0. We love our nurses!!
ZDoggMD
channels his inner Billy Joel for a melodic tribute to nurses.
1. Stroke Research
A. Rapid Blood Pressure Reduction Safe for Ischemic Stroke
Patients Receiving Lytics
Summary
by Anita Slomski, MA. JAMA. 2019;321(16):1558.
Intensive
blood pressure control reduced the risk of intracranial hemorrhage without
increasing the risk of death or disability in patients with acute ischemic
stroke receiving intravenous thrombolysis, according to a trial published in
the Lancet. Previous studies raised concern that quickly reducing blood
pressure might worsen cerebral ischemia in these patients.
Within
6 hours of acute ischemic stroke onset, 2196 patients with a systolic blood
pressure of 150 mm Hg or more were randomly assigned to receive intensive blood
pressure lowering (systolic target, 130-140 mm Hg ≤1 hour) or
guideline-recommended blood pressure lowering (systolic target, less than 180
mm Hg) for up to 72 hours after intravenous thrombolysis.
Functional
status at 90 days did not differ between groups. However, in the intensive
group, only 14.8% of patients had any intracranial hemorrhage compared with
18.7% in the guideline group. Rates of serious adverse events were similar
between groups.
Due
to the lack functional improvement, the findings may not support a shift to
intensive blood pressure lowering among patients with mild to moderate acute
ischemic stroke, according to the authors.
Abstract:
Anderson CS, et al. Intensive blood pressure reduction with intravenous
thrombolysis therapy for acute ischaemic stroke (ENCHANTED): an international,
randomised, open-label, blinded-endpoint, phase 3 trial. Lancet. 2019;393(10174):877-888.
https://www.ncbi.nlm.nih.gov/pubmed/30739745
B. Patent Foramen Ovale and Ischemic Stroke in Patients with
Pulmonary Embolism: A Prospective Cohort Study
Le
Moigne E, et al. Ann Intern Med. 2019 May 7 [Epub ahead of print].
BACKGROUND:
Pulmonary
embolism (PE) is associated with increased risk for ischemic stroke, but the
underlying mechanism remains unclear. The authors hypothesized that paradoxical
embolism through patent foramen ovale (PFO) should be the main mechanism.
OBJECTIVE:
To
determine the frequency of recent ischemic stroke in patients with symptomatic
PE according to whether PFO was detected.
DESIGN:
Prospective
cohort study with masked assessment of stroke outcomes. (ClinicalTrials.gov:
NCT01216423).
SETTING:
4
French hospital centers.
PARTICIPANTS:
361
consecutive patients with symptomatic acute PE from 13 November 2009 through 21
December 2015.
INTERVENTION:
Systematic
contrast transthoracic echocardiography (TTE) and cerebral magnetic resonance
imaging (MRI) within 7 days after enrollment.
MEASUREMENTS:
Recent
symptomatic or silent ischemic stroke was diagnosed on the basis of clinical
examination and cerebral MRI showing a hypersignal on the trace
diffusion-weighted image with reduction or pseudonormalization of apparent
diffusion coefficient.
RESULTS:
Contrast
TTE was conclusive in 324 of 361 patients and showed PFO in 43 patients (13%).
The median age was 66 years (interquartile range, 54 to 77 years). In total,
51% of patients (145/284) had associated deep venous thrombosis, 91% (279/306)
had cardiovascular risk factors, and 10% (16/151) presented with arrhythmia (no
difference between PFO and non-PFO groups). Cerebral MRI was conclusive in 315
patients. Recent ischemic stroke was more frequent in the PFO group than in the
non-PFO group (9 of 42 patients [21.4%] vs. 15 of 273 patients [5.5%];
difference in proportions, 15.9 percentage points [95% CI, 4.7 to 30.7
percentage points]).
LIMITATION:
Because
of inconclusive contrast TTE or MRI, 46 patients were excluded from analysis.
CONCLUSION:
Frequency
of recent ischemic stroke in patients with symptomatic PE was higher in patients
with PFO than in those without PFO. This finding supports the hypothesis that
paradoxical embolism is an important mechanism of ischemic stroke in patients
with PFO.
C. Risk for Major Hemorrhages in Patients Receiving Clopidogrel
and Aspirin Compared with Aspirin Alone After TIA or Minor Ischemic Stroke: A
Secondary Analysis of the POINT RCT
Tillman
H, et al. JAMA Neurol. 2019 Apr 29 [Epub ahead of print]
Key
Points
Question What is the bleeding profile of clopidogrel
plus aspirin vs aspirin alone when used to prevent strokes in patients with
acute transient ischemic attack or minor ischemic stroke?
Findings In this secondary analysis of a multinational
randomized clinical trial of 4881 patients who received clopidogrel plus
aspirin vs placebo plus aspirin, the risk of major hemorrhage was low and most
were extracranial and treatable. Intracranial hemorrhages were rare.
Meaning Short-term treatment with clopidogrel plus
aspirin after acute transient ischemic attack or minor ischemic stroke has a
low major hemorrhage complication rate and reduces the risk of ischemic stroke.
IMPORTANCE:
Results
show the short-term risk of hemorrhage in treating patients with acute transient
ischemic attack (TIA) or minor acute ischemic stroke (AIS) with clopidogrel
plus aspirin or aspirin alone.
OBJECTIVE:
To
characterize the frequency and kinds of major hemorrhages in the
Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT)
trial.
DESIGN,
SETTING, AND PARTICIPANTS:
This
secondary analysis of the POINT randomized, double-blind clinical trial
conducted in 10 countries in North America, Europe, and Australasia included
patients with high-risk TIA or minor AIS who were randomized within 12 hours of
symptom onset and followed up for 90 days. The total enrollment, which occurred
from May 28, 2010, through December 17, 2017, was 4881 and constituted the
intention-to-treat group; 4819 (98.7%) were included in the as-treated analysis
group. The primary safety analyses were as-treated, classifying patients based
on study drug actually received. Intention-to-treat analyses were performed as
secondary analyses. Data were analyzed in April 2018.
INTERVENTIONS:
Patients
were assigned to receive clopidogrel (600 mg loading dose on day 1 followed by
75 mg daily for days 2-90) or placebo; all patients also received open-label
aspirin, 50 to 325 mg/d.
MAIN
OUTCOMES AND MEASURES:
The
primary safety outcome was all major hemorrhages. Other safety outcomes
included minor hemorrhages.
RESULTS:
A
total of 269 sites worldwide randomized 4881 patients (median age, 65.0 years
[interquartile range, 55-74 years]; 2195 women [45.0%]); the primary results
have been published previously. In the as-treated analyses, major hemorrhage
occurred in 21 patients (0.9%) receiving clopidogrel plus aspirin and 6 (0.2%)
in the aspirin alone group (hazard ratio, 3.57; 95% CI, 1.44-8.85; P = .003;
number needed to harm, 159). There were 4 fatal hemorrhages (0.1%; 3 in the
clopidogrel plus aspirin group and 1 in the aspirin alone group); 3 of the 4
were intracranial. There were 7 intracranial hemorrhages (0.1%); 5 were in the
clopidogrel plus aspirin group and 2 in the aspirin plus placebo group. The
most common location of major hemorrhages was in the gastrointestinal tract.
CONCLUSIONS
AND RELEVANCE:
The
risk for major hemorrhages in patients receiving either clopidogrel plus
aspirin or aspirin alone after TIA or minor AIS was low. Nevertheless,
treatment with clopidogrel plus aspirin increased the risk of major hemorrhages
over aspirin alone from 0.2% to 0.9%.
D. Dabigatran Failed to Prevent Recurrent Stroke after Embolic
Stroke of Undetermined Source.
Diener
HC, et al. N Engl J Med. 2019 May 16;380(20):1906-1917.
BACKGROUND:
Cryptogenic
strokes constitute 20 to 30% of ischemic strokes, and most cryptogenic strokes
are considered to be embolic and of undetermined source. An earlier randomized
trial showed that rivaroxaban is no more effective than aspirin in preventing
recurrent stroke after a presumed embolic stroke from an undetermined source.
Whether dabigatran would be effective in preventing recurrent strokes after
this type of stroke was unclear.
METHODS:
We
conducted a multicenter, randomized, double-blind trial of dabigatran at a dose
of 150 mg or 110 mg twice daily as compared with aspirin at a dose of 100 mg
once daily in patients who had had an embolic stroke of undetermined source.
The primary outcome was recurrent stroke. The primary safety outcome was major
bleeding.
RESULTS:
A
total of 5390 patients were enrolled at 564 sites and were randomly assigned to
receive dabigatran (2695 patients) or aspirin (2695 patients). During a median
follow-up of 19 months, recurrent strokes occurred in 177 patients (6.6%) in
the dabigatran group (4.1% per year) and in 207 patients (7.7%) in the aspirin
group (4.8% per year) (hazard ratio, 0.85; 95% confidence interval [CI], 0.69
to 1.03; P = 0.10). Ischemic strokes occurred in 172 patients (4.0% per year)
and 203 patients (4.7% per year), respectively (hazard ratio, 0.84; 95% CI,
0.68 to 1.03). Major bleeding occurred in 77 patients (1.7% per year) in the
dabigatran group and in 64 patients (1.4% per year) in the aspirin group
(hazard ratio, 1.19; 95% CI, 0.85 to 1.66). Clinically relevant nonmajor
bleeding occurred in 70 patients (1.6% per year) and 41 patients (0.9% per
year), respectively.
CONCLUSIONS:
In
patients with a recent history of embolic stroke of undetermined source,
dabigatran was not superior to aspirin in preventing recurrent stroke. The
incidence of major bleeding was not greater in the dabigatran group than in the
aspirin group, but there were more clinically relevant nonmajor bleeding events
in the dabigatran group.
E. Thrombolysis Guided by Perfusion Imaging up to 9 Hours after
Onset of Stroke
Ma
H, et al. the EXTEND Investigators. N Engl J Med. 2019 May 9;380(19):1795-1803.
BACKGROUND:
The
time to initiate intravenous thrombolysis for acute ischemic stroke is
generally limited to within 4.5 hours after the onset of symptoms. Some trials
have suggested that the treatment window may be extended in patients who are
shown to have ischemic but not yet infarcted brain tissue on imaging.
METHODS:
We
conducted a multicenter, randomized, placebo-controlled trial involving
patients with ischemic stroke who had hypoperfused but salvageable regions of
brain detected on automated perfusion imaging. The patients were randomly
assigned to receive intravenous alteplase or placebo between 4.5 and 9.0 hours
after the onset of stroke or on awakening with stroke (if within 9 hours from
the midpoint of sleep). The primary outcome was a score of 0 or 1 on the
modified Rankin scale, on which scores range from 0 (no symptoms) to 6 (death),
at 90 days. The risk ratio for the primary outcome was adjusted for age and
clinical severity at baseline.
