Research and Reviews in the Fastlane 136

Research and Reviews in the Fastlane

Welcome to the 136th edition of Research and Reviews in the Fastlane. R&R in the Fastlane is a free resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature.

This edition contains 6 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Soren Rudolph, Justin Morgenstern, Anand Swaminathan and, of course, Chris Nickson. Find more R&R in the Fastlane reviews in the R&R Archive, read more about the R&R project or check out the full list of R&R contributors

This Edition’s R&R Hall of Famer

Research and Critical Appraisal
R&R Hall of Famer - You simply MUST READ this!

 

Gaudry S, et al. Initiation Strategies for Renal-Replacement Therapy in the Intensive Care Unit. New England Journal of Medicine. 2016 PMID: 25902813

  • The Artificial Kidney Initiation in Kidney Injury (AKIKI) trial was an unblinded, prospective, multicentre, open-label, two-group randomized study conducted in France. 620 patients with severe acute kidney injury defined as KDIGO stage 3 (Kidney Disease: Improving Global Outcomes classification, who required mechanical ventilation, catecholamine infusion, or both and did not have a potentially life-threatening complication directly related to renal failure were randomized to either either an early or a delayed strategy of renal-replacement therapy. Mortality at day 60 (primary outcome) did not vary between intervention groups however, the rate of catheter-related bloodstream infections was higher in the early-strategy group than in the delayed-strategy group (10% vs. 5%, P=0.03) and diuresis as a marker of improved kidney function, occurred earlier in the delayed-strategy group.
  • Recommended by: Nudrat Rashid
  • Read More: Mehta. Renal-Replacement Therapy in the Critically Ill — Does Timing Matter? New England Journal of Medicine. May 15, 2016. PMID: 27181293

The Best of the Rest

Resuscitation
Grunau BE, et al. Emergency Department Corticosteroid Use for Allergy or Anaphylaxis Is Not Associated With Decreased Relapses. Ann Emerg Med. 2015. PMID: 25820033

  • Big observational study looking at 2700 allergic reactions (nearly 500 with anaphylaxis). Nearly half (only half?) got steroid bursts, with no difference in outcomes. Notably there were no deaths, only a handful of biphasic reactions, and single-digit ED revisits in both groups; and, of course, this is only an observational study. Won’t change my practice (is there much harm in 3 days of prednisone?) but certainly makes me think.
  • Recommended by: Seth Trueger

Resuscitation
R&R Landmark paper that will make a differenceJoshi R, et al. Optimizing oxygen delivery in the critically ill: the utility of lactate and central venous oxygen saturation (ScvO2) as a roadmap of resuscitation in shock. J Emerg Med. 2014. PMID: 25124137

  • Excellent paper highlighting resuscitation of both the O2 delivery and cellular metabolism and then providing a stepwise approach on how to evaluate the two specific endpoints: ScvO2 levels and lactate production.
  • Recommended by: Soren Rudolph

Emergency Medicine
R&R Eureka - Revolutionary idea or conceptR&R Trash - Must read, because it is so wrong!
Wasserman JK, et al. Isolated transient aphasia at emergency presentation is associated with a high rate of cardioembolic embolism. CJEM. 2015. PMID: 25782453

  • In this prospective cohort of TIA patients, they found that having isolated aphasia at presentation was associated with double the rate of a cardioembolic etiology of stroke. Although this is strong, believable data, I disagree with the conclusion that “emergency patients with isolated aphasia with a TIA warrant a rapid and thorough assessment for a cardioembolic source”. Non-aphasic patients still had an 11% chance of a cardiac source as compared to 22% with aphasia. Those two numbers clearly necessitate the exact same work up. This is interesting, but I think clinically irrelevant data.
  • Recommended by: Justin Morgenstern

Emergency
R&R Hot Stuff - Everyone’s going to be talking about thisBonadio W, et al. Meta-analysis to Determine Risk for Serious Bacterial Infection in Febrile Outpatient Neonates With RSV Infection. Pediatr Emerg Care. 2016. PMID: 27139289

  • The issue if it is necessary to pursue a complete septic workup in kids at risk for serious bacterial infections (SBI) and simultaneous viral syndrome with positive test for RSV has been going around for some time now. For older kids, the risk of an SBI in presence of a positive RSV test is about 5-10% (7%). This papers is a meta-analsysis for the risk of SBI in neonates (<28 days) in patients presenting to their center plus a pool data from a larger study. The methodology is somewhat obtuse, but pooling data, they found the risk of SBI in neonates with +RSV is about 10.5% and 15.3% in those with -RSV; the difference is not statistically significant. The authors conclude that the presence of +RSV is not a good indicator of the absence of SBI. Bottomline, similar to older kids, we should probably keep doing a full workup in febrile neonates with a bronchiolitis syndrome and at the same time, I wait anxiously for the PECARN SBI rule.
  • Recommended by: Daniel Cabrera

Education
R&R Mona Lisa -Brilliant writing or explanation” width=
Green SM, Schriger DL. The Sinking STONE: What a Failed Validation Can Teach Us About Clinical Decision Rules. Ann Emerg Med 2016. PMID: 26803703

  • We see multiple decision instruments trotted out only to be thwarted during validation studies. The STONE score is another such instrument. This editorial discusses the lessons we can learn from failed validation of studies and is an excellent guide to use when considering any clinical decision instrument.
  • Recommended by: Anand Swaminathan

The R&R iconoclastic sneak peek icon key

Research and Reviews The list of contributors R&R in the FASTLANE 009 RR Vault 64 The R&R ARCHIVE
R&R in the FASTLANE Hall of Famer R&R Hall of famer You simply MUST READ this! R&R Hot Stuff 64 R&R Hot stuff! Everyone’s going to be talking about this
R&R in the FASTLANELandmark Paper R&R Landmark paper A paper that made a difference R&R Game Changer 64 R&R Game Changer? Might change your clinical practice
R&R Eureka 64 R&R Eureka! Revolutionary idea or concept R&R in the FASTLANE RR Mona Lisa R&R Mona Lisa Brilliant writing or explanation
R&R in the FASTLANE RR Boffin 64 R&R Boffintastic High quality research R&R in the FASTLANE RR Trash 64 R&R Trash Must read, because it is so wrong!
R&R in the FASTLANE 009 RR WTF 64 R&R WTF! Weird, transcendent or funtabulous!

That’s it for this week…

That should keep you busy for a week at least! Thanks to our wonderful group of editors and contributors Leave a comment below if you have any queries, suggestions, or comments about this week’s R&R in the FASTLANE or if you want to tell us what you think is worth reading.

The post Research and Reviews in the Fastlane 136 appeared first on LITFL: Life in the Fast Lane Medical Blog.

LITFL Review 232

LITFL review

Welcome to the 232nd LITFL Review! Your regular and reliable source for the highest highlights, sneakiest sneak peeks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team casts the spotlight on the blogosphere’s best and brightest and deliver a bite-sized chuck of FOAM.

The Most Fair Dinkum Ripper Beauts of the Week

resizer Cliff Reid offers an amazing reflection on training, stress exposure and pushing one self to achieve even in the face of defeat. [AS]

Nadim Lalani writes one of the most incredible pieces I have ever read on courageous collegiality in medicine, a guide to having challenging conversations. (Thanks Brent Thoma for the tip) [SO]

The Best of #FOAMed Emergency Medicine

  • Should we transfuse platelets to patients with spontaneous ICH on antiplatelet therapy? St. Emlyn’s and EM Lit of Note review a recent RCT in the Lancet that essentially says, no. [AS]
  • Here’s a nice summary from St Emlyn’s on recent UK guidelines on managing acute behavioural disturbance. [SO]
  • Do patients attending the ED have a higher mortality if they attend at weekends? The Bottom Line review a topical recent paper from the UK looking at this. [SO]

The Best of #FOAMcc Critical Care

The Best of #FOAMtox Toxicology

The Best of #FOAMus Ultrasound

The Best of #FOAMped Paediatrics

The Best of #FOAMim Internal Medicine


The Best of Medical Education and Social Media

  • P-cubed presentation skills has reached its 200th post and here is a reflective piece on those 200, highlighting the most and least popular postings.  There’s some absolute gold here.  Enjoy.  [CC]

News from the Fast Lane

Reference Sources and Reading List

Brought to you by:

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Funtabulously Frivolous Friday Five 146

Just when you thought your brain could unwind on a Friday, you realise that it would rather be challenged with some good old fashioned medical trivia FFFF…introducing Funtabulously Frivolous Friday Five 146

Question 1

What was James Lind famous for (clue = physician in the Royal Navy)?

