Monthly Bolus - #FOAMed
Prefer to get one article at a time?
NNR* This Month = 85
You'd have to read 2968 articles to find these 35.
*NNR = Number Needed to Read
Academic Emergency Medicine
- Coronary CTA use has increased in frequency and is associated with increased subsequent "PCI, CABG, repeat non-invasive testing, hospitalization, and return ED visits." This test for CAD seems to beget more testing and invasive procedures without improving the outcome, which begs the question - is CCTA the wisest non-invasive way to evaluate patients presenting to the ED with chest pain?
- Do you have the anecdotal sense that ultrasound guided IVs blow more often with IV contrast in CT? Your hunch is now proven with this study. Unadjusted RR for contrast extravasation compared with standard IV was 14.
- To determine which patients with blunt trauma need chest CT, the NEXUS CT chest rule may help. In this study, if one criterion (excluding abnormal CXR) was present, it was worth discussing the risk of CT vs the very small risk of clinically major injury (1.1% prevalence). But if the CXR was abnormal (13% prevalence major injury) or there was >1 NEXUS criterion (~3% prevalence major injury), the risk of CT was warranted.
Acad Emerg Med. 2016 May 7. doi: 10.1111/acem.13005. [Epub ahead of print]
1Mayo Medical School, Mayo Clinic College of Medicine, Rochester, MN.
2Division of Emergency Medicine Research, Department of Emergency Medicine, Mayo Clinic, Rochester, MN.
3Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, MN.
4Division of Healthcare Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN.
5Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN.
6Optum Labs, Cambridge, MA.
7Department of Cardiology, Mayo Clinic, Rochester, MN.
8Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN.
Coronary computerized tomography angiography (CCTA) is a rapidly emerging technology for the evaluation of chest pain in the Emergency Department (ED). We assessed trends in CCTA use and compared downstream healthcare utilization between CCTA and cardiac stress testing modalities.
Using administrative claims data (Optum Labs Data Warehouse) from over 100 million geographically diverse privately insured and Medicare Advantage enrollees across the U.S., we identified 2,047,799 ED patients from January 2006 to December 2013 who presented with chest pain and had a CCTA or cardiac stress test within 72 hours. Cohorts were established based on CCTA or functional stress testing (myocardial perfusion scintigraphy [MPS], stress echocardiogram [SE], or treadmill exercise electrocardiogram [TMET]) performed within 72 hours of the ED visit. We tracked subsequent invasive cardiac procedures (invasive coronary angiography [ICA], percutaneous coronary intervention [PCI], and coronary artery bypass grafting [CABG]), repeat noninvasive testing, return ED visits, hospitalization, and the rate of acute myocardial infarction (AMI) within 30 days. We used propensity-score matching to adjust for coronary artery disease (CAD) risk factors, Charlson-Deyo comorbidity index, and baseline differences between patients selected for CCTA or cardiac stress testing. Logistic regression was used to measure adjusted associations between testing modality and outcomes.
During the study period, CCTA use increased from 0.8% to 4.5% of all cardiac testing within 72-hours, a change of 434% (P for trend < .001), while rates of other cardiac stress testing modalities decreased (-22% for TMET [P< .001]; -11% for SE [P= .11]; -6% for MPS [P= .04]. After matching, there was no difference in the 30-day rate of AMI between testing modalities. Compared to myocardial perfusion scintigraphy, CCTA was associated with higher rates of PCI (odds ratio [OR]=1.25, 95% confidence interval [CI] 1.04-1.51), and CABG (OR=1.47; 95% CI, 1.03-2.13). Compared to stress echocardiography and treadmill stress testing, CCTA was associated with more invasive procedures, hospitalizations, return ED visits, and repeat noninvasive testing.
CCTA use increased four-fold during the study period and was associated with higher rates of PCI, CABG, repeat noninvasive testing, hospitalization, and return ED visits. This article is protected by copyright. All rights reserved.
This article is protected by copyright. All rights reserved.
PMID: 27155236 [PubMed - as supplied by publisher]
Acad Emerg Med. 2016 May 6. doi: 10.1111/acem.13000. [Epub ahead of print]
1Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.
2Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.
3School of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.
Ultrasound guided intravenous catheter (USGIV) insertion is increasingly being used for administration of intravenous contrast for computed tomography (CT) scans. The goal of this investigation was to evaluate the risk of contrast extravasation among patients receiving contrast through USGIV catheters.
A retrospective observational study of adult patients who underwent a contrast-enhanced CT scan at a tertiary-care emergency department during a recent 64-month period was conducted. The unadjusted prevalence of contrast extravasation was compared between patients with an USGIV and those with a standard peripheral IV inserted without ultrasound. Then, a two-stage sampling design was used to select a subset of the population for a multivariable logistic regression model evaluating USGIVs as a risk factor for extravasation while adjusting for potential confounders.
In total, 40,143 patients underwent a contrasted CT scan, including 364 (0.9%) who had contrast administered through an USGIV. Unadjusted prevalence of extravasation was 3.6% for contrast administration through USGIVs and 0.3% for standard IVs (relative risk: 13.9, 95% CI: 7.7 to 24.6). After adjustment for potential confounders, CT contrast administered through USGIVs was associated with extravasation (adjusted odds ratio: 8.6; 95% CI: 4.6, 16.2). No patients required surgical management for contrast extravasation; one patient in the standard IV group was admitted for observation due to extravasation.
Patients who received contrast for a CT scan through an USGIV had a higher risk of extravasation than those who received contrast through a standard peripheral IV. Clinicians should consider this extravasation risk when weighing the risks and benefits of a contrast-enhanced CT scan in a patient with USGIV vascular access. This article is protected by copyright. All rights reserved.
This article is protected by copyright. All rights reserved.
PMID: 27151898 [PubMed - as supplied by publisher]
Acad Emerg Med. 2016 May 10. doi: 10.1111/acem.13010. [Epub ahead of print]
1Departments of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA.
2Department of Emergency Medicine, University of California, Los Angeles, CA.
3Department of Emergency Medicine, University of California, Davis, CA.
4Department of Emergency Medicine, San Francisco Fresno Medical Education Program, San Francisco, CA.
5Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, NJ.
6Department of Emergency Medicine, University of California, San Diego School of Medicine, San Diego, CA.
7Department of Emergency Medicine, University of California, San Francisco, CA.
The use of chest computed tomography (CT) to evaluate emergency department (ED) patients with adult blunt trauma is rising. The NEXUS Chest CT decision instruments are highly sensitive identifiers of adult blunt trauma patients with thoracic injuries. However, many patients without injury exhibit one of more of the criteria so cannot be classified "low-risk." We sought to determine screening performance of both individual and combined NEXUS Chest CT criteria as predictors of thoracic injury to inform chest CT imaging decisions in "non-low-risk" patients.
This secondary analysis of data on patients in the derivation and validation cohorts of the prospective, observational NEXUS Chest CT study was performed September 2011-May 2014 in eleven Level 1 trauma centers. Institutional Review Board approval was obtained at all study sites. Adult blunt trauma patients receiving chest CT were included. The primary outcome was injury and major clinical injury prevalence and screening performance in patients with combinations of one, two or three of seven individual NEXUS Chest CT criteria.
Across the eleven study sites, rates of chest CT performance ranged from 15.5% to 77.2% (median 43.6%). We found injuries in 1,493/5,169 patients (28.9%) who had chest CT; 269 patients (5.2%) had major clinical injury (e.g., pneumothorax requiring chest tube). With sensitivity of 73.7 (95% confidence interval [CI] 68.1-78.6) and specificity of 83.9 (95% CI 83.6-84.2) for major clinical injury, abnormal CXR was the single most important screening criterion. When patients had only abnormal CXR, injury and major clinical injury prevalence were 60.7% (95% CI 52.2-68.6) and 12.9% (95% CI 8.3-19.4), respectively. Injury and major clinical injury prevalence when any other single criterion alone (other than abnormal CXR) was present were 16.8% (95% CI 15.2-18.6) and 1.1% (95% CI 0.1-1.8) respectively. Injury and major clinical injury prevalence among patients when two and three criteria (not abnormal CXR) were present were 25.5% (95% CI 23.1-28.0) and 3.2% (95% CI 2.3-4.4), and 34.9% (95% CI 31.0-39.0) and 2.7% (95% CI 1.6-4.5) respectively.
We recommend that clinicians check for the six clinical NEXUS Chest CT criteria and review the CXR (if obtained). If patients have one clinical criterion (other than abnormal CXR), they will have a very low risk of clinically major injury. We recommend that clinicians discuss the potential risks and benefit of chest CT in these cases. The risks of injury and major clinical injury rise incrementally with more criteria, rendering the risk/benefit ratio toward performing CT in most cases. If the patient has an abnormal CXR, the risks of major clinical injury and minor injury are considerably higher than with the other criteria-chest CT may be indicated in cases requiring greater anatomical detail and injury characterization. This article is protected by copyright. All rights reserved.
This article is protected by copyright. All rights reserved.
PMID: 27163732 [PubMed - as supplied by publisher]
American Journal of Emergency Medicine
- A small RCT showed nebulized magnesium sulfate improved peak flow and decreased hospitalization.
- A potassium threshold of 4.35 mmol/L or more had 100% specificity for brain anoxia on CT in this 19 patient cohort of avalanche burial arrest victims. I'm a little perplexed by this number. A NEJM review article encourages resuscitative efforts with a view toward ECMO if the potassium is < 12 mmol/L. So take this small study with a grain of salt.
Am J Emerg Med. 2016 May;34(5):883-6. doi: 10.1016/j.ajem.2016.01.024. Epub 2016 Jan 21.
1Emergency medicine management Research center, Rasoul-e-Akram Hospital, Iran university of Medical Sciences, Tehran, Iran.
2Emergency medicine management Research center, Rasoul-e-Akram Hospital, Iran university of Medical Sciences, Tehran, Iran. Electronic address: firstname.lastname@example.org.
Thirty percent of people with asthma do not respond to standard treatment, and complementary therapies are needed. The objective of this study was to investigate the impact of inhaled magnesium sulfate on the treatment response in emergency department (ED) patients with moderate to severe attacks of asthma.
This study is a randomized controlled trial, enrolling patients with moderate to severe asthma in the ED. Subjects allocated to the study group were treated with the standard, plus 3ml of 260mmol/L solution of magnesium sulfate every 20 to 60minutes. The control group was treated with nebulized saline as a placebo in addition to standard protocol. The study results included admission rate and changes in peak expiratory flow rate (PEFR) (primary outcomes) as well as dyspnea severity score, respiratory rate and peripheral oxygen saturation.
A total of 50 patients were enrolled (25 allocated to the study group and 25 to the control group). The study group as compared to the control group had significantly more improvement in the intensity of dyspnea, PEFR and Spo2 20, 40 and 60minutes after intervention. In the control group, 11 patients (44%) required admission as compared to 18 (72%) in the control group (P=.02).
Adding nebulized magnesium sulfate to standard therapy in patients with moderate to severe asthma attacks leads to greater and faster improvement in PEFR, respiratory rate, oxygen saturation and respiratory rate. It also reduces hospitalization rates in this patient population.
Copyright © 2016 Elsevier Inc. All rights reserved.
PMID: 26964827 [PubMed - in process]
Am J Emerg Med. 2016 May;34(5):856-60. doi: 10.1016/j.ajem.2016.01.037. Epub 2016 Feb 12.
1Pôle Imagerie, Centre Hospitalier Universitaire de Grenoble, CS 10217, F-38043 Grenoble, France.
2Pôle Anesthésie Réanimation, Centre Hospitalier Universitaire de Grenoble, CS 10217, F-38043 Grenoble, France.
3Pôle Santé Publique, Centre Hospitalier Universitaire de Grenoble, CS 10217, F-38043, Grenoble, France; Laboratoire Techniques de l'Ingénierie Médicale et de la Complexité, CNRS UMR5525, F-38043 Grenoble, France.
4Pôle Imagerie, Centre Hospitalier Universitaire de Grenoble, CS 10217, F-38043 Grenoble, France; Grenoble Institut des Neurosciences, INSERM U836, F-38043 Grenoble, France; Grenoble Alpes Université, F-38043 Grenoble, France.
5Pôle Urgence-Médecine Aiguë, Centre Hospitalier Universitaire de Grenoble, CS 10217, F-38043 Grenoble, France.
6Pôle Imagerie, Centre Hospitalier Universitaire de Grenoble, CS 10217, F-38043 Grenoble, France; Grenoble Alpes Université, F-38043 Grenoble, France.
7Pôle Anesthésie Réanimation, Centre Hospitalier Universitaire de Grenoble, CS 10217, F-38043 Grenoble, France; Grenoble Institut des Neurosciences, INSERM U836, F-38043 Grenoble, France; Grenoble Alpes Université, F-38043 Grenoble, France. Electronic address: PBouzat@chu-grenoble.fr.
Brain anoxia after complete avalanche burial and cardiac arrest (CA) may occur despite adequate on-site triage.
To investigate clinical and biological parameters associated with brain hypoxia in a cohort of avalanche victims with whole body computed tomographic (CT) scan.
Retrospective study of patients with CA and whole body CT scan following complete avalanche burial admitted in a level-I trauma center.