RESULTS:
After
225 of the planned 310 patients had been enrolled, the trial was terminated
because of a loss of equipoise after the publication of positive results from a
previous trial. A total of 113 patients were randomly assigned to the alteplase
group and 112 to the placebo group. The primary outcome occurred in 40 patients
(35.4%) in the alteplase group and in 33 patients (29.5%) in the placebo group
(adjusted risk ratio, 1.44; 95% confidence interval [CI], 1.01 to 2.06;
P = 0.04). Symptomatic intracerebral hemorrhage occurred in 7 patients (6.2%)
in the alteplase group and in 1 patient (0.9%) in the placebo group (adjusted
risk ratio, 7.22; 95% CI, 0.97 to 53.5; P = 0.05). A secondary ordinal analysis
of the distribution of scores on the modified Rankin scale did not show a
significant between-group difference in functional improvement at 90 days.
CONCLUSIONS:
Among
the patients in this trial who had ischemic stroke and salvageable brain
tissue, the use of alteplase between 4.5 and 9.0 hours after stroke onset or at
the time the patient awoke with stroke symptoms resulted in a higher percentage
of patients with no or minor neurologic deficits than the use of placebo. There
were more cases of symptomatic cerebral hemorrhage in the alteplase group than
in the placebo group.
Radecki
comments:
“Therefore, in modern systems of stroke care, this trial probably has zero
effect on care. The better approach to tailoring treatment to individual
patient heterogeneity in our modern systems is to find new ways of integrating
MRI into the rapid assessment of stroke.”
His
review: https://www.emlitofnote.com/?p=4446
2. Test Decreases Time-to-Diagnosis in Bloodstream
Infections
Elia
J. Journal Watch. May 14, 2019.
The
T2Bacteria Panel (T2B), an FDA-cleared assay for five common causes of
bloodstream infection, cuts diagnostic time by nearly an order of magnitude,
according to an Annals of Internal Medicine study. Editorialists say its value
is "yet to be proved."
T2B
uses blood samples from which microbial-associated DNA is amplified and
evaluated with magnetic resonance technology. The test detects the most common
"ESKAPE" organisms: Enterococcus faecium, Staphylococcus aureus,
Klebsiella pneumoniae, Pseudomonas aeruginosa, and Escherichia coli.
In
a multicenter study funded by the test's manufacturer, some 1400 adults for
whom blood cultures had been ordered also had samples taken for T2B. The average
interval between sampling and positive findings was 39 hours with blood
culture, versus 4 hours with T2B. Similar time savings occurred for species
identification.
Calculated
sensitivity and specificity of T2B were both 90%, with a negative predictive
value approaching 100%.
Editorialists
cite the need for outcome studies to determine T2B's "place in modern
[antimicrobial] stewardship and patient care."
Nguyen
MH, et al. Performance of the T2Bacteria Panel for Diagnosing Bloodstream
Infections: A Diagnostic Accuracy Study. Ann Intern Med. 2019 May 14 [Epub
ahead of print]
ABSTRACT
BACKGROUND:
Blood
cultures, the gold standard for diagnosing bloodstream infections (BSIs), are
insensitive and limited by prolonged time to results. The T2Bacteria Panel (T2
Biosystems) is a direct-from-blood, nonculture test that identifies the most
common ESKAPE bacteria (Enterococcus faecium, Staphylococcus aureus, Klebsiella
pneumoniae, Pseudomonas aeruginosa, and Escherichia coli).
OBJECTIVE:
To
assess performance of the T2Bacteria Panel in diagnosing suspected BSIs in
adults.
DESIGN:
Prospective
patient enrollment (8 December 2015 through 4 August 2017).
SETTING:
Eleven
U.S. hospitals.
PATIENTS:
1427
patients for whom blood cultures were ordered as standard of care.
INTERVENTION:
Paired
blood culture and T2Bacteria testing.
MEASUREMENTS:
Performance
of T2Bacteria compared with a single set of blood cultures in diagnosing
proven, probable, and possible BSIs caused by T2Bacteria-targeted organisms.
RESULTS:
Blood
culture and T2Bacteria results were positive for targeted bacteria in 3% (39 of
1427) and 13% (181 of 1427) of patients, respectively. Mean times from start of
blood culture incubation to positivity and species identification were 38.5
(SD, 32.8) and 71.7 (SD, 39.3) hours, respectively. Mean times to species
identification with T2Bacteria were 3.61 (SD, 0.2) to 7.70 (SD, 1.38) hours,
depending on the number of samples tested. Per-patient sensitivity and
specificity of T2Bacteria for proven BSIs were 90% (95% CI, 76% to 96%) and 90%
(CI, 88% to 91%), respectively; the negative predictive value was 99.7% (1242
of 1246). The rate of negative blood cultures with a positive T2Bacteria result
was 10% (146 of 1427); 60% (88 of 146) of such results were associated with
probable (n = 62) or possible (n = 26) BSIs. If probable BSIs and both probable
and possible BSIs were assumed to be true positives missed by blood culture,
per-patient specificity of T2Bacteria was 94% and 96%, respectively.
LIMITATION:
Low
prevalence of positive blood cultures, collection of a single set of culture
specimens, and inability of T2Bacteria to detect nontargeted pathogens.
CONCLUSION:
The
T2Bacteria Panel rapidly and accurately diagnoses BSIs caused by 5 common
bacteria.
Wikipedia
on ESKAPE pathogens: https://en.wikipedia.org/wiki/ESKAPE
3. Progesterone for First-Trimester Bleeding?
Radekci
R. EM Lit of Note. May 14, 2019
Emergency
Department evaluation for patients with first-trimester bleeding is fairly
straightforward. Most of the time, an ultrasound identifies an unremarkable
intrauterine pregnancy and patients are provided with expectant management and
best wishes. However, there is some evidence progesterone supplementation – in
this trial, an intravaginal progesterone supplement – may help implantation and
prevent pregnancy loss. This, the Progesterone in Spontaneous Miscarriage
(PRISM) trial, is the first, large, high-quality investigation of this
intervention.
Over
the course of two years, 12,862 women with bleeding before 12 weeks of
pregnancy were screened, and 4,153 enrolled across 48 hospitals in the United
Kingdom. Enrolled patients were randomized to either 400mg intravaginal
micronized progesterone twice daily through 16 weeks of pregnancy, or identical
placebo. The primary outcome was live birth after at least 34 weeks, with
secondary outcomes being other early pregnancy milestones, as well.
Per
the authors, and hewing fast to their frequentist analysis, this is a negative
trial. The primary outcome occurred in 75% of the progesterone cohort and 72%
of placebo, a relative rate of 1.03 (1.00 to 1.07) and a p-value of 0.08. The
authors conclusion: “treatment with progesterone did not result in significant
improvement in the incidence of live births among women with vaginal bleeding
during the first 12 weeks of pregnancy.”
Maybe?
It
is always curious to look at the statistical analysis portion of these articles
and consider the decisions leading to the inability to detect a difference. In
this trial they state their choice of sample size was driven by the “minimally
important absolute difference of 5 percentage points between the progesterone
group and the placebo group in the incidence of live births after at least 34
weeks of gestation (65% vs. 60%)”. If we had a medication for use in sepsis
that was inexpensive and readily available, would we require a 5% difference in
mortality for its use? Anti-hypertensives, taken for five years, prevent heart
attack, stroke, and all-cause mortality with numbers-needed-to-treat swimming
right around a 1% difference – and these are taken in massive numbers at the
population level. Without delving into any sort of personhood argument, a lost
pregnancy is effectively a mortality benefit – and, despite the massive scale
required, it might have rather been more appropriate to choose a smaller “minimally
important absolute difference.”
If
the observed difference of 2 to 3% were to be confirmed, these are NNTs in the
33-50 range to prevent pregnancy loss. While this would not be rank as a
profoundly effective intervention, we are rather talking about producing an
actual new human being. No harms were detected, although a trial such as this
would be expected to be even further from powered to detect very rare events
such as congenital deformities. I would expect the debate regarding this to
continue, and I wouldn’t be surprised if you found some groups encouraging its
use or initiation in the ED.
4. Should We Add Muscle Relaxants to Ibuprofen for
Acute Low Back Pain? No
A
high-quality study of three muscle relaxants confirms what most of us already
know: They don't help.
Friedman
BW, et al. A Randomized, Placebo-Controlled Trial of Ibuprofen Plus Metaxalone,
Tizanidine, or Baclofen for Acute Low Back Pain. Ann Emerg Med. 2019 Apr 5 [Epub ahead of print].
STUDY
OBJECTIVE:
Patients
with low back pain are often treated with nonsteroidal anti-inflammatory drugs
and skeletal muscle relaxants. We compare functional outcomes and pain among
patients with acute low back pain who were randomized to a 1-week course of
ibuprofen plus placebo versus ibuprofen plus 1 of 3 skeletal muscle relaxants:
baclofen, metaxalone, and tizanidine.
METHODS:
This
was a randomized, double-blind, parallel-group, 4-arm study conducted in 2
urban emergency departments (EDs). Patients with nonradicular low back pain for
less than or equal to 2 weeks were eligible if they had a score greater than 5
on the Roland-Morris Disability Questionnaire, a 24-item inventory of
functional impairment caused by low back pain. All participants received 21
tablets of ibuprofen 600 mg, to be taken 3 times a day as needed. Additionally,
they were randomized to baclofen 10 mg, metaxalone 400 mg, tizanidine 2 mg, or
placebo. Participants were instructed to take 1 or 2 of these capsules 3 times
a day as needed. All participants received a 10-minute educational session. The
primary outcome was improvement on the Roland-Morris Disability Questionnaire
between ED discharge and 1week later. Secondary outcomes included pain
intensity 1 week after ED discharge (severe, moderate, mild, or none).
RESULTS:
Three
hundred twenty patients were randomized. One week later, the mean Roland-Morris
Disability Questionnaire score of patients randomized to placebo improved by
11.1 points (95% confidence interval [CI] 9.0 to 13.3), baclofen by 10.6 points
(95% CI 8.6 to 12.7), metaxalone by 10.1 points (95% CI 8.0 to 12.3), and
tizanidine by 11.2 points (95% CI 9.2 to 13.2). At 1-week follow-up, 30% of
placebo patients (95% CI 21% to 41%) reported moderate to severe low back pain
versus 33% of baclofen patients (95% CI 24% to 44%), 37% of metaxalone patients
(95% CI 27% to 48%), and 33% of tizanidine patients (95% CI 23% to 44%).
CONCLUSION:
Adding
baclofen, metaxalone, or tizanidine to ibuprofen does not appear to improve
functioning or pain any more than placebo plus ibuprofen by 1 week after an ED
visit for acute low back pain.
5. Emerg Med News Sampler
A. Emergentology: All That's Wrong Right with the World
Walker
G. Emerg Med News. 2019;41(5):10
I
was recently talking to a friend who had given up reading the news. She
admitted she was sacrificing knowledge for the sake of her mental health: The
political divisiveness across the country left her with worry of an uncertain
future for her children. The frequent and continued mass shootings seem to have
left us numb to death and carnage. She told me she still occasionally skims
newspaper headlines, but it just wasn't worth it to her anymore to be informed
about local, national, or world events.
I
can't tell if things are grimmer than they were just 10 years ago because
obviously I'm a different person from who I was 10 years ago. The stock market
had crashed and banks were being bailed out. I was an intern, completely
oblivious to everything except how many hours I had slept on call during my ICU
rotation. Now I have a mortgage and a dog, and 10 years ago seems really far
away.
Certainly,
medicine has always had a negativity bias. By law and regulation, every
hospital has to have a quality assurance, quality review, or morbidity and
mortality process to systematically evaluate what went wrong. People have often
recommended a Good Save award or Great Teamwork recognition, but I'm not seeing
hospital accreditors clamoring for a positivity mandate. Sure, we might tell
colleagues about a great case, talk about how it is better to be lucky than good,
or thank a nurse for her quick thinking during a code. But overall, medicine
focuses on the rare bad outcome and mostly ignores all the good ones.
Even
our research skews negative. I read a recent study in the Annals of Emergency
Medicine looking at discharge diagnoses of back pain and headache. (2019. pii:
S0196-0644[19]30027-7.) It included a data set of almost 3.5 million ED
encounters, and 0.2 percent of back pain patients and 0.5 percent of headache
patients had something bad. The conclusion? A small proportion of ED patients
discharged with nonspecific diagnoses of headache or back pain returned with a
serious neurologic condition or in-hospital death within 30 days.
I
took this as, “Wow, emergency medicine is really good at finding the needle in
the haystack! If we think you have nonspecific back pain, 998 times out of 1000
we're right!”
The
rest of the essay: https://journals.lww.com/em-news/Fulltext/2019/05000/Emergentology__All_That_s_Wrong_Right_with_the.12.aspx
B. Medically Clear: A Practice Changer for AF Cardioversion in
Obesity
Ballard
DW, et al. Emerg Med News. 2019;41(5):6.
An
emergency physician we know recently had a challenge. A very big challenge.
Under the care of Akhila Pamula, MD, was a large man—6'5” and 500 pounds—who
presented with palpitations. And diaphoresis. And a heart rate higher than 200
bpm, which surely contributed to him feeling a bit winded.
Dr.
Pamula was not quite sure of the rhythm, but knew it was fast and labile with
runs of what could be ventricular tachycardia. She knew that this gentleman
needed emergent cardioversion and that sedation would be a significant risk.
She also knew that cardioversion can be difficult in obese patients, with
historical failure rates of 10 percent and higher. (Europace. 2018. doi:
10.1093/europace/euy285; Europace. 2012;14[5]:666; Heart 2008;94[7]:884.)
The
Evidence
What
is the best approach to electrical cardioversion of atrial dysrhythmias in the
obese patient? This is a growing and evolving area in the literature. Ramirez,
et al., reported tremendous success across all body habitus of a four-step
approach to cardioversion for atrial fibrillation (AF). (Europace. 2018. doi:
10.1093/europace/euy285.) Step 1: 200 J biphasic shock delivered using
anteroposterior self-adhesive electrodes; step 2: 200 J shock with
anterolateral configuration while applying pressure over the electrodes with
disconnected standard handheld paddles; step 3: 360 J biphasic shock delivered
using the same technique as in step 2; step 4, wild type: at the treating
physician's discretion.
This
protocol—the Ottawa AF cardioversion protocol, or OAFCP—was associated with a
99 percent (386/389) cardioversion rate, which was sustained in 91.4 percent
and remained significantly improved compared with prior practice even when
adjusted for confounding factors such as body mass index (BMI) and
transthoracic impedance. Of note, a stunning 50 percent of their enrolled
patients met the criteria for obesity with a mean BMI of 31.1 (+/- 7.5). The
OAFCP protocol would seem to be a reasonable choice for morbidly obese
cardioversion, but what about evidence specifically tailored to this
demographic? You are in luck!
Voskoboinik,
et al., compared shock success in obese patients (BMI ≥30) with persistent AF
randomized to receive transthoracic synchronized biphasic direct-current
cardioversion by handheld paddles or by adhesive patches. (J Cardiovasc
Electrophysiol. 2019;30[2]:155; http://bit.ly/2Ty50AB.) The superiority of
paddles over patches after the initial shock of 100 J, then 200 J if needed,
was remarkable—90 percent (56/62) v. 68 percent (43/63), respectively. The
authors drew a sensible conclusion: “Routine use of adhesive patches at 200 J
is inadequate in obesity.”
Interestingly,
the success in this study was unaffected by electrode location and vector
(anteroapical v. anteroposterior), which contradicts other studies. This
investigation included a substudy of manual pressure augmentation (MPA), where
they found MPA to be 80 percent effective in 20 patients who had failed to
respond to 200 J with patches and paddles. The MPA technique seems simple
enough—apply manual force to the adhesive patches with gloved hands for
cardioversion during end-exhalation. Furthermore, it was safe and caused no
injury to the physician. The trial did not directly compare initial augmented
patch use with initial paddle use, but one could reasonably argue that
physicians who lack handheld paddles should start with patches and MPA at 200
J. This, however, awaits formal evaluation….
The
rest of the essay: https://journals.lww.com/em-news/Fulltext/2019/05000/Medically_Clear__A_Practice_Changer_for.9.aspx
C. What to D.O.: Steroids for Cellulitis Reduce Symptoms,
Bouncebacks
Pescatore
R. Emerg Med News. 2019;41(5):1,31
Buried
deep within the Infectious Diseases Society of America guidelines for treating
patients with skin and soft tissue infections is a weak recommendation to
consider adjunctive systemic corticosteroid treatment in nondiabetic patients
presenting with uncomplicated cellulitis. (Clin Infect Dis. 2014;59[2]:e10;
http://bit.ly/2HIvic7.)
Mired
as we've been for so many years in the debates over the most appropriate
empiric antibiotic therapy for this common presentation (cephalexin four times
a day; keep Bactrim at bay unless there is suppuration and abscess), the use of
concomitant corticosteroids hasn't been part of the mainstream EM approach to
cellulitis. Growing face validity, however, makes its incorporation something
that should more frequently find its way into routine practice.
Consider
the daily presentation of a patient with a fiery red cellulitic leg or painful
and warm sheen over the arm. The clinical diagnosis of cellulitis is a
straightforward one, though previous investigations have demonstrated that
ultrasound may be a helpful diagnostic tool to identify those with occult
suppuration.
Overwhelmingly,
cellulitis is caused by streptococci of various groups, where pathogens gain
entry into the dermis through breaks in the skin. Cellulitis is accompanied by
dermal edema, lymphatic dilation, and diffuse, heavy neutrophil infiltration
around blood vessels. (JAMA. 2016;316[3]:325.)
The
invading organisms drive significant inflammatory reaction, but further
immunologic response likely arises from bacterial antigens and extracellular
products, such as streptokinase, DNAse, and hyaluronidase, an observation borne
from multiple studies demonstrating underwhelming success rates in culturing
pathogenic bacteria from cellulitis and relatively low concentrations of
organisms when isolated.
I
was taught in residency to outline the erythematous margins of a patient's
cellulitis with a surgical marker and to send him home with stern warnings to
return should redness, pain, or swelling begin to creep beyond the strictly
drawn borders or if symptoms hadn't improved within a few days, perhaps
suggesting treatment failure and the need to escalate therapy.
A
few years into practice, however, I've watched too often as patients bounce
back with even the slightest progression of red beyond marked margins or when
24 hours of antibiotics haven't worked wonders on their painful red wounds.
We're often put into the difficult situation of parsing which patients
represent true treatment failures and which are simply traversing the natural
course of healing and who can be expected to continue to thrive as outpatients
with continuation of current therapy….
The
rest of the essay: https://journals.lww.com/em-news/Fulltext/2019/05000/What_to_D_O___Steroids_for_Cellulitis_Reduce.1.aspx
D. Reasonable Doubt: Don't Be Fooled
by New Study, Tamiflu Still Pretty Worthless for H1N1
Runde
D. Emerg Med News. 2019;41(4):6
A
new study in support of Tamiflu is in fact a negative study showing that giving
the drug early didn’t save any lives, even in a very sick cohort.
It's
possible that the Tamiflu pandemonium may be peaking for most emergency and
primary care physicians because the dubious benefits of oseltamivir have now
been well documented, discussed, and disseminated. (See box.) But there's also
a new kid on the block (baloxavir marboxil, AKA Xofluza) that is all too likely
to be jammed down our collective throats, displacing its controversial cousin.
That
said, it seems we never go too long before another article comes along touting
the life-saving properties of this wonder drug. It's not that the medicine
doesn't work, its proponents claim, it's that we're giving it to the wrong
population or with the wrong timing or in the wrong amount. We end up with
endless speculation on how the mechanism of action for this medication might be
more or less effective against various subtypes of influenza, despite the fact
that the authors of the definite Cochrane Review about this subject have
written that “the influenza virus-specific mechanism of action proposed by the
producers does not fit the clinical evidence.” (Cochrane Database Syst Rev 2014
Apr 10;[4]:CD008965; http://bit.ly/2Hdwgx5.)
The
newest entry in the saga to find the elusive One True Cohort™ for Tamiflu is an
article by Lytras, et al., a retrospective cohort of 1330 very sick patients
admitted to Grecian ICUs over eight flu seasons starting in 2010. (Clin Infect
Dis 2019 Feb 7. doi: 10.1093/cid/ciz101.) By very sick, I mean very sick: All
the patients were intubated, had laboratory-confirmed influenza, and were
treated with oseltamivir. Nearly half (46.8%) of the patients in this study
died in the ICU. This publication has generated some pro-oseltamivir headlines,
so it's probably worth taking a look at the results for patients treated early
(48 hours or less from symptom onset ) or late (48 hours or more after
symptoms):
- Death in the ICU (primary outcome): No difference
- Death in the ICU for A type H1N1 strain: No difference
- Death in the ICU for A type H3N2 strain: No difference
- Death in the ICU for B type influenza: No difference (obviously)
- Increased cause-specific hazard for discharge for A type H3N2 strain: csHR 1.89, 95% CrI 1.33-2.70
The
rest of the essay: https://journals.lww.com/em-news/Fulltext/2019/04000/Reasonable_Doubt__Don_t_Be_Fooled_by_New_Study_.5.aspx
6. Best Practice Advice on Coagulation in Patients
with Cirrhosis
Atif
Zaman, MD, MPH in Journal Watch, May 3, 2019. Reviewing O'Leary JG et al.
