Action
Points
·
Even when no symptoms exist, if neuroimaging shows brain
tissue injury, the insult should be called a stroke, according to an expert
consensus document from the American Heart Association/American Stroke
Association (AHA/ASA).
·
Point out that brain tissue injury rather than a fixed time
designation should now be the primary distinguishing factor between stroke and
transient ischemic attack.
If
neuroimaging shows brain tissue injury, the insult should be called a stroke,
even if no symptoms exist, according to an expert consensus document from the
American Heart Association/American Stroke Association (AHA/ASA).
"A
tissue-based definition of ischemic stroke and transient ischemic attack
enhances diagnostic criteria and relies on utilization of various imaging
techniques in the acute phase of the stroke," according to writing
committee co-chair Scott E. Kasner, MD, of the University of Pennsylvania in
Philadelphia, and colleagues.
The
experts correlated the updated stroke definition with a similar update to the
definition of myocardial infarction, in which the term "acute coronary
syndrome" is used before the determination of infarction has been made. "Nevertheless,
these [cardiac] patients receive urgent evaluations and treatments intended to
avert or minimize permanent myocardial tissue damage," they wrote in the
statement published online in Stroke: Journal of the American Heart
Association.
Comparatively,
the term "acute cerebrovascular syndromes" would not be inappropriate
for the potential diagnosis of cerebral infarction, transient ischemic attack
(TIA), or hemorrhage "in patients presenting within the first 24 hours
from onset and before the completion of imaging tests."
"The
most important message here is that advances in neuroimaging, and in medical
science in general, allow us to define stroke as any permanent injury to the
central nervous system caused by a vascular disorder, whether there are
symptoms or not," Kasner told MedPage Today. "If we have objective
evidence of tissue injury, the insult should be called an ischemic stroke. If
there is no objective evidence of tissue injury, it should be called a
transient ischemic attack. But a transient event with evidence of tissue injury
is now considered a stroke," Kasner explained. "The main difference
from the standing definition of stroke is that we no longer base the
determination of stroke on event duration, but rather on evidence of tissue
injury," he said.
Kasner,
along with co-chair Ralph L. Sacco, MD, of the University of Miami, and other
members of the team, were convened by the Stroke Council of the AHA/ASA to
develop an expert consensus document for an "updated definition of stroke
for the 21st century."
One of
the concerns of the committee was that the term "stroke" was not
consistently defined in clinical practice, clinical research, or in assessments
of the public health. The new definition, however, incorporates clinical and
tissue criteria that will be useful in these three domains, researchers wrote.
Kasner
and colleagues outlined how the term "stroke" should be defined:
·
Central nervous system (CNS) infarction -- CNS infarction is
brain, spinal cord, or retinal cell death attributable to ischemia based on
pathological, imaging, or other objective evidence or clinical evidence
including symptoms that persist more than 24 hours
·
Ischemic stroke -- An episode of neurological dysfunction
caused by focal cerebral, spinal, or retinal infarction
·
Silent CNS infarction -- Imaging or neuropathological
evidence of CNS infarction, without a history of acute neurological dysfunction
attributable to the lesion
·
Intracerebral hemorrhage -- Focal collection of blood in the
brain that is not caused by trauma (includes parenchymal hemorrhages after CNS
infarction, types I and II)
Other
types of brain insults the committee defined were stroke caused by
intracerebral hemorrhage; cerebral hemorrhage; subarachnoid hemorrhage; stroke
caused by subarachnoid hemorrhage; stroke caused by cerebral venous thrombosis;
and stroke not otherwise specified.
Particularly
troubling to the writing committee were silent infarctions -- those discovered
during routine MRI exams for non-stroke purposes such as dementia or head
injury. "What should we do with patients who have silent infarcts? Should
we treat them? Perform more carotid surgery or be more aggressive with
medications?" Kasner asked. Treating them could be a slippery slope
because for every one clinically identified stroke, there are five times as
many silent infarctions, he said.
There
is little evidence about the long-term outcomes associated with silent
infarctions. Ultimately, the writing group decided that its task was more about
the definition of stroke, not its treatment.
Overall,
this update solidifies knowledge known for about a decade and increasingly
incorporated into clinical practice. "Regarding silent infarcts, however,
we probably need more time," Kasner commented.
One of
the challenges for hospitals is to have an MRI scanner available for diagnosing
acute stroke. A head CT is a common imaging test in the acute setting, but MRI
scanners are not as ubiquitous in U.S. emergency departments. "The CT scan
can help rule out hemorrhage, but an MRI exam can tell us exactly what is
wrong, especially in patients with transient symptoms," Kasner said.
"No
matter how transient, evidence of tissue injury puts those patients at a much
higher risk of subsequent stroke in the short term. We need to have a high
level of suspicion for stroke and identify those with tissue injury so
secondary preventive measures can be taken," he concluded.
Sacco
RL, et al. An Updated Definition of Stroke for the 21st Century: A Statement for
Healthcare Professionals From the AHA/American Stroke Association. 2013 7 May.
[Epub ahead of print]
Full-text
pdf (free): http://stroke.ahajournals.org/content/early/2013/05/07/STR.0b013e318296aeca.full.pdf+html
Objective
To assess the cancer risk in children and adolescents following exposure to low
dose ionising radiation from diagnostic computed tomography (CT) scans.
Design
Population based, cohort, data linkage study in Australia.
Cohort
members 10.9 million people identified from Australian Medicare records, aged
0-19 years on 1 January 1985 or born between 1 January 1985 and 31 December
2005; all exposures to CT scans funded by Medicare during 1985-2005 were
identified for this cohort. Cancers diagnosed in cohort members up to 31
December 2007 were obtained through linkage to national cancer records.
Main
outcome Cancer incidence rates in individuals exposed to a CT scan more than
one year before any cancer diagnosis, compared with cancer incidence rates in
unexposed individuals.
Results
60 674 cancers were recorded, including 3150 in 680 211 people exposed to a CT
scan at least one year before any cancer diagnosis. The mean duration of
follow-up after exposure was 9.5 years. Overall cancer incidence was 24%
greater for exposed than for unexposed people, after accounting for age, sex,
and year of birth (incidence rate ratio (IRR) 1.24 (95% confidence interval
1.20 to 1.29); P less than 0.001). We saw a dose-response relation, and the IRR
increased by 0.16 (0.13 to 0.19) for each additional CT scan. The IRR was
greater after exposure at younger ages (P less than 0.001 for trend). At 1-4,
5-9, 10-14, and 15 or more years since first exposure, IRRs were 1.35 (1.25 to
1.45), 1.25 (1.17 to 1.34), 1.14 (1.06 to 1.22), and 1.24 (1.14 to 1.34),
respectively. The IRR increased significantly for many types of solid cancer
(digestive organs, melanoma, soft tissue, female genital, urinary tract, brain,
and thyroid); leukaemia, myelodysplasia, and some other lymphoid cancers. There
was an excess of 608 cancers in people exposed to CT scans (147 brain, 356
other solid, 48 leukaemia or myelodysplasia, and 57 other lymphoid). The
absolute excess incidence rate for all cancers combined was 9.38 per 100 000
person years at risk, as of 31 December 2007. The average effective radiation
dose per scan was estimated as 4.5 mSv.
