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Highlights from the January 2016 issue: Emergency Medicine Journal.

11 Jan, 16 | by scarley

Click here for full table of contents.

Screening older patients in the ED

Having screening tools that are accurate in terms of specificity and sensitivity is essential to improving care for this vulnerable group. This issue includes two papers from different parts of the world that will be of interest to ED clinicians’ intent on improving screening and outcomes for older patients attending their departments.

The ISAR tool: how useful is it?

The Identifying Seniors at Risk (ISAR) tool has mixed predictive ability. Suffoletto and colleagues in Pittsburg undertook a prospective study of 202 adults over the age of 65 presenting to the ED to evaluate the ability of the ISAR tool to differentiate between older patients having a poor outcome within 30 days of ED care and those that did not. They also sought to establish whether self-reported ISAR risk factors correlated with objective measures and whether objective measures altered predictive ability. Their findings suggest that the ISAR tool does not differentiate well between older adults with or without 30 day hospital revisit or death. Furthermore, they found that related objective risk factors did not improve the performance so, clearly, we need to develop more effective tools and in the meantime use ISAR judiciously and with caution.

Missing delirium

In Thailand, Sri-on and colleagues conducted a prospective cross sectional study to determine the prevalence of delirium in patients over the age of 65 in their urban tertiary care emergency department. A secondary objective of this study was to identify risk factors and short term outcomes in elderly patients with delirium. In their sample of 232 patients, 27 (12%) were delirious in the ED of which 16 (59%) were not recognized as being delirious by ED clinicians. Unsurprisingly, patients with delirium had a higher mortality rate than those without delirium (15% versus 2% P=0.004). These findings from a middle income country are consistent with research findings from high income countries where the detection of delirium by ED physicians is also low. Clearly raising the profile of delirium as a medical emergency as well as further training for clinicians in recognizing this reversible condition is urgently needed.

Editor’s choice

Traumatic brain injury (TBI) in young people is a common presentation to the ED and many of these children, approximately 50% undergo computed tomography (CT) even though the majority with a mild TBI GCS 13–15 have no intracranial injury. Concerns have been raised over the possible overuse of CTs because ionizing radiation can lead to malignancies, so it was interesting to read of a prospective cohort study in three paediatric emergency departments in Switzerland by Manzano and colleagues which sought to assess the accuracy of S100B serum level to detect intracranial injury in children with mild traumatic brain injury. They found S100B has an excellent sensitivity but poor specificity. So, it may be an accurate tool to help rule out an intracranial injury but it cannot be used as a sole marker due to its specificity. Used with clinical decision rules, S100B may contribute to decrease the number of unnecessary CTs and this itself is worthy of further consideration.

Why is it so difficult to recruit patients to research studies in the ED?

It’s long been recognized that medical research studies frequently struggle to meet patient recruitment targets. Many of the barriers and impediments to recruiting patients will be familiar to those of us who have undertaken research in the ED. Johnson et al in the UK have attempted to explore this problem further using the large multicenter AHEAD study which recruited patients at 33 Type-1 emergency departments in England and Scotland. They found overall recruitment varied greatly between sites with an eightfold variation in recruitment rates. In addition to the usual problems already documented in the literature, detailed interviews with three research nurses from the study identified other barriers and facilitators to recruiting patients. Interestingly, key to the success of the AHEAD study was a protocol that minimized the involvement of clinicians who are invariably too busy to engage. Retrospective recruitment and anopt out consent strategy also helped. So if you are in the process of planning research do read this paper, it may well change your recruitment strategy and help you reach your target.

Reader’s choice

Attending the ED: an automatic choice – open access paper

Patients attending the ED with non-urgent medical problems is a growing problem in many parts of the world and St Vincents and the Grenadines in the West Indies is no exception.In this issue, Keizer-Beache and Gueli describe a qualitative study they undertook to understand why Vincentian patients with non urgent medical problems seek care in the emergency department rather than primary care facilities. Many of the reasons cited by participants have previously been documented and will be familiar to ED clinicians everywhere, such as convenience, dissatisfaction with primary care facilities etc. Perhaps more interestingly in this study, participants revealed that attending ED is automatic, describing this as a locally shared custom. They also suggested that this habitual use of the ED is reinforced by health professionals who routinely refer non urgent cases to the ED. The authors suggest that further health services research should reconsider rational choice behavior models. Is there a salient message in this paper for us all? Are we as ED clinicians inadvertently encouraging attendances in our own departments? I‘ll leave you to read this paper and ponder this question yourself.

Mary Dawood

Associate Editor

Why do Emergency Medicine?

