Whether
all acute stroke patients with large vessel occlusion need to undergo
intravenous thrombolysis before mechanical thrombectomy (MT) is debated as (1)
the incidence of post-thrombolysis early recanalization (ER) is still unclear;
(2) thrombolysis may be harmful in patients unlikely to recanalize; and,
conversely, (3) transfer for MT may be unnecessary in patients highly likely to
recanalize. Here, we determined the incidence and predictors of
post-thrombolysis ER in patients referred for MT and derive ER prediction
scores for trial design.
Methods—
Registries
from 4 MT-capable centers gathering patients referred for MT and thrombolyzed
either on site (mothership) or in a non MT-capable center (drip-and-ship) after
magnetic resonance– or computed tomography–based imaging between 2015 and 2017.
ER was identified on either first angiographic run or noninvasive imaging. In
the magnetic resonance imaging subsample, thrombus length was determined on
T2*-based susceptibility vessel sign. Independent predictors of no-ER were
identified using multivariable logistic regression models, and scores were
developed according to the magnitude of regression coefficients. Similar
registries from 4 additional MT-capable centers were used as validation cohort.
Results—
In
the derivation cohort (N=633), ER incidence was ≈20%. In patients with
susceptibility vessel sign (n=498), no-ER was independently predicted by long
thrombus, proximal occlusion, and mothership paradigm. A 6-point score derived
from these variables showed strong discriminative power for no-ER (C statistic,
0.854) and was replicated in the validation cohort (n=353; C statistic, 0.888).
A second score derived from the whole sample (including negative T2* or
computed tomography–based imaging) also showed good discriminative power and
was similarly validated. Highest grades on both scores predicted no-ER with above
90% specificity, whereas low grades did not reliably predict ER.
Conclusions—
The
substantial ER rate underlines the benefits derived from thrombolysis in
bridging populations. Both prediction scores afforded high specificity for
no-ER, but not for ER, which has implications for trial design.
B. Delayed Recognition of Acute Stroke by ED Staff Following
Failure to Activate Stroke by EMS
Tennyson
JC, et al. West J Emerg Med. 2019;20(2).
Introduction:
Early recognition and pre-notification by emergency medical services (EMS)
improves the timeliness of emergency department (ED) stroke care; however,
little is known regarding the effects on care should EMS providers fail to
pre-notify. We sought to determine if potential stroke patients transported by
EMS, but for whom EMS did not provide pre-notification, suffer delays in ED
door-to-stroke-team activation (DTA) as compared to the other available cohort
of patients for whom the ED is not pre-notified–those arriving by private
vehicle.
Methods:
We queried our prospective stroke registry to identify consecutive stroke team
activation patients over 12 months and retrospectively reviewed the electronic
health record for each patient to validate registry data and abstract other
clinical and operational data. We compared patients arriving by private vehicle
to those arriving by EMS without pre-notification, and we employed a
multivariable, penalized regression model to assess the probability of meeting
the national DTA goal of ≤15 minutes, controlling for a variety of clinical
factors.
Results:
Our inclusion criteria were met by 200 patients. Overall performance of the
regression model was excellent (area under the curve 0.929). Arrival via EMS
without pre-notification, compared to arrival by private vehicle, was
associated with an adjusted risk ratio of 0.55 (95% confidence interval,
0.27-0.96) for achieving DTA ≤ 15 minutes.
Conclusion:
Our single-center data demonstrate that potential stroke patients arriving via
EMS without pre-notification are less likely to meet the national DTA goal than
patients arriving via other means. These data suggest a negative, unintended
consequence of otherwise highly successful EMS efforts to improve stroke care,
the root of which may be ED staff over-reliance on EMS for stroke recognition.
C. A Battle for My Life: A Patient’s Report on SAH
I
had just finished filming Season 1 of “Game of Thrones.” Then I was struck with
the first of two aneurysms.
Emilia
Clarke. The New Yorker. March 21, 2019
…I
was getting dressed in the locker room of a gym in Crouch End, North London,
when I started to feel a bad headache coming on. I was so fatigued that I could
barely put on my sneakers. When I started my workout, I had to force myself
through the first few exercises.
Then
my trainer had me get into the plank position, and I immediately felt as though
an elastic band were squeezing my brain. I tried to ignore the pain and push
through it, but I just couldn’t. I told my trainer I had to take a break.
