Tuesday, August 2, 2011

It's Impossible To Catch All Pediatric Pneumonia

Another glass half-full vs half-empty, depending on how you read it.  Their editor capsule summary says "Children without hypoxia, fever, and ausculatory findings are low risk."  The numbers say - in the absence of hypoxia, fever, or focal ausculatory findings, radiographic pneumonia was seen in 7.6% (CI 5.3-10.0).  Interesting numbers that, to me, say that pediatric pneumonia is still a black box of uncertainty.

However, what the authors call "definite" pneumonia was only 2.9% in the absence of those findings, and the editor's capsule conclusion is that low-risk patients are best served by follow-up rather than radiology.  And, this is where the half-full/half-empty comes in - because a lot of EPs don't want to the guy that sends home pneumonia even in a "low risk" situation, given than 30% of their pneumonia diagnoses required admission.  I'd rather take the half-full approach - recognizing that the majority of radiographic pneumonias are viral anyway, and, if the patient has adequate follow-up and tunes up nicely, do my best to avoid unnecessary testing in a low pretest probability setting that will end up with more false positives and unnecessary antibiotics.

"Prediction of Pneumonia in a Pediatric Emergency Department"

Monday, August 1, 2011

Does EHR Decision Support Make You More Liable?

That's the question these JAMA article authors asked themselves, and they say - probably.  The way they present it, it's probably true - using the specific example of drug-drug interactions.  If you put an anticoagulated elderly person on TMP-SMX and they come back a few days later bleeding with an INR of 7, you might be in trouble for clicking away the one important drug alert out of the one hundred you're inundated on your shift.  The authors note how poorly designed the alerts are, how few are relevant, and "alert fatigue" - but really, if you're getting any kind of alerts or have any EHR tools available to you during your practice, each time you dismiss one, someone could turn it around against you.

The authors potential solutions are an "expert" drug-drug interaction list or legislative legal safe harbors.

"Clinical Decision Support and Malpractice Risk."
www.ncbi.nlm.nih.gov/pubmed/21730245

Friday, July 29, 2011

"Narcotic Bowel Syndrome"

I had never heard this specific diagnosis bandied about in an Emergency Medicine context - but, essentially, it's a gastroenterology entity (and diagnosis of exclusion) that entails, essentially, chronic, intractable, crampy abdominal pain of unknown etiology and concurrent narcotic use.  I can't even describe how many of these patients I saw each shift during residency - and how many of those people had multiple CT scans in the past year.  The key feature in this particular diagnosis, as described in their case, is they had extensive follow-up evaluation, were weaned from their narcotics, and had resolution of symptoms.

I think this is a diagnosis spectrum we see a lot in the ED - whether it be constipation, IBS, cyclic vomiting syndrome, "feeling sick", or the multitudinous abdominal pain of unknown etiology.  With more and more patients being prescribed (or secretly taking) narcotics, what we see in our EDs is not just the overdose emergencies, but the various side effect spectrums of dependence and withdrawal.

You'd think that with all our medical technological prowess we'd have better mechanisms to treat pain than they did thousands of years ago.

"Narcotic Bowel Syndrome"
http://www.ncbi.nlm.nih.gov/pubmed/21719232

Thursday, July 28, 2011

Endotracheal Tube Verification Via Ultrasound

I think I've discovered the new paradigm of research in ultrasound.  Every time you do a procedure or make a diagnosis, slap the ultrasound on someone and see if you can reliably identify anatomic changes.

It looks like, with their practiced ultrasonographers, that they can get some preliminary information regarding endotracheal tube placement by performing transtracheal ultrasound.  Their "gold standard" was waveform capnography - which is a fair gold standard, but not universally sensitive and specific for tube placement in all clinical situations.  Essentially, if the ETT is in the correct place, there is only one "air-mucosal interface" observed with high-frequency linear probe, and, if the ETT is in the esophagus, you have a second, posterior air-mucosal interface.

Seems reasonable.

Experts did it correctly with 99% sensitivity and 94% specificity, and the main advantage was speed.

"Tracheal rapid ultrasound exam (T.R.U.E.) for confirming endotracheal tube
placement during emergency intubation."

Tuesday, July 26, 2011

Online Publishing of ED Wait Times

When a small city only has two Emergency Departments, you can run a study like this to see what effect publication of ED wait times has on visits.

While it is fabulously logical that if 18 to 40 people a day are looking at your Emergency Department wait times that some portion of those people will choose a facility with a shorter wait time - or choose not to come to the ED at all - or choose to come in when they might not have otherwise come in if the wait time is short - this study doesn't actually try to study the population of interest.  They need to somehow capture individuals who are using the published information to make decisions, rather than looking generally at their overall wait time statistics - because, even though they say their results "were consistent with the hypothesis that the publication of wait time information leads to patients selecting the site with shorter wait time", they are making a huge unsubstantiated leap.