21 Dec, 15 | by scarley

Great work from colleagues in Edinburgh.

Why would you do EM? Learn more by visiting their website at http://www.edinburghemergencymedicine.com/ and join the #EDvolution.

vb

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Mistakes Were Made

17 Dec, 15 | by rradecki

This past month a pair of articles were published online in the EMJ concerning diagnostic error in the Emergency Department. This pair of articles, with the fabulous Hardeep Singh as senior author on each, attempt to describe the underlying foundations of error.

These are particularly important in the context of the ongoing resource constraints facing medical care. A common strategy to reduce the potential for error, and, certainly, the “easy way out”, is simply to overtest. This strategy seems to be associated with a pattern of reduced medicolegal liability, although it is a bit of a stretch to apply this surrogate to diagnostic accuracy. However, besides the obvious up-front costs associated with overtesting, there is an under-appreciated incidence of false-positive results in the setting of low pretest probability.

The first of two articles, by Medford-Davis, focuses on the errors associated with abdominal pain presentations in the Emergency Department. These authors reviewed patients with an initial presentation of abdominal pain, who then subsequently returned to the same institution within 14 days and were admitted. These cases, totalling 100 in all, were retrospectively examined for potential diagnostic error.

Rather distressingly, a full one-third of the return visits may have resulted in part to some diagnostic error on the initial visit, although the reviewers were not in good agreement on the presence of error in all cases. A small number of adverse outcomes were related to non-remedial patient factors, such as poor compliance, poor follow-up, and other factors relating to the study occurring at a facility comprised of an inner-city, indigent, and undocumented immigrant population. The bulk of errors, however, are tucked into the patient encounter itself. The initial root of errors is in the initial evaluation – if elements of history or physical exam are inadequately described, there is a cascading effect of missed indicated testing. Then, a second roadblock seemed to occur on the processing of information resulting from initial orders. Many patients returning for subsequent admission had abnormal studies that were incompletely addressed at the initial visit.

The second article, by Okafor, analyzed the content of cases from an institutional error reporting system. Rather than focusing on the specific phase of care in which errors occurred, these authors focus on the primary domains of error. They found, unsurprisingly, the cognitive dimensions of errors are complex, and include issues such as faulty data gathering, premature closure, and misinterpretation of results. However, they importantly observe errors rarely occurred in isolation. Cognitive errors were frequently complicated by process or resource-related issues, as well as simple factors relating to patient complexity. In all, three-quarters of errors resulted from a combination of factors.

The basic takeaway here probably relates to some of the most difficult issues to address in the Emergency Department. Diagnostic accuracy will be maximized when properly resourced physicians have the time they need to evaluate their most complex patients. Resources, time, and complexity, however, are not frequently seen in their optimal concentrations in the ED – but it is important to recognize any quality improvement efforts would be remiss without accounting for these factors, and focusing solely on individual physician remediation.

Diagnostic errors related to acute abdominal pain in the emergency department

Using voluntary reports from physicians to learn from diagnostic errors in emergency medicine

The Balance of Risks and Harms in Trauma Immobilization

11 Dec, 15 | by rradecki

In a recent online-first publication in the EMJ, McDonald et al canvas the literature regarding selective immobilization protocols in trauma. Their most significant finding, unfortunately, is the low quality of the evidence and the high degree of bias present across included studies. This limits the authors’ attempted analysis of sensitivity and specificity of selective immobilization protocols.

From a qualitative standpoint, however, their data bears examination. The included studies or prehospital immobilization range in size from 3 to 504 spinal injuries. Within these cohorts, 76 patients were identified with injuries who did not undergo immobilization. None of these patients had any reported neurologic deterioration in spine of their missed immobilization.

This small snapshot ties into another recent publication, in AEM, looking specifically at cases of neurologic deterioration in the context of failed prehospital immobilization. These authors identify 41 qualifying cases across 12 studies. Most patients had normal function at the scene, but many had substantial disability or death following a period of non-immobilization.

This leads, then, to two related questions raised by each of these authors. The first: how do we reform our prehospital protocols to reduce unnecessary immobilization, while potentially still capturing those few with spinal injuries. The second: how much benefit does pre-hospital immobilization convey regarding long-term outcomes? McDonald et al report their sensitivity and specificity based simply on the presence of an injury, but, long-term disability is the patient-oriented outcome. To truly address and refine pre-hospital immobilization strategies, further study should be designed and powered to detect – if possible – the presence of subsequent neurologic deterioration. Only then, when deterioration rates can be compared between the immobilized and non-, will we have a better grasp of the value of continued, dogmatic, pre-hospital trauma care.

