American Headache Society (AHS) published in Headache Journal list of 5 things physicians and patients should question in Nov 2013. This is a quick review and you can find full text
1. Don’t perform neuroimaging studies in patients with stable headaches that meet criteria for migraine.
You may ask what is the Migraine Headache? This is criteria that they refer to based on International Classification of Headache Disorders Diagnostic criteria:
- At least 5 attacks fulfilling criteria B-D
- Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated)
- Headache has at least two of the following characteristics:
- unilateral location
- pulsating quality
- moderate or severe pain intensity
- aggravation by or causing avoidance of routine physical activity (eg, walking or climbing stairs)
- During headache at least one of the following:
- nausea and/or vomiting
- photophobia and phonophobia
- Not attributed to another disorder
2. Don’t perform CT imaging for headache when MRI is available, except in emergency settings.
CT is indicated in emergency settings when hemorrhage, acute stroke, or head trauma are suspected. MRI is more sensitive than CT for the detection of neoplasm, vascular disease, posterior fossa and cervicomedullary lesions, and high and low intracranial pressure disorders. CT of the head is associated with substantial radiation exposure that may elevate the risk of later cancers, while there are no known biologic risks from MRI.
Patients may ask you about this:
3. Don’t recommend surgical deactivation of migraine trigger points outside of a clinical trial.
The value of this form of “migraine surgery” is still a research question.
4. Don’t prescribe opioid or butalbital-containing medications as first-line treatment for recurrent headache disorders.
These medications impair alertness and may produce dependence or addiction syndromes, an undesirable risk for the young, otherwise healthy people most likely to have recurrent headaches.
Bulbital containing meds are Fioricet or Phrenilin or Fiorinal!!!
5. Don’t recommend prolonged or frequent use of over-the-counter (OTC) pain medications for headache.
OTC medications are appropriate treatment for occasional headaches if they work reliably without intolerable side effects. Frequent use (especially of caffeine-containing medications) can lead to an increase in headaches, resulting in “medication overuse headache” (MOH). To avoid this, OTC medication should be limited to no more than 2 days per week.
Discharge Against Medical Advice, Pitfalls and Troubleshooting. There is a very interesting article from JAMA in Nov. 2013, explaining of misconception and how misleading is information regarding discharge patient with AMA. I always discuss with residents that signing an AMA form does not mean anything unless you document the patient’s condition and mental status and details of your discussion in medical record.
Remember, patient should have discharge instruction and also clearly should understand that we are happy to take care of her/him as soon as return or change their ideas. You should remain doors OPEN and let them to come back if they need help. This article clearly discuss some misleading information regarding insurance and pitfalls in discharge AMA.
What Is Wrong With Discharges Against Medical Advice (and How to Fix Them)
Dilemma: cough, smoker, discoloured sputum, diagnosis: Bronchitis, now: Abx or no Abx
BMJ, Oct 2013:
Efficacy of anti-inflammatory or antibiotic treatment in patients with non-complicated acute bronchitis and discoloured sputum: randomised placebo controlled trial
Study Group: 416 participants were randomized into 3 different groups (136 to ibuprofen, 137 to antibiotic, and 143 to placebo). Their presentation symptoms were associated with respiratory tract infection of 1) less than one week’s duration, 2) with cough as the predominant symptom and 3) discoloured sputum and 4) at least one other criterion of lower respiratory tract infection such as dyspnoea, wheezing, chest discomfort, or chest pain.
The mean duration of cough was 14.6 (SD 6) days.
1. The most common symptoms associate with lower respiratory tract infections is COUGH.
2. An oral anti-inflammatory(Ibuprofen) treatment or an antibiotic( Amoxi-Clav) are not more effective than placebo for shortening the duration of cough in patients with otherwise non-complicated acute bronchitis with discoloured sputum.
Link to article
What evidence does exist regarding dosage of Ketolorac? Our practice is usually 60 mg IM and 30 mg IV, but interesting review by Medscape showed may be this is not a right dose.
JAMA published an article emphasizing our EM textbooks highlights regarding the simple treatment of MSK back pain are NSAIDS and Acetaminophen and then muscle relaxant. Unfortunately, rate of prescribing narcotics is increasing and rate of prescribing NSAIDS and Acetaminophen decreased.
Worsening Trends in the Management and Treatment of Back Pain
John N. Mafi, MD1; Ellen P. McCarthy, PhD, MPH1; Roger B. Davis, ScD1; Bruce E. Landon, MD, MBA, MSc1,2
JAMA Intern Med. 2013;173(17):1573-1581. doi:10.1001/jamainternmed.2013.8992.
Link to article
Epmonthly had a very nice review with a mini board review perspective, regarding common complications of shoulder dislocation and reduction. There are four complications explained which they could find at the following link: