Top Articles of 2016

December 31, 2016

Airway/Anesthesia/Procedures

Major Adverse Events and Relationship to Nil per Os Status in Pediatric Sedation/Anesthesia Outside the Operating Room: A Report of the Pediatric Sedation Research Consortium.
Anesthesiology. 2016 Jan;124(1):80-8. doi: 10.1097/ALN.0000000000000933.
Spoon Feed: NPO status did not predict aspiration or other complication in this large pediatric sedation cohort.  Read more

Randomized Trial of Apneic Oxygenation during Endotracheal Intubation of the Critically Ill.
Am J Respir Crit Care Med. 2016 Feb 1;193(3):273-80. doi: 10.1164/rccm.201507-1294OC.  FELLOW trial.
Spoon Feed: Smaller RCTs have shown benefit for apneic oxygenation.  This Vanderbilt study is the largest RCT to tackle this topic, and it showed no difference.  Read more

Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial.
Ann Emerg Med. 2016 Dec 14. pii: S0196-0644(16)31244-6. doi: 10.1016/j.annemergmed.2016.10.014. [Epub ahead of print]
Spoon Feed: For analgesia, there was no difference in 10mg, 15mg, and 30mg of IV ketorolac

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Hundreds of hours of work went into this post!
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Cardiology

Randomized comparison of intravenous procainamide vs. intravenous amiodarone for the acute treatment of tolerated wide QRS tachycardia: the PROCAMIO study.
Eur Heart J. 2016 Jun 28. pii: ehw230. [Epub ahead of print]
Spoon Feed: Procainamide beat amiodarone for stable VT in this RCT. Read more

Patients without ST elevation after return of spontaneous circulation may benefit from emergent percutaneous intervention: A systematic review and meta-analysis.
Resuscitation. 2016 Sep 15;108:54-60. doi: 10.1016/j.resuscitation.2016.09.004. [Epub ahead of print]
Spoon Feed: A large percentage of patients would benefit from post-arrest cath even if they lack STEMI criteria on ECG.  Read more

Cardiac Mortality Among 200 000 Five-Year Survivors of Cancer Diagnosed at 15 to 39 Years of Age: The Teenage and Young Adult Cancer Survivor Study.
Circulation. 2016 Nov 15;134(20):1519-1531. Epub 2016 Nov 7.
Spoon Feed: If a young person presents with chest pain and has had prior treatment for cancer, his or her risk of cardiac disease is far greater than the baseline population.  Read more

Shared decision making in patients with low risk chest pain: prospective randomized pragmatic trial.
BMJ. 2016 Dec 5;355:i6165. doi: 10.1136/bmj.i6165.
Spoon Feed: Use of an online decision aid helped patients with low risk chest pain better understand their condition and reduced admission rate without increasing risk for adverse outcome.  See the decision aid.

Critical Care-Pulmonary

Impact of Initial Central Venous Pressure on Outcomes of Conservative Versus Liberal Fluid Management in Acute Respiratory Distress Syndrome.
Crit Care Med. 2016 Jan 6. [Epub ahead of print]
Spoon Feed: ARDS patients with lower CVP had significantly lower mortality, favoring a conservative fluid strategy.  Read more

The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3).
JAMA. 2016 Feb 23;315(8):801-10. doi: 10.1001/jama.2016.0287.
Spoon Feed: Sepsis and septic shock have been redefined.  Read more

Effect of Conservative vs Conventional Oxygen Therapy on Mortality Among Patients in an Intensive Care Unit: The Oxygen-ICU Randomized Clinical Trial.
JAMA. 2016 Oct 18;316(15):1583-1589. doi: 10.1001/jama.2016.11993.
Spoon Feed: Target SpO2 94-97% in critically ill patients.  This study adds more evidence that hyperoxia is bad for patients.  Read more

EMS

Assessing the Risk of Prehospital Administration of Naloxone with Subsequent Refusal of Care.
Prehosp Emerg Care. 2016 Sep-Oct;20(5):566-9. doi: 10.3109/10903127.2016.1142626. Epub 2016 Mar 28.
Spoon Feed: Transport is recommended after rescue with naloxone, but refusal of EMS transport carries a low risk for the patient.  Read more

Helicopters and injured kids: Improved survival with scene air medical transport in the pediatric trauma population.
J Trauma Acute Care Surg. 2016 May;80(5):702-10. doi: 10.1097/TA.0000000000000971.
Spoon Feed: 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.  Read more

General Medicine

Pleural effusions at first emergency department encounter predict worse clinical outcomes in pneumonia patients.
Chest. 2016 Jan 16. pii: S0012-3692(16)00449-9. doi: 10.1016/j.chest.2015.12.027. [Epub ahead of print]
Spoon Feed: Patients with parapneumonic effusion on ED presentation do worse and die more often.  Read more

Efficacy and Safety of Corticosteroids for Community-Acquired Pneumonia: A Systematic Review and Meta-Analysis.
Chest. 2016 Jan;149(1):209-19. doi: 10.1378/chest.15-1733. Epub 2016 Jan 6.
Spoon Feed: Steroids in CAP reduce progression to ARDS and decrease LOS.  Read more

National Cluster-Randomized Trial of Duty-Hour Flexibility in Surgical Training.
N Engl J Med. 2016 Feb 25;374(8):713-727. Epub 2016 Feb 2.
Spoon Feed: Duty hour restrictions in surgical residents did not improve patient care or improve resident work satisfaction.  Read more

Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society.
Clin Infect Dis. 2016 Sep 1;63(5):e61-e111. doi: 10.1093/cid/ciw353. Epub 2016 Jul 14.
Spoon Feed: New IDSA guidelines for HAP and VAP.  HCAP is no more.  Read more

Prevalence and Localization of Pulmonary Embolism in Unexplained Acute Exacerba
tions of COPD: A systematic review and meta-analysis.
Chest. 2016 Aug 11. pii: S0012-3692(16)53752-0. doi: 10.1016/j.chest.2016.07.034. [Epub ahead of print]
Spoon Feed: PE prevalence was high in patients with acute exacerbation of COPD, 16.1%.  Read more

GI

Effectiveness of glucagon in relieving esophageal foreign body impaction: a multicenter study.
Am J Emerg Med. 2016 Mar 9. pii: S0735-6757(16)00198-4. doi: 10.1016/j.ajem.2016.03.016. [Epub ahead of print]
Spoon Feed: Glucagon doesn’t work for esophageal foreign body impaction (14% resolution vs 10% with no glucagon) and it made 13% of patients vomit.  Read more

Heme-Onc

An Age-Adjusted D-dimer Threshold for Emergency Department Patients With Suspected Pulmonary Embolus: Accuracy and Clinical Implications.
Ann Emerg Med. 2016 Feb;67(2):249-57. doi: 10.1016/j.annemergmed.2015.07.026. Epub 2015 Aug 29.
Spoon Feed: An age adjusted D-dimer is safe to use.  Read More

Prevalence of Pulmonary Embolism among Patients Hospitalized for Syncope.
N Engl J Med. 2016 Oct 20;375(16):1524-1531.
Spoon Feed: 1 in 6 patients admitted for syncope were found to have PE, but this study has issues.  Read More

Neurology

Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH): a randomised, open-label, phase 3 trial.
Lancet. 2016 May 9. pii: S0140-6736(16)30392-0. doi: 10.1016/S0140-6736(16)30392-0. [Epub ahead of print]
Spoon Feed: This multicenter study found that platelet transfusion in patients with ICH on antiplatelet agents 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.  Read More

Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage.
N Engl J Med. 2016 Jun 8. [Epub ahead of print]
Spoon Feed: This RCT called ATACH-2 was stopped early due to futility.  There was no difference in intensive BP lowering, and this group had increased adverse renal outcomes.  Read More

Determination of a Testing Threshold for Lumbar Puncture in the Diagnosis of Subarachnoid Hemorrhage after a Negative Head CT: A Decision Analysis.
Acad Emerg Med. 2016 Jul 5. doi: 10.1111/acem.13042. [Epub ahead of print]
Spoon Feed: Unless your patient population has a much higher prevalence of disease that the Perry study and the meta-analysis last month, a negative head CT effectively rules out SAH.  Read more

Review article: Why is there still a debate regarding the safety and efficacy of intravenous thrombolysis in the management of presumed acute ischaemic stroke? A systematic review and meta-analysis.
Emerg Med Australas. 2016 Oct;28(5):496-510. doi: 10.1111/1742-6723.12653. Epub 2016 Aug 25.
Spoon Feed: tPA increased the chance of a better functional outcome but at the cost of increased ICH and early mortality.  Read more

OB-GYN

Ondansetron in pregnancy and risk of adverse fetal outcomes in the United States.
Reprod Toxicol. 2016 Jul;62:87-91. doi: 10.1016/j.reprotox.2016.04.027. Epub 2016 May 2.
Spoon Feed: Ondansetron is safe in hyperemesis gravidarum and does not appear to increase risk for birth defects.  Read more

Treatments for Hyperemesis Gravidarum and Nausea and Vomiting in Pregnancy: A Systematic Review.
JAMA. 2016 Oct 4;316(13):1392-1401. doi: 10.1001/jama.2016.14337.
Spoon Feed: All of the agents discussed worked.  Ondansetron worked better than others as severity increased.  Corticosteroids are an option for severe cases. Here is an audio summary of ondansetron safety in pregnancy on UC:RAP, in case you missed it.  Read more

Ortho/Sports

Does the Use of Ibuprofen in Children with Extremity Fractures Increase their Risk for Bone Healing Complications?
J Emerg Med. 2016 Oct 14. pii: S0736-4679(16)30802-2. doi: 10.1016/j.jemermed.2016.09.027. [Epub ahead of print]
Spoon Feed: The dogma is – no NSAIDs for fractures – because it increases the risk of bone healing complications, but this study challenges that.  Read more

Effectiveness of reduction maneuvers in the treatment of nursemaid’s elbow: A systematic review and meta-analysis.
Am J Emerg Med. 2016 Nov 2. pii: S0735-6757(16)30775-6. doi: 10.1016/j.ajem.2016.10.059. [Epub ahead of print]
Spoon Feed: Hyperpronation beats supination/flexion for nursemaid’s elbow.  Read more

Association Between Early Participation in Physical Activity Following Acute Concussion and Persistent Postconcussive Symptoms in Children and Adolescents.
JAMA. 2016 Dec 20;316(23):2504-2514. doi: 10.1001/jama.2016.17396.
Spoon Feed: Physical rest after concussion appears to be unhelpful, even harmful, in children and young people after concussion.  This is a major paradigm shift.

Pediatrics

Radiograph-Negative Lateral Ankle Injuries in Children: Occult Growt
h Plate Fracture or Sprain?
JAMA Pediatr. 2016 Jan 4;170(1):e154114. doi: 10.1001/jamapediatrics.2015.4114. Epub 2016 Jan 4.
Spoon Feed: We routinely splint kids with lateral malleolar tenderness and no fracture in case an occult Salter-Harris 1 (SH1) injury is present, but only 3% of kids had SH1 fractures at follow up.  All recovered just as quickly as kids with sprains. It looks like an ankle brace and self-determined return to activity is OK for these kids.  Read more

Early Volume Expansion and Outcomes of Hemolytic Uremic Syndrome.
Pediatrics. 2016 Jan;137(1):1-9. doi: 10.1542/peds.2015-2153. Epub 2015 Dec 7.
Spoon Feed: Too much IV fluid in HUS causes volume overload, but judicious early volume expansion (10% baseline weight) drastically improved the clinical course for these patients.  Read more