Highlights from the December issue: Emergency Medicine Journal.

11 Dec, 15 | by scarley

Click here for full table of contents.

Even if one does not work in a “major trauma centre,” we all see trauma. Victims of stabbings and bike accidents do not follow “trauma criteria” when they head for the nearest ED. Elderly patients with seemingly minor injuries are brought to a local hospital, only to discover that there are 4 rib fractures, a pulmonary contusion and a subdural haematoma.

2015 marks the silver anniversary of UK’s Trauma Audit Research Network (TARN). For those of you not living in the UK, TARN is a national registry that collects prospectively entered data on the epidemiology, treatment and outcomes from major trauma. TARN serves two major functions: it publicly reports its findings and it allows trauma researchers to use its large, prospectively collected data set to conduct research. Our first editorial, by Fiona Lecky, TARN’s research director, describes the humble birth, development and accomplishments of TARN over the past 25 years. In an accompanying commentary, Dr Karim Brohi, clinical lead for London Major Trauma System, takes the opportunity to pause to consider the challenges created by the growth of TARN from a local audit tool to both a national quality assurance program and a research enterprise.

To celebrate 25 years of TARN, this issue’s research and reviews are centred on the theme of trauma. There are articles from TARN, which illustrate the value of a large, prospectively collected data set. We also include several intriguing articles from France (on telemedicine in head injury), and South Africa, on the role of interpersonal violence in trauma care. Two articles—one on c-spine immobilisation and the other a review of traumatic cardiac arrest—will make you reconsider what you’ve always known.

The changing face of trauma

Using data from the TARN database, Kehoe and colleagues describe how the mechanisms and victims of major trauma have been changing over the past 25 years. Road traffic accidents are down; falls are up. Major trauma patients are increasingly elderly. This could be a matter of better data collection as a result of TARN, and improved detection with the rising use of CT. In either case, the data not only confirm what many of us are seeing, but prompt consideration of whether our systems are adapting as they should.

Editor’s choice: Do anti-coagulated trauma patients have worse outcomes?

It is estimated that 1% of the UK population is anticoagulated, and the prevalence rises with age. A study in Japan showed that about 25% of patients over 80 were on anti-thrombotic therapy. Warfarin remains the most commonly prescribed anti-coagulant, and whether trauma patients on warfarin do worse is controversial. An RCT is impossible of course; but even with multivariate analysis, it is difficult to account for the substantial burden of comorbidity in the patients on warfarin. In this carefully conducted observational study using the TARN database, Battle et al used a matched case-control design to compare the outcomes of trauma patients who were receiving warfarin pre-injury and those who weren’t. The result: warfarin is indeed an independent risk factor for mortality in trauma patients.

The trauma burden of interpersonal violence: a preventable disease

In this descriptive study of a small emergency department in KwaZulu-Natal, South Africa, Bola and colleagues found 41% of surgical admissions were due to trauma, and interpersonal violence accounted for more than a third of this trauma burden. Community assault, not uncommon in the rural areas of this region, was responsible for 14% of traumas and its victims spend longer times in the resuscitation areas. Victims of interpersonal violence stay an average of 9.8 days and require significant amounts of blood (a scarce resource), and the use of imaging and theatre time, a clear additional burden to a health care system that can least afford it.

Traumatic cardiac arrest—time for a paradigm shift?

Most of us were taught that traumatic cardiac arrest had a dismal outcome. However, that may be because we were applying the wrong therapy. In this review of new evidence on traumatic cardiac arrest, Captain Surgeon Jason Smith explains that TCA may really be a low-flow state, for which traditional CPR will not work. A new approach that focuses on stopping haemorrhage and aggressive resuscitation (preferably blood) appears to have substantial promise, as evidenced by the military experience.

Graphic

So, is there more to be done to control haemorrhage?

Resuscitative endovascular balloon occlusion of the aorta (REBOA) has the potential to bridge patients to definitive haemostasis in patients with noncompressible torso haemorrhage. However its potential for trauma patients is unknown. Barnard and colleagues used the TARN database to determine the number of trauma patients in 2012–13 who might have benefited from the intervention. Out of 72000 patients, 397 were identified. They had a median ISS of 32 and, coincidentally, a mortality of 32%. The authors point out that although the numbers are small, the patients are, without REBOA, quite resource intensive and are largely seen at major trauma centers, making it potentially worthwhile to evaluate the use of REBOA at these hospitals.

