1. Ibuprofen outperforms morphine for fracture pain in children
Ibuprofen
was as effective as oral morphine in relieving the pain of children and teens
with fractures and was linked to fewer severe adverse reactions, Canadian
researchers wrote in Canadian Medical Association Journal. Morphine was
associated with side effects such as nausea, vomiting and drowsiness.
Poonai N,
et al. Oral administration of morphine versus ibuprofen to manage postfracture
pain in children: a randomized trial. CMAJ 2014 October 27 [Epub ahead of
print].
Background:
Recent warnings from Health Canada regarding codeine for children have led to
increased use of nonsteroidal anti-inflammatory drugs and morphine for common
injuries such as fractures. Our objective was to determine whether morphine
administered orally has superior efficacy to ibuprofen in fracture-related
pain.
Methods: We
used a parallel group, randomized, blinded superiority design. Children who
presented to the emergency department with an uncomplicated extremity fracture
were randomly assigned to receive either morphine (0.5 mg/kg orally) or
ibuprofen (10 mg/kg) for 24 hours after discharge. Our primary outcome was the
change in pain score using the Faces Pain Scale — Revised (FPS-R). Participants
were asked to record pain scores immediately before and 30 minutes after
receiving each dose.
Results: We
analyzed data from 66 participants in the morphine group and 68 participants in
the ibuprofen group. For both morphine and ibuprofen, we found a reduction in
pain scores (mean pre–post difference ± standard deviation for dose 1: morphine
1.5 ± 1.2, ibuprofen 1.3 ± 1.0, between-group difference [δ] 0.2 [95%
confidence interval (CI) –0.2 to 0.6]; dose 2: morphine 1.3 ± 1.3, ibuprofen
1.3 ± 0.9, δ 0 [95% CI –0.4 to 0.4]; dose 3: morphine 1.3 ± 1.4, ibuprofen 1.4
± 1.1, δ –0.1 [95% CI –0.7 to 0.4]; and dose 4: morphine 1.5 ± 1.4, ibuprofen
1.1 ± 1.2, δ 0.4 [95% CI –0.2 to 1.1]). We found no significant differences in
the change in pain scores between morphine and ibuprofen between groups at any
of the 4 time points (p = 0.6). Participants in the morphine group had
significantly more adverse effects than those in the ibuprofen group (56.1% v.
30.9%, p less than 0.01).
Interpretation:
We found no significant difference in analgesic efficacy between orally
administered morphine and ibuprofen. However, morphine was associated with a
significantly greater number of adverse effects. Our results suggest that
ibuprofen remains safe and effective for outpatient pain management in children
with uncomplicated fractures. Trial registration: ClinicalTrials.gov, no.
NCT01690780.
2. Low-dose Ketamine Improves Pain Relief in Pts Receiving IV
Opioids for Acute Pain in the ED: Results of a Randomized, Double-blind,
Clinical Trial
Beaudoin FL,
et al. Acad Emerg Med. 2014;21:1193-1202.
Low-dose
ketamine has been used perioperatively for pain control and may be a useful
adjunct to intravenous (IV) opioids in the control of acute pain in the
emergency department (ED). The aim of this study was to determine the
effectiveness of low-dose ketamine as an adjunct to morphine versus standard
care with morphine alone for the treatment of acute moderate to severe pain
among ED patients.
Methods: A
double-blind, randomized, placebo-controlled trial with three study groups was
conducted at a large, urban academic ED over a 10-month period. Eligible
patients were 18 to 65 years old with acute moderate to severe pain (score of
at least 5 out of 10 on the numerical pain rating scale [NRS] and pain duration
less than 7 days) who were deemed by their treating physician to require IV
opioids. The three study groups were: 1) morphine and normal saline placebo
(standard care group), 2) morphine and 0.15 mg/kg ketamine (group 1), or 3)
morphine and 0.3 mg/kg ketamine (group 2). Participants were assessed at 30,
60, and 120 minutes after study medication administration and received rescue
analgesia as needed to target a 50% reduction in pain. The primary outcome
measure of pain relief, or pain intensity reduction, was derived using the NRS
and calculated as the summed pain-intensity (SPID) difference over 2 hours. The
amount and timing of rescue opioid analgesia was evaluated as a secondary
outcome. The occurrence of adverse events was also measured.
Results: Sixty
patients were enrolled (n = 20 in each group). There were no differences
between study groups with respect to age, sex, race/ethnicity, preenrollment
analgesia, or baseline NRS. Over the 2-hour poststudy medication administration
period, the SPIDs were higher (greater pain relief) for the ketamine study
groups than the control group (standard care 4.0, interquartile range [IQR] =
1.8 to 6.5; group 1 7.0, IQR = 4.3 to 10.8; and group 2 7.8, IQR = 4.8 to 12.8;
p less than 0.02). The SPIDs for the ketamine groups were similar (p less than
0.46). When compared to standard care, group 2 sustained the reduction in pain
intensity up to 2 hours, whereas group 1 was similar to standard care by 2
hours. Similar numbers of patients received rescue analgesia: standard care
group, seven of 20, 35%; group 1, four of 20, 20%; and group 2, four of 20, 20%
(p = 0.48). Among those receiving rescue analgesia, those in the standard care
group received analgesia sooner than either low-dose ketamine group, on
average. More participants in the low-dose ketamine groups reported dysphoria
and dizziness.
Conclusions:
Low-dose ketamine is a viable analgesic adjunct to morphine for the treatment
of moderate to severe acute pain. Dosing of 0.3 mg/kg is possibly more
effective than 0.15 mg/kg, but may be associated with minor adverse events.
Future studies should evaluate additional outcomes, optimum dosing, and use in
specific populations.
3. Accuracy of Reduced-Dose CT for Ureteral Stones in ED
Patients
Moore CL,
et al. Ann Emerg Med 2014 Nov 04 [Epub ahead of print]
Study
objective: Reduced-dose computed tomography (CT) scans have been recommended for
diagnosis of kidney stone but are rarely used in the emergency department (ED)
setting. Test characteristics are incompletely characterized, particularly in
obese patients. Our primary outcome is to determine the sensitivity and
specificity of a reduced-dose CT protocol for symptomatic ureteral stones,
particularly those large enough to require intervention, using a protocol
stratified by patient size.
Methods: This
was a prospective, blinded observational study of 201 patients at an academic
medical center. Consenting subjects underwent both regular- and reduced-dose
CT, stratified into a high and low body mass index (BMI) protocol based on
effective abdominal diameter. Reduced-dose CT scans were interpreted by
radiologists blinded to regular-dose interpretations. Follow-up for outcome and
intervention was performed at 90 days.
Results: CT
scans with both regular and reduced doses were conducted for 201 patients, with
63% receiving the high BMI reduced-dose protocol. Ureteral stone was identified
in 102 patients (50.7%) of those receiving regular-dose CT, with a ureteral
stone greater than 5 mm identified in 26 subjects (12.9%). Sensitivity of the
reduced-dose CT for any ureteral stone was 90.2% (95% confidence interval [CI]
82.3% to 95.0%), with a specificity of 99.0% (95% CI 93.7% to 100.0%). For
stones greater than 5 mm, sensitivity was 100% (95% CI 85.0% to 100.0%).
Reduced-dose CT identified 96% of patients who required intervention for
ureteral stone within 90 days. Mean reduction in size-specific dose estimate
was 18.6 milligray (mGy), from 21.7 mGy (SD 9.7) to 3.4 mGy (SD 0.9).
Conclusion:
CT with substantial dose reduction was 90.2% (95% CI 82.3% to 95.0%) sensitive
and 98.9% (95% CI 85.0% to 100.0%) specific for ureteral stones in ED patients
with a wide range of BMIs. Reduced-dose CT was 96.0% (95% CI 80.5% to 99.3%)
sensitive for ureteral stones requiring intervention within 90 days.
4. U.S. Emergency Physicians Announce New List of Procedures
That Deserve A Second Look
Robert
Glatter, MD, Forbes Magazine, Oct 28, 2014
The
American College of Emergency Physicians (ACEP) today announced a second list
of five tests and procedures that should be discussed with patients seeking
care in an emergency department who require further diagnostic evaluation. The
goal is to help patients make smart decisions about the most appropriate
testing based on their individual situation.
In the end, the aim is twofold — reducing health care costs, but
ultimately improving patient care.
These
recommendations were announced at the annual ACEP meeting in Chicago, and are
part of ACEP’s participation in the American Board of Internal Medicine (ABIM)
Foundation’s Choosing Wisely campaign.
The goal of
the Choosing Wisely campaign is to help patients and physicians develop a
dialogue about the importance of using appropriate evaluations and treatments
and avoiding certain modes of treatments when harm may outweigh potential
benefits.
Over 80
national, regional and state medical specialty societies and consumer groups
have joined the Choosing Wisely campaign as partners, after launching in April
of 2012. ACEP became part of the campaign in February of 2013.
ACEP’s five
latest recommendations were developed through a multi-step process that
included research and input from an expert panel of emergency physicians and
the ACEP Board of Directors. These are
recommendations that physicians have control over and are not dictated by
hospitals or trauma system protocols.
Also, they do not expose patients to danger or physicians to medical
liability risks.
As all
clinical situations are unique, the recommendations serve as guidelines to help
guide treatment decisions between patients and their treating physicians.
The
following is a list of the five most recent “Choosing Wisely” evidence based
recommendations approved by ACEP’s Board of Directors.
1. Avoid CT of the head in asymptomatic adult
patients in the emergency department with syncope, insignificant trauma and a
normal neurological evaluation. Syncope (passing out or fainting) or near
syncope (lightheadedness or almost passing out) is a common reason for visiting
an emergency department and most of those visits are not serious. Many tests may be ordered to identify the
cause of the problem. However, these
tests should not be routinely ordered, and the decision to order them should be
guided by information obtained from the patient’s history or physical
examination.
2.
Avoid CT pulmonary angiography in emergency department patients with a
low-pretest probability of pulmonary embolism and either a negative Pulmonary
Embolism Rule-Out Criteria (PERC) or a negative D-dimer. Advances in medical technology have
increased the ability to diagnose even small blood clots in the lung. Now, the most commonly used test is known as
a CT pulmonary angiogram (CTPA). It is
readily available in most hospitals and emergency departments. However, disadvantages of the CTPA include
patient exposure to radiation, the use of dye in the veins that can damage
kidneys and high cost.
3.
Avoid lumbar spine imaging in the emergency department for adults with
atraumatic back pain unless the patient has severe or progressive neurologic
deficits or is suspected of having a serious underlying condition, such as
vertebral infection or cancer with bony metastasis. Low back pain without trauma is a
common presenting complaint in the emergency department. Most of the time, such pain is caused by
conditions such as a muscle strain or a bulging disc that cannot be identified
on an x-ray or CT scan.
4.
Avoid prescribing antibiotics in the emergency department for
uncomplicated sinusitis. Sinusitis
is a common reason for patients to visit the emergency department. Most
patients with acute sinusitis do not require antibiotic treatment, because 98 percent
of acute sinusitis cases are caused by a viral infection and resolve in 10-14
days without treatment.
5.
Avoid ordering CT of the abdomen and pelvis in young otherwise health
emergency department patients with known histories of ureterolithiasis
presenting with symptoms consistent with uncomplicated kidney stones. Many patients in the emergency
department who are less than 50 years old and who have symptoms of recurrent
kidney stones do not need a CT scan unless these symptoms persist or worsen, of
if there is a fever, or a history of severe obstruction with previous
stones. CT scans of patients in the
emergency department with symptoms of a recurrent kidney stone usually don’t
change treatment decisions, and the cost and radiation exposure can often be
avoided in these cases.
In 2013,
ACEP released the first five Choosing Wisely recommendations of tests and
procedures to question. ACEP had
initially decided not to be part of the campaign due to potential concerns
about the unique way emergency medicine is practiced compared with office-based
practice, along with concerns that advocacy for medical liability reform was
not part of the messaging of the initial campaign.
5. Dabigatran: More Bleeds in Practice Than Expected
By Crystal
Phend, Senior Staff Writer, MedPage Today. Nov 5, 2014
- Note that this analysis of Medicare data revealed that dabigatran has a higher overall bleeding risk compared with warfarin treatment of atrial fibrillation.
- This study reveals the importance of careful postmarketing research to elucidate risks that may not have been seen in primary efficacy trials.
Dabigatran
(Pradaxa) was associated with higher risk of bleeding than warfarin (Coumadin)
in a large Medicare population sample, unlike the equal risk seen in the
pivotal RE-LY trial.
The
relative risk was 30% higher for any bleeding with the direct thrombin
inhibitor than warfarin and 58% higher for major bleeding (propensity adjusted
rate 9.0% versus 5.9%, P less than 0.001), Yuting Zhang, PhD, of the University
of Pittsburgh, and colleagues reported online in JAMA Internal Medicine.
By
contrast, the pivotal RE-LY trial had shown no difference in major bleeding
risk between the two drugs, with an annual rate of 3.36% for warfarin versus
3.11% with the approved 150-mg dose of dabigatran, for a relative risk of 0.93
(P=0.31).
The
nationally-representative, 5%-sample Medicare analysis did agree qualitatively
with the trial results on higher risk of GI bleeds and lower likelihood of
intracranial bleeding than warfarin.
The hazard
ratio for GI bleeding on dabigatran was 1.85 (95% confidence interval
1.64-2.07) versus warfarin, whereas the hazard ratio for intracranial
hemorrhage of 0.32 (95% CI 0.20-0.50) favored dabigatran over the older drug.
In RE-LY, the hazard ratio for major GI bleeding with the 150-mg dabigatran
dose versus warfarin was considerably lower, at 1.50.
A prior FDA
analysis of Medicare data had agreed with the trial on overall bleeding risk,
but Zhang's group argued that its lack of adjustment for patient factors was a
major flaw. "Dabigatran and warfarin users are very different in several
factors that directly affect the risk of bleeding, and failing to adjust would
bias the results, as our unadjusted estimates indicate," they wrote.