Effect of Dilute Apple Juice and Preferred Fluids vs Electrolyte Maintenance Solution on Treatment Failure Among Children With Mild Gastroenteritis: A Randomized Clinical Trial.
JAMA. 2016 Apr 30. doi: 10.1001/jama.2016.5352. [Epub ahead of print]
Spoon Feed: Dilute apple juice was better for oral rehydration than electrolyte solution in children 6-60 months with acute gastroenteritis.  Read more

A Randomized Trial of Single-Dose Oral Dexamethasone Versus Multidose Prednisolone for Acute Exacerbations of Asthma in Children Who Attend the Emergency Department.
Ann Emerg Med. 2016 May;67(5):593-601.e3. doi: 10.1016/j.annemergmed.2015.08.001. Epub 2015 Oct 14.
Spoon Feed: Single dose dexamethasone 0.3mg/kg, up to 12mg, was not inferior to multiple dose prednisolone in pediatric asthma exacerbation.  Read more

Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants.
Pediatrics. 2016 May;137(5). pii: e20160590. doi: 10.1542/peds.2016-0590. Epub 2016 Apr 25.
Spoon Feed: 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.”  Read more

Validation of the “Step-by-Step” Approach in the Management of Young Febrile Infants.
Pediatrics. 2016 Jul 5. pii: e20154381. [Epub ahead of print]
Spoon Feed: A stepwise approach to febrile infant <90 days had high sensitivity and NPV and was superior to the Rochester Criteria and Lab-score.  Read more

Psychiatric

Ketamine as Rescue Treatment for Difficult-to-Sedate Severe Acute Behavioral Disturbance in the Emergency Department.
Ann Emerg Med. 2016 Feb 10. pii: S0196-0644(15)01562-0. doi: 10.1016/j.annemergmed.2015.11.028. [Epub ahead of print]
Spoon Feed: After large droperidol doses (some patients got 10-30mg), ketamine up to 4-5mg/kg, 200-300mg IM, was safe. Of 49 patients, 2 vomited and 1 had transient desaturation to 90%, improved with O2.  Read more

Midazolam-Droperidol, Droperidol, or Olanzapine for Acute Agitation: A Randomized Clinical Trial.
Ann Emerg Med. 2016 Oct 10. pii: S0196-0644(16)30456-5. doi: 10.1016/j.annemergmed.2016.07.033. [Epub ahead of print]
Spoon Feed: For agitation, the combination of midazolam 5 mg/droperidol 5 mg IV was better and faster onset than droperidol 10 mg IV and olanzapine 10 mg IV.  Read more

Resuscitation

Defibrillation time intervals and outcomes of cardiac arrest in hospital: retrospective cohort study from Get With The Guidelines-Resuscitation registry.
BMJ. 2016 Apr 6;353:i1653. doi: 10.1136/bmj.i1653.
Spoon Feed: In arrest patients with initial defibrillation, delayed defibrillation (over a minute later) was associated with worse ROSC and survival to discharge, although the practice of deferred defibrillation has doubled since 2004.  Read more

Duration of Prehospital Resuscitation Efforts After Out-of-Hospital Cardiac Arrest.
Circulation. 2016 Apr 5;133(14):1386-96. doi: 10.1161/CIRCULATIONAHA.115.018788. Epub 2016 Feb 26.
Spoon Feed: This suggests prehospital resuscitation efforts in adults should be continued for at least 40 minutes to have a >99% sensitivity for 30-day neurologically intact survival.  Survival rates declined with longer resuscitation times.  Read more

Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest.
N Engl J Med. 2016 May 5;374(18):1711-22. doi: 10.1056/NEJMoa1514204. Epub 2016 Apr 4.
Spoon Feed: Neither amiodarone nor lidocaine made an impact on survival or neurological outcome for out-of-hospital arrest due to v-fib or pulseless v-tach.  Read more