Out of 19 buried patients with whole body CT scan, eight patients had refractory CA and 11 patients had pre-hospital return of spontaneous circulation. Six patients survived at hospital discharge and only two had good neurologic outcome. Twelve patients had signs of brain hypoxia on initial CT scan, defined as brain edema, loss of gray/white matter differentiation and/or hypodensity of basal ganglia. No clinical pre-hospital parameter was associated with brain anoxia. Serum potassium concentration at admission was higher in patients with brain anoxia as compared to patients with normal CT scan: 5.5 (4.1-7.2) mmol/L versus 3.3 (3.0-4.2) mmol/L, respectively (P<.01). A threshold of 4.35mmol/L serum potassium had 100% specificity to predict brain anoxia on brain CT scan.
Serum potassium concentration had good predictive value for brain anoxia after complete avalanche burial. This finding further supports the use of serum potassium concentration for extracorporeal life support insertion at hospital admission in this context.
Copyright © 2016 Elsevier Inc. All rights reserved.
PMID: 26935228 [PubMed - in process]
Annals of Emergency Medicine
- Cardiac arrest patients who underwent targeted temperature management (mild hypothermia) may take longer to awaken than previously thought. Nineteen percent of the 360 patients who regained responsiveness in this statewide study out of Arizona took > 48 hours to awaken. Many of them had a good neurological recovery. Take care not to give up too soon after targeted temperature management.
- Single dose dexamethasone 0.3mg/kg, up to 12mg, was not inferior to multiple dose prednisolone in pediatric asthma exacerbation. Fewer dex kids vomited, and more dex kids had additional steroids prescribed. I covered this article last year.
Ann Emerg Med. 2016 May 27. pii: S0196-0644(16)30089-0. doi: 10.1016/j.annemergmed.2016.04.021. [Epub ahead of print]
1Arizona Emergency Medicine Research Center, University of Arizona, Phoenix, AZ; Bureau of EMS & Trauma System, Arizona Department of Health Services, Phoenix, AZ.
2Mayo Clinic, Jacksonville, FL.
3Arizona Emergency Medicine Research Center, University of Arizona, Phoenix, AZ.
4Sarver Heart Center, University of Arizona, Tucson, AZ.
5Bureau of EMS & Trauma System, Arizona Department of Health Services, Phoenix, AZ.
6Arizona Emergency Medicine Research Center, University of Arizona, Phoenix, AZ; Bureau of EMS & Trauma System, Arizona Department of Health Services, Phoenix, AZ. Electronic address: email@example.com.
We evaluate the time to awakening after out-of-hospital cardiac arrest in patients treated with targeted temperature management and determine whether there was an association with any patient or event characteristics.
This was a prospective, observational cohort study of consecutive adult survivors of out-of-hospital cardiac arrest of presumed cardiac cause who were treated with targeted temperature management between January 1, 2008, and March 31, 2014. Data were obtained from hospitals and emergency medical services agencies responding to approximately 90% of Arizona's population as part of a state-sponsored out-of-hospital cardiac arrest quality improvement initiative.
Among 573 out-of-hospital cardiac arrest patients who completed targeted temperature management, 316 became responsive, 60 (19.0%) of whom woke up at least 48 hours after rewarming. Eight patients (2.5%) became responsive more than 7 days after rewarming, 6 of whom were discharged with a good Cerebral Performance Category score (1 or 2). There were no differences in standard Utstein variables between the early and late awakeners. The early awakeners were more likely to be discharged with a good Cerebral Performance Category score (odds ratio 2.93; 95% confidence interval 1.09 to 7.93).
We found that a substantial proportion of adult out-of-hospital cardiac arrest survivors treated with targeted temperature management became responsive greater than 48 hours after rewarming, with a resultant good neurologic outcome.
Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
PMID: 27238827 [PubMed - as supplied by publisher]
Ann Emerg Med. 2016 May;67(5):593-601.e3. doi: 10.1016/j.annemergmed.2015.08.001. Epub 2015 Oct 14.
1Paediatric Emergency Research Unit, National Children's Research Centre, Dublin 12, Ireland; Department of Emergency Medicine, Our Lady's Children's Hospital, Crumlin, Dublin 12, Ireland.
2Department of Emergency Medicine, St James's Hospital, Dublin 8, Ireland.
3Paediatric Emergency Research Unit, National Children's Research Centre, Dublin 12, Ireland.
4Emergency Care Research Unit, Division of Population Health Sciences, Royal College of Surgeons, Dublin 2, Ireland.
5StatisticaMedica Ltd., Dublin 18, Ireland.
6Paediatric Emergency Research Unit, National Children's Research Centre, Dublin 12, Ireland; Department of Emergency Medicine, Our Lady's Children's Hospital, Crumlin, Dublin 12, Ireland; Department of Paediatrics, University College Dublin, Belfield, Dublin 4, Ireland.
7Paediatric Emergency Research Unit, National Children's Research Centre, Dublin 12, Ireland; Department of Emergency Medicine, Our Lady's Children's Hospital, Crumlin, Dublin 12, Ireland; Department of Paediatrics, University College Dublin, Belfield, Dublin 4, Ireland; School of Medicine, University College Cork, Cork, Ireland. Electronic address: firstname.lastname@example.org.
In acute exacerbations of asthma in children, corticosteroids reduce relapses, subsequent hospital admission, and the need for ß2-agonist bronchodilators. Prednisolone is the most commonly used corticosteroid, but prolonged treatment course, vomiting, and a bitter taste may reduce patient compliance. Dexamethasone has a longer half-life and has been used safely in other acute pediatric conditions. We examine whether a single dose of oral dexamethasone is noninferior to prednisolone in the emergency department (ED) treatment of asthma exacerbations in children, as measured by the Pediatric Respiratory Assessment Measure (PRAM) at day 4.
We conducted a randomized, open-label, noninferiority trial comparing oral dexamethasone (single dose of 0.3 mg/kg) with prednisolone (1 mg/kg per day for 3 days) in patients aged 2 to 16 years and with a known diagnosis of asthma or at least 1 previous episode of ß2-agonist-responsive wheeze who presented to a tertiary pediatric ED. The primary outcome measure was the mean PRAM score (range of 0 to 12 points) performed on day 4. Secondary outcome measures included requirement for further steroids, vomiting of study medication, hospital admission, and unscheduled return visits to a health care practitioner within 14 days.
There were 245 enrollments involving 226 patients. There was no difference in mean PRAM scores at day 4 between the dexamethasone and prednisolone groups (0.91 versus 0.91; absolute difference 0.005; 95% CI -0.35 to 0.34). Fourteen patients vomited at least 1 dose of prednisolone compared with no patients in the dexamethasone group. Sixteen children (13.1%) in the dexamethasone group received further systemic steroids within 14 days after trial enrollment compared with 5 (4.2%) in the prednisolone group (absolute difference 8.9%; 95% CI 1.9% to 16.0%). There was no significant difference between the groups in hospital admission rates or the number of unscheduled return visits to a health care practitioner.
In children with acute exacerbations of asthma, a single dose of oral dexamethasone (0.3 mg/kg) is noninferior to a 3-day course of oral prednisolone (1 mg/kg per day) as measured by the mean PRAM score on day 4.
Copyright © 2015 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
PMID: 26460983 [PubMed - in process]
Annals of Internal Medicine
This is another study, a meta-analysis, using dichotomized Well's score and age-adjusted D-dimer that specifically looked at several subgroups: inpatients and persons with cancer, chronic obstructive pulmonary disease, previous venous thromboembolism, delayed presentation, and age 75 years or older. They found that using an age-adjusted D-dimer (age x 10 if >50 years) would have resulted in 28% vs 33% needing further workup. Also, the failure rate was <3% in all subgroups. It was a post-hoc analysis with a limited number of patients in some of the subgroups, which decreased the statistical power to detect failure.
Ann Intern Med. 2016 May 17. doi: 10.7326/M16-0031. [Epub ahead of print]
The performance of different diagnostic strategies for pulmonary embolism (PE) in patient subgroups is unclear.
To evaluate and compare the efficiency and safety of the Wells rule with fixed or age-adjusted d-dimer testing overall and in inpatients and persons with cancer, chronic obstructive pulmonary disease, previous venous thromboembolism, delayed presentation, and age 75 years or older.
MEDLINE and EMBASE from 1 January 1988 to 13 February 2016.
6 prospective studies in which the diagnostic management of PE was guided by the dichotomized Wells rule and quantitative d-dimer testing.
Individual data of 7268 patients; risk of bias assessed by 2 investigators with the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies 2) tool.
The proportion of patients in whom imaging could be withheld based on a "PE-unlikely" Wells score and a negative d-dimer test result (efficiency) was estimated using fixed (≤500 µg/L) and age-adjusted (age × 10 µg/L in patients aged >50 years) d-dimer thresholds; their 3-month incidence of symptomatic venous thromboembolism (failure rate) was also estimated. Overall, efficiency increased from 28% to 33% when the age-adjusted (instead of the fixed) d-dimer threshold was applied. This increase was more prominent in elderly patients (12%) but less so in inpatients (2.6%). The failure rate of age-adjusted d-dimer testing was less than 3% in all examined subgroups.
Post hoc analysis, between-study differences in patient characteristics, use of various d-dimer assays, and limited statistical power to assess failure rate.
Age-adjusted d-dimer testing is associated with a 5% absolute increase in the proportion of patients with suspected PE in whom imaging can be safely withheld compared with fixed d-dimer testing. This strategy seems safe across different high-risk subgroups, but its efficiency varies.
Primary Funding Source:
PMID: 27182696 [PubMed - as supplied by publisher]
British Medical Journal
The ingredients and dose matter in oral contraceptives. Lower dose estrogen - 20 vs 30-40 micrograms - was safer, with lower risk for PE, stroke, and MI. Desogestrel and gestodene, compared to levonorgestrel, were associated with ~2x the risk of PE but not stroke or MI.
BMJ. 2016 May 10;353:i2002. doi: 10.1136/bmj.i2002.
1Department of Studies in Public Health, French National Health Insurance, 75986 Paris Cedex 20, France email@example.com.
2Department of Studies in Public Health, French National Health Insurance, 75986 Paris Cedex 20, France.
3French National Agency for Medicines and Health Products Safety, Saint-Denis, France.
To assess the risk of pulmonary embolism, ischaemic stroke, and myocardial infarction associated with combined oral contraceptives according to dose of oestrogen (ethinylestradiol) and progestogen.
Observational cohort study.
Data from the French national health insurance database linked with data from the French national hospital discharge database.
4 945 088 women aged 15-49 years, living in France, with at least one reimbursement for oral contraceptives and no previous hospital admission for cancer, pulmonary embolism, ischaemic stroke, or myocardial infarction, between July 2010 and September 2012.
MAIN OUTCOME MEASURES:
Relative and absolute risks of first pulmonary embolism, ischaemic stroke, and myocardial infarction.
The cohort generated 5 443 916 women years of oral contraceptive use, and 3253 events were observed: 1800 pulmonary embolisms (33 per 100 000 women years), 1046 ischaemic strokes (19 per 100 000 women years), and 407 myocardial infarctions (7 per 100 000 women years). After adjustment for progestogen and risk factors, the relative risks for women using low dose oestrogen (20 µg v 30-40 µg) were 0.75 (95% confidence interval 0.67 to 0.85) for pulmonary embolism, 0.82 (0.70 to 0.96) for ischaemic stroke, and 0.56 (0.39 to 0.79) for myocardial infarction. After adjustment for oestrogen dose and risk factors, desogestrel and gestodene were associated with statistically significantly higher relative risks for pulmonary embolism (2.16, 1.93 to 2.41 and 1.63, 1.34 to 1.97, respectively) compared with levonorgestrel. Levonorgestrel combined with 20 µg oestrogen was associated with a statistically significantly lower risk than levonorgestrel with 30-40 µg oestrogen for each of the three serious adverse events.
For the same dose of oestrogen, desogestrel and gestodene were associated with statistically significantly higher risks of pulmonary embolism but not arterial thromboembolism compared with levonorgestrel. For the same type of progestogen, an oestrogen dose of 20 µg versus 30-40 µg was associated with lower risks of pulmonary embolism, ischaemic stroke, and myocardial infarction.
PMCID: PMC4862376 Free PMC Article
PMID: 27164970 [PubMed - in process]
Intuitively, we know most patients requiring ECMO will have a bad prognosis but how bad? This study of Taiwanese patients over 10 years found that long term survival was around 20% for most medical patients requiring ECMO. Trauma patients needing ECMO fared a little better, with long term survival around 30%.
Circulation. 2016 May 19. pii: CIRCULATIONAHA.115.019143. [Epub ahead of print]
1National Taiwan University, Taipei, Taiwan & National Taiwan University Hospital, Taipei, Taiwan.
2National Taiwan University, Taipei, Taiwan.
3University of North Texas Health Science Center, Fort Worth, TX.
4National Taiwan University Hospital Yun-Lin Branch, Dou-Liou City, Taiwan.
5National Taiwan University, Taipei, Taiwan & National Taiwan University Hospital Yun-Lin Branch, Dou-Liou City, Taiwan firstname.lastname@example.org.
