Research and Reviews in the Fastlane 169

Research and Reviews in the Fastlane

Welcome to the 169th 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 5 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Soren Rudolph, Justin Morgenstern 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

Emergency Medicine
R&R Hall of Famer - You simply MUST READ this!
Motov S et al. Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med 2016. PMID: 27993418

  • What’s the therapeutic ceiling for ketorlac? According to this high-quality RDCT it’s just 10 mg IV, not the 30 mg that we typically use. Without added benefit at higher doses, all we’re left with is the increased risk of side effects and harm. Without any good evidence speaking to the necessity of higher doses, it’s time to drop our dose down when using this drug.
  • This well done study examined the analgesic effect of ketorolac at 3 different doses for patients presenting to the emergency department with abdominal pain, flank pain, musculoskeletal pain, or headache. Doses of 10mg, 15mg, or 30mg were administered in a convenience sample, and the authors found no difference in pain relief. In the absence of any increased benefit, all that is left is potential harm in providing doses higher than the apparent analgesic ceiling of 10mg and all practitioners should consider using that as their standard dose in the future.
  • The ceiling analgesic dose of ketorolac is 10 mg – IV or IM. This study confirms this dosage for acute pain in the ED. This was an RCT of ED patients with acute (<30 days) of musculoskeletal, flank, abdominal, or head pain rated at least 5/10. The authors set out to examine mean difference in pain scores between 10mg IV, 15 mg IV, and 30 mg IV and, unsuprisingly, they found no significant difference between mean pain scores. These results are consistent with prior literature and, given side effects of NSAIDs tend to increase in a dose related fashion, it’s a good idea to give the 10mg dose a try.
  • Recommended by: Anand Swaminathan, Jeremy Fried, Lauren Westafer

The Best of the Rest

Emergency Medicine
R&R Hot Stuff - Everyone’s going to be talking about thisFreund Y et al. Prognostic Accuracy of Sepsis-3 Criteria for In-Hospital Mortality Among Patients With Suspected Infection Presenting to the Emergency Department. JAMA 2016. doi:10.1001/jama.2016.20328

  • In 2016, the Sepsis-3 criteria were launched shifting our definition of sepsis to life-threatening organ dysfunction caused by a dysregulated host response to infection. Along with this shift was the change from SIRS to SOFA and qSOFA to predict mortality in septic patients. This article looks to prospectively validate the qSOFA score. Although the study is multinational, it was primarily performed in France (27 out of 30 centers) and found that patients with a qSOFA < 2 had a mortality rate of just 3% versus 24% in the qSOFA >/= 2. The article concludes that this study validates qSOFA and that this tool is more specific than SIRS without unacceptable decrease in sensitivity. However, some caution should be taken. The overall mortality rate was very low (~ 8%) and a much larger retrospective study published in the same issue from the ANZICS group showed that qSOFA was no better than SIRS but that SOFA was superior. Clearly, this isn’t the last we’ll hear on Sepsis-3.
  • Recommended by: Anand Swaminathan
  • Read more: Alfred researchers validate new sepsis criteria – with a catch (Intensive)

Emergency Medicine
R&R Hot Stuff - Everyone’s going to be talking about thisStanley Adrian J, et al. Comparison of risk scoring systems for patients presenting with upper gastrointestinal bleeding: international multicentre prospective study. BMJ 2017. PMID: 28053181

  • This paper is a comparison for the performance of the most used pre-EGD scores to predict important outcomes (mortality, rebleeding, intervention and hospital LOS) in patients with GI bleeding. The Glasgow Blatchord scale outperformed all others in all categories except on 30-day mortality. En general the disposition of patients with upper GI bleeding is straightforward, but when in doubt (close outpatient follow-up vs. admission) the use of the GBS may be helpful in determining the dispo and level of care.
  • Recommended by: Daniel Cabrera

R&R Game Changer? Might change your clinical practiceMagana JN, Kuppermann N. The PECARN TBI rules do not apply to abusive head trauma. Acad Emerg Med 2016. PMID: 28039943

  • An excellent commentary which examines the findings of Ide et al (PMID: 27862642) in their retrospective review validation of the PECARN head trauma decision tool. The authors remind us that the PECARN traumatic brain injury rules are not intended to be utilized in cases of suspected child abuse, and that in those cases the threshold to image should be low, as “The morbidity and mortality and social implications of abusive head trauma demand a different screening approach.”
  • Recommended by: Jeremy Fried

Systems and administration
R&R Game Changer? Might change your clinical practiceSimone JV. Understanding academic medical centers: Simone’s Maxims. Clinical cancer research 1999. PMID: 10499593

  • This is a great read for anyone hanging from the leadership chain in a complex organisation, especially so if the organisation is an academic medical center. Born from hard won experience, these are “Simone’s Maxims”: 

