Month: July 2015

Goodness Gracious We’re &*@ing Up Sinusitis

The American Academy of Allergy, Asthma, and Immunology has a lovely Choosing Wisely statement on sinusitis, featuring the following highlights:

  • Antibiotics usually do not help sinus problems.
  • Antibiotics cost money.
  • Antibiotics have risks.

So, how does one of the United States largest organized health systems fare for the treatment of such a simple, basic, commonplace condition?  A system, perhaps, that prides itself on internal quality initiatives and guideline adherence?  Well, based on this sample of 152,774 Primary Care, Urgent Care, and Emergency Department patients in Kaiser Southern California, they are: still awful.

  • ED patients received antibiotics 72.8% of the time.
  • UC patients received antibiotics 89.3% of the time.
  • PC patients received antibiotics 89.8% of the time.

And, not only that, antibiotic usage was all over the map, with large cohorts receiving prescriptions for less-appropriate options such as azithromycin and trimethoprim-sulfamethoxazole.

Why are we so terrible at this?

“Low-Value Care for Acute Sinusitis Encounters: Who’s Choosing Wisely?”
http://www.ajmc.com/journals/issue/2015/2015-vol21-n7/Low-Value-Care-for-Acute-Sinusitis-Encounters-Choosing-Wisely

When Anaphylaxis Makes a Comeback

The frequency of biphasic anaphylaxis is a subject of some controversy, with most estimates derived from retrospective chart review.  The frequency may be as high as 20%, as low as 3%, or those may yet be gross overestimations based on partial symptom recurrence.

For these folks, the answer was: 14.7%.

This is yet another evaluation of Emergency Department visits for anaphylaxis, as collected by retrospective chart review.  Looking at one year’s worth of data collected at two pediatric hospitals in Canada, these authors identified 484 visits for anaphylaxis with adequate data for analysis.  Of these visits, 71 met their criteria for a biphasic reaction: a period of full symptom resolution lasting at least an hour, followed by recurrence of symptoms requiring additional pharmacologic intervention.  They subsequently reviewed features of the initial reaction to determine any potential predictors of biphasic manifestations.

Some of their features make sense, and some – none.  Independent predictors included delayed ED presentation, wide pulse pressure, multiple doses of epinephrine to treat the initial episode, and administration of beta-agonists in the initial episode.  Essentially, those patients with the most severe, multi-system involvement.  However, their strongest odds ratio for predicting return of symptoms was for patients simply aged 6-9 years of age – and the authors do not address the aberration in their discussion.

So, ultimately, this study doesn’t reliably alter our management.  Chances are, you’ve already been observing the mildest anaphylaxis for the shortest time, and the most severely ill for longer.  Thus, as seen in this cohort, most of these severely ill patients were still undergoing observation in the ED when the biphasic reaction occurred – 3 to 6.5 hours later.  All told, 18 patients were discharged from the ED and returned with biphasic symptoms – with a median time of 18.5 hours to return.  So, unfortunately, there’s no reasonably useful clinical endpoint to observation that would catch all revisits – and the best course of action is simply to ensure patients have epinephrine for home use at discharge, and inform them of the small likelihood of recurrence.

“Epidemiology and clinical predictors of biphasic reactions in children with anaphylaxis”
http://www.ncbi.nlm.nih.gov/pubmed/26112147

A Little Intubation Checklist Magic

In the interests of patient safety, many have turned to peri-procedural checklists.  Rather than,
essentially, “winging it”, a standardized protocol is followed each time, reducing the chance of an important omission.

These authors describe a checklist intervention for, as they describe, the high-risk procedure of endotracheal intubation in the setting of trauma.  The checklist involves, generally, assignment of roles, explicit back-up airway planning, and adequate patient positioning.  The authors used a before-and-after design using video review of all intubation events to compare steps performed.

In the six-month pre-checklist period, 7 of 76 intubation events resulted in complications – 6 desaturations, 2 emesis, and 2 hypotension.  In the post-intervention period, using the checklist, events were reduced to a single episode of desaturation in 65 events.  So, success?