6National Taiwan University Hospital, Taipei, Taiwan.
-Extracorporeal membrane oxygenation (ECMO) provides circulatory and respiratory support for patients with severe acute cardiopulmonary failure. The objective of this study was to examine the survival outcomes for patients who received ECMO.
METHODS AND RESULTS:
-Adult patients who received ECMO from September 1, 2002 to December 31, 2012 were identified from Taiwan's National Health Insurance Database associated with 1) coronary artery bypass surgery (CABG), 2) myocardial infarction/cardiogenic shock (MI/CS), 3) injury, and 4) infection/septic shock (Infection). A Cox-regression model was used to determine hazard ratios (HR) and compare 30-day and one-year survival rates using the MI/CS group as the reference. The mean age and standard deviation of the 4,227 patient cohort was 57±17 years and 72% were male. The overall mortalities were 59.8% and 76.5% at one month and one year. Survival statistics deteriorated sharply when ECMO was required for more than 3 days. Acute (30-day) survival was more favorable in the Infection (n = 1,076, HR: 0.61, 95% CI: 0.55-0.67), CABG (n = 1,077, HR: 0.68 [0.61-0.75]), and Injury (n = 369, HR: 0.82 [0.70-0.95]) groups. The extended survival rapidly approached an asymptote near 20% for the Infection, MI/CS (n = 1,705), and CABG groups. The pattern of survival for the injury group was somewhat better, exceeding 30% at yearend.
-Regardless of initial pathology, patients requiring ECMO were critically ill with similar guarded prognoses. Those in the trauma group had somewhat better outcomes. Determining the efficacy and cost-effectiveness of ECMO should be a critical future goal.
PMID: 27199466 [PubMed - as supplied by publisher]
- Proton pump inhibitors (PPI) reduced clinically important and overt GI bleeding vs. H2-blockers in this meta-analysis of RCTs. But mortality and ICU length of stay was not impacted. There has been recent concern PPIs may increase risk of C. difficile colitis, but this study could not speak to that outcome.
- Prehospital TXA was evaluated in this retrospective civilian-based study in Germany. Early survival at 24 hours was better, but long-term mortality showed no benefit. It just took longer for the patients who received prehospital TXA to die. The authors conclude there is benefit, but I think this study doesn't clarify the issue.
Crit Care. 2016 May 4;20(1):120. doi: 10.1186/s13054-016-1305-6.
1Department of Medicine, McMaster University, Hamilton, Canada.
2Department of Internal Medicine, United Arab Emirates University, Alain, United Arab Emirates.
3Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Canada.
4Department of Surgery, Division of Neurosurgery, McMaster University, Hamilton, Canada.
5Department of Critical Care, Security Forces Hospital, Riyadh, Saudi Arabia.
6Department of Medicine, Alfaisal University, Riyadh, Saudi Arabia.
7Department of Medicine, McMaster University, Hamilton, Canada. email@example.com.
8Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Canada. firstname.lastname@example.org.
9Department of Medicine, Division of Critical Care, St Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada. email@example.com.
The relative efficacy and safety of proton pump inhibitors (PPIs) compared to histamine-2-receptor antagonists (H2RAs) should guide their use in reducing bleeding risk in the critically ill.
We searched the Cochrane library, MEDLINE, EMBASE, ACPJC, clinical trials registries, and conference proceedings through November 2015 without language or publication date restrictions. Only randomized controlled trials (RCTs) of PPIs vs H2RAs for stress ulcer prophylaxis in critically ill adults for clinically important bleeding, overt gastrointestinal (GI) bleeding, nosocomial pneumonia, mortality, ICU length of stay and Clostridium difficile infection were included. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess our confidence in the evidence for each outcome.
In 19 trials enrolling 2117 patients, PPIs were more effective than H2RAs in reducing the risk of clinically important GI bleeding (RR 0.39; 95 % CI 0.21, 0.71; P = 0.002; I (2) = 0 %, moderate confidence) and overt GI bleeding (RR 0.48; 95 % CI 0.34, 0.66; P < 0.0001; I (2) = 3 %, moderate confidence). PPI use did not significantly affect risk of pneumonia (RR 1.12; 95 % CI 0.86, 1.46; P = 0.39; I (2) = 2 %, low confidence), mortality (RR 1.05; 95 % CI 0.87, 1.27; P = 0.61; I (2) = 0 %, moderate confidence), or ICU length of stay (mean difference (MD), -0.38 days; 95 % CI -1.49, 0.74; P = 0.51; I (2) = 30 %, low confidence). No RCT reported Clostridium difficile infection.
PPIs were superior to H2RAs in preventing clinically important and overt GI bleeding, without significantly increasing the risk of pneumonia or mortality. Their impact on Clostridium difficile infection is yet to be determined.
PMCID: PMC4855320 Free PMC Article
PMID: 27142116 [PubMed - in process]
Crit Care. 2016 May 12;20(1):143. doi: 10.1186/s13054-016-1322-5.
1Department of Trauma and Orthopedic Surgery, University of Witten/Herdecke, Cologne-Merheim Medical Center, Ostmerheimer Strasse 200, D-51109, Cologne, Germany. firstname.lastname@example.org.
2Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109, Cologne, Germany.
3Department of Trauma and Orthopedic Surgery, University of Witten/Herdecke, Cologne-Merheim Medical Center, Ostmerheimer Strasse 200, D-51109, Cologne, Germany.
4Department of Anesthesiology and Intensive Care Medicine, University of Witten/Herdecke, Cologne-Merheim Medical Center, Ostmerheimer Strasse 200, D-51109, Cologne, Germany.
5Department of Medicine - ADAC Air Rescue Service (Subsidiary of the General German Automobile Club), Munich, Germany.
Evidence on prehospital administration of the antifibrinolytic tranexamic acid (TXA) in civilian trauma populations is scarce. The aim was to study whether prehospital TXA use in trauma patients was associated with improved outcomes.
The prehospital database of the ADAC (General German Automobile Club) Air Rescue Service was linked with the TraumaRegister of the German Trauma Society to reidentify patients documented in both registries. Primarily admitted trauma patients (2012 until 2014) who were treated with TXA during the prehospital phase were matched with patients who had not received prehospital TXA, applying propensity score-based matching.
The matching yielded two identical cohorts (n = 258 in each group), since there were no significant differences in demographics or injury characteristics (mean Injury Severity Score 24 ± 14 [TXA] vs. 24 ± 16 [control]; p = 0.46). The majority had sustained blunt injury (90.3 % vs. 93.0 %; p = 0.34). There were no differences with respect to prehospital therapy, including rates of intubation, chest tube insertion or both administration of i.v. fluids and catecholamines. During ER treatment, the TXA cohort received fewer numbers of red blood cells and plasma units, but without reaching statistical significance. Incidences of organ failure, sepsis or thromboembolism showed no significant differences as well, although data were incomplete for these parameters. Early mortality was significantly lower in the TXA group (e.g., 24-h mortality 5.8 % [TXA] vs. 12.4 % [control]; p = 0.01), and mean time to death was 8.8 ± 13.4 days vs. 3.6 ± 4.9 days, respectively (p = 0.001). Overall hospital mortality was similar in both groups (14.7 % vs. 16.3 %; p = 0.72). The most pronounced mortality difference was observed in patients with a high propensity score, reflecting severe injury load.
This is the first civilian study, to our knowledge, in which the effect of prehospital TXA use in trauma patients has been examined. TXA was associated with prolonged time to death and significantly improved early survival. Until further evidence emerges, the results of this study support the use of TXA during prehospital treatment of severely injured patients.
PMCID: PMC4866028 Free PMC Article
PMID: 27176727 [PubMed - in process]
Critical Care Medicine
These authors draw a conclusion that is the direct opposite to the article in Critical Care this month, namely that there is no advantage to PPIs over H2 blockers.
Crit Care Med. 2016 May 9. [Epub ahead of print]
11Department of Pharmacy Practice, Midwestern University, College of Pharmacy-Glendale, Glendale, AZ. 2Division of Pharmacy, University of Texas MD Anderson Cancer Center, Houston, TX. 3Department of Pharmacy, Banner-University Medical Center-Phoenix, Phoenix AZ. 4Departments of Medicine and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada.
Stress ulcer prophylaxis is commonly administered to critically ill patients for the prevention of clinically important stress-related mucosal bleeding from the upper gastrointestinal tract. Despite widespread incorporation of stress ulcer prophylaxis into practice around the world, questions are emerging about its indications and impact. This clinically focused article will review current controversies related to stress ulcer prophylaxis for critically ill adult patients, including bleeding frequency, risk factors, comparative efficacy, adverse effect profile, and overall cost-effectiveness of the available stress ulcer prophylaxis regimens.
A MEDLINE search was conducted from inception through August 2015.
Selected publications describing stress ulcer prophylaxis in adult patients were retrieved (original research, systematic reviews, and practice guidelines); their bibliographies were also reviewed to identify additional pertinent publications.
Data from relevant publications were abstracted and summarized.
The existing evidence is organized to describe the patients most likely to benefit from stress ulcer prophylaxis, review the comparative efficacy of proton pump inhibitors and histamine 2 receptor antagonists, the adverse effects of stress ulcer prophylaxis, and overall cost-effectiveness.
Many stress ulcer prophylaxis recommendations are based on older studies at risk of bias, which may not be applicable to modern practice. Stress ulcer prophylaxis should be limited to patients considered to be at high risk for clinically important bleeding. When evaluating only the trials at low risk for bias, the evidence does not clearly support lower bleeding rates with proton pump inhibitors over histamine 2 receptor antagonists; however, proton pump inhibitors appear to be the dominant drug class used worldwide today. The current rate of upper gastrointestinal bleeding and the relative adverse effects of acid suppression on infectious risk may drive not only the effectiveness, but also the cost-effectiveness of stress ulcer prophylaxis today. Research is currently underway to better address these issues.
PMID: 27163192 [PubMed - as supplied by publisher]
Emergency Medicine Journal
This single-center study found that in ED patients with chest pain and negative serial troponin, stress testing found an additional 4.5% that went on for revascularization during the index admission. Of course, the question is, did this make a difference? Did this prevent subsequent adverse cardiac outcomes? Were these culprit lesions? We simply don't know on the basis of this study.
Emerg Med J. 2016 May;33(5):319-24. doi: 10.1136/emermed-2015-204823. Epub 2015 Oct 28.
The incremental value of stress testing in patients with acute chest pain beyond serial cardiac troponin testing.
1Cardiology Department, Christchurch Hospital, Christchurch, New Zealand.
2National University Heart Centre, Singapore, Singapore Christchurch Heart Institute, University of Otago, Christchurch, New Zealand.
3Royal Brisbane and Women's Hospital, Brisbane, Australia.
4Department of Medicine, University of Otago, Christchurch, New Zealand Emergency Department, Christchurch Hospital, New Zealand.
5Christchurch Hospital, Christchurch, New Zealand.
In patients with acute chest pain and normal range cardiac troponin (cTn), accurate risk stratification for acute coronary syndrome is challenging. This study assesses the incremental value of stress testing to identify patients for angiography with a view to revascularisation.
A single-centre observational study recruited patients with acute chest pain in whom serial cTn tests were negative and stress testing (exercise tolerance testing/dobutamine stress echocardiography) was performed. Stress tests were reported as negative, non-diagnostic or positive. The primary outcomes were revascularisation on index admission, or cardiac death and myocardial infarction over 1 year follow-up.
Of 749 patients recruited, 709 underwent exercise tolerance testing and 40 dobutamine stress echo of which 548 (73.2%) were negative, 169 (22.6%) were non-diagnostic and 32 (4.3%) were positive. Patients with positive tests (n=19 (59.4%)) were more likely to undergo index admission revascularisation than patients with non-diagnostic (n=15 (8.9%)) (p<0.001) tests who in turn were more likely undergo index admission revascularisation than those with negative tests (n=2 (0.4%)) (p<0.001). The risks of adverse events including cardiovascular death/acute myocardial infarction were low and were similar across stress test outcomes.
The incremental value of stress testing was the identification of an additional 34 (4.5% (95% CI 3.0% to 6.0%)) patients who underwent index admission revascularisation with a view to preventing future adverse events. Uncertainty in whether revascularisation prevents adverse events in patients with negative cTn means the choice to undertake stress testing depends on whether clinicians perceive value in identifying 4.5% of these patients for revascularisation.
CLINICAL TRIAL REGISTRATIONS:
PMID: 26511125 [PubMed - in process]
Journal of Trauma
Pediatric trauma patients do better when transported from the scene by helicopter - lots better. Odds ratio for survival in-hospital was 1.72 for helicopter vs. propensity matched ground transport. The number needed to treat (or fly...) to save one life is 41.
J Trauma Acute Care Surg. 2016 May;80(5):702-10. doi: 10.1097/TA.0000000000000971.
1From the Division of Trauma and General Surgery (J.B.B., C.M.L., A.B.P., T.R.B.), Department of Surgery, University of Pittsburgh Medical Center; and Division of Pediatric General and Thoracic Surgery (C.M.L., B.A.G.), Department of Surgery, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and Division of Acute Care Surgery (M.L.G.), Department of Surgery, University of Rochester Medical Center, Rochester, New York.