Gastroenterology 2019 Apr 12
Based
on an expert review, clinicians should reevaluate some traditional management
practices.
Complications
from both pro- and antithrombotic states are seen in patients with cirrhosis.
Therefore, a common scenario for the clinician is considering anticoagulation
in a patient while worrying about bleeding risk.
Four
experts reviewed the current and evolving data on coagulation in this
population and provided clinical practice advice, including the following:
Clinicians
should not routinely correct thrombocytopenia and coagulopathy for low-risk
procedures such as band ligation of varices, paracentesis, and thoracentesis.
For
active bleeding and to minimize bleeding in high-risk procedures:
- A platelet count target greater than 50,000 is still advised.
- Less reliance on international normalized ratio (INR) as a measure of hemostasis is advised.
- New measures of hemostasis including fibrinogen level (target greater than 120 mg/dL) and viscoelastic tests that are global tests of clot formation, such as thromboelastography (TEG), are becoming a part of routine practice.
The
use of procoagulants, typically platelets and fresh frozen plasma, can lead to
infectious, transfusion-related, and immunologic complications if overutilized.
Alternatives to consider include:
- Antifibrinolytic therapy, such as tranexamic acid, in patients with persistent bleeding from mucosal oozing or puncture wound
- Desmopressin, in patients with renal failure
Anticoagulation
considerations:
- In patients with symptomatic deep venous thrombosis (DVT) or portal vein thrombosis (PVT), systemic heparin infusion is recommended.
- Treatment of incidental PVT should be considered in transplantation candidates, as extensive thrombosis could impact surgical candidacy.
- For PVT therapy, low-molecular-weight heparin, direct-acting anticoagulants, and vitamin K antagonists are recommended.
- Once anticoagulation for PVT is started, 6-month follow-up imaging is recommended to assess efficacy.
COMMENT
This
up-to-date review encourages clinicians to reevaluate traditional practices in
management of coagulation issues in patients with cirrhosis. Based on this
review, I plan to avoid correcting INR and thrombocytopenia for minor
procedures, measure fibrinogen level and evaluate hemostasis using a newer
method like TEG in patients undergoing high-risk procedures, and take a more
aggressive stance in treating incidental PVT.
Source:
O'Leary JG et al. Coagulation in cirrhosis. Gastroenterology 2019 Apr 12 [Epub
ahead of print].
7. Health care utilization prior to
out-of-hospital cardiac arrest: A population-based study.
Shuvy
M, et al. Resuscitation. 2019 Apr 27 [Epub ahead of print].
INTRODUCTION:
Although
out-of-hospital cardiac arrest (OHCA) is thought of as a sudden event, recent
studies suggest that many patients have symptoms or have sought medical
attention prior to their arrest. Our objective was to evaluate patterns of
healthcare utilization before OHCA.
METHODS:
We
conducted a population-based cohort study in Ontario, Canada, which included
all patients ≥20 years, who suffered out-of-hospital cardiac arrest and
transferred to an emergency department (ED) from 2007 to 2018. Measurements
included emergency room assessments, hospitalizations and physician visits
prior to arrest.
RESULTS:
The
cohort comprised 38,906 patients, their mean age was 66.5 years, and 32.7% were
women. Rates of ED assessments and hospital admissions were relatively constant
until 90 days prior to arrest where they markedly increased to the time before
arrest. Within 90 days, rates of ED assessment, hospitalization, and primary
care physician visit were 29.5%, 16.4%, and 70.1%, respectively. Cardiovascular
conditions were diagnosed in 14.4% of ED visits, and 33.7% of hospitalizations
in this time period. The largest age-difference was the mental and behavioural
disorders within 90 days of OHCA in the ED, where rates were 12.2% among
patients less than 65 years vs. 1.9% for patients ≥65 years.
CONCLUSIONS:
In
contrast to the conventional wisdom that OHCA occurs without prior contacts to
the health care system, we found that more than 1 in 4 patients were assessed
in the ED prior within 90 days of their arrest. Identification of warning signs
of OHCA may allow future development of prevention strategies.
8. Alternatives to Rapid Sequence Intubation:
Contemporary Airway Management with Ketamine
Merelman
AH, et al. West J Emerg Med 2019;20(3):466-471.
Endotracheal
intubation (ETI) is a high-risk procedure commonly performed in emergency
medicine, critical care, and the prehospital setting. Traditional rapid
sequence intubation (RSI), the simultaneous administration of an induction
agent and muscle relaxant, is more likely to harm patients who do not allow
appropriate preparation and preoxygenation, have concerning airway anatomy, or
severe hypoxia, acidemia, or hypotension.
Ketamine,
a dissociative anesthetic, can be used to facilitate two alternatives to RSI to
augment airway safety in these scenarios: delayed sequence intubation – the use
of ketamine to allow airway preparation and preoxygenation in the agitated
patient; and ketamine-only breathing intubation, in which ketamine is used
without a paralytic to facilitate ETI as the patient continues to breathe
spontaneously. Ketamine may also provide hemodynamic benefits during standard
RSI and is a valuable agent for post-intubation analgesia and sedation. When
RSI is not an optimal airway management strategy, ketamine’s unique
pharmacology can be harnessed to facilitate alternative approaches that may
increase patient safety.
Full-text
(free): https://escholarship.org/uc/item/4b27s3ks
9. Association of Statewide Implementation of the
Prehospital TBI Treatment Guidelines with Patient Survival Following TBI: The
Excellence in Prehospital Injury Care (EPIC) Study.
Spaite
DW, et al. JAMA Surg. 2019 May 8 [Epub ahead of print]
Key
Points
Question Is implementation of prehospital TBI
treatment guidelines in demographically diverse emergency medical services
systems associated with survival in patients with major traumatic brain injury
(TBI)?
Findings In this cohort study, among 21 852 patients
with moderate, severe, or critical TBI (15 228 preimplementation and 6624
postimplementation), guideline implementation was not associated with improved
adjusted survival. However, it was associated with improved outcome in the
severe and severe, intubated subgroups.
Meaning Statewide implementation of the prehospital
TBI guidelines was independently associated with improvement in survival among
patients with severe TBI and in the severe, intubated group; these findings
support the widespread implementation of the prehospital TBI treatment
guidelines.
IMPORTANCE:
Traumatic
brain injury (TBI) is a massive public health problem. While evidence-based
guidelines directing the prehospital treatment of TBI have been promulgated, to
our knowledge, no studies have assessed their association with survival.
OBJECTIVE:
To
evaluate the association of implementing the nationally vetted, evidence-based,
prehospital treatment guidelines with outcomes in moderate, severe, and
critical TBI.
DESIGN,
SETTING, AND PARTICIPANTS:
The
Excellence in Prehospital Injury Care (EPIC) Study included more than 130
emergency medical services systems/agencies throughout Arizona. This was a
statewide, multisystem, intention-to-treat study using a before/after
controlled design with patients with moderate to critically severe TBI (US
Centers for Disease Control and Prevention Barell Matrix-Type 1 and/or
Abbreviated Injury Scale Head region severity ≥3) transported to trauma centers
between January 1, 2007, and June 30, 2015. Data were analyzed between October
25, 2017, and February 22, 2019.
INTERVENTIONS:
Implementation
of the prehospital TBI guidelines emphasizing avoidance/treatment of hypoxia,
prevention/correction of hyperventilation, and avoidance/treatment of
hypotension.
MAIN
OUTCOMES AND MEASURES:
Primary:
survival to hospital discharge; secondary: survival to hospital admission.
RESULTS:
Of
the included patients, the median age was 45 years, 14 666 (67.1%) were men,
7181 (32.9%) were women; 16 408 (75.1% ) were white, 1400 (6.4%) were Native
American, 743 (3.4% ) were Black, 237 (1.1%) were Asian, and 2791 (12.8%) were
other race/ethnicity. Of the included patients, 21 852 met inclusion criteria
for analysis (preimplementation phase [P1]: 15 228; postimplementation [P3]:
6624). The primary analysis (P3 vs P1) revealed an adjusted odds ratio (aOR) of
1.06 (95% CI, 0.93-1.21; P = .40) for survival to hospital discharge. The aOR
was 1.70 (95% CI, 1.38-2.09; P less than .001) for survival to hospital
admission. Among the severe injury cohorts (but not moderate or critical),
guideline implementation was significantly associated with survival to
discharge (Regional Severity Score-Head 3-4: aOR, 2.03; 95% CI, 1.52-2.72; P less
than .001; Injury Severity Score 16-24: aOR, 1.61; 95% CI, 1.07-2.48; P = .02).
This was also true for survival to discharge among the severe, intubated
subgroups (Regional Severity Score-Head 3-4: aOR, 3.14; 95% CI, 1.65-5.98; P less
than .001; Injury Severity Score 16-24: aOR, 3.28; 95% CI, 1.19-11.34;
P = .02).
CONCLUSIONS
AND RELEVANCE:
Statewide
implementation of the prehospital TBI guidelines was not associated with
significant improvement in overall survival to hospital discharge (across the
entire, combined moderate to critical injury spectrum). However, adjusted
survival doubled among patients with severe TBI and tripled in the severe,
intubated cohort. Furthermore, guideline implementation was significantly
associated with survival to hospital admission. These findings support the
widespread implementation of the prehospital TBI treatment guidelines.
10. Images in Clinical Practice
Image
Diagnosis: Boxers Ear
Man
With Pain in Both Legs
Man
With Bilateral Heel Pain
Pregnant
Woman With Abdominal Pain
Young
Man With Hip Injury
Elderly
Woman With Flank Pain
Man
With Sore Throat and Dyspnea
11. Diagnostic Accuracy and Financial Implications
of Age-Adjusted D-Dimer Strategies for the Diagnosis of DVT in the ED.
Reardon
PM, et al. J Emerg Med. 2019 May;56(5):469-477.
BACKGROUND:
Multiple
D-dimer cutoffs have been suggested for older patients to improve diagnostic
specificity for venous thromboembolism. These approaches are better established
for pulmonary embolism.
OBJECTIVES:
We
evaluated the diagnostic performance and compared the health system cost for
previously suggested cutoffs and a new D-dimer cutoff for low-risk emergency
department (ED) deep venous thrombosis (DVT) patients.
METHODS:
We
conducted a retrospective cohort study in two large EDs involving patients aged
greater than 50 years who had low pretest probability for DVT and had a D-dimer
performed. The outcome was a diagnosis of DVT at 30 days. We evaluated the
diagnostic accuracy and estimated the difference in cost for cutoffs of 500
ng/mL and the age-adjusted (age × 10) rule. A derived cutoff of 1000 ng/mL was
also assessed.
RESULTS:
Nine
hundred and seventy-two patients were included (median age 66 years; 59.5%
female); 63 (6.5%) patients were diagnosed with DVT. The conventional cutoff of
less than 500 ng/mL demonstrated a sensitivity of 100% (95% confidence interval
[CI] 94.3-100%) and a specificity of 35.6% (95% CI 32.5-38.8%). The
age-adjusted approach increased specificity while maintaining high sensitivity.
A new cutoff of 1000 ng/mL demonstrated improved performance: sensitivity 100%
(95% CI 94.3-00%) and specificity 66.3% (95% CI 63.2-69.4%). Compared to the
conventional approach, both the 1000 ng/mL cutoff and the age-adjusted cutoffs
could save healthcare dollars. A cutoff of 1000 ng/mL could have saved 310 ED
length of stay hours and $166,909 (Canadian dollars) in our cohort, or an average
savings of 0.32 h and $172 per patient.
CONCLUSIONS:
Among
patients aged greater than 50 years with suspected DVT, the age-adjusted
D-dimer and a cutoff of 1000 ng/mL improved specificity without compromising
sensitivity, and lowered the health care system cost compared to that for the
conventional approach.
12. Brief Lit Reviews by Ann Emerg Med
A. Are Antibiotics Effective in the Treatment of Children With
Prolonged Wet Cough?
Take-Home
Message
Antibiotics
may improve clinical cure and reduce progression of illness in children with
prolonged wet cough.
B. Can S100B Serum Biomarker Testing Reduce Head Computed
Tomography Scanning in Children With Mild Traumatic Brain Injury?
Take-Home
Message
S100B
serum biomarker has high sensitivity and negative predictive value for
detecting traumatic intracranial lesions in children with mild traumatic brain
injury. However, how to incorporate this into existing risk-stratification
tools is unclear, and reduced availability of the test currently limits its
practical application in the emergency department (ED).
C. Do Glucocorticoids Improve Symptoms and Reduce Return Visits or
Admission Rates Among Children With Croup?
Take-Home
Message
Compared
with placebo, glucocorticoids improve symptoms of croup at 2 through 24 hours
and reduce rates of return visits and admissions among children with croup.
D. Is Low-Dose Ketamine an Effective Alternative to Opioids for
Acute Pain?
Take-Home
Message
In
adult emergency department (ED) patients with acute pain, low-dose intravenous
ketamine (0.3 to 0.5 mg/kg) may provide pain relief within 10 minutes that is
similar to that of single-dose intravenous morphine (0.1 mg/kg).
E. What Is the Diagnostic Accuracy of Cardiac Biomarkers for the
Prediction of Adverse Cardiac Events in Patients Presenting With Acute Syncope?
Take-Home
Message
The
sensitivity of brain-type natriuretic peptides and troponin for identifying
syncopal patients at risk for major cardiac adverse events is inadequate.
F. Is Point-of-Care Ultrasonography Effective for the Diagnosis of
Urolithiasis?
Take-Home
Message
Moderate
or severe hydronephrosis is highly specific for the presence of a stone in
patients presenting with renal colic, whereas the absence of hydronephrosis
cannot exclude the diagnosis.
13. Putting healing back at the center of healthcare
Harvard
Business Review
The
primary mission of healthcare is to facilitate healing. People often associate
healing only with "cure," but it is much broader. A clinician heals
when she reassures a patient that a symptom does not signal a feared health
condition. A treatment heals when it mitigates pain and slows progression of
disease. Healing even occurs when a very sick patient dies at home surrounded
by family instead of in a hospital attached to machines. Each unique instance
of healing represents a physical and emotional journey through difficulty,
toward contentment and even peace. All patients need healing, and when
clinicians and their institutions actively foster it, they renew themselves,
too.
14. More Neuro Research
A. Brain Trust: Some of What You Think about Concussions is Wrong
Dolbec
K. Emerg Med News 2019;41(5):9.
The
recent hype surrounding concussion may make you feel even more confused than
your concussed patient when it comes to workup, diagnosis, and plan for mild
traumatic brain injury. But fear not! Hot off the press is the American Medical
Society for Sports Medicine's updated position statement on concussion.
Sport-related
concussion has become a hot topic in medicine and the lay press over the past
decade. It is a common injury in adults and kids, with up to 1.8 million
sports-related concussions occurring annually in children under 18 in the
United States. (Pediatrics. 2016;138[1]. pii: e20154635;
http://bit.ly/2F65Af1.) Sports-related concussion has been associated with
post-concussion syndrome, second impact syndrome, and chronic traumatic
encephalopathy. Health care professionals are left scratching their heads as
they try to decide whether to get a CT, how long to relegate their patients to
confinement in a dark, stimulus-free room, and when to allow patients to return
to school, work, and sports.
Concussion
is a traumatically induced transient disturbance of brain function that
involves a complex pathophysiological process.” (Br J Sports Med.
2019;53[4]:213; http://bit.ly/2EYCmhZ.) It is not completely understood, but
involves a complex metabolic and biochemical disturbance in response to
post-impact neuronal stretching. A clinical diagnosis of concussion is
established in a patient with history and examination consistent with mild
traumatic brain injury after ruling out intoxication, underlying medical
conditions, and other injuries.
Clinical
signs and symptoms are currently the only reliable way to diagnose concussion.
Patients describe symptoms such as headache, dizziness, mood changes,
fogginess, feeling “out of it,” visual changes, and neck pain. Objective
findings of concussion include loss of consciousness, post-impact seizure,
tonic posturing, gross motor instability, confusion, and amnesia. Findings such
as prolonged loss of consciousness, severe or worsening headache, multiple
episodes of vomiting, mental status deterioration, focal neurologic deficits,
and concern for cervical spinal injury warrant additional workup for more
severe closed head or cervical spinal injury. This generally involves the use
of imaging. Biomarkers that may someday prove useful for ruling out structural
brain damage exist, but they are not ready for prime time.
So
you diagnosed your patient with a concussion. Now what? For starters, you can
provide reassurance that concussion symptoms are generally self-limiting. The
vast majority of older adolescents and adults will be back to baseline within
two weeks. The recovery process for younger children is generally slower, but
most recover within four weeks.
A
Big Change
Perhaps
the biggest paradigm shift with the updated guidelines is a change in treatment
recommendations for acute concussion. Mounting evidence shows that the
previously held mainstay of treatment, complete brain and physical rest, is
actually harmful. The new recommendation is to engage in symptom-limited rest
for the first 24-48 hours, followed by a gradual increase in activity, making
sure to avoid exertion that causes the return of symptoms. Light aerobic
exercise may actually accelerate recovery from a concussion.
Patients
should be advised to return to work and school as soon as they are able to do
so without experiencing symptom exacerbation. Return to sports should not begin
until there is complete return to school or work, and should follow a
supervised, graded plan with 24-hour symptom-free periods between each
progressive step.
Patients
should be counseled about the potential risks of driving after sustaining a
concussion. Reaction time, concentration, memory, and visual perception are
compromised during the acute concussive period and even for a period of time
after symptom resolution and may make driving unsafe. Unfortunately, there is
not yet good evidence or available guidelines about driving after concussion,
so you will just need to use your best judgment and encourage your patient to
do the same.
The
risks of returning to sports too early include delayed recovery and increased
risk of musculoskeletal injury. Another rare and controversial consequence of
premature return to sports is second impact syndrome, the rapid development of
diffuse cerebral edema, herniation, and death when a brain recovering from
concussion sustains a subsequent traumatic blow. This risk should deter even
the most zealous athlete from attempting to play too soon.
New
guidelines from American Medical Society for Sports Medicine (full-text free): Br
J Sports Med. 2019;53[4]:213; https://bjsm.bmj.com/content/53/4/213.long
B. Episodic Vertigo Is Linked to Migraine
Neurology
Advisor (5/8, Rothbard) reports that research indicated that “nearly a third of
patients with migraine were found to experience vestibular-type episodic
vertigo before and/or during an acute attack.” The findings were published in
the Journal of Headache and Pain.
Journal
article: https://thejournalofheadacheandpain.biomedcentral.com/articles/10.1186/s10194-019-0991-2
15. Brief cognitive therapy not helpful compared
with treatment as usual in patients with non-cardiac CP
Mulder
R, et al. Int J Cardiol. 2019 Feb 5. [Epub ahead of print]
BACKGROUND:
Non-cardiac
chest pain (NCCP) is a common reason for presenting to an emergency department
(ED). Many patients re-present with similar symptoms despite reassurance.
OBJECTIVE:
To
investigate the clinical value of a brief cognitive behavioural treatment (CBT)
in reducing re-presentations of patients who present with NCCP.
METHOD:
A
randomised controlled trial (RCT) comparing three or four sessions of NCCP
directed CBT with treatment as usual (TAU). The primary outcome measure was
reducing health service use measured as re-presentations to the ED and
hospitalisations for NCCP over 12 months of follow-up. Secondary outcomes were
chest pain, health anxiety, depression, anxiety, quality of life and social
functioning.
RESULTS:
214
patients received CBT and 210 TAU. There was no difference in ED visits or
hospitalisation at three months or 12 months follow-up. Those with prior ED
presentations for NCCP were significantly less likely to present with NCCP at
three months follow-up but not at 12 months. Health anxiety was less at three
months in those who received CBT but this effect was not present at 12 months.
No other differences in secondary outcome measures were present.
CONCLUSIONS:
A
brief CBT intervention for NCCP failed to reduce representations or improve
psychological health over 12 months. We do not recommend such an intervention
to unselected patients with NCCP. Patients presenting with prior episodes of
NCCP obtain benefit for a three-month period. Working with those patients to
sustain their improvement might be worthwhile.
16. Register to donate while you wait: Assessing
public opinions of the acceptability of utilizing the ED waiting room for organ
and tissue donor registration
Ellis
B, et al. CJEM. 2019 May 14:1-4.
OBJECTIVE:
Our
objectives were to identify barriers to the organ donation registration process
in Ontario; and to determine the acceptability of using the emergency
department (ED) waiting room to provide knowledge and offer opportunities for
organ and tissue donor registration.
METHODS:
We
conducted a paper based in-person survey over nine days in March and April
2017. The survey instrument was created in English using existing literature
and expert opinion, pilot tested and then translated into French. Data was collected
from patients and visitors in an urban academic Canadian tertiary care ED
waiting room. All adults in the waiting room were approached to participate
during study periods. We excluded patients who were too ill and required
immediate treatment.