    1. Institutions Don’t Love You Back
    2. Institutions Have Infinite Time Horizons to Attain Goals, But an Individual Has a Relatively Short Productive Period.
    3. Members of Most Institutional Committees Consist of About 30% Who Will Work at It, Despite Other Pressures, and 20% Who Are Idiots, Status Seekers, or Troublemakers.
    4. Institutional Incompetents and Troublemakers Are Often Transferred to Another Area, Where They Continue to Be Incompetent or Troublemakers.LEADERSHIP
    5. Leadership Does Matter
    6. Leaders Are Often Chosen Primarily for Characteristics That Have Little or No Correlation with a Successful Tenure as Leader.
    7. For Academic Leaders, the Last 10% of Job Accomplishment May Take as Much Time as the First 90% and May Not Be Worth the Effort.
    8. With Rare Exceptions, the Appropriate Maximum Term for an Academic Leader/Administrator Is 10 Years, Plus or Minus 3 Years.
    9. In Academic Institutions, Muck Flows Uphill.RECRUITING
    10. In Recruiting, First-Class People Recruit First-Class People; Second-Class People Recruit Third-Class People.
    11. Personal Attitude and Team Compatibility Is Grossly Underrated in Faculty Recruiting.
    12. The Longer and More Detailed the Written Offer to a New Faculty Recruit, the More Likely Both Sides Will End Up Unhappy.
    13. Faculty Fired for Incompetence Will Almost Always Land a Better Job at Higher Pay.JOB CHANGES
    14. One Should Consider an Academic Move Only for an Improvement in Anticipated Opportunity and Environment of 50% or More.
    15. Every Job Relocation Is Due to a Combination of “Push and Pull”; However, the More “Push” Dominates the Decision, the More Unlikely the Move Will Be Satisfactory.
    16. The “Fit” in a New Job Often Is Not Apparent for at Least 18 Months.
    17. The Time Course of Academic Jobs Is Like the Classic Sigmoid Growth Curve of Bacteria in Culture, with a Lag Phase, Log Growth Phase, and Plateau.
    18. Academic Battles Are Recurring and Continuous, and No One Can Win Them All.

    19. Academic Success, Ironically, Depends on Recognizing and Adapting to the Dominant Cultural and Financial Features of One’s Academic Era.
    20. There Are Strong Temptations to Compromise One’s Academic Mission by Unhealthy Alliances with Sources of Power or Dollars
    21. Academic Medicine Is a Noble Calling.

    Read the full article to learn more about them.

    Hat tip to Daniel Cabrera for sharing this one on Twitter!

  • Recommended by: Chris Nickson

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.

Last update: Jan 19, 2017 @ 5:44 am

The post Research and Reviews in the Fastlane 169 appeared first on LITFL: Life in the Fast Lane Medical Blog.

A SEPSIS 3.0 validálása. Összehasonlítás a SIRS kritériumokkal…

A SEPSIS 3.0 validálása. Összehasonlítás a SIRS kritériumokkal egy nagy Ausztrál intenzíves és egy Francia sürgősségis mintán.

A sepsis 3.0 definíció nem meglepő módon jelentős vitát kavart. Kritikusai a következő problémákat vetették fel a teljesség igénye nélkül:

  1. Az új definíció nincs validálva széles, nemzetközi betegpopuláción és azon a szűk mintán, amin vizsgálták, nem jelzi jobban előre a mortalitást (csak ITOs betegeken, de ott sem sokkal jobb)
  2. Egyfajta betegségsúlyosság előrejelző pontrendszer, nem fejezi ki jobban az élettani problémát és továbbra sincs előrelépés az infekció meglétének diagnózisában
  3. A SOFA pontrendszer bizonyos országokban kevéssé használt (más, pl. APACHE terjedt el), bizonyos szegény országokban túl drága. Egyenlőre sok „nagy” ország releváns társasága nem fogadta el a definíciót (pl. USA, Ausztrália)
  4. Nehéz lesz értelmezni a szepszis irodalmat a jövőben a definícióváltozás miatt.

A most bemutatandó két vizsgálatban az egyes pontra próbálnak választ adni, Ausztrál mintán validálják a Sepsis 3.0 definícióit összevetve a Sepsis 2.0-val.