As with every before-and-after study, it is hard to separate the use of the checklist to the educational diffusion associated with checklist exposure.  Would another, less intrusive, intervention been just successful?  Will the checklist lose effectiveness over time as it is superseded by newer safety initiatives?  And, most importantly, what did operators actually do differently after checklist implementation?

Only 4 of 15 checklist elements differed from the pre-checklist period: verbalization of backup intubation technique (61.8% vs. 90.8%), pre-oxygenation (47.3% vs. 75.4%), team member roles verbalized (76.4% vs. 98.5%), and optimal patient positioning (80.3% vs. 100%).  If only four behaviors were substantially changed, are they responsible for the outcomes difference – which, technically, is solely episodes of hypoxia?

Their intervention seems reasonable, and the procedure is likely high-risk enough to warrant a checklist.  However, I probably would not implement their specific checklist, as some refinement to the highest-yield items would probably be of benefit.

“A Preprocedural Checklist Improves the Safety of Emergency Department Intubation of Trauma Patients”
http://www.ncbi.nlm.nih.gov/pubmed/26194607

Patients Packin’ Heat

Does your Emergency Department have a metal detector?  No?  Then, read on.

These authors describe the installation of a typical arch-style metal detector at a single, Midwest, urban teaching hospital.  Between 2011 and 2013, security personnel screened all walk-in guests during hours of operation, ranging from 8h per day at initiation to 16h by the end of the study period.  In just two years of limited operation, they collected:

  • 268 firearms
  • 4,842 knives
  • 512 chemical sprays
  • 275 other weapons (brass knuckles, stun guns, box cutters)

Hospital maintenance also reported finding additional discarded weapons in the landscaping just outside the Emergency Department after the implementation of screening, while triage personnel also anecdotally noted some potential visitors turned away whence they came upon the security station.

Thus, the authors reasonably speculate their findings are representative – or even under-representative – of the weapons present, and concealed, inside their Emergency Department when security screening was absent.  The authors do not simultaneously evaluate any change in reduction in violent events in the Emergency Department, but it’s a fair conclusion their department is now a much safer workplace.

“Weapons retrieved after the implementation of emergency department metal detection.”
http://www.ncbi.nlm.nih.gov/pubmed/26153030

And The Stoning Continues

A couple months ago, the world of ureterolithiasis was upended by The Lancet and its publication of a trial examining medical expulsive therapy.  In direct contrast to the prior (worthless) Cochrane Review, this large, reasonably-designed trial, does away with the notion of universal benefit of alpha- and calcium channel-blockers for MET.

Following on its heels comes the publication of another trial of moderate size, but with even more rigorous follow-up.  Rather than previously mentioned trial’s “urologic intervention” as the patient-oriented outcome, this trial used a disease-oriented outcome.  This trial, enrolling patients with distal ureteral stones, required patients to under go CT at 28 days to definitively assess for stone passage.

The trial randomized 403 patients to either tamsulosin 0.4mg daily for 28 days or identical placebo, but, unfortunately, 87 did not ultimately undergo second CT.  Of the patients that did undergo CT, there was no statistically significant difference in stone passage: 87.0% tamsulosin vs. 81.9% placebo, an absolute difference of 5.0% (95% CI -3.0 to 13.0).  Of the 87, 77 were available for follow-up regarding urologic intervention.  If a combined endpoint of CT passage and lack of urologic intervention is used, the results remain unchanged.

However, the trial was designed specifically to enroll adequate numbers of patients with stones of 5-10mm in size – targeting adequate sample size with which to include at least 49 patients to detect a difference in stone passage of 5 to 25%.  They ultimately randomized 103 large stones and completed imaging or clinical follow-up on 77.  The difference in stone passage rate in the large stones was 83.3% in the tamsulosin group, compared with 61.0% with placebo, for an absolute difference of 22.4% (95% CI 3.1 to 41.6).

So, what’s the takeaway – from decades of poor-quality studies, the recent Lancet publication, and now this?  There’s probably some signal in the noise – and that signal, all along, has probably been these large, distal stones.  Unless there’s a truly diminished risk of stone passage, there’s never been any reasonableness to the use of MET – but if passage rates are ~60%, the likelihood of a clinically meaningful benefit is finally possible.

If I’ve obtained a CT in a patient and diagnosed a large, distal stone – I am offering tamsulosin.  Otherwise, no.

Rory Spiegel also shares his typically excellent similar evaluation of the evidence: EM Nerd

“Distal Ureteric Stones and Tamsulosin: A Double-Blind, Placebo-Controlled, Randomized, Multicenter Trial”

Doctor Internet Will Misdiagnose You Now

Technology has insidiously infiltrated all manner of industry.  Many tasks, originally accomplished by humans, have been replaced by computers and robots.  All manner of industrialization is now automated, Deep Blue wins at chess, and Watson wins at Jeopardy!

But, don’t rely on Internet symptom checkers to replace your regular physician.

These authors evaluated 23 different online symptom checkers, ranging from the British National Health Service Symptom Checker to privately owned reference sites such as WebMD, with a variety of underlying methodologies.  The authors fed each symptom checker 45 different standardized patient vignettes, ranging in illness severity from pulmonary embolism to otitis media.  The study evaluated twin goals: are the diagnoses generated accurate?  And, do the tools triage patients to the correct venue for medical care?

Eh.

For symptom checkers providing a diagnosis, the correct diagnosis was provided 34% of the time.  This seems pretty decent – until you go further into the data and note these tools left the correct diagnosis completely off the list another 42% of the time.  Most tools providing triage information performed well at referring emergent cases to high levels of care, with 80% sensitivity.  However, this performance was earned by simply referring the bulk of all cases for emergency evaluation, with 45% of non-emergent and 67% of self-care cases being referred to inappropriate levels of medical care.

Of course, this does not evaluate the performance of these online checkers versus telephone advice lines, or even against primary care physicians given the same limited information.  Before being too quick to tout these results as particularly damning, they should be evaluated in the context of their intended purpose.  Unfortunately, due to their general accessibility and typical over-triage, they are likely driving patients to seek higher levels of care than necessary.

“Evaluation of symptom checkers for self diagnosis and triage: audit study”
http://www.ncbi.nlm.nih.gov/pubmed/26157077

Let’s Poison Our Kids With E-Cigarettes

The hazards of the natural world are not an issue for those of us born into “civilization”.  Without lions, tigers, bears, and dingoes to endanger our babies, we’ve had to become more creative.  Firearms in the home, detergent packets, and, now:  highly concentrated nicotine from e-cigarettes.  This short review provides a brief look at an increasingly prevalent health hazard.

The lethal dose of nicotine is approximately 1 mg/kg.  Concentrations of liquid nicotine cartridges may be as high as 35 mg/mL.  A typical 10 mL refill bottle, then, has easily a lethal dose for children, while a 50 mL bottle could have more than enough to bring down a horse.  For comparison, a conventional cigarette contains 10 to 1 5mg of nicotine – certainly a danger, but on a different scale entirely.

The expected clinical effects are consistent with the classical nicotinic and muscarinic toxodromes – vomiting, diarrhea, salivation, bronchorrhea, seizures, rhabdomyolysis, and respiratory failure.  Therapeutic management remains supportive – intravenous fluids, atropine, and mechanical ventilation as needed.  Inadvertent exposures are typical, but liquid nicotine may also be used for intentional overdose in suicide attempts.

Another proud cultural innovation for the 21st century.

“Liquid Nicotine Toxicity”
http://www.ncbi.nlm.nih.gov/pubmed/26148101

Expunging “Zero-Miss” from Chest Pain Evaluation

The admit rate for chest pain from the Emergency Department varies widely.  In some instances, the rule “chest pain = admit” is the norm – or, at the least, observation and provocative or anatomic radiology from the Emergency Department.  Indeed, such studies exhorting the advantages of CCTA in the ED included those aged as low as 30 years – patients in whom the false positives from testing far outweigh the true.

The typical motivating factor for such aggressive admission rates has been a culture of “zero miss”, motivated by huge settlements for missed MI.  Accordingly, this brief study followed Emergency Physicians and asked – what if there were no legal liability?  What if there was an acceptable miss rate of 1 or 2% in chest pain?  How many of these people would be discharged instead of admitted?

Based on 259 surveys completed regarding a convenience sample of admitted chest pain patients, the answer from this single-center study is: 30%.

With over 5 million ED visits for chest pain annually, cutting the current 35% admission rate by 30% turns into a massive reduction in resource utilization.  And, frankly, it’s not as daunting to implement such thresholds as one might imagine: ED physicians set the standard of care, not lawyers.  As Jeff Kline has alluded to the possibility, it’s time for domain experts to set reasonable practice variation and resource utilization, rather than leave it up to lawyers and their hired guns:

Some argue that “standard of care” is only determined by a jury. I disagree. Physician topic experts should write the standard of care.

— jeffrey kline (@klinelab) July 12, 2015

This definitely should be done.

“The Association Between Medicolegal and Professional Concerns and Chest Pain Admission Rates”
http://www.ncbi.nlm.nih.gov/pubmed/26118834

Narcotic Overdoses Are Just Who We Expect

Deaths from narcotic overdose have jumped tremendously in the past years – to the point where naloxone distribution has become a life-saving public health initiative.  But, far more effective than treatment of overdose is prevention – and this small retrospective evaluation of Medicaid enrollees provides an insight into those at risk.

Based on an analysis of 90,010 Medicaid beneficiaries prescribed long-term opiate therapy, these authors made the following observations:

  • Patients without overlapping narcotic prescriptions, and who did not fill prescriptions at more than 3 pharmacies: 0.63% overdose incidence
  • Patients with overlapping narcotic prescriptions, and who filled prescriptions at more than 3 pharmacies: 6.09% overdose incidence

Other strongly predictive features for overdose were:

  • Morphine equivalent opioid doses >50mg per day
  • Concurrent sedative use
  • History of alcohol abuse
  • Depression diagnosis

Considering the increasing morbidity and mortality associated with opioid use and abuse, studies such as these help proactively identify those at greatest risk for early intervention.

“Defining Risk of Prescription Opioid Overdose: Pharmacy Shopping and Overlapping Prescriptions Among Long-Term Opioid Users in Medicaid”
http://www.ncbi.nlm.nih.gov/pubmed/25681095

The Utility of Urinalysis in Young Infants

When faced with the diagnostic evaluation of the young, febrile infant fewer than three months of age, the definitive tool for sepsis from urinary tract infection has traditionally been urine culture.  This stems from uncertainty over the adequacy of urinalysis sensitivity for serious bacterial infection, i.e., those truly bacteremic from a urinary source.

This is an analysis of a multicenter database of infants with bacteremia and urinary tract infection, as measured by isolation of the same pathologic organism from both blood and urine.  The key numbers:

  • Trace or greater leukocyte esterase: 97.6% (94.5-99.2) sensitive and 93.9% (87.9-97.5) specific.
  • Pyuria, >3 WBC/HPF: 96% (92.5-98.1) sensitive and 91.3% (84.6-95.6) specific.
  • Pyuria or any LE: 99.5% (98.5-100) sensitive and 87.8% (80.4-93.2) specific.

These are pretty impressive statistics, and differ significantly from the prior supposed sensitivity of the UA in young infants.  These authors postulate the problem with prior study has been its over-reliance on urine culture, and the resulting false positives.  If this seems a reasonable interpretation of the evidence, it has substantial ramifications for the diagnostic evaluation of young infants.  Importantly, it has the potential for obviating invasive procedures and unnecessary over-treatment.

I would like to see independent confirmation of these authors’ findings, but, considering this study required 15 years to produce the 276 patients analyzed in this paper, this may be the best evidence we see for awhile.

“Diagnostic Accuracy of the Urinalysis for Urinary Tract Infection in Infants, 3 Months of Age”
http://www.ncbi.nlm.nih.gov/pubmed/26009628