2021 Wrap-Up

A few items to collate from the last several months’ efforts.

The Annals of Emergency Medicine Podcast continues apace, with free monthly updates from the original research published in the journal:

Likewise, the Annals of Emergency Medicine Journal Club has published several monthly installments:

Two more pieces in ACEPNow:

And, finally, from a talk I gave our ACEM trainees – the list of included articles, highlighting some of the most interesting articles published in 2021:

The Use of Tranexamic Acid to Reduce the Need for Nasal Packing in Epistaxis (NoPAC): Randomized Controlled Trial
No advantage to routine use of topical TXA for epistaxis.
https://doi.org/10.1016/j.annemergmed.2020.12.013

Ultra-early tranexamic acid after subarachnoid haemorrhage (ULTRA): a randomised controlled trial
No advantage to routine use of IV TXA for aneurysmal SAH.
https://doi.org/10.1016/S0140-6736(20)32518-6

Effect of Endovascular Treatment Alone vs Intravenous Alteplase Plus Endovascular Treatment on Functional Independence in Patients With Acute Ischemic Stroke
Stopped early due poor outcomes in patients receiving alteplase prior to endovascular therapy.
https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2020.23523

A Randomized Trial of Intravenous Alteplase before Endovascular Treatment for Stroke
Heterogenous outcomes showing a small advantage, primarily recanalization, in patients receiving alteplase prior to endovascular therapy.
https://doi.org/10.1056/NEJMoa2107727

Effect of Mechanical Thrombectomy Without vs With Intravenous
Thrombolysis on Functional Outcome Among Patients With Acute Ischemic Stroke

No reliable differences between patients regardless of therapy.
https://doi.org/10.1001/jama.2020.23522

Prospective, Multicenter, Controlled Trial of Mobile Stroke Units
A “mobile stroke unit” administered tPA more rapidly, demonstrating an association with improved outcomes – the entire effect size made up of “Stroke reversed by tPA”.
https://doi.org/10.1056/NEJMoa2103879

Effect of Intravenous Fluid Treatment With a Balanced Solution vs 0.9% Saline Solution on Mortality in Critically Ill Patients
No patient-oriented difference in outcomes regardless of fluid choice, although resuscitation volumes were not excessive.
https://doi.org/10.1001/jama.2021.11684

Short-Course Antimicrobial Therapy for Pediatric Community-Acquired Pneumonia
5 days of high-dose amoxicillin was no different than 10 days of high-dose amoxicillin.
https://doi.org/10.1001/jamapediatrics.2020.6735

Effect of Amoxicillin Dose and Treatment Duration on the Need for Antibiotic Re-treatment in Children With Community-Acquired Pneumonia
No difference between 3 days vs. 7 days, nor between high-dose or low-dose amoxicillin.
https://doi.org/10.1001/jama.2021.17843

Delayed Antibiotic Prescription for Children With Respiratory Infections: A Randomized Trial
“Delayed” antibiotic prescribe was a safe strategy for reducing inappropriate antibiotic treatment – but so was “no” antibiotics.
https://doi.org/10.1542/peds.2020-1323

Effect of Oral Moxifloxacin vs Intravenous Ertapenem Plus Oral Levofloxacin for Treatment of Uncomplicated Acute Appendicitis
Outcomes in patients with appendicitis managed with antibiotics were similar regardless of whether patients began with oral antibiotics or started with intravenous and then transitions to oral.
https://doi.org/10.1001/jama.2020.23525

Antibiotics versus Appendectomy for Acute Appendicitis — Longer-Term Outcomes
Within 90 days, 29% of patients managed with antibiotics underwent appendectomy. At 1 year, 46%; 2 years, 46%, 3 and 4 years, 49%.
https://doi.org/10.1056/NEJMc2116018

Effect of Use of a Bougie vs Endotracheal Tube With Stylet on Successful Intubation on the First Attempt Among Critically Ill Patients Undergoing Tracheal Intubation
First-pass intubation success was ~83% for trainees using video laryngoscopy, regardless of using bougie or stylet for ET tube.
https://doi.org/10.1001/jama.2021.22002

Effect of Moderate vs Mild Therapeutic Hypothermia on Mortality and Neurologic Outcomes in Comatose Survivors of Out-of-Hospital Cardiac Arrest
31°C was no better than 34°C for improving neurologic outcomes following OHCA.
https://doi.org/10.1001/jama.2021.15703

Hypothermia versus Normothermia after Out-of-Hospital Cardiac Arrest
Hypothermia, under the conditions typically implemented in major centers, did not improve neurologic outcomes following OHCA.
https://doi.org/10.1056/NEJMoa2100591

Angiography after Out-of-Hospital Cardiac Arrest without ST-Segment Elevation
An RCT showing no advantage to routine immediate angiography in non-STEMI OHCA.
https://doi.org/10.1056/NEJMoa2101909

Pathway with single-dose long-acting intravenous antibiotic reduces emergency department hospitalizations of patients with skin infections
A sponsor encouraging discharge of patients with SSTI results in discharge of patients with SSTI.
https://doi.org/10.1111/acem.14258

Self-obtained vaginal swabs are not inferior to provider- performed endocervical sampling for emergency department diagnosis of Neisseria gonorrhoeae and Chlamydia trachomatis
A woman can self-swab for STI every bit as effectively as a clinician performing a pelvic examination.
https://doi.org/10.1111/acem.14213

Invasive Bacterial Infections in Afebrile Infants Diagnosed With Acute Otitis Media
Afebrile infants ≤ 90 days diagnosed with AOM do not seem to be at risk for IBI.
https://doi.org/10.1542/peds.2020-1571

Effect of Vasopressin and Methylprednisolone vs Placebo on Return of Spontaneous Circulation in Patients With In-Hospital Cardiac Arrest
An IHCA protocol incorporating vasopressin and methylprednisolone improved immediate outcomes, but not hospital discharge.
https://doi.org/10.1001/jama.2021.16628

Risk for Recurrent Venous Thromboembolism in Patients With Subsegmental Pulmonary Embolism Managed Without Anticoagulation
Non-trivial rates of recurrent VTE, particularly in the elderly and those with multiple SSPE, mean anticoagulation is likely indicated.
https://doi.org/10.7326/M21-2981

Effect of a Diagnostic Strategy Using an Elevated and Age-Adjusted D-Dimer Threshold on Thromboembolic Events in Emergency Department Patients With Suspected Pulmonary Embolism
Another successful example of adjusting D-dimer thresholds, this time combining pretest likelihood and age.
https://doi.org/10.1001/jama.2021.20750

Outpatient Management of Patients Following Diagnosis of Acute Pulmonary Embolism
Of the few low-risk patients with PE managed as outpatients in the U.S., the subsequent hospitalization rate was around 10%.
https://doi.org/10.1111/acem.14181

Rapid Administration of Methoxyflurane to Patients in the Emergency Department (RAMPED) Study: A Randomized Controlled Trial of Methoxyflurane Versus Standard Care
More patients treated with methoxyflurane had reductions in pain, but more patients in the methoxyflurane arm received oral and/or parenteral opioids.
https://doi.org/10.1111/acem.14144

Repeat head computed tomography for anticoagulated patients with an initial negative scan is not cost-effective
Only 1% of patients on anticoagulation with an initial negative head CT developed subsequent ICH, none of whom developed symptoms or required intervention.
https://doi.org/10.1016/j.surg.2021.02.024

Risk of Traumatic Brain Injuries in Infants Younger than 3 Months With Minor Blunt Head Trauma
2+% of infants aged less than 3 months meeting PECARN low-risk criteria still had ICH, although only 1 – 0.2% – was clinically important.
https://doi.org/10.1016/j.annemergmed.2021.04.015

Impact of oral corticosteroids on respiratory outcomes in acute preschool wheeze: a randomised clinical trial
Prednisolone hastens improvement in wheezing and reduced hospital admission, while symptoms were equivalent by 24 hours, regardless.
https://doi.org/10.1136/archdischild-2020-318971

Association of Intravenous Radiocontrast With Kidney Function
An interesting analysis centered around the dichotomous D-dimer cut-off for CTPA found no association of contrast exposure with follow-up eGFR.
https://doi.org/10.1001/jamainternmed.2021.0916

Maximizing the Morning Commute: A Randomized Trial Assessing the Effect of Driving on Podcast Knowledge Acquisition and Retention
Similar knowledge retention resulted from podcast listening whether attention was focused or during driving.
https://doi.org/10.1016/j.annemergmed.2021.02.030