January EM Articles

NNR This Month = 48

you'd have to Read 1827 articles to find these 38.


Academic Emergency Medicine

  1. How do we find the most important articles - citation counts or media coverage? Altmetrics uses a composite of real-time metrics to score articles and may give a good early indication of what's important.
  2. Pulsus paradoxus on SpO2 may be an indicator of asthma severity.
  3. Urinary squamous cells predict poor performance of the UA dip but don't accurately predict contaminated culture results.
  4. Negative MRI with no secondary signs of appendicitis performed better than ultrasound, but both were poor predictors if the appendix was not seen but secondary signs were.
  5. EM residents improved efficiency and earned their keep in a before/after study in Chattanooga.
  6. Aspiration, laryngospasm, and intubation were exceedingly rare events in adult ED sedation.

1.

Acad Emerg Med. 2016 Jan 7. doi: 10.1111/acem.12898. [Epub ahead of print]

An analysis of Altmetrics in emergency medicine.

or Full text

Barbic D1, Tubman M2, Lam H3, Barbic S4.

Author information:

1Department of Emergency Medicine, St Paul's Hospital, and the University of British Columbia, Vancouver, BC, Canada.

2Royal College Emergency Medicine Residency Program, University of Toronto, Toronto, ON, Canada.

3Library Services, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.

4Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada.

Abstract

OBJECTIVES:

Alternative level metrics (Altmetrics) are a new method to assess the sharing and spread of scientific knowledge. The primary objective of this study was to describe the traditional metrics and Altmetric scores of the fifty most frequently cited articles published in emergency medicine (EM) journals. Since many articles related to EM are published in other journals, the secondary aim of this study was to describe the Altmetric scores of the most frequently cited articles relevant to EM in other biomedical journals.

METHODS:

A structured search of the Institute for Scientific Information (ISI) Web of Science version of the Science Citation Index Expanded was conducted. The 200 most frequently cited articles in the top ten EM journals (2011 Journal Citation Report) were identified. The 200 most frequently cited articles from the rest of the medical literature, matching a pre-defined list of keywords relevant to the specialty of EM, were identified. Two authors reviewed the lists of citations for relevance to EM and a consensus approach was used to arrive at the final lists of the top 50 cited articles. The Altmetric scores for the top fifty cited articles in EM and other journals were determined. Descriptive statistics and Spearman correlation were performed.

RESULTS:

The highest Altmetric score for EM articles was 25.0, the mean was 1.9 [SD=5.0]. The EM journal with the highest average article Altmetric score was Resuscitation. The main clinical areas shared for articles from EM articles were trauma (mean 11.0, median 11.0 [SD=15.6]) and cardiac arrest (mean 2.7, median 0 [SD=5.8]). The highest Altmetric score for other journals was 176.0, mean 23.3 [SD=40.8]. The other journal with the highest average article Altmetric score was the New England Journal of Medicine. The main clinical areas shared for articles were critical care (mean score 36.5, median 36.5 [SD= 47.4], sepsis (mean 24.6, median 12.0 [SD=48.8]), cardiology (mean 19.2, median 7.0 [SD=35.6]) and infectious diseases (mean 17.0, median 17.0 [SD=12.7]). Spearman correlation demonstrated weakly positive correlation between citation counts and Altmetric scores for EM articles, and other journals.

CONCLUSIONS:

This study is the first analysis of Altmetric scores for the top cited articles in emergency medicine. We demonstrated that there is a mild correlation between citation counts and Altmetric scores for the top papers in emergency medicine and other biomedical journals. We also demonstrated that there is a gap between the sharing of the top articles in emergency medicine journals and those related to emergency medicine in other biomedical journals. Future research to explore this relationship and its temporal trends will benefit the understanding of the reach and dissemination of emergency medicine research within the scientific community and society in general. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

PMID: 26743680 [PubMed - as supplied by publisher]

 

2.

Acad Emerg Med. 2016 Jan 4. doi: 10.1111/acem.12886. [Epub ahead of print]

Pulse oximeter plethysmograph estimate of pulsus paradoxus as a measure of acute asthma exacerbation severity and response to treatment.

or Full text

Arnold DH1,2, Wang L3, Hartert TV4,2.

Author information:

1Department of Pediatrics, Division of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA.

2Center for Asthma Research, Vanderbilt University School of Medicine, Nashville, TN, USA.

3Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA.

4Department of Medicine, Division of Allergy, Pulmonary & Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA.

Abstract

OBJECTIVES:

Pulsus paradoxus is one of the few objective, bedside measures of acute asthma exacerbation severity but is difficult to measure in tachypneic and tachycardic patients and in noisy clinical environments. Our primary objective was to examine whether pulse oximeter plethysmograph-estimate-of-pulsus-paradoxus (PEP) is associated with physiologic and symptom measures of acute exacerbation severity (airway resistance by impulse oscillometry [%IOS] and the Acute Asthma Intensity Research Score [AAIRS]). Secondary objectives were to validate the previous association of PEP with %FEV1 and to examine associations of change of PEP with change of these outcomes after 2 hours of treatment.

METHODS:

This was a secondary analysis of data from a prospective observational study of patients aged 5-17 years with acute asthma exacerbations. The predictor variable, PEP, was measured using a dedicated pulse oximeter and waveform analysis program. Outcome measures included the AAIRS, %IOS and %FEV1 at baseline and after 2-hours of treatment. We examined associations of PEP with %IOS and the AAIRS at baseline using multiple linear regression models adjusted for age, gender and race. As secondary analyses we similarly examined the association of PEP with %FEV1 at baseline and change of PEP with change of %IOS, the AAIRS, and %FEV1 after 2-hours of treatment using multiple linear regression models adjusted for the baseline value of the outcome measure and the AAIRS.

RESULTS:

Amongst 684 participants (61% males; 61% African-American) there were associations of baseline PEP with %IOS, the AAIRS, and %FEV1 (P < 0.001). Change of PEP after 2-hours of treatment was associated with change of %FEV1 (P < 0.001) and change of the AAIRS (P = 0.01) but not with change of %IOS (P = 0.60).

CONCLUSIONS:

PEP demonstrates criterion validity in predicting baseline %IOS, the AAIRS, %FEV1 and responsiveness to change of the AAIRS and %FEV1. Data contained in the oximeter plethysmograph waveform might be utilized as a continuous, objective measure of acute asthma exacerbation severity and real-time response to treatment. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

PMID: 26727986 [PubMed - as supplied by publisher]

 

3.

Acad Emerg Med. 2016 Jan 19. doi: 10.1111/acem.12894. [Epub ahead of print]

Urinary squamous epithelial cells do not accurately predict urine culture contamination, but may predict urinalysis performance in predicting bacteriuria.

Mohr NM1, Harland KK2, Crabb V3, Mutnick R2, Baumgartner D2, Spinosi S2, Haarstad M2, Ahmed A2, Schweizer M4, Faine B2,5.

Author information:

1Department of Emergency Medicine, Division of Critical Care, Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa.

2Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa.

3Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa.

4Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City Veterans Administration Health Care System, Iowa City, Iowa.

5Department of Pharmaceutical Care, University of Iowa Hospitals and Clinics, Iowa City, Iowa.

Abstract

OBJECTIVES:

The presence of squamous epithelial cells (SECs) has been advocated to identify urinary contamination despite a paucity of evidence supporting this practice. We sought to determine the value of using quantitative SECs as a predictor of urinalysis contamination.

METHODS:

Retrospective cross-sectional study of adults (≥ 18 years old) presenting to a tertiary academic medical center who had urinalysis with microscopy and urine culture performed. Patients with missing or implausible demographic data were excluded (2.5% of total sample). The primary analysis aimed to determine an SEC threshold that predicted urine culture contamination using receiver operating characteristics (ROC) curve analysis. The a priori secondary analysis explored how demographic variables (age, sex, BMI) may modify the SEC test performance and whether SECs impacted traditional urinalysis indicators of bacteriuria.

RESULTS:

Nineteen-thousand three-hundred twenty-eight records were included. Receiver operating curve analysis demonstrated that SEC count was a poor predictor of urine culture contamination (AUC 0.680, 95%CI 0.671 - 0.689). In secondary analysis, the positive likelihood ratio (LR+) of predicting bacteriuria via urinalysis among non-contaminated specimens was 4.98 (95% CI 4.59 - 5.40) in the absence of SECs, but the LR+ fell to 2.35 (95% CI 2.17 - 2.54) for samples with more than 8 SEC/lpf. In an independent validation cohort, urinalysis samples with fewer than 8 SEC/lpf predicted bacteriuria better (sensitivity 75%, specificity 84%) than samples with more than 8 SEC/lpf (sensitivity 86%, specificity 70%) [diagnostic odds ratio 17.5 (14.9 - 20.7) vs. 8.7 (7.3 - 10.5)].

CONCLUSION:

Squamous epithelial cells are a poor predictor of urine culture contamination, but may predict poor predictive performance of traditional urinalysis measures. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

PMID: 26782662 [PubMed - as supplied by publisher]

 

4.

Acad Emerg Med. 2016 Jan 14. doi: 10.1111/acem.12873. [Epub ahead of print]

Accuracy of Magnetic Resonance Imaging and Ultrasound for Appendicitis in Diagnostic and Nondiagnostic Studies.

Kearl YL1, Claudius I1, Behar S1, Cooper J2, Dollbaum R3, Hardasmalani M1, Hardiman K4, Rose E1, Santillanes G1, Berdahl C4.

Author information:

1Department of Emergency Medicine, University of Southern California, Keck School of Medicine, Los Angeles, CA.

2Department of Pediatrics, Los Angeles County and University of Southern California Hospital, Los Angeles, CA.

3University of Southern California, Keck School of Medicine, Los Angeles, CA.

4Department of Emergency Medicine, Los Angeles County and University of Southern California Hospital, Los Angeles, CA.

Abstract

OBJECTIVES:

Suggestive radiographic studies with nonvisualization of the appendix can present a challenge to clinicians in the evaluation of pediatric abdominal pain. The primary objective of this study was to quantify the accuracy of magnetic resonance imaging (MRI) and of ultrasound (US) in the setting of nonvisualization of the appendix. Secondary objectives reported include sensitivity of MRI and US overall and correlation between MRI and US for diagnosis of appendicitis.

METHODS:

Records of pediatric emergency department patients aged 3 to 21 years undergoing MRI and/or US for the evaluation of appendicitis were retrospectively reviewed. Radiographs were categorized as a normal appendix, neither demonstrating the appendix nor demonstrating abnormalities consistent with appendicitis; equivocal, not demonstrating the appendix but showing evidence of appendicitis; demonstrating an abnormal appendix consistent with appendicitis; or demonstrating an alternate pathology. The reading was compared with the final diagnosis for accuracy.

RESULTS:

Of the 589 patients included, 146 had appendicitis. Diagnostic accuracy for studies with a nonvisualized appendix without secondary signs of appendicitis was 100% for MRI and 91.4% (95% CI = 87.3% to 94.2%) for US. Diagnostic accuracy for studies with a nonvisualized appendix with secondary signs of appendicitis was 50% (95% CI = 2.5% to 97.5%) for MRI and 38.9% (95% CI = 18.2% to 64.5%) for US. Appendicitis was ultimately diagnosed in 8.6% of patients with an otherwise negative right lower quadrant (RLQ) US that failed to directly identify the appendix. There was a moderate correlation between US and MRI (ρ = 0.573, p = 0.0001) when all studies were considered.

CONCLUSIONS:

Magnetic resonance imaging without secondary signs of appendicitis is effective in excluding appendicitis regardless of whether the appendix is directly visualized, while otherwise negative RLQ US that fail to identify the appendix are less useful. Secondary signs of appendicitis without visualization of the appendix were not helpful regardless of radiographic modality. Results of MRI and US correlated moderately well.

© 2016 by the Society for Academic Emergency Medicine.

PMID: 26765503 [PubMed - as supplied by publisher]

 

5.

Acad Emerg Med. 2016 Jan;23(1):78-82. doi: 10.1111/acem.12834. Epub 2015 Dec 29.

The Effect of Emergency Medicine Residents on Clinical Efficiency and Staffing Requirements.

Clinkscales JD1, Fesmire FM1, Hennings JR1, Severance HW1, Seaberg DC1, Patil N2.

Author information:

1Department of Emergency Medicine, Erlanger Institute for Clinical Research, University of Tennessee College of Medicine Chattanooga, Erlanger Health System, Chattanooga, TN.

2Department of Quality Management, Greenville Health System, Greenville, SC.

OBJECTIVES:

The effect of emergency medicine (EM) residents on the clinical efficiency of attending physicians is controversial. The authors hypothesized that implementing a new EM residency program would result in an increase in relative value units (RVUs) generated per hour by attending physicians and decrease staffing requirements.

METHODS:

This was a retrospective observational analysis of an emergency department before, during, and after the establishment of a new EM residency program. We analyzed the change in RVUs billed, patients seen, and hours worked by attending physicians, midlevel providers (MLPs), and residents, and addressed potential confounding factors.

RESULTS:

The clinical efficiency of attending physicians increased by 70%, or 4.98 RVUs/hour (from 7.12 [SD ± 1.4] RVUs/hour to 12.1 [SD ± 2.2] RVUs/hour, p < 0.001) with the implementation of an EM residency program. Overall, net department RVU generation rose by 32%, even as attending physician coverage decreased by 6.3% (p < 0.05), and MLP coverage dropped by 60% (p < 0.05). We estimated that the implementation of the residency saved 4,860 hours of attending physician coverage and 5,828 hours of MLP coverage per year. This represents an estimated $1,741,265 in annual staffing savings, comparable to the residency program's annual operating cost of $1,821,108.

CONCLUSIONS:

The implementation of an EM residency program had a positive effect on the clinical efficiency of attending physicians and decreased staffing requirements.