Conclusions
The increased incidence of cancer after CT scan exposure in this cohort was
mostly due to irradiation. Because the cancer excess was still continuing at
the end of follow-up, the eventual lifetime risk from CT scans cannot yet be
determined. Radiation doses from contemporary CT scans are likely to be lower
than those in 1985-2005, but some increase in cancer risk is still likely from
current scans. Future CT scans should be limited to situations where there is a
definite clinical indication, with every scan optimised to provide a diagnostic
CT image at the lowest possible radiation dose.
3. Critical Care in the ED
Is Increasing — It's Not Just Your Imagination!
Mullins
PM, et al. Acad Emerg Med. 2013;20:479-486.
Objectives:
The authors describe national trends in use, reasons for visit, most common
diagnoses, and resource utilization in patients admitted to intensive care
units (ICUs) from hospital-based emergency departments (EDs) in the United
States.
Methods:
This was an observational study using data from the National Hospital
Ambulatory Care Survey, a nationally representative, weighted sample of U.S.
hospital-based EDs from 2002 through 2009. The sample comprised a total of
4,267 patients aged 18 years or older admitted to the ICU from the ED, which
represent over 14.5 million ED encounters from 2002 through 2009.
Results:
Over the study period, ICU admissions from EDs increased from 2.79 million in
2002/2003, to 4.14 million in 2008/2009, an absolute increase of 48.8% and a
mean biennial increase of 14.2%. By comparison, overall ED visits increased a
mean of 5.8% per biennial period. The three most common diagnoses for ICU
admissions were unspecified chest pain, congestive heart failure, and
pneumonia. Utilization rates of most tests and services delivered to patients
admitted to the ICU from the ED increased, with the largest increase occurring
in computed tomography (CT) and magnetic resonance imaging (MRI), which
increased from 16.8% in 2002/2003 to 37.4% in 2008/2009, a 6.9% mean biennial
increase. Across all years, mean ED length of stay (LOS) for ICU admissions was
304 minutes (95% confidence interval [CI] = 286 to 323 minutes), and mean
hospital LOS was 6.6 days (95% CI = 6.2 to 7.0 days). There was no significant change
in either mean ED or hospital LOS over the study period.
Conclusions:
Intensive care unit admissions from EDs are increasing at a greater rate than
both population growth and overall ED visits. ED resource use, specifically
advanced diagnostic imaging, has increased markedly among ICU admissions. While
mean ED and hospital LOS have not changed significantly, the mean ICU admission
spends over 5 hours in the ED prior to transfer to an ICU bed. A greater
emphasis on the ED–ICU interface and critical care delivered in the ED may be
warranted.
B.
Increasing critical care admissions from U.S. EDs, 2001-2009.
Herring
AA, et al. Crit Care Med. 2013; May;41(5):1197-204
OBJECTIVES:
Little is known about how recent system-wide increases in demand for critical
care have affected U.S. emergency departments (EDs). This study describes
changes in the amount of critical care provided in U.S. EDs between 2001 and
2009.
DESIGN:
Analysis of data from the National Hospital Ambulatory Medical Care Survey for
the years 2001-2009.
SETTING:
National multistage probability sample of U.S. ED data. U.S. ED capacity was
estimated using the National Emergency Department Inventory-United States.
PATIENTS:
ED patients admitted a critical care unit.
INTERVENTIONS:
None.
MEASUREMENTS:
Annual hours of ED-based critical care and annual number critical care ED
visits. Clinical characteristics, demographics, insurance status, setting,
geographic region, and ED length of stay for critically ill ED patients.
MAIN
RESULTS: Annual critical care unit admissions from U.S. EDs increased by 79%
from 1.2 to 2.2 million. The proportion of all ED visits resulting in critical
care unit admission increased from 0.9% to 1.6% (ptrend less than 0.001).
Between 2001 and 2009, the median ED length of stay for critically ill patients
increased from 185 to 245 minutes (+ 60 min; ptrend less than 0.02). For the
aggregated years 2001-2009, ED length of stay for critical care visits was
longer among black patients (12.6% longer) and Hispanic patients (14.8% longer)
than among white patients, and one third of all critical care ED visits had an
ED length of stay greater than 6 hrs. Between 2001 and 2009, total annual hours
of critical care at U.S. EDs increased by 217% from 3.2 to 10.1 million (ptrend
less than 0.001). The average daily amount of critical care provided in U.S.
EDs tripled from 1.8 to 5.6 hours per ED per day.
CONCLUSIONS:
The amount of critical care provided in U.S. EDs has increased substantially
over the past decade, driven by increasing numbers of critical care ED visits
and lengthening ED length of stay. Increased critical care burden will further
stress an already overcapacity U.S. emergency care system.
4. Preparing the United
States for High-Sensitivity Cardiac Troponin Assays
It is
only a matter of time before the use of high-sensitivity cardiac troponin
assays (hs-cTn) becomes common throughout the United States. In preparation for
this inevitability, this article raises a number of important issues regarding
these assays that deserve consideration. These include: the need for the
adoption of a universal nomenclature; the importance of defining uniform
criteria for reference populations; the challenge of discriminating between
acute and nonacute causes of hs-cTn elevations, and between type 1 and type 2
acute myocardial infarction (AMI); factors influencing the analytical precision
of hs-cTn; ascertaining the optimal duration of the rule-out period for AMI;
the need for further evaluation to determine the causes of a positive hs-cTn in
non-AMI patients; and the use of hs-cTn to risk-stratify patients with disease
conditions other than AMI. This review elaborates on these critical issues as a
means of educating clinicians and researchers about them.
5. Effective analgesia with
low-dose ketamine and reduced dose hydromorphone in ED patients with severe
pain
Objective:
We assessed the analgesic effect and feasibility of low-dose ketamine combined
with a reduced dose of hydromorphone for emergency department (ED) patients with
severe pain.
Methods:
This was a prospective observational study of adult patients with severe pain
at an urban public hospital. We administered 0.5 mg of intravenous (IV)
hydromorphone and 15 mg of IV ketamine, followed by optional 1 mg hydromorphone
IV at 15 and 30 minutes. Pain intensity was assessed at 12 intervals over 120
minutes using a 10-point verbal numerical rating scale (NRS). Patients were
monitored throughout for adverse events. Dissociative side effects were
assessed using the side effects rating scale for dissociative anesthetics.
Results:
Of 30 prospectively enrolled patients with severe pain (initial mean NRS, 9),
14 reported complete pain relief (NRS, 0) at 5 minutes; the mean reduction in
NRS pain score was 6.0 (SD, 3.2). At 15 minutes, the mean reduction in NRS pain
score was 5.0 (SD, 2.8). The summed pain intensity difference and percent
summed pain intensity difference scores were 25 (95% confidence interval [CI],
21-30) and 58% (95% CI, 49-68) at 30 minutes and 41 (95% CI, 34-48) and 50%
(95% CI, 42-58) at 60 minutes, respectively. Most patients (80%) reported only
weak or modest side effects. Ninety percent of patients reported that they
would have the medications again. No significant adverse events occurred.
Conclusions:
Low-dose ketamine combined with a reduced dose hydromorphone protocol produced
rapid, profound pain relief without significant side effects in a diverse
cohort of ED patients with acute pain.
6. Diagnostic accuracy of
conventional or age adjusted D-dimer cut-off values in older patients with
suspected venous thromboembolism: systematic review and meta-analysis
Objective
To review the diagnostic accuracy of D-dimer testing in older patients (above 50
years) with suspected venous thromboembolism, using conventional or age
adjusted D-dimer cut-off values.
Design
Systematic review and bivariate random effects meta-analysis.
Data
sources We searched Medline and Embase for studies published before 21 June
2012 and we contacted the authors of primary studies.
Study
selection Primary studies that enrolled older patients with suspected venous
thromboembolism in whom D-dimer testing, using both conventional (500 µg/L) and
age adjusted (age×10 µg/L) cut-off values, and reference testing were
performed. For patients with a non-high clinical probability, 2×2 tables were
reconstructed and stratified by age category and applied D-dimer cut-off level.
Results
13 cohorts including 12 497 patients with a non-high clinical probability were
included in the meta-analysis. The specificity of the conventional cut-off
value decreased with increasing age, from 57.6% (95% confidence interval 51.4%
to 63.6%) in patients aged 51-60 years to 39.4% (33.5% to 45.6%) in those aged
61-70, 24.5% (20.0% to 29.7% in those aged 71-80, and 14.7% (11.3% to 18.6%) in
those aged over 80. Age adjusted cut-off values revealed higher specificities
over all age categories: 62.3% (56.2% to 68.0%), 49.5% (43.2% to 55.8%), 44.2%
(38.0% to 50.5%), and 35.2% (29.4% to 41.5%), respectively. Sensitivities of
the age adjusted cut-off remained above 97% in all age categories.
Conclusions
The application of age adjusted cut-off values for D-dimer tests substantially increases
specificity without modifying sensitivity, thereby improving the clinical
utility of D-dimer testing in patients aged 50 or more with a non-high clinical
probability.
7. Palliative Care in
the ED?
A. Hospital Administrators' Views on Barriers and
Opportunities to Delivering Palliative Care in the ED
Grudzen CR, et al. Ann Emerg
Med. 2013;61:654-660.
Study objective: We identify hospital-level factors from the administrative
perspective that affect the availability and delivery of palliative care
services in the emergency department (ED).
Methods: Semistructured interviews were conducted with 14 key
informants, including hospital executives, ED directors, and palliative care directors
at a tertiary care center, a public hospital, and a community hospital. The
discussions were digitally recorded and transcribed to conduct a thematic
analysis using grounded theory. A coding scheme was iteratively developed to
subsequently identify themes and subthemes that emerged from the interviews.
Results: Barriers to integrating palliative care and emergency
medicine from the administrative perspective include the ED culture of
aggressive care, limited knowledge, palliative care staffing, and medicolegal
concerns. Incentives to the delivery of palliative care in the ED from these
key informants' perspective include improved patient and family satisfaction,
opportunities to provide meaningful care to patients, decreased costs of care
for admitted patients, and avoidance of unnecessary admissions to more
intensive hospital settings, such as the ICU, for patients who have little
likelihood of benefit.
Conclusion: Though hospital administration at 3 urban hospitals on the
East coast has great interest in integrating palliative care and emergency
medicine to improve quality of care, patient and family satisfaction, and
decrease length of stay for admitted patients, palliative care staffing,
medicolegal concerns, and logistic issues need to be addressed.
B. Demonstrations of Clinical Initiatives to Improve
Palliative Care in the ED: A Report From the
IPAL-EM Initiative
Quest
T, et al. Ann Emerg Med. 2013;61:661-667.
Study objective: We describe 11 clinical demonstrations of emergency
department (ED) and palliative care integration to include traditional
consultation services with hospital-based palliative care consultants through
advanced integration demonstrations in which the ED provides subspecialty
palliative care practice.
Methods: An interview guide was developed by the Improving
Palliative Care in Emergency Medicine board that consists of emergency
clinicians and palliative care practitioners. Structured interviews of 11
program leaders were conducted to describe the following key elements of the
ED–palliative care integration, to include structure, function, and process of
the programs, as well as strengths, areas of improvement, and any tools or
outcome measures developed.
Results: In this limited number of programs, a variety of
strategies are used to integrate palliative care in the ED, from traditional
consultation to well-defined partnerships that include board-certified
emergency clinicians in hospice and palliative medicine.
Conclusion: A variety of methods to integrate palliative care in the
emergency setting have emerged. Few programs collect outcomes-based metrics,
and there is a lack of standardization about what metrics are tracked when
tracking occurs.
8. Decision Aids for
Low-Risk Chest Pain
The
combination of TIMI score and HEART score identifies patients at less than 1%
risk for death or cardiac events within 30 days.
Marcoon
S et al. Crit Pathw Cardiol 2013 Mar; 12:1
OBJECTIVE:
The ability to risk stratify patients presenting to the emergency department
(ED) with potential acute coronary syndrome (ACS) is critical. The thrombolysis
in myocardial infarction (TIMI) risk score can risk stratify ED patients with
potential ACS but cannot identify patients safe for ED discharge. The
symptom-based HEART score identifies very low-risk patients. Our hypothesis was
that patients with a TIMI score of 0 or 1 may be stratified further with the
HEART score to identify a group of patients at less than 1% risk of 30-day
cardiovascular events.
METHODS:
We conducted a secondary analysis of a prospective cohort study in a tertiary
care hospital ED. Patients with potential ACS who were greater than 30 years of
age were included. Data collected included demographics, history,
electrocardiogram, laboratories, and components of the TIMI and HEART scores.
Follow-up was conducted by structured record review and phone. The main outcome
was a composite of death, acute myocardial infarction, or revascularization at
30 days.
RESULTS:
There were 8815 patients enrolled (mean age, 52.8 ± 15.1 years; 57% women, and
69% black). At 30 days, the composite event rate was 8.0% (660 patients): 108
deaths, 410 acute myocardial infarction, and 301 revascularizations. Of the 485
patients with both a TIMI score of 0 and a HEART score of 0, there were no
cardiovascular events (95% confidence interval, 0-0.8%); but no other score
combination had an upper limit confidence interval less than 1%.