RESULTS:
The
number of attempted surveys was 324; 67 individuals (20.7%) declined
participation. A total of 257 surveys were distributed and five were returned
blank. This gave us a response rate of 77.8% with 252 completed surveys. The
median age group was 51-60 years old with 55.9% female. Forty-six percent
reported their religion as Christian and 34.1% did not declare a religious
affiliation. 44.1% were already registered donors. Most participants agreed or
were neutral that the ED waiting room was an acceptable place to provide
information on donation, and for registration as an organ and tissue donor
(83.3% and 82.1%, respectively).
CONCLUSIONS:
Individuals
waiting in the ED are generally supportive of using the waiting room for
distributing information regarding organ and tissue donation, and to allow
donor registration.
17. Syncope Research
A. The Yield of CT of the Head Among Patients Presenting with
Syncope: A Systematic Review.
Viau
JA, et al. Acad Emerg Med. 2019 May;26(5):479-490.
BACKGROUND:
Overuse
of head computed tomography (CT) for syncope has been reported. However, there
is no literature synthesis on this overuse. We undertook a systematic review to
determine the use and yield of head CT and risk factors for serious
intracranial conditions among syncope patients.
METHODS:
We
searched Embase, Medline, and Cochrane databases from inception until June
2017. Studies including adult syncope patients with part or all of patients
undergoing CT head were included. We excluded case reports, reviews, letters,
and pediatric studies. Two independent reviewers screened the articles and
collected data on CT head use, diagnostic yield (proportion with acute
hemorrhage, tumors or infarct), and risk of bias. We report pooled percentages,
I2 , and Cochran's Q-test.
RESULTS:
Seventeen
articles with 3,361 syncope patients were included. In eight ED studies (n =
1,669), 54.4% (95% confidence interval [CI] = 34.9%-73.2%) received head CT
with a 3.8% (95% CI = 2.6%-5.1%) diagnostic yield and considerable
heterogeneity. In six in-hospital studies (n = 1,289), 44.8% (95% CI =
26.4%-64.1%) received head CT with a 1.2% (95% CI = 0.5%-2.2%) yield and no
heterogeneity. In two articles, all patients had CT (yield 2.3%) and the third
enrolled patients ≥ 65 years old (yield 7.7%). Abnormal neurologic findings,
age ≥ 65 years, trauma, warfarin use, and seizure/stroke history were
identified as risk factors. The quality of all articles referenced was strong.
CONCLUSION:
More
than half of patients with syncope underwent CT head with a diagnostic yield of
1.1% to 3.8%. A future large prospective study is needed to develop a robust
risk tool.
B. Do High-sensitivity Troponin and Natriuretic Peptide Predict
Death or Serious Cardiac Outcomes After Syncope?
Clark
CL, et al. Acad Emerg Med. 2019 May;26(5):528-538.
OBJECTIVES:
An
estimated 1.2 million annual emergency department (ED) visits for syncope/near
syncope occur in the United States. Cardiac biomarkers are frequently obtained
during the ED evaluation, but the prognostic value of index high-sensitivity
troponin (hscTnT) and natriuretic peptide (NT-proBNP) are unclear. The
objective of this study was to determine if hscTnT and NT-proBNP drawn in the
ED are independently associated with 30-day death/serious cardiac outcomes in
adult patients presenting with syncope.
METHODS:
A
prespecified secondary analysis of a prospective, observational trial enrolling
participants ≥ age 60 presenting with syncope, at 11 United States hospitals,
was conducted between April 2013 and September 2016. Exclusions included
seizure, stroke, transient ischemic attack, trauma, intoxication, hypoglycemia,
persistent confusion, mechanical/electrical invention, prior enrollment, or
predicted poor follow-up. Within 3 hours of consent, hscTnT and NT-proBNP were
collected and later analyzed centrally using Roche Elecsys Gen 5 STAT and 2010
Cobas, respectively. Primary outcome was combined 30-day all-cause mortality
and serious cardiac events. Adjusting for illness severity, using multivariate
logistic regression analysis, variations between primary outcome and biomarkers
were estimated, adjusting absolute risk associated with ranges of biomarkers
using Bayesian Markov Chain Monte Carlo methods.
RESULTS:
The
cohort included 3,392 patients; 367 (10.8%) experienced the primary outcome.
Adjusted absolute risk for the primary outcome increased with hscTnT and
NT-proBNP levels. HscTnT levels ≤ 5 ng/L were associated with a 4% (95%
confidence interval [CI] = 3%-5%) outcome risk, and hscTnT greater than 50
ng/L, a 29% (95% CI = 26%-33%) risk. NT-proBNP levels ≤ 125 ng/L were
associated with a 4% (95% CI = 4%-5%) risk, and NT-proBNP greater than 2,000
ng/L a 29% (95% CI = 25%-32%) risk. Likelihood ratios and predictive values
demonstrated similar results. Sensitivity analyses excluding ED index serious
outcomes demonstrated similar findings.
CONCLUSIONS:
hscTnT
and NT-proBNP are independent predictors of 30-day death and serious outcomes
in older ED patients presenting with syncope.
C. The Famed Ben Sun Syncope Study
Here
are the most recent publications from this large, well-done multicenter study: https://www.ncbi.nlm.nih.gov/pubmed/?term=sun+bc+and+syncope+and+2019
18. Accuracy and timeliness of an abbreviated ED MRCP
protocol for choledocholithiasis.
Tso
DK, et al. Emerg Radiol. 2019 Apr 27 [Epub ahead of print]
PURPOSE:
To
determine the diagnostic accuracy and time savings of an abbreviated magnetic
resonance cholangiopancreatography (A-MRCP) protocol for detecting
choledocholithiasis in patients visiting the emergency department (ED) for
suspected biliary obstruction.
METHODS
AND MATERIALS:
This
retrospective study evaluated adult patients (ages 18+ years) visiting an
academic Level 1 trauma center between January 1, 2016, and December 31, 2017,
who were imaged with MRCP for suspected biliary obstruction. Patients were scanned
with either a four-sequence A-MRCP protocol or a conventional eight-sequence
MRCP (C-MRCP) protocol. Image acquisition and MRI room time were compared. The
radiology report was used to determine whether a study was limited by motion or
prematurely aborted, as well as for the presence of pertinent biliary findings.
Diagnostic accuracy of A-MRCP studies were compared with any available
endoscopic retrograde cholangiopancreatography (ERCP) report within 30 days.
RESULTS:
One
hundred sixteen patients met inclusion criteria; 85 were scanned with the
A-MRCP protocol (45.9% male, mean 57.4 years) and 31 with the C-MRCP protocol
(38.7% male, mean 58.3 years). Mean image acquisition time and MRI room time
for the A-MRCP protocol were significantly lower compared to those for the
C-MRCP protocol (16 and 34 min vs. 42 and 61 min, both p less than 0.0001).
Choledocholithiasis was seen in 23.5% of A-MRCP cases and 19.4% of C-MRCP
cases. Non-biliary findings were common in both cohorts, comprising 56.5% of
A-MRCP cases and 41.9% of C-MRCP cases. 44.7% of A-MRCP patients received
subsequent (diagnostic or therapeutic) ERCP (mean follow-up time 3 days), in
which A-MRCP accurately identified choledocholithiasis in 86.8% of cases, with
sensitivity of 85%, specificity of 88.9%, positive predictive value (PPV) of
89.5%, and negative predictive value (NPV) of 84.2%. In comparison, 38.7% of
C-MRCP patients underwent ERCP (mean follow-up of 2.3 days) with an accuracy of
91.7%, sensitivity of 80%, specificity of 100%, PPV of 100%, and NPV of 87.5%.
Only 4.7% of A-MRCP exams demonstrated motion artifact vs. 12.9% of C-MRCP
exams. One study was prematurely aborted due to patient discomfort in the
A-MRCP cohort while no studies were terminated in the C-MRCP cohort.
CONCLUSION:
An
abbreviated MRCP protocol to evaluate for choledocholithiasis provides
significant time savings and reduced motion artifact over the conventional MRCP
protocol while providing similar diagnostic accuracy.
19. AMI Complicated by Cardiogenic Shock
A. PCI Benefits Older Patients with STEMI and Cardiogenic Shock.
Damluji
AA, et al. J Am Coll Cardiol. 2019 Apr 23;73(15):1890-1900.
BACKGROUND:
Older
adults ≥75 years of age carry an increased risk of mortality after ST-segment
elevation myocardial infarction (STEMI) complicated by cardiogenic shock.
OBJECTIVES:
The
purpose of this study was to examine the use of percutaneous coronary
intervention (PCI) in older adults with STEMI and shock and its influence on
in-hospital mortality.
METHODS:
We
used a large publicly available all-payer inpatient health care database
sponsored by the Agency for Healthcare Research and Quality between 1999 and
2013. The primary outcome was in-hospital mortality. The influence of PCI on
in-hospital mortality was assessed by quintiles of propensity score (PS).
RESULTS:
Of
the 317,728 encounters with STEMI and shock in the United States, 111,901 (35%)
were adults age ≥75 years. Of these, 53% were women and 83% were Caucasians.
The median number of chronic conditions was 8 (interquartile range: 6 to 10).
The diagnosis of STEMI and cardiogenic shock in older patients decreased
significantly over time (proportion of older adults with STEMI and shock: 1999:
42% vs. 2013: 29%). Concomitantly, the rate of PCI utilization in older adults
increased (1999: 27% vs. 2013: 56%, p less than 0.001), with declining
in-hospital mortality rates (1999: 64% vs. 2013: 46%; p less than 0.001).
Utilizing PS matching methods, PCI was associated with a lower risk of
in-hospital mortality across quintiles of propensity score (Mantel-Haenszel
odds ratio: 0.48; 95% confidence interval [CI]: 0.45 to 0.51). This reduction
in hospital mortality risk was seen across the 4 different U.S. census bureau
regions (adjusted odds ratio: Northeast: 0.41; 95% CI: 0.36 to 0.47; Midwest: 0.49;
95% CI: 0.42 to 0.57; South: 0.51; 95% CI: 0.46 to 0.56; West: 0.46; 95% CI:
0.41 to 0.53).
CONCLUSIONS:
This
large and contemporary analysis shows that utilization of PCI in older adults
with STEMI and cardiogenic shock is increasing and paralleled by a substantial
reduction in mortality. Although clinical judgment is critical, older adults
should not be excluded from early revascularization based on age in the absence
of absolute contraindications.
B. Impella use in AMI complicated by cardiogenic shock and cardiac
arrest: Analysis of 10 years registry data.
Davidsen
C, et al. Resuscitation. 2019 Apr 19 [Epub ahead of print]
AIMS:
To
assess characteristics and outcome of patients treated with Impella for acute
myocardial infarction (AMI) complicated by severe cardiogenic shock (CS) or
cardiac arrest (CA).