© 2015 by the Society for Academic Emergency Medicine.

PMID: 26714030 [PubMed - in process]

 

6.

Acad Emerg Med. 2016 Feb;23(2):119-34. doi: 10.1111/acem.12875. Epub 2016 Jan 22.

Incidence of Adverse Events in Adults Undergoing Procedural Sedation in the Emergency Department: A Systematic Review and Meta-analysis.

Bellolio MF1,2, Gilani WI1, Barrionuevo P3,2, Murad MH3,2, Erwin PJ4, Anderson JR1, Miner JR5,6, Hess EP1,2.

Author information:

1Department of Emergency Medicine, Mayo Clinic, Rochester, MN.

2Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.

3Division of Preventive, Occupational, and Aerospace Medicine, Mayo Clinic, Rochester, MN.

4Mayo Medical Library, Mayo Clinic, Rochester, MN.

5Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN.

6Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN.

OBJECTIVES:

This was a systematic review and meta-analysis to evaluate the incidence of adverse events in adults undergoing procedural sedation in the emergency department (ED).

METHODS:

Eight electronic databases were searched, including MEDLINE, EMBASE, EBSCO, CINAHL, CENTRAL, Cochrane Database of Systematic Reviews, Web of Science, and Scopus, from January 2005 through 2015. Randomized controlled trials and observational studies of adults undergoing procedural sedation in the ED that reported a priori selected outcomes and adverse events were included. Meta-analysis was performed using a random-effects model and reported as incidence rates with 95% confidence intervals (CIs).

RESULTS:

The search yielded 2,046 titles for review. Fifty-five articles were eligible, including 9,652 procedural sedations. The most common adverse event was hypoxia, with an incidence of 40.2 per 1,000 sedations (95% CI = 32.5 to 47.9), followed by vomiting with 16.4 per 1,000 sedations (95% CI = 9.7 to 23.0) and hypotension with 15.2 per 1,000 sedations (95% CI = 10.7 to 19.7). Severe adverse events requiring emergent medical intervention were rare, with one case of aspiration in 2,370 sedations (1.2 per 1,000), one case of laryngospasm in 883 sedations (4.2 per 1,000), and two intubations in 3,636 sedations (1.6 per 1,000). The incidence of agitation and vomiting were higher with ketamine (164.1 per 1,000 and 170.0 per 1,000, respectively). Apnea was more frequent with midazolam (51.4 per 1,000), and hypoxia was less frequent in patients who received ketamine/propofol compared to other combinations. The case of laryngospasm was in a patient who received ketamine, and the aspiration and intubations were in patients who received propofol. When propofol and ketamine are combined, the incidences of agitation, apnea, hypoxia, bradycardia, hypotension, and vomiting were lower compared to each medication separately.

CONCLUSIONS:

Serious adverse events during procedural sedation like laryngospasm, aspiration, and intubation are exceedingly rare. Quantitative risk estimates are provided to facilitate shared decision-making, risk communication, and informed consent.

© 2016 The Authors. Academic Emergency Medicine published by Wiley Periodicals, Inc. on behalf of Society for Academic Emergency Medicine.

PMID: 26801209 [PubMed - in process]


American Journal of Emergency Medicine

EPs are not the ones writing prescriptions for opiates in patients who die of OD.

Am J Emerg Med. 2016 Jan;34(1):30-5. doi: 10.1016/j.ajem.2015.09.003. Epub 2015 Sep 8.

Who is prescribing controlled medications to patients who die of prescription drug abuse?

Lev R1, Lee O2, Petro S3, Lucas J4, Castillo EM5, Vilke GM5, Coyne CJ6.

Author information:

1Department of Emergency Medicine, Scripps Mercy Hospital, San Diego, CA 92103.

2University of Arizona, Tucson, AZ 85721.

3Keck School of Medicine, University of Southern California, Los Angeles, CA 90033.

4San Diego County Medical Examiners Office, San Diego, CA 92123.

5University of California San Diego, Department of Emergency Medicine, San Diego, CA 92103.

6University of California San Diego, Department of Emergency Medicine, San Diego, CA 92103. Electronic address: cjcoyne@ucsd.edu.

Abstract

BACKGROUND:

Prescription drug-related fatalities remain a significant issue in the United States, yet there is a relative lack of knowledge on the specialty-specific prescription patterns for drug-related deaths.

METHODS:

We designed a study that investigated medical examiner reports of prescription drug-related deaths that occurred in San Diego County during 2013. A Prescription Drug Monitoring Program search was performed on each of these cases to ascertain which physician specialties had prescribed controlled substances to these patients. The data were analyzed for each specialty, including pills per prescription, type of prescription, doctor shoppers (4 physicians + 4 pharmacies over 1 year), and chronic users (≥3 consecutive months of medications).

MAIN FINDINGS:

In 2013, 4.5% of all providers in San Diego County wrote a prescription for a patient who died a prescription-related death. There were a total of 713 providers who prescribed 4366 medications totaling 328928 pills. Overall, emergency physicians gave the lowest number of prescriptions per provider (1.6), whereas pain management provided the highest amount per provider (12.9). Most prescriptions went to doctor shoppers (>50%) and chronic users (95.8%). Hydrocodone was the most frequently prescribed medication to those patients whose deaths were related to prescription drugs.

CONCLUSIONS:

Emergency physicians appear to provide fewer prescriptions to those patients who die due to prescription drugs. Emergency physicians do, however, account for a significant proportion of total providers in this study. These results highlight the need to use Prescription Drug Monitoring Program data to closely monitor prescription patterns and to intervene when necessary.

Copyright © 2015 Elsevier Inc. All rights reserved.

PMID: 26476578 [PubMed - in process]


American Journal of Respiratory and Critical Care Medicine

Too much oxygen is not a good thing. A lower O2 strategy was safe and showed a non-significant trend toward improving mortality.

Am J Respir Crit Care Med. 2016 Jan 1;193(1):43-51. doi: 10.1164/rccm.201505-1019OC.

Conservative versus Liberal Oxygenation Targets for Mechanically Ventilated Patients. A Pilot Multicenter Randomized Controlled Trial.

Panwar R1,2, Hardie M1, Bellomo R3,4, Barrot L5, Eastwood GM3,4, Young PJ6,7, Capellier G4,5, Harrigan PW1,2, Bailey M4; CLOSE Study Investigators and the ANZICS Clinical Trials Group.

Author information:

11 Intensive Care Unit, John Hunter Hospital, Newcastle, Australia.

22 School of Medicine and Public Health, University of Newcastle, Newcastle, Australia.

33 Department of Intensive Care, Austin Hospital, The University of Melbourne, Melbourne, Australia.

44 Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.

55 Critical Care Unit, University Hospital Besançon and University of Franche-Comté, Besançon, France.

66 Intensive Care Unit, Wellington Hospital, Wellington, New Zealand; and.

77 Medical Research Institute of New Zealand, Wellington, New Zealand.

RATIONALE:

There are no randomized controlled trials comparing different oxygenation targets for intensive care unit (ICU) patients.

OBJECTIVES:

To determine whether a conservative oxygenation strategy is a feasible alternative to a liberal oxygenation strategy among ICU patients requiring invasive mechanical ventilation (IMV).

METHODS:

At four multidisciplinary ICUs, 103 adult patients deemed likely to require IMV for greater than or equal to 24 hours were randomly allocated to either a conservative oxygenation strategy with target oxygen saturation as measured by pulse oximetry (SpO2) of 88-92% (n = 52) or a liberal oxygenation strategy with target SpO2 of greater than or equal to 96% (n = 51).

MEASUREMENTS AND MAIN RESULTS:

The mean area under the curve and 95% confidence interval (CI) for SpO2 (93.4% [92.9-93.9%] vs. 97% [96.5-97.5%]), SaO2 (93.5% [93.1-94%] vs. 96.8% [96.3-97.3%]), PaO2 (70 [68-73] mm Hg vs. 92 [89-96] mm Hg), and FiO2 (0.26 [0.25-0.28] vs. 0.36 [0.34-0.39) in the conservative versus liberal oxygenation arm were significantly different (P < 0.0001 for all). There were no significant between-group differences in any measures of new organ dysfunction, or ICU or 90-day mortality. The percentage time spent with SpO2 less than 88% in conservative versus liberal arm was 1% versus 0.3% (P = 0.03), and percentage time spent with SpO2 greater than 98% in conservative versus liberal arm was 4% versus 22% (P < 0.001). The adjusted hazard ratio for 90-day mortality in the conservative arm was 0.77 (95% CI, 0.40-1.50; P = 0.44) overall and 0.49 (95% CI, 0.20-1.17; P = 0.10) in the prespecified subgroup of patients with a baseline PaO2/FiO2 less than 300.

CONCLUSIONS:

Our study supports the feasibility of a conservative oxygenation strategy in patients receiving IMV. Larger randomized controlled trials of this intervention appear justified. Clinical trial registered with Australian New Zealand Clinical Trials Registry (ACTRN 12613000505707).

PMID: 26334785 [PubMed - in process]


American Journal of Sports Medicine

Stress fractures are often missed on plain x-ray. MRI is the best test but is best ordered as an outpatient, not in the ED.

Am J Sports Med. 2016 Jan;44(1):255-63. doi: 10.1177/0363546515574066. Epub 2015 Mar 24.

Diagnostic Accuracy of Various Imaging Modalities for Suspected Lower Extremity Stress Fractures: A Systematic Review With Evidence-Based Recommendations for Clinical Practice.

Wright AA1, Hegedus EJ1, Lenchik L2, Kuhn KJ3, Santiago L4, Smoliga JM5.

Author information:

1Department of Physical Therapy, High Point University, High Point, North Carolina, USA.

2Department of Radiology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina, USA.

3Internal Medicine Department, Oakland Medical Center-Kaiser Permanente, Oakland, California, USA.

4Department of Exercise Science, High Point University, High Point, North Carolina, USA.

5Department of Physical Therapy, High Point University, High Point, North Carolina, USA jsmoliga@highpoint.edu.

BACKGROUND:

The literature is filled with conflicting findings regarding diagnostic accuracy and protocols for imaging suspected lower extremity stress fractures. The absence of systematic reviews on this topic has limited the development of evidence-based recommendations for appropriate imaging protocols in cases of suspected lower extremity stress fractures.

PURPOSE:

To determine the diagnostic accuracy statistics of imaging modalities used to diagnose lower extremity stress fractures and to synthesize evidence-based recommendations for clinical practice.

STUDY DESIGN:

Systematic review.

METHODS:

A generic search strategy for published studies was performed using multiple databases. A study was eligible for inclusion if it met all of the following criteria: (1) at least 1 diagnostic imaging modality was studied, (2) at least 1 radiological reference standard was used, (3) the study reported or allowed computation of diagnostic accuracy statistics (sensitivity, specificity, positive likelihood ratio, negative likelihood ratio), (4) a full-text version was available, (5) the article was written in English, and (6) the study included lower extremity stress fractures. Studies that examined asymptomatic individuals or patients with fractures due to disease or pharmacologic intervention were excluded.

RESULTS:

Reported sensitivity and specificity (95% CI) were as follows: For conventional radiography, sensitivity ranged from 12% (0%-29%) to 56% (39%-72%) and specificity ranged from 88% (55%-100%) to 96% (87%-100%). For nuclear scintigraphy (NS), sensitivity ranged from 50% (23%-77%) to 97% (90%-100%) and specificity from 33% (12%-53%) to 98% (93%-100%). For magnetic resonance imaging (MRI), sensitivity ranged from 68% (45%-90%) to 99% (95%-100%) and specificity from 4% (0%-11%) to 97% (88%-100%). For computed tomography, sensitivity ranged from 32% (8%-57%) to 38% (16%-59%) and specificity from 88% (55%-100%) to 98% (91%-100%). For ultrasound, sensitivity ranged from 43% (26%-61%) to 99% (95%-100%) and specificity from 13% (0%-45%) to 79% (61%-96%).

CONCLUSION:

MRI was identified as the most sensitive and specific imaging test for diagnosing stress fractures of the lower extremity. When MRI is available, NS is not recommended because of its low specificity, high dosage of ionizing radiation, and other limitations. Conventional radiographs are likely to result in false negatives upon initial presentation, particularly in the early stages of stress fracture, and in some cases may not reveal an existing stress fracture at any time. A diagnostic imaging algorithm was developed with specific recommendations for cost-efficient imaging of low-risk and high-risk suspected stress fractures.

© 2015 The Author(s).

PMID: 25805712 [PubMed - in process]


Annals of Emergency Medicine

  1. A zero and 1 hour high sensitivity troponin rule out looks feasible with NPV 99.1%, assuming it gets approval for use in the US.
  2. A global EM journal club was very successful and allowed asynchronous academic discussion of an Annals article.

1.

Ann Emerg Med. 2016 Jan 8. pii: S0196-0644(15)01501-2. doi: 10.1016/j.annemergmed.2015.11.013. [Epub ahead of print]

Multicenter Evaluation of a 0-Hour/1-Hour Algorithm in the Diagnosis of Myocardial Infarction With High-Sensitivity Cardiac Troponin T.

Mueller C1, Giannitsis E2, Christ M3, Ordóñez-Llanos J4, deFilippi C5, McCord J6, Body R7, Panteghini M8, Jernberg T9, Plebani M10, Verschuren F11, French J12, Christenson R13, Weiser S14, Bendig G14, Dilba P14, Lindahl B15; TRAPID-AMI Investigators.

Author information:

1Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland. Electronic address: chmueller@uhbs.ch.

2University Hospital Heidelberg, Heidelberg, Germany.

3Department of Emergency and Critical Care Medicine, General Hospital, Paracelsus Medical University, Nuremberg, Germany.

4Department of Clinical Biochemistry, Institut d'Investigacions Biomèdiques Sant Pau, Barcelona, Spain.

5Department of Medicine, University of Maryland School of Medicine, Baltimore, MD.

6Henry Ford Heart and Vascular Institute, Henry Ford Health System, Detroit, MI.

7Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK.

8Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan Medical School, Milan, Italy.

9Department of Medicine, Karolinska Institutet, Huddinge, Sweden.

10Department of Laboratory Medicine, University Hospital of Padova, Padua, Italy.

11Department of Acute Medicine, Cliniques Universitaires St-Luc and Université Catholique de Louvain, Brussels, Belgium.

12Liverpool Hospital and University of New South Wales, Liverpool, NSW, Australia.

13Department of Pathology, University of Maryland School of Medicine, Baltimore, MD.

14Roche Diagnostics Germany, Penzberg, Germany.

15Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden.

STUDY OBJECTIVE:

We aim to prospectively validate the diagnostic accuracy of the recently developed 0-h/1-h algorithm, using high-sensitivity cardiac troponin T (hs-cTnT) for the early rule-out and rule-in of acute myocardial infarction.

METHODS:

We enrolled patients presenting with suspected acute myocardial infarction and recent (<6 hours) onset of symptoms to the emergency department in a global multicenter diagnostic study. Hs-cTnT (Roche Diagnostics) and sensitive cardiac troponin I (Siemens Healthcare) were measured at presentation and after 1 hour, 2 hours, and 4 to 14 hours in a central laboratory. Patient triage according to the predefined hs-cTnT 0-hour/1-hour algorithm (hs-cTnT below 12 ng/L and Δ1 hour below 3 ng/L to rule out; hs-cTnT at least 52 ng/L or Δ1 hour at least 5 ng/L to rule in; remaining patients to the "observational zone") was compared against a centrally adjudicated final diagnosis by 2 independent cardiologists (reference standard). The final diagnosis was based on all available information, including coronary angiography and echocardiography results, follow-up data, and serial measurements of sensitive cardiac troponin I, whereas adjudicators remained blinded to hs-cTnT.

RESULTS:

Among 1,282 patients enrolled, acute myocardial infarction was the final diagnosis for 213 (16.6%) patients. Applying the hs-cTnT 0-hour/1-hour algorithm, 813 (63.4%) patients were classified as rule out, 184 (14.4%) were classified as rule in, and 285 (22.2%) were triaged to the observational zone. This resulted in a negative predictive value and sensitivity for acute myocardial infarction of 99.1% (95% confidence interval [CI] 98.2% to 99.7%) and 96.7% (95% CI 93.4% to 98.7%) in the rule-out zone (7 patients with false-negative results), a positive predictive value and specificity for acute myocardial infarction of 77.2% (95% CI 70.4% to 83.0%) and 96.1% (95% CI 94.7% to 97.2%) in the rule-in zone, and a prevalence of acute myocardial infarction of 22.5% in the observational zone.

CONCLUSION:

The hs-cTnT 0-hour/1-hour algorithm performs well for early rule-out and rule-in of acute myocardial infarction.

Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

PMID: 26794254 [PubMed - as supplied by publisher]

 

2.

Ann Emerg Med. 2016 Jan;67(1):49-55. doi: 10.1016/j.annemergmed.2015.04.012. Epub 2015 May 21.

Global Emergency Medicine Journal Club: A Social Media Discussion About the Lack of Association Between Press Ganey Scores and Emergency Department Analgesia.

Westafer L1, Hensley J2, Shaikh S3, Lin M4.

Author information:

1Department of Emergency Medicine, Baystate Medical Center/Tufts University, Springfield, MA. Electronic address: westafer@gmail.com.

2Department of Emergency Medicine, Texas A&M Health Science Center, Corpus Christi, TX.

3Department of Emergency Medicine, Sinai-Grace Hospital/Wayne State University, Detroit, MI.

4Department of Emergency Medicine, University of California-San Francisco, San Francisco, CA.

Abstract

Annals of Emergency Medicine collaborated with an educational Web site, Academic Life in Emergency Medicine (ALiEM), to host a public discussion featuring the 2014 Annals article on the association between Press Ganey scores and emergency department (ED) analgesia by Schwartz et al. The objective was to curate a 14-day (December 1 through 14, 2014) worldwide academic dialogue among clinicians in regard to preselected questions about the article. Five online facilitators hosted the multimodal discussion on the ALiEM Web site, Twitter, and Google Hangout. Comments across the social media platforms were curated for this report, as framed by the 4 preselected questions. Engagement was tracked through Web analytic tools and analysis of tweets. Blog comments, tweets, and video expert commentary involving the featured article are summarized and reported. The dialogue resulted in 978 page views from 342 cities in 33 countries on the ALiEM Web site, 464,345 Twitter impressions, and 83 views of the video interview with experts. Of the unique 169 identified tweets, discussion (53.3%) and learning points (32.5%) were the most common category of tweets identified. Common themes that arose in the open-access multimedia discussions included Press Ganey data validity and the utility of patient satisfaction in determining pain treatment efficacy. This educational approach using social media technologies demonstrates a free, asynchronous means to engage a worldwide scholarly discourse.

Copyright © 2015 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

PMID: 26003003 [PubMed - in process]


Anesthesiology

NPO status did not predict aspiration or other complication in this large pediatric sedation cohort. Delay sedation only if the patient has a cheeseburger in their mouth. Remove the burger, and push drugs.

Anesthesiology. 2016 Jan;124(1):80-8. doi: 10.1097/ALN.0000000000000933.

Major Adverse Events and Relationship to Nil per Os Status in Pediatric Sedation/Anesthesia Outside the Operating Room: A Report of the Pediatric Sedation Research Consortium.

Beach ML1, Cohen DM, Gallagher SM, Cravero JP.

Author information:

1From the Departments of Anesthesiology and Pediatrics (M.L.B.) and Department of Biomedical Data Science (M.L.B., S.M.G.), Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Department of Emergency Medicine, Nationwide Children's Hospital, Columbus, Ohio (D.M.C.); and Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts (J.P.C.).

Abstract

BACKGROUND:

Studies that have attempted to define the incidence of aspiration or pulmonary complications during sedation/anesthesia of children with respect to nil per os (NPO) status or other factors are difficult because of the relatively infrequent rate of these complications.

METHODS:

The Pediatric Sedation Research Consortium consists of 42 participating institutions with elective sedation services that submit consecutive patient encounter information to a central database. The authors evaluated aspiration episodes and a combined outcome of major adverse events (defined as aspiration, death, cardiac arrest, or unplanned hospital admission) with respect to NPO status, American Society of Anesthesiologists physical status, age, propofol use, procedure types, and urgency of the procedure.

RESULTS:

A total of 139,142 procedural sedation/anesthesia encounters were collected between September 2, 2007 and November 9, 2011. There were 0 deaths, 10 aspirations, and 75 major complications. NPO status was known for 107,947 patients, of whom 25,401 (23.5 %) were not NPO. Aspiration occurred in 8 of 82,546 (0.97 events per 10,000) versus 2 of 25,401 (0.79 events per 10,000) patients who were NPO and not NPO, respectively (odds ratio, 0.81; 95% CI, 0.08 to 4.08; P = 0.79). Major complications occurred in 46 of 82,546 (5.57 events per 10,000) versus 15 of 25,401 (5.91 events per 10,000) (odds ratio, 1.06; 95% CI, 0.55 to 1.93; P = 0.88). Multivariate adjustment did not appreciably impact the effect of NPO status.

CONCLUSIONS:

The analysis suggests that aspiration is uncommon. NPO status for liquids and solids is not an independent predictor of major complications or aspiration in this sedation/anesthesia data set.

PMID: 26551974 [PubMed - in process]


Critical Care Medicine

Two articles on ARDS this month:

  1. ARDS patients with lower CVP had significantly lower mortality, favoring a conservative fluid strategy.
  2. Earlier intubation of ARDS patients decreased mortality.

1.

Crit Care Med. 2016 Jan 6. [Epub ahead of print]

Impact of Initial Central Venous Pressure on Outcomes of Conservative Versus Liberal Fluid Management in Acute Respiratory Distress Syndrome.

Semler MW1, Wheeler AP, Thompson BT, Bernard GR, Wiedemann HP, Rice TW; National Institutes of Health National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome Network.

Author information:

11Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN. 2Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA. 3Division of Pulmonary and Critical Care Medicine, Cleveland Clinic Foundation, Cleveland, OH.

Abstract

OBJECTIVES:

In acute respiratory distress syndrome, conservative fluid management increases ventilator-free days without affecting mortality. Response to fluid management may differ based on patients' initial central venous pressure. We hypothesized that initial central venous pressure would modify the effect of fluid management on outcomes.

DESIGN:

Retrospective analysis of the Fluid and Catheter Treatment Trial, a multicenter randomized trial comparing conservative with liberal fluid management in acute respiratory distress syndrome. We examined the relationship between initial central venous pressure, fluid strategy, and 60-day mortality in univariate and multivariable analysis.

SETTING:

Twenty acute care hospitals.

PATIENTS:

Nine hundred thirty-four ventilated acute respiratory distress syndrome patients with a central venous pressure available at enrollment, 609 without baseline shock (for whom fluid balance was managed by the study protocol).

INTERVENTIONS:

None.

MEASUREMENTS AND MAIN RESULTS:

Among patients without baseline shock, those with initial central venous pressure greater than 8 mm Hg experienced similar mortality with conservative and liberal fluid management (18% vs 18%; p = 0.928), whereas those with central venous pressure of 8 mm Hg or less experienced lower mortality with a conservative strategy (17% vs 36%; p = 0.005). Multivariable analysis demonstrated an interaction between initial central venous pressure and the effect of fluid strategy on mortality (p = 0.031). At higher initial central venous pressures, the difference in treatment between arms was predominantly furosemide administration, which was not associated with mortality (p = 0.122). At lower initial central venous pressures, the difference between arms was predominantly fluid administration, with additional fluid associated with increased mortality (p = 0.013).

CONCLUSIONS:

Conservative fluid management decreases mortality for acute respiratory distress syndrome patients with a low initial central venous pressure. In this population, the administration of IV fluids seems to increase mortality.

PMID: 26741580 [PubMed - as supplied by publisher]


2.

Crit Care Med. 2016 Jan;44(1):120-9. doi: 10.1097/CCM.0000000000001359.

Timing of Intubation and Clinical Outcomes in Adults With Acute Respiratory Distress Syndrome.

Kangelaris KN1, Ware LB, Wang CY, Janz DR, Zhuo H, Matthay MA, Calfee CS.

Author information:

11Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA.2Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine and Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, TN.3Department of Critical Care Medicine, Taichung Veteran General Hospital, Taichung, Taiwan.4Section of Pulmonary and Critical Care Medicine, Department of Medicine, Louisiana State University School of Medicine New Orleans, LA.5Division of Pulmonary and Critical Care, University of California, San Francisco, San Francisco, CA.6Departments Medicine and Anesthesia and the Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA.

Abstract

OBJECTIVE:

The prevalence, clinical characteristics, and outcomes of critically ill, nonintubated patients with evidence of the acute respiratory distress syndrome remain inadequately characterized.

DESIGN:

Secondary analysis of a prospective observational cohort study.

SETTING:

Vanderbilt University Medical Center.

PATIENTS:

Among adult patients enrolled in a large, multi-ICU prospective cohort study between the years of 2006 and 2011, we studied intubated and nonintubated patients with acute respiratory distress syndrome as defined by acute hypoxemia (PaO2/FIO2 ≤ 300 or SpO2/FIO2 ≤ 315) and bilateral radiographic opacities not explained by cardiac failure. We excluded patients not committed to full respiratory support.

INTERVENTIONS:

None.

MEASUREMENTS AND MAIN RESULTS:

Of 457 patients with acute respiratory distress syndrome, 106 (23%) were not intubated at the time of meeting all other acute respiratory distress syndrome criteria. Nonintubated patients had lower morbidity and severity of illness than intubated patients; however, mortality at 60 days was the same (36%) in both groups (p = 0.91). Of the 106 nonintubated patients, 36 (34%) required intubation within the subsequent 3 days of follow-up; this late-intubation subgroup had significantly higher 60-day mortality (56%) when compared with the both early intubation group (36%, P<0.03) and patients never requiring intubation (26%; p = 0.002). Increased mortality in the late intubation group persisted at 2-year follow-up. Adjustment for baseline clinical and demographic differences did not change the results.

CONCLUSIONS:

A substantial proportion of critically ill adults with acute respiratory distress syndrome were not intubated in their initial days of intensive care, and many were never intubated. Late intubation was associated with increased mortality. Criteria defining the acute respiratory distress syndrome prior to need for positive pressure ventilation are required so that these patients can be enrolled in clinical studies and to facilitate early recognition and treatment of acute respiratory distress syndrome.

PMID: 26474112 [PubMed - in process]


EMJ

Using a mathematical simulation, LP (vs. CTA) in negative CT patients appears to be favored if SAH pre-test probability exceeds 1.6% or CT sensitivity for bleed is <99.6%. But see the article in JEM below.

Emerg Med J. 2016 Jan;33(1):30-6. doi: 10.1136/emermed-2015-204634. Epub 2015 Jun 4.

Utility analysis of management strategies for suspected subarachnoid haemorrhage in patients with thunderclap headache with negative CT result.

Wu X1, Kalra VB1, Durand D1, Malhotra A1.

Author information:

1Department of Diagnostic Radiology, Yale School of Medicine, New Haven, Connecticut, USA.

Abstract

PURPOSE:

To determine the most effective follow-up strategy for evaluation of patients with thunderclap headache and negative initial non-contrast CT for acute subarachnoid haemorrhage (SAH).