CONCLUSION:
At all levels of TIMI score, the HEART score was able to further substratify
patients with respect to 30-day risk. A HEART score of 0 in a patient with a
TIMI of 0 identified a group of patients at less than 1% risk for 30-day
adverse events
9. FFP for Progressive and
Refractory ACE Inhibitor-induced Angioedema
Hassen
GW, et al. J Emerg Med. 2013;44(4):764-772.
BACKGROUND:
Angioedema secondary to angiotensin-converting enzyme inhibitors (ACEI) is a
commonly encountered problem in the Emergency Department (ED). The treatment of
ACEI-induced edema with conventional methods such as epinephrine, steroids, and
antihistamines is usually not effective. There is limited experience using
bradykinin receptor blockers and fresh frozen plasma (FFP) as a treatment modality
for ACEI-induced angioedema.
OBJECTIVE:
To emphasize alternative treatment option for ACEI-induced angioedema in the
ED.
CASE
REPORTS: We report a case series of progressive and refractory presumed
ACEI-induced angioedema that all improved in temporal association with
administration of FFP, with a brief review of the literature.
CONCLUSION:
There was a temporal association between the administration of FFP and
improvement in angioedema in seven cases of presumed ACEI-induced angioedema
that were refractory to antihistamines, corticosteroids, and epinephrine.
10. Antipyretics neither slow nor hasten recovery process in children
Although children who were given
fever-reducing antipyretic medications returned to normal body temperature four
hours earlier, on average, than those without such drugs, the recovery time for
both groups was the same, a review in the Journal of Pediatrics showed. Experts
said that the findings show antipyretics do not slow the recovery process but
that parents may be too willing to use them without evidence of much benefit.
11. Prevalence and Clinical
Importance of Alternative Causes of Symptoms Using a Renal Colic CT Protocol in
Patients With Flank or Back Pain and Absence of Pyuria
Moore CL,
et al. Acad Emerg Med. 2013;20:470-478.
Objectives:
The study was undertaken to determine the prevalence and clinical importance of
alternative causes of symptoms discovered in patients undergoing flank pain
protocol (FPP) computed tomography (CT) scans in patients with classic symptoms
of kidney stone (flank pain, back pain, or both) without evidence of urine
infection.
Methods:
This was a retrospective observational analysis of all adult patients
undergoing FPP CT scans at two emergency departments (EDs) between April 2005
and November 2010. All CTs (N = 5,383) were reviewed and categorized as “no
cause of symptoms seen on CT,” “ureteral stone as cause of symptoms,” or
“non–kidney stone cause of symptoms.” Non–kidney stone scans were further
categorized as “acutely important,” “follow-up recommended,” or “unimportant
cause,” based on a priori diagnostic classifications. All nonstone causes of
pain and a random subset of subjects (n = 1,843; 34%) underwent full record
review blinded to CT categorization to determine demographics, whether flank
and/or back pain was present, and whether there was objective evidence of
pyuria.
Results:
Of all FPP CT scans during the study period, a ureteral stone was found to
cause symptoms in 47.7% of CTs, with no cause of symptoms found in 43.3% of
CTs. A non–kidney stone diagnosis was found in 9.0% of all CTs, with 6.1% being
categorized as “acutely important,” 2.2% as “follow-up recommended,” and 0.65%
with symptoms from an “unimportant cause.” In the randomly selected subset
undergoing full record review, categorizations were similar, with 49.0% of CTs
showing kidney stone as cause of pain and 9.0% a non–kidney stone cause (5.9%
“acutely important”). When subjects with evidence of urine infection or without
flank or back pain were excluded, ureteral stone was identified as the cause of
pain in 54.9% of CTs, while non–kidney stone cause of symptoms was found in
5.4% of scans and acutely important alternate causes in 2.8% of scans.
Conclusions:
While a non–kidney stone cause for a patient's symptoms are found in nearly 10%
of CTs done using a FPP, acutely important findings occur in less than 3% of scans
done in patients with flank or back pain and absence of pyuria.
12. A descriptive study of
myoclonus associated with etomidate procedural sedation in the ED
Yates
AM, et al. Amer J Emerg Med. 2013;31:852-854.
Background:
Myoclonus is a well-recognized side effect of etomidate when given in induction
doses for rapid sequence intubation. Most of the data reported on myoclonus
with emergency department (ED) sedation doses are reported as a secondary
finding.
Study
objectives: Our objective was to prospectively quantify the incidence and
duration of myoclonus associated with the administration of etomidate in the
lower doses given for procedural sedation in the ED.
Methods:
This was a prospective descriptive study performed between September 2008 and
September 2010 at an urban teaching hospital ED with approximately 50000
patient visits per year. Procedural sedation was performed at the discretion of
the treating emergency physician, and adult patients receiving etomidate were
eligible for enrollment. The occurrence and duration of myoclonus were observed
and recorded. Any interference of myoclonus with the ability to complete the
procedure was recorded, and adverse effects were identified.
Results:
Thirty-four eligible subjects were enrolled, and 36 separate sedation
procedures were performed. The mean initial etomidate dose was 0.13 mg/kg
(range, 0.077-0.20), and the mean total etomidate dose was 0.15 mg/kg (range,
0.077-0.29). Myoclonus was noted in 26 (72%) of 36 sedations. Mean time to
onset of myoclonus was 50 seconds (range, 15-146), and the mean duration was 93
seconds (range, 03-557). Myoclonus interfered with the procedure in only 1 (3%)
of 36 attempted procedures, and no procedure was unsuccessful because of
myoclonus.
Conclusion:
Myoclonus associated with sedation doses of etomidate was common but rarely
interfered with the completion of a procedure.
13. Images in Clinical
Medicine
A
Ticking Time Bomb
Nutcracker
Esophagus
Mastoiditis
An Adolescent Male with a Large Palatal Mass
A Child with Blunt Head Injury
14. Therapeutic
Hypothermia Advances: A Summary
Amal
Mattu, MD. Ice Ice Baby! A Decade of Therapeutic Hypothermia. Medscape EM Apr
12, 2013
Indications
for TH
•
Initial rhythm
‣ TH was originally
studied in patients with ROSC after VF/VT cardiac arrest and is now considered
a class I intervention for these patients. However, the recommendation for
implementation of TH has been extended to patients with ROSC after cardiac
arrest associated with other rhythms, according to the AHA (class IIb
recommendation) and the recommendations from the European Resuscitation Council
and the International Liaison Committee on Resuscitation.
‣ All 3 organizations
acknowledge a lower level of evidence for the recommendation to implement TH in
patients with ROSC after nonshockable rhythms.
•
Candidates for TH are those who remain comatose following ROSC.
"Comatose" in this setting is generally regarded as failing "to
meaningfully respond to verbal commands."
