Tuesday, June 7, 2011

Move Over MRSA - It's VISA and VRSA Time

Is it too late to buy stock in the company that makes linezolid?

This group up in Detroit reviewed 320 patients with MRSA bacteremia and found that 52.5% experienced Vancomycin failure.  Their conclusion states several significant OR for failure, but review of the between-group differences doesn't show a lot of significant differences.  Nursing homes, for example, were the only p < 0.05, and predicted vancomycin success with a p of 0.02.

What is more important than their clinical predictors, however, is their review of the bactericidal activity of vancomycin - and that higher MICs and higher troughs are needed to effectively treat patients.  I've seen our pharmacists recognize this at my hospital as well - the 1g IV Vancomycin standard initial load is transitioning to a weight-based dose.

But, more importantly, what we're probably really observing is the initial stages of the end of vancomycin's utility for MRSA.  And, I hate to see what happens when TMP/SMX stops working, too....

http://www.ncbi.nlm.nih.gov/pubmed/21460309

Monday, June 6, 2011

Overdiagnosis of Pulmonary Embolism

Another over-testing over-diagnosis article effectively illustrating issues endemic to our current medical culture.

They do a retrospective national database review regarding the impact of the introduction of CTPA protocol for rule-out PE, and note that we've diagnosed three times as many PEs in 2006 as we did in 1998.  And, by detecting more PEs, we managed to reduce mortality attributed to PE...along the same gradually decreasing trendline that was present prior to the introduction of CTPA.

Figure 2 is the truly damning graphic - look at all those extra PEs we're finding and treating for effectively no substantial benefit.  Their secondary analysis was in-hospital anticoagulation complications on patients with any diagnosis of PE, which has jumped 71%.  Thank goodness we can put them on dagibatran now instead of coumadin and not be able to reverse their life-threatening bleeding episodes....

Again, we are testing people who shouldn't be testing, finding disease of uncertain clinical significance, and harming them with overtreatment - and let's not even start with the costs.

http://www.ncbi.nlm.nih.gov/pubmed/21555660

Sunday, June 5, 2011

Physician Perception of Ethnicity Preferences at End Of Life

I'm not sure what this paper definitely adds to the body of literature, but it's been awhile since I read anything on this topic, so I thought it was interesting.

I will give the disclaimer that this has been my limited anecdotal experience during my time in MICU, SICU, PICU etc., that certain ethnic groups were less likely to be amenable to withdrawal of care discussions, transitions to comfort care, hospice, etc., much to our absolute frustration that we were expending inordinate resources to torture some poor ventilated husk of person with no chance of functional recovery.  This study, in a small single-center sample, more or less confirms that we all share that same perception - but, in theory, it doesn't change our practice.

This study surveyed physicians regarding their perceptions of black vs. white end-stage cancer patients, and they tended to believe that a black person would be more likely to want continued aggressive treatment at the end of life.  The remainder of their article, which is a little more difficult to interpret, basically said that regardless of the perceptions, they still recommended the same (in statistical aggregate) treatment to the black vs. white hypothetical cohorts.

While this study didn't find any measurable treatment differences, we've seen all throughout the literature that perception tends towards reality, and that there are many cases of measurable outcomes differences for different ethnicities.  This study just leaves me with a sour taste and more questions than answers.

http://www.ncbi.nlm.nih.gov/pubmed/21460710

Friday, June 3, 2011

Testing For Pulmonary Embolism is More Harmful Than Helpful

This is, in my opinion, the most conceptually important article I have read in the few months I've been posting to this blog.

This is where Dr. Newman and Dr. Schriger, outstanding clinicians and analysts of data, present a compelling case regarding the diagnosis and treatment of pulmonary embolism.  In brief, the authors try to estimate, based on the limited evidence, both the benefits and harm of diagnosis and treatment of pulmonary embolism.  In their review, very few patients were found to benefit from treatment of pulmonary embolism - the existing evidence is weakly supportive of anticoagulation.  Additionally, they show a great many patients were harmed by excessive testing and treatment of clinically unimportant pulmonary embolisms.

This is, while a complicated opinion piece, a lovely summation in a nutshell of the concept that finding more "disease" does not equal better outcomes.  And, depending on the risks of testing and treatment - the barbaric contrast, radiation, and rat poison that diagnosis of PE typically entails - more people would be alive today if we all stopped testing for pulmonary embolism.

This is not unique to pulmonary embolism - this is partly the same issue we encounter with overtesting our low-risk chest pain patients, particularly with CTA.  What this means - and, of course, subject to legal challenge in our bizarre society - is that with our current methods of detection and treatment, society would be better off as a whole if we missed a few pulmonary embolisms in order to find and treat the few clinically relevant ones.  The only shame in this article is that not nearly enough people will read it and take it to heart.

http://www.ncbi.nlm.nih.gov/pubmed/21621091

Thursday, June 2, 2011

Liability Protections For Emergency Services

Smart folks at ACEP - tying liability reform to cost savings, which makes liability protection for Emergency Physicians an easier sell.  I have to say, the training environment these days is so skewed, I don't think anyone graduating now knows how to practice without scanning everyone, as it's become generally the standard of care.  The "quality of care" argument is a little new to me - but I certainly could move patients through more quickly, have less sign-out liability, etc., if I weren't tying up beds waiting for scans.

But, the threat of a lawsuit is a big one.  And it's not just us - so many PMDs refer their patients to the ED for a CT scan - whether the test is indicated, how miserable a malpractice hearing would it be to have testimony from the PMD who thought a CT was indicated after you declined to order it.

Next step beyond liability protection - Press-Ganey protection - for all these patients who expect answers, and CTs at the minimum, and aren't going to fill out very favorable patient satisfaction surveys without getting what they want....

http://www.acep.org/Content.aspx?id=79958

Wednesday, June 1, 2011

Hurricane Season

June 1st marks the start of Hurricane season.

Many Emergency Physicians are acutely aware of the need for disaster preparedness, but there are also many areas that have not sustained significant natural calamity and may be complacent.

Most of the expert predictions are expecting above-average Hurricane activity - and the Eastern Pacific wind environment that pushed all of last year's storms out to sea in the Atlantic is not present this year.

We will have a major hurricane event somewhere on U.S. soil this year.  Or, at least, we should be preparing like there will be one.

http://www.nhc.noaa.gov/

And, on a related note, where disasters are like to occur:

http://www.nytimes.com/interactive/2011/05/01/weekinreview/01safe.html

Two Months

So, it's been two months since I started this little professional development experiment.

April: 31 posts, 49 pageviews
May: 30 posts, 221 pageviews

Still working off the "if you build it, they will come" premise that if I create a resource that people think is worthwhile and important, it will gather steam of its own accord and slowly gather an audience and referrals with minimal intervention.

The next thing I am working on to complement the blog is an audio digest podcast for each month.  I'm about halfway through April and it's fun, but a little time consuming.

Update: I finished the April Podcast - and it's really not very good.  It's going to stay on the cutting room floor.  I'm going to rethink the format and content before recording another month.

Tuesday, May 31, 2011

72-Hour Returns - Fun, But Not Useful

Our EMR lets us generate reports of our 72-hour returns - and it's a fun toy, but, reading through it is rarely illuminating.  On a rare occasion you see a "true miss", where one of your colleagues finds something through another line of thinking.  But, mostly, it's wound checks, admissions for failed outpatient antibiotic therapy for cellulitis, or the town drunk coming back in again.  It is a valuable tool, at least, in the sense that our ED is the only one for 40 miles and is the only tertiary center for 90 miles, so we should get most of our own bouncebacks.

And, this study essentially confirms my anecdotal observations - most people who come back return for non-emergent conditions, do not require significant additional testing, and are no more likely to be admitted.  Their conclusion, then, is that 72-hour returns are of limited utility as a quality measure - something of which I tend to agree...although, if it were, the unintended consequence of discouraging that 2-day wound check/abscess repacking might finally put abscess packing to rest....

http://www.ncbi.nlm.nih.gov/pubmed/21496142

Monday, May 30, 2011

Bypassing The ER With STEMI

This is a paper cited in the most recent ACEP Weekend review that tries to draw more profound conclusions than it probably should.

It's another piece of the growing body of literature that says "Hurry!  Prehospital activation is all we need in STEMI!"  From Israel, it's a retrospective review of performance variables and patient outcomes between a cohort that was assessed in the ER and a cohort that went straight to the lab.  They draw a few conclusions, some of which are valid.

First, time.  One of the two "primary" outcome variables is door-to-balloon time.  No argument that skipping steps along the way will save you time.  No study is needed to prove that.