Helicopter emergency medical services (HEMS) are frequently used to transport injured children, despite unclear evidence of benefit. The study objective was to evaluate the association of HEMS compared with ground emergency medical services (GEMS) transport with outcomes in a national sample of pediatric trauma patients.
Patients 15 years or younger undergoing scene transport by HEMS or GEMS in the National Trauma Data Bank from 2007 to 2012 were included. Propensity score matching was used to match HEMS and GEMS patients for likelihood of HEMS transport based on demographics, prehospital physiology and time, injury severity, and geographic region. Absolute standardized differences of less than 0.1 indicated adequate covariate balance between groups after matching. The primary outcome was in-hospital survival, while the secondary outcome was discharge disposition in survivors. Conditional logistic regression determined the association between HEMS versus GEMS transport with outcomes while controlling for demographics, admission physiology, injury severity, nonaccidental trauma, and in-hospital complications not accounted for in the propensity score. Subgroup analysis was performed in patients with a transport time of greater than 15 minutes to capture patients with the potential for HEMS transport.
A total of 25,700 HEMS/GEMS pairs were matched from 166,594 patients. Groups were well matched, with all propensity score variables having absolute standardized differences of less than 0.1. In matched patients, HEMS was associated with a 72% increase in odds of survival compared with GEMS (adjusted odds ratio, 1.72; 95% confidence interval, 1.26-2.36; p < 0.01). Transport mode was not associated with discharge disposition (p = 0.47). Subgroup analysis included 17,657 HEMS/GEMS pairs. HEMS was again associated with a significant increase in odds of survival (adjusted odds ratio, 1.81; 95% confidence interval, 1.24-2.65; p < 0.01), while transport mode was not associated with discharge disposition (p = 0.58).
Scene transport by HEMS was associated with improved odds of survival compared with GEMS in pediatric trauma patients. Further study is warranted to understand the underlying mechanisms and develop specific triage criteria for HEMS transport in this population.
LEVEL OF EVIDENCE:
Therapeutic study, level III.
PMCID: PMC4840038 [Available on 2017-05-01]
PMID: 26808033 [PubMed - in process]
In 2010-2011, for every 1000 patients, 506 were prescribed antibiotics in the US. Unfortunately, 30% of the antibiotic prescriptions were deemed inappropriate based on this retrospective analysis. Although it seems like the results are concur with my experience, this feels a little like armchair quarterbacking to try to determine this retrospectively using a large population database.
JAMA. 2016 May 3;315(17):1864-73. doi: 10.1001/jama.2016.4151.
Fleming-Dutra KE1, Hersh AL2, Shapiro DJ3, Bartoces M1, Enns EA4, File TM Jr5, Finkelstein JA6, Gerber JS7, Hyun DY8, Linder JA9, Lynfield R10, Margolis DJ11, May LS12, Merenstein D13, Metlay JP14, Newland JG15, Piccirillo JF16, Roberts RM1, Sanchez GV1, Suda KJ17, Thomas A18, Woo TM19, Zetts RM8, Hicks LA1.
1Centers for Disease Control and Prevention, Atlanta, Georgia.
2Pediatric Infectious Diseases, University of Utah, Salt Lake City.
3School of Medicine, University of California, San Francisco, San Francisco.
4Division of Health Policy and Management, University of Minnesota, Minneapolis.
5Summa Health System and Northeast Ohio Medical University, Akron.
6Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts.
7Children's Hospital of Philadelphia, Philadelphia, Pennsylvania8University of Pennsylvania Perelman School of Medicine, Philadelphia.
8Pew Charitable Trusts, Washington, DC.
9Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.
10Minnesota Department of Health, St Paul.
11University of Pennsylvania Perelman School of Medicine, Philadelphia.
12Department of Emergency Medicine, University of California-Davis, Sacramento.
13Department of Family Medicine, Georgetown University Medical Center, Washington, DC.
14Division of General Internal Medicine, Massachusetts General Hospital, Boston.
15Division of Pediatric Infectious Diseases, Washington University School of Medicine, St Louis, Missouri.
16Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri.
17Department of Veterans Affairs, University of Illinois at Chicago, Chicago.
18Oregon Public Health Division, Portland.
19Pacific Lutheran University, Tacoma, Washington.
- Addressing the Appropriateness of Outpatient Antibiotic Prescribing in the United States: An Important First Step. [JAMA. 2016]
The National Action Plan for Combating Antibiotic-Resistant Bacteria set a goal of reducing inappropriate outpatient antibiotic use by 50% by 2020, but the extent of inappropriate outpatient antibiotic use is unknown.
To estimate the rates of outpatient oral antibiotic prescribing by age and diagnosis, and the estimated portions of antibiotic use that may be inappropriate in adults and children in the United States.
DESIGN, SETTING, AND PARTICIPANTS:
Using the 2010-2011 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, annual numbers and population-adjusted rates with 95% confidence intervals of ambulatory visits with oral antibiotic prescriptions by age, region, and diagnosis in the United States were estimated.
Ambulatory care visits.
MAIN OUTCOMES AND MEASURES:
Based on national guidelines and regional variation in prescribing, diagnosis-specific prevalence and rates of total and appropriate antibiotic prescriptions were determined. These rates were combined to calculate an estimate of the appropriate annual rate of antibiotic prescriptions per 1000 population.
Of the 184,032 sampled visits, 12.6% of visits (95% CI, 12.0%-13.3%) resulted in antibiotic prescriptions. Sinusitis was the single diagnosis associated with the most antibiotic prescriptions per 1000 population (56 antibiotic prescriptions [95% CI, 48-64]), followed by suppurative otitis media (47 antibiotic prescriptions [95% CI, 41-54]), and pharyngitis (43 antibiotic prescriptions [95% CI, 38-49]). Collectively, acute respiratory conditions per 1000 population led to 221 antibiotic prescriptions (95% CI, 198-245) annually, but only 111 antibiotic prescriptions were estimated to be appropriate for these conditions. Per 1000 population, among all conditions and ages combined in 2010-2011, an estimated 506 antibiotic prescriptions (95% CI, 458-554) were written annually, and, of these, 353 antibiotic prescriptions were estimated to be appropriate antibiotic prescriptions.
CONCLUSIONS AND RELEVANCE:
In the United States in 2010-2011, there was an estimated annual antibiotic prescription rate per 1000 population of 506, but only an estimated 353 antibiotic prescriptions were likely appropriate, supporting the need for establishing a goal for outpatient antibiotic stewardship.
PMID: 27139059 [PubMed - indexed for MEDLINE]
Have you ever heard of C. difficile associated reactive arthritis in pediatric patients? Me neither! So I thought we could learn something with this article. After C. difficile infection, a reactive arthritis may occur that can mimic septic arthritis. Make sure to ask about preceding antibiotics and diarrhea in your next pediatric patient with unexplained polyarthritis.
JAMA Pediatr. 2016 May 16:e160217. doi: 10.1001/jamapediatrics.2016.0217. [Epub ahead of print]
1Rutgers Biomedical and Health Sciences, New Brunswick, New Jersey2 Division of Pediatric Rheumatology, Department of Pediatrics, Nemours A.I. duPont Hospital for Children, Wilmington, Delaware3Center for Clinical Epidemiology and Biostatistics, Department.
2Rutgers Biomedical and Health Sciences, New Brunswick, New Jersey3Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia.
3Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia.
4Division of Pediatric Rheumatology, Department of Pediatrics, Nemours A.I. duPont Hospital for Children, Wilmington, Delaware.
5Division of Pediatric Rheumatology, Department of Pediatrics, Perelman School of Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia.
6Division of Infectious Diseases, Department of Pediatrics, Infection Prevention and Control, Perelman School of Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia.
The incidence of Clostridium difficile infection has increased among children. The epidemiology of pediatric C difficile infection-associated reactive arthritis is poorly understood.
To characterize the incidence, recognition, and distinguishing clinical features of pediatric C difficile infection-associated reactive arthritis among children with C difficile infection.
Design, Setting, and Participants:
In this cohort and nested case-control study using electronic health records from January 1, 2004, to December 31, 2013, across 3 geographically diverse pediatric health care networks, we screened for reactive arthritis among 148 children between ages 2 and 21 years with diagnostic or procedural codes suggesting musculoskeletal disease associated with C difficile diagnosis or positive testing. We identified 26 cases with acute arthritis or tenosynovitis within 4 weeks before to 12 weeks after confirmed C difficile infection with (1) no alternative explanation for arthritis and (2) negative synovial cultures (if obtained). Network-matched C difficile-infected controls without arthritis were randomly selected at the time of cohort member C difficile infections.
Main Outcomes and Measures:
Incidence of C difficile infection-associated reactive arthritis was calculated based on (1) pediatric source population and (2) children with C difficile infection. Characteristics of cases and controls were compared using conditional logistic regression.
Based on the cases identified within the source population of the 3 hospital networks, we estimated that C difficile infection-associated reactive arthritis incidence was 5.0 cases per million person-years (95% CI, 3.0-7.8). Reactive arthritis affected 1.4% of children with C difficile infection yearly (95% CI 0.8%-2.3%). Joint symptoms began a median of 10.5 days after initial gastrointestinal symptoms, often accompanied by fever (n = 15 [58%]) or rash (n = 14 [54%]). Only 35% of cases of C difficile infection-associated reactive arthritis were correctly diagnosed by treating health care professionals (range across centers, 0%-64%). Five affected children (19%) were treated for presumed culture-negative septic hip arthritis despite having prior postantibiotic diarrhea and/or other involved joints. Compared with controls, cases of C difficile infection-associated reactive arthritis were less likely to have underlying chronic conditions (odds ratio [OR], 0.3; 95% CI, 0.1-0.8). Although all cases had community-onset C difficile infection and fewer comorbidities, they were more likely to be treated in emergency departments and/or hospitalized (OR, 7.1; 95% CI, 1.6-31.7).
Conclusions and Relevance:
C difficile infection-associated reactive arthritis is an underdiagnosed, potentially morbid reactive arthritis associated with C difficile infection occasionally misdiagnosed as septic arthritis. Given the rising incidence of pediatric C difficile infections, better recognition of its associated reactive arthritis is needed.
PMID: 27182697 [PubMed - as supplied by publisher]
- It makes sense that patients on antiplatelet agents with spontaneous ICH would benefit from transfusion of new, sticky platelets. But this multicenter study found that it increased the odds of death or dependence at 3 months by 105% (Odds ratio 2.05). And more in the transfusion group died while still in the hospital. Mention this study the next time neurosurgery tells you to do this. I'll bet they don't read the Lancet.
- We usually tell all our patients with some risk factors for heart disease to eat a low sodium diet, but only patients with hypertension benefit from that advice, according to this month's study. As a matter of fact, patients without hypertension who ate a low sodium diet had increased cardiovascular events. Please pass the salt.
- In this meta-analysis focusing on time since TIA, early use of aspirin after TIA reduced the incidence of recurrent stroke at 6 weeks by 60%, NNT = 72. The hazard ratio for those receiving aspirin vs control from 0-2 weeks was 0.07, NNT = 269. This is a dramatically reduced risk. Aspirin had decreased benefit after 12 weeks from the TIA. In patients discharged after TIA, tell them to take a daily aspirin for 3 months, any dose.
- In patients with renal colic, 75mg IM ketorolac was barely better than 0.1mg/kg IV morphine and 1000mg IV acetaminophen in this RCT. Although this approach worked, I am uncomfortable giving such a large dose of ketorolac. And I usually will not give it until I know the patient's renal function is normal. So I am not sure this will change practice for me.
Lancet. 2016 May 9. pii: S0140-6736(16)30392-0. doi: 10.1016/S0140-6736(16)30392-0. [Epub ahead of print]
1Department of Neurology, Academic Medical Centre, Amsterdam, Netherlands.
2Université Lille, Inserm U1171, Degenerative and Vascular Cognitive Disorders, CHU Lille, Department of Neurology, Lille, France.
3Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.
4Department of Neurology, Groene Hart Ziekenhuis, Gouda, Netherlands.
5Sanquin Bloodbank, Amsterdam, Netherlands.
6Department of Radiology, Academic Medical Centre, Amsterdam, Netherlands.
7Department of Radiology, Academic Medical Centre, Amsterdam, Netherlands; Department of Biomedical Engineering and Physics, Academic Medical Centre, Amsterdam, Netherlands.
8Clinical Research Unit, Academic Medical Centre, Amsterdam, Netherlands.
9Department of Neurology, Academic Medical Centre, Amsterdam, Netherlands. Electronic address: email@example.com.
Platelet transfusion after acute spontaneous primary intracerebral haemorrhage in people taking antiplatelet therapy might reduce death or dependence by reducing the extent of the haemorrhage. We aimed to investigate whether platelet transfusion with standard care, compared with standard care alone, reduced death or dependence after intracerebral haemorrhage associated with antiplatelet therapy use.