Primum non nocere…the growing evidence for self-extrication

Dixon et al placed biomechanical sensors on paramedic volunteers and studied them with infrared motion analysis when being extricated from a test crash vehicle. Compared with equipment-assisted extrication, self-extrication showed the least movement. The authors suggest that it may be time for a “spinal rule-in” policy in for stable patients, where self-extrication is the first option if the paramedics have carefully assessed the victim.

Ellen Weber.

Editor in Chief.

Highlights from the November issue: Emergency Medicine Journal

11 Nov, 15 | by scarley

Click here for full table of contents.

Bored of Boarding

I’m sure that many of us have felt pangs of guilt as we walk past rows of patients on corridors waiting to get into beds. The ‘boarded’ patient is a gentle term for what is an obvious and embarrassing symbol of overcrowding in our emergency departments. I often feel ashamed of our health care systems when we subject patients to the indignity and poor care associated with boarding, but what is it like for patients? Liu et al have examined the experience of boarding from the patient perspective using qualitative methods. They found that patients do find waiting frustrating and characterised by a lack of communication. They conclude that if we are to deliver kind and compassionate care then we must listen to the voices of our patients and eradicate the practice of boarding.

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Complications of prehospital intubation

Prehospital airway management is always controversial and so it is again this month with a retrospective review of cases intubated in the field. The data suggests a high complication rate as compared to in hospital airway care. It is interesting to note that the airway assessments suggest that views are often poor in the prehospital setting which will raise the question of whether these are difficult airways, difficult environments, or less skilled operators. No doubt it will generate debate as all papers relating to prehospital airway management appear to do.

Do we need to give antibiotics to every dog bite?

In the UK it is custom and practice to give antibiotics to all dog bites (well it is in Manchester) but the wisdom of this has been questioned many times over the years. Tabaka et al have looked at wound infection rates over a 4.5 year period to determine characteristics of wounds that get infected. The findings are interesting with a relatively low overall rate of infection and a suggestion that those that are closed, or which are puncture wounds are at higher risk. They conclude that these are high risk wounds and should be treated with antibiotics. As for other wounds, it’s tricky to say as the vast majority of wounds received antibiotics as a routine. These are interesting results although we arguably still await the randomised controlled trial that might finally answer the question.

UK Paediatric research priorities

Is an interesting study on research priorities for paediatric emergency medicine in the UK and Ireland. Paediatric Emergency Research in the UK and Ireland (PERUKI), is a group of 43 centres aiming to deliver high quality research in paediatric emergency care and they have been very productive to date, but they need to set priorities for the next generation of paediatric researchers. What is heartening is that the results clearly lead towards potential trials in the future which have the potential to significantly improve the care we give to injured and ill children. If paediatric emergency medicine is your thing, this is a must read.

Aspirin in the US

Another database study this month looks at the administration of aspirin to patients with potential acute coronary syndromes. Overall the figures from Tataris et al are a bit disappointing with fewer than half of patients receiving the medication. Beyond this the data has been mined for factors that might predict administration and interestingly race and US location appear to have an influence. However, we must be cautious as studies of this type can show association, but not necessarily causation. Read for yourself and decide.

The hurt of Head Injury Retrieval Trial

Arguably one of the most expensive trials in prehospital care, the HIRT trial has raised many controversies in the prehospital community. Originally set up as a randomised controlled trial of helicopter assisted physician led prehospital care vs. paramedic care in head injury. The final analysis is complex and requires thought on the part of the reader. Overall the data suggests that there is no statistical difference between paramedics and physician responders, though the authors point to some subgroups that may show a benefit to physician care. This study requires careful consideration as one of the largest prehospital physician trials in history. Whether it is or whether it could ever be definitive is as much a question for those interested in research design as it is for the reader.

Do we overinvestigate patients for pulmonary embolus?

Yes we do, or at least that’s the claim from Mongan et al in this month’s journal. The data supports their view with a prevalence of disease in some groups investigated as low as 0.6%. PE prevalence increases with age and yet we appear to investigate the young fit and healthy as frequently as we do the elderly. This is clearly questionable practice, particularly when the effects of investigation and therapy are associated with harm. This study based on two large data sets suggests modifications to established risk factors to raise awareness of the differences in prevalence between young and old, male and female. It hints at further refinements to diagnostic tools in the future.

Editor’s choice

You cannot deliver high quality care without staff. Underpinning this is that you cannot deliver safe care without staff, but how many staff are enough? Pope et al present data collated for the National Institute for Clinical Effectiveness on safe nursing staff levels. This is essential reading for all emergency department staff and highlights the association between low staffing and poor patient experience, quality and outcome. An accompanying editorial outlines why this paper is so important to emergency care and why we must ensure that we have the resources to deliver a safe and high quality service.