Somehow, almost crawling, I made it to the locker room. I reached the toilet,
sank to my knees, and proceeded to be violently, voluminously ill. Meanwhile,
the pain—shooting, stabbing, constricting pain—was getting worse. At some
level, I knew what was happening: my brain was damaged.
For
a few moments, I tried to will away the pain and the nausea. I said to myself,
“I will not be paralyzed.” I moved my fingers and toes to make sure that was
true…
Full-text
(free): https://www.newyorker.com/culture/personal-history/emilia-clarke-a-battle-for-my-life-brain-aneurysm-surgery-game-of-thrones/amp
15. Psych and Substance Abuse
A. Assessing Risk of Future Suicidality in ED Patients.
Brucker
K, et al. Acad Emerg Med. 2019 Apr;26(4):376-383.
Introduction
With
more than 4 million visits to the ED annually in the United States for mental
disorders, the ED is considered by many to be the first line of evaluation for
patients at risk and in crisis, with or without overt suicidality (ideation,
attempts).1 The weighted national estimate of patients with a diagnosis of
“suicide or intentional self‐harm” in the National Emergency Department Sample
for 2013 was 1,411,770, patients, with 98.8% of those with suicidality as a
first diagnosis discharged from the ED. In 2013, visits for suicidal ideation
accounted for nearly 1% of all adult ED visits (108.3 million visits).2
To
better predict and prevent suicides, emergency care providers need improved
risk stratification tools for patients with overt or covert mental health
crisis. Several tools—PHQ93, the ED‐Safe Patient Safety Screener4 and the
Suicide Behaviors Questionnaire–Revised (SBQ‐R)5—have been created and
validated for suicide screening. All of these include direct questioning about
current or recent suicidal thoughts. None of these tools has been compared to
physician gestalt or evaluated for their ability to predict rates of adverse
suicide‐related events in patients who screen negative using the tool. There
are yet no widespread clinically used simple objective tools to assess and
track changes in suicidal risk without asking the individuals directly,
although others in the field besides us are actively working on this problem
and progress is being made (for example Nock and colleagues,6, 7 Boudreaux and
colleagues8-10). Such tools are desperately needed, as individuals at risk may
choose not to share their ideation or intent with others, for fear of stigma or
hospitalization or that in fact their plans may be thwarted.
The
Convergent Functional Information for Suicidality (CFI‐S) is a novel suicide
risk instrument that comprises 22 questions and has shown good to excellent
predictive value for suicidality in settings other than the emergency
department (ED).11-13 The CFI‐S is a checklist of risk factors for suicidality
from a variety of domains including life satisfaction, mental health, physical
health, environmental stress, addictions, cultural factors, and demographic
information and assigns a numeric point value for each response, 0 for absent
or 1 for present. In essence, it is a “polyphenic” risk score, by analogy with
polygenic risk scores. The tool was designed to be easy to score by
self‐administration or clinician administration or based on medical records or
next‐of‐kin information. Of note, it does not ask directly about suicidal
ideation, as that is a delicate question in many nonspecialized settings, and
people who are truly suicidal might not share that information for fear of
being stopped.
We
hypothesized that the CFI‐S could be used in a heterogeneous sample of ED
patients to identify high‐risk patients whose elevated risk was missed by both
standard screening and by physician evaluation as measured by their gestalt
impression of future risk.
We
sought to test the accuracy of the CFI‐S and physician gestalt visual analog
scale (VAS) in a sample of urban ED patients, with a traditionally high
proportion of non‐Caucasians and low‐income individuals. The reason for this is
this population has a higher‐than‐average risk of suicidality14 but with the
lowest access to mental health services.15 Thus, in this population, the need
for accurate suicide risk assessment is compounded by the lack of current
identification of nonovert suicidal ideation and the need for pragmatic use of
limited resources.
BACKGROUND:
Emergency
departments (ED) are the first line of evaluation for patients at risk and in
crisis, with or without overt suicidality (ideation, attempts). Currently
employed triage and assessments methods miss some of the individuals who
subsequently become suicidal. The Convergent Functional Information for
Suicidality (CFI-S) 22-item checklist of risk factors, which does not ask
directly about suicidal ideation, has demonstrated good predictive ability for
suicidality in previous studies in psychiatrict patients but has not been
tested in the real-world setting of EDs.
METHODS:
We
administered CFI-S prospectively to a convenience sample of consecutive ED
patients. Patients were also asked at triage about suicidal thoughts or
intentions per standard ED suicide clinical screening (SCS), and the treating
ED physician was asked to fill a physician gestalt visual analog scale (VAS)
for likelihood of future suicidality spectrum events (SSE; ideation,
preparatory acts, attempts, completed suicide). We performed structured chart
review and telephone follow-up at 6 months post-index visit.
RESULTS:
The
median time to complete the CFI-S was 3 minutes (first to third quartile = 3-6
minutes). Of the 338 patients enrolled, 45 (13.3%) were positive on the initial
SCS, and 32 (9.5%) experienced a SSE in the 6 months of follow-up. Overall, SCS
had modest diagnostic accuracy sensitivity 14/32 = 44%, (95% CI: 26-62%) and
specificity 275/306 = 90%, (86-93%). The physician VAS also had moderate
overall diagnostic accuracy (AUC 0.75, confidence interval [CI] = 0.66-0.85),
and the CFI-S was best (AUC = 0.81, CI = 0.76-0.87). The top CFI-S
differentiating items were psychiatric illness, perceived uselessness, and
social isolation.
CONCLUSIONS:
Using
CFI-S, or some of its items, in busy EDs may help improve the detection of
patients at high risk for future suicidality.
See
also “Youth ED Visits for Suicidality Doubled from 2007 to 2015”. Subscription
required: https://jamanetwork.com/journals/jamapediatrics/article-abstract/2730063
B. Benzos vs barbs for alcohol withdrawal: Analysis of 3 different
treatment protocols.
Nelson
AC, et al. Am J Emerg Med. 2019 Apr;37(4):733-736.
INTRODUCTION:
Alcohol
withdrawal treatment varies widely. Benzodiazepines are the standard of care,
with rapid onset and long durations of action. Recent drug shortages involving
IV benzodiazepines have required incorporation of alternative agents into
treatment protocols. Phenobarbital has similar pharmacokinetics to select
benzodiazepines frequently used for alcohol withdrawal. The objective of this
study is to describe the effectiveness and safety of our institutional
protocols during three time periods utilizing benzodiazepines and barbiturates
for the acute treatment of alcohol withdrawal in the emergency department.
METHODS:
Adult
patients presenting to the ED for acute alcohol withdrawal from April 1st, 2016
to January 31st, 2018 were reviewed. Patients who received at least one dose of
treatment were included. Treatments were based on availability of medication
and given protocol at time of presentation. The primary outcome was the rate of
ICU admission.
RESULTS:
300
patient encounters were included. Overall baseline characteristics were equal
across groups, except for age. There was no difference in rate of ICU admission
from the ED between groups (D:8, L&P:11, P:13 patients, p = 0.99). Rate of
mechanical ventilation was no different across all groups (D:1, L&P:3, P:3
patients, p = 0.55).
CONCLUSION:
During
benzodiazepine shortages, phenobarbital is a safe and effective treatment
alternative for alcohol withdrawal. Incorporating phenobarbital into a
benzodiazepine based protocol or as sole agent led to similar rates of ICU
admission, length of stay, and need for mechanical ventilation in patients
treated for alcohol withdrawal in the emergency department.
16. Utilizing the Boston Syncope Observation
Management Pathway to Reduce Hospital Admission and Decrease Adverse Outcomes.
Mechanic
OJ, et al. West J Emerg Med. 2019;20(2).
Introduction:
In an age of increasing scrutiny of each hospital admission, emergency department
(ED) observation has been identified as a low-cost alternative. Prior studies
have shown admission rates for syncope in the United States to be as high as
70%. However, the safety and utility of substituting ED observation unit (EDOU)
syncope management has not been well studied. The objective of this study was
to evaluate the safety of EDOU for the management of patients presenting to the
ED with syncope and its efficacy in reducing hospital admissions.
Methods:
This was a prospective before-and-after cohort study of consecutive patients
presenting with syncope who were seen in an urban ED and were either admitted
to the hospital, discharged, or placed in the EDOU. We first performed an
observation study of syncope management and then implemented an ED
observation-based management pathway. We identified critical interventions and
30-day outcomes. We compared proportions of admissions and adverse events rates
with a chi- squared or Fisher’s exact test.
Results:
In the “before” phase, 570 patients were enrolled, with 334 (59%) admitted and
27 (5%) placed in the EDOU; 3% of patients discharged from the ED had critical
interventions within 30 days and 10% returned. After the management pathway was
introduced, 489 patients were enrolled; 34% (p less than 0.001) of pathway
patients were admitted while 20% were placed in the EDOU; 3% (p=0.99) of
discharged patients had critical interventions at 30 days and 3% returned
(p=0.001).
Conclusion:
A focused syncope management pathway effectively reduces hospital admissions
and adverse events following discharge and returns to the ED.
To
see the “Boston Syncope Pathway”, see the full-text (free): https://escholarship.org/uc/item/9bq2t7rf
17. A comparison of early vs delayed elective
electrical cardioversion for recurrent episodes of persistent A Fib: A
multi-center study.
Voskoboinik
A, et al. Int J Cardiol. 2019 Jun 1;284:33-37.
BACKGROUND:
Due
to barriers to accessing timely elective electrical cardioversion (CV) for
persistent AF (PeAF), we adopted a policy of instructing patients to present
directly to the Emergency Department (ED) for CV.
OBJECTIVE:
We
compare a strategy of Emergency CV (ED-CV) versus Elective CV (EL-CV) for
treatment of symptomatic PeAF.
METHODS:
Between
2014 and 7, we evaluated 150 patients undergoing CV for PeAF. ED-CV patients
were provided an AF action plan for recurrent symptoms and advised to present to
ED within 36 h. EL-CV patients followed standard care, including cardiologist
referral and placement on an elective hospital waiting list. Follow-up was
12 months.
RESULTS:
We
included 75 consecutive ED-CV patients and 75 consecutive EL-CV patients. ED-CV
patients had a significantly shorter median AF duration prior to CV (1 day vs
3 months; p less than 0.01) and less overall AF-related symptoms at 12 months
(modified EHRA symptom score ≥ 2a in 44% vs 72%; p = 0.005). Time to next AF
recurrence was longer in the ED-CV group (295 ± 15 vs 245 ± 15 days; logrank
p = 0.001), as was time to AF ablation referral (314 ± 13 vs 276 ± 15 days;
logrank p = 0.01). Baseline LA area was similar (ED-CV 27 ± 4 cm2 vs EL-CV
28 ± 11 cm2; p = 0.67), however EL-CV had larger atria at follow-up (31 ± 8 vs
26 ± 6 cm2; p = 0.01). There were no complications in either group.
CONCLUSION:
ED-CV
is an acceptable strategy for symptomatic PeAF. In addition to reduced time
spent in AF and improved symptom scores, this strategy may also slow progression
of atrial substrate & delay onset of next AF episode.
18. Standard long IV catheters versus extended dwell
catheters: A randomized comparison of ultrasound-guided catheter survival.
Bahl
A, et al. Am J Emerg Med. 2019 Apr;37(4):715-721
INTRODUCTION:
Establishing
peripheral intravenous (IV) access is a vital step in providing emergency care.
Ten to 30% of Emergency Department (ED) patients have difficult vascular access
(DVA). Even after cannulation, early failure of US-guided IV catheters is a
common complication. The primary goal of this study was to compare survival of
a standard long IV catheter to a longer extended dwell catheter.
METHODS:
This
study was a prospective, randomized comparative evaluation of catheter
longevity. Two catheters were used in the comparison: [1] a standard long IV
catheter, the 4.78 cm 20 gauge Becton Dickinson (BD); and [2] a 6 cm 3 French
(19.5 gauge) Access Scientific POWERWAND™ extended dwell catheter (EDC). Adult
DVA patients in the ED with vein depths of 1.20 cm-1.60 cm and expected
hospital admissions of at least 24 h were recruited.
RESULTS:
120
patients were enrolled. Ultimately, 70 patients were included in the survival
analysis, with 33 patients in the EDC group and 37 patients in the standard
long IV group. EDC catheters had lower rates of failure (p = 0.0016). Time to
median catheter survival was 4.04 days for EDC catheters versus 1.25 days for
the standard long IV catheter. Multivariate survival analysis also showed a
significant survival benefit for the EDC catheter (p = 0.0360).
CONCLUSION:
A
longer extended dwell catheter represents a viable and favorable alternative to
the standard longer IVs used for US-guided cannulation of veins above 1.20 cm
in depth. These catheters have significantly improved survival rates with
similar insertion success characteristics.
19. Reducing ED Length of Stay
Mercer
MP et al. JAMA. 2019;321(14):1402-1403.
Case
Summary
A
middle-aged woman injured her wrist during a fall. She went to the emergency
department (ED) but left without being seen by a clinician after waiting 4
hours. Three days later, she returned with continued wrist swelling and pain
but was worried that another long wait could cause her to be late for work. She
wondered if her primary care physician’s next available appointment in a month
would be sufficient to address her injury. She was eventually seen and
diagnosed as having a scaphoid fracture. A splint was placed and a follow-up
appointment was made with an orthopedic surgeon. The total ED length of stay
was 6 hours. The patient was concerned that her delay in receiving treatment
may have long-term consequences for her physical function and made a complaint
to the hospital.
What
Should Be Done Next?
1.Apologize
to the patient and state that ED staff are working hard with limited resources.
2.Explain
to the patient that a delay in treatment will not affect her recovery given a
low-acuity injury.
3.Instruct
the physician who was on duty during the patient’s initial visit on how to work
more efficiently.
4.Assemble
an interdisciplinary team to evaluate the flow of patients through the ED to
reduce wait times and improve access to care.
Consider
the Options
Apologizing
to the patient helps patients know that concerns they have are important, but
it does not address the core problem of long ED wait times. Trauma centers,
teaching hospitals, and safety net hospitals may have longer lengths of stay
and higher rates of patients leaving without being seen compared with
nonteaching, for-profit hospitals.1
The
second option dismisses the patient’s injury as nonurgent, which is neither
patient centered nor medically appropriate. Although it recognizes that the
needs of critically ill patients must be prioritized, no consideration is given
to the broader effect of longer wait times.
The
third scenario implies that ED staff are not already working at maximal effort.
Targeting individual physicians perpetuates the myth that individual heroics
can overcome systemic deficiencies. This approach ignores literature
demonstrating that EDs typically have extreme crowding and the reality of
increasing demand for acute care.2,3 Focusing on an individual clinician
ignores systemic issues and precludes the ability to achieve lasting change.
A
fourth option is to participate in coordinated, interdisciplinary improvement
efforts to create efficient, patient-centered processes. This approach has the
greatest potential for achieving and sustaining meaningful change.4
The
ED team chose to pursue this fourth option, recognizing that long wait times
affected nearly all patients, with implications for safety and quality of care.
Analysis
of the Case
An
interdisciplinary team of front-line physicians, nurses, medical assistants,
and executives assembled and used value stream mapping to assess the entire ED
care process, from patient arrival to admission or discharge. Value stream
mapping uses visual documentation to analyze all repeatable steps in a care
delivery process.5 The team closely observed each step of care (eg,
registration through discharge) from the patient perspective and built a
schematic representation of each step, including any waits or delays. The
finished map helps teams identify opportunities for improvement (eFigure in the
Supplement). Executive staff participating in this process spent significant
amounts of time in the ED, observing the rapid pace of work and crowded
conditions. For the ED staff, the mapping process enabled them to personally
experience the delays and crowding from patients’ perspectives. By direct
observation, the team members noted many inefficiencies and errors experienced
by both patients and staff. For example, the team found that it took 75 minutes
and 3 different monitors (because of broken equipment) for a nurse to complete
the preliminary orders for a patient with chest pain. In addition, a triage
nurse and a patient with a simple hand laceration walked to several areas of
the ED before finding an open hallway chair to wait to be seen.
Variability
in the evaluation and treatment processes for patients was identified as a root
cause of delays in care. For patients with low-acuity suspected simple
fractures, there was no standard process to determine (1) if x-ray imaging
would be ordered in triage or only after clinician assessment; (2) what type of
clinician (nurse practitioner, trainee, or physician) would initiate care; or
(3) if the patient should follow up in an outpatient orthopedics clinic or
receive definitive care with an in-person consultation in the ED.
Comingling
patients with high- and low-acuity conditions together throughout the ED
exacerbated the variability in care processes. The urgent needs of high-acuity
conditions routinely led to long delays in care of patients with lower-acuity
conditions. Such delays frustrated patients and resulted in a misalignment of
work needed by physicians and nurses to care for all patients in a timely
manner.
Further
examination of the health system revealed broader issues that impeded ED flow.
For example, limited patient access to same-day primary care and urgent care
contributed to increasing low-acuity ED patient volume. Limited hospital bed
capacity resulted in frequent boarding of patients in the ED, reducing the
availability of treatment space for new acute care patients.