  • He conducted the first ever clinical trial.
  • Lind thought scurvy was due to putrefaction of the body and could be cured by acids. 2 months into a trip at sea, 12 sailors became ill. He split them into 6 groups of 2, each group received an addition to their normal diet. Group 1 – quart of cider, Group 2 – 25 drops of sulphuric acid, Group 3 – 6 spoonfuls of vinegar, Group 4 – half a pint of seawater, Group 5 – 2 oranges and 1 lemon, Group 6 – a spicy paste plus a drink of barley water.
  • Group 5 recovered by six days and were fit for work. This trial was ignored and the results not fully implemented for another 47 years. [Reference]

Question 2

What has Dr Semmelweis and cadaverous poisoning got to do with modern medicine?

    • Washing your hands
    • Dr Semmelweis a Hungarian physician, noted that doctors were infecting childbearing women during labour as they transferred “cadaverous material” to the labouring patients. Germ theory had not been discovered at the time but he noted reduced mortality if the doctors washed their hands with chlorinated lime between autopsy work and examining the patients.
    • Ironically Dr Semmelweis went mad as his theory was largely ignored (partly because he called anyone ignoring his advice a murderer) and he died in an asylum after developing sepsis from a wound – possibly the puerperal fever (Streptococcus pyogenes) he was trying to prevent.
    • See Chris Nickson’s SMACC talk for more information.

Question 3

Who was the first female doctor of the modern medical era?

  • James Barry.
  • Born Margaret Ann Bulkley, chose to live a life as a male, partly in order to attend the University of Edinburgh Medical School. She worked as a military surgeon and was buried James Barry with full rank. The discovery of her true sex was only made on inspection of the body after death but announced to the public and colleagues after the funeral. [Reference]
  • James Barry qualified in 1812 beating Elizabeth Garrett Anderson (quoted as the first British female physician) by 58 years and Elizabeth Blackwell (the first woman to obtain a medical degree in the USA) by 37 years.

Question 4

What is a scybalum?

  • A hardened faecal mass.
  • Rarely can cause perforation [Reference]

Question 5

How many mls of blood can a medicinal leech drink at a single meal?
leech

  • 5-15 ml
  • Large adults consuming up to 10x their body weight in a single meal. [Reference]

….and for something different

And for something you might like to adopt instead of handshaking, the fistbump. Not a replacement for washing your hands and would probably make poor Semmelweis roll over in his grave but maybe slightly less gross than handshaking.

Last update: May 20, 2016 @ 12:25 pm

The post Funtabulously Frivolous Friday Five 146 appeared first on LITFL: Life in the Fast Lane Medical Blog.

PEM Guides Online

This month sees the release of two new eBooks for brushing up on your Paediatric Emergency Medicine Skills. Both of these eBooks are a truly great addition to your PEM reference resources. They are both free and there’s no excuse not to have them handy on your mobile.

PEM Guides 2.0 by NYU Langone Medical Center

WebsiteiBooks

PEM (Pediatric Emergency Medicine) Guides was developed as a point of care resource in our pediatric emergency departments at Bellevue Hospital Center and NYU Langone Medical Center. The PEM Guides focus on the essential diagnostic, treatment and disposition decisions. – Michael Mojica, MD

This is one not to be missed. PEM Guides 2.0 is an online book, aimed to provide a point-of-care resource for doctors training in PEM. It is it edited and authored by the team at New York University School of Medicine.

  • The book looks great. The design is clear and easy to follow, with some nice icons and images. iBooks allows you to browse around without any problems.
  • The content covers everything you are ever likely to see in PEM. It ranges from removal of ear foreign bodies to managing the agitated adolescent to child protection. Each topic considers the presentation, assessment, diagnosis and management.
  • And it’s all for FREE.
  • The only disappointing thing is that at the moment it’s only available for iPhone or Mac users. So, if you’re an Android or PC person then you’ll be missing out.