We did this multicentre, open-label, masked-endpoint, randomised trial at 60 hospitals in the Netherlands, UK, and France. We enrolled adults within 6 h of supratentorial intracerebral haemorrhage symptom onset if they had used antiplatelet therapy for at least 7 days beforehand and had a Glasgow Coma Scale score of at least 8. With use of a secure web-based system that concealed allocation and used biased coin randomisation, study collaborators randomly assigned participants (1:1; stratified by hospital and type of antiplatelet therapy) to receive either standard care or standard care with platelet transfusion within 90 min of diagnostic brain imaging. Participants and local investigators giving interventions were not masked to treatment allocation, but allocation was concealed from outcome assessors and investigators analysing data. The primary outcome was shift towards death or dependence rated on the modified Rankin Scale (mRS) at 3 months, and analysed by ordinal logistic regression, adjusted for stratification variables and the Intracerebral Haemorrhage Score. The primary analysis was done in the intention-to-treat population and safety analyses were done in the intention-to-treat and as-treated populations. This trial is registered with the Netherlands Trial Register, number NTR1303, and is now closed.
Between Feb 4, 2009, and Oct 8, 2015, 41 sites enrolled 190 participants. 97 participants were randomly assigned to platelet transfusion and 93 to standard care. The odds of death or dependence at 3 months were higher in the platelet transfusion group than in the standard care group (adjusted common odds ratio 2·05, 95% CI 1·18-3·56; p=0·0114). 40 (42%) participants who received platelet transfusion had a serious adverse event during their hospital stay, as did 28 (29%) who received standard care. 23 (24%) participants assigned to platelet transfusion and 16 (17%) assigned to standard care died during hospital stay.
Platelet transfusion seems inferior to standard care for people taking antiplatelet therapy before intracerebral haemorrhage. Platelet transfusion cannot be recommended for this indication in clinical practice.
The Netherlands Organisation for Health Research and Development, Sanquin Blood Supply, Chest Heart and Stroke Scotland, French Ministry of Health.
Copyright © 2016 Elsevier Ltd. All rights reserved.
PMID: 27178479 [PubMed - as supplied by publisher]
Lancet. 2016 May 20. pii: S0140-6736(16)30467-6. doi: 10.1016/S0140-6736(16)30467-6. [Epub ahead of print]
Mente A1, O'Donnell M2, Rangarajan S3, Dagenais G4, Lear S5, McQueen M6, Diaz R7, Avezum A8, Lopez-Jaramillo P9, Lanas F10, Li W11, Lu Y12, Yi S12, Rensheng L13, Iqbal R14, Mony P15, Yusuf R16, Yusoff K17, Szuba A18, Oguz A19, Rosengren A20, Bahonar A21, Yusufali A22, Schutte AE23, Chifamba J24, Mann JF25, Anand SS26, Teo K3, Yusuf S26; PURE, EPIDREAM and ONTARGET/TRANSCEND Investigators.
1Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON, Canada; Department of Clinical Epidemiology and Biostatistics, Hamilton, ON, Canada. Electronic address: firstname.lastname@example.org.
2Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medicine, Hamilton, ON, Canada; HRB-Clinical Research Facility, NUI Galway, Ireland.
3Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON, Canada.
4Laval University Heart and Lungs Institute, Quebec City, QC, Canada.
5Faculty of Health Sciences, Simon Fraser University, BC, Canada; Division of Cardiology, Providence Health Care, BC, Canada.
6Department of Laboratory Medicine, McMaster University, Hamilton, ON, Canada.
7Estudios Clínicos Latinoamérica, Rosario, Argentina.
8Dante Pazzanese Institute of Cardiology, Sao Paulo, SP, Brazil.
9Fundacion Oftalmologica de Santander-FOSCAL, Medical School, Universidad de Santander Floridablanca-Santander, Colombia.
10Universidad de La Frontera, Temuco, Chile.
11National Centre for Cardiovascular Diseases, Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China.
12Medical Research & Biometrics Center, National Center for Cardiovascular Diseases, FuWai Hospital, Beijing, China.
13Center for Disease Control & Prevention Nanchang County, Nanchang City, Jiangxi Province, China.
14Departments of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan.
15Community Health & Epidemiology, St John's Research Institute, Bangalore, India.
16The School of Life Sciences and The Centre for Health, Population, and Development, Independent University, Bangladesh.
17Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia.
18Division of Angiology, Wroclaw Medical University, Wrocław, Poland; Department of Internal Medicine, 4th Military Hospital in Wroclaw, Poland.
19Istanbul Medeniyet University, Faculty of Medicine, Department of Internal Medicine, Istanbul, Turkey.
20Sahlgrenska Academy University of Gothenburg, Gothenburg, Sweden.
21Hypertension Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran.
22Hatta Hospital, Dubai Health Authority, Dubai, UAE.
23MRC Unit for Hypertension and CVD/Hypertension in Africa Research Team, North-West University, Potchefstroom, North West Province, South Africa.
24University of Zimbabwe, College of Health Sciences, Physiology Department, Harare, Zimbabwe.
25Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON, Canada; Department of Nephrology, University of Erlangen-Nurnberg and Munich General Hospitals, Munich, Germany.
26Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON, Canada; Department of Clinical Epidemiology and Biostatistics, Hamilton, ON, Canada; Department of Medicine, Hamilton, ON, Canada.
Several studies reported a U-shaped association between urinary sodium excretion and cardiovascular disease events and mortality. Whether these associations vary between those individuals with and without hypertension is uncertain. We aimed to explore whether the association between sodium intake and cardiovascular disease events and all-cause mortality is modified by hypertension status.
In this pooled analysis, we studied 133 118 individuals (63 559 with hypertension and 69 559 without hypertension), median age of 55 years (IQR 45-63), from 49 countries in four large prospective studies and estimated 24-h urinary sodium excretion (as group-level measure of intake). We related this to the composite outcome of death and major cardiovascular disease events over a median of 4·2 years (IQR 3·0-5·0) and blood pressure.
Increased sodium intake was associated with greater increases in systolic blood pressure in individuals with hypertension (2·08 mm Hg change per g sodium increase) compared with individuals without hypertension (1·22 mm Hg change per g; pinteraction<0·0001). In those individuals with hypertension (6835 events), sodium excretion of 7 g/day or more (7060 [11%] of population with hypertension: hazard ratio [HR] 1·23 [95% CI 1·11-1·37]; p<0·0001) and less than 3 g/day (7006 [11%] of population with hypertension: 1·34 [1·23-1·47]; p<0·0001) were both associated with increased risk compared with sodium excretion of 4-5 g/day (reference 25% of the population with hypertension). In those individuals without hypertension (3021 events), compared with 4-5 g/day (18 508 [27%] of the population without hypertension), higher sodium excretion was not associated with risk of the primary composite outcome (≥7 g/day in 6271 [9%] of the population without hypertension; HR 0·90 [95% CI 0·76-1·08]; p=0·2547), whereas an excretion of less than 3 g/day was associated with a significantly increased risk (7547 [11%] of the population without hypertension; HR 1·26 [95% CI 1·10-1·45]; p=0·0009).
Compared with moderate sodium intake, high sodium intake is associated with an increased risk of cardiovascular events and death in hypertensive populations (no association in normotensive population), while the association of low sodium intake with increased risk of cardiovascular events and death is observed in those with or without hypertension. These data suggest that lowering sodium intake is best targeted at populations with hypertension who consume high sodium diets.
Full funding sources listed at end of paper (see Acknowledgments).
Copyright © 2016 Elsevier Ltd. All rights reserved.
PMID: 27216139 [PubMed - as supplied by publisher]
Lancet. 2016 May 18. pii: S0140-6736(16)30468-8. doi: 10.1016/S0140-6736(16)30468-8. [Epub ahead of print]
1Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK. Electronic address: email@example.com.
2Department of Neurology, Rudolph Magnus Institute for Neuroscience, and Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands.
3Nuffield Department of Population Health, University of Oxford, Oxford, UK.
4Department of Neurology, University Duisburg-Essen, Essen, Germany.
5Department of Clinical Sciences, Section of Neurology, Lund University, Sweden.
6Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.
Aspirin is recommended for secondary prevention after transient ischaemic attack (TIA) or ischaemic stroke on the basis of trials showing a 13% reduction in long-term risk of recurrent stroke. However, the risk of major stroke is very high for only the first few days after TIA and minor ischaemic stroke, and observational studies show substantially greater benefits of early medical treatment in the acute phase than do longer-term trials. We hypothesised that the short-term benefits of early aspirin have been underestimated.
Pooling the individual patient data from all randomised trials of aspirin versus control in secondary prevention after TIA or ischaemic stroke, we studied the effects of aspirin on the risk and severity of recurrent stroke, stratified by the following time periods: less than 6 weeks, 6-12 weeks, and more than 12 weeks after randomisation. We compared the severity of early recurrent strokes between treatment groups with shift analysis of modified Rankin Scale (mRS) score. To understand possible mechanisms of action, we also studied the time course of the interaction between effects of aspirin and dipyridamole in secondary prevention of stroke. In a further analysis we pooled data from trials of aspirin versus control in which patients were randomised less than 48 h after major acute stroke, stratified by severity of baseline neurological deficit, to establish the very early time course of the effect of aspirin on risk of recurrent ischaemic stroke and how this differs by severity at baseline.
We pooled data for 15 778 participants from 12 trials of aspirin versus control in secondary prevention. Aspirin reduced the 6 week risk of recurrent ischaemic stroke by about 60% (84 of 8452 participants in the aspirin group had an ischaemic stroke vs 175 of 7326; hazard ratio [HR] 0·42, 95% CI 0·32-0·55, p<0·0001) and disabling or fatal ischaemic stroke by about 70% (36 of 8452 vs 110 of 7326; 0·29, 0·20-0·42, p<0·0001), with greatest benefit noted in patients presenting with TIA or minor stroke (at 0-2 weeks, two of 6691 participants in the aspirin group with TIA or minor stroke had a disabling or fatal ischaemic stroke vs 23 of 5726 in the control group, HR 0·07, 95% CI 0·02-0·31, p=0·0004; at 0-6 weeks, 14 vs 60 participants, 0·19, 0·11-0·34, p<0·0001). The effect of aspirin on early recurrent ischaemic stroke was due partly to a substantial reduction in severity (mRS shift analysis odds ratio [OR] 0·42, 0·26-0·70, p=0·0007). These effects were independent of dose, patient characteristics, or aetiology of TIA or stroke. Some further reduction in risk of ischaemic stroke accrued for aspirin only versus control from 6-12 weeks, but there was no benefit after 12 weeks (stroke risk OR 0·97, 0·84-1·12, p=0·67; severity mRS shift OR 1·00, 0·77-1·29, p=0·97). By contrast, dipyridamole plus aspirin versus aspirin alone had no effect on risk or severity of recurrent ischaemic stroke within 12 weeks (OR 0·90, 95% CI 0·65-1·25, p=0·53; mRS shift OR 0·90, 0·37-1·72, p=0·99), but dipyridamole did reduce risk thereafter (0·76, 0·63-0·92, p=0·005), particularly of disabling or fatal ischaemic stroke (0·64, 0·49-0·84, p=0·0010). We pooled data for 40 531 participants from three trials of aspirin versus control in major acute stroke. The reduction in risk of recurrent ischaemic stroke at 14 days was most evident in patients with less severe baseline deficits, and was substantial by the second day after starting treatment (2-3 day HR 0·37, 95% CI 0·25-0·57, p<0·0001).
Our findings confirm that medical treatment substantially reduces the risk of early recurrent stroke after TIA and minor stroke and identify aspirin as the key intervention. The considerable early benefit from aspirin warrants public education about self-administration after possible TIA. The previously unrecognised effect of aspirin on severity of early recurrent stroke, the diminishing benefit with longer-term use, and the contrasting time course of effects of dipyridamole have implications for understanding mechanisms of action.
Wellcome Trust, the National Institute of Health Research (NIHR) Biomedical Research Centre, Oxford.
Copyright © 2016 Rothwell et al. Open Access article distributed under the terms of CC BY. Published by Elsevier Ltd.. All rights reserved.
PMID: 27209146 [PubMed - as supplied by publisher]
Lancet. 2016 May 14;387(10032):1999-2007. doi: 10.1016/S0140-6736(16)00652-8. Epub 2016 Mar 16.
1Emergency Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar; Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia. Electronic address: firstname.lastname@example.org.
2Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia; Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia; National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia.
3Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia.
4Emergency Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar.
5Emergency Radiology Section-Radiology Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar.
6Department of Urology, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar.
7Emergency Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar; Weill Cornell Medical College in Qatar, Doha, Qatar.
8Emergency Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar; Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia; Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia; National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia.
- Non-steroidal anti-inflammatory drugs for renal colic. [Lancet. 2016]
The excruciating pain of patients with renal colic on presentation to the emergency department requires effective analgesia to be administered in the shortest possible time. Trials comparing intramuscular non-steroidal anti-inflammatory drugs with intravenous opioids or paracetamol have been inconclusive because of the challenges associated with concealment of randomisation, small sample size, differences in outcome measures, and inadequate masking of participants and assessors. We did this trial to develop definitive evidence regarding the choice of initial analgesia and route of administration in participants presenting with renal colic to the emergency department.