Their
results were propensity weighted to account for demographic variables (age,
sex, race, and Medicaid eligibility) and clinical characteristics, including
the stroke risk CHADS2 score, chronic kidney disease, hypertension, history of
stroke or transient ischemic attack, history of acute myocardial infarction,
diabetes, congestive heart failure, acquired hypothyroidism, the number of
other CMS-priority comorbidities, and history of bleeding in the year prior to
treatment initiation.
And there
was a significantly higher prevalence of chronic kidney disease, congestive
heart failure, diabetes, and history of stroke or transient ischemic attack in
those who took warfarin. Propensity score weighting balanced out those
characteristics.
The
retrospective analysis of pharmacy and medical claims from a random 5% sample
of Medicare beneficiaries newly diagnosed with atrial fibrillation from Oct. 1,
2010, through Oct. 31, 2011 included 1,302 starting on dabigatran and 8,102
initiating warfarin within 60 days of initial diagnosis.
Clinical Implications
"Thus,
dabigatran should be prescribed with caution, especially among high-risk
patients," they cautioned. The risk of major bleeding on dabigatran was
particularly high for African Americans (HR 2.12, 95% confidence interval
1.39-3.24) and patients with chronic kidney disease (HR 2.07, 95% CI
1.66-2.58).
The
findings were cause for concern, according to an editor's note accompanying the
paper from Rita F. Redberg, MD, calling the bleeding risks of dabigatran
"significantly greater than originally appeared at the time of the FDA
approval."
"Dabigatran
was approved by the FDA in 2010 via the accelerated pathway after a 6-month
review. The haste to approve novel drugs places an increasing importance on
post-approval data to help better understand risks and benefits," wrote
Redberg, a cardiologist at the University of California San Francisco. "This
study reminds us of the importance of postmarketing data and of having adequate
data on risks and benefits to advise our patients accurately."
Judy
Mackall, MD, section chief for cardiac electrophysiology at University
Hospitals Case Medical Center in Cleveland, was less convinced that the data
were influential for practice. "A lot of what's in this study we were
already aware of from RE-LY study," she told MedPage Today. As far as the
increased risk of GI bleeding, Mackall pointed to one theory. "Dabigatran
is delivered as a pro-drug," she said. "About 6% gets absorbed and the
rest passes through the GI tract as an inactive anticoagulant."
But the
lower risk of intracranial bleeding outweighs the concern about GI bleeds, she
suggested. "GI bleed is significant, yes, it's treatable most often.
Getting a lower risk of intracranial bleeding is a big safety concern,"
she said. "Intracranial bleeding is the major bleeding that we worry about
because that's not easily correctable."
The
researchers urged that because of the GI bleeding risk across all subgroups
"it is important for physicians to explain to patients how to detect
gastrointestinal bleeding so that it can be controlled as early as
possible." But "intracranial hemorrhage is the most feared
complication associated with warfarin," they agreed, "thus, patients
at high risk of intracranial hemorrhage may be willing to accept the higher
risk of other bleeding events associated with dabigatran for a lower likelihood
of intracranial bleeding. Arguably, this is the subgroup in which dabigatran is
most likely to be a favorable choice in terms of safety."
6. Benign syncope in long QT syndrome family members
The data
indicate that family members from families with long QT syndrome have a benign
form of syncope, most likely related to vasovagal syncope and not ventricular
tachyarrhythmic syncope.
Nordkamp O,
et al. Syncope in Genotype-Negative Long
QT Syndrome Family Members. Am J Cardiol. 2014 Oct 15;114(8):1223-8
Highlights
•Syncope
occurred in 11% of family members of patients with LQTS.
•These
syncope events occurred mainly in female family members during midadolescence.
•None of
the family members had life-threatening events after the syncope episodes.
•These data
suggest that family members most likely have benign vasovagal syncope.
Abstract
Unaffected
long-QT syndrome family members (FMs) frequently experience syncope. The aims
of this study were to test the hypothesis that syncope events in FMs are benign
events and to compare clinical characteristics, triggers eliciting the syncope
events, and long-term outcomes between FMs and those with LQT1 or LQT2
mutations from the international Long QT Syndrome Registry.
A total of
679 FMs, 864 LQT1 patients, and 782 LQT2 patients were included. Seventy-eight
FMs (11%) experienced cardiovascular events. Almost all cardiovascular events
were nonfatal syncope; only 1 FM, with an additional mitral valve prolapse, experienced
aborted cardiac arrest during exercise. The mean age at first syncope in FMs
was 17 years, and female FMs experienced syncope more frequently than male FMs
(14% vs 9%, p = 0.027). Syncope was more frequently triggered by exercise in
LQT1 patients (43% in LQT1 patients vs 5% in FMs, p less than 0.001), while
syncope triggered by a variety of other triggers was more frequent in FMs (54%
in FMs vs 22% in LQT1 patients and 30% in LQT2 patients, p less than 0.001 for
both). None of the FMs experienced aborted cardiac arrest or sudden cardiac
death after the first syncopal episode.
In conclusion,
syncope is frequently present in FMs, and these syncopal events occurred more
frequently in female than in male FMs, with an increased incidence in
midadolescence. Triggers eliciting the syncopal events were different between
FMs and patients with long-QT syndrome mutations. Hence, the type of trigger is
useful in distinguishing between high- and low-risk syncope. These data
indicate that FMs from families with LQTS have a benign form of syncope, most
likely related to vasovagal syncope and not ventricular tachyarrhythmic
syncope.
7. Association between the Seat Belt Sign and Intra-abdominal
Injuries in Children with Blunt Torso Trauma in Motor Vehicle Collisions
Borgialli DA,
et al, for the Pediatric Emergency Care Applied Research Network (PECARN). Acad
Emerg Med. 2014;21:1240-8.
Objectives:
The objective was to determine the association between the abdominal seat belt
sign and intra-abdominal injuries (IAIs) in children presenting to emergency
departments with blunt torso trauma after motor vehicle collisions (MVCs).
Methods: This
was a planned subgroup analysis of prospective data from a multicenter cohort
study of children with blunt torso trauma after MVCs. Patient history and
physical examination findings were documented before abdominal computed
tomography (CT) or laparotomy. Seat belt sign was defined as a continuous area
of erythema, ecchymosis, or abrasion across the abdomen secondary to a seat
belt restraint. The relative risk (RR) of IAI with 95% confidence intervals
(CIs) was calculated for children with seat belt signs compared to those
without. The risk of IAI in those patients with seat belt sign who were without
abdominal pain or tenderness, and with Glasgow Coma Scale (GCS) scores of 14 or
15, was also calculated.
Results: A
total of 3,740 children with seat belt sign documentation after blunt torso
trauma in MVCs were enrolled; 585 (16%) had seat belt signs. Among the 1,864
children undergoing definitive abdominal testing (CT, laparotomy/laparoscopy,
or autopsy), IAIs were more common in patients with seat belt signs than those
without (19% vs. 12%; RR = 1.6, 95% CI = 1.3 to 2.1). This difference was
primarily due to a greater risk of gastrointestinal injuries (hollow viscous or
associated mesentery) in those with seat belt signs (11% vs. 1%; RR = 9.4, 95%
CI = 5.4 to 16.4). IAI was diagnosed in 11 of 194 patients (5.7%; 95% CI = 2.9%
to 9.9%) with seat belt signs who did not have initial complaints of abdominal
pain or tenderness and had GCS scores of 14 or 15.