•
These indications apply to adult victims of presumed primary cardiac arrest. If
cardiac arrest is due to other conditions such as intracranial hemorrhage,
exsanguination, severe sepsis, or if the patient is pregnant or remains
hypotensive despite the use of multiple vasopressors, the risk of using TH may
exceed the benefit. In nonprimary cardiac arrest conditions, the use of TH
should be determined on a case-by-case basis.
Initiation
and Maintenance of TH
• TH
should be initiated as soon as possible after ROSC. Scirica cites a 20%
increase in mortality for every hour of delay in initiation of TH; this same
increase in mortality was cited in a 2011 research article.[3]
•
There are multiple methods to induce TH. The easiest and most inexpensive
method is the use of cooled IV fluids (eg, 30 mL/kg over 30 minutes of 4°C
lactated ringer's) during or immediately after resuscitation.
•
Maintenance of TH can be accomplished using external cooling techniques such as
ice packs on the groin, neck, and axilla; water-soaked towels with fanning; or
cooling blankets. More advanced (and expensive) methods that allow closer
titration and maintenance of core temperature in the 32°C-34°C range can be
accomplished using endovascular catheters, cooling helmets, and other novel
techniques or devices.
•
Patients should be maintained in the hypothermic state for 12-24 hours.
Consequences
and Complications
•
Shivering is the most common complication and must be treated in order to avoid
thermogenesis.
‣ Sedation and analgesia
should be provided to reduce shivering. Benzodiazepines are typically used for
sedation and opiates for analgesia.
‣ Magnesium sulfate can
raise the shivering threshold. Scirica reports the routine use of a 4-g IV
bolus dose of magnesium sulfate to all patients receiving TH.
‣ If shivering persists
despite use of medications noted above, neuromuscular blockade with paralytics
is recommended.
•
Hemodynamics
‣ TH typically induces
bradycardia and prolongation of the QT interval. These are typically
well-tolerated but should be treated if they result in hemodynamic instability.
‣ Hypotension is common
in patients receiving TH. Underlying causes of hypotension should be sought out
and treated aggressively (eg, intravascular depletion is common in these
patients). A mean arterial pressure should be maintained at goals of 80-100 mm
Hg in order to improve cerebral perfusion. Early use of vasopressors will help
in achieving this goal.
•
Hyperglycemia is common during TH because of impaired insulin secretion and
increased insulin resistance. During rewarming, blood glucose typically falls.
Therefore, blood glucose should be measured frequently. Insulin therapy is
typically not needed unless glucose levels exceed 200 mg/mL.
• TH
causes mild suppression of the immune system, although this has not been linked
to an increase in mortality. Note, however, that more than two thirds of
patients experience an infectious complication, especially pulmonary
infections, which are likely due to aspiration during cardiac arrest.
References
Scirica
BM. Therapeutic Hypothermia after Cardiac Arrest. Circulation. 2013;127:244-250
Delhaye
C, et al. Hypothermia Therapy: Neurological and Cardiac Benefits. J Am Coll
Cardiol. 2012;59:197-210
15. ED Physician-level and Hospital-level Variation in Admission Rates
Study objective: We explore the variation in physician- and hospital-level
admission rates in a group of emergency physicians in a single health system.
Methods: This was a cross-sectional study that used retrospective
data during various periods (2005 to 2010) to determine the variation in
admission rates among emergency physicians from 3 emergency departments (EDs)
within the same health system. Patients who left without being seen or left
against medical advice, patients treated in fast-track departments, patients
with primary psychiatric complaints, and those younger than 18 years were
excluded, as were physicians with fewer than 500 ED encounters during the study
period. Emergency physician–level and hospital-level admission rates were
estimated with hierarchic logistic regression, which adjusted for patient age, sex,
race, chief complaint, arrival mode, and arrival day and time.
Results: A total of 389,120 ED visits were included in the
analysis, and patients were treated by 89 attending emergency physicians. After
adjusting for patient and clinical characteristics, the hospital-level
admission rate varied from 27% to 41%. At the physician level, admission rates
varied from 21% to 49%.
Conclusion: There was 2.3-fold variation in emergency physician
adjusted admission rates and 1.7-fold variation at the hospital level. In the
new era of cost containment, wide variation in this common, costly decision
requires further exploration.
16. Update on the
Management of Subarachnoid Hemorrhage
Wartenberg
KE. Future Neurology. 2013;8(2):205-224.
Subarachnoid
hemorrhage (SAH) is a devastating cerebrovascular disease. Outcome after SAH is
mainly determined by the initial severity of the hemorrhage. Neuroimaging, in
particular computed tomography, and aneurysm repair techniques, such as coiling
and clipping, as well as neurocritical care management, have improved during
the last few years. The management of a patient with SAH should have an interdisciplinary
approach with case discussions between the neurointensivist, interventionalist
and the neurosurgeon.
The
patient should be treated in a specialized neurointensive care unit of a center
with sufficient SAH case volume. Poor-grade patients can be observed for
complications and delayed cerebral ischemia through continuous monitoring
techniques in addition to transcranial Doppler ultrasonography such as
continuous electroencephalography, brain tissue oxygenation, cerebral
metabolism, cerebral blood flow and serial vascular imaging. Neurocritical care
should focus on neuromonitoring for delayed cerebral ischemia, management of
hydrocephalus, seizures and intracranial hypertension, as well as of medical
complications such as hyperglycemia, fever and anemia.
17. Yield of Routine Provocative Cardiac Testing among Patients in an ED-Based CP Unit
Hermann LK, et al. JAMA Intern Med.
2013 May 20. Epub ahead of print.
Importance The American Heart Association recommends
routine provocative cardiac testing in accelerated diagnostic protocols for
coronary ischemia. The diagnostic and therapeutic yield of this approach are
unknown.
Objective To assess the yield of routine provocative
cardiac testing in an emergency department–based chest pain unit.
Design and Setting We examined a prospectively collected
database of patients evaluated for possible acute coronary syndrome between
March 4, 2004, and May 15, 2010, in the emergency department–based chest pain
unit of an urban academic tertiary care center.
Participants Patients with signs or symptoms of possible
acute coronary syndrome and without an ischemic electrocardiography result or a
positive biomarker were enrolled in the database.
Exposures All patients were evaluated by exercise
stress testing or myocardial perfusion imaging.
Main Outcomes and Measures Demographic and clinical features, results of
routine provocative cardiac testing and angiography, and therapeutic
interventions were recorded. Diagnostic yield (true-positive rate) was calculated,
and the potential therapeutic yield of invasive therapy was assessed through
blinded, structured medical record review using American Heart Association
designations (class I, IIa, IIb, or lower) for the potential benefit from
percutaneous intervention.