The second "primary" outcome variable is MACE within 30 days - another combined endpoint kludge of death, CHF, reinfarction, CVA, TIA, and urgent revascularization.  This one favored the direct-to-ICCU group, 22% to 30%.  How is 30-day CVA/TIA directly related to the effectiveness of PCI?  Looking at their secondary outcomes - death was not significantly different - but CHF was 8% different, which therefore accounts for essentially the entire difference between groups in this primary outcome.

And the problem?  Well, they also show in a secondary outcome that LVEF >30% was 7% greater in the direct-to-ICCU group...from which it follows there would obviously be less heart failure in that group.  But, in their demographic information, they don't know the pre-intervention LVEF for their patients - only the Killip class on presentation, which is a measure of the heart failure associated with the acute cardiac event, not their pre-existing LVEF.

So, the only thing they've effectively proven in this study is that skipping steps saves time.  And, they don't comment on the number of false positives in each group, either.

http://www.ima.org.il/imaj/ar11apr-07.pdf

Sunday, May 29, 2011

Fluid Boluses Increase Mortality In Children

...or, at least, that's the gist of the New England Journal Article making rounds in the news.

And, while a close reading of the article doesn't offer great support for harm, it certainly supports saying that albumin, saline, or nothing were equivalent.

The absolute difference in survival was 3% - and, looking at the demographic breakdown, there were 2-3% differences or trends in favor of the control group regarding dehydration, acidemia, base-deficit, and bacteremia.  Enough that it lets me cling in denial to standard practice and teaching here in the U.S., in addition to whatever you want to say about external validity of a study in resource-poor settings in Africa.

It is an odd and unexpected finding, so say the least.  The authors attribute at least part of the unusual discovery to the high percentage of malaria cases they treated, and that fluid resuscitation in malaria is controversial - but regardless, this is going to be a frequently discussed study on the Pediatric Critical Care side of things for some time.  I also expect follow-up confirmatory studies to be a tough sell to U.S. IRBs.

http://www.nejm.org/doi/full/10.1056/NEJMoa1101549

Friday, May 27, 2011

Red Cell Distribution Width... Means What Now?

"Red cell distribution width is a robust predictor of... all-cause patient mortality."

I saw this article when I was browsing abstracts, and I thought, "Huh!  That sounds interesting, though, probably not relevant."

So, yes, increasing red cell distribution width is associated with increased mortality.  However - and this is something I've never seen before in an article - looking at the table describing the differences between their various divisions of RDW% - every other descriptive statistic is different between groups.  More septic patients with high RDW%.  More renal failure.  Differences in hematocrit.  More organ failure.  They claim by statistical multivariate massage, that RDW shakes out as an independent factor, but, sheesh...it's almost like saying decrease in temperature is highly associated with death, when they're cold because the blood isn't circulating, the breathing has stopped, the brain has shut down, etc....

Another fine example of where reading the abstract is absolutely no replacement for perusing the article.

http://www.ncbi.nlm.nih.gov/pubmed/21532476

Thursday, May 26, 2011

Pediatric Septic Shock Protocol

Another sort of goal-directed sepsis study, this time in Pediatrics at Primary Children's.  They implemented a protocolized triage system in their ED designed explicitly identify more cases of sepsis - which led to increased percentages getting early fluid resuscitation, early lactate level measurements, and more frequently antibiotics in the first three hours.

But the net effect of all these interventions...the only detectable difference in their 345 patient cohort was improved length-of-stay for survivors, from IQR 103-328 hours pre-intervention to IQR 86-214 post-intervention.  Total hospital costs were not significantly different.  No change in mortality - which was already low at 7%.

So, yet again - adherence to "quality measures" has debatable clinical significance.

Wednesday, May 25, 2011

Procalcitonin Misleads Antibiotic Therapy In Sepsis

An important negative study of an inflammatory biomarker that's been getting a fair amount of push.

It is absolutely true that procalcitonin levels may be elevated in an inflammatory states such as sepsis.  This group tried to make a clinically relevant protocol for procalcitonin trends by saying, if the procalcitonin level is not decreasing with current therapy, then antibiotic coverage should be expanded and aggressive testing should be undertaken to evaluate for missed source control.

Unfortunately, in the treatment arm where procalcitonin was used in clinical decision making, there was extensively greater broad-spectrum and multiple-antibiotic utilization without any demonstrated mortality benefit.  In addition, LOS and ventilator-depended days were longer in the procalcitonin arm.

There were very minor differences between the two groups, probably favoring the control, but not nearly enough to suggest that procalcitonin has any value in assessing failure of current therapy.

http://www.ncbi.nlm.nih.gov/pubmed/21572328

Tuesday, May 24, 2011

Massachusetts Health Reform Is "Working"

By some measures, at least, you can claim that the Health Reform is working.  I've seen a few articles out there saying it failed, because ED visits continue to rise.  But, if this study is reliable, the increases in ED utilization are a result in increased illness severity, not inability to access a physician.

Non-acute visits for the uninsured/low-income cohort in Massachusetts went down, from 43.8% to 41.2% - a greater decrease as compared to their "control" group of private insurance that is supposedly unaffected by health reform, which decreased from 35.7% to 34.9%.  So, one way to interpret this is that increased access has kept some of the non-urgent uninsured out of the ED.

...but they're still seeing, by their definition, a solid nearly 40% of patients in our EDs that have less than a 25% of requiring true Emergency Department care.  So things have incrementally improved - but the problem is not simply that a patient has nominal access to a PMD, they actually need to be able to access that PMD on a semi-urgent basis to truly reduce ED utilization...and that PMD needs to be more than simply a revolving door back to the ED.

http://www.ncbi.nlm.nih.gov/pubmed/21570157

Monday, May 23, 2011

Early Antibiotics Show No Benefit in Sepsis

Interesting analysis of the EMSHOCKNET cohort, looking to see if there was any association between time to antibiotic administration and survival benefit in septic shock.

And, no.  Earlier antibiotic administration, as measured by arrival time in the the ED, showed no significant impact.

They do another secondary analysis where they try to say, well, if the patient received antibiotics before they met criteria for septic shock - then they had a 2.59 (1.17 - 5.74) OR for survival.  I'm not sure how to interpret this finding - perhaps because they looked at 10 different cut-off points for antibiotic administration, they found one that favored antibiotics by chance.

Or, perhaps antibiotics really aren't the lynchpin in treating sepsis - if you can give antibiotics ahead of SIRS, perhaps you have a milder case - but once you have end-organ dysfunction, the interventions that target improving the physiologic changes of sepsis are more important.

http://www.ncbi.nlm.nih.gov/pubmed/21572327

Sunday, May 22, 2011

Delivering Clinical Evidence

These are a couple interesting commentaries regarding the state of clinical evidence and the difficulty of applying it at the point of care.  One, from the BMJ, worries about the sheer number of studies and trials being generated, and that the data will never be able to be appropriately digested, and we'll all die slow deaths from information overload.  And, to some extent, this is true - how many of us carry around "peripheral brains" in our pocket?  Before smartphones, it was the Washington Manual or Tarrascon's, and now we have MedCalc, Epocrates, etc.  And, we desperately try to simplify things so we can wrap our brains around it and integrate it into a daily practice by distilling tens of thousands of heterogenous patients into a single clinical decision instrument like NEXUS, CCT, CHADS2, etc.  While this is better than flailing about in the dark, it's still repairing a watch with a hammer.  These tools tell us about the average patient in that particular study, and have only limited external validity towards the patient actually sitting in front of us.

Dr. Smith's BMJ article proposes the "machine", which is a magical box that knows all and provides seamless patient-specific evidence.  Dr. Davidoff isn't sure that's feasible, and, as a stopgap measure, promotes the rise of the informatician or medical librarian, a new role for utilizing the available electronic health databases.  This librarian will be expert in reading medical literature, will be expert in data mining healthcare information systems, and discover the most relevant ways to target quality and guideline improvement initiatives.

They're both right, in a way.  And we should definitely train and mature the growing discipline of this clinical informatician while we keep working on the magic box....

http://www.ncbi.nlm.nih.gov/pubmed/21558524
http://www.ncbi.nlm.nih.gov/pubmed/21159764

Saturday, May 21, 2011

Abdominal Aorta Pressure During CPR Increases CPP

I like that the big focus these days is on increasing cerebral perfusion pressure in cardiac arrest - sure, we can focus on more interventions to flog the heart back into coordinated activity, but, sometimes, it's just not going to happen.  But, for when we are able to get the heart rolling again, unless you're a big organ donation proponent, we need to preserve neurologic outcomes.  After all, that's where a lot of our studies of ACLS fall off - we get short-term ROSC, but survival to hospital discharge is unchanged because the brain is unrecoverable.

Here's another trick in pigs - sustained AA pressure resulting in measurable increases in CPP.  Better CPP = better neurologic outcomes in other studies.  Seems like a no-brainer.

I particularly like this intervention because it's basically no-cost and should be easy to test for outcome efficacy in humans.

http://www.ncbi.nlm.nih.gov/pubmed/21550162

Friday, May 20, 2011

Heart Fatty Acid Binding Protein

A nice comparison of the sensitivities and specificities of the various biomarkers for acute myocardial infarction at ~3.5 hours after symptom onset.  Each biomarker was set at the 95th or 99th percentile based on manufacturers definitions for their reference table, and then they also show ROC curves and calculate AUCs for each.

Essentially, none of the biomarkers is completely adequate for ruling out AMI given the constraints of their study.  Their best combination, for both sensitivity and specificity, is combining the heart fatty acid binding protein and the troponin - which they state provides an NPV of 95.6%, outperforming the "triple rule out" of troponin, CKMB, and myoglobin at 92.1%.  Interestingly, they also state that if they used clinical risk stratification, they could select a population in which HFAP and troponin together get up to 96.9% NPV...showing that regardless the resources we throw at the problem of "low risk chest pain", it is an absolutely Quixotic quest to definitively rule out every MI in the Emergency Department.  3% of their "very low risk" population that was biomarker negative with the best sensitivity they could muster ended up ruling in for AMI during their subsequent hospital stay.  They only way we're going to prevent healthcare from becoming bankrupt is increasing our levels of acceptable risk.

As a side note, this article gets the award for "best vs. least professional" title so far this year.

http://www.ncbi.nlm.nih.gov/pubmed/21561701

Thursday, May 19, 2011

Near-Daily Updates

The presence of near-daily updates is somewhat an artifact that I've had an easy time finding interesting research papers to queue up, plus I've been in a bit of a lull regarding clinical responsibilities.

The eventual goal will probably be to have something up 3 to 5 days a week from myself, and, if other clinicians start contributing, then, even more than that.

Speaking of which, if you're at least a senior resident in Emergency Medicine, have opinions, and like writing little blurbs about new literature, you're welcome to drop a comment regarding potentially contributing to this blog.

Cardiac Arrest - Never Bathe Again (in Japan)

Or, alternatively, never bathe in fall and winter.

Data mining expedition evaluating the event rate of out-of-hospital arrest where activity could be determined, and then using the Japanese averages of time-per-day to evaluate for hourly rates of arrest per activity.

Working was the most cardioprotective per hour spent - and it had the best ROSC and survival, mostly because it was highly witnessed.  Sleeping and exercising were riskier behaviors than working - sleeping moreso, because it was infrequently witnessed and had minimal survival.  So, you might as well just keep working.

But, definitely don't bathe because 1) no one is watching you bathe, so the survival is dismal and 2) the risk of cardiac arrest was a preposterous 40 times greater than working, and when the time of year was taken into account, bathing in cold winter months led to up to 100-fold increase in arrest rate.

The authors believe this is specifically related to Japanese homes being poorly insulated, leading to predictable large blood pressure drops when entering their traditional very hot baths.

Work harder, live longer.

http://www.ncbi.nlm.nih.gov/pubmed/21543146

Wednesday, May 18, 2011

Difficult Intubations and Association With Complications

Retrospective data out of the ketamine vs. etomidate prospective survival study.

Doesn't prove anything - and it makes me want to go back and look at the original ketamine vs etomidate article to see if difficulty of intubation was included as a demographic factor - and, I wish this study indicated which sedative medication was used as well.

In any event, the more complicated an intubation was, the more likely there were complications with the intubation.  And, further down the road, more patients who had intubation complications were deceased at the end of their follow-up period.  Things that predicted complications during procedure included age, illness severity, BMI, specific medical disorders, respiratory distress, and difficult intubation.

Nothing here changes practice - since intubation is not an elective procedure.  This is more a recognition that, yet again, sick people die.

http://www.ncbi.nlm.nih.gov/pubmed/21345571

Tuesday, May 17, 2011

NSAIDS Kill - Especially Diclofenac

While the protections for individuality make America the colorful place it is today, it sure is easy to run massive cohort studies in European countries where they sacrifice a little bit of anonymity for the common good.

Everyone in Denmark has a number, and they tracked every patient in Denmark with a history of MI to see if they had any adverse events after receiving a prescription for NSAIDs.  There were a few significant differences in the populations receiving each different kind of NSAID - rofecoxib and celecoxib tended to be given to older, female populations, and there were some differences throughout their groups regarding the prevalence of other co-administered cardiac medications.

This article really annoys me because the page with which they present their incidence of death by week has six charts that lend themselves immediately to visual comparison - but their chart scales are grossly different.  Ibuprofen looks terrible at first glance, but then you realize it has the smallest y-axis scale, and actually performs quite well.  In the end, they all demonstrated worsening of outcomes regarding death/MI compared to the total study population rate of death/MI not proximate to NSAID use.

In the end, ibuprofen and naproxen had the least effect on the OR for death; it is fair to avoid rofecoxib, celecoxib, and diclofenac in your routine prescribing without specific indications.

http://www.ncbi.nlm.nih.gov/pubmed/21555710

Monday, May 16, 2011

Erythropoietin is of No Benefit in STEMI

I have to say, the outcomes of this study both surprised and did not surprise me.  A couple years ago, I read a few articles regarding erythropoietin administration in animal models of myocardial ischemia, and they actually tended towards cardioprotective effects.  However, there have been some other retrospective reviews looking at erythropoietin levels in humans that have not been quite as conclusive.

The efficacy cohort rather favored the intervention group - the most important significant difference was primary vs. rescue PCI, and significantly more EPO group patients received primary PCI.  But, then, their results section is mostly a long list of non-significant differences, and some secondary outcomes favoring placebo.  Adverse events also favored placebo.  So, I don't think we'll be seeing EPO on the code STEMI order sheet anytime soon.

As another aside, and sort of a follow-up to the Annals of Internal Medicine article a month ago regarding conflicts of interest in the new ACC Guidelines - the disclosure list for this article is massive.  It is clearly the standard of care in Cardiology to be on the payroll of multiple pharmaceutical companies in one fashion or another.

http://www.ncbi.nlm.nih.gov/pubmed/21558517

Sunday, May 15, 2011

Advanced Life Support - Not Dead Yet?

Meta-analysis of published trials, 9 for trauma and 9 for non-trauma met their inclusion criteria after review, examining OR for survival when comparing ALS to BLS.

Trauma, unsurprisingly, derives no benefit from ALS in cardiac arrest.  They even found a pooled OR of 0.89 for survival with ALS, but the CI just barely crosses 1.

But, contrary to the two most recently published prospective trials, their meta-analysis of non-trauma arrest still shows a survival benefit for ALS.  They do include a few trials from before AEDs were available in BLS in 1995, but it still doesn't explain the entire benefit.  They also cite a few studies in which a physician is part of the paramedic team, which may mean there's more to ALS than AHA ACLS, so that might be a bit of a confounder.  Hard to know what to make of this data, considering the lack of demonstrable benefit from ACLS medications and the decreased survival of patients intubated in the field in out-of-hospital arrest.

My take is still that cardiac arrest, for the moment, is still a place where significant out-of-hospital resource investment is low yield, and CPR and AED is all they need en route to the ED.

Saturday, May 14, 2011

Computerized Resuscitation in Severe Burns

This is a critical care study that showcases an interesting tool developed for ICU resuscitation of severe burns.  The authors make the case that adequate resuscitation for burns, i.e., the Parkland Formula, is necessary - but that patients are frequently over-resuscitated.  Rather than simply settling for the rigid, formulaic crystalloid infusion over the first 24 hours, they developed a computer feedback loop that altered the infusion rates based on urine output.  Think of it as insulin drip protocol or heparin infusion protocol - but instead of glucose or PTT, you're measuring UOP and adjusting the fluid rate dynamically on an hourly basis.

I like this study because they have a primary outcome - improved adherence to their UOP target - and then secondary outcome variables that matter, mortality, ICU days, ventilator-free days.  While secondary outcomes are hypothesis-generating tools, making a rational leap to connect the association between their UOP adherence and the massive improvement in mortality demonstrated would not be reproachable.

It is not a large study - and the control group had the same % BSA burn, but had significantly more % full thickness burns.  The magnitude of the mortality outcome could certainly be affected by more demographics than they report, so a follow-up is necessary.  However, the premise of a feedback loop offloading cognitive tasks from providers as part of the management of a complex system is almost certainly something we're going to see more of in medicine.

http://www.ncbi.nlm.nih.gov/pubmed/21532472

Friday, May 13, 2011

Augmentin Is Non-Inferior to Appendectomy

A lovely study out of The Lancet that tells us what we already know…is not as right as we thought it was.  We've all seen the pediatric patient, usually female, that went to their pediatrician's office with abdominal pain, had evidence of cystitis on a UA, and was prescribed amoxicillin or cephalexin.  They got a little better, but they're still having some nausea, some pain, and some loose stools.  In your ED, the ultrasound is positive for free-fluid without visualization of the appendix, and a CT scan subsequently shows evidence for appendiceal rupture.  But – as we'll see here – most cases probably resolved before you saw them.

This is a prospective study randomizing patients to antibiotics versus early surgery, and the antibiotic group here actually had a lot more success than we imagine – since all we see/remember are those patients where we discovered the "latent" appendicitis, partially treated and festering after that initial course of antibiotics.  Only 12% of their CT-proven uncomplicated appendicitis went on to have a appendectomy in the first 30 days, and 30% within a year.  So, you could almost argue that with an 88% short-term cure rate with antibiotics and a 70% medium-term cure rate, antibiotics should be first-line therapy with observation for clinical worsening.

Definitive therapy has its advantages – you could almost equate the appendix to the gallbladder, and say that the 30% recurrence is almost certain to rise in subsequent years.  But, is there an advantage to waiting to do an appendectomy on an elective basis?  Are the adhesions that might develop more or less of an issue that the risks associated with emergent surgery?  And, of course, in the female pelvis, any undertreated appendicitis represents a significant fertility risk.  This study raises great questions about whether we should change our practice regarding our approach to appendicitis, and it might just be we find a role for being less aggressive with surgery.

“Amoxicillin plus clavulanic acid versus appendicectomy for treatment of acute uncomplicated appendicitis: an open-label, non-inferiority, randomised controlled trial.”
http://www.ncbi.nlm.nih.gov/pubmed/21550483

Thursday, May 12, 2011

2010 ACLS Guidelines

I'm sure you've seen summary articles from various sources regarding updates to the ACLS algorithm for 2010.  The change in the BLS component from an A-B-C to a C-A-B with a focus on providing high-quality compression-only CPR is well-publicized.

On EM:RAP - an educational resource I simply cannot recommend highly enough as a way to mix entertainment with CME - Mel Herbert issued the challenge to submit proof of the "epinephrine-free code".  They made this hypothetical challenge based on a close reading of the new ACLS guidelines for PEA/asystole - which, if you look closely, reflect a tacit acknowledgement of the futility of ACLS medications.  Between atropine, bicarbonate, epinephrine, and calcium - various pieces of the kitchen sink available in the code cart - only epinephrine still has a role in the guidelines, but the level of evidence has decayed to IIb, which is at the "expert opinion or consensus" level.

There are a couple large studies with limitations from Scandinavia that show associations of epinephrine with poorer outcomes, or no improvement in survival with ACLS medication administration pre-hospital.  And, if you consider the vasoactive properties of epinephrine - sure it increases CPP, but its effects on the oxygen-debt of the peripheral vascular bed, the effect on subendocardial perfusion and infarct size - imagine giving epinephrine to a STEMI patient.  We're injuring the most important organ system of interest in cardiac arrest.  I am more than willing to take up the challenge of epinephrine-free resuscitation - I just need to find some evidence to support something else to give in the meantime so I'm not reported to the Chief of Staff so it looks like I'm trying.  Anyone have anything in mind?

http://circ.ahajournals.org/content/vol122/18_suppl_3/
http://www.ncbi.nlm.nih.gov/pubmed/12104107
http://www.ncbi.nlm.nih.gov/pubmed/19934423

Wednesday, May 11, 2011

Comparison of Adult Head CT Rules in Pediatrics

Interesting - if limited in prospective use - retrospective comparison of the New Orleans, Canadian, and NEXUS II instruments for risk stratifying adults suffering minor head trauma.  Busy, urban children's ED went through 8 years of data to find over 6000 patients with minor head trauma.