Correct
the Errors
1.
Creating a fast-track care pathway for patients with low-acuity conditions. In
this hospital, more than 65 patients per day (30% of ED patient volume) had
low-acuity conditions. The team developed a uniform care pathway called Fast
Track that included strict inclusion and exclusion criteria of low-acuity
conditions such as dysuria or cough in patients with normal vital signs. There
was a standardized workflow for managing these patients throughout the ED stay
that included assigned roles and actions for each staff member from rooming the
patient to delivering discharge instructions (eFigure in the Supplement). By
cohorting patients with low-acuity conditions and implementing a standard
workflow, the staff could estimate the resources needed to accommodate patient
demand. It was determined that 6 treatment spaces and a flexible treatment team
were needed, a solution that had been successful at other institutions.5,6
2.
Standardized processes. After designation of a treatment area and team, a daily
team huddle was developed. At the start of each shift, expectations for each
staff member were reviewed. For example, medical assistants reviewed specific
procedures for wound care preparation, while physicians and nurse practitioners
reviewed the standard approach to charting and discharge practices. Standard
processes for rooming, documentation, procedures, and discharges were
reinforced through coaching by departmental leaders, which included managers,
peer nurses, medical assistants, and physicians who participated in the new
process design and testing. The daily huddle provided opportunities for staff
to ask questions, offer feedback for improvement, and troubleshoot issues in
real time.
3.
Dissemination of real-time performance metrics. After standard processes were
implemented, daily data reports were shared with frontline and executive staff,
facilitating adjustments of the new processes. For instance, when the team
moved Fast Track to a different physical location within the ED, rates for
length of stay and patients leaving without being seen worsened by 30%. This
real-time data allowed the team to address the new problems efficiently.
4.
Staffing to maintain team consistency. Data analysis revealed that 30% of
patient volume could be managed by a small interdisciplinary team. This
improvement was best achieved by positioning the Fast Track team in a separate
geographical area of the ED, which enabled increased capacity for managing more
complex patients in other parts of the ED.
5.
Engagement and alignment with executive strategic plan. Engagement of hospital
executive sponsors, including the chief of staff, chief quality officer, chief
nursing office, chief medical officer, and chief executive officer, via daily
data-driven huddles, weekly planning sessions, and quarterly workshops helped
accelerate ED improvement efforts. Through these interactions, the executive team
developed a clearer understanding of ED improvement needs and were able to
facilitate integration of ED issues into hospital-wide strategic objectives,
such as reducing ED boarding and ambulance diversion. This executive-level
involvement also facilitated qualitative improvements in ED patient and staff
experience. For example, observing the burden of nonclinical work asked of ED
staff to manage after-hours visitors for the entire hospital resulted in
increasing the main hospital building’s security hours and the addition of a
patient navigator available to the ED.
Outcomes
After
the initiation of the Fast Track process in December 2015, and without making
any other changes to ED workflow or staffing, there was a 25% decrease in the
length of stay of patients with low-acuity conditions (from 190 minutes to less
than 150 minutes) and the rate of patients leaving without being seen decreased
from 8% to 4% in just 5 months. At the same time, patients with moderate- and
high-acuity conditions who were discharged had reduced length of stay in the ED
and stable or reduced rates of leaving without being seen because of increased
capacity in high-acuity treatment areas.
Bottom
Line
1.
Multidisciplinary engagement of both frontline and executive staff by ED
leadership, coupled with clear standards and real-time data, are essential to
the success and sustainability of any improvement work.
2.
Separating patients with low- and high-acuity conditions in the ED can enhance
the efficiency of managing both groups.
3.
Frequent review of performance metrics by frontline staff and hospital
leadership facilitates real-time recognition of problems and evaluation of
changes.
21. US ED Visits and Hospital Discharges Among
Uninsured Patients Before and After Implementation of the Affordable Care Act
Singer
AJ, et al. JAMA Netw Open. 2019;2(4):e192662..2019.2662
Key
Points
Question Were the 2014 insurance provisions in the
Affordable Care Act (ACA) associated with changes in US emergency department
(ED) visits or hospital discharges among uninsured individuals?
Findings In this cross-sectional study of 1.4 billion
US ED visits from between 2006 and 2016 and 405 million hospital discharges
between 2006 and 2016, proportions of ED visits and hospital discharges by
uninsured patients declined from 16% to 8% and 6% to 4%, respectively, after
the 2014 ACA insurance expansions. Among patients aged 18 to 64 years, declines
were from 20% to 11% and 10% to 7%, respectively.