Results In total, 4181 patients were enrolled in the
study. Chest pain was initially reported in 93.5%, most (73.2%) were at
intermediate risk for coronary artery disease, and 37.6% were male. Routine
provocative cardiac testing was positive for coronary ischemia in 470 (11.2%),
of whom 123 underwent coronary angiography. Obstructive disease was confirmed
in 63 of 123 (51.2% true positive), and 28 (0.7% overall) had findings
consistent with the potential benefit from revascularization (American Heart
Association class I or IIa).
Conclusions and Relevance In an emergency department–based chest pain
unit, routine provocative cardiac testing generated a small therapeutic yield,
new diagnoses of coronary artery disease were uncommon, and false-positive results
were common.
18. Helping Coping
with Death in the ED
A.
Dying, Naturally, in the Emergency Department
How to
walk a dying patient and their family through an unimpeded natural death in the
emergency department
by Kei Ouchi, MD & Ashley Shreves, MD. EP
Monthly on May 6, 2013
B. Supporting
the family after the death of a child.
Wender
E; Committee on Psychosocial Aspects of Child and Family Health. Pediatrics.
2012 Dec;130(6):1164-9.
The
death of a child can have a devastating effect on the family. The pediatrician
has an important role to play in supporting the parents and any siblings still
in his or her practice after such a death. Pediatricians may be poorly prepared
to provide this support. Also, because of the pain of confronting the grief of
family members, they may be reluctant to become involved. This statement gives
guidelines to help the pediatrician provide such support. It describes the
grief reactions that can be expected in family members after the death of a
child. Ways of supporting family members are suggested, and other helpful
resources in the community are described. The goal of this guidance is to
prevent outcomes that may impair the health and development of affected parents
and children.
19. Ultrasound
in EM
A. Role
of IVC and RV diameter in assessment of volume status: a comparative study
Zengin
S, et al. Amer J Emerg Med. 2013;31:763-767.
Objective:
Ultrasonography has been suggested as a useful noninvasive tool for the
detection and follow-up for hypovolemia. Two possible sonographic markers as a
surrogate for hypovolemia are the diameters of the inferior vena cava (dIVC)
and the right ventricle (dRV). The goal of this study was to evaluate IVC and
RV diameters and diameter changes in patients treated for hypovolemia and
compare these findings with healthy volunteers.
Methods:
Fifty healthy volunteers and 50 consecutive hypovolemic patients were enrolled
in the study. The dIVC, both during inspiration (IVCi) and expiration (IVCe),
was measured in hypovolemic patients both before and after fluid resuscitation,
and they were also measured in healthy volunteers during the time they
participated in the study. The dIVC, in hypovolemic patients both before and
after fluid resuscitation, was measured ultrasonographically by M-mode in the
subxiphoid area. The dRV was measured ultrasonographically by B-mode in the
third and fourth intercostals spaces.
Results:
The average diameters of the IVCe, IVCi, and dRV in hypovolemic patients upon
arrival were significantly lower compared with healthy volunteers (P = .001).
After fluid resuscitation, there was a significant increase in the mean
diameters of the IVCe, IVCi, and RV in hypovolemic patients (P = .001).
Conclusions:
The results indicate that the dIVC and dRV are consistently low in hypovolemic
subjects when compared with euvolemic subjects. Bedside serial measurements of
dIVC and dRV could be a useful noninvasive tool for the detection and follow-up
of patients with hypovolemia and evaluation of the response to the treatment.
B. US
guidance for radial arterial puncture: a RCT
Bobbia
X, et al. Amer J Emerg Med. 2013;31:810-815.
Study
Objective and Background: Arterial puncture for blood gas analysis is a
frequent procedure and could be difficult in the emergency setting. The aim of
the study was to compare ultrasonographically guided arterial radial puncture
vs conventional sampling.
Materials
and Methods: This is a prospective, randomized study. The inclusion criteria
are all patients needing arterial blood gas at admission in the emergency unit.
The exclusion criteria are the following: Hallen test positive, local sepsis,
local trauma, known sever local arteriopathy, refusal of consent by the
patient, participation in another study, and cardiac arrest. Patients were
randomized into 2 groups: radial arterial puncture obtained through an
ultrasonographically guided technique (group 1) or radial arterial puncture by
conventional method (group 2). The main objective is the number of attempts
after enrollment. The secondary objectives are time to success, patient
satisfaction and pain, and physician satisfaction. Immediate complications were
collected. Groups were compared with nonparametric analysis.
Results:
The data were usable for 72 of 74 patients included. Lung disease (acute
exacerbation of chronic obstructive pulmonary disease and pneumonia) at 45% (n
= 32) and suspicion of pulmonary embolism in 31% (n = 22) were the most common
reasons. Demographics data were comparable in the 2 groups. In group 1, the
number of attempts significantly increased (2.35 [1-3] vs 1.66 [1-2] [P =
.017]), and the sample was 2.4 times longer (132 seconds [50-200] vs 55 [20-65]
[P less than .01] by standard method). There was no significant difference in
terms of pain (visual analog scale [VAS], 3.6 [2-5] for both groups [P =
.743]), patient satisfaction (VAS, 7.2 [5-9] vs 6.8 [5-9] [P = .494]), and
physician satisfaction (VAS, 6.0 [3.5-8] vs 6.9 [5-9] [P = .233]). No immediate
complications were found in the 2 groups.
Conclusion:
Ultrasonographically guided arterial puncture increases the number and duration
of implementations. This technique, however, does not alter the patient's pain,
the number of immediate complications, or patient and physician satisfaction.
C.
Diagnostic Accuracy of US Examination in the Management of Shoulder Dislocation
in the ED
Abbasi
S, et al. Ann Emerg Med. 2013 Mar 8. [Epub ahead of print]
STUDY
OBJECTIVE: Emergency physicians frequently encounter shoulder dislocation in
their practice. The objective of this study is to assess the diagnostic
accuracy of ultrasonography in detecting shoulder dislocation and confirming
proper reduction in patients presenting to the emergency department (ED) with
possible shoulder dislocation. We hypothesize that ultrasonography could be a
reliable alternative for pre- and postradiographic evaluation of shoulder
dislocation.
METHODS:
This was a prospective observational study. A convenience sample of patients
suspected of having shoulder dislocation was enrolled in the study.
Ultrasonography was performed before and after reduction procedure with a 7.5-
to 10-MHz linear transducer. Shoulder dislocation was confirmed by taking
radiographs in 3 routine views as a criterion standard. The operating
characteristics of ultrasonography to detect dislocation in patients with
possible shoulder dislocation and to confirm reduction in patients with
definitive dislocation were calculated as the primary endpoints.
RESULTS:
Seventy-three patients were enrolled. The ultrasonography did not miss any
dislocation. The results of ultrasonography and radiography were identical and
the sensitivity of ultrasonography in detection of shoulder dislocation was
100% (95% confidence interval 93.4% to 100%). The sensitivity of
ultrasonography for assessment of complete reduction of the shoulder joint
reached 100% (95% confidence interval 93.2% to 100%) in our study as well.
CONCLUSION:
We suggest that ultrasonography be performed in all patients who present to the
ED with a clinical impression of shoulder dislocation on admission time. The
results of this study provide promising preliminary support for the ability of
ultrasonography to detect shoulder dislocation. However, further investigation
is necessary to validate the results and assess the ability of ultrasonography
in detecting fractures associated with dislocation.
D.
Case Study: Demented 72 Year Old with Distended Abdomen
by Teresa S. Wu, MD & Brady Pregerson, MD.
Emergency Physician Monthly, April 28, 2013
“I
need a breath of fresh air,” your senior resident states. He has had a pretty
rough night. He missed an LP on a rather robust woman with “the worst headache
of her life” and then the trauma team swooped in and “stole” his thoracotomy on
a GSW that was dropped off at the ambulance door. You tell him to take all the
time he needs as you turn your attention to the intern that has been patiently
awaiting your emergence from the critical care bay.
Jealous
that she hasn’t had a single procedure yet during the shift, your intern is
eager to tell you about the next patient she saw. It sounds like a relatively
straightforward case: a 72-year-old male brought in by his nursing home aide
for abdominal distension. He has a history of dementia and is primarily
bedridden at baseline. The patient cannot give any reliable history, but on
physical exam, his otherwise thin abdomen shows obvious signs of suprapubic
distension. Your intern recaps his vital signs, which include tachycardia at
120 bpm, a blood pressure of 190/86 mmHg, a respiratory rate of 20/min, and a
normal temperature and O2 saturation.
“What
should we be worried about?” you ask. Your intern rattles off a differential
diagnosis straight out of Tintinalli. Without missing a beat, she continues to
explain how she plans to rule-out the scary etiologies such as acute
intraperitoneal hemorrhage or ascites, AAA, mesenteric ischemia, perforated
bowel, acute cholecystitis, appendicitis, and SBO. Her initial orders are
spot-on, and before you can utter another syllable, she grabs the ultrasound
machine and wheels it over to the patient’s bedside. You follow a few steps
behind her, and observe with pride as she performs a scan of Morrison’s pouch,
followed by a quick look at the gallbladder, aorta, splenorenal space and
right-lower quadrant. She gently calms the agitated patient as she slides the
probe down towards his suprapubic region…
The
remainder of the essay (with images): http://www.epmonthly.com/clinical-skills/ultrasound/case-study-demented-72-year-old-with-distended-abdomen/
20. NEJM Interactive Case: A Pain in the
Brain
Redig
AJ, et al. N Engl J Med 2013; 368:e20
A
54-year-old woman presented with a headache that had started 8 days earlier.
She had awoken with stabbing, squeezing pain around her entire head. She rated
the pain at 10 on a scale of 0 to 10 (known as 10/10), with 10 representing the
worst pain imaginable. The pain was not alleviated by nonsteroidal
antiinflammatory drugs (NSAIDs). She reported having had no headache on going
to sleep . . .
21. Multicenter
Observational Study of the Development of Progressive Organ Dysfunction and
Therapeutic Interventions in Normotensive Sepsis Patients in the ED
Arnold
RC, et al. Acad Emerg Med. 2013;20:433-440.
Objectives:
Progressive organ dysfunction is the leading cause of sepsis-associated
mortality; however, its incidence and management are incompletely understood.
Sepsis patients with moderately impaired perfusion (serum lactate 2.0 to 3.9
mmol/L) who are not in hemodynamic shock (“preshock” sepsis patients) may be at
increased risk for progressive organ dysfunction and increased mortality. The
objectives of this study were to: 1) quantify the occurrence of progressive
organ dysfunction among preshock sepsis patients, 2) examine if there were
baseline differences in demographic and physiologic parameters between preshock
sepsis patients who experienced progressive organ dysfunction and those who did
not, and 3) examine if intravenous (IV) fluid administered in the emergency
department (ED) differed between these two groups of patients.
Methods:
This was a prospective, observational study in four urban EDs targeting the
preshock sepsis population, defined as adults (18 years or older) with
suspected infection, serum lactate between 2.0 and 3.9 mmol/L, and without
hypotension (systolic blood pressure [sBP] below 90 mm Hg or mean arterial
pressure [MAP] below 70 mm Hg) or requiring mechanical ventilation at ED
presentation. The primary composite outcome was progressive organ dysfunction,
defined as a rise in the Sequential Organ Failure Assessment (SOFA) score of
≥1, vasopressor use, mechanical ventilation use within 72 hours after ED
presentation, or in-hospital death. The secondary outcomes were any intensive
care unit (ICU) admission, and total ICU and hospital lengths of stay (LOS).
Results:
Among 94 preshock sepsis patients, the primary composite outcome occurred in 24
of 94 (26%). In patients with the primary outcome, 22 of 24 (92%) experienced a
rise in SOFA score of ≥1, five of 24 (21%) received vasopressor agents, and
seven of 24 (30%) required mechanical ventilation. There were no baseline
demographic or physiologic parameter differences between patients who met the
primary outcome versus those who did not, while patients with the primary
outcome had a higher average SOFA score at admission (2.4 vs. 1.3, p = 0.011)
and at all subsequent time points. Median IV fluid volume administered to all
preshock sepsis patients during their ED stay was 1,225 mL (interquartile range
[IQR] = 712 to 2,000 mL) and did not differ significantly between patients with
(1,150 mL, IQR = 469 to 2,000 mL) or without (1,250 mL, IQR = 750 to 2,000 mL)
the primary outcome (p = 0.73). Patients with progressive organ dysfunction or
death were more likely to be admitted to an ICU (50% vs. 20%, p less than 0.01)
and have an increased median hospital LOS (6 days vs. 3 days, p = 0.005),
compared to those without progressive organ dysfunction.
Conclusions:
Over one-quarter of preshock sepsis patients developed progressive organ
dysfunction with associated increased resource use. Demographic and physiologic
parameters were unable to differentiate patients with progressive organ
dysfunction, while the initial SOFA score was increased in patients meeting the
outcome. Overall, these patients received relatively little IV fluid therapy
during their ED stays. Further research to determine if more aggressive therapy
can prevent progressive organ dysfunction in this population is warranted.
22. 5-day Steroid Burst Best for COPD Exacerbations: The REDUCE RCT
Leuppi JD, et al. JAMA 2013
May 21. Epub ahead of print.
Importance International guidelines advocate a 7- to
14-day course of systemic glucocorticoid therapy in acute exacerbations of
chronic obstructive pulmonary disease (COPD). However, the optimal dose and
duration are unknown.
Objective To investigate whether a short-term (5 days)
systemic glucocorticoid treatment in patients with COPD exacerbation is
noninferior to conventional (14 days) treatment in clinical outcome and whether
it decreases the exposure to steroids.