MATERIALS AND METHODS:

Institutional review was performed to assess the frequency of CT angiography (CTA) in screening patients with negative non-contrast CT. A comparative effectiveness analysis based on decision tree modelling was subsequently performed to assess three different strategies-no follow-up, lumbar puncture (LP) and CTA. The clinical probabilities and utilities from literature were used to design the decision tree. Base-case scenario utility calculations, sensitivity analyses and probabilistic Monte Carlo simulation were performed.

RESULTS:

Institutional review of recent data in the last two years demonstrates frequent use of CTA in patients with thunderclap headache with limited utility. The decision tree analysis shows CT with LP follow-up to be the most effective strategy with the highest expected utility of 0.79926 quality-adjusted life-year (QALY) compared with 0.79875 QALY for no follow-up and 0.79869 QALY for CTA follow-up. Monte Carlo simulation showed LP was the best strategy in 86.4% of all iterations. Sensitivity analyses demonstrate that CT without follow-up is the best strategy only when the sensitivity of CT is very high (99.6%) or the pre-test probability of SAH in a patients with thunderclap headache with negative initial CT is low (1.6%).

CONCLUSIONS:

CT with no follow-up was shown to be the best strategy when the pre-test probability of SAH is low (<1.6%) or the sensitivity of initial non-contrast CT for blood is high (>99.6%). Otherwise, LP should be the preferred strategy for follow-up.

PMID: 26045444 [PubMed - in process]


Annals of Internal Medicine

Maybe sudden cardiac arrest isn't so sudden. Many had warning signs within 24 hours of arrest, such as chest pain or dyspnea, that were ignored.

Ann Intern Med. 2016 Jan 5;164(1):23-9. doi: 10.7326/M14-2342. Epub 2016 Dec 22.

Warning Symptoms Are Associated With Survival From Sudden Cardiac Arrest.

Marijon E, Uy-Evanado A, Dumas F, Karam N, Reinier K, Teodorescu C, Narayanan K, Gunson K, Jui J, Jouven X, Chugh SS.

Comment in

Abstract

BACKGROUND:

Survival after sudden cardiac arrest (SCA) remains low, and tools for improved prediction of patients at long-term risk for SCA are lacking. Alternative short-term approaches aimed at preemptive risk stratification and prevention are needed.

OBJECTIVE:

To assess characteristics of symptoms in the 4 weeks before SCA and whether response to these symptoms is associated with better outcomes.

DESIGN:

Ongoing prospective population-based study.

SETTING:

Northwestern United States (2002 to 2012).

PATIENTS:

Residents aged 35 to 65 years with SCA.

MEASUREMENT:

Assessment of symptoms in the 4 weeks preceding SCA and association with survival to hospital discharge.

RESULTS:

Of 839 patients with SCA and comprehensive assessment of symptoms (mean age, 52.6 years [SD, 8]; 75% men), 430 (51%) had warning symptoms (50% of men vs. 53% of women; P = 0.59), mainly chest pain and dyspnea. In most symptomatic patients (93%), symptoms recurred within the 24 hours preceding SCA. Only 81 patients (19%) called emergency medical services (911) to report symptoms before SCA; these persons were more likely to be patients with a history of heart disease (P < 0.001) or continuous chest pain (P < 0.001). Survival when 911 was called in response to symptoms was 32.1% (95% CI, 21.8% to 42.4%) compared with 6.0% (CI, 3.5% to 8.5%) in those who did not call (P < 0.001).

LIMITATION:

Potential for recall and response bias, symptom assessment not available in 24% of patients, and missing data for some patients and SCA characteristics.

CONCLUSION:

Warning symptoms frequently occur before SCA, but most are ignored. Emergent medical care was associated with survival in patients with symptoms, so new approaches are needed for short-term prevention of SCA.

PRIMARY FUNDING SOURCE:

National Heart, Lung, and Blood Institute.

PMID: 26720493 [PubMed - in process]


Annals of Surgery

When fluids were restricted to sub-Parkland formula levels, acute kidney injury was more common.

Ann Surg. 2016 Jan 13. [Epub ahead of print]

Hold the Pendulum: Rates of Acute Kidney Injury are Increased in Patients Who Receive Resuscitation Volumes Less than Predicted by the Parkland Equation.

Mason SA1, Nathens AB, Finnerty CC, Gamelli RL, Gibran NS, Arnoldo BD, Tompkins RG, Herndon DN, Jeschke MG; Inflammation and the Host Response to Injury Collaborative Research Program.

Author information:

1*Department of Surgery, Sunnybrook Health Sciences Centre and Division of General Surgery, University of Toronto, Toronto, Canada †Shriners Hospitals for Children - Galveston and Department of Surgery, University of Texas Medical Branch, Galveston, TX ‡Sealy Center for Molecular Medicine and the Institute for Translational Science, University of Texas Medical Branch, Galveston, TX §Department of Surgery, Loyola University Stritch School of Medicine, Maywood, IL ¶Department of Surgery, University of Washington School of Medicine, Harborview Medical Center, Seattle, WA ||Department of Surgery, University of Texas Southwestern Medical School, Dallas, TX **Department of Surgery, Massachusetts General Hospital, Shriners Hospital for Children, Harvard Medical School, Boston, MA ††Ross Tilley Burn Centre Sunnybrook Health Sciences Centre and Division of Plastic Surgery University of Toronto, Toronto, ON, Canada.

Abstract

OBJECTIVE:

To determine whether restrictive fluid resuscitation results in increased rates of acute kidney injury (AKI) or infectious complications.

BACKGROUND:

Studies demonstrate that patients often receive volumes in excess of those predicted by the Parkland equation, with potentially detrimental sequelae. However, the consequences of under-resuscitation are not well-studied.

METHODS:

Data were collected from a multicenter prospective cohort study. Adults with greater than 20% total burned surface area injury were divided into 3 groups on the basis of the pattern of resuscitation in the first 24 hours: volumes less than (restrictive), equal to, or greater than (excessive) standard resuscitation (4 to 6 cc/kg/% total burned surface area). Multivariable regression analysis was employed to determine the effect of fluid group on AKI, burn wound infections (BWIs), and pneumonia.

RESULTS:

Among 330 patients, 33% received restrictive volumes, 39% received standard resuscitation volumes, and 28% received excessive volumes. The standard and excessive groups had higher mean baseline APACHE scores (24.2 vs 16, P < 0.05 and 22.3 vs 16, P < 0.05) than the restrictive group, but were similar in other characteristics. After adjustment for confounders, restrictive resuscitation was associated with greater probability of AKI [odds ratio (OR) 3.25, 95% confidence interval (95% CI) 1.18-8.94]. No difference in the probability of BWI or pneumonia among groups was found (BWI: restrictive vs standard OR 0.74, 95% CI 0.39-1.40, excessive vs standard OR 1.40, 95% CI 0.75-2.60, pneumonia: restrictive vs standard, OR 0.52, 95% CI 0.26-1.05; excessive vs standard, OR 1.12, 95% CI 0.58-2.14).

CONCLUSIONS:

Restrictive resuscitation is associated with increased AKI, without changes in infectious complications.

PMID: 26764868 [PubMed - as supplied by publisher]


Blood

Dexamethasone was better than prednisone for ITP.

Blood. 2016 Jan 21;127(3):296-302. doi: 10.1182/blood-2015-07-659656. Epub 2015 Oct 19.

High-dose dexamethasone vs prednisone for treatment of adult immune thrombocytopenia: a prospective multicenter randomized trial.

Wei Y1, Ji XB1, Wang YW1, Wang JX2, Yang EQ3, Wang ZC4, Sang YQ5, Bi ZM6, Ren CA7, Zhou F8, Liu GQ9, Peng J10, Hou M11.

Author information:

1Department of Hematology, Qilu Hospital, Shandong University, Jinan, China;

2Department of Hematology, Liaocheng People's Hospital, Liaocheng, China;

3Department of Hematology, People's Hospital of Rizhao, Rizhao, China;

4Department of Hematology, Central Hospital of Zibo, Zibo, China;

5Department of Hematology, Heze Municipal Hospital, Heze, China;

6Department of Hematology, Zibo First Hospital, Zibo, China;

7Department of Hematology, Weifang People's Hospital, Weifang, China;

8Department of Hematology, Jinan Military General Hospital, Jinan, China;

9Department of Hematology, Shengli Oilfield General Hospital, Dongying, China;

10Department of Hematology, Qilu Hospital, Shandong University, Jinan, China; Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, Qilu Hospital, Shandong University, Jinan, China; and.

11Department of Hematology, Qilu Hospital, Shandong University, Jinan, China; Shandong Provincial Key Laboratory of Immunohematology, Qilu Hospital, Shandong University, Jinan, China.

Abstract

This study compared the efficacy and safety of high-dose dexamethasone (HD-DXM) and conventional prednisone (PDN) on the largest cohort to date as first-line strategies for newly diagnosed adult primary immune thrombocytopenia (ITP). Patients enrolled were randomized to receive DXM 40 mg/d for 4 days (n = 95, nonresponders received an additional 4-day course of DXM) or prednisone 1.0 mg/kg daily for 4 weeks and then tapered (n = 97). One or 2 courses of HD-DXM resulted in a higher incidence of overall initial response (82.1% vs 67.4%, P = .044) and complete response (50.5% vs 26.8%, P = .001) compared with prednisone. Time to response was shorter in the HD-DXM arm (P < .001), and a baseline bleeding score ≥8 was associated with a decreased likelihood of initial response. Sustained response was achieved by 40.0% of patients in the HD-DXM arm and 41.2% in the PDN arm (P = .884). Initial complete response was a positive indicator of sustained response, whereas presence of antiplatelet autoantibodies was a negative indicator. HD-DXM was generally tolerated better. We concluded that HD-DXM could be a preferred corticosteroid strategy for first-line management of adult primary ITP. This study is registered at www.clinicaltrials.gov as #NCT01356511.

© 2016 by The American Society of Hematology.

PMID: 26480931 [PubMed - in process]


Chest

  1. Major bleeding was less with direct oral anticoagulants vs. warfarin, even is patients with renal dysfunction.
  2. Patients with parapneumonic effusion on ED presentation do worse and die more often.
  3. Kids with wet cough >4 weeks do better with antibiotics.
  4. Steroids in CAP reduce progression to ARDS and decrease LOS.
  5. PE patients who also have a DVT have increased 30-day mortality.

1.

Chest. 2016 Jan 18. pii: S0012-3692(16)00451-7. doi: 10.1016/j.chest.2015.12.029. [Epub ahead of print]

Major Bleeding and Hemorrhagic Stroke with Direct Oral Anticoagulants in Patients with Renal Failure: Systematic Review and Meta-Analysis of Randomized Trials.

Raccah BH1, Perlman A2, Danenberg HD3, Pollak A3, Muszkat M4, Matok I5.

Author information:

1Division of Clinical Pharmacy, School of Pharmacy, Faculty of Medicine, Hebrew University of Jerusalem; Department of cardiology, Hadassah University Hospital.

2Division of Clinical Pharmacy, School of Pharmacy, Faculty of Medicine, Hebrew University of Jerusalem; Department of Medicine, Hadassah University Hospital.

3Department of cardiology, Hadassah University Hospital.

4Department of Medicine, Division of Clinical Pharmacology, Hadassah University Hospital.

5Division of Clinical Pharmacy, School of Pharmacy, Faculty of Medicine, Hebrew University of Jerusalem. Electronic address: Ilan.Matok@ekmd.huji.ac.il.

Abstract

BACKGROUND:

Direct oral anticoagulants (DOACs) are used as an alternative for traditional antithrombotic therapy. However, the safety profile of DOACs in patients with renal failure (RF) has not been determined.

METHODS:

A systematic review was performed assessing the reported safety of DOACs compared to vitamin K antagonists (VKA) in patients with RF, creatinine clearance (eCrCL) <50mL/min and eCrCL 50-80 mL/min. MEDLINE, EMBASE, Cochrane, and the Clinical Trials Registry (ClinicalTials.gov) were searched for Randomized clinical trials up to Nov 2015. The data were pooled using both traditional frequentist and Bayesian random-effects models.

RESULTS:

Nine trials met inclusion criteria. Among 94,897 participants, 54,667 (58%) had RF. Compared to VKA, DOACs were associated with a significantly decreased risk for major bleeding in patients with eCrCL 50-80 mL/min (risk ratio [RR] 0.84; 95% CI, 0.78-0.91), and a non-significant decrease in the risk for major bleeding in patients with eCrCL <50mL/min (RR, 0.80; 95% CI, 0.63-1.01), with evidence of significant heterogeneity. Indirect comparisons, using Bayesian network analysis, indicated that apixaban was associated with a decreased rate of major bleeding compared to other DOACs in patients with eCrCL <50mL/min. DOACs were associated with a significant decrease in the risk for hemorrhagic stroke compared to VKA in patients with eCrCL <50mL/min and 50-80mL/min.

CONCLUSIONS:

As a class, DOACs are associated with reduced risk for hemorrhagic stroke in patients with RF compared to VKA. However, DOACs may differ from each other in their relative risk for major bleeding in patients with eCrCL <50mL/min.

Copyright © 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

PMID: 26836922 [PubMed - as supplied by publisher]

 

2.

Chest. 2016 Jan 16. pii: S0012-3692(16)00449-9. doi: 10.1016/j.chest.2015.12.027. [Epub ahead of print]

Pleural effusions at first emergency department encounter predict worse clinical outcomes in pneumonia patients.

Dean NC1, Griffith PP2, Sorensen J3, McCauley L4, Jones BE5, Lee YC6.

Author information:

1Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, Utah, USA; Department of Medicine, University of Utah School of Medicine - Salt Lake City, Utah. Electronic address: Nathan.Dean@imail.org.

2Department of Pediatrics, University of Utah School of Medicine - Salt Lake City, Utah.

3Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, Utah, USA.

4Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, Utah, USA; Department of Medicine, University of Utah School of Medicine - Salt Lake City, Utah.

5Division of Pulmonary and Critical Care Medicine, Salt Lake City VA Health System; Department of Medicine, University of Utah School of Medicine - Salt Lake City, Utah.

6Pleural Diseases Unit, Sir Charles Gairdner Hospital, University of Western Australia - Perth, Western Australia, AU.

Abstract

BACKGROUND:

Pleural effusions are present in 15% to 44% of hospitalized pneumonia patients. Whether effusions at first presentation to the emergency department (ED) effect outcomes, or should be managed differently is unknown.

METHODS:

We studied patients in 7 hospital EDs with ICD-9 codes for pneumonia, or empyema, sepsis, or respiratory failure with secondary pneumonia, excluding patients without confirmatory chest imaging. We identified pleural effusions by radiographic imaging.

RESULTS:

Over 24 months, 4771 of 458,837 adult ED patients fulfilled entry criteria. Among 690 (14.5%) with pleural effusion(s), median age was 68 years and 46% were male. Patients with higher Elixhauser scores (OR=1.13, CI=1.09-1.18, p<0.001), brain-natriuretic peptide (OR=1.20, CI=1.12-1.28, p<0.001), bilirubin (OR=1.07, CI=1.00-1.15,p=0.04), and age (OR=1.15, CI=1.09-1.21, p<0.001) were more likely to have parapneumonic effusion(s). In patients without effusion, electronic CURB-65 (eCURB) accurately predicted mortality (4.7% predicted vs. 5.0% actual). However, eCURB underestimated mortality in those with effusion(s) (predicted 7.0% vs. actual 14.0%, p<0.001). Patients with effusion(s) were more likely to be admitted (77% vs. 57%, p<0.001), and had longer hospital stay (median 2.8 vs. 1.3 days, p<0.001). After severity adjustment, likelihood of 30-day mortality was greater among patients with effusion(s) (OR=2.6, CI 2.0-3.5, p<0.001), and hospital stay was disproportionately longer (Coefficient 0.22, CI=0.14 to 0.29, p<0.001).

CONCLUSIONS:

Pneumonia patients with pleural effusions at ED presentation were more likely to die, be admitted, and had longer hospital stays. Why parapneumonic effusions are associated with adverse outcomes, and whether different management of these patients might improve outcome needs urgent investigation.

Copyright © 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

PMID: 26836918 [PubMed - as supplied by publisher]

 

3.

Chest. 2016 Jan;149(1):120-42. doi: 10.1378/chest.15-2065. Epub 2016 Jan 6.

Children With Chronic Wet or Productive Cough-Treatment and Investigations: A Systematic Review.

Chang AB1, Oppenheimer JJ2, Weinberger M3, Rubin BK4, Irwin RS5.

Author information:

1Child Health Division, Menzies School of Health Research, Darwin, Australia; Department of Respiratory and Sleep Medicine, Lady Cilento Children's Hospital, Queensland Uni of Technology, Children's Health Queensland, Queensland, Australia. Electronic address: annechang@ausdoctors.net.

2New Jersey Medical School, Pulmonary and Allergy Associates, Morristown, NJ.

3Pediatric Allergy, Immunology, and Pulmonology Division, University of Iowa Children's Hospital, Iowa City, IA.

4Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, VA.

5UMass Memorial Medical Center, Worcester, MA.

Abstract

BACKGROUND:

Systematic reviews were conducted to examine two related key questions (KQs) in children with chronic (> 4 weeks' duration) wet or productive cough not related to bronchiectasis: KQ1-How effective are antibiotics in improving the resolution of cough? If so, what antibiotic should be used and for how long? KQ2-When should they be referred for further investigations?

METHODS:

The systematic reviews were undertaken based on the protocol established by selected members of the CHEST expert cough panel. Two authors screened searches and selected and extracted data. The study included systematic reviews, randomized controlled trials (RCTs), cohort (prospective and retrospective) studies, and cross-sectional studies published in English.

RESULTS:

Data were presented in Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowcharts, and the summaries were tabulated. Fifteen studies were included in KQ1 (three systematic reviews, three RCTs, five prospective studies, and four retrospective studies) and 17 in KQ2 (one RCT, 11 prospective studies, and five retrospective studies). Combining data from the RCTs (KQ1), the number needed to treat for benefit was 3 (95% CI, 2.0-4.3) in achieving cough resolution. In general, findings from prospective and retrospective studies were consistent, but there were minor variations.

CONCLUSIONS:

There is high-quality evidence that in children aged ≤ 14 years with chronic (> 4 weeks' duration) wet or productive cough, the use of appropriate antibiotics improves cough resolution. There is also high-quality evidence that when specific cough pointers (eg, digital clubbing) are present in children with wet cough, further investigations (eg, flexible bronchoscopy, chest CT scans, immunity tests) should be conducted. When the wet cough does not improve by 4 weeks of antibiotic treatment, there is moderate-quality evidence that children should be referred to a major center for further investigations to determine whether an underlying lung or other disease is present.

Copyright © 2016 American College of Chest Physicians. All rights reserved.

PMID: 26757284 [PubMed - in process]

 

4.

Chest. 2016 Jan;149(1):209-19. doi: 10.1378/chest.15-1733. Epub 2016 Jan 6.

Efficacy and Safety of Corticosteroids for Community-Acquired Pneumonia: A Systematic Review and Meta-Analysis.

Wan YD1, Sun TW2, Liu ZQ1, Zhang SG1, Wang LX3, Kan QC4.

Author information:

1Department of Integrated ICU, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.

2Department of Integrated ICU, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China. Electronic address: suntongwen@163.com.

3School of Biomedical Sciences, Charles Sturt University, Australia.

4Pharmaceutical Department, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.

Abstract

BACKGROUND:

Corticosteroids are an option in the treatment of community-acquired pneumonia (CAP). However, the benefits and adverse effects of corticosteroids, especially in severe CAP, have not been well assessed.

METHODS:

PubMed, Embase, and Cochrane library databases from inception to May 2015 were searched. Randomized controlled trials (RCTs) and cohort studies that evaluated use of corticosteroids in adult patients with CAP were included. The quality of outcomes was evaluated using Grading of Recommendations Assessment, Development and Evaluation methodology. The Mantel-Haenszel method with random-effects modeling was used to calculate pooled relative risks (RRs) and 95% CIs.

RESULTS:

Nine eligible RCTs (1,667 patients) and six cohort studies (4,095 patients) were identified. The mean corticosteroid dose and treatment duration were 30 mg/day methylprednisolone for 7 days. Corticosteroids did not have a statistically significant effect on mortality (RR, 0.72; 95% CI, 0.43-1.21; evidence rank, low) in patients with CAP and patients with severe CAP (RCTs: RR, 0.72; 95% CI, 0.43-1.21; evidence rank, low; cohort studies: RR, 1.00; 95% CI, 0.86-1.17 ). Corticosteroids treatment was associated with a decreased risk of ARDS (RR, 0.21; 95% CI, 0.08-0.59) and may reduce lengths of hospital and ICU stay, duration of IV antibiotic treatment, and time to clinical stability. Corticosteroids were not associated with increased rates of adverse events.

CONCLUSIONS:

Short-term treatment with corticosteroids is safe and may reduce the risk of ARDS, shortening the length of the disease in patients with CAP.

Copyright © 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

PMID: 26501852 [PubMed - in process]

 

5.

Chest. 2016 Jan;149(1):192-200. doi: 10.1378/chest.15-0808. Epub 2016 Jan 6.

Risk Stratification of Patients With Acute Symptomatic Pulmonary Embolism Based on Presence or Absence of Lower Extremity DVT: Systematic Review and Meta-analysis.

Becattini C1, Cohen AT2, Agnelli G1, Howard L3, Castejón B4, Trujillo-Santos J5, Monreal M6, Perrier A7, Yusen RD8, Jiménez D9.

Author information:

1Department of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy.

2Department of Haematological Medicine, Guys and St. Thomas' NHS Foundation Trust, London, England.

3National Pulmonary Hypertension Service, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, England.

4Vascular Department, Ramón y Cajal Hospital, IRYCIS, Madrid, Spain.

5Medicine Department, Santa Lucía Hospital, Cartagena, Murcia, Spain.

6Medicine Department, Germans Trias i Pujol Hospital, Badalona, Spain.

7Division of General Internal Medicine, Department of Internal Medicine, Rehabilitation, and Geriatrics, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland.

8Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO; Division of General Medical Sciences, Washington University School of Medicine, St. Louis, MO.

9Respiratory Department, Ramón y Cajal Hospital and Alcala de Henares University, IRYCIS, Madrid, Spain. Electronic address: djimenez.hrc@gmail.com.

Abstract

BACKGROUND:

For patients diagnosed with acute pulmonary embolism (PE), the prognostic significance of concomitant DVT lacks clarity.

METHODS:

We performed a meta-analysis of studies that enrolled patients with acute PE to assess the prognostic value of concomitant DVT for the primary outcome of 30-day all-cause mortality and the secondary outcome of 90-day PE-related adverse events. We conducted unrestricted searches of PubMed and Embase from 1980 through September 30, 2014, and used the terms "deep vein thrombosis," "pulmonary embolism," and "prognos*." We used a random-effects model to pool study results, Begg rank-correlation method to evaluate for publication bias, and I(2) testing to assess for heterogeneity.

RESULTS:

The meta-analysis included a total of nine studies (10 cohorts, as one study had two cohorts) with 8,859 patients. Of the seven cohorts with 7,868 participants who had PE and provided results on the primary outcome, 4,379 (56%) had concomitant DVT; 272 of 4,379 (6.2%) patients with concomitant DVT died 30 days after the diagnosis of PE compared with 133 of 3,489 (3.8%) without DVT. Concomitant DVT had a significant association with 30-day all-cause mortality in all patients (seven cohorts; OR, 1.9; 95% CI, 1.5-2.4; I(2) = 0%). Concomitant DVT was not significantly associated with 90-day PE-related adverse outcomes (five cohorts; OR, 1.6; 95% CI, 0.8-3.4; I(2) = 75%).

CONCLUSIONS:

In patients diagnosed with acute symptomatic PE, concomitant DVT was significantly associated with an increased risk of death within 30 days of PE diagnosis.

Copyright © 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

PMID: 26204122 [PubMed - in process]


Journal of Emergency Medicine

  1. This group scoured the literature and concluded that CT CTA is a reasonable way to work up suspect SAH, contrary to the utility analysis in EMJ this month.
  2. Early volume expansion corrected metabolic derangements more quickly in DKA but did not affect overall LOS.

1.

J Emerg Med. 2016 Jan 25. pii: S0736-4679(15)01386-4. doi: 10.1016/j.jemermed.2015.07.048. [Epub ahead of print]

Clinical Guidelines for the Emergency Department Evaluation of Subarachnoid Hemorrhage.

Meurer WJ1, Walsh B2, Vilke GM3, Coyne CJ3.

Author information:

1Department of Emergency Medicine, University of Michigan Health System, Ann Arbor, Michigan.

2Department of Emergency Medicine, Morristown Medical Center, Morristown, New Jersey.

3Department of Emergency Medicine, University of California San Diego School of Medicine, San Diego, California.

Abstract

BACKGROUND:

Subarachnoid hemorrhage (SAH) is frequently caused by the rupture of an intracranial aneurysmal vessel or arteriovenous malformation, leading to a cascade of events that can result in severe disability or death. When evaluating for this diagnosis, emergency physicians have classically performed a noncontrast computed tomography (NCCT) scan, followed by a lumbar puncture (LP). Recently, however, as CT technology has advanced, many studies have questioned the necessity of the LP in the SAH diagnostic algorithm and have instead advocated for noninvasive techniques, such as NCCT alone or NCCT with CT angiogram (CTA).

OBJECTIVE:

The primary goal of this literature search was to determine the appropriate emergency department (ED) management of patients with suspected SAH.

METHODS:

A MEDLINE literature search from October 2008 to June 2015 was performed using the keywords computed tomography AND subarachnoid hemorrhage AND lumbar puncture, while limiting the search to human studies written in the English language. General review articles and single case reports were omitted. Each of the selected articles then underwent a structured review.

RESULTS:

Ninety-one articles were identified, with 31 papers being considered appropriate for analysis. These studies then underwent a rigorous review from which recommendations were developed.

CONCLUSIONS:

The literature search supports that NCCT followed by CTA is a reasonable approach in the evaluation of ED patients with possible SAH.

Copyright © 2016 Elsevier Inc. All rights reserved.

PMID: 26823138 [PubMed - as supplied by publisher]

 

2.

J Emerg Med. 2016 Jan 25. pii: S0736-4679(15)01384-0. doi: 10.1016/j.jemermed.2015.12.003. [Epub ahead of print]

Effect of Volume of Fluid Resuscitation on Metabolic Normalization in Children Presenting in Diabetic Ketoacidosis: A Randomized Controlled Trial.

Bakes K1, Haukoos JS2, Deakyne SJ3, Hopkins E1, Easter J1, McFann K4, Brent A5, Rewers A5.

Author information:

1Department of Emergency Medicine, Denver Health Medical Center, University of Colorado, School of Medicine, Denver, Colorado.

2Department of Emergency Medicine, Denver Health Medical Center, University of Colorado, School of Medicine, Denver, Colorado; Department of Epidemiology, Colorado School of Public Health, University of Colorado, Aurora, Colorado.

3Department of Research Informatics, Children's Hospital Colorado, Research Institute, Aurora, Colorado.

4Colorado School of Public Health, University of Colorado, Aurora, Colorado.

5Section Emergency Medicine, Department of Pediatrics, University of Colorado, School of Medicine, Aurora, Colorado.

Abstract

BACKGROUND:

The optimal rate of fluid administration in pediatric diabetic ketoacidosis (DKA) is unknown.

OBJECTIVE:

Our aim was to determine whether the volume of fluid administration in children with DKA influences the rate of metabolic normalization.

METHODS:

We performed a randomized controlled trial conducted in a tertiary pediatric emergency department from December 2007 until June 2010. The primary outcome was time to metabolic normalization; secondary outcomes were time to bicarbonate normalization, pH normalization, overall length of hospital treatment, and adverse outcomes. Children between 0 and 18 years of age were eligible if they had type 1 diabetes mellitus and DKA. Patients were randomized to receive intravenous (IV) fluid at low volume (10 mL/kg bolus + 1.25 × maintenance rate) or high volume (20 mL/kg bolus + 1.5 × maintenance rate) (n = 25 in each).

RESULTS:

After adjusting for initial differences in bicarbonate levels, time to metabolic normalization was significantly faster in the higher-volume infusion group compared to the low-volume infusion group (hazard ratio [HR] = 2.0; 95% confidence interval [CI] 1.0-3.9; p = 0.04). Higher-volume IV fluid infusion appeared to hasten, to a greater extent, normalization of pH (HR = 2.5; 95% CI 1.2-5.0; p = 0.01) than normalization of serum bicarbonate (HR = 1.2; 95% CI 0.6-2.3; p = 0.6). The length of hospital treatment HR (0.8; 95% CI 0.4-1.5; p = 0.5) and time to discharge HR (0.8; 95% CI 0.4-1.5; p = 0.5) did not differ between treatment groups.

CONCLUSIONS:

Higher-volume fluid infusion in the treatment of pediatric DKA patients significantly shortened metabolic normalization time, but did not change overall length of hospital treatment. ClinicalTrials.gov ID NCT01701557.

Copyright © 2016 Elsevier Inc. All rights reserved.

PMID: 26823137 [PubMed - as supplied by publisher]


Journal of Thrombosis and Haemostasis

  1. Corticosteroids had a mild procoagulant effect on healthy subjects. Whether this increases thromboembolism risk in patients with inflammatory conditions on steroids remains to be seen.
  2. Patients with high pretest probability of PE and negative CTPA were false negatives 5.2% of the time. It may not be safe to withhold anticoagulation from these people without further testing in addition to CTPA.

1.

J Thromb Haemost. 2016 Jan 21. doi: 10.1111/jth.13265. [Epub ahead of print]

The influence of corticosteroids on haemostasis in healthy subjects.

Majoor CJ1, Sneeboer MM1, de Kievit A1, Meijers JC2,3, van der Poll T4, Lutter R1,5, Bel EH1, Kamphuisen PW6.

Author information:

1Dept of Respiratory Medicine, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.

2Experimental Vascular Medicine, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.

3Dept of Plasma Proteins, Sanquin Research, Amsterdam, the Netherlands.

4Center of Experimental and Molecular Medicine, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.

5Experimental Immunology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.

6Dept of Vascular Medicine, University Medical Center Groningen, Hanzeplein 1, 9700 HB, Groningen, The Netherlands.

Abstract

BACKGROUND:

Corticosteroids have been associated with an increased risk for venous thromboembolism (VTE) in patients treated for inflammatory diseases. It is unclear whether the thrombotic risk is induced by the inflammation of the underlying inflammatory diseases or whether corticosteroids are prothrombotic as well. Considering the widespread use of corticosteroids in clinical practice, it is critical to know whether corticosteroids enhance coagulation.

OBJECTIVE:

To investigate whether a 10-day prednisolone burst therapy activates haemostasis in healthy individuals.

METHODS:

Healthy subjects received either 0.5 mg/kg/day of oral prednisolone or placebo. Venous blood was collected at baseline, day 1 and day 10 and tested for thrombin-antithrombin complexes (TATc), D-dimer, plasmin-alpha2-antiplasmin complexes (PAPc), plasminogen-activator inhibitor type-1 (PAI-1), von Willebrand factor (vWF) and thrombin generation (peak thrombin, velocity index and endogenous thrombin potential (ETP)).

RESULTS:

Fifteen subjects received prednisolone and 16 placebo (median age 29 vs. 22 years, female 33% vs. 56%, respectively). Peak thrombin and velocity index were higher in the placebo group at baseline. After 10 days of treatment, peak thrombin, velocity index, PAI-1 and vWF increased in the oral prednisolone group as compared to the placebo group (15.8 (SD 16.3) vs. -0.1 (SD 16.1); 41.2 (SD 41.3) vs. -2.3 (SD 42.7); 18.0 (IQR 8.0-37.0) vs. 0.5 (IQR -18.5-13.0); 4.0 (IQR -1.0-12.0) vs. 0.0 (IQR -2.5-1.5), respectively). No changes were observed for TATc, ETP, PAPc and D-dimer.

CONCLUSIONS:

Oral prednisolone induces a procoagulant state in healthy subjects, suggesting that corticosteroid treatment may increase thromboembolic risk in patients with inflammatory diseases. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

PMID: 26791678 [PubMed - as supplied by publisher]

 

2.

J Thromb Haemost. 2016 Jan;14(1):114-20. doi: 10.1111/jth.13188. Epub 2015 Dec 14.

Multidetector computed tomographic pulmonary angiography in patients with a high clinical probability of pulmonary embolism.

Moores L1, Kline J2, Portillo AK3, Resano S4, Vicente A4, Arrieta P5, Corres J6, Tapson V7, Yusen RD8, Jiménez D5.

Author information:

1F. Edward Hebert School of Medicine, Uniformed Services University, Bethesda, MD, USA.

2Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.

3Department of Internal Medicine, Instituto Ramon y Cajal de Investigacion Sanitaria IRYCIS, Ramón y Cajal Hospital, Madrid, Spain.

4Radiology Department, Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Ramón y Cajal Hospital, Madrid, Spain.

5Respiratory Department, Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Ramón y Cajal Hospital, Alcala de Henares University, Madrid, Spain.

6Emergency Department, Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Ramón y Cajal Hospital, Madrid, Spain.

7Divisions of Pulmonary and Critical Care Medicine, Cedars-Sinai, Los Angeles, CA, USA.

8Divisions of Pulmonary and Critical Care Medicine and General Medical Sciences, Washington University School of Medicine, St Louis, MO, USA.

Abstract

Essentials: When high probability of pulmonary embolism (PE), sensitivity of computed tomography (CT) is unclear. We investigated the sensitivity of multidetector CT among 134 patients with a high probability of PE. A normal CT alone may not safely exclude PE in patients with a high clinical pretest probability. In patients with no clear alternative diagnosis after CTPA, further testing should be strongly considered.

SUMMARY:

Background: Whether patients with a negative multidetector computed tomographic pulmonary angiography (CTPA) result and a high clinical pretest probability of pulmonary embolism (PE) should be further investigated is controversial. Methods This was a prospective investigation of the sensitivity of multidetector CTPA among patients with a priori clinical assessment of a high probability of PE according to the Wells criteria. Among patients with a negative CTPA result, the diagnosis of PE required at least one of the following conditions: ventilation/perfusion lung scan showing a high probability of PE in a patient with no history of PE, abnormal findings on venous ultrasonography in a patient without previous deep vein thrombosis at that site, or the occurrence of venous thromboembolism (VTE) in a 3-month follow-up period after anticoagulation was withheld because of a negative multidetector CTPA result. Results We identified 498 patients with a priori clinical assessment of a high probability of PE and a completed CTPA study. CTPA excluded PE in 134 patients; in these patients, the pooled incidence of VTE was 5.2% (seven of 134 patients; 95% confidence interval [CI] 1.5-9.0). Five patients had VTEs that were confirmed by an additional imaging test despite a negative CTPA result (five of 48 patients; 10.4%; 95% CI 1.8-19.1), and two patients had objectively confirmed VTEs that occurred during clinical follow-up of at least 3 months (two of 86 patients; 2.3%; 95% CI 0-5.5). None of the patients had a fatal PE during follow-up. Conclusions A normal multidetector CTPA result alone may not safely exclude PE in patients with a high clinical pretest probability.

© 2015 International Society on Thrombosis and Haemostasis.

PMID: 26559176 [PubMed - in process]


Journal of Trauma and Acute Care Surgery

  1. REBOA may actually be bad in torso trauma.
  2. Clinical T/L spine clearance in patients with distracting injury has poor diagnostic test characteristics: sensitivity 75%. Note, this is not the conclusion of the authors! They say this is good...

1.

J Trauma Acute Care Surg. 2016 Jan 21. [Epub ahead of print]

Resuscitative endovascular balloon occlusion of the aorta might be dangerous in patients with severe torso trauma: a propensity score analysis.

Inoue J1, Shiraishi A, Yoshiyuki A, Haruta K, Matsui H, Otomo Y.

Author information:

1Tokyo Medical Dental University.

Abstract

BACKGROUND:

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a key procedure in early trauma care that provides hemorrhage control in hemodynamically unstable torso trauma patients. However, the clinical efficacy of REBOA remains uncertain. The objective of this study was to estimate the efficacy of REBOA in surgically-treated severe torso trauma patients.

METHODS:

We obtained data from the nationwide trauma registry in Japan (the Japan Trauma Databank [JTDB]) for trauma subjects who had undergone emergency surgery or transcatheter embolization against torso trauma. A logistic regression analysis estimated a propensity score to predict REBOA use from available predictors of in-hospital mortality. We then used a propensity score matching analysis to compare in-hospital mortality and door-to-primary-surgery time in subjects who underwent REBOA and those who did not. Additionally, we used an instrumental variable method to adjust for unmeasured confounding variables as a sensitivity analysis.

RESULTS:

Overall, 12,053 of the 183,457 trauma patients registered in the JTDB were eligible based on selection criteria. Propensity score matching selected 625 patients each for the with-REBOA and without-REBOA groups. The in-hospital mortality was significantly higher in subjects who underwent REBOA (61.8% versus 45.3%, absolute difference: +16.5% [95% confident interval +10.9%, +22.0%]). Door-to-primary-surgery time was shorter in subjects who underwent REBOA than in those who did not (97 minutes versus 110 minutes, absolute difference: -14 minutes [95% confidence interval -25 minutes, -3 minutes]). The sensitivity analysis with the instrumental variable method did not alter the results and estimated non-significantly lower in-hospital mortality in REBOA subjects (+16.4%, [95% confidence interval -0.6, 33.3%]).

CONCLUSION:

This study showed an association between use of REBOA and excess mortality in patients with hemodynamically unstable torso trauma that had a median door-to-primary-surgery time of 97 minutes. Further observational studies with detailed REBOA data are necessary to assess whether selected trauma subgroups could benefit from REBOA.

LEVEL OF EVIDENCE:

Level III, therapeutic study.

PMID: 26808039 [PubMed - as supplied by publisher]

 

2.

J Trauma Acute Care Surg. 2016 Jan;80(1):125-30. doi: 10.1097/TA.0000000000000884.

Thoracolumbar spine clearance: Clinical examination for patients with distracting injuries.

Cason B1, Rostas J, Simmons J, Frotan MA, Brevard SB, Gonzalez RP.

Author information:

1From the Department of Surgery (B.C., J.R., J.S., S.B.B.), University of South Alabama, Mobile, Alabama; Department of Surgery (M.A.F.), Texas Health Presbyterian, Dallas, Texas; and Division of Trauma, Surgical Critical Care, Burns (R.P.G.), Loyola University Medical Center, Maywood, Illinois.

Abstract

BACKGROUND:

The purpose of this study was to prospectively assess the sensitivity of clinical examination to screen for thoracolumbar spine (TLS) injury in awake and alert blunt trauma patients with distracting injuries.

METHODS:

From December 2012 to June 2014, all blunt trauma patients older than 13 years were prospectively evaluated as per standard TLS examination protocol at a Level 1 trauma center. Awake and alert patients with Glasgow Coma Scale (GCS) score of 14 or greater underwent clinical examination of the TLS. Clinical examination was performed regardless of distracting injuries. Patients with no complaints of pain or tenderness on examination of the TLS were considered clinically cleared of injury. Patients with distracting injuries, including those clinically cleared and those with complaints of TLS pain or tenderness, underwent computed tomographic scan of the entire TLS. Patients with minor distracting injuries were not considered to have a distracting injury.

RESULTS:

A total of 950 blunt trauma patients were entered, 530 (56%) of whom had at least one distracting injury. Two hundred nine patients (40%) with distracting injuries had a positive TLS clinical examination result, of whom 50 (25%) were diagnosed with TLS injury. Three hundred twenty-one patients (60%) with distracting injuries were initially clinically cleared, in whom 17 (5%) TLS injuries were diagnosed. There were no missed injuries that required surgical intervention, with only four injuries receiving TLS orthotic bracing. This yielded an overall clinical clearance sensitivity for injury of 75% and sensitivity for clinically significant injury of 89%.

CONCLUSION:

In awake and alert blunt trauma patients with distracting injuries, clinical examination is a sensitive screening method for significant TLS injury. Radiologic assessment may be unnecessary for safe clearance of the asymptomatic TLS in patients with distracting injuries. These findings suggest significant potential reduction of both health care cost and patient radiation exposure.

LEVEL OF EVIDENCE:

Diagnostic study, level IV; therapeutic/care management study, level IV.

PMID: 26491795 [PubMed - in process]


JAMA Pediatrics

  1. We routinely splint kids with lateral malleolar tenderness and no fracture in case an occult Salter-Harris 1 (SH1) injury is present, but only 3% of kids had SH1 fractures at follow up.  All recovered just as quickly as kids with sprains. It looks like an ankle brace and self-determined return to activity is OK for these kids.
  2. Does procalcitonin obviate the need for sepsis workup in very young infants? It performs fairly well, with AUC 0.81 for SBI and 0.91 for invasive bacterial infection. I don't think we can forego the sepsis workup yet with biomarkers.

1.

JAMA Pediatr. 2016 Jan 4;170(1):e154114. doi: 10.1001/jamapediatrics.2015.4114. Epub 2016 Jan 4.

Radiograph-Negative Lateral Ankle Injuries in Children: Occult Growth Plate Fracture or Sprain?

Boutis K1, Plint A2, Stimec J3, Miller E4, Babyn P5, Schuh S1, Brison R6, Lawton L7, Narayanan UG8.

Author information:

1Division of Emergency Medicine, Department of Pediatrics, the Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada.

2Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Eastern Ontario and University of Ottawa, Ottawa, Ontario, Canada.

3Department of Diagnostic Imaging, The Hospital for Sick Children and University of Toronto, University of Toronto, Toronto, Ontario, Canada.

4Department of Medical Imaging, Children's Hospital of Eastern Ontario and University of Ottawa, Ottawa, Ontario, Canada.

5Department of Radiology, University of Saskatchewan and Saskatoon Health Region, Saskatoon, Saskatchewan, Canada.

6Department of Emergency Medicine, Kingston General Hospital and Queen's University, Kingston, Ontario, Canada.

7Division of Orthopaedic Surgery, Department of Surgery, Children's Hospital of Eastern Ontario and University of Ottawa, Ottawa, Ontario, Canada.

8Division of Orthopaedic Surgery, Department of Surgery, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada.

Abstract

IMPORTANCE:

Lateral ankle injuries without radiographic evidence of a fracture are a common pediatric injury. These children are often presumed to have a Salter-Harris type I fracture of the distal fibula (SH1DF) and managed with immobilization and orthopedic follow-up. However, previous small studies suggest that these injuries may represent ankle sprains rather than growth plate fractures.

OBJECTIVES:

To determine the frequency of SH1DF using magnetic resonance imaging (MRI) and compare the functional recovery of children with fractures identified by MRI vs those with isolated ligament injuries.

DESIGN, SETTING, AND PARTICIPANTS:

A prospective cohort study was conducted between September 2012 and August 2014 at 2 tertiary care pediatric emergency departments. We screened 271 skeletally immature children aged 5 to 12 years with a clinically suspected SH1DF; 170 were eligible and 140 consented to participate.

INTERVENTIONS:

Children underwent MRI of both ankles within 1 week of injury. Children were managed with a removable brace and allowed to return to activities as tolerated.

MAIN OUTCOMES AND MEASURES:

The proportion with MRI-confirmed SH1DF. A secondary outcome included the Activity Scale for Kids score at 1 month.

RESULTS:

Of the 135 children who underwent ankle MRI, 4 (3.0%; 95% CI, 0.1%-5.9%) demonstrated MRI-confirmed SH1DF, and 2 of these were partial growth plate injuries. Also, 108 children (80.0%) had ligament injuries and 27 (22.0%) had isolated bone contusions. Of the 108 ligament injuries, 73 (67.6%) were intermediate to high-grade injuries, 38 of which were associated with radiographically occult fibular avulsion fractures. At 1 month, the mean (SD) Activity Scale for Kids score of children with MRI-detected fibular fractures (82.0% [17.2%]) was not significantly different from those without fractures (85.8% [12.5%]) (mean difference, -3.8%; 95% CI, -1.7% to 9.2%).

CONCLUSIONS AND RELEVANCE:

Salter-Harris I fractures of the distal fibula are rare in children with radiograph fracture-negative lateral ankle injuries. These children most commonly have ligament injuries (sprains), sometimes associated with radiographically occult avulsion fractures. Children with fractures detectable only by MRI had a comparable recovery with those with sprains when treated with a removable ankle brace and self-regulated return to activities. This work has the potential to simplify the care of these common injuries, safely minimizing the inconveniences and costs of overtreatment.

PMID: 26747077 [PubMed - in process

 

2.

JAMA Pediatr. 2016 Jan 1;170(1):62-9. doi: 10.1001/jamapediatrics.2015.3210.

Use of Procalcitonin Assays to Predict Serious Bacterial Infection in Young Febrile Infants.

Milcent K1, Faesch S2, Gras-Le Guen C3, Dubos F4, Poulalhon C5, Badier I6, Marc E7, Laguille C8, de Pontual L9, Mosca A10, Nissack G11, Biscardi S12, Le Hors H13, Louillet F14, Dumitrescu AM15, Babe P16, Vauloup-Fellous C17, Bouyer J5, Gajdos V1.

Author information:

1Department of Pediatrics, Antoine Béclère University Hospital, Assistance Publique-Hôpitaux de Paris, Clamart, France2INSERM, CESP Centre for Research in Epidemiology and Population Health, Paris-Sud, Paris-Saclay University, Villejuif, France.

2Pediatric Emergency Department, Paris Descartes University, Necker Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.

3Department of Pediatrics, Hôpital Mère Enfant, Nantes University Hospital, Nantes, France.

4Pediatric Emergency Unit and Infectious Diseases, Lille University, Lille, France.

5INSERM, CESP Centre for Research in Epidemiology and Population Health, Paris-Sud, Paris-Saclay University, Villejuif, France.

6Department of Pediatrics, Poissy Hospital, Poissy, France.

7Department of Pediatrics, Kremlin Bicêtre University Hospital, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre, France.

8Department of Pediatrics, Dupuytren University Hospital, Limoges, France.

9Department of Pediatrics, Jean Verdier Hospital, Assistance Publique-Hôpitaux de Paris, Paris 13 University, Bondy, France.

10Department of Pediatrics, Sud Francilien Hospital, Corbeil-Essonnes, France.

11Department of Pediatrics, Centre Hospitalier de Marne La Vallée, Jossigny, France.

12Department of Pediatrics, Créteil Hospital, Créteil, France.

13Department of Paediatric Surgery, Hôpital d'Enfants de La Timone, Marseille, France.

14Department of Pediatrics, Rouen University Hospital, Rouen, France.

15Department of Pediatrics, Louis Mourier University Hospital, Assistance Publique-Hôpitaux de Paris, Colombes, France.

16Pediatric Emergency Unit, Hôpitaux Pédiatriques de Nice, CHU Lenval, Nice, France.

17Assistance Publique-Hôpitaux de Paris, Hôpital Paul Brousse, Virologie, National Reference Laboratory for Maternofetal Rubella Infections, Villejuif, France.

Abstract

IMPORTANCE:

The procalcitonin (PCT) assay is an accurate screening test for identifying invasive bacterial infection (IBI); however, data on the PCT assay in very young infants are insufficient.

OBJECTIVE:

To assess the diagnostic characteristics of the PCT assay for detecting serious bacterial infection (SBI) and IBI in febrile infants aged 7 to 91 days.

DESIGN, SETTING, AND PARTICIPANTS:

A prospective cohort study that included infants aged 7 to 91 days admitted for fever to 15 French pediatric emergency departments was conducted for a period of 30 months (October 1, 2008, through March 31, 2011). The data management and analysis were performed from October 1, 2011, through October 31, 2014.

MAIN OUTCOMES AND MEASURES:

The diagnostic characteristics of the PCT assay, C-reactive protein (CRP) concentration, white blood cell (WBC) count, and absolute neutrophil cell (ANC) count for detecting SBI and IBI were described and compared for the overall population and subgroups of infants according to the age and the duration of fever. Laboratory test cutoff values were calculated based on receiver operating characteristic (ROC) curve analysis. The SBIs were defined as a pathogenic bacteria in positive culture of blood, cerebrospinal fluid, urine, or stool samples, including bacteremia and bacterial meningitis classified as IBIs.

RESULTS:

Among the 2047 infants included, 139 (6.8%) were diagnosed as having an SBI and 21 (1.0%) as having an IBI (11.0% and 1.7% of those with blood culture (n = 1258), respectively). The PCT assay offered an area under the curve (AUC) of ROC curve similar to that for CRP concentration for the detection of SBI (AUC, 0.81; 95% CI, 0.75-0.86; vs AUC, 0.80; 95% CI, 0.75-0.85; P = .70). The AUC ROC curve for the detection of IBI for the PCT assay was significantly higher than that for the CRP concentration (AUC, 0.91; 95% CI, 0.83-0.99; vs AUC, 0.77; 95% CI, 0.65-0.89; P = .002). Using a cutoff value of 0.3 ng/mL for PCT and 20 mg/L for CRP, negative likelihood ratios were 0.3 (95% CI, 0.2-0.5) for identifying SBI and 0.1 (95% CI, 0.03-0.4) and 0.3 (95% CI, 0.2-0.7) for identifying IBI, respectively. Similar results were obtained for the subgroup of infants younger than 1 month and for those with fever lasting less than 6 hours.

CONCLUSIONS AND RELEVANCE:

The PCT assay has better diagnostic accuracy than CRP measurement for detecting IBI; the 2 tests perform similarly for identifying SBI in febrile infants aged 7 to 91 days.

PMID: 26595253 [PubMed - in process]


Pediatric Emergency Care

  1. VL is replacing DL in adult EM.  Storz and Glidescope were similar to DL in pediatric patients with inline stabilization intubated by PGY3 anesthesia residents, both taking a bit longer than DL, but with better glottic view.
  2. Adult ETT cuff pressures go up in a helicopter.  Not surprisingly, they also go up in cuffed pediatric-sized ETTs as well.

1.

Pediatr Emerg Care. 2016 Jan 16. [Epub ahead of print]

Comparison of the GlideScope Cobalt and Storz DCI Video Laryngoscopes in Children Younger Than 2 Years of Age During Manual In-Line Stabilization: A Randomized Trainee Evaluation Study.

Vadi MG1, Roddy KJ, Ghazal EA, Um M, Neiheisel AJ, Applegate RL 2nd.

Author information:

1From the Department of Anesthesiology, Loma Linda University School of Medicine, Loma Linda, CA.

Abstract

OBJECTIVES:

Video laryngoscopy facilitates tracheal intubation during manual in-line stabilization in adults, but it is not clear whether these findings translate to children. We compared trainee intubation times obtained using the GlideScope Cobalt and Storz DCI video laryngoscopes versus direct laryngoscopy in young children with immobilized cervical spines.

METHODS:

Ninety-three children younger than 2 years underwent laryngoscopy with manual in-line stabilization using direct laryngoscopy, GlideScope Cobalt video laryngoscopy, or Storz DCI video laryngoscopy. Laryngoscopists were anesthesiology trainees in postgraduate training year of 3 or more. Total time to successful intubation (TTSI), best glottic view, and maximum degrees of neck deviation were recorded. An intubation time difference longer than 10 seconds was defined as clinically significant.

RESULTS:

Data are reported as median; 95% confidence interval. The TTSI was similar among groups although Storz times were longer (median, 33.3 seconds; 95% confidence interval, 26.2-43.3 seconds) when compared to direct laryngoscopy (median, 23.3 seconds; 95% confidence interval, 20.7-26.5 seconds; P = 0.02). Obtaining a grade 1 Cormack-Lehane glottic view was less likely with direct laryngoscopy (P = 0.002). Maximum degrees of neck deviation were: Storz (median, 2.0; 95% confidence interval, 1.2-2.8), GlideScope (median, 2.0; 95% confidence interval, 1.4-2.6), and direct laryngoscopy (median, 1.9; 95% confidence interval, 1.2-2.1; P = 0.48).

CONCLUSIONS:

Trainees were able to safely perform tracheal intubation in children younger than 2 years using any of the studied laryngoscopes, although Storz use resulted in a longer TTSI when compared to direct laryngoscopy. Video laryngoscopy may enhance best Cormack-Lehane glottic view during manual in-line cervical spine immobilization, but additional technical skills are needed to successfully complete tracheal intubation.

PMID: 26785097 [PubMed - as supplied by publisher]

 

2.

Pediatr Emerg Care. 2016 Jan;32(1):20-2. doi: 10.1097/PEC.0000000000000365.

Pediatric Endotracheal Tube Cuff Pressures During Aeromedical Transport.

Orsborn J1, Graham J, Moss M, Melguizo M, Nick T, Stroud M.

Author information:

1From the *Department of Pediatrics, Section of Emergency Medicine, †College of Medicine, ‡Department of Pediatrics, Section of Critical Care, and §Department of Pediatrics, Biostatistics Program, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR.

Abstract

OBJECTIVES:

Cuffed endotracheal tubes (ETTs) are frequently used in children, allowing fewer air leaks and helping prevent ventilator-associated pneumonia. Tracheal mucosal perfusion is compromised at an ETT cuff pressure (ETTCP) of 30 cm H2O with blood flow completely absent above 50 cm H2O. Our objective was to compare multiple pediatric-sized ETTCPs at ground level and various altitudes during aeromedical transport.

METHODS:

Simulating the transport environment, 4 pediatric-sized mannequin heads were intubated with appropriately sized cuffed ETTs (3.0, 4.0, 5.0, 6.0) and transported by helicopter or nonpressurized fixed-wing aircraft 20 times each. The ETTCP was set to 10 cm H2O before transport, and the pressure was measured with a standard manometer at 1000-ft intervals until reaching peak altitude or CP greater than 60 cm H2O. Ground elevation ranged from 400-650 ft mean sea level (MSL) and peak altitude from 3500 to 5000 ft MSL.

RESULTS:

Increased altitude caused a significant increase in ETTCP of all ETT sizes (P < 0.001). However, there is no statistical difference in pressures between ETT sizes (P = 0.28). On average, ETTCP in 3.0, 4.0, and 6.0 ETTs surpassed 30 cm H2O at approximately 1500 ft MSL and 50 cm H2O at approximately 2800 ft MSL. In the 5.0 ETT, the CP reached 30 cm H2O at 2000 ft MSL and 50 cm H2O at 3700 ft MSL.

CONCLUSIONS:

The ETTCP in pediatric-sized ETTs regularly exceed recommended pressure limits at relatively low altitudes. There is no additional pressure increase related to ETT size. This has the potential to decrease mucosal blood flow, possibly increasing risk of subsequent tracheal stenosis, rupture, and other complications.

PMID: 25834962 [PubMed - in process]


Pediatrics

Too much IV fluid in HUS causes volume overload, but judicious early volume expansion (10% baseline weight) drastically improved the clinical course for these patients.

Pediatrics. 2016 Jan;137(1):1-9. doi: 10.1542/peds.2015-2153. Epub 2015 Dec 7.

Early Volume Expansion and Outcomes of Hemolytic Uremic Syndrome.

Ardissino G1, Tel F2, Possenti I2, Testa S2, Consonni D3, Paglialonga F2, Salardi S4, Borsa-Ghiringhelli N4, Salice P5, Tedeschi S4, Castorina P2, Colombo RM6, Arghittu M6, Daprai L6, Monzani A7, Tozzoli R8, Brigotti M9, Torresani E6.

Author information:

1Center for HUS Control, Prevention and Management, ardissino@centroseu.org.

2Center for HUS Control, Prevention and Management.

3Epidemiology Unit.

4Laboratory of Medical Genetics.

5Pediatric Cardiology Unit, and.

6Unit of Microbiology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy;

7Division of Pediatrics, Department of Health Science, University of Piemonte Orientale, Novara, Italy;

8Istituto Superiore di Sanità, Roma, Italy; and.

9Univerità di Bologna, Bologna, Italy.

Abstract

BACKGROUND:

Hemolytic uremic syndrome associated with Shiga toxin-producing Escherichia coli (STEC-HUS) is a severe acute illness without specific treatment except supportive care; fluid management is concentrated on preventing fluid overload for patients, who are often oligoanuric. Hemoconcentration at onset is associated with more severe disease, but the benefits of volume expansion after hemolytic uremic syndrome (HUS) onset have not been explored.

METHODS:

All the children with STEC-HUS referred to our center between 2012 and 2014 received intravenous infusion targeted at inducing an early volume expansion (+10% of working weight) to restore circulating volume and reduce ischemic or hypoxic tissue damage. The short- and long-term outcomes of these patients were compared with those of 38 historical patients referred to our center during the years immediately before, when fluid intake was routinely restricted.

RESULTS:

Patients undergoing fluid infusion soon after diagnosis showed a mean increase in body weight of 12.5% (vs 0%), had significantly better short-term outcomes with a lower rate of central nervous system involvement (7.9% vs 23.7%, P = .06), had less need for renal replacement therapy (26.3% vs 57.9%, P = .01) or intensive care support (2.0 vs. 8.5 days, P = .02), and needed fewer days of hospitalization (9.0 vs 12.0 days, P = .03). Long-term outcomes were also significantly better in terms of renal and extrarenal sequelae (13.2% vs 39.5%, P = .01).

CONCLUSIONS:

Patients with STEC-HUS had great benefit from early volume expansion. It is speculated that early and generous fluid infusions can reduce thrombus formation and ischemic organ damage, thus having positive effects on both short- and long-term disease outcomes.

Copyright © 2016 by the American Academy of Pediatrics.

PMID: 26644486 [PubMed - in process]


Prehospital Emergency Care

EMS units running with lights and sirens (LS) increases the risk of crash and death for the occupants, so unnecessary LS is a bad thing. Normal VS and GCS suggest against LS.

Prehosp Emerg Care. 2016 Jan 25:1-8. [Epub ahead of print]

Unnecessary Use of Red Lights and Sirens in Pediatric Transport.

Burns B, Hansen ML, Valenzuela S, Summers C, Van Otterloo J, Skarica B, Warden C, Guise JM.

Abstract

INTRODUCTION:

Approximately 25.5 million pediatric patients are treated in Emergency Departments around the United States annually. Roughly 7% of these patients are transported by ambulance; of these, approximately 7% arrive in ambulances running red lights and sirens (RLS). Compared to those transporting without RLS, emergency vehicles employing RLS are involved in more accidents and are associated with more fatalities.

OBJECTIVE:

To characterize the use of RLS in pediatric transports and identify factors associated with unnecessary use of RLS.

METHODS:

As part of the Children's Safety Initiative (CSI-EMS), a large, multi-phased National Institutes of Health-funded study, we conducted a medical record review of all pediatric RLS transports in an urban EMS system over a 4-year period (2008-11). A standardized chart abstraction tool was adapted for the out-of-hospital setting and pilot tested. Charts were independently reviewed by physicians and paramedics, with disagreements arbitrated by a pediatric emergency physician. Reviewers were asked to judge whether RLS transport was necessary and to provide comments justifying their position. Descriptive statistics were used to measure the frequency of unnecessary transports and logistic regression analysis was employed to identify factors associated with unnecessary use of RLS.

RESULTS:

Of 490 RLS transports, experts identified 96 (19.6%) as unnecessary use of RLS. Necessary and unnecessary RLS transports had similar patient sex and duration of transport, though unnecessary use of RLS tended to increase with patient age. The call reasons that represented the largest proportion of unnecessary RLS transports were trauma (49.0%), respiratory distress (16.7%), and seizure/altered mental status (11.5%). Compared with necessary RLS transports, unnecessary RLS transports were less likely to require resuscitation, airway management, or medication administration. Univariate analysis revealed that patient vital signs within normal limits were associated with increased risk of unnecessary RLS transport, with the most pronounced effect seen in the normal GCS score group (odds ratio 7.74, p-value 0.001).

CONCLUSIONS:

This analysis identified patient and transport characteristics associated with unnecessary use of RLS. Our results could help serve as the basis for designing and prospectively evaluating protocols for use of RLS, potentially mitigating the risk associated with transport in pediatric patients.

PMID: 26808349 [PubMed - as supplied by publisher]


Resuscitation

  1. 1% of patients survived to discharge beyond 32 minutes of CPR, and no one survived beyond 48 minutes of CPR.
  2. Using telemetry beds wisely: acutely ill patients with heart failure and LV systolic dysfunction had the highest risk of life-threatening ventricular arrhythmia (LT-VA) but not patients with CAD. Overall risk of LT-VA was only 0.6% in the entire cohort.
  3. An exhaustive article from ILCOR and AHA on post-arrest cooling

1.

Resuscitation. 2016 Mar;100:25-31. doi: 10.1016/j.resuscitation.2015.12.011. Epub 2016 Jan 13.

Impact of cardiopulmonary resuscitation duration on survival from paramedic witnessed out-of-hospital cardiac arrests: An observational study.

Nehme Z1, Andrew E2, Bernard S3, Smith K4.

Author information:

1Department of Research and Evaluation, Ambulance Victoria, Blackburn North, Victoria, Australia; Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Prahran, Victoria, Australia. Electronic address: ziad.nehme@ambulance.vic.gov.au.

2Department of Research and Evaluation, Ambulance Victoria, Blackburn North, Victoria, Australia; Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Prahran, Victoria, Australia.

3Department of Research and Evaluation, Ambulance Victoria, Blackburn North, Victoria, Australia; Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Prahran, Victoria, Australia; Intensive Care Unit, Alfred Hospital, Prahran, Victoria, Australia.

4Department of Research and Evaluation, Ambulance Victoria, Blackburn North, Victoria, Australia; Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Prahran, Victoria, Australia; Discipline of Emergency Medicine, School of Primary, Aboriginal and Rural Health Care, University of Western Australia, Crawley, Western Australia, Australia.

Abstract

BACKGROUND:

Resuscitation guidelines often recommend ongoing cardiopulmonary resuscitation (CPR) efforts to hospital for out-of-hospital cardiac arrests (OHCA) witnessed by emergency medical service (EMS) personnel. In this study, we examine the relationship between EMS CPR duration and survival to hospital discharge in EMS witnessed OHCA patients.

METHODS:

Between January 2003 and December 2011, 1035 adult EMS witnessed arrests of presumed cardiac aetiology were included from the Victorian Ambulance Cardiac Arrest Registry. CPR duration was defined as the total sum of prehospital CPR time in minutes. Adjusted logistic regression analyses were used to assess the impact of EMS CPR duration on survival to hospital discharge.

RESULTS:

382 (37.3%) patients were discharged alive. The median CPR duration was 12min (95% CI: 11-13) overall, but was higher in non-survivors compared to survivors (24min vs. 2min, p<0.001). The 99th percentile CPR duration in patients surviving to hospital discharge differed by the initial rhythm of arrest: 32min (95% CI: 27-44) overall, 32min (95% CI: 23-44) for ventricular fibrillation and pulseless ventricular tachycardia (VF/VT), 34min (95% CI: 30-34) for pulseless electrical activity (PEA), and 28min (95% CI: 21-28) for asystole. There were no survivors after 44min for all rhythms. After adjusting for prehospital confounders, every minute increase in CPR duration was associated with a 13% reduction in the odds of survival to hospital discharge (OR 0.87, 95% CI: 0.84-0.89, p<0.001). The multivariable model predicted no chance of survival at or after a CPR duration of 48min for VF/VT patients, 47min for PEA patients and 45min for asystole patients.

CONCLUSION:

Resuscitation efforts exceeding 32min yielded less than 1% of survivors from EMS witnessed OHCA. On the basis of this data, EMS witnessed OHCA patients may benefit from ongoing CPR efforts up to 48min in duration.

Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

PMID: 26774172 [PubMed - in process]

 

2.

Resuscitation. 2016 Jan 21;101:6-11. doi: 10.1016/j.resuscitation.2015.12.019. [Epub ahead of print]

Life-threatening ventricular tachyarrhythmias in the cardiology department: Implications for appropriate prescription of telemetry monitoring.

Zorzi A1, Peruzza F1, Stella F2, Del Monte A1, Migliore F1, Gasparetto N1, Badano L1, Iliceto S1, Corrado D3.

Author information:

1Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy.

2Department of Medicine, University of Padova, Padova, Italy.

3Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy. Electronic address: domenico.corrado@unipd.it.

Abstract

BACKGROUND:

in-hospital life-threatening ventricular arrhythmias (LT-VA) may complicate the course of cardiovascular patients. We aimed to assess the incidence, circumstances, determinants, and outcome of in-hospital LT-VA in order to help clinicians in prescribing appropriate levels of monitoring.

METHODS:

the study population consisted of all 10,741 consecutive patients (65±15 years, 67.7% males) admitted to a cardiology department in 2009-2014. Terminally ill patients and those with primary arrhythmia diagnosis were excluded. The composite end-point included sudden arrhythmic death, ventricular fibrillation, unstable ventricular tachycardia and appropriate ICD shock unrelated to invasive interventions.

RESULTS:

the incidence of LT-VA was 0.6%, with no differences regarding age, gender and primary diagnosis of coronary artery disease between patients with and without LT-VA. The incidence of LT-VA was significantly higher (1.2% versus 0.1%, p<0.001) among urgent compared with elective admissions and among patients with left ventricular ejection fraction (LV-EF) <45% (1.7% versus 0.2%, p<0.001). At multivariable analysis, urgent admission and LV-EF <45%, but not primary diagnosis of coronary artery disease, remained independent predictors of LT-VA. At the time of the event, 97.1% fulfilled either class I or class II indications for telemetry monitoring according to the American Heart Association guidelines. Survival to discharge with good neurological status was 70.6%.

CONCLUSIONS:

acutely ill patients with heart failure and LV systolic dysfunction showed the highest rate of LT-VAs, regardless of the underlying cardiac disease (ischemic or non-ischemic). Current guidelines demonstrated high sensitivity in identifying patients at risk. These findings may favor proper utilization of telemetry monitoring resources.

Copyright © 2016. Published by Elsevier Ireland Ltd.

PMID: 26803063 [PubMed - as supplied by publisher]

 

3.

Resuscitation. 2016 Jan;98:97-104. doi: 10.1016/j.resuscitation.2015.09.396. Epub 2015 Oct 9.

Temperature Management After Cardiac Arrest: An Advisory Statement by the Advanced Life Support Task Force of the International Liaison Committee on Resuscitation and the American Heart Association Emergency Cardiovascular Care Committee and the Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation.

Donnino MW, Andersen LW, Berg KM, Reynolds JC, Nolan JP, Morley PT, Lang E, Cocchi MN, Xanthos T, Callaway CW, Soar J; ILCOR ALS Task Force.

Abstract

For more than a decade, mild induced hypothermia (32°C-34°C) has been standard of care for patients remaining comatose after resuscitation from out-of-hospital cardiac arrest with an initial shockable rhythm, and this has been extrapolated to survivors of cardiac arrest with initially nonshockable rhythms and to patients with in-hospital cardiac arrest. Two randomized trials published in 2002 reported a survival and neurological benefit with mild induced hypothermia. One recent randomized trial reported similar outcomes in patients treated with targeted temperature management at either 33°C or 36°C. In response to these new data, the International Liaison Committee on Resuscitation Advanced Life Support Task Force performed a systematic review to evaluate 3 key questions: (1) Should mild induced hypothermia (or some form of targeted temperature management) be used in comatose post-cardiac arrest patients? (2) If used, what is the ideal timing of the intervention? (3) If used, what is the ideal duration of the intervention? The task force used Grading of Recommendations Assessment, Development and Evaluation methodology to assess and summarize the evidence and to provide a consensus on science statement and treatment recommendations. The task force recommends targeted temperature management for adults with out-of-hospital cardiac arrest with an initial shockable rhythm at a constant temperature between 32°C and 36°C for at least 24hours. Similar suggestions are made for out-of-hospital cardiac arrest with a nonshockable rhythm and in-hospital cardiac arrest. The task force recommends against prehospital cooling with rapid infusion of large volumes of cold intravenous fluid. Additional and specific recommendations are provided in the document.

Copyright © 2015. Published by Elsevier Ireland Ltd.

PMID: 26449873 [PubMed - in process]

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