Highlights from the October issue: Emergency Medicine Journal.

11 Oct, 15 | by scarley

Click here for full table of contents

Quality care

How we care for patients with learning difficulties may vary from country to country but the evidence suggests that few emergency departments are adequately equipped to respond effectively to adolescents and young adults with Autistic Spectrum Disorder (ASD). In this issue, Lusky et al from Ontario describe the use of emergency services by adolescents and young adults with ASD in order to identify predictors of emergency use. Although a small study, their findings are informative, suggesting that patients with ASD are likely to attend the ED, thus there is a need to train emergency personnel to work more effectively with these patients and their carers. This is a timely piece of work and particularly pertinent for UK readers as NHS England has recently published a new set of rules called “The Accessible Information Standard”. This standard details how healthcare professionals should communicate with people who are disabled in any way or have sensory impairments. Healthcare organizations in the UK will be expected to meet these standards by July 2016. Lusky’s paper is a good starting point, it is well referenced and highlights many of the challenges ED’s face in improving care for this vulnerable group.

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When to fly

Employing scarce resources judiciously is key to achieving best outcome in pre hospital trauma care. London’s air ambulance provides a doctor and paramedic team 24 hours a day to compliment London Ambulance ground paramedic teams. In such a densely populated area as London, how do the air ambulance medics judge which incidents they should respond to? Wilmer et al describe their study which sought to determine which dispatch methods were most effective in terms of accuracy and time in identifying patients with serious injury. They conducted a retrospective review of three years of data 2,203 helicopter activations and found that a flight paramedic using telephone interrogation is as accurate as ambulance crews’ requests and both are significantly better than just the mechanism of injury. Combining MOI and interrogation identifies most of the seriously injured patients while minimising delays and over triage. So, if you have often wondered as I have how such decisions are made then read this interesting paper.

Chilling patients

It is recognised that mild hypothermia limits neurological injury and improves outcomes for patients following successful cardiopulmonary resuscitation, but what is the most effective way to cool a patient? This was the question de Waard and colleagues from the Netherlands sought to answer. They undertook a retrospective study comparing the effects of intravascular cooling in post cardiac arrest patients (n=97) in one university hospital with non invasive surface cooling of post cardiac arrest patients (n=76) in another university hospital. They found invasive cooling systems result in equal cooling speed as surface cooling but less variation in temperature during the cooling phase. They do point out that mean temperature during the maintenance phase may be associated with survival independently of the cooling system.

The heart of the matter

Chest pain is a very common presentation in emergency departments around the world and ruling out serious causes such as Acute Coronary Syndrome (ACS) continues to concern clinicians as is evidenced by two papers in this issue from two different countries.

Using a prospective cohort study, Body et al in Manchester aimed to validate the Manchester Acute Coronary Syndrome (MACS) decision rules with an automated h-FABP assay that could be used clinically to “rule in” or “rule out” acute coronary syndrome in the ED. The rule which incorporates heart type fatty acid binding protein (h-FABP) and high sensitivity troponin T (hs-cTnT) levels was previously validated using a semi –automated h-FABP assay but was not considered practical for clinical use. Of the 456 patients included in the study, 78 had an acute myocardial infarction (AMI) and 97 developed Major Adverse Cardiac Events (MACE). The authors conclude that their findings validate the performance of a refined MACS but recommend verification by an interventional trial prior to implementation.

In Tunisia, Boubaker and colleagues considered the need for a valid clinical score to improve diagnostic accuracy of ACS. They compared the performance of a model combining the TIMI score and a score describing chest pain (ACSDiagnostic score: ACSD Score) with that of both scores alone in diagnosing ACS in patients presenting with chest pain associated with a non diagnostic ECG and a normal troponin. They enrolled 809 patients with a normal ECG and a normal Troponin in their study. They found the ACSD score showed a good discrimination performance and an excellent predictive value which would allow clinicians to safely rule out ACS in patients presenting with undifferentiated chest pain. They recommend a larger multi centre study to validate their findings. So for now, affairs of the heart continue to exercise scientific inquiry.

Global Emergency Medicine Highlights

In this issue, we launch another new section – Global Emergency Medicine Highlights. Each month we’ll bring you an abstract selected by the editor-in-chief of the African Journal of Emergency Medicine, the Annals of Emergency Medicine, and Emergencias. We are very proud to be participating in this partnership with our colleagues from Africa, the US and Spain.

Mary Dawood

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Balancing Resources in the Emergency Department

22 Sep, 15 | by rradecki

Predictions are tricky, especially whenThