Monday, July 11, 2011

Send Children With Negative CTs Home

We should all love PECARN.  I love PECARN (Pediatric Emergency Care Applied Research Network) - and not just because I helped set it up as a research assistant peon before medical school.  I love it because it takes multicenter enrollment cohorts to conduct adequately powered research in a population that is rarely affected by serious morbidity and mortality.

Of 13,543 children with GCS 14 or 15 and a normal CT scan, none needed neurosurgical intervention in their follow-up period.  A small handful of these patients had a repeat CT or MRI for some reason, and between 10-25% of the hospitalized patients and 2-10% of the discharged patients had an abnormal result on repeat imaging.  None led to any intervention...which then, of course, begs the question whether it was appropriate to perform a test that did not result in meaningful change in management.  But, there's not enough patients in this group to draw conclusions as to whether repeat scans should or should not be performed.

My only caveat - when you take an over-utilized test in which nearly all patients are certainly fine and will continue to be fine, you actually dilute its external validity to the patient population that really matters.  However, even in a higher-risk patient population in which CTs are used far more conservatively, the clinically relevant answer is still going to be same - the only reasonable practice is still going to be to discharge these patients home.

"Do children with blunt head trauma and normal cranial tomography scan results require hospitalization for neurologic observation?"

Sunday, July 10, 2011

Groomsman Gifts

I bought all my groomsmen whiskey as gifts - at the world's largest liquor store, which is conveniently located 7 blocks from my new home in Houston.

Longrow 14 Year Old Sherry Cask Finish
It's a Campbeltown region Scotch whiskey that's a peatier version of the Springbank that I think is very nice.  Made by the same distillery in a limited run every year.

Suntory Yamazaki 18 Year Old
I posted once upon a time about the 12 year version of this whiskey, which is a Japanese whiskey aged in three types of oak cask.  I really liked the reasonably-priced 12 year, and I hope my best man will enjoy the 18.

Ardbeg Corryvreckan
Named after a famous maelstrom, it's a viscous, peaty Scotch whiskey for my friend who loves all things Islay.

Woodford Reserve Master's Collection
For my bride's brother, who prefers Bourbon whiskey, the seasoned oak finish Master's Collection edition.

Saturday, July 9, 2011

Annie + Ryan

Wedding today!

Posting schedule MTuThF for the rest of the month - we'll be in Scandinavia.

Friday, July 8, 2011

Babesiosis - Scourge of the Lower Hudson Valley

Fascinatingly, babesiosis has suddenly become endemic to New York.  From 6 cases per year between 2001-08, it's now up to 100+ cases per year in the region.  Still nothing compared to the 4600 cases of Lyme disease, but nearly rivaling the 213 cases of ehrlichiosis.

Hospitalized patients had fever and hemolytic anemia, and were treated with azithromycin and atovaquone.  5.6% case-fatality rate, although, the parasitemia in these cases was exacerbated by underlying medical conditions.  Won't see this down here in Texas, but the public health surveillance responsibility of Emergency Medicine is always important to remember.

"Babesiosis in Lower Hudson Valley, New York, USA."

Thursday, July 7, 2011

If You Don't Reperfuse STEMI, That's Bad

I'm not sure why this is earthshaking news - other than some good statisticians had access to some good data.  Of course, that's pretty much what research is about - have data, will travel.

This JAMA article looks at door-in-door-out time for STEMI at transferring hospitals - and they suggest an association between between quicker transfer times and unadjusted mortality.  There is still some debate regarding how much time to primary PCI matters, but, if you say this in-and-out time is a surrogate marker for time to primary PCI, you could presumably support the hypothesis of rapid PCI mattering.

There are a few interesting nuggets of information in the article - particularly looking at patients for whom the transfer time was exceptionally prolonged.  Essentially, left bundle and patients with ambiguous or non-obvious STEMI were delayed.  I.e., when the diagnosis is hard, it's hard to make the diagnosis.

As usual, time matters to the individual, but system factors affect many patients.  Mortality for STEMI is improved by faster transport, but you still need to consider the consequences of faster transport.  Reckless abandon towards shoving a semi-stable patient out the door won't always lead to better outcomes, but, then again, I have worked in some of those hospitals....