Association of Bystander Cardiopulmonary Resuscitation With Overall and Neurologically Favorable Survival After Pediatric Out-of-Hospital Cardiac Arrest in the United States: A Report From the Cardiac Arrest Registry to Enhance Survival Surveillance Registry.
JAMA Pediatr. 2016 Nov 12. doi: 10.1001/jamapediatrics.2016.3643. [Epub ahead of print]
Spoon Feed: Bystander CPR improved the odds of neurologically intact survival in pediatric patients, but only if conventional CPR was performed. Read more

Association Between Tracheal Intubation During Pediatric In-Hospital Cardiac Arrest and Survival.
JAMA. 2016 Nov 1;316(17):1786-1797. doi: 10.1001/jama.2016.14486.
Spoon Feed: Intubation during pediatric arrest does not appear to benefit and may be harmful.  Read more

Toxicology

Outcomes of Patients With Premature Discontinuation of the 21-h Intravenous N-Acetylcysteine Protocol After Acute Acetaminophen Overdose.
J Emerg Med. 2016 Feb 15. pii: S0736-4679(15)01385-2. doi: 10.1016/j.jemermed.2015.12.004. [Epub ahead of print]
Spoon Feed: Patients with acetaminophen OD who did not complete 21-hour NAC IV protocol did very well, even if there were delays in starting treatment.  Read more

Can a serum acetaminophen concentration obtained less than 4 hours post-ingestion determine which patients do not require treatment with acetylcysteine?
Clin Toxicol (Phila). 2016 Oct 28:1-7. [Epub ahead of print]
Spoon Feed: You really do need a 4-hour APAP level.  But if the <4 hour level is undetectable or “very low” you are in the clear.  Read more

Trauma-Surgery

Evaluation of Cervical Spine Clearance by Computed Tomographic Scan Alone in Intoxicated Patients With Blunt Trauma
JAMA Surg. 2016 Jun 15. doi: 10.1001/jamasurg.2016.1248. [Epub ahead of print]
Spoon Feed:  C-spine CT had a “negative predictive value of 99.8% for ruling out CSIs that required immobilization or stabilization.”  In patients with no gross motor deficits and normal c-spine CT, it appears safe to remove the collar, even if intoxicated.  Read more

Cervical Spinal Clearance: A Prospective Western Trauma Association Multi-Institutional Trial.
J Trauma Acute Care Surg. 2016 Jul 20. [Epub ahead of print]
Spoon Feed: Unless the neurological exam was abnormal, CT c-spine detected all clinically significant cervical spine injuries.  Read more

Immediate total-body CT scanning versus conventional imaging and selective CT scanning in patients with severe trauma (REACT-2): a randomised controlled trial.
Lancet. 2016 Jun 28. pii: S0140-6736(16)30932-1. doi: 10.1016/S0140-6736(16)30932-1. [Epub ahead of print]
Spoon Feed: Is the trauma pan-scan helping our patients?  This non-blinded, multicenter RCT found that immediate pan-scan vs. conventional x-ray and selective CT scan did not improve in-hospital mortality.  Read more

Effect of time to operation on mortality for hypotensive patients with gunshot wounds to the torso: The golden 10 minutes.
J Trauma Acute Care Surg. 2016 Aug 3. [Epub ahead of print]
Spoon Feed: Hypotensive patients with gunshot wounds are almost half as likely to die if in the OR in under 10 minutes.  Read more

Urology-GU

Effect of Tamsulosin on Stone Passage for Ureteral Stones: A Systematic Review and Meta-analysis.
Ann Emerg Med. 2016 Sep 7. pii: S0196-0644(16)30364-X. doi: 10.1016/j.annemergmed.2016.06.044. [Epub ahead of print]
Spoon Feed: Tamsulosin helps larger stones pass but is of no benefit for smaller (<5 mm) stones, according this this meta-analysis of 8 RCTs.  Read more

Alpha blockers for treatment of ureteric stones: systematic review and meta-analysis.
BMJ. 2016 Dec 1;355:i6112. doi: 10.1136/bmj.i6112.
Spoon Feed: In a similar vein, this larger meta-analysis found essentially the same thing.

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