Meaning The implementation of the ACA insurance
provisions in 2014 was associated with decreased ED and hospital use by
uninsured individuals, but by 2016 many patients seeking care in US hospitals
remained uninsured.
Abstract
Importance The US Patient Protection and Affordable Care
Act of 2010 (ACA) was enacted in 2010 with several provisions that targeted
reducing numbers of uninsured Americans.
Objective To assess the numbers and proportion of
emergency department (ED) visits (2006-2016) and hospital discharges
(2006-2016) by uninsured patients, focusing on the 2014 ACA insurance reforms
(Medicaid expansion, individual mandate, and private insurance exchanges).
Design,
Setting, and Participants
Cross-sectional study of visitors to US EDs and patients discharged from
US hospitals using National Hospital Ambulatory Care Survey data and Healthcare
Cost and Utilization Project data, respectively, from 2006 to 2016. Data
analysis took place in February 2019.
Main
Outcomes and Measures Numbers and
proportions of total and uninsured ED visits and hospital discharges. Simple
descriptive statistics and interrupted time-series analysis were used to assess
changes in uninsured visits over time and after the implementation of insurance
provisions in 2014.
Results There were an estimated 1.4 billion US ED
visits from 2006 to 2016 and 405 million hospital discharges from 2006 to 2016.
Over the study period, ED visits increased by 2.3 million per year, while
hospital discharges decreased from approximately 38 million per year prior to
2009 to approximately 36 million per year after, with no clear decrease after
2013. Proportions of uninsured ED visits were largely unchanged from 2006 (16%)
until 2013 (14%) (−0.2 percentage point per year; 95% CI, −0.46 to −0.01
percentage point; P = .11) but then decreased by 2.1 percentage points per year
from 2014 to 2016 (95% CI, −4.3 to −1.8 percentage points; P = .003), with
uninsured visits composing 8% of the total in 2016. For patients aged 18 to 64
years, uninsured ED visits declined from approximately 20% from 2006 through
2013 to 11% in 2016 (3.1% decrease per year after 2013; 95% CI, −4.3 to −1.8
percentage points; P = .003). The proportion of hospital discharges by
uninsured patients remained steady at approximately 6% from 2006 to 2013, then
declined to 5% in 2014 and 4% in 2016. Similar changes were seen for patients
aged 18 to 64 years, with a decrease in hospital discharges from 10% to 7% over
the study period.
Conclusions
and Relevance Proportions of ED visits
and hospital discharges by uninsured patients decreased considerably after the
implementation of the 2014 ACA insurance provisions. Despite these changes,
approximately 1 in 10 ED visits and 1 in 20 hospital discharges were made by
uninsured individuals in 2014 to 2016. This suggests that continued attention
is needed to address the lack of insurance in US hospital visits, particularly
among people aged 18 to 64 years who have less access to government-sponsored
insurance.
22. Micro Bits
A. UBC
researchers create robot to help soothe pain of neonatal intensive care unit
babies
The
Guardian
Nothing
soothes a newborn's pain like the tender touch of a loving parent, but
researchers at the University of B.C. hope their new robot might help sometimes.
"Calmer" was created to mimic hand-hugging, a treatment in which a
premature baby's head, hands and legs are gently held in a curled position to
help manage pain from medical procedures. Lead inventor Liisa Holsti developed
the robot with colleagues at UBC and said it mimics some of the therapeutic
aspects of skin-to-skin holding.
B. Artificial
Intelligence in Medicine
B1. Warnings
of a Dark Side to A.I. in Health Care
Last
year, the Food and Drug Administration approved a device that can capture an
image of your retina and automatically detect signs of diabetic blindness.
This
new breed of artificial intelligence technology is rapidly spreading across the
medical field, as scientists develop systems that can identify signs of illness
and disease in a wide variety of images, from X-rays of the lungs to C.A.T.
scans of the brain. These systems promise to help doctors evaluate patients
more efficiently, and less expensively, than in the past.
Similar
forms of artificial intelligence are likely to move beyond hospitals into the
computer systems used by health care regulators, billing companies and
insurance providers. Just as A.I. will help doctors check your eyes, lungs and
other organs, it will help insurance providers determine reimbursement payments
and policy fees.
Ideally,
such systems would improve the efficiency of the health care system. But they
may carry unintended consequences, a group of researchers at Harvard and M.I.T.
warns.
In
a paper published on Thursday in the journal Science, the researchers raise the
prospect of “adversarial attacks” — manipulations that can change the behavior
of A.I. systems using tiny pieces of digital data. By changing a few pixels on
a lung scan, for instance, someone could fool an A.I. system into seeing an
illness that is not really there, or not seeing one that is.
B2. How Can
Doctors Be Sure A Self-Taught Computer Is Making The Right Diagnosis?
Richard
Harris. NPR, All Things Considered. April 1, 2019
Some
computer scientists are enthralled by programs that can teach themselves how to
perform tasks, such as reading X-rays.
Many
of these programs are called "black box" models because the
scientists themselves don't know how they make their decisions. Already these
black boxes are moving from the lab toward doctors' offices.
The
technology has great allure, because computers could take over routine tasks
and perform them as well as doctors do, possibly better. But as scientists work
to develop these black boxes, they are also mindful of the pitfalls.
Pranav
Rajpurkar, a computer science graduate student at Stanford University, got
hooked on this idea after he discovered how easy it was to create these models.
The
National Institutes of Health one weekend in 2017 made more than 100,000 chest
X-rays publicly available, each tagged with the condition that the person had
been diagnosed with. Rajpurkar texted a lab mate and suggested they should
build a quick and dirty algorithm that could use the data to teach itself how
to diagnose the conditions linked to the X-rays….
C. Laws
Against Texting While Driving Reduced ED Visits
New
evidence from Texas A&M School of Public Health indicates that
texting-while-driving laws may avert the need for emergency treatment following
a motor vehicle crash. Researchers found that states with a primary texting ban
on all drivers on average saw an 8 percent reduction in emergency department
visits resulting from a motor vehicle crash. The research, led by Alva O.
Ferdinand, DrPH, JD, assistant professor at the School of Public Health, was
published by the American Journal of Public Health.
D. What Did
the Apple Heart Study Really Find? Milton Packer dissects the data and proposes
a formal challenge to tech giant
Six
months ago in this space, I wondered if the new Apple Watch was the worst heart
device ever. Some readers may have thought I was exaggerating. Others may have
imagined that I was being too cynical.
But
based on the results of the Apple Heart Study -- which were released at the
American College of Cardiology meeting this week -- it is now official. The
Apple Watch is a serious competitor for the worst heart device ever….
E.
Personality Traits in Patients with MINOCA
MINOCA
= Myocardial Infarction with Nonobstructive Coronary Arteries
F. Study: One
in Six U.S. Children Has a Mental Illness
March
18, 2019 — Survey results indicate that as many as one in six U.S. children
between the ages of 6 and 17 has a treatable mental health disorder such as
depression, anxiety or attention-deficit/hyperactivity disorder.
AAFP
overview: https://www.aafp.org/news/health-of-the-public/20190318childmentalillness.html?cmpid=em_AP_20190327
G.
Ultrasound-guided transverse abdominis plane block for ED appendicitis pain
control.
H. 200 People
Possibly Exposed to Measles at California Emergency Department
USA
Today
A
Sacramento, California, medical center sent about 200 patients letters saying
they might have been exposed to measles after a girl who visited the emergency
department was diagnosed with the highly contagious infection. The young girl
with measles visited the ED at UC Davis Medical Center on March 17, the center
told USA TODAY. The letters were sent March 25 and 26.
I.
Researchers Say They May Have Found the Cause of SIDS and Other Sudden Death
Syndromes
J. Skipping
breakfast tied to higher risk of heart-related death, study finds
K. 2018-2019
U.S. Flu Season: Preliminary Burden Estimates
L. Improving
physician well-being: Lessons from palliative care
The
well-being of doctors has become a primary concern of medical associations
globally, and for good reason: physicians, on the whole, are not doing well.
One relatively unexamined factor related to physician burnout is coping with
patient death. Treating patients at the end of their lives, and coping with
patient death, can undoubtedly cause stress, including burnout, but little
research has documented this relationship empirically. One medical discipline
deals with death more often, and much better, than most others: palliative care.
M. ACEP:
Emergency Visits Reach All-Time High
Only
4.3 Percent of Emergency Visits Are Considered Nonurgent, New CDC Data Shows