Design, Setting, and Patients REDUCE (Reduction in the Use of
Corticosteroids in Exacerbated COPD), a randomized, noninferiority multicenter
trial in 5 Swiss teaching hospitals, enrolling 314 patients presenting to the
emergency department with acute COPD exacerbation, past or present smokers (≥20
pack-years) without a history of asthma, from March 2006 through February 2011.
Interventions Treatment with 40 mg of prednisone daily for
either 5 or 14 days in a placebo-controlled, double-blind fashion. The
predefined noninferiority criterion was an absolute increase in exacerbations
of at most 15%, translating to a critical hazard ratio of 1.515 for a reference
event rate of 50%.
Main Outcome and Measure Time to next exacerbation within 180 days.
Results Of 314 randomized patients, 289 (92%) of whom
were admitted to the hospital, 311 were included in the intention-to-treat
analysis and 296 in the per-protocol analysis. Hazard ratios for the short-term
vs conventional treatment group were 0.95 (90% CI, 0.70 to 1.29; P = .006 for
noninferiority) in the intention-to-treat analysis and 0.93 (90% CI, 0.68 to
1.26; P = .005 for noninferiority) in the per-protocol analysis, meeting our noninferiority
criterion. In the short-term group, 56 patients (35.9%) reached the primary end
point; 57 (36.8%) in the conventional group. Estimates of reexacerbation rates
within 180 days were 37.2% (95% CI, 29.5% to 44.9%) in the short-term; 38.4%
(95% CI, 30.6% to 46.3%) in the conventional, with a difference of −1.2% (95%
CI, −12.2% to 9.8%) between the short-term and the conventional. Among patients
with a reexacerbation, the median time to event was 43.5 days (interquartile
range [IQR], 13 to 118) in the short-term and 29 days (IQR, 16 to 85) in the
conventional. There was no difference between groups in time to death, the
combined end point of exacerbation, death, or both and recovery of lung
function. In the conventional group, mean cumulative prednisone dose was
significantly higher (793 mg [95% CI, 710 to 876 mg] vs 379 mg [95% CI, 311 to
446 mg], P less
than .001), but treatment-associated
adverse reactions, including hyperglycemia and hypertension, did not occur more
frequently.
Conclusions and Relevance In patients presenting to the emergency
department with acute exacerbations of COPD, 5-day treatment with systemic
glucocorticoids was noninferior to 14-day treatment with regard to
reexacerbation within 6 months of follow-up but significantly reduced glucocorticoid
exposure. These findings support the use of a 5-day glucocorticoid treatment in
acute exacerbations of COPD.
23.1 Book of the Month
Sonja Lyubomirsky's The Myths of Happiness: What Should Make You Happy, but Doesn't, What Shouldn't Make You Happy, but Does (New York: Penguin Press, 2013). She brings the best of today's experimental psychology to bear on the big milestones and crises of life: e.g., relationships, singleness, work, money, aging, regret. It's an excellent book, as applicable as it accessible.
If you want to get a feel for the author, below is a video presentation she gave at Google on her first book, The How of Happiness: A New Approach to Getting the Life You Want (New York: Penguin, 2008).
Book: http://www.amazon.com/dp/1594204373/
Related NY Times article:
23.2 Tid Bits
23.2 Tid Bits
A.
Primary care physicians can use Q-and-A to form pain prognosis
Primary
care physicians who asked patients with musculoskeletal pain three questions,
in addition to doing a normal work-up, more accurately predicted those who
still would have pain six months later than those who just did a work-up, U.K.
researchers said. The study in JAMA Internal Medicine said patients were asked
when they last were pain free for a month or longer, whether pain had
interfered with daily activities in the past month, and if they had pain
anywhere else within that time.
B.
Hastings Center updates recommendations for end-of-life care
The
Hastings Center updated its 1987 guidelines for the ethical care of terminally
ill patients, adding decision-making for dying children, specific issues for
patients with disabilities and the use of palliative sedation, among other
changes. The guidelines say a physician's offer or a family's request to
"do everything" to keep a patient alive may not respect patient
rights or ensure good care.
C.
Texting while driving linked to other risky behaviors among teens
About
45% of 8,505 high-school students said they have texted while driving at least
once over the past month, while nearly 12% reported doing it on a daily basis,
according to a study in the journal Pediatrics. Researchers noted that these
teens had a greater likelihood of engaging in other risky activities such as
driving after drinking alcohol and not wearing seat belts.
D.
Cause of Death: 50% of Medical Residents Fib
E. Doctors
have lowest overweight, absenteeism rates in study
Physicians
had the lowest rate of being overweight or having at least one chronic
condition compared with other job types, data from a Gallup survey showed.
Researchers also found physicians had low absenteeism levels and incurred
absenteeism costs of only $250 million annually, compared with $15.7 billion
per year among managers and executives.
F.
Sleep drugs tied to 19,000 ED visits in 2010
The
number of emergency department visits linked to Ambien and other zolpidem-based
sleep medications increased from around 6,000 in 2005 to more than 19,000 in
2010, with women more often affected than men, researchers from the U.S.
Substance Abuse and Mental Health Services Administration found. Total cases of
adverse reactions to zolpidem jumped nearly 220% between 2005 and 2010,
according to the report.
G. Predicting
Difficult Intubations — Easier to Say Who Isn't at Risk
A new
scoring system predicts low-risk intubations fairly well.
De
Jong A et al. Am J Respir Crit Care Med 2013 Apr 15; 187:832
H. Just 2 Months'
Exposure to Anticholinergics Affects Cognition
I. Snack
(Healthily) Before Shopping
Shopping
for groceries on an empty stomach does in fact influence food choices.
Anahad
O’Connor. NY Times Blog. May 13, 2013
Most
people know the age-old diet advice about grocery shopping when you are hungry:
You are more likely to buy fattening, unhealthy foods. So avoid it.
But the
weight loss maxims found in diet books do not always hold up in the real world.
So two researchers at Cornell University recently devised an experiment that
put this notion to the test.
The
study, published in JAMA Internal Medicine, was carried out in two phases. In
the first, 68 men and women were brought into a lab on two separate days after
having been told not to eat for five hours. Then they were allowed to “shop”
for food in a simulated grocery store, which offered low-calorie options like
fruits, vegetables and chicken breasts, as well as higher-calorie junk foods.
Before
shopping, half of the subjects were given a snack. Both groups ultimately
purchased a similar number of items, but those who shopped while hungry picked
the highest-calorie foods.
In the
second phase of the study, the researchers followed 82 actual shoppers in a
grocery store. Once again, they found that people shopping at times when they
were most likely to be hungry opted for the foods that were more calorically
dense.
In an
accompanying editorial, Dr. Rita F. Redberg, a cardiologist, said the findings
provided scientific support for common-sense advice.
“I
think all diet guides include the advice to ‘never go grocery shopping when you
are hungry,’ ” she wrote, “and when I had young children, I added ‘and never
with young children’ – because either of these factors seem to lead to less
wise food choices.”