In this three-treatment group, double-blind, randomised controlled trial, adult participants (aged 18-65 years) presenting to the emergency department of an academic, tertiary care hospital in Qatar, with moderate to severe renal colic (Numerical pain Rating Scale ≥ 4) were recruited. With the use of computer-generated block randomisation (block sizes of six and nine), participants were assigned (1:1:1) to receive diclofenac (75 mg/3 mL intramuscular), morphine (0.1 mg/kg intravenous), or paracetamol (1 g/100 mL intravenous). Participants, clinicians, and trial personnel were masked to treatment assignment. The primary outcome was the proportion of participants achieving at least a 50% reduction in initial pain score at 30 min after analgesia, assessed by intention-to-treat analysis and per-protocol analysis, which included patients where a calculus in the urinary tract was detected with imaging. This trial is registered with ClinicalTrials.gov, number NCT02187614.
Between Aug 5, 2014, and March 15, 2015, we randomly assigned 1645 participants, of whom 1644 were included in the intention-to-treat analysis (547 in the diclofenac group, 548 in the paracetemol group, and 549 in the morphine group). Ureteric calculi were detected in 1316 patients, who were analysed as the per-protocol population (438 in the diclofenac group, 435 in the paracetemol group, and 443 in the morphine group). The primary outcome was achieved in 371 (68%) patients in the diclofenac group, 364 (66%) in the paracetamol group, and 335 (61%) in the morphine group in the intention-to-treat population. Compared to morphine, diclofenac was significantly more effective in achieving the primary outcome (odds ratio [OR] 1·35, 95% CI 1·05-1·73, p=0·0187), whereas no difference was detected in the effectiveness of morphine compared with intravenous paracetamol (1·26, 0·99-1·62, p=0·0629). In the per-protocol population, diclofenac (OR 1·49, 95% CI 1·13-1·97, p=0·0046) and paracetamol (1·40, 1·06-1·85, p=0·0166) were more effective than morphine in achieving the primary outcome. Acute adverse events in the morphine group occurred in 19 (3%) participants. Significantly lower numbers of adverse events were recorded in the diclofenac group (7 [1%] participants, OR 0·31, 95% CI 0·12-0·78, p=0·0088) and paracetamol group (7 [1%] participants, 0·36, 0·15-0·87, p=0·0175) than in the morphine group. During the 2 week follow-up, no additional adverse events were noted in any group.
Intramuscular non-steroidal anti-inflammatory drugs offer the most effective sustained analgesia for renal colic in the emergency department and seem to have fewer side-effects.
Hamad Medical Corporation Medical Research Center, Doha, Qatar.
Copyright © 2016 Elsevier Ltd. All rights reserved.
PMID: 26993881 [PubMed - indexed for MEDLINE]
New England Journal of Medicine
Low dose (0.6mg/kg) tPA was found to be (barely) inferior to standard dose (0.9mg/kg) tPA in regard to the primary outcome of death or severe disability at 90 days, but there were fewer bleeds (1% vs 2.1%) in the low-dose group. This was predominantly an Asian population, which limits generalizability.
N Engl J Med. 2016 May 10. [Epub ahead of print]
Anderson CS1, Robinson T1, Lindley RI1, Arima H1, Lavados PM1, Lee TH1, Broderick JP1, Chen X1, Chen G1, Sharma VK1, Kim JS1, Thang NH1, Cao Y1, Parsons MW1, Levi C1, Huang Y1, Olavarría VV1, Demchuk AM1, Bath PM1, Donnan GA1, Martins S1, Pontes-Neto OM1, Silva F1, Ricci S1, Roffe C1, Pandian J1, Billot L1, Woodward M1, Li Q1, Wang X1, Wang J1, Chalmers J1; ENCHANTED Investigators and Coordinators.
1From the George Institute for Global Health (C.S.A., R.I.L., H.A., X.C., L.B., M.W., Q.L., X.W., J.C.) and Sydney Medical School (C.S.A., R.I.L., H.A., X.C., L.B., M.W., Q.L., J.C.), University of Sydney, and the Neurology Department, Royal Prince Alfred Hospital, Sydney Health Partners (C.S.A.), Sydney, the Neurology Department, John Hunter Hospital, and Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW (M.W.P., C.L.), and the Florey Institute of Neuroscience and Mental Health, Parkville, VIC (G.A.D.) - all in Australia; the George Institute China, Peking University (C.S.A.), and the Department of Neurology, Peking University First Hospital (Y.H.), Beijing, the Department of Neurology, Xuzhou Central Hospital, Xuzhou (G.C.), the Department of Neurology, the Second Affiliated Hospital of Soochow University, Suzhou (Y.C.), and the Shanghai Institute of Hypertension, Rui Jin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai (J.W.) - all in China; the University of Leicester, Department of Cardiovascular Sciences and National Institute of Health Research Biomedical Research Unit, Leicester (T.R.), the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham (P.M.B.), the Department of Neurosciences, Royal Stoke University Hospital, Stoke-on-Trent (C.R.), and the George Institute for Global Health, University of Oxford, Oxford (M.W.) - all in the United Kingdom; the Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan (H.A.); Clinica Alemana de Santiago, Facultad de Medicina, Clinica Alemana Universidad del Desarrollo (P.M.L., V.V.O.), and Departamento de Ciencias Neurológicas, Facultad de Medicina, Universidad de Chile (P.M.L.), Santiago, Chile; the Department of Neurology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan (T.-H.L.); the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati (J.P.B.); the Division of Neurology, Department of Medicine, National University Hospital and School of Medicine, National University of Singapore, Singapore (V.K.S.); the Department of Neurology, University of Ulsan, Asan Medical Center, Seoul, South Korea (J.S.K.); the Department of Cerebrovascular Disease, People's 115 Hospital, Ho Chi Minh City, Vietnam (N.H.T.); Calgary Stroke Program, Department of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (A.M.D.); the Stroke Division of Neurology Service, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre (S.M.), and the Stroke Service, Neurology Division, Department of Neuroscience and Behavior, Ribeirão Preto School of Medicine, University of São Paulo, São Paulo (O.M.P.-N.) - both in Brazil; the Neurovascular Sciences Group, Neurosciences Department, Bucaramanga, Colombia (F.S.); Unita Operativa de Neurologia, USL Umbria 1, Sedi di Città di Castello e Branca, Italy (S.R.); the Department of Neurology, Christian Medical College, Ludhiana, India (J.P.); and the Department of Epidemiology, Johns Hopkins University, Baltimore (M.W.).
Background: Thrombolytic therapy for acute ischemic stroke with a lower-than-standard dose of intravenous alteplase may improve recovery along with a reduced risk of intracerebral hemorrhage.
Methods: Using a 2-by-2 quasi-factorial open-label design, we randomly assigned 3310 patients who were eligible for thrombolytic therapy (median age, 67 years; 63% Asian) to low-dose intravenous alteplase (0.6 mg per kilogram of body weight) or the standard dose (0.9 mg per kilogram); patients underwent randomization within 4.5 hours after the onset of stroke. The primary objective was to determine whether the low dose would be noninferior to the standard dose with respect to the primary outcome of death or disability at 90 days, which was defined by scores of 2 to 6 on the modified Rankin scale (range, 0 [no symptoms] to 6 [death]). Secondary objectives were to determine whether the low dose would be superior to the standard dose with respect to centrally adjudicated symptomatic intracerebral hemorrhage and whether the low dose would be noninferior in an ordinal analysis of modified Rankin scale scores (testing for an improvement in the distribution of scores). The trial included 935 patients who were also randomly assigned to intensive or guideline-recommended blood-pressure control.
Results: The primary outcome occurred in 855 of 1607 participants (53.2%) in the low-dose group and in 817 of 1599 participants (51.1%) in the standard-dose group (odds ratio, 1.09; 95% confidence interval [CI], 0.95 to 1.25; the upper boundary exceeded the noninferiority margin of 1.14; P=0.51 for noninferiority). Low-dose alteplase was noninferior in the ordinal analysis of modified Rankin scale scores (unadjusted common odds ratio, 1.00; 95% CI, 0.89 to 1.13; P=0.04 for noninferiority). Major symptomatic intracerebral hemorrhage occurred in 1.0% of the participants in the low-dose group and in 2.1% of the participants in the standard-dose group (P=0.01); fatal events occurred within 7 days in 0.5% and 1.5%, respectively (P=0.01). Mortality at 90 days did not differ significantly between the two groups (8.5% and 10.3%, respectively; P=0.07).
Conclusions: This trial involving predominantly Asian patients with acute ischemic stroke did not show the noninferiority of low-dose alteplase to standard-dose alteplase with respect to death and disability at 90 days. There were significantly fewer symptomatic intracerebral hemorrhages with low-dose alteplase. (Funded by the National Health and Medical Research Council of Australia and others; ENCHANTED ClinicalTrials.gov number, NCT01422616 .).
PMID: 27161018 [PubMed - as supplied by publisher]
If you are a little cray-cray before your concussion, you complain of symptoms longer than if you're not. Pre-injury somatization symptom score was the best predictor of post-concussive symptom duration.
Neurology. 2016 May 17;86(20):1856-63. doi: 10.1212/WNL.0000000000002679. Epub 2016 Apr 20.
1From the Departments of Neurosurgery & Neurology (L.D.N., M.A.M.), Department of Neurosurgery (A.A.L.), Division of Biostatistics, Institute for Health and Society (S.T.), Department of Psychiatry & Behavioral Medicine (T.A.H.), Medical College of Wisconsin, Milwaukee; Department of Neurology (W.B.B.), New York University School of Medicine, New York; Department of Exercise and Sport Science (K.G.), University of North Carolina, Chapel Hill; and Department of Neurology (C.R.), Loyola University Medical Center, Maywood, IL. email@example.com.
2From the Departments of Neurosurgery & Neurology (L.D.N., M.A.M.), Department of Neurosurgery (A.A.L.), Division of Biostatistics, Institute for Health and Society (S.T.), Department of Psychiatry & Behavioral Medicine (T.A.H.), Medical College of Wisconsin, Milwaukee; Department of Neurology (W.B.B.), New York University School of Medicine, New York; Department of Exercise and Sport Science (K.G.), University of North Carolina, Chapel Hill; and Department of Neurology (C.R.), Loyola University Medical Center, Maywood, IL.
To determine the degree to which preinjury and acute postinjury psychosocial and injury-related variables predict symptom duration following sport-related concussion.
A total of 2,055 high school and collegiate athletes completed preseason evaluations. Concussed athletes (n = 127) repeated assessments serially (<24 hours and days 8, 15, and 45) postinjury. Cox proportional hazard modeling was used to predict concussive symptom duration (in days). Predictors considered included demographic and history variables; baseline psychological, neurocognitive, and balance functioning; acute injury characteristics; and postinjury clinical measures.
Preinjury somatic symptom score (Brief Symptom Inventory-18 somatization scale) was the strongest premorbid predictor of symptom duration. Acute (24-hour) postconcussive symptom burden (Sport Concussion Assessment Tool-3 symptom severity) was the best injury-related predictor of recovery. These 2 predictors were moderately correlated (r = 0.51). Path analyses indicated that the relationship between preinjury somatization symptoms and symptom recovery was mediated by postinjury concussive symptoms.
Preinjury somatization symptoms contribute to reported postconcussive symptom recovery via their influence on acute postconcussive symptoms. The findings highlight the relevance of premorbid psychological factors in postconcussive recovery, even in a healthy athlete sample relatively free of psychopathology or medical comorbidities. Future research should elucidate the neurobiopsychosocial mechanisms that explain the role of this individual difference variable in outcome following concussive injury.
© 2016 American Academy of Neurology.
PMCID: PMC4873681 [Available on 2017-05-17]
PMID: 27164666 [PubMed - in process]
Pediatric Critical Care Medicine
Pediatric post-arrest EEG finding of "normal" or "generalized slowing" was associated with a good prognosis.
Pediatr Crit Care Med. 2016 May 9. [Epub ahead of print]
11Department of Neurology, Washington University School of Medicine, St. Louis, MO. 2Department of Pediatrics, Washington University School of Medicine, St. Louis, MO.
To determine the clinical and electroencephalographic findings associated with prognosis in nonneonate children following cardiac arrest.
Retrospective observational study.
PICU and cardiac ICU.
Nonneonate children with a history of cardiac arrest more than 2 minutes.
Electroencephalographic monitoring within 72 hours of return of spontaneous circulation.
MEASUREMENTS AND MAIN RESULTS:
Clinical and features, neurophysiologic data, and Pediatric Cerebral Performance Category scores were collected. Electroencephalographic traces were reviewed in a blinded manner, all seizures and electroencephalographic findings noted, and the electroencephalography was scored at 1 hour, 24 hours, and continuous electroencephalographic end. Discrete data regarding specific characteristics of the electroencephalographic background and seizures were studied. Univariate and multivariate analyses were performed to identify associations between clinical variables, electroencephalographic findings, and Pediatric Cerebral Performance Category score at hospital discharge. Multivariate analysis of 73 children revealed duration of cardiac arrest less than 20 minutes or continuous electroencephalographic background activity within 12 hours postreturn of spontaneous circulation were associated with good short term neurologic outcome. Change in electroencephalographic background score over time and electroencephalographic data collected after the initial hour were not associated with outcome.
Following pediatric cardiac arrest, an initially normal electroencephalography or generalized slowing of the electroencephalographic background was associated with good neurologic outcome at hospital discharge.
