Rational Clinical Examination: GI Bleeding

This series of articles, “The Rational Clinical Examination” in JAMA is by far one of my favorite approaches to medicine.  They ask simple clinical questions, and they do literature searches to find evidence to apply.  Additionally, the form in which they distill the evidence tends to be likelihood ratios – a far more useful statistical construct in estimating how a particular finding contributes to ruling-in or ruling-out disease.

This most recent literature review covers gastrointestinal bleeding – and it covers a few worthwhile points.  Most encouragingly, the authors are exceedingly skeptical about the utility of NG tube placement – reasonable positive LR for UGIB, but, as the authors note, a suspected source is usually well-established prior to NG tube placement.  Additionally, they note that the NG lavage does not tend to influence final patient-oriented outcomes – and lean towards not recommending its use.  Secondly, they also cover the Blatchford and Rockall scores, which are decision instruments that might have value in helping triage patients for outpatient management.

“Does This Patient Have a Severe Upper Gastrointestinal Bleed?”
www.ncbi.nlm.nih.gov/pubmed/22416103

How Medical Students Choose Residencies

Turns out, it’s only mildly earthshaking – for some students, location is more important.  For other students, the program “fit” is more important.

The article goes on to evaluate whether there are specific factors that residency directors can influence in terms of attracting the right candidates and, obviously, none of the location-based factors are easily influenced by program leadership.  The top location-based factor was simply the attractiveness of a particular geographic location, with proximity to family being the next most important factor.

Drilling into the features of individual programs that residency directors can modify, it seems as though candidates base their decision mostly on “gut feeling” – coming down to how well they clicked during the interview session or when meeting with current residents.  After “fit” characteristics, then factors such as curriculum, length of program, and reputation came into play.  Relatively unimportant features were compensation, program size, and websites/social media run by a program.

Unfortunately, the article does not delve into what specific program characteristics residents were looking for – presumably 3-year programs were preferred to 4-year, and one of the popular curriculum questions during visits is regarding the presence of “floor” months.  However, it is an interesting overview of how candidates self-report the importance of their ranking influences.

“Factors That Influence Medical Student Selection of an Emergency Medicine Residency Program: Implications for Training Programs”

“Consequences” of Conflict of Interest Disclosure

As if physicians are children, and truths must be hidden from them, three consultants of the healthcare industry have published a commentary in JAMA regarding the possible adverse effects of conflict of interest disclosure. 
They provide cautionary justification for their belief that physicians who have conflicts of interest will overstate or exaggerate their results.  They believe this will happen either as a compensatory mechanism to overcome any skepticism created their reported COI, or because physicians will use their disclosure as an excuse to provide biased results “because the [audience] has been warned.”  They also feel that disclosures of conflicts of interests to patients might make them anxious, which would impact the therapeutic relationship built on trust.  And, finally, they believe that all this hullabaloo about disclosure distracts from the real COI issues associated with fee-for-service and other financial arrangements that should be prioritized for reform.  I tend to think these are narrow, paternalistic arguments that downplay the critical importance of transparency.
Additionally, given a ten citation limit, they cite their own prior articles six times.  I’m not sure if this is an effective strategy to build trust in their evidence or the legitimacy of their message.
But it got them in JAMA.
“The Unintended Consequences of Conflict of Interest Disclosure”

Hopping To Rule Out Appendicitis

The “Best Evidence Topic” reports from the Manchester Royal Infirmary are published in the Journal of Emergency Medicine.  Overall, they are meant to summarize evidence regarding more practical, clinical applications.  One of the recent summaries focuses on appendicitis, and whether eliciting pain during coughing, percussion, or hopping is useful in ruling in or out disease.
For this topic, they summarize a few articles – mostly following a prospective derivation study in which hopping/percussion/coughing was 93% sensitive and 100% specific for appendicitis.  Unfortunately, the test performance didn’t quite hold up – sensitivity ranging from 72% to 89%, depending on age group, and highly variable specificities.
So, unfortunately, somewhat like the “hamburger test,” you won’t be able to base the entirety of your clinical disposition on this, but it’s not an irrelevant input into your general clinical gestalt.
“BET 1: Is abdominal pain when asked to hop suggestive of appendicitis in children?”