"Association of Door-In to Door-Out Time With Reperfusion Delays and Outcomes Among Patients Transferred for Primary Percutaneous Coronary Intervention."

Wednesday, July 6, 2011

Electronic Health Records & Patient Safety

Shameless self-promotion, regretfully.

From my other life as a clinical informatician working on patient safety and human factors as it relates to electronic medical records - my commentary on how electronic medical records might be applied to the 2011 JCHAO National Patient Safety Goals was published today in JAMA.

"Application of Electronic Health Records to the Joint Commission's 2011 National Patient Safety Goals."

I am also the spotlight author for the current issue, and you can hear my interview at:

Tuesday, July 5, 2011

Regression To The Mean

To bias is to be human, and this is a nice review of some of our own intrinsic publication biases.  It's fun to get excited about a new biomarker promising more sensitive or specific identification of disease, promising to streamline our medical decision making.  And then you get stuck with something like d-Dimer or BNP that gives us information people rarely use appropriately.

These authors pulled "highly-cited" articles evaluating biomarker utility, examined the reported findings, and then pooled the results of subsequent, larger follow-up studies and meta-analyses.  83% of their "highly cited" studies had effect sizes larger than the corresponding meta-analyses, and only 7 of the 35 biomarkers they reviewed even had RR estimates greater than 1.37 in the meta-analyses.

Jerry Hoffman likes to say on Emergency Medical Abstracts that if you just sit back and skeptically critique everything - you'll end up being right most of the time.  This article demonstrates just how frequently you'll look smart by not getting overexcited by the most recent fantastic discovery.

"Comparison of Effect Sizes Associated With Biomarkers Reported in Highly Cited Individual Articles and in Subsequent Meta-analyses."

Monday, July 4, 2011

CCTA Only Predicts Revascularizations

This is an interesting systematic review of coronary computer tomography angiography that, I think, shows mostly that the endpoints for cardiology studies need to be re-evaluated.  The conclusion that circulates in the new has been that positive CCTA was highly predictive of coronary events - patients with >1 segment of >50% stenosis on CCTA had an 11.9% annualized rate of coronary "events" when compared to the 1.1% annualized rate of patients without any >50% stenosis.  This generates the 10.74 hazard ratio that has been circulating through the press releases trumpeting the predictive value of CCTA.

Unfortunately, this predictive value is a self-fulfilling prophecy because 62% of their "events" were revascularizations.  If you subtract out the portion that went for revascularization, the remaining all-cause mortality, cardiovascular death, nonfatal MI, UA requiring hospitalization, that's 5% annualized rate.  Still higher than folks without any coronary stenoses at all, but you have to wonder - could we have predicted the population with a 5% cardiovascular morbidity risk without a CCTA?  Does the management decision to perform revascularization confer upon this population a cardiovascular morbidity/mortality benefit?  We are seeing a lot more in the literature showing that medical management is as advantageous as stenting, so, again, I'm not sure what the role of CCTA is - particularly from the Emergency Department.

"Meta-analysis and systematic review of the long-term predictive value of assessment of coronary atherosclerosis by contrast-enhanced coronary computed tomography angiography."

Saturday, July 2, 2011

Ambulance Diversion Kills People? Maybe?

This article got a ton of press - but it tries to take far too simple an approach to far too complicated an issue.  I've done research like this, where you use zip code centroids and calculated distances to nearest hospitals, and it's just one way a blind man describes an elephant.

These authors look retrospectively at all the acute MIs in four California counties, then looked at hospital daily diversion logs for each day from each of those hospitals - and tried to merge them together to prove that if your nearest hospital was on diversion for a lot of the day you had your acute MI, you had worse outcomes.

Their final analysis says, basically, there's a 3-5% difference in 30-day, 90-day, and 1-year mortality if your nearest hospital is on diversion >12 hours in a day vs. if your nearest hospital is on diversion <6 hours per day.  The between 6-12 hour diversion cohort performed identically to the <6 hour per day cohort.  So, I don't know exactly what to make of this.  Their 95% CI almost crosses zero.  Something magical happens at 12 hours that changes your acute MI mortality risk.  So, yes, what the authors are trying to prove is probably true - but this article's data mining and massage can only hypothesize the association, and doesn't prove anything.