PEMguide1PEM Guide1

EM Cases Vol 2: Paediatric Emergencies

Website

“EM Cases Digest Volume 2 has officially been released and available for download exclusively here on the EM Cases website. This will be the second release of six Free Open Access Medical Education eBooks that will cover six pillars of Emergency Medicine. Each one is designed specifically to maximize your EM learning with interactive cases, Q&As, pearls & pitfalls, updates, images, videos, links to top-notch resources and references drawn from the library of more than 150 EM Cases podcasts to date. The EM Cases Team in collaboration with 9 authors has been working diligently over the past year to bring you this second eBook of the series – Anton Helman

The fabulous EM Cases podcasters have adapted their PEM cases into a readable format. This can be downloaded as a pdf or in epub format which you can open on your tablet/computer regardless of whether or not you love Apple.

  • It contains 17 cases (along with links to the original podcasts) covering topics such as fever without focus, orthopaedic injuries, and bronchiolitis. Each case is broken down into assessment and management and includes expert tips, clinical decisions rules, pitfalls and cautionary advice. The cases integrate images and videos flawlessly.
  • It’s not quite as easy to navigate as PEM Guides 2.0, because it’s not been specifically designed for iBooks. However, once you get to the right case, the design is excellent. The cases are broken down into bite-size sections that make it very readable. EM Cases Vol 2 covers a narrower range than PEM Guides 2.0 but it’s not aiming to be a comprehensive guide – the book is full of practical advice that will help your management of kids in ED.
  • And it’s also FREE.

EMCases1 EMCases3 EMCases2

Last update: May 19, 2016 @ 9:15 pm

The post PEM Guides Online appeared first on LITFL: Life in the Fast Lane Medical Blog.

Research and Reviews in the Fastlane 135

Research and Reviews in the Fastlane

Welcome to the 135th edition of Research and Reviews in the Fastlane. R&R in the Fastlane is a free resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature.

This edition contains 6 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Soren Rudolph, Justin Morgenstern, Anand Swaminathan and, of course, Chris Nickson. Find more R&R in the Fastlane reviews in the R&R Archive, read more about the R&R project or check out the full list of R&R contributors

This Edition’s R&R Hall of Famer

Critical Care, Respiratory Medicine                                                                                                      R&R Hall of Famer - You simply MUST READ this!

Kor DJ,  et al. Effect of Aspirin on Development of ARDS in At-Risk Patients Presenting to the Emergency Department: The LIPS-A Randomized Clinical Trial. JAMA. Published online May 15, 2016. doi:10.1001/jama.2016.6330.

  • This multi-centred, double blind, placebo controlled RCT involving 390 patients was conducted in the US. It assessed the safety and efficacy of early administration of aspirin in preventing ARDS in patients determined to be at risk of ARDS (Lung Injury Prediction Score ≥4) in the Emergency department. For patients randomized to the intervention group, a 325-mg loading dose of aspirin was administered on day 1, followed by 81 mg of aspirin once daily up to day 7, hospital discharge, or death, whichever occurred first. No difference was observed in between groups on the incidence of ARDS or any of the secondary outcomes e.g. ventilator free days, ICU and hospital LOS.
  • Recommended by: Nudrat Rashid
  • Read more: Is It Possible to Prevent ARDS?

The Best of the Rest

Retrieval, Prehospital and Disaster
R&R Landmark paper that will make a differenceEdwards DS et al. 40 years of terrorist bombings – A meta-analysis of the casualty and injury profile. Injury. 2015 Dec 31. PMID 26830126