Looking at their descriptive statistics, hardly anything changed to actually justify their conclusions, and, really, it looks like patients just based their decisions pretty heavily on which of the two hospitals was closer - particularly Victoria Hospital, which people only went to if it was nearer.  I do also find it fascinating that their mean wait time rose from about 105 minutes to 115 minutes, yet the amount of time their wait time was >2 hours (120 minutes) actually dropped from 13% to 9%.  This is how they justify their conclusion that the "spikes" are mitigated by online usage - and it may be true - but there are too many moving parts and they aren't actually asking people if they used the website and used the information from it.

"The effects of publishing emergency department wait time on patient utilization patterns in a community with two emergency department sites: a retrospective, quasi-experiment design."
http://www.ncbi.nlm.nih.gov/pubmed/21672236

Monday, July 25, 2011

Facebook, Savior of Healthcare

This is just a short little letter I found published in The Lancet.  Apparently, the Taiwan Society of Emergency Medicine has been wrangling with the Department of Health regarding appropriate solutions to the national problem of ED overcrowding.  To make their short story even shorter, apparently, they ended up forming a group on Facebook, and then posting their concerns to the Minister of Health's Facebook page.  This then prompted the Minister of Health to make surprise visits to several EDs, and, in some manner, the Taiwanese feel their social networking has led to a fortuitous response to their public dialogue.

So, slowly but surely, I'm sure all these little blogs will save the world, too.

"Facebook use leads to health-care reform in Taiwan."
http://www.ncbi.nlm.nih.gov/pubmed/21684378

Friday, July 22, 2011

CTCA Studies Are Not Externally Valid

This is a multicenter study from Canada that looked at the diagnostic accuracy of computed tomographic coronary angiography using invasive coronary angiography as the gold standard - and they found that it's not bad.  Specifically, they found it was not bad at one of their four centers used in the study, and terrible at three of the four centers used in the study.  In a patient population with a pretest probability of CAD less than 50%, the AUC for CTCA was 0.951 at center 1, and 0.597 at centers 2, 3, and 4 combined.

So, clearly, the most important factor affecting the results of your CTCA is your institution's skill at performing and interpreting the test.  Which, if you take it one step further, means that unless your institution is a CTCA center of excellence like the ones pumping out the CTCA studies, you can't apply their results to your practice.  Specificity stays reasonable, but you lose a lot of sensitivity - and when the CTCA for low-risk rapid rule-out is predicated on the high NPV, you can't afford to lose sensitivity.

"Ontario Multidetector Computed Tomographic Coronary Angiography Study"
www.ncbi.nlm.nih.gov/pubmed/21403014

Thursday, July 21, 2011

"Time-Out" In The ED Is Nearly Universally Useless

...but still probably a good idea.

Out of 225 ACEP councillors responding to a survey, 5 knew of an instance in the past year where a time-out may have prevented an error.  So, a year's worth of personal patient encounters, plus whatever they heard about in their department, multiplied by 225 - which means we're looking at hundreds of thousands of patient encounters - and there were only a handful of events where a time-out would have helped.

That being said, time-outs have been a Universal Protocol with the National Patient Safety Goals since 2004 because performing the wrong procedure, at the wrong site, on the wrong patient really falls into a category of a "never event".  It does seem like a no-brainer in the ED, where the procedures we're performing on patients are specifically related to the unique presenting event, but errors still occur - and the magnitude of the harm to the patients who are being harmed is probably greater than the consequences of the additive delay in care to other patients from the cumulative time performing the time-out.

"A Survey of the Use of Time-Out Protocols in Emergency Medicine"

Tuesday, July 19, 2011

Residency Is Thinly Veiled Healthcare Rationing!

Apparently, we're still $376 million dollars short in funding just to meet the 2003 ACGME work hours regulations, in terms of hiring additional staff, etc.  So, of course, there should be no problem getting the remaining $1.4 billion needed to bring us up to date with the new rules.  And there's still the matter of these authors saying that's still not good enough.

They also say, more stick, less carrot.  For patients!  Think of the children!

Of course, they're probably right.  A lot of EM training is stressful, but it isn't barbaric.  We have enough off-service rotations to realize we're one of the relatively coddled residencies in brute terms of sleep deprivation and time away from the hospital.  My sister just finished her PGY-1 in general surgery by going Q2 into the break before 2nd year.  We're not in compliance, we're not operating at our peak abilities, and we're not exhaustively supervised.  Patients are harmed, no doubt.

But that's the reality of the funding situation and the budgets proscribed by Congress.

Now, if you want go out and inflame a mob, you could invoke this as part of healthcare "rationing", letting undertrained, barely-doctors practice on the sickest patients because we choose to allow a few people to be harmed to save money.

"Implementing the 2009 Institute of Medicine recommendations on resident physician work hours, supervision, and safety."
http://www.dovepress.com/implementing-the-2009-institute-of-medicine-recommendations-on-residen-peer-reviewed-article-NSS

Monday, July 18, 2011

It's Not An Abscess (Yes It Is)

These studies pretty much all end up saying the same thing - academic faculty can't agree on the presence or absence of differentiating characteristics between abscess and cellulitis.  This particular study is in a pediatric population, and, there's a lot of kappa and absolute agreement to comb through in their tables, but, basically, about 20% of the time two attendings substantially disagreed.  The authors then follow this up by observing that an I&D was performed 75% time, and purulent material was found 92% of the time.

The best conclusion from this might be - if there's some ambiguity, put a scalpel in it.  I'd say this is reasonable - because we've seen a hundred times the child who bounces into the ED on day 3 of cephalexin for cellulitis because what he really had was a MRSA abscess to begin with.

Or, if you have an ultrasound with a high-frequency probe, you might be able to differentiate homogenous hyperemia from fluid collection.

"Interexaminer Agreement in Physical Examination for Children With Suspected Soft Tissue Abscesses"
www.ncbi.nlm.nih.gov/pubmed/21629150

Friday, July 15, 2011

Video Education For Emergency Departments

I know you can't get published if you say something like "Our intervention is probably not useful and serves only as a cautionary tale for other wayward sailors", but it still bothers me when you stretch the conclusions out by saying that an intervention that is probably not better than the control group "appears promising".

This is a group that looked at the best way to improve parent education in pediatric asthma encounters in the Emergency Department.  They compared a video-based education program to a written handout and found...it didn't make much difference.  They had two groups of parents, those with "low health literacy" and those with "adequate health literacy".  The low literacy group improved a ton regardless of which educational modality was used.  The adequate literacy group barely budged with written and had a little bit more of bump with video - but the relative change in their level of literacy really wasn't anything to write home about and they don't try to offer an explanation for why intelligent people derive no benefit from written education.

But it doesn't stop them from stating it "appears promising" - which, I suppose, means it's probably better than not educating people at all, or potentially educating the illiterate.

"Parental Health Literacy and Asthma Education Delivery During a Visit to a Community-Based Pediatric Emergency Department."
http://www.ncbi.nlm.nih.gov/pubmed/21629152

Thursday, July 14, 2011

The Diagnose-a-Tron of the Future: FDG-PET

Imagine, if necessary, a case you see every hour in the ED - a child with a fever.  Wave a magic wand in triage, find the source of the fever, and let the doctor pick up the decision-making process advance from there.

This scenario is, of course, totally farfetched - after all, you still need a certain number of HPI and ROS elements before you wave the magic wand to bill at a higher level of service.

But, the principle - this is a fascinating article regarding the workup of "fever of unknown origin" in adults.  These 81 patients had fevers for 3 weeks without a satisfactory explanation, and their cases were retrospectively reviewed following referral to FDG-PET scans.  Essentially, any time this FDG-PET scan localized to an area of high uptake, it provided significant helpful localizing information regarding the underlying disease process.  Examples of diagnoses it identified were infectious endocarditis, tuberculosis, pyogenic spondylitis, graft infections, Takayasu arteritis, and a host of other fascinatingly difficult diseases to identify.

The main diagnostic drawback is that it is mostly only structurally/anatomically specific, not necessarily disease specific, so there is a lot to do in terms of clinical correlation with imaging findings.  And then there is the small issue where it's a nuclear medicine study requiring 5 hours of fasting and an injection of the FDG tracer 1 hour before the study is performed.  But, someday a decade out, the next generations of these devices might be more clinician-friendly....

"FDG-PET for the diagnosis of fever of unknown origin: a Japanese multi-center study."
www.ncbi.nlm.nih.gov/pubmed/21344168

Tuesday, July 12, 2011

5% of Patients Spend 50% of Our Healthcare Dollars

Per-capita spending doubled from 1997 through 2009 from $4100 to $8100 - with 5% of patients spending $35,800 on average annually to account for 47.5% of healthcare spending.  Overall, the five most expensive conditions are heart disease, cancer, trauma, mental disorders, and pulmonary conditions.

Unsurprisingly, people over 55 made up the majority of the high spending groups.  Unhappily enough, the authors note a "flattening" of the distribution of spending, where younger individuals are responsible for a greater proportion of the spending.  This is not due to more cost-effective care in the elderly, it's a result of increasing disease prevalence in the young, primarily attribute to obesity-related diseases such as hypertension, diabetes, hyperlipidemia.

May you live in interesting times, indeed.

"Understanding U.S. Health Care Spending - NIHCM Foundation Data Brief July 2011"
http://www.nihcm.org/images/stories/NIHCM-CostBrief-Email.pdf

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?"
www.ncbi.nlm.nih.gov/pubmed/21683474

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.

http://lux-et-radecki.com/

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."
www.cdc.gov/eid/content/17/5/pdfs/10-1334.pdf

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."
http://www.ncbi.nlm.nih.gov/pubmed/21693742

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."
http://www.ncbi.nlm.nih.gov/pubmed/21632484

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."
http://www.ncbi.nlm.nih.gov/pubmed/21658564