METHODS
AND RESULTS:
From
2008 through 2017, 92 patients with AMI complicated by CS were treated with
Impella. Survival varied according to clinical presentation. Patients in
cardiogenic shock without CA had a 75% 30-day survival. Patients with CA and
return of spontaneous circulation (ROSC) had a 43% survival and those with CA
and ongoing cardio-pulmonary resuscitation (CPR) had a 6% 30-day survival. Age,
pre-existing hypertension, coronary disease, ventilatory support and use of
adrenergic agents were associated with worse prognosis. Complications were
predominantly access site related.
CONCLUSIONS:
In
this registry of patients with AMICS treated with Impella, hypertension and
older age were found to be negatively predictive for survival. Patients without
CA had the highest 30-day survival. In patients with ROSC, survival was
strongly related to age and comorbidity. Patients with ongoing CPR had very
high mortality.
20. Nonmydriatic Fundus Photography in Patients in
the ED
A. Ophthalmoscopy in the 21st century: The 2017 H. Houston Merritt
Lecture.
Biousse
V, et al. Neurology. 2018 Jan 23;90(4):167-175.
Although
the usefulness of viewing the ocular fundus is well-recognized, ophthalmoscopy
is infrequently and poorly performed by most nonophthalmologist physicians,
including neurologists. Barriers to the practice of ophthalmoscopy by
nonophthalmologists include not only the technical difficulty related to direct
ophthalmoscopy, but also lack of adequate training and discouragement by
preceptors.
Recent
studies have shown that digital retinal fundus photographs with electronic
transmission and remote interpretation of images by an ophthalmologist are an
efficient and reliable way to allow examination of the ocular fundus in
patients with systemic disorders such as diabetes mellitus. Ocular fundus
photographs obtained without pharmacologic dilation of the pupil using
nonmydriatic fundus cameras could be of great value in emergency departments
(EDs) and neurologic settings.
The
Fundus Photography vs Ophthalmoscopy Trial Outcomes in the Emergency Department
(FOTO-ED) study showed that ED providers consistently failed to correctly
identify relevant ocular funduscopic findings using the direct ophthalmoscope,
and that nonmydriatic fundus photography was an effective alternate way of
providing access to the ocular fundus in the ED. Extrapolating these results to
headache clinics, outpatient neurology clinics, and adult and pediatric primary
care settings seems self-evident. As technology advances, nonmydriatic ocular
fundus imaging systems will be of higher quality and more portable and
affordable, thereby circumventing the need to master the use of the
ophthalmoscope. Visualizing the ocular fundus is more important than the method
used. Ocular fundus photography facilitates nonophthalmologists' performance of
this essential part of the physical examination, thus helping to reestablish
the value of doing so.
B. Nonmydriatic Fundus Photography in Patients with Acute Vision
Loss.
Vasseneix
C, et al. Telemed J E Health 2018 Dec 20 [Epub ahead of print]
BACKGROUND:
Acute
visual loss is a common chief complaint in emergency department (ED) patients,
but the scarcity of ophthalmologists in most EDs limits its evaluation.
INTRODUCTION:
Our
objective was to evaluate whether nonmydriatic fundus photography (NMFP) in the
ED helps triage patients with acute visual loss.
MATERIALS
AND METHODS:
We
included 213 patients with acute visual loss evaluated in the ED with NMFP as
part of the Fundus Photography versus Ophthalmoscopy Trial Outcomes in the ED
studies. Demographics, referral patterns, results of NMFP, and final diagnoses
were recorded.
RESULTS:
A
final ophthalmological diagnosis was made in 109/213 (51%) patients. NMFP
allowed a definite diagnosis in 51/109 (47%) patients: 14 nonglaucomatous optic
neuropathies, 10 papilledema, 13 acute retinal ischemia, 2 retinal detachments,
2 choroidal metastases, 4 maculopathies, and 6 glaucoma. In 58/109 (53%)
patients, NMFP was not diagnostic even when interpreted remotely by
ophthalmologists due to disorders undiagnosable with NMFP. Ophthalmology
consultation was requested in 109/213 (51%) patients, 41/54 (76%) patients with
abnormal NMFP versus 68/159 (43%) patients with normal NMPF (p less than
0.001).
DISCUSSION:
Although
NMFP allowed rapid diagnosis in 51/213 (24%) patients presenting to the ED with
acute visual loss, NMFP alone was not sufficient to detect all ocular diseases;
ophthalmology consultation was more often requested when NMFP was abnormal.
CONCLUSIONS:
Our
study emphasizes the limitations of teleophthalmology with NMFP in remotely
detecting ocular diseases related to acute visual loss in the ED. NMFP helped
triage and referral decisions and can be used to complement ophthalmology
consultations in the ED.
21. Pediatrics
A. Time to perforation for button batteries lodged in the
esophagus.
Soto
PH, et al. Am J Emerg Med. 2019 May;37(5):805-809.
INTRODUCTION:
New
strategies recently proposed to mitigate injury caused by lithium coin cell
batteries lodged in the esophagus include prehospital administration of honey
to coat the battery and prevent local hydroxide generation and in-hospital
administration of sucralfate suspension (or honey). This study was undertaken
to define the safe interval for administering coating agents by identifying the
timing of onset of esophageal perforations.
METHODS:
A
retrospective study of 290 fatal or severe battery ingestions with esophageal
lodgment was undertaken to identify cases with esophageal perforations.
RESULTS:
Esophageal
perforations were identified in 189 cases (53 fatal, 136 severe; 95.2% in
children ≤4 years). Implicated batteries were predominantly lithium (91.0%) and
92.0% were ≥20 mm diameter. Only 2% of perforations occurred in less than 24 h
following ingestion, including 3 severe cases with perforations evident at
11-17 h, 12 h, and 18 h. Another 7.4% of perforations (11 cases) became evident
24 to 47 h post ingestion and 10.1% of perforations (15 cases) became evident
48 to 71 h post ingestion. By 3 days post ingestion, 26.8% of perforations were
evident, 36.9% by 4 days, 46.3% by 5 days, and 66.4% by 9 days.
CONCLUSION:
Esophageal
perforation is unlikely in the 12 h after battery ingestion, therefore the
administration of honey or sucralfate carries a low risk of extravasation from
the esophagus. This first 12 h includes the period of peak electrolysis
activity and battery damage, thus the risk of honey or sucralfate is low while
the benefit is likely high.
B. A Cost-Effectiveness Analysis Comparing Clinical Decision Rules
PECARN, CATCH, and CHALICE with Usual Care for the Management of Pediatric Head
Injury.
Dalziel
K, et al. and PREDICT. Ann Emerg Med. 2019 May;73(5):429-439.
STUDY
OBJECTIVE:
To
determine the cost-effectiveness of 3 clinical decision rules in comparison to
Australian and New Zealand usual care: the Children's Head Injury Algorithm for
the Prediction of Important Clinical Events (CHALICE), the Pediatric Emergency
Care Applied Research Network (PECARN), and the Canadian Assessment of
Tomography for Childhood Head Injury (CATCH).
METHODS:
A
decision analytic model was constructed from the Australian health care system
perspective to compare costs and outcomes of the 3 clinical decision rules compared
with Australian and New Zealand usual care. The study involved multicenter
recruitment from 10 Australian and New Zealand hospitals; recruitment was based
on the Australian Pediatric Head Injury Rules Study involving 18,913 children
younger than 18 years and with a head injury, and with Glasgow Coma Scale score
13 to 15 on presentation to emergency departments (EDs). We determined the
cost-effectiveness of the 3 clinical decision rules compared with usual care.
RESULTS:
Usual
care, CHALICE, PECARN, and CATCH strategies cost on average AUD $6,390, $6,423,
$6,433, and $6,457 per patient, respectively. Usual care was more effective and
less costly than all other strategies and is therefore the dominant strategy.
Probabilistic sensitivity analyses showed that when simulated 1,000 times,
usual care dominated all clinical decision rules in 61%, 62%, and 60% of
simulations (CHALICE, PECARN, and CATCH, respectively). The difference in cost
between all rules was less than $36 (95% confidence interval -$7 to $77) and
the difference in quality-adjusted life-years was less than 0.00097 (95%
confidence interval 0.0015 to 0.00044). Results remained robust under
sensitivity analyses.
CONCLUSION:
This
evaluation demonstrated that the 3 published international pediatric head
injury clinical decision rules were not more cost-effective than usual care in
Australian and New Zealand tertiary EDs. Understanding the usual care context
and the likely cost-effectiveness is useful before investing in implementation
of clinical decision rules or incorporation into a guideline.
C. Pediatric vaccine-proximate febrile seizures not a cause for
worry
Youths
experiencing vaccine-proximate febrile seizures were not at greater risk of
having seizures that lasted more than 15 minutes, being hospitalized for more
than a day, being admitted to the intensive care unit or requiring
anti-epileptic treatment than children with nonvaccine-proximate febrile
seizures, according to an Australian study in Pediatrics. "We hope the
findings of this study give parents and immunization providers the confidence
to continue vaccinating children who have had a febrile seizure after
vaccination," researcher and pediatrician Lucy Deng said.
Deng
L, et al. Postvaccination Febrile Seizure Severity and Outcome. Pediatrics.
2019 May;143(5).
BACKGROUND:
Febrile
seizures (FSs) are a common pediatric condition caused by a sudden rise in
temperature, affecting 3% to 5% of children aged ≤6 years. Although vaccination
can cause FSs, little is known on whether FSs occurring in the time soon after
vaccination (vaccine-proximate febrile seizures [VP-FSs] differ clinically from
non-vaccine-proximate febrile seizures [NVP-FSs]). We compared the clinical
profile and outcomes of VP-FS to NVP-FS.
METHODS:
Prospective
cohort study of children aged ≤6 years presenting with their first FS at 1 of 5
Australian pediatric hospitals between May 2013 and June 2014. Clinical
features, management, and outcomes were compared between VP-FS and NVP-FS.
RESULTS:
Of
1022 first FS cases (median age 19.8 months; interquartile range 13.6-27.6), 67
(6%) were VP-FSs. When comparing VP-FS to NVP-FS, there was no increased risk
of prolonged (greater than 1 day) hospitalization (odds ratio [OR] 1.61; 95%
confidence interval [95% CI] 0.84-3.10), ICU admission (OR 0.72; 95% CI
0.10-5.48), seizure duration greater than 15 minutes (OR 1.47; 95% CI
0.73-2.98), repeat FS within 24 hours (OR 0.80; 95% CI 0.34-1.89), or
requirement for antiepileptic treatment on discharge (OR 1.81; 95% CI
0.41-8.02). VP-FS patients with a laboratory-confirmed infection (12%) were
more likely to have a prolonged admission compared with those without.
CONCLUSIONS:
VP-FS
accounted for a small proportion of all FS hospital presentations. There was no
difference in outcomes of VP-FS compared with NVP-FS. This is reassuring data
for clinicians and parents of children who experience FS after vaccination and
can help guide decisions on revaccination.
22. Reducing ED Visits
A. Interventions to Decrease Use in Prehospital and Emergency Care
Settings Among Super-Utilizers in the United States: A Systematic Review.
Iovan
S, et al. Med Care Res Rev. 2019 Apr 26
[Epub ahead of print]
Interest
in high users of acute care continues to grow as health care organizations look
to deliver cost-effective and high-quality care to patients. Since
"super-utilizers" of acute care are responsible for
disproportionately high health care spending, many programs and interventions
have been implemented to reduce medical care use and costs in this population.
This article presents a systematic review of the peer-reviewed and grey
literature on evaluations of interventions to decrease prehospital and emergency
care use among U.S. super-utilizers. Forty-six distinct evaluations were
included in the review. The most commonly evaluated intervention was case
management. Although a number of interventions reported reductions in
prehospital and emergency care utilization and costs, methodological and study
design weaknesses-especially regression to the mean-were widespread and call
into question reported positive findings. More high-quality research is needed
to accurately assess the impact of interventions to reduce prehospital and
emergency care use in the super-utilizer population.
B. Can the Right Technology Reduce
Avoidable ED Visits?
By
Rob Waters. California Health Care Foundation. APRIL 23, 2019
In
2014, a record 141 million patients (PDF) visited US emergency departments
(EDs). As the nation’s health care system looks for ways to reduce unnecessary
treatment and spending, health policy experts have debated how many of those ED
visits could be avoided, and exactly what constitutes an “avoidable” visit.
Whatever side one may take in this debate, the number of ED visits grew faster
than the overall population for the decade ending in 2015, according to a
recent article in Health Affairs.
Many
industry leaders believe that demand for ED care could be reduced through
smarter management of chronic diseases in primary care settings along with
easier access to mental health and substance use disorder treatment. Achieving
gains in this arena would not only be important for the national health system,
it would confer a significant benefit to Medicaid programs and safety-net
providers. In 2016, California’s Medi-Cal — the nation’s largest Medicaid
program — was projected to pay for 43% of all ED visits in the state.
While
“avoidable” ED visits are not a top driver of overall health spending, it’s
clear that “a subpopulation of ED patients can be better treated elsewhere at
lower costs,” said Renee Hsia, MD, MSc, an emergency medicine professor and
researcher at UCSF. “There are plenty of people who don’t have access to timely
primary care, and then they come to the emergency department for things that
could be done in outpatient clinics or a primary care doctor’s office.”
Among
people visiting an ED for a potentially avoidable reason, she said, the top
complaints are toothache, back pain, headache, symptoms of psychosis or
anxiety, and throat soreness. When those people leave the ED, the three most
common diagnoses placed in their records are alcohol use disorder, dental
conditions, and depression and other mood disorders, Hsia said.
Technologies
That Could Avert ED Visits
The
CHCF Innovation Fund focuses on improving health outcomes for vulnerable
Californians through better access to care and technologies — including
solutions that help patients enhance their health status and avoid preventable
ED visits. Some of the Innovation Fund’s investments are geared toward helping
patients better manage chronic conditions that, when not controlled, can spiral
into costly, life-threatening medical emergencies. Two of them are Propeller
Health and Quartet Health….
The
remainder of the essay: https://www.chcf.org/blog/can-the-right-technology-reduce-avoidable-emergency-department-visits/
23. California ED Patients Increasingly Leaving
Hospitals Before Medical Care Is Complete, Data Indicate
Kaiser
Health News (5/17, Reese) reports that emergency department “patients
increasingly leave California hospitals against medical advice, and experts say
crowded” EDs “are likely to blame.” Around “352,000 California” ED “visits in
2017 ended when patients left after seeing a doctor but before their medical
care was complete,” which is “up by 57%, or 128,000 incidents, from 2012,
according to data from the Office of Statewide Health Planning and
Development.” Further, “in 2017, the median” ED “wait time for patients before
admission as inpatients to California hospitals was 336 minutes,” which “is up
15 minutes from 2012, according to the federal Centers for Medicare &
Medicaid Services.”
24. Micro Bits
A. Buccally
absorbed as good as intravenous prochlorperazine for treatment of migraines
headaches
B.
Antibody-Based Ticagrelor Reversal Agent in Healthy Volunteers
C. Seriously
ill children often resist treatment. Can offering simple rewards change that?
PBS
Video (8m): https://www.pbs.org/newshour/show/seriously-ill-children-often-resist-treatment-can-offering-simple-rewards-change-that
D. Viruses
genetically engineered to kill bacteria rescue girl with antibiotic-resistant
infection
Alex
Fox, Science Mag. May. 8, 2019
One
week after Helen Spencer's 15-year-old cystic fibrosis patient had a double
lung transplant in September 2017, the incision wound turned bright red. For
half her life, Isabelle Carnell had been battling a drug-resistant infection of
Mycobacterium abscessus, and now it was rapidly spreading, erupting in weeping
sores and swollen nodules across her frail body. "My heart sinks when I
see that a [lung transplant] patient has got a wound infection, because I know
what the trajectory is going to be," says Spencer, Isabelle's respiratory
pediatrician at Great Ormond Street Hospital in London. "It's a torturous
course that has ended in death for all those children."
With
the standard treatments failing, Isabelle's mother asked Spencer about
alternatives—adding that she had read something about using viruses to kill
bacteria. Spencer decided to take a gamble on what seemed like a far-fetched
idea: phages, viruses that can destroy bacteria and have a long—if
checkered—history as medical treatments. She collaborated with leading phage
researchers, who concocted a cocktail of the first genetically engineered
phages ever used as a treatment—and the first directed at a Mycobacterium, a
genus that includes tuberculosis (TB). After 6 months of the tailor-made phage
infusions, Isabelle's wounds healed and her condition improved with no serious
side effects, the authors report today in Nature Medicine.
"This
is a convincing proof of concept, even though it's just a single case
study," says infectious disease researcher Eric Rubin of the Harvard T.H.
Chan School of Public Health in Boston. But, he adds, "This needs to be
tested rigorously with a real clinical trial."
The
rest of the essay: https://www.sciencemag.org/news/2019/05/viruses-genetically-engineered-kill-bacteria-rescue-girl-antibiotic-resistant-infection
E. FDA
strengthens warning about sleeping pill dangers
F. World's
1st 'cocoon' bed aims to lower ICU delirium
9News
Up
to 80% of ICU patients suffer some form of delirium, a change in consciousness
that can involve confusion, agitation, restlessness, nightmares and
hallucinations, and 30% develop post-traumatic stress disorder. Brisbane's
Prince Charles Hospital Foundation wants to improve the treatment of patients
in ICU by lowering rates of delirium with a world-first hospital bed dubbed the
Intensive Care Cocoon. The bed features noise-cancelling technology that moves
the incessant beeping of monitoring equipment away from the patient's head,
simulates day and night, and even allows the patient to view live video of
their home so they can talk to their family and pets.
G. Repetition
helps preschoolers learn to eat healthy foods
H. Venous
thromboembolism risk in US hospitals
Over
half of adult patients who spent more than two days in US acute care hospitals
met the American College of Chest Physicians criteria for consideration of
venous thromboembolism prophylaxis, based on risk factors associated with
surgery and acute medical illness. Data presented here provide an objective
basis for estimating the potential impact of venous thromboembolism prevention
on patient care, together with associated costs, risks, and benefits.
I. No-Spin
Zone'? Not in Cardiology: High proportion of abstracts and papers up-sell their
findings, study finds
J. Motivational
Interviewing: Four Steps to Get Started
When
patients have unhealthy behaviors, what they “should do” is often obvious —
e.g., lose weight. What is less obvious is why patients are so reluctant to
change. These four steps of motivational interviewing can help.
K. Music
therapy in NICUs can help babies get home sooner
Research
shows that music therapy in neonatal intensive care units helps infants get
released from the hospital early. Experts in Florida helped pioneer the
practice, and now it's expanding. For centuries, lullabies have helped soothe
babies to sleep. But it's only in the last couple decades that research showed,
for premature babies, these slow, simple tunes could be life-changing.
L. Azithromycin
appears to reduce treatment failure in severe, acute COPD exacerbations
The
antibiotic azithromycin may reduce treatment failure in patients hospitalized
for an acute exacerbation of chronic obstructive pulmonary disease, according
to a randomized, controlled trial published online in the American Thoracic
Society's American Journal of Respiratory and Critical Care Medicine. Previous
studies have shown that azithromycin prevents acute COPD exacerbations, but
whether the antibiotic could reduce the need to intensify care of patients
hospitalized for an exacerbation or improve their chances of not having another
exacerbation once they left the hospital was unclear.
M. I Did the
Math: Full-Time, Full-Service Doctors Cannot Ever Have a Work-Life Balance
By
Steven F. Gordon, MD. Doximity. May 7, 2019
N. A New
Study Backs Up a Lifesaving Approach to the Opioid Epidemic
A
new study in JAMA Internal Medicine suggests that expanding access to naloxone,
the opioid overdose antidote, may result in fewer overdose deaths — a
lifesaving outcome as America deals with an opioid epidemic that;s now the
deadliest drug overdose crisis in U.S. history. The study, from researchers at
William Paterson University and the RAND Corporation, compared the effects of
three different policy changes.
O. Ibuprofen
tied to higher odds of severe bleeding post-tonsillectomy
P. Misdiagnosis
common among patients with type 1 diabetes
A
UK study in Diabetologia found that 38% of patients with type 1 diabetes were
misdiagnosed and initially received treatment for type 2 diabetes, with
one-third not receiving an insulin prescription and 50% still receiving medication
for type 2 diabetes 13 years after the misdiagnosis. The findings showed that
patients with type 1 diabetes who don't receive insulin may be at an increased
risk of having very high blood glucose levels and may develop diabetic
ketoacidosis.
Q. The glass
half-full: How optimism can bias prognosis in serious illness
Even
among palliative care docs: https://www.ncbi.nlm.nih.gov/pubmed/30391655
R. About 55%
of older patients die within 12 months of starting dialysis
Researchers
analyzed data from 1994 to 2014 for patients ages 65 and older with end-stage
kidney disease undergoing dialysis and found that the mortality rate after
starting dialysis was nearly 23% in the first month, nearly 45% within six
months and almost 55% within 12 months, according to a study in the journal
JAMA Internal Medicine. "Spending the better part of three days a week
doing dialysis may not be the right choice for everyone and people should
factor this new evidence into their decisions," lead author Melissa
Wachterman said.