Conclusions:
Patients with seat belt signs after MVCs are at greater risk of IAI than those
without seat belt signs, predominately due to gastrointestinal injuries.
Although IAIs are less common in alert patients with seat belt signs who do not
have initial complaints of abdominal pain or tenderness, the risk of IAI is
sufficient that additional evaluation such as observation, laboratory studies,
and potentially abdominal CT scanning is generally necessary.
8. Dual Antibiotic Treatment Best for Moderately Severe
Pneumonia
By Megan
Brooks. October 07, 2014
NEW YORK
(Reuters Health) - Dual antibiotic therapy is needed for patients hospitalized
with moderately severe community-acquired pneumonia (CAP), suggests a
randomized controlled trial.
The study
team tried and failed to demonstrate noninferiority of a beta-lactam alone over
a beta-lactam-macrolide combination in this patient population.
There is
ongoing debate about optimal antibiotic therapy for patients hospitalized with
CAP. North American guidelines currently advise dual antibiotic therapy that
covers typical and atypical bacterial pathogens for all patients hospitalized
for CAP (i.e., beta-lactam plus macrolide or fluoroquinolone monotherapy),
while British guidelines reserve such therapy for moderately to severely ill
patients.
Dr. Nicolas
Garin, from Hopital Riviera-Chablais, Switzerland, and colleagues conducted an
open-label, multicenter noninferiority trial of 580 patients admitted to six
hospitals in Switzerland for moderately severe CAP. Patients were randomly
allocated to receive monotherapy with a beta-lactam or dual therapy with a
beta-lactam and a macrolide. Legionella pneumophila infection was diagnosed
using urinary antigen testing, and macrolide therapy was added for patients in
the monotherapy arm testing positive.
On hospital
day 7, more patients in the monotherapy arm compared with the dual therapy arm
had not reached clinical stability (the primary outcome: 41.3% vs 33.4%;
p=0.07). "The upper limit of the 1-sided 90% CI was 13.0%, exceeding the
predefined noninferiority boundary of 8%," the authors say.
In subgroup
analyses, patients infected with atypical pathogens (hazard ratio, 0.33) or
with Pneumonia Severity Index (PSI) category IV (HR 0.81) were less likely to
reach clinical stability with one antibiotic. Outcomes were similar in patients
not infected with atypical pathogens (HR 0.99) or with PSI category I to III
pneumonia (HR 1.06).
A smaller
proportion of patients treated with dual therapy were readmitted at 30 days
(3.1% vs 7.9%; p=0.01), but none of the other secondary outcomes (mortality,
ICU admission, complications, length of stay or pneumonia recurrence within 90
days) varied between the treatment arms.
In email to
Reuters Health, Dr. Garin said, "I think the take home message is: for
empiric treatment of CAP, beta-lactam monotherapy should be reserved for
patients with PSI class I to III severity (or CURB-65 score 0-1). A macrolide
should be combined with a beta-lactam for patients in PSI class IV or V or with
a CURB-65 score above 1."
In an
editorial, Dr. Jonathan Lee and Dr. Michael Fine of the University of
Pittsburgh School of Medicine in Pennsylvania say the evidence from this trial
"pushes the pendulum further in favor of antibiotic therapy covering
atypical and typical bacterial pathogens for patients hospitalized for CAP.
Lessons learned from its design and results should inform future trials
required to definitively settle this debate."
Until then,
they conclude, "dual therapy should remain the recommended treatment for
patients hospitalized for CAP."
9. McGyver Goes to the ED: Rewiring a VAD Driveline
Cubillo EI
4th, et al. Emergent Reconnection of a Transected Left Ventricular Assist
Device Driveline. J Emerg Med. 2014;47:546–551.
BACKGROUND:
Recent clinical advances with new mechanical circulatory systems have led to
additional strategies in the treatment of end-stage heart failure. The
third-generation HeartWare Left Ventricular Device (LVAD) System utilizes a
blood pump and a driveline (cable) that exits the patient's skin connecting the
implanted pump to an externally worn controller. We report a rare case of a
HeartWare LVAD driveline rewiring after accidental (presumed) transection of
the driveline system.
CASE
REPORT: A 67-year-old male with a medical history of ischemic cardiomyopathy
status post HeartWare LVAD implantation presented to the emergency department
(ED) after acute LVAD failure. On the morning of presentation, he attempted to
cut the paper tape off of his adult diaper with scissors and accidentally
(presumed) and unwitnessed severed the driveline system. The patient
immediately went into cardiac arrest and was transported to a regional medical
center. On arrival, he exhibited no appreciable vital signs and was subsequently
intubated, vascular access was placed, and inotropic support initiated. The
emergency physician individually stripped and reconnected the color-coded
driveline wires using multiple hemostats, electrical tape, and cardboard, which
resulted in regeneration of positive LVAD flows.
WHY SHOULD
AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: VAD patients will present in extremis
typically to the ED with manifestations of pump dysfunction ranging from
diminished flows needing fluid management or pump adjustments to full pump
failure manifesting as cardiogenic shock, needing rapid resuscitation and
transfer to a cardiothoracic surgical unit with on-site VAD-perfusion
specialists.
10. Airway Management
A. Airway Management for Adults with
Prehospital Cardiac Arrest: Is Intubation Passé?
Patients
who were intubated had similar outcomes to those who had a supraglottic airway
device inserted.
Tiah L et
al. Does Pre-hospital Endotracheal Intubation Improve Survival Outcomes among
Adults with Non-traumatic Out-of-hospital Cardiac Arrest? A Systematic Review.
West J Emerg Med 2014 Oct 28 [Epub ahead of print]
Objective:
Endotracheal intubation (ETI) is currently considered superior to supraglottic
airway devices (SGA) for survival and other outcomes among adults with
non-traumatic out-of-hospital cardiac arrest (OHCA). We aimed to determine if
the research supports this by conducting a systematic review.
Methods: We
searched the MEDLINE, Scopus and CINAHL databases for studies published between
1 January 1980 and 30 April 2013 that compared pre-hospital use of ETI with SGA
for outcomes of return of spontaneous circulation (ROSC); survival to hospital
admission; survival to hospital discharge; and favourable neurological or
functional status. Studies were selected using pre-specified criteria. Included
studies were independently screened for quality using the Newcastle-Ottawa
scale. Results were not pooled because of study variability. Study outcomes
were extracted and results presented as summed odds ratios with 95% confidence
intervals.
Results: We
identified five eligible studies: one quasi-randomised controlled trial and
four cohort studies, involving 303,348 patients in total. Only three of the
five studies reported a higher proportion of ROSC with ETI versus SGA with no
difference reported in the remaining two. None found significant differences
between ETI and SGA for survival to hospital admission or discharge. One study
reported better functional status at discharge for ETI versus SGA. Two studies
reported no significant difference for favourable neurological status between
ETI and SGA.