PMID: 27164188 [PubMed - as supplied by publisher]
Pediatric Emergency Care
- Prochlorperazine was better than metoclopramide, which was better than promethazine for pediatric ED migraine therapy. This was a small retrospective study.
- In neonates 28 days and under, rates of serious bacterial infection (SBI) were the same (11-15%) regardless of whether the patient was RSV + or not. Don't be reassured by a febrile neonate with a positive RSV test.
Pediatr Emerg Care. 2016 May 12. [Epub ahead of print]
1From the *Department of Emergency Medicine, Oregon Health & Science University, Portland, OR; and †Division of Pediatric Emergency Medicine, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada.
Migraine headaches are common in the pediatric emergency department. The mainstay of abortive treatment consists of nonsteroidal anti-inflammatories and dopamine antagonists. The objective of this study was to compare the effectiveness of 3 commonly used dopamine antagonists to abort pediatric migraine.
This was a retrospective cohort study of all patients who presented to the pediatric emergency department at a tertiary care pediatric hospital between January 2010 and December 2013. Patients were treated for a migraine headache with a combination of ketorolac and one of the following dopamine antagonists: prochlorperazine, metoclopramide, or promethazine. The primary outcome was treatment failure and receiving non-evidence-based treatment defined by the need for opioids. Secondary outcomes included pain score reduction and return visit within 48 hours.
There were 57 patients during this period with 67 visits that met inclusion criteria: 27 (40.3%) visits in which patients were treated with prochlorperazine, 23 (34.3%) visits in which patients were treated with metoclopramide, and 17 (25.4%) visits in which patients were treated with promethazine. Across visits, the mean age was 14.5 years, and 63% were women. Opioids were given for treatment failure in 8.7% of visits in which patients received prochlorperazine, 25% in which patients received metoclopramide, and 42.8% in which patients received promethazine. Patients treated with promethazine had significantly higher odds of needing opioids and experiencing less than 50% reduction in pain score compared with prochlorperazine after adjusting for patient characteristics.
This study suggests variable efficacy among 3 commonly used dopamine antagonists for pediatric migraine headache. Promethazine seems least effective and results in higher use of opioids compared with other available dopamine antagonists.
PMID: 27176905 [PubMed - as supplied by publisher]
Pediatr Emerg Care. 2016 May;32(5):286-9. doi: 10.1097/PEC.0000000000000799.
1From the Maimonides Medical Center, Brooklyn, NY.
This study aimed to analyze a large group of febrile neonates 28 days or younger who received outpatient sepsis evaluation and nasopharyngeal aspirate antigen testing (NPAT) for respiratory syncytial viral (RSV) infection to determine whether there is a clinically significant association between viral study results and risk for serious bacterial infection (SBI: bacterial meningitis, bacteremia, urinary tract infection, bacterial enteritis).
We evaluated consecutive febrile neonates 28 days or younger presenting to our urban pediatric emergency department [Maimonides Medical Center (MMC)] during a 6-year period, all of whom received a sepsis evaluation (cerebrospinal fluid, blood, urine cultures) and RSV NPAT. To achieve adequate power (80%), the MMC data were combined with similar data reported from a prior prospective PEM-CRC study of like-aged febrile neonates who received similar evaluation.
From the MMC data of consecutively evaluated cases, the prevalence rate of +RSV in 387 febrile neonates was 6%. Of these, 378 (98%) received both a sepsis evaluation and RSV NPAT; +SBI occurred in 4/22 (18.1%) with +RSV versus 58/356 (16.2%) with -RSV (P = 0.77). Combined with the PEM-CRC cohort of 411 febrile neonates 28 days or younger who received similar evaluation, a total of 789 cases were analyzed using meta-analysis. Overall, there were 117 (14.8%) cases of +SBI and 104 (13.2%) cases of +RSV. The rate of +SBI was 11.5% in those with +RSV versus 15.3% in those with -RSV. Meta-analysis performed showed no significant difference in rates of +SBI between those with and without +RSV (odds ratio, 0.78; 95% confidence interval, 0.41-1.50; P = 0.46).
Rates of +SBI are not significantly different between febrile neonates 28 days or younger with and without +RSV. Respiratory viral infection status is not an accurate clinical determinant in distinguishing SBI risk in febrile neonates.
PMID: 27139289 [PubMed - in process]
- Apparent Life Threatening Event (ALTE) has undergone a name change and redefinition. The new name for this is BRUE - Brief Resolved Unexplained Events. A BRUE consists of: "sudden, brief, and now resolved episode of ≥1 of the following: (1) cyanosis or pallor; (2) absent, decreased, or irregular breathing; (3) marked change in tone (hyper- or hypotonia); and (4) altered level of responsiveness. A BRUE is diagnosed only when there is no explanation for a qualifying event after conducting an appropriate history and physical examination." I personally think it would have been cooler to call it BRIE - Brief Resolved Inexplicable Event, but they didn't ask me. This is in contradistinction to a BEER - Brief Explained Event Resolved. Actually, I just made that up. This review covers treatment of BRUE and is worth reading.
- Detergent packets are dangerous when kids munch them. And the number of exposures is increasing. I would like to advocate for making the pods less eye appealing to kids. If it was packed to look like a piece of broccoli, exposures would stop overnight. In all seriousness, they look like candy - that's a problem.
- You may lay your child in a manger (but only on his or her back), but do not wrap them in swaddling clothes. Swaddling babies is associated with increased risk of SIDS according to this meta-analysis.
Pediatrics. 2016 May;137(5). pii: e20160590. doi: 10.1542/peds.2016-0590. Epub 2016 Apr 25.
Tieder JS, Bonkowsky JL, Etzel RA, Franklin WH, Gremse DA, Herman B, Katz ES, Krilov LR, Merritt JL 2nd, Norlin C, Percelay J, Sapién RE, Shiffman RN, Smith MB; SUBCOMMITTEE ON APPARENT LIFE THREATENING EVENTS.
This is the first clinical practice guideline from the American Academy of Pediatrics that specifically applies to patients who have experienced an apparent life-threatening event (ALTE). This clinical practice guideline has 3 objectives. First, it recommends the replacement of the term ALTE with a new term, brief resolved unexplained event (BRUE). Second, it provides an approach to patient evaluation that is based on the risk that the infant will have a repeat event or has a serious underlying disorder. Finally, it provides management recommendations, or key action statements, for lower-risk infants. The term BRUE is defined as an event occurring in an infant younger than 1 year when the observer reports a sudden, brief, and now resolved episode of ≥1 of the following: (1) cyanosis or pallor; (2) absent, decreased, or irregular breathing; (3) marked change in tone (hyper- or hypotonia); and (4) altered level of responsiveness. A BRUE is diagnosed only when there is no explanation for a qualifying event after conducting an appropriate history and physical examination. By using this definition and framework, infants younger than 1 year who present with a BRUE are categorized either as (1) a lower-risk patient on the basis of history and physical examination for whom evidence-based recommendations for evaluation and management are offered or (2) a higher-risk patient whose history and physical examination suggest the need for further investigation and treatment but for whom recommendations are not offered. This clinical practice guideline is intended to foster a patient- and family-centered approach to care, reduce unnecessary and costly medical interventions, improve patient outcomes, support implementation, and provide direction for future research. Each key action statement indicates a level of evidence, the benefit-harm relationship, and the strength of recommendation.
Copyright © 2016 by the American Academy of Pediatrics.
PMID: 27244835 [PubMed - in process]
Pediatrics. 2016 May;137(5). pii: e20154529. doi: 10.1542/peds.2015-4529.
1Center for Injury Research and Policy at Nationwide Children's Hospital, Columbus, Ohio; School of Medicine, University of Washington, Seattle, Washington;
2Central Ohio Poison Center, Columbus, Ohio; Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, Ohio; and.
3Center for Injury Research and Policy at Nationwide Children's Hospital, Columbus, Ohio;
4Center for Injury Research and Policy at Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, Ohio; and Child Injury Prevention Alliance, Columbus, Ohio firstname.lastname@example.org.
This study analyzes and compares pediatric exposures to packet and nonpacket forms of laundry and dishwasher detergents in the United States.
Data from the National Poison Data System involving exposures to laundry and dishwasher detergents among children younger than 6 years old from 2013 through 2014 were analyzed.
There were 62 254 children younger than 6 years old exposed to laundry and dishwasher detergents from 2013 to 2014. The number of exposures to detergent increased over the study period, but the increase was greatest for laundry detergent packets (17.0%) and dishwasher detergent packets (14.0%). Eighty-five percent of children were exposed through ingestion. The odds of clinical effects (3.9-8.2), hospitalization (4.8-23.5), intubation (6.9-71.3), and serious medical outcomes (8.4-22.6) were significantly higher for laundry detergent packet exposures than for other types of detergent. There were 117 children who required intubation, and 104 of these were exposed to laundry detergent packets. There were 2 deaths, and both were associated with laundry detergent packets.
This national study demonstrates that pediatric laundry detergent packet exposures are more severe than laundry detergent nonpacket and dishwasher detergent (packet and nonpacket) exposures. Pediatric exposures to laundry detergent packets increased by 17% during the study period nationally and should be closely monitored to assess the effectiveness of the newly adopted voluntary safety standard; this standard should be strengthened if the number of exposures does not demonstrate a substantial decrease.
Copyright © 2016 by the American Academy of Pediatrics.
PMID: 27244825 [PubMed - in process]
Pediatrics. 2016 Jun;137(6). pii: e20153275. doi: 10.1542/peds.2015-3275. Epub 2016 May 9.
1School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom; email@example.com.
2School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom;
3Departments of Family Medicine and.
4Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia;
5The Ritchie Centre, Hudson Institute of Medical Research and Department of Pediatrics, Monash University, Victoria, Australia;
6TNO Innovation for Life, Child Health, Leiden, Netherlands; and.
7Murdoch Childrens Research Institute, Royal Children's Hospital, University of Melbourne, and Menzies Institute for Medical Research, University of Tasmania, Tasmania, Australia.
Swaddling is a traditional practice of wrapping infants to promote calming and sleep. Although the benefits and risks of swaddling in general have been studied, the practice in relation to sudden infant death syndrome remains unclear.
The goal of this study was to conduct an individual-level meta-analysis of sudden infant death syndrome risk for infants swaddled for sleep.
Additional data on sleeping position and age were provided by authors of included studies.
Observational studies that measured swaddling for the last or reference sleep were included.
Of 283 articles screened, 4 studies met the inclusion criteria.
There was significant heterogeneity among studies (I(2) = 65.5%; P = .03), and a random effects model was therefore used for analysis. The overall age-adjusted pooled odds ratio (OR) for swaddling in all 4 studies was 1.58 (95% confidence interval [CI], 0.97-2.58). Removing the most recent study conducted in the United Kingdom reduced the heterogeneity (I(2) = 28.2%; P = .25) and provided a pooled OR (using a fixed effects model) of 1.38 (95% CI, 1.05-1.80). Swaddling risk varied according to position placed for sleep; the risk was highest for prone sleeping (OR, 12.99 [95% CI, 4.14-40.77]), followed by side sleeping (OR, 3.16 [95% CI, 2.08-4.81]) and supine sleeping (OR, 1.93 [95% CI, 1.27-2.93]). Limited evidence suggested swaddling risk increased with infant age and was associated with a twofold risk for infants aged >6 months.
Heterogeneity among the few studies available, imprecise definitions of swaddling, and difficulties controlling for further known risks make interpretation difficult.
Current advice to avoid front or side positions for sleep especially applies to infants who are swaddled. Consideration should be given to an age after which swaddling should be discouraged.
Copyright © 2016 by the American Academy of Pediatrics.
PMID: 27244847 [PubMed - in process]
Prehospital Emergency Care
- Around 20% of pediatric prehospital lights and sirens (LS) transports were deemed unnecessary in this retrospective study. Normal vitals and especially normal GCS were variables that made it most likely that LS transport would be unnecessary. To protect our prehospital professionals and the patients they transport, LS must be saved for those in dire need to warrant the increased risk.
- Tourniquets can save lives but could cause injury if not used appropriately. In this retrospective review of civilian use of tourniquets, 56% were placed but no vascular injury ultimately identified. Of tourniquets ultimately found to be unnecessary, authors concluded that no complications arose from tourniquet use.
Prehosp Emerg Care. 2016 May-Jun;20(3):354-61. doi: 10.3109/10903127.2015.1111477. Epub 2016 Jan 25.
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.
To characterize the use of RLS in pediatric transports and identify factors associated with unnecessary use of RLS.
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.
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).
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 - in process]
Prehosp Emerg Care. 2016 May 31:1-11. [Epub ahead of print]
The United States military considers tourniquets to be effective for controlling bleeding from major limb trauma. The purpose of this study was to assess whether tourniquets are safely applied to the appropriate civilian patient with major limb trauma of any etiology.