Lactate Clearance and ScvO2 Goals in Sepsis

Early goal-directed sepsis care is successful – but no one can say precisely what makes it successful.  Hawthorne effect?  Early antibiotics appear to have uncertain association with better outcomes.  Is it the blood?  Is it meeting the central venous oxygenation goal of >70%?

Other studies have shown equivalency in outcomes while performing serial lactic acid measurements, and this is another study in the same vein.  203 patients form the analysis cohort, in which 93 received management decisions based on lactate clearance and 110 which received management decisions based on the ScvO2.  All included patients had both values measured simultaneously, but were blinded to the opposition.

And, this is another study where the two measures are different but similar – which is probably why the analysis is so convoluted.  Of the 203 enrolled, 175 either fortuitously or by design met the ScvO2 goal, while 178 met the lactate clearance goal.  Meeting the ScvO2 goal led to a death rate of 21% and meeting the lactate clearance goal led to a death rate of 17%.  There was no difference in therapeutic interventions between the ScvO2 goal group and the lactate clearance group.

However, if you met the lactate clearance without meeting the ScvO2 goal, you had an 8% (2/25) mortality, while the ScvO2 group that didn’t clear lactate had a 41% mortality (9/22).  Unfortunately, there were a number of baseline differences between the groups, and it’s hard to draw any conclusions or hypotheses from this finding.  It’s also clear they didn’t identify any specific interventions that improved survival in their cohort – and, more appropriately, simply observed that poor lactate clearance simply portends a worse outcome, without any specific recommendation on how to address it.

“Prognostic Value and Agreement of Achieving Lactate Clearance or Central Venous Oxygen Saturation Goals During Early Sepsis Resuscitation”

Most Severe Mechanism Children Don’t Need Head CTs

The PECARN group has published a set of criteria that identify children at very low risk for significant traumatic injury.  This is publicly available and an excellent decision instrument to enhance your clinical judgement.  But, the problem is, with excellent sensitivity, the specificity is weak – such that a great number of patients who fail to meet low-risk criteria will still have good outcomes.

So, this is a follow-on study attempting to determine whether the severe mechanism portion of the decision instrument was predictive of significant TBI, or whether scans could be avoided if mechanism was the only positive feature in their decision instrument.  And, yes, a severe injury mechanism in isolation – at least in the 35% of their cohort who received a head CT – had only a 0.3% chance of significant injury in age <2 years and 0.6% chance of significant injury in age >2 years.  Severe injury mechanisms associated with additional PECARN criteria, however, had 4% and 6% incidence of TBI, depending on age.

Probably the most important aspect of these numbers is they allow for a better discussion of risks with parents and families.  While 1 in 150 or 1 in 300 sound like pretty good odds, when you practice long enough, those odds will catch up with you.  Even with severe mechanism and additional features, 19 of 20 CTs will be negative – you can still make a reasonable case for observation rather than knee-jerk scanning.

“Prevalence of Clinically Important Traumatic Brain Injuries in Children With Minor Blunt Head Trauma and Isolated Severe Injury Mechanisms”

Mobile Stroke Units – Probably Not Helpful

Door to needle times too long?  Well, take the needle to the patient, then.

This is an interesting idea that, unfortunately, probably isn’t a good idea.  They loaded a CT scanner, a stroke physician, a paramedic, and a mobile laboratory into a truck, and sent it out to meet acute stroke patients in the field.  The primary endpoint of the study – alarm to thrombolysis time – was great, with a mean time from alarm to therapy decision of 35 minutes.

The authors are very excited about the concept – as they feel the accelerated time scale in terms of acute stroke thrombolysis represents a paradigm shift in management.  Unfortunately, the patient-oriented outcomes – which were not part of the primary endpoint – don’t support their enthusiasm.

All their safety and therapeutic outcomes are underpowered, but, out of their 47 intervention patients and 53 control (in-hospital thrombolysis) patients, 12 vs. 6 were treated stroke mimics and 3 vs. 0 were dead within 7 days.  Comorbidities and stroke severity should have favored the intervention group, so, these outcomes are surprising.  But, it is underpowered, so more data is needed.

“Diagnosis and treatment of patients with stroke in a mobile stroke unit versus in hospital: a randomised controlled trial.”
http://www.ncbi.nlm.nih.gov/pubmed/22497929

“Malodorous” Urine Isn’t Necessarily a UTI

Which is to say, when a parent brings in a child with a fever and the urine “smells bad”, plenty of those kids have normal urine cultures and plenty of children with Febreeze for urine have a urinary tract infection, regardless.


This is a prospective cohort study enrolling children receiving a urine culture as part of an evaluation for fever without a source in the Emergency Department – and then they went back and data mined for associations between the group diagnosed with UTI and not.  The overall incidence of UTI was 15%.  The overall incidence of UTI in those with “malodorous” urine was 24%.  It was the most significant contributing factor they found, but it’s still not sensitive or specific enough to use in isolation to change management.


Other interesting tidbits:  no circumcised male had a UTI, known high-grade vesicoureteral reflux predicted UTI.


“Association of Malodorous Urine With Urinary Tract Infection in Children Aged 1 to 36 Months”
http://www.ncbi.nlm.nih.gov/pubmed/22473364

Uninterrupted CPR is Better Than Interrupted

This is from King County, which has been publishing retrospective pre- and post- intervention outcomes related to out-of-hospital cardiac arrest for several years now.  This article focuses on the AHA guidelines for PEA and asystole, and the changes that were made in 2004 and 2005.  Those changes, if you recall, involve fewer pauses for pulse and rhythm checks and decreasing the number of ventilations.


Good news!  You were 1.5 times more likely to survive neurologically intact to hospital discharge after the introduction of the new guidelines.  Bad news: good neurological outcome was still only 5.1%, up from 3.4%.  So, yes, this is another piece of evidence supporting the “uninterrupted, high-quality CPR” concept, but perhaps the other important question that need be asked at the same time is:  how can we reduce the unnecessary resource expenditure associated with attempted resuscitation for the 95% that doesn’t benefit?


“Impact of Changes in Resuscitation Practice on Survival and Neurological Outcome After Out-of-Hospital Cardiac Arrest Resulting From Nonshockable Arrhythmias”
http://www.ncbi.nlm.nih.gov/pubmed/22474256

Post-Arrest Troponin Measurements Predict Little

Taking post-arrest patients to cardiac catheterization improves outcomes – as long as they have a cardiac occlusion as the underlying etiology of their arrest.  Otherwise, you’re simply delaying the diagnosis and treatment of alternative causes, as well as post-arrest ICU-level care.  Therefore, if there is some clinical feature that can be identified on initial Emergency Department evaluation that predicts a coronary occlusion, that would be of great value.

So, this is a retrospective analysis of a prospective registry of out-of-hospital arrests from Paris, where much of the post-arrest catheterization work has been done.  And, unfortunately, there isn’t any useful association – 92% of their patients had elevated troponin on initial evaluation.  There was a nonsignificant trend towards higher troponin levels in patients with coronary occlusion, but even at their “optimum” cut-off of 4.66ng/mL, the sensitivity and specificity were nearly coin-flip at 66% each.  A troponin of 31ng/mL was required for 95% specificity.

ST-segment elevation, incidentally, was more predictive of a coronary occlusion – OR 10.19 (CI 5.39 to 19.26).

“Can early cardiac troponin I measurement help to predict recent coronary occlusion in out-of-hospital cardiac arrest survivors?”
http://www.ncbi.nlm.nih.gov/pubmed/22488008