Conclusion:
Current evidence does not conclusively support the superiority of ETI over SGA
for multiple outcomes among adults with OHCA.
B. A Dose of Ketamine Can Facilitate
Preoxygenation before Emergency Intubation
In a new
technique called “delayed sequence intubation,” ketamine facilitated preoxygenation
in patients with altered mental status.
Weingart SD
et al. Delayed Sequence Intubation: A Prospective Observational Study.
Ann Emerg
Med 2014 Oct 22 [Epub ahead of print]
Study
objective: We investigate a new technique for the emergency airway management
of patients with altered mental status preventing adequate preoxygenation.
Methods: This
was a prospective, observational, multicenter study of patients whose medical
condition led them to impede optimal preintubation preparation because of
delirium. A convenience sample of emergency department and ICU patients was
enrolled. Patients received a dissociative dose of ketamine, allowing
preoxygenation with high-flow nonrebreather mask or noninvasive positive
pressure ventilation (NIPPV). After preoxygenation, patients were paralyzed and
intubated. The primary outcome of this study was the difference in oxygen
saturations after maximal attempts at preoxygenation before delayed sequence
intubation compared with saturations just before intubation. Predetermined
secondary outcomes and complications were also assessed.
Results: A
total of 62 patients were enrolled: 19 patients required delayed sequence
intubation to allow nonrebreather mask, 39 patients required it to allow NIPPV,
and 4 patients required it for nasogastric tube placement. Saturations
increased from a mean of 89.9% before delayed sequence intubation to 98.8%
afterward, with an increase of 8.9% (95% confidence interval 6.4% to 10.9%).
Thirty-two patients were in a predetermined group with high potential for
critical desaturation (pre–delayed sequence intubation saturations ≤93%). All
of these patients increased their saturations post–delayed sequence intubation;
29 (91%) of these patients increased their post–delayed sequence intubation
saturations to greater than 93%. No complications were observed in the patients
receiving delayed sequence intubation.
Conclusion:
Delayed sequence intubation could offer an alternative to rapid sequence
intubation in patients requiring emergency airway management who will not
tolerate preoxygenation or peri-intubation procedures. It is essentially
procedural sedation, with the procedure being preoxygenation. Delayed sequence
intubation seems safe and effective for use in emergency airway management.
11. Images in Clinical Practice
Destructive
Ulcerated Lesions of the Hard Palate
Herpetic
Whitlow
Carotid
Cavernous Fistula
Ectopia
Lentis in Marfan's Syndrome
12. Can emergency physicians ‘rule in’ and ‘rule out’ AMI with
clinical judgement?
Body R, et
al. Emerg Med J 2014;31:872-876
Objective
To determine the diagnostic accuracy of emergency physician gestalt in
emergency department (ED) patients with suspected cardiac chest pain, both
alone and in combination with initial troponin level and ECG findings.
Methods We
prospectively included patients presenting to the ED with suspected cardiac
chest pain. Clinicians recorded their ‘gestalt’ at the time of presentation
using a five-point Likert scale, blinded to outcome. Troponin T and
high-sensitivity troponin T (hs-cTnT; both Roche Diagnostics Elecsys) levels
were measured in admission blood samples. All patients underwent troponin
testing at least 12 h after peak symptoms. The primary outcome was acute
myocardial infarction (AMI).
Results 458
patients were included in this study, 81 (17.7%) of whom had AMI. Clinician
gestalt alone had an area under the receiver operating characteristic curve of
0.76 (95% CI 0.70 to 0.82) for AMI. Immediately discharging patients with
normal initial troponin and ECG in whom the clinician felt the diagnosis was
‘probably not’ or ‘definitely not’ acute coronary syndrome (ACS) would have
avoided admission for 23.1% (95% CI 19% to 28%) patients with 100% sensitivity
(95% CI 95.6% to 100%). With hs-cTnT, 100% sensitivity could have been achieved
even if only patients with ‘probable’ or ‘definite’ ACS were investigated
further, which would have allowed 41.7% patients to be discharged immediately.
Conclusions
Gestalt alone cannot be used to ‘rule in’ or ‘rule out’ ACS. By combining
clinician gestalt with the admission ECG and troponin level, we found 100%
sensitivity without the need for serial troponin testing. These findings have
the potential to reduce unnecessary hospital admissions for suspected ACS but
must be prospectively validated before considering clinical implementation.
13. Diagnosing Appendicitis
A. A Lit Review
Diagnosing Appendicitis:
An Evidence-Based Review of the Diagnostic Approach to Appendicitis in 2014.
Shogilev
DJ, et al. West J Emerg Med 2014 Oct 7 [Epub ahead of print].
Introduction:
Acute appendicitis is the most common abdominal emergency requiring emergency surgery.
However, the diagnosis is often challenging and the decision to operate,
observe or further work-up a patient is often unclear. The utility of clinical
scoring systems (namely the Alvarado score), laboratory markers, and the
development of novel markers in the diagnosis of appendicitis remains
controversial. This article presents an update on the diagnostic approach to
appendicitis through an evidence-based review.
Methods: We
performed a broad Medline search of radiological imaging, the Alvarado score,
common laboratory markers, and novel markers in patients with suspected
appendicitis.
Results:
Computed tomography (CT) is the most accurate mode of imaging for suspected
cases of appendicitis, but the associated increase in radiation exposure is problematic.
The Alvarado score is a clinical scoring system that is used to predict the
likelihood of appendicitis based on signs, symptoms and laboratory data. It can
help risk stratify patients with suspected appendicitis and potentially
decrease the use of CT imaging in patients with certain Alvarado scores. White
blood cell (WBC), C-reactive protein (CRP), granulocyte count and proportion of
polymorphonuclear (PMN) cells are frequently elevated in patients with
appendicitis, but are insufficient on their own as a diagnostic modality. When
multiple markers are used in combination their diagnostic utility is greatly
increased. Several novel markers have been proposed to aid in the diagnosis of
appendicitis; however, while promising, most are only in the preliminary stages
of being studied.
Conclusion:
While CT is the most accurate mode of imaging in suspected appendicitis, the
accompanying radiation is a concern. Ultrasound may help in the diagnosis while
decreasing the need for CT in certain circumstances. The Alvarado Score has
good diagnostic utility at specific cutoff points. Laboratory markers have very
limited diagnostic utility on their own but show promise when used in
combination. Further studies are warranted for laboratory markers in combination
and to validate potential novel markers.
B. During Pregnancy
Thompson
MM, et al. West J Emerg Med. 2014 Sep;15(6):652-4.
Abdominal
pain frequently represents a diagnostic challenge in the acute setting. In
pregnant patients, the gravid abdomen and concern for ionizing radiation
exposure further limit evaluation. If undiagnosed, appendicitis may cause
disastrous consequences for the mother and fetus.
We present
the case of a pregnant female who was admitted for right lower quadrant
abdominal pain. Advanced imaging of the abdomen and pelvis was interpreted to
be either indeterminate or normal and a diagnosis of acute appendicitis was
made on purely clinical grounds. This patient’s management and a literature
review of diagnostic techniques for acute appendicitis during pregnancy are
discussed.
C. False Positive Appendicitis on
Bedside US
14. Comparison of parenteral treatments of acute primary HA in a
large academic ED cohort.
McCarthy LH,
et al. Cephalalgia. 2014 Nov 3 [Epub ahead of print].
OBJECTIVE:
The objective of this article is to compare acute primary headache patient
outcomes in those initially treated with parenteral opiates or non-opiate
recommended headache medications in a large academic medical emergency
department (ED).
BACKGROUND:
Many acute primary headache patients are not diagnosed with a specific headache
type and are treated with opiates and nonspecific pain medications in the ED
setting. This is inconsistent with multiple expert recommendations.
METHODS:
Electronic charts were reviewed from 574 consecutive patients who visited the
ED for acute primary headache (identified by chief complaint and ICD9 codes)
and were treated with parenteral medications.
RESULTS:
Non-opiate recommended headache medications were given first line to 52.6% and
opiates to 22.8% of all participants. Patients given opiates first had
significantly longer length of stays (median 5.0 vs. 3.9 hours, p less than 0.001)
and higher rates of return ED visits within seven days (7.6% vs. 3.0%,
p = 0.033) compared with those given non-opiate recommended medications in
univariate analysis. Only the association with longer length of stay remained
significant in multivariable regression including possible confounding
variables.
CONCLUSIONS:
Initial opiate use is associated with longer length of stay compared with
non-opiate first-line recommended medications for acute primary headache in the
ED. This association remained strong and significant even after multivariable
adjustment for headache diagnosis and other possible confounders.
Associated editorial: Friedman B, et
al. Convincing the skeptic. How to fix emergency department headache
management.
In their
analysis of a research database from an academic emergency department (ED) in
California (1), Drs McCarthy and Cowan identify three features of emergency
headache care that have been reported by multiple clinical investigators from a
multitude of North American EDs (2–7): (i) emergency physicians often fail to
assign specific primary headache diagnoses to their headache patients; (ii)
emergency physicians frequently treat migraine in particular and headaches in
general with opioids; (iii) emergency physicians use triptans infrequently and
dihydroergotamine rarely.
These
practices seem difficult to understand. In the outpatient setting, an accurate
headache diagnosis will lead to appropriate treatment. Parenteral opioid use
has been associated with undesirable headache outcomes, such as headache
recurrence and ED recidivism (3). Long-term problems associated with recurrent
use of opioids include refractoriness to standard headache medications (8) and
chronification of migraine (9). Triptans and dihydroergotamine on the other
hand are evidence-based therapies. The number needed to treat for subcutaneous sumatriptan,
for example, is a very impressive ‘2’ (10).
Unfortunately,
there are no data available to help us comprehend and contextualize emergency
practice—why do emergency physicians practice as they do? It is clear that time
has not changed long-held practice patterns—opioid use for management of
migraine in the ED is as prevalent today as it was 15 years ago (4). As
demonstrated by Drs McCarthy and Cowan and elsewhere (1,4), this practice is
highly prevalent in academic settings, the setting in which one might most
expect to see appropriate practice.
Use of
opioids in the ED for migraine may be an education issue—it could be that
emergency physicians simply do not appreciate the long-term sequelae of
repeated opioid use. Alternatively, it may be an informed choice. Consider how
a skeptic might respond to the American Headache Society’s Choosing Wisely
guidelines (11): ‘Parenteral opioids are a guideline-supported, evidence-based
therapy (12). There are no high quality clinical data demonstrating detrimental
effects of parenteral opioids when compared to alternative therapy. Much of the
data come from non-randomized studies, which failed to account for important
baseline factors’. For example, Drs McCarthy and Cowan did indeed find an
association between parenteral opioid use and length of stay. However, is this
because of opioid administration, or are there plausible unmeasured
confounders, such as the severity of the underlying headache disorder or
duration of the acute attack? Could it be that the patients treated with
parenteral non-steroidal anti-inflammatory drugs (NSAIDs) in Drs McCarthy and
Cowan’s database were some of the many patients who present to the ED having
not taken any medication at all, while the ones given opioids were the patients
with chronic migraine and medication overuse headache who had already exceeded
recommended doses of triptans and NSAIDs? Failure to account for these baseline
differences is a limitation encountered in many retrospective ED analyses.
There are compelling data demonstrating an association between outpatient oral
opioids and progression of episodic to chronic migraine (9). However, it is not
clear if these data are relevant to patients who receive a single dose of
parenteral hydromorphone in the ED.
Consider
the dilemma of the busy emergency physician when deciding among acute headache
therapeutics; metoclopramide, droperidol and ketorolac each have FDA black box
warnings. All the parenteral anti-dopaminergics can cause akathisia, which is
often an unpleasant experience for the patient and, at least theoretically, may
cause tardive dyskinesia. Subcutaneous sumatriptan causes adverse medication
effects in more than 50% of patients when administered in the ED setting (13).
While triptans are probably safe in pregnant or mildly hypertensive patients,
unknown pregnancy status and high blood pressure certainly might give the
emergency physician pause before administering one of these medications. Early
pregnancy cannot be excluded by history alone. One-quarter of ED headache
patients present with at least moderately elevated blood pressure (14). In our
ED-based sumatriptan trials, we have excluded more than 25% of potential
subjects for pregnancy and elevated cardiovascular risk. Finally, some patients
may have recently taken large enough doses of triptans or NSAIDs that further
administration of these agents would be both contraindicated and unlikely to
succeed.
Now
consider the appeal of opioids. Emergency physicians know this class of
medication well. Opioids are quite potent, but are safe when administered in a
monitored setting (15). Importantly, opioids can be administered in successive
doses until a patient’s pain is controlled………
For the
remainder of the essay (full-text free): http://cep.sagepub.com/content/early/2014/10/29/0333102414557704.long
15. Evaluating the Pediatric Early Warning Score (PEWS) System
for Admitted Patients in the Pediatric ED
Gold DL, et
al. Acad Emerg Med. 21:1249-56.
Objectives:
The Pediatric Early Warning Score (PEWS) systems were developed to provide a
reproducible assessment of a child's clinical status while hospitalized. Most
studies investigating the PEWS evaluate its usefulness in the inpatient
setting. Limited studies evaluate the effectiveness and integration of PEWS in
the pediatric emergency department (ED). The goal of this study was to explore
the test characteristics of an ED-assigned PEWS score for intensive care unit
(ICU) admission or clinical deterioration in admitted patients.
Methods: This
was a prospective 12-month observational study of patients, aged 0 to 21 years,
admitted from the ED of an urban, tertiary care children's hospital. ED nurses
were instructed in PEWS assignment and electronic medical record (EMR)
documentation. Interrater reliability between nurses was evaluated. PEWS scores
were measured at initial assessment (P0) and time of admission (P1). Patients
were stratified into outcome groups: those admitted to the ICU either from the
ED or as transfers from the floor and those admitted to the floor only.
Clinical deterioration was defined as transfer to the ICU within 6 hours or
within 6 to 24 hours of admission. PEWS scores and receiver operating
characteristic (ROC) curves were compared for patients admitted to the floor,
ICU, and with clinical deterioration.
Results: The
authors evaluated 12,306 consecutively admitted patients, with 99% having a
PEWS documented in the EMR. Interrater reliability was excellent (intraclass
coefficient = 0.91). A total of 1,300 (10.6%) patients were admitted to the ICU
and 11,066 (89.4%) were admitted to the floor. PEWS scores were higher for
patients in the ICU group (P0 = 2.8, SD ± 2.4; P1 = 3.2, SD ± 2.4; p less than
0.0001) versus floor patients (P0 = 0.7, SD ± 1.2; P1 = 0.5, SD ± 0.9; p less
than 0.0001). To predict the need for ICU admission, the optimal cutoff points
on the ROC are P0 = 1 and P1 = 2, with areas under the ROC curve (AUCs) of 0.79
and 0.86, respectively. The likelihood ratios (LRs) for these optimal cutoff
points were as follows: P0 +LR = 2.5 (95% confidence interval [CI] = 2.4 to
2.6, p less than 0.05), –LR = 0.32 (95% CI = 0.28 to 0.36, p less than 0.05);
and P1 +LR = 6.2 (95% CI = 5.8 to 6.6, p less than 0.05), –LR = 0.32 (95% CI =
0.29 to 0.35, p less than 0.05). For every unit increase in P0 and P1, the odds
of admission to the ICU were 1.9 times greater (95% CI = 1.8 to 1.9, p less
than 0.0001) and 2.9 times greater (95% CI = 2.7 to 3.1, p less than 0.0001)
than to the floor. There were 89 patients in the clinical deterioration group,
with 36 (0.3%) patients transferred to the ICU within 6 hours of admission and
53 (0.4%) patients transferred within 6 to 24 hours. In this group, an elevated
P0 and P1 were statistically associated with an increased risk of transfer with
optimal cutoff points similar to above; however, there were poorer AUCs and
test characteristics.
Conclusions:
A PEWS system was implemented in this pediatric ED with excellent data capture
and nurse interrater reliability. The study found that an elevated PEWS is
associated with need for ICU admission directly from the ED and as a transfer,
but lacks the necessary test characteristics to be used independently in the ED
environment.
16. Pediatric Procedural Sedation with Propofol Using a Higher
Initial Bolus Dose
Young TP,
et al. Pediatr Emerg Care. 2014 Oct;30(10):689-93.
Objectives:
We sought to describe the doses of propofol used for sedation in our pediatric
emergency department, along with the range of procedures performed under
propofol sedation. We also planned to describe clinically important physiologic
changes seen and physician satisfaction with propofol at the doses observed.
Methods:
This was a prospective observational case series. Physicians completed a data
collection form after the propofol sedation. The physicians were asked to
report physiologic changes that occurred during sedation and rate their
satisfaction with propofol as a sedation agent on a 100-mm visual analog scale.
Results:
Eight hundred eighty-six sedation events were reported. The median initial dose
of propofol given was 2.0 mg/kg and the median total dose was 3.6 mg/kg.
Propofol was used for a wide range of procedures. The most common physiologic
change was desaturation/hypoxia (desaturation to less than 90% in 7.2%). No
deaths, unplanned intubations, or surgical airway placements were reported.
Treating physicians reported a median satisfaction score of 97 mm.
Conclusions:
A 2-mg/kg initial bolus dose of propofol for pediatric sedation was well
tolerated and useful for a wide range of procedures. Physicians should expect
to find a high level of satisfaction with this dose.
17. Contribution of verbal suggestion to the therapeutic
efficacy of an analgesic agent for acute primary headache
[DRV
comment: If the simple suggestion to a pt “Hey, this is really gonna work
great!” had boosted the medication’s analgesic effect, we could really have put
this to use in the ED. But it didn’t work. Too bad.]
Oktay C, et
al. Cephalalgia 2014 Sept 8 [Epub ahead of print]
Objective
The therapeutic response of a patient cannot purely be explained by the method
of therapy or the efficacy of a drug. Clinician-patient interaction,
psychosocial factors, patients’ expectations, hopes, beliefs and fears are all
related to the healing outcome. Malleability and suggestibility are also
important in the placebo or nocebo effect. The purpose of this study was to
evaluate whether adding brief verbal suggestions for pain relief could change
the magnitude of an analgesic’s efficacy.
Methods
This prospective study was performed in the emergency department of a
university hospital. Patients who were ordered analgesia with diclofenac sodium
for primary headache were divided into three groups. All groups were informed
that they would be administered a pain killer by intramuscular injection. The
second and third groups were given positive and reduced treatment expectations
about the therapeutic efficacy, respectively. Patients were asked to rate their
pain on a VAS at 0 and 45 minutes and if they needed any additional analgesic
45 minutes after the injection.
Results A
total of 153 patients were included in the study. The paired univariate
analyses showed significant differences for all groups between 0- and 45-minute
VAS scores. However, there was no difference between the three groups according
to the differences in VAS scores between 45 and 0 minutes and according to the
administration of an additional drug.
Conclusion
Simple verbal suggestions did not alter the efficacy of an analgesic agent for
headache in an emergency setting. The contributions of suggestibility, desire
and expectation in acute primary headache patients should be further
investigated.
18. US-Assisted Pediatric Forearm Fracture Reduction Doesn't
Supplant Radiography
Ultrasound
assessment missed 50% of inadequately reduced fractures and classified 11% of
properly reduced fractures as misaligned.
Dubrovsky
AS et al. Ann Emerg Med 2014 Oct 15 [Epub ahead of print].
Study
objective: The primary objective of this study is to assess the accuracy of
point-of-care ultrasonography compared with blinded orthopedic assessment of
fluoroscopy in determining successful realignment of pediatric forearm
fractures. The secondary objective is to determine the rate of agreement of
ultrasonography and fluoroscopy in real-time by the treating physician.
Methods: A
cross-sectional study was conducted in children younger than 18 years and
presenting to an academic emergency department with forearm fractures requiring
realignment of a single bone. Physicians performed closed reductions with
ultrasonographic assessment of realignment until the best possible reduction
was achieved. Fluoroscopy was then immediately performed and images were saved.
A positive test result was defined as an inadequately reduced fracture on
fluoroscopy by a blinded pediatric orthopedic surgeon (reference standard) and
on ultrasonography (index test) and fluoroscopy in real-time by the treating
physician.
Results: One
hundred patients were enrolled (median age 12.1 years; 74% male patients); the
radius was involved in 98%, with 27% involving the growth plate. The
sensitivity, specificity, positive predictive value, and negative predictive
value were 50% (95% confidence interval [CI] 15.4% to 84.6%), 89.1% (95% CI
82.8% to 95.5%), 28.6% (95% CI 4.9% to 52.2%), and 95.3% (95% CI 90.9% to
99.8%), respectively. The treating physicians’ agreement rate of the real-time
images was 98%.
Conclusion:
Point-of-care ultrasonography can help emergency physicians determine when
pediatric forearm fractures have been adequately realigned, but inadequate
reductions should be confirmed by other imaging modalities.
19. Physical Pain is More than Just a Metaphor for Social Pain
Exit Wounds by The Script
My hands
are cold, my body's numb
I'm still
in shock, what have you done?
My head is
pounding, my vision's blurred
Your mouth
is moving, I don't hear a word
And it
hurts so bad that I search my skin
For the
entry point, where love went in
And
ricocheted and bounced around
And left a
hole when you walked out
I'm falling
through the doors of the emergency room
Can anybody
help me with these exit wounds?
I don't
know how much more love this heart can lose
And I'm
dying, dying from the exit wounds…
The
remainder of the lyrics (along with the music) is here: http://www.youtube.com/watch?v=gYehN7mWMyU
For the science underlying the
analogy between social pain and physical pain:
- Eisenberger NI. The pain of social disconnection: examining the shared neural underpinnings of physical and social pain. Nat Rev Neurosci. 2012;13(6):421-34. Abstract: http://www.ncbi.nlm.nih.gov/pubmed/22551663
- Dewall CN, et al. Acetaminophen reduces social pain: behavioral and neural evidence. Psychol Sci. 2010 Jul;21(7):931-7. Abstract: http://www.ncbi.nlm.nih.gov/pubmed/20548058
20. Study links years of shift work to impaired cognition
French
researchers found people whose vocations require shift work may face elevated
risk of memory and thinking problems. Working nonstandard hours for more than a
decade was linked to the equivalent of 6.5 additional years of age-related
cognition declines, and the effect lasts even after workers return to normal
schedules, according to the findings. Data were reported in Occupational and
Environmental Medicine.
Essay in
Health Day: http://consumer.healthday.com/cognitive-health-information-26/brain-health-news-80/long-term-shift-work-dulls-the-brain-study-693312.html
21. Recommended Reading
Nicholas D.
Kristof, Sheryl WuDunn, A Path Appears:
Transforming Lives, Creating Opportunity (New York: Knopf, 2014). http://www.amazon.com/dp/0385349912/
Roman
Krznaric, Empathy: Why It Matters, and
How to Get It Hardcover (New York: Perigee Trade, 2014). http://www.amazon.com/dp/0399171398/
22. Micro Lit Bits
A. U.S. lags behind other rich
nations in terms of health care access
A 2013
survey by the Commonwealth Fund revealed the U.S. ranked last in terms
of health care access compared with 10 other industrialized nations. The U.S.
also showed the poorest performance in addressing patient needs outside regular
business hours, the poll found. The findings were published in the New England
Journal of Medicine.
B. Prognostic value of automatically
detected early repolarization
The authors
concluded that early repolarization was not associated with an increased risk
of death, regardless of race or sex, and should not trigger additional
diagnostic testing. The American Journal of Cardiology.
C. Three Wearables that Could Change
Afib Screening
Atrial
fibrillation is an increasingly prevalent arrhythmia; it currently affects 3 to
6 million of Americans and that number is expected to rise. And unlike many
other medical conditions, it is often silent until discovered either
incidentally or after a serious complication like a stroke.
Recently,
the EMBRACE and CRYSTAL-AF trials looked at the use of continuous long-term
cardiac monitoring in a high-risk patient population -- individuals with recent
cryptogenic cerebrovascular accident (CVA). Both trials found an increase in
the detection of atrial fibrillation as well as the use of oral anticoagulant
therapy.
There were
however notable limitations in the screening strategies used. In EMBRACE,
patients had to wear a cumbersome chest strap with several wires attached to a
belt-clipped event monitor. Not unexpectedly, the compliance rates were less
than stellar. In CRYSTAL-AF, the $5,000 price-tag of the Reveal XT monitor
coupled with its complication rate, albeit low, are important limitations when
considering whether this strategy can be applied on a large scale.
Here, we'll
look at some of the growing cadre of wearable devices that can provide
continuous cardiac monitoring options to address those limitations…
D. Co-trimoxazole and sudden death
in patients receiving inhibitors of renin-angiotensin system: population based
study
Conclusions
In older patients receiving angiotensin converting enzyme inhibitors or
angiotensin receptor blockers, co-trimoxazole is associated with an increased
risk of sudden death. Unrecognized severe hyperkalemia may underlie this
finding. When appropriate, alternative antibiotics should be considered in such
patients.
E. Cardiologist calls stethoscope a
"relic" amid new technologies
The
stethoscope is a "relic" because physicians now have technology to
visualize the heart instead of just listen to it, cardiologist Eric Topol,
M.D., told attendees of the 2014 AAFP Assembly. Topol said new innovations
include a glucose monitor that works with a smartphone and earbuds that track
heart rate and blood pressure, but patients will continue to need the
experience and treatment only physicians can offer.
F. Morality in
everyday life.
Hoffman W,
et al. Science 2014;345:1340-3.
The science
of morality has drawn heavily on well-controlled but artificial laboratory
settings. To study everyday morality, we repeatedly assessed moral or immoral
acts and experiences in a large (N = 1252) sample using ecological momentary
assessment. Moral experiences were surprisingly frequent and manifold. Liberals
and conservatives emphasized somewhat different moral dimensions. Religious and
nonreligious participants did not differ in the likelihood or quality of
committed moral and immoral acts. Being the target of moral or immoral deeds
had the strongest impact on happiness, whereas committing moral or immoral
deeds had the strongest impact on sense of purpose. Analyses of daily dynamics
revealed evidence for both moral contagion and moral licensing. In sum,
morality science may benefit from a closer look at the antecedents, dynamics,
and consequences of everyday moral experience.
G. Point-and-shoot memories: the
influence of taking photos on memory for a museum tour.
Henkel LA.
Psychol Sci. 2014 Feb;25(2):396-402.
Two studies
examined whether photographing objects impacts what is remembered about them.
Participants were led on a guided tour of an art museum and were directed to
observe some objects and to photograph others. Results showed a
photo-taking-impairment effect: If participants took a photo of each object as
a whole, they remembered fewer objects and remembered fewer details about the
objects and the objects' locations in the museum than if they instead only
observed the objects and did not photograph them.
However,
when participants zoomed in to photograph a specific part of the object, their
subsequent recognition and detail memory was not impaired, and, in fact, memory
for features that were not zoomed in on was just as strong as memory for
features that were zoomed in on. This finding highlights key differences
between people's memory and the camera's "memory" and suggests that
the additional attentional and cognitive processes engaged by this focused
activity can eliminate the photo-taking-impairment effect.
H. Current evidence does support the
use of a negative D-dimer to rule out suspected pulmonary embolism in pregnancy
Emerg Med
J 2014;31:946-947
A short cut
review was carried out to establish whether a negative D-dimer could be used to
rule out pulmonary embolism in the presence of clinical suspicion in a pregnant
patient. Five studies were considered directly relevant to the clinical
question. The author, date and country of publication, patient group studied,
study type, relevant outcomes and study weaknesses were tabulated. The clinical
bottom line was that a negative D-dimer result was considered sensitive enough
to rule out pulmonary embolism in patients who were in the first two trimesters
of pregnancy but that the false positive rate was so high as to render the test
useless in patients in the third trimester if standard cut-off values were
used.