Following IRB approval, patients arriving to a level-1 trauma center between October 2008 and May 2013 with a prehospital (PH) or emergency department (ED) tourniquet were reviewed. Cases were assigned the following designations: absolute indication (operation within 2 hours for limb injury, vascular injury requiring repair/ligation, or traumatic amputation); relative indication (major musculoskeletal/soft-tissue injury requiring operation 2-8 hours after arrival, documented large blood loss); and non-indicated. Patients with absolute or relative indications for tourniquet placement were defined as indicated, while the remaining were designated as non-indicated. Complications potentially associated with tourniquets, including amputation, acute renal failure, compartment syndrome, nerve palsies, and venous thromboembolic events, were adjudicated by orthopedic, hand or trauma surgical staff. Univariate analysis was performed to compare patients with indicated versus non-indicated tourniquet placement.
A total of 105 patients received a tourniquet for injuries sustained via sharp objects, i.e., glass or knives (32%), motor vehicle collisions (30%), or other mechanisms (38%). A total of 94 patients (90%) had indicated tourniquet placement; 41 (44%) of which had a vascular injury. Demographics, mechanism, transport, and vitals were similar between patients that had indicated or non-indicated tourniquet placement. 48% of the indicated tourniquets placed PH were removed in the ED, compared to 100% of the non-indicated tourniquets (p < 0.01). The amputation rate was 32% among patients with indicated tourniquet placement (vs. 0%; p = 0.03). Acute renal failure (3.2 vs. 0%, p = 0.72), compartment syndrome (2.1 vs. 0%, p = 0.80), nerve palsies (5.3 vs. 0%; p = 0.57), and venous thromboembolic events (9.1 vs. 8.5%; p = 0.65) and were similar in patients that had indicated compared to non-indicated tourniquet placement. After adjudication, no complication was a result of tourniquet use.
The current study suggests that PH and ED tourniquets are used safely and appropriately in civilians with major limb trauma that occur via blunt and penetrating mechanisms.
PMID: 27245978 [PubMed - as supplied by publisher]
- Summertime = water = drowning. When is the time to pivot from rescue to recovery of the body? This is a tragic question but is crucial for the safety of rescuers risking their own lives. Submersion < 5 minutes is usually associated with favorable outcome. But >25 minutes was universally fatal. This can guide prehospital rescue/recovery efforts.
- Time to intubation in arrest was inversely correlated with favorable neurological outcome. Intubation < 8.8 minutes was associated with better survival and favorable neurological outcome.
- Is it ever beneficial to do CPR longer than 10 minutes, as survival theoretically drops 10% per minute? In this Danish study, an amazing 14% with CPR > 25 minutes survived at 30 days (18/19 able to live at home vs. nursing home).
- Mild therapeutic hypothermia did not seem to benefit pediatric arrest victims in this study.
Resuscitation. 2016 May 3;104:63-75. doi: 10.1016/j.resuscitation.2016.04.006. [Epub ahead of print]
1Department of Pediatrics, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA 98195, USA; Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98145, USA; Harborview Injury Prevention & Research Center, 401 Broadway, University of Washington, Seattle, WA 98122, USA. Electronic address: firstname.lastname@example.org.
2Research Group Emergency and Disaster Medicine, Vrije Universiteit Brussels, Pleinlaan 2, 1050 Elsene, Belgium.
3Department of Epidemiology, School of Public Health, 1959 NE Pacific St, Seattle, WA 98195, USA.
4Harborview Injury Prevention & Research Center, 401 Broadway, University of Washington, Seattle, WA 98122, USA; Department of Epidemiology, School of Public Health, 1959 NE Pacific St, Seattle, WA 98195, USA.
5Royal Melbourne Hospital Clinical School, University of Melbourne, Grattan Street, Parkville, Victoria 3050, Australia.
6Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK; Heart of England NHS Foundation Trust, Bordesley Green East, Birmingham B9 5SS, UK.
To identify factors available to rescuers at the scene of a drowning that predict favourable outcomes.
Systematic review and meta-analysis.
PubMed, Embase and Cochrane Library were searched (1979-2015) without restrictions on age, language or location and references lists of included articles.
Cohort and case-control studies reporting submersion duration, age, water temperature, salinity, emergency services response time and survival and/or neurological outcomes were eligible. Two reviewers independently screened articles for inclusion, extracted data, and assessed quality using GRADE. Variables for all factors, including time and temperature intervals, were categorized using those used in the articles. Random effects meta-analyses, study heterogeneity and publication bias were evaluated.
Twenty-four cohort studies met the inclusion criteria. The strongest predictor was submersion duration. Meta-analysis showed that favourable outcome was associated with shorter compared to longer submersion durations in all time cutoffs evaluated: ≤5-6min: risk ratio [RR]=2.90; (95% confidence interval [CI]: 1.73, 4.86); ≤10-11min: RR=5.11 (95% CI: 2.03, 12.82); ≤15-25min: RR=26.92 (95% CI: 5.06, 143.3). Favourable outcomes were seen with shorter EMS response times (RR=2.84 (95% CI: 1.08, 7.47)) and salt water versus fresh water 1.16 (95% CI: 1.08, 1.24). No difference in outcome was seen with victim's age, water temperatures, or witnessed versus unwitnessed drownings.
Increasing submersion duration was associated with worse outcomes. Submersion durations <5min were associated with favourable outcomes, while those >25min were invariably fatal. This information may be useful to rescuers and EMS systems deciding when to perform a rescue versus a body recovery.
Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.
PMID: 27154004 [PubMed - as supplied by publisher]
Resuscitation. 2016 May 27. pii: S0300-9572(16)30075-2. doi: 10.1016/j.resuscitation.2016.05.012. [Epub ahead of print]
1Department of Emergency Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.
2Department of Emergency Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; Department of Emergency Medicine, Lotung Poh-Ai Hospital, Yilan, Taiwan.
3Department of Emergency Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
4Department of Emergency Medicine, Taipei Hospital, Ministry of Health and Welfare, New Taipei City, Taiwan.
5Departments of Internal Medicine and Nuclear Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; Department of Nuclear Medicine and Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital, New Taipei City, Taiwan; National Yang-Ming University School of Medicine, Taipei, Taiwan. Electronic address: email@example.com.
6Department of Emergency Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan. Electronic address: firstname.lastname@example.org.
Resuscitation guidelines indicate the ideal timing of tracheal intubation during in-hospital cardiac arrest (IHCA) has not been adequately studied.
A retrospective observational study in a single medical centre was conducted that evaluated patients with IHCA between 2006 and 2014. Multivariable logistic regression analysis was used to evaluate associations between independent variables and outcomes. Time to intubation was defined as elapsed time from the first chest compression to the time of completion of endotracheal intubation, tracheostomy, or cricothyroidotomy.
A total of 702 patients were included. The mean time to intubation was 8.8min. Ninety-five (13.5%) patients survived to hospital discharge, and 44 (6.3%) patients displayed favourable neurological status at discharge. Time to intubation was shown to be inversely associated with favourable neurological outcome (odds ratio [OR]: 0.86, 95% confidence interval [CI]: 0.80-0.93; p-value <0.001). Delayed time to intubation was noted to be particularly unfavourable for survival outcome in patients with non-shockable rhythms (OR: 0.95, 95% CI: 0.91-0.98; p-value=0.005). Intubation within 8.8min of arrest was demonstrated to be positively associated with both favourable neurological outcome (OR: 7.28, 95% CI: 2.98-20.52; p-value <0.001) and survival to hospital discharge (OR: 2.09, 95% CI: 1.27-3.52; p-value=0.004).
Earlier tracheal intubation during cardiopulmonary resuscitation might be beneficial for clinical outcomes following IHCA. Intubation within 8.8min appears favourable for both neurological and survival outcomes. Nevertheless, this goal should be attempted by clinicians who experienced in intubation to avoid potential complications and harm.
Copyright © 2016. Published by Elsevier Ireland Ltd.
PMID: 27241332 [PubMed - as supplied by publisher]
Resuscitation. 2016 May 17. pii: S0300-9572(16)30057-0. doi: 10.1016/j.resuscitation.2016.05.004. [Epub ahead of print]
1Department of Cardiology, Copenhagen University Hospital Gentofte. Kildegårdvej 28, Post 635, 2900 Hellerup, Denmark. Electronic address: email@example.com.
2Department of Cardiology, Rigshospitalet, Copenhagen University Hospital. Blegdamsvej 9, 2100 Copenhagen, Denmark; Emergency Medical Services Copenhagen, University of Copenhagen. Telegrafvej 5, 2750 Ballerup, Denmark.
3Cardiovascular Research Center, Department of Anesthesiology, Aalborg University Hospital. Sdr. Skovvej 15, 9000 Aalborg, Denmark.
4Department of Cardiology, Copenhagen University Hospital Gentofte. Kildegårdvej 28, Post 635, 2900 Hellerup, Denmark.
5Duke Clinical Research Institute. 2400 Pratt St, Durham, NC, USA.
6Department of Health, Science and Technology, Aalborg University. Niels Jernes Vej 12, 9220 Aalborg, Denmark.
7Emergency Medical Services Copenhagen, University of Copenhagen. Telegrafvej 5, 2750 Ballerup, Denmark.
8Department of Cardiology, Rigshospitalet, Copenhagen University Hospital. Blegdamsvej 9, 2100 Copenhagen, Denmark.
9The National Institute of Public Health, University of Southern Denmark. Øster Farimagsgade 5A, 1353 Copenhagen K, Denmark.
10Department of Cardiology, Copenhagen University Hospital Gentofte. Kildegårdvej 28, Post 635, 2900 Hellerup, Denmark; Emergency Medical Services Copenhagen, University of Copenhagen. Telegrafvej 5, 2750 Ballerup, Denmark.
It is unclear whether prolonged resuscitation can result in successful outcome following out-of-hospital cardiac arrests (OHCA). We assessed associations between duration of pre-hospital resuscitation on survival and functional outcome following OHCA in patients achieving pre-hospital return of spontaneous circulation (ROSC).
We included 1,316 adult OHCA individuals with pre-hospital ROSC (2005-2011) handled by the largest nationwide ambulance provider in Denmark. Patients were stratified into 0-5, 6-10, 11-15, 16-20, 21-25 and >25minutes of cardiopulmonary resuscitation (CPR) by emergency medical services until ROSC was achieved. Nursing home admission and diagnosis of anoxic brain damage were measured as proxies of poor neurological/functional outcomes.
Median time from CPR initiation to ROSC was 12minutes (IQR: 7-18) while 20.4% achieved ROSC after >25minutes. Overall, 37.5% (494) of the study population achieved 30-day survival. Thirty-day survival was inversely related to minutes of CPR to ROSC: ranging from 59.6% (127/213) for ≤5minutes to 13.8% (19/138) for >25minutes. If bystander initiated CPR before ambulance arrival, corresponding values ranged from 70.4% (107/152) to 21.8% (12/55). Of 30-day survivors, patients discharged to own home rather than nursing home ranged from 95.0% (124/127) to 84.7% (18/19), respectively. Of 30-day survivors, patients discharged without diagnosis of anoxic brain damage ranged from 98.4% (125/127) to 73.7% (14/19) for corresponding intervals.
Even those requiring prolonged resuscitation duration prior to ROSC had meaningful survival rates with the majority of survivors able to return to live in own homes. These data suggest that prolonged resuscitation is not futile.
Copyright © 2016. Published by Elsevier Ireland Ltd.
PMID: 27224447 [PubMed - as supplied by publisher]
Resuscitation. 2016 May 13;105:8-15. doi: 10.1016/j.resuscitation.2016.04.021. [Epub ahead of print]
1Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea. Electronic address: firstname.lastname@example.org.
2Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea. Electronic address: email@example.com.
3Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea. Electronic address: firstname.lastname@example.org.
4Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Republic of Korea. Electronic address: Ro.email@example.com.
5Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea. Electronic address: firstname.lastname@example.org.
6Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Republic of Korea. Electronic address: email@example.com.
7Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea. Electronic address: firstname.lastname@example.org.
This study aimed to analyse the association between mild therapeutic hypothermia (MTH) and outcomes in paediatric patients who survived out-of-hospital cardiac arrest (OHCA) by using their initial electrocardiogram (ECG) rhythm, which is the key factor used to predict prognosis in paediatric OHCA.
This cross-sectional observational study utilised the registry of paediatric OHCA patients who survived to admission from 2008 to 2014 in the national OHCA database. MTH was defined as all cooling methods applied after the return of spontaneous circulation. Primary and secondary outcomes were survival to discharge and good neurologic recovery, respectively. Multivariable logistic regression analysis with an interaction term between MTH and the initial ECG at the scene was conducted to calculate adjusted odds ratios (AORs) and 95% confidence intervals (CIs) after adjusting for potential confounders.
Among the 663 enrolled patients, the rates of survival to discharge and good neurological recovery in the MTH and non-MTH groups were similar, at 48.1% vs. 40.2% (P=0.17, AOR 1.05 [0.59-1.88]) and 22.2% vs. 8.7% (P=0.45, AOR 1.22 [0.59-2.51]). In the interaction model, the AORs of MTH in shockable rhythm vs. non-shockable rhythm for survival to discharge (AOR 0.62 [0.15-2.52] vs. 1.17 [0.62-2.2]) and good neurological recovery (0.42 [0.12-1.45] vs. 2.22 [0.83-5.98]) were not significantly different.
MTH and the effect of MTH across the initial ECG at the scene were not significantly associated with survival or good neurologic recovery in paediatric OHCA survivors.
Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.
PMID: 27185217 [PubMed - as supplied by publisher]