  • The last 40 years an average of 2000 terrorist bombings are recorded every year. The trend is increasing with 6665 incidens occuring in 2013, most of which occur in the Middle East. Although suicide bombs are very scary, receive much media attention and have profound psychological effects on the local societies they only account for arounf 5 % of incidents. This review provides knowledge about some specific details we as clinicians need when preparing for a mass casualty incident: – Was it a suicide bomb? Suicide bombs are 8,9 times more deadly than non-suicide bombs averaging 10 killed and 24 wounded compared to only 1,14 killed and 3,45 wounded in non-suicide bombings. – In what kind of enviroment did the bombing occur? eventhough open and close space bombs carry the same mortality rates they have different injury pattern profiles with close space bombs having more primary blast injuries and open space bombs have second and tertiary injuries. – Are there reports of collapsed buildings? As this increases death rates substantially
  • Recommended by: Søren Rudolph

Emergency Medicine
Friedman BW, et al. Current management of migraine in US emergency departments: an analysis of the National Hospital Ambulatory Medical Care Survey. Cephalalgia. 2015. PMID: 24948146

  • Wow, we use a lot of opioids — for headaches! The authors looked at ED visits in the big NHAMCS database, in both 2010 and 1998. The good news is we use a lot less meperidine than we used to. The bad news is we use hydromorphone instead. And, 59% of ED patients with headaches got opioids (which, incidentally, don’t work for headache). We need to do better.
  • Recommended by: Seth Trueger

Emergency Medicine
R&R Eureka - Revolutionary idea or concept
Gágyor I, et al. Ibuprofen versus fosfomycin for uncomplicated urinary tract infection in women: randomised controlled trial. BMJ (Clinical research ed.). 2015. PMID: 26698878

  • Despite being one of the greatest advances in modern medicine, antibiotics get a bad rap in EBM. Do they work in UTI? Probably, as this RCT shows lower rates of dysuria and less (though not statistically) pyelonephritis when comparing fosfomycin to ibuprofen. However, what I think is the interesting point is that 70% of the women in the ibuprofen group had their symptoms resolve and never required antibiotics. So they probably work, but they clearly aren’t essential. If you call someone back with a positive culture and they no longer have symptoms, they are probably cured – they don’t need antibiotics.
  • Recommended by: Justin Morgenstern

Resuscitation
R&R Hot Stuff - Everyone’s going to be talking about thisDonino MW et al. Corticosteroid therapy in refractory shock following cardiac arrest: a randomized, double-blind, placebo-controlled, trial. Crit Care 2016. PMID: 27038920

  • Are you using corticosteroids in patients with refractory shock after cardiac arrest? This well-done RDCT demonstrated no benefit to this therapy for time to shock reversal. Clinical outcomes were no different either although this was a secondary outcome of the study.
  • Recommended by: Anand Swaminathan

Paediatrics
R&R Landmark paper that will make a difference
Shakti D, et al. Idiopathic pericarditis and pericardial effusion in children: contemporary epidemiology and management. J Am Heart Assoc. 2014. PMID: 25380671

  • Pediatric Chest Pain is common… and fortunately, often due to benign causes. Before you announce that this is merely costochondritis, be sure to contemplate Pericarditis.
  • Recommended by: Sean Fox

The R&R iconoclastic sneak peek icon key

Research and Reviews The list of contributors R&R in the FASTLANE 009 RR Vault 64 The R&R ARCHIVE
R&R in the FASTLANE Hall of Famer R&R Hall of famer You simply MUST READ this! R&R Hot Stuff 64 R&R Hot stuff! Everyone’s going to be talking about this
R&R in the FASTLANELandmark Paper R&R Landmark paper A paper that made a difference R&R Game Changer 64 R&R Game Changer? Might change your clinical practice
R&R Eureka 64 R&R Eureka! Revolutionary idea or concept R&R in the FASTLANE RR Mona Lisa R&R Mona Lisa Brilliant writing or explanation
R&R in the FASTLANE RR Boffin 64 R&R Boffintastic High quality research R&R in the FASTLANE RR Trash 64 R&R Trash Must read, because it is so wrong!
R&R in the FASTLANE 009 RR WTF 64 R&R WTF! Weird, transcendent or funtabulous!

That’s it for this week…

That should keep you busy for a week at least! Thanks to our wonderful group of editors and contributors Leave a comment below if you have any queries, suggestions, or comments about this week’s R&R in the FASTLANE or if you want to tell us what you think is worth reading.

The post Research and Reviews in the Fastlane 135 appeared first on LITFL: Life in the Fast Lane Medical Blog.