Unfortunately, they only looked at the 2,101 that received a head CT, so we lose a huge chunk of our population to "clinical judgement" that could have profoundly affected the specificity of the rules and perhaps had small effects on their sensitivity.

Full of interesting tidbits - 25% of their study population was under 2 years old, but 41% of their injuries were detected in the under 2 population.  Sensitivity and specificity essentially rose and fell with the percentage of the cohort scanned - the New Orleans rule would have scanned 89% of their cohort...that had an incidence of 4.4% of intracranial injury.  That made the sensitivity 96%, but the specificity 11% - and I hate to think what the specificity would have been if the other 4000 patients had been included.  The Canadian Rule scanned the least, missed the most at 65% sensitivity, but achieved a 36% specificity.

But the real question is - what's the point?  The PECARN criteria get you up to ~96% sensitivity with a specificity of 53-58%.  Kids aren't small adults - especially infants, and especially in trauma.  Don't apply adult criteria in kids.

http://www.ncbi.nlm.nih.gov/pubmed/21465153

Tuesday, May 10, 2011

"Suspended Animation"

This is, actually, an important avenue of contemporary research, highly funded by DARPA at Texas A&M - although this research is from Germany - and this article is about one of the methods tested that got into the lay press a year two back.

The driving principle is that, the best way to keep someone newly dead from starting to go down all those cellular pathways that make cells go "pop", is to shut down cellular metabolism and starve those pathways of cellular energy.  This seems like a sound idea - although, a lot of other cellular pathways that maintain cellular integrity and electrochemical gradient stability are also funded by those same pathways.  But, the theory is that if you have a tissue hypoxic event, slow everything down to buy you more time, fix the overriding problem, and then resuscitate the patient.

Didn't work for these folks.  61 Wistar rats given hydrogen sulfide as their agent to paralyze cellular metabolism.  Significantly better pH and less base excess initially during acute resuscitation from cellular hypoxia, so it is doing something to prevent tissue oxygen debt - but their primary outcome of neurologic preservation, they showed temporary neurologic preservation at an interim test, but no differences at the 7 day point, and no histochemical differences after sacrifice.

This sort of research is still clearly poking about in the dark right now, but it is absolutely the future of resuscitation - to give us a reason for hope in the trauma bay that return of circulation is neurologically intact and not simply just for organ donation.

http://dx.doi.org/10.1016/j.resuscitation.2011.03.038

Monday, May 9, 2011

Vital Sign "Triggers"

So, this was an interesting article about a system of vital sign "triggers" an ED implemented to get nurses to flag specific patients for more urgent attention.  Not unexpectedly, the study finds that, when nurses get physician's attention, everything happens more rapidly to those patients, orders, antibiotics, and disposition.  The problem is, the article doesn't address the appropriateness or any unintended consequences of this sort of intervention.  The theory would be that these abnormal vital signs represent patients that need more urgent evaluation, but vital signs are always just one piece of the puzzle.  In any event, this study spotlights something that can be reasonably construed as important - nurses should be educated to recognize potentially ill patients and notify physicians.

Of course, in the back of my mind, I was envisioning our ED (and likely many around it) which rooms patients first, and then triages them - and it then becomes the responsibility of the nurse whose zone they have entered to take and record vital signs.  This results in patients being roomed much faster - which many studies have shown is likely a good thing.  Unfortunately, when a patient is roomed to the high-acuity side based on chief complaint, the nurse to which they are assigned may be quite busy with their other high-acuity patients...and that patient may just sit in the room for some time without an assessment or vital signs.

Everything has potential unintended consequences.

http://www.ncbi.nlm.nih.gov/pubmed/21521399

Sunday, May 8, 2011

...and Here is Why the Elderly Are Falling

Orthostatic intolerance.

Not much more to say.

An entire quarter of their convenience sample of elderly (mostly female) volunteers had a 60 point drop in their blood pressure upon standing, with only a modicum of recovery within 2 minutes.

Antihypertensive polypharmacy was weakly associated with orthostatic intolerance, and the presence of orthostatic intolerance was weakly associated with an increased number of falls.

So, if the disease (hypertension) doesn't harm you, the treatment will.

http://www.ncbi.nlm.nih.gov/pubmed/21438868