Intenzív Osztály

Az Ausztrálok elővették az legtöbb intenzíves felvételt tömörítő ANZICS adatbázist és fellapozták a 2010 és 2015 között fertőzés gyanúval ITOra felvetteket. Az így megkapott 184 875 betegnél kiszámolták a SOFA, qSOFA és SIRS eredményeket, majd összevetették a kórházi mortalitással (elsődleges végpont), valamint egy kórházi halálozásból és ITOn töltött időből összegyúrt végponttal (másodlagos). Az eredeti cikkben részletesen bemutatják az egyes pontokhoz tartozó eredményeket. A legfontosabb eredmény az elsődleges végpont előrejelzésének pontossága tekintetében a következő (AUROC):

  • SIRS 0.75
  • qSOFA 0.76
  • SOFA 0.81

Ezek az eredmények különböző végpontoknál és a különböző rizikójú betegek alcsoportjában is megállták a helyüket. (ld. cikk)

A qSOFA összefüggése a mortalitással:

  1. 15%
  2. 20%
  3. 35%

A SRIS esetében

  1. 10%
  2. 15%
  3. 20%
  4. 25%

Sürgősségire felvettek

Ez egy multinacionális (főleg Francia) vizsgálat, ahol 4 hétig vizsgálták a fertőzés gyanúval srügősségire jövő betegeket. Tehát ez az előrővel ellentétben prospektív cohort vizsgálat volt. 879 beteg eredményeit nézték át. A kórházi mortalitás 8% volt.Az AUROC az egyes definíciókra a következő képpen alakult:

  • qSOFA 0.8
  • SOFA 0.77
  • SIRS 0.65
  • Súlyos szepszis (sepsis 2.0) 0.65
  • A qSOFA jobban szerepelt a többi score-nál az ITO felvétel és tartózkodás előrejelzésében is.

Összefoglalásképp, jobb a Sepsis 3.0, mint súlyossági score?


Meg fogja ez a legtöbb ember véleményét változtatni az új definícióról úgy általában?


Buckle and Greenstick Fractures

What? A 9-year-old male presents to the Emergency Department (ED) following a fall whilst playing rugby at school earlier that day. He presents with left wrist pain and mild swelling. There are no wounds or breaks to the skin. On examination he is noted to be both swollen and tender over the distal radius. An

Rest vs Physical Activity After Mild Pediatric Concussion: Which Is Better?

One of the most common recommendations after a child or young adult sustains a mild TBI is to rest. And even better, brain rest. I’ve written about that topic several times over the years.

But what about physical rest? There is a large body of literature documenting the numerous mental and physical benefits of exercise. Couldn’t they also apply after concussive injury to the brain? A study published recently tried to determine if physical activity or lack of it after mild TBI was helpful in reducing the incidence of post-concussive symptoms.

This was a planned analysis of prospectively collected data from nine research network hospital emergency departments in Canada. Children from age 5 through 17 were enrolled if they had received a concussion within 48 hours of the ED visit, as defined by the 2012 Zurich consensus. They were excluded if they had a positive head CT, GCS < 14, or pre-existing cognitive deficits.

Initial research data was collected during the ED visit, and followup phone calls were made by the research team at 7 and 28 days. They asked about self-reported level of physical activity on day 7, and post-concussive symptoms and their change over time on days 7 and 28.

Here are the factoids:

  • Of 3063 patients enrolled, 84% completed the ED assessment. 171 were excluded because they could not be contacted for the activity assessment on day 7.
  • Post-concussive symptoms were present in 30% of these children overall
  • 70% participated in physical activity during the first week: 32% light aerobic, 9% sport-specific, 6% non-contact drills, 4% full-contact practice, and 18% full competition (ignoring doctor’s orders?)
  • Overall, early activity was associated with a lower risk of post-concussive symptoms (25% vs 44%)
  • In patients who were symptomatic at day 7, symptoms were decreased at 28 days in patients who engaged in light aerobic activity, moderate activity, and even full-contact activity

Bottom line: This was a well designed study, but obviously with a number of limitations. Physical activity was self-reported, there may have been other factors that could not be controlled, and the study did not inquire about activity between days 7 and 28.

But this study appears to suggest that, like in most other areas, exercise is good. Even for the brain recovering from a concussion. Obviously, a really good randomized study would be the gold standard, but I doubt that will be done anytime soon. Trauma professionals may want to consider a cautious return to light to moderate activity as soon as the child feels well enough. But keep in mind that, in general, the onset of fatigue is a good indicator that it is time to stop activity and rest. And full contact should probably be avoided, especially because of the risk of re-injury.

Related posts:

Reference: Association between early participation in physical activity following acute concussion and persistent postconcussive symptoms in children and adolescents. JAMA 316(23):2504-2514, 2016.


Azithromycin was no help in asthma exacerbations (AZALEA)

Adding azithromycin to usual treatment for asthma exacerbations in adults did not improve asthma symptoms or speed their resolution, investigators reported in the AZALEA randomized clinical trial. Patients getting azithromycin also had no improvement in lung function. Azithromycin is known to have some activity against viruses that infect bronchial cells; viruses are causative or contributory [... read more]

The post Azithromycin was no help in asthma exacerbations (AZALEA) appeared first on PulmCCM.