"Association Between Ambulance Diversion and Survival Among Patients With Acute Myocardial Infarction."

Friday, July 1, 2011

Algorithmic Approach To Detect Sepsis Fails

I was asked to blog about this little article - since it lies at the intersection of Emergency Medicine and informatics.

So, that feeling you get when you look at a patient who is obviously ill?  Computers don't have that yet.  These folks tried to encapsulate that feeling of "sick" vs. "not sick" into the criteria for severe sepsis, which includes SIRS and hypotension.  The hope was that an algorithmic approach that automatically recognized the vital sign and physiologic criteria for SIRS would trigger reminders to clinicians that would spark them to initiate certain quality care processes sooner.

Out of 33,460 patients processed by the system, 398 triggered the system.  Less than half (46%) of those were true positives.  To follow that up, they tried to evaluate their system for sensitivity and specificity by pulling 1 week's worth of data (1,386 patients) for closer review - and they found the system generated 6 false positives, 7 true positives, and 4 false negatives.  And those numbers speak for themselves.

Looking back at their four quality measures, they all showed a trend towards improvement - unfortunately three of their four quality measures don't even have a theoretical connection to improved outcomes.  Chest x-ray, blood cultures, and measuring a serum lactate are all clinically relevant in certain situations, but they are all diagnostic and management decisions independent of "quality".  Antibiotic administration, however, is part of EGDT for sepsis (for what it's worth), and that trended towards improvement (OR 2.8, CI 0.9 to 8.6).  

But the final killer?  "In approximately half of patients electronically detected, patients had been detected by caregivers earlier".  So, clinicians were receiving automated pages suggesting they might consider an infectious cause to hypotension, probably while already placing central lines for septic shock.

Great concept - but automated systems just don't yet have robust, rapid, high-quality inputs like those a clinician gets just by walking in the room.  But, EM physicians in busy departments overlook things - and a well-designed system might in the future help catch some of those misses.

"Prospective Trial of Real-Time Electronic Surveillance to Expedite Early Care of Severe Sepsis."

Wednesday, June 29, 2011

Time To Let ABCD2 Die

The problem - the most difficult clinical situations are the ones where we need a handy decision tool - and the hardest to come up with an effective one.  Syncope rules, PE prediction rules, ACS prediction rules, and now TIA evaluation.

The most important number to come out of this paper is probably 1.8% - the number of patients with a TIA who went on to have a stroke in the next seven days.  That's 38 out of their 2056 patients enrolled.  The next number is 2.7%, which is the 56 patients who had another TIA within 7 days.  So somehow a rule has to magically pick out that tiny proportion of patients who are going to have bad outcomes without excessively testing the remaining supermajority.

Nearly everyone had a CT of the head, nearly everyone had an EKG, very few (15% with an ABCD2 score ≤ 5 and 22.% with a score > 5) had consultation with a neurologist, and even fewer were admitted.  The specificity for stroke within 7 days with a score >2 - the AHA definition of "high risk" - is only 12.5%.  Not only that, but there was significant disagreement between enrolling physicians and the study center regarding the correct ABCD2 score for a patient.

So, in the end, ABCD2 is difficult to apply and only minimally useful.  You're going to miss half the strokes at 7 days if you apply it in a situation where the specificity is >50% - so, sure, a sky-high score tells you they're in trouble, but that still doesn't help you discharge the majority of your TIAs safely for outpatient follow-up.

"Prospective validation of the ABCD2 score for patients in the emergency department with transient ischemic attack."

Tuesday, June 28, 2011

Surfactant for Hydrocarbon Aspiration

I've seen surfactant administered for alveolar collapse following near-drowning, but this is a case report regarding surfactant use in severe pneumonitis after low viscosity/low volatility lamp oil.  Less than 1mL of similar aspirated hydrocarbons may result in significant lung injury.  In their specific case they administered 80 mL/m2 of surfactant intratracheally as rescue therapy when their patient continued to become hypoxemic despite recruitment maneuvers on mechanical ventilation.

Definitely something to keep in mind depending on the pathophysiology of the lung injury.

"Early administration of intratracheal surfactant (Calfactant) after hydrocarbon aspiration."

Monday, June 27, 2011

Kids Are Too Fat For The Broselow Tape Now

Now that increasing numbers of children are overweight and obese (up to 36% of 10 to 17 year olds now), 53% of this pediatric sample from West Virginia fell out of the Broselow tape estimate based on height.  Of these, 77.1% of the incorrect weights were greater than that predicted by the Broselow.

It is West Virginia - not the healthiest state in the U.S. - but any hospital that serves a predominantly disadvantaged population may have similar results, and should realize that they may be under dosing their medications.  The authors suggest only a couple alternative strategies, but I think we're probably just best off using clinical judgement as to whether the tape is accurate in each individual clinical situation.

"Is the Broselow tape a reliable indicator for use in all pediatric trauma patients?"

Sunday, June 26, 2011

The Mortality Burden of Homelessness

Anyone working in the Emergency Department knows that homelessness and psychiatric disorders go hand-in-hand - and that also goes psychiatric disorders and substance abuse.  This study confirms what we already know about the prevalence of these issues in the homeless population.

The most interesting number I read out of it was that the life expectancy of a homeless male aged 15-24 years was 38.7, and 47.4 for similarly aged homeless females - compared to life expectancies of 60.3 and 64.8 in their general population.  It makes me wonder how much of that life expectancy difference is just the homelessness, or whether it's the psychiatric and substance abuse disorders - I would probably say most of that difference is made up with the substance abuse.

"Psychiatric disorders and mortality among people in homeless shelters in Denmark: a nationwide register-based cohort study."

Friday, June 24, 2011

Pediatric Sexual History Should Not Be Neglected

I am torn regarding whether 82% represents appropriate performance on history taking in pediatric adolescent (ages 14 - 19) lower abdominal pain/dysuria/vaginal complaint, or whether that remaining 18% represents potentially uncaptured pathology.  Considering that 76% of patients asked regarding sexual history reported sexual activity, and 83% of their subgroup completing anonymous questionnaires reported sexual activity, I think >90% enquiry regarding sexual activity would be a better target.

So, we're doing a pretty good job - but it could be better.

"Sexual history documentation in adolescent emergency department patients."

Thursday, June 23, 2011

Ceftaroline - The New Wonder Drug

Don't use it.

If you're like me, every journal you pick up nowadays has a three page glossy fold-out of some confident-looking fake doctor showing off the new broad-spectrum magic medicine, ceftaroline fosamil (Teflaro).  600mg IV q12, ask your doctor if you should be receiving Teflaro.

So, finally, when I got a booklet mailed to my house, I gave in and looked at the literature.  And, I was almost legitimately defeated by the literature because most of the recent, relevant published literature regarding outcomes in the phase III written by employees of Forest Laboratories and published in a special "clinical supplement" to an infectious disease journal.  There isn't much data out there that isn't just advertising.

However, my survey of the animal studies, and presuming the human studies aren't blatantly made up, seems to indicate this is a great antibiotic.  It doesn't work against VRE, pseudomonas, ESBL e. coli, ESBL klebsiella, or acinetobacter, but it's active against many strains of MRSA, DNS MRSA, and VISA, along with the other strep and staph we worry about.

Which is exactly why we shouldn't use this antibiotic - it's so good it should be on every hospital's formulary, but locked in a vault with the same key system a nuclear launch requires.  Keep it as third- or fourth-line to prevent additional resistances.  But, don't use it.

Sadly, the article I have for you is just a review of all the manufacturer-supported data - but at least it's not written by them.

"Ceftaroline: a comprehensive update."

Wednesday, June 22, 2011

Patients Bleed When On Aspirin and Plavix

And they bleed a heck of a lot more on Plavix than Aspirin.  This is probably the first article I've ever read out of Academic Dermatology, and it's mildly relevant to EM in the sense that we perform a lot of minor cutaneous procedures - suturing, I&D, etc.

This is a retrospective review of bleeding associated with minor surgical dermatology, and, the good news, it was rare - at 0.3% of cases on clopidogrel, and even rarer on aspirin alone, and then zero when on neither.  Bleeding doesn't stress us out as much, probably, so this isn't practice changing.  They do importantly mention in their discussion that holding/changing these medications prior to the procedure can be associated with thrombotic complications - I wouldn't be rushing off to give DDAVP to wake any platelets up if I ran into procedural troubles.

"Complications of cutaneous surgery in patients taking clopidogrel-containing anticoagulation."

Monday, June 20, 2011

Public Insurance Places Children At Risk

Determining proper payment for healthcare services is a fascinating problem of substantial complexity, and, with the "Affordable Care Act" and various past and future movements towards public insurance, there is a great deal of uncertainty regarding physician payment - both in the amount (public vs. private insurance) or whether (uncompensated care in hospitals, emergency departments).

This is a very interesting study out of NEJM that is applicable to the 70 to 80% of emergency departments we send home with instructions to "follow-up with X".  They nicely demonstrate that, in Chicago, at least, "follow-up with X" is nearly trivially easy with private insurance, and much more difficult if funded by one of their Medicaid providers for children.  Excepting child psychiatry - which is in shortage - when calling a specialist for follow-up claiming to have private insurance, their research assistants could schedule an appointment well over 90% of the time.  Alternatively, when stating they had public insurance for their child, ability to follow-up ranged from 20 to 57%, depending on the specialty.

Not only that, public insurance patients waited a mean of 42 days for their appointment versus 22 days for private insurance, when they looked at clinics that would even accept that insurance option.

And, the clinical scenarios they presented for follow-up were not just routine new patient appointments - they were pediatric patients with legitimate uncontrolled morbid disease with the potential to significantly worsen and impact their overall health.

I don't have a solution to a complex social, financial, and political problem with complex social, financial, and political obstacles - but the more good articles like this are published, the more likely smart folks will start working on solutions.

"Auditing access to specialty care for children with public insurance."

Sunday, June 19, 2011

Do Not Use Etomidate/Fentanyl For Orthopedic Reduction In Children

Sometimes, when I read a study, I think to myself - great study!  If only they had sufficient enrollment to have power and validity!  When I read this study, I thought, Heavens to Betsy - I am so glad they only subjected 12 patients to etomidate/fentanyl for sedation.

This is comparing ketamine/midazolam to etomidate/fentanyl for procedural sedation and the authors hoped that, perhaps, the shorter duration of action of etomidate would make it a viable alternative.  But, it isn't.  Objective measures of procedural distress favored ketamine, parents favored ketamine, and the practitioners favored ketamine.  Sedation time and recovery time favored etomidate - but at what cost?  18% of the ketamine group had an adverse event (vomiting, emergency reaction), while 50% of the etomidate group did (hypoxemia, etc.)

Propofol/fentanyl may be considered, but not etomidate/fentanyl.

"Ketamine/midazolam versus etomidate/fentanyl procedural sedation for pediatric orthopedic reductions."

Saturday, June 18, 2011

Sensitivity of CT Angiography for Aneurysms

Not exactly the article I was expecting when I pulled it, but mildly interesting nonetheless.  The real applicability of this article is towards those folks who say the LP for SAH is outdated, and we should just proceed with CTA to identify the culprit aneurysm.

As opponents say, many aneurysms identified by CTA are asymptomatic and unrelated to the acute headache in the Emergency Department, and, without the LP, you don't know their clinical relevance.  This study lets them also say that CTA doesn't even necessarily perform well enough at this task to warrant use - it will miss 5% of aneurysms and overcall 3.8%.

However, it must be said, this meta-analysis uses data from a number of old studies that have older CT scanners that were very poor at detecting <4mm aneurysms.  Once you get to 16 and 64 row CT, your sensitivity is closer to 98-99% - and then you have to fall back to the asymptomatic/clinical relevance argument.

"Diagnosing cerebral aneurysms by computed tomographic angiography: meta-analysis"

Thursday, June 16, 2011

Neurothrombectomy Devices - Still Not The Answer

Catheter-based endovascular treatment of acute ischemic stroke has been around for several years - this is a nice, concise review of the published literature regarding their use.

The abstract sounds a little more favorably skewed than the actual content of the article - their discussion is appropriately skeptical regarding the efficacy and applicability of this particular treatment modality.  It is certainly true that restoring flow to affected regions in stroke is advantageous, and the theory behind the use of these devices is to mechanically ensure open vessels in situations where systemic thrombolysis may not be efficacious and the disability is likely to be profound.

The problem is, there really isn't any "evidence" in this article.  The published literature on this topic is primarily retrospective cohort/case-reports by industry-affiliated inventors of these devices and, even despite this bias, that literature tends to report unacceptable levels of procedural complications while trying desperately to show benefit.

Regardless, as the authors mention, there are many studies of MERCI and Penumbra ongoing - slowly chasing that inexorable statistical probability of finally performing enough studies that, by chance, one of them will be favorable enough upon which to base widespread marketing efforts.

"Neurothrombectomy devices for the treatment of acute ischemic stroke: state of the evidence"

Wednesday, June 15, 2011

Patients With Brugada May Have Normal EKGs ...and Then Drop Dead

The sodium-channelopathy that went many years before being described, now increasingly well-known.  More interestingly, the phenotype is apparently autosomal dominant in inheritance.  These investigators use this inheritance to retroactively diagnose deceased family members with a Brugada cause to their sudden cardiac death.

They found, unfortunately, that not only were most individuals who died of Brugada young, most were asymptomatic - and of the five patients for whom they could find an antemortem EKG, only one of them had a typical Type I Brugada pattern, and one had a single lead with a Type III pattern.

I think my take-home point from this article is that, in the young patients presenting with syncope, it's important not just to do the EKG, but also to enquire regarding family history of sudden cardiac death - and then hope whatever cardiologist you refer them to is insightful enough to order a amajaline provocation test if needed.

Tuesday, June 14, 2011

Significant Populations Have No Timely Access to Stroke, Pediatric Trauma Care

These are a couple studies from a family of publications that use population data, GIS mapping tools, and travel times by air and ground to estimate what percentage of the population has access to a certain healthcare resource.  In these two papers, the resources in question are Primary Stroke Centers and Pediatric Trauma Centers.  They estimate that 71% of the pediatric population is within 60 minutes of a pediatric trauma center by ground or air - which is appropriate, because trauma systems are set up to use aeromedical transport.  However - and, depending on what direction the TPA pendulum swings - only 55.4% of the population has access to a stroke center within 60 minutes - by ground, which is typical.  They say this could be increased to 79% within 60 minutes if aeromedical resources were involved, but I think we should wait to establish a greater treatment effect for acute stroke treatment before we go nuts with air travel.

I like maps; I worked with one of the authors (Dr. Branas) on previous iterations of descriptive articles similar to these.  The problem with these articles is the statistic they describe - timeliness of care - may or may not have significant effects on patient outcomes.  And, in theory, the solutions - moving trauma center designations, establishing new stroke centers, increasing aeromedical use, etc., have significant costs and unintended consequences.

Monday, June 13, 2011

Shoulder Reduction - Spanish-Style

Another interesting article regarding shoulder reduction techniques.

Essentially, what I read into shoulder reduction is that - if there many usually successful ways to do something, pretty much anything works.  And, what seems to be the generally accepted way to do it - excepting the scapular manipulation technique - is pulling on it.  What is different between methods seems to be how exactly you apply the traction.

This is a single-operator method with direct axial traction on the distal humerus with one hand and counter-traction on the acromium with the other hand.  The trouble I foresee with this method is that you're fighting a lot of large muscles on the patient with your own, smaller, rotator cuff and shoulder abductors.  I think you'd end up fatiguing before a lot of your patients.

The variation I might suggest is the snowbird technique, where you use the weight of your leg to provide downward traction via stockinette around the forearm.  You can sometimes get away from having to do full procedural sedation if you can perform a technique like this where the patient fatigues before you do.