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.

http://www.ncbi.nlm.nih.gov/pubmed/21620607

rFactor VII Is Not Safe (Despite Their Conclusions)

When NovoNordisk writes an article analyzing safety data from the CONTROL trial, you get a skewed perspective on the data.  Specifically, if you only read the abstract, you’re going to think that it’s safer in some ways(ARDS was less), and there was no difference in adverse events (except for all that investigator-reported AMI/NSTEMI).  So, that sounds favorable.

But, the real reason there’s no significant differences in outcomes – and the reason why they terminated the trial early – is because the interim data is underpowered to detect a difference.  As you see, the 30-day mortality is 12% vs 11% in favor of placebo – and that wasn’t helping NovoNordisk, so they quit before they could reach sufficient statistical power to prove their product was unhelpful.  However, they can now benefit from that same lack of power to detect differences by applying it to the safety aspect, and trumpeting its equivalency in terms of AEs.

When taken in the context of the original trial, this is just a flawed piece of pharmaceutical propaganda to try and prevent the building crackdown on off-label Factor VII use.

http://www.ncbi.nlm.nih.gov/pubmed/21610529

The Single Troponin After 8 Hours of Symptoms

The ACEP guidelines still have, as level B recommendations, that a single cardiac biomaker “8 to 12 hours” after symptom onset is adequate to exclude the diagnosis of NSTEMI.

This study looked at all of Highland’s patients that received more than one troponin measurement in their ED.  Then, they looked at all the patients with initially negative troponins, and subsequently positive ones.  And, finally, they tried to see how many of those had symptoms >8 hours.  Their definitions are that troponins <0.06 ng/mL are negative, between 0.06 and 0.6 are indeterminate, and >0.6 are positive.

After starting with 5,596 patients, they had 125 that were negative initially, and then positive.  And, for symptoms greater than 8 hours, a grand total of seven troponins ≤0.06 ng/mL and then subsequently positive, and 18 others that were indeterminate and then subsequently positive.  They then say only two had a diagnosis of ACS.

Regardless, despite the size of the study, when you start talking about these sorts of tiny numbers and getting into splitting hairs on the diagnosis, you’re basically working on anecdotal evidence.  So, take it with a grain of salt – you’re usually safe in a patient with that symptom duration, but you’re working off mostly consensus opinion as opposed to great evidence.

More interesting, really, would be some kind of follow-up on the 1,086 patients that were discharged after a single negative troponin (many of which probably fulfilled the >8 hour criterion) – but there’s no way to actually make that sort of follow happen realistically.

http://www.hindawi.com/isrn/cardiology/2011/364728/

CT Coronary Angiography Screening Is Not Beneficial

Disclaimer: I despise CCTA for low-risk chest pain in the ED.  It leads to additional unnecessary testing, interventions, and harms that outweigh the risk of coronary events in its target population.  Our liability-sensitive practice has us evaluating an ever-increasing cohort of low- and (mostly) zero-risk young chest pain patients, and this is purported to be a test of choice for identifying a zero-zero risk population.
But there are just far too many false positives that have coronary artery disease of uncertain clinical significance.
This is a Korean study that compared 1000 matched controls that did not undergo CCTA with 1000 who did.  215 asymptomatic patients had positive CCTA – defined as any atherosclerotic plaque.  52 had >50% stenosis and 21 had >75% stenosis.
Their control cohort and their CCTA cohort were very similar – and 55-59% low risk, 34-29% intermediate, and 10% high risk based on NCEP risk stratification.
And their control group had a grand total of 1 cardiac event within their 18 month follow-up period, as did a single person in their positive CCTA group.  However, the CCTA group ended up with more additional testing and cardiac revascularization procedures during their follow-up time frames – with no change in outcomes.
Now, these are asymptomatic patients chosen for screening – not the same as our chest pain patients in the ED – but it’s another call for caution regarding overtesting and overtreating.

Move Over MRSA – It’s VISA and VRSA Time

Is it too late to buy stock in the company that makes linezolid?

This group up in Detroit reviewed 320 patients with MRSA bacteremia and found that 52.5% experienced Vancomycin failure.  Their conclusion states several significant OR for failure, but review of the between-group differences doesn’t show a lot of significant differences.  Nursing homes, for example, were the only p < 0.05, and predicted vancomycin success with a p of 0.02.

What is more important than their clinical predictors, however, is their review of the bactericidal activity of vancomycin – and that higher MICs and higher troughs are needed to effectively treat patients.  I’ve seen our pharmacists recognize this at my hospital as well – the 1g IV Vancomycin standard initial load is transitioning to a weight-based dose.

But, more importantly, what we’re probably really observing is the initial stages of the end of vancomycin’s utility for MRSA.  And, I hate to see what happens when TMP/SMX stops working, too….

http://www.ncbi.nlm.nih.gov/pubmed/21460309

Overdiagnosis of Pulmonary Embolism

Another over-testing over-diagnosis article effectively illustrating issues endemic to our current medical culture.

They do a retrospective national database review regarding the impact of the introduction of CTPA protocol for rule-out PE, and note that we’ve diagnosed three times as many PEs in 2006 as we did in 1998.  And, by detecting more PEs, we managed to reduce mortality attributed to PE…along the same gradually decreasing trendline that was present prior to the introduction of CTPA.

Figure 2 is the truly damning graphic – look at all those extra PEs we’re finding and treating for effectively no substantial benefit.  Their secondary analysis was in-hospital anticoagulation complications on patients with any diagnosis of PE, which has jumped 71%.  Thank goodness we can put them on dagibatran now instead of coumadin and not be able to reverse their life-threatening bleeding episodes….

Again, we are testing people who shouldn’t be testing, finding disease of uncertain clinical significance, and harming them with overtreatment – and let’s not even start with the costs.

http://www.ncbi.nlm.nih.gov/pubmed/21555660

Physician Perception of Ethnicity Preferences at End Of Life

I’m not sure what this paper definitely adds to the body of literature, but it’s been awhile since I read anything on this topic, so I thought it was interesting.

I will give the disclaimer that this has been my limited anecdotal experience during my time in MICU, SICU, PICU etc., that certain ethnic groups were less likely to be amenable to withdrawal of care discussions, transitions to comfort care, hospice, etc., much to our absolute frustration that we were expending inordinate resources to torture some poor ventilated husk of person with no chance of functional recovery.  This study, in a small single-center sample, more or less confirms that we all share that same perception – but, in theory, it doesn’t change our practice.

This study surveyed physicians regarding their perceptions of black vs. white end-stage cancer patients, and they tended to believe that a black person would be more likely to want continued aggressive treatment at the end of life.  The remainder of their article, which is a little more difficult to interpret, basically said that regardless of the perceptions, they still recommended the same (in statistical aggregate) treatment to the black vs. white hypothetical cohorts.

While this study didn’t find any measurable treatment differences, we’ve seen all throughout the literature that perception tends towards reality, and that there are many cases of measurable outcomes differences for different ethnicities.  This study just leaves me with a sour taste and more questions than answers.

http://www.ncbi.nlm.nih.gov/pubmed/21460710

Testing For Pulmonary Embolism is More Harmful Than Helpful

This is, in my opinion, the most conceptually important article I have read in the few months I’ve been posting to this blog.

This is where Dr. Newman and Dr. Schriger, outstanding clinicians and analysts of data, present a compelling case regarding the diagnosis and treatment of pulmonary embolism.  In brief, the authors try to estimate, based on the limited evidence, both the benefits and harm of diagnosis and treatment of pulmonary embolism.  In their review, very few patients were found to benefit from treatment of pulmonary embolism – the existing evidence is weakly supportive of anticoagulation.  Additionally, they show a great many patients were harmed by excessive testing and treatment of clinically unimportant pulmonary embolisms.

This is, while a complicated opinion piece, a lovely summation in a nutshell of the concept that finding more “disease” does not equal better outcomes.  And, depending on the risks of testing and treatment – the barbaric contrast, radiation, and rat poison that diagnosis of PE typically entails – more people would be alive today if we all stopped testing for pulmonary embolism.

This is not unique to pulmonary embolism – this is partly the same issue we encounter with overtesting our low-risk chest pain patients, particularly with CTA.  What this means – and, of course, subject to legal challenge in our bizarre society – is that with our current methods of detection and treatment, society would be better off as a whole if we missed a few pulmonary embolisms in order to find and treat the few clinically relevant ones.  The only shame in this article is that not nearly enough people will read it and take it to heart.

http://www.ncbi.nlm.nih.gov/pubmed/21621091

Liability Protections For Emergency Services

Smart folks at ACEP – tying liability reform to cost savings, which makes liability protection for Emergency Physicians an easier sell.  I have to say, the training environment these days is so skewed, I don’t think anyone graduating now knows how to practice without scanning everyone, as it’s become generally the standard of care.  The “quality of care” argument is a little new to me – but I certainly could move patients through more quickly, have less sign-out liability, etc., if I weren’t tying up beds waiting for scans.

But, the threat of a lawsuit is a big one.  And it’s not just us – so many PMDs refer their patients to the ED for a CT scan – whether the test is indicated, how miserable a malpractice hearing would it be to have testimony from the PMD who thought a CT was indicated after you declined to order it.

Next step beyond liability protection – Press-Ganey protection – for all these patients who expect answers, and CTs at the minimum, and aren’t going to fill out very favorable patient satisfaction surveys without getting what they want….

http://www.acep.org/Content.aspx?id=79958

72-Hour Returns – Fun, But Not Useful

Our EMR lets us generate reports of our 72-hour returns – and it’s a fun toy, but, reading through it is rarely illuminating.  On a rare occasion you see a “true miss”, where one of your colleagues finds something through another line of thinking.  But, mostly, it’s wound checks, admissions for failed outpatient antibiotic therapy for cellulitis, or the town drunk coming back in again.  It is a valuable tool, at least, in the sense that our ED is the only one for 40 miles and is the only tertiary center for 90 miles, so we should get most of our own bouncebacks.

And, this study essentially confirms my anecdotal observations – most people who come back return for non-emergent conditions, do not require significant additional testing, and are no more likely to be admitted.  Their conclusion, then, is that 72-hour returns are of limited utility as a quality measure – something of which I tend to agree…although, if it were, the unintended consequence of discouraging that 2-day wound check/abscess repacking might finally put abscess packing to rest….

http://www.ncbi.nlm.nih.gov/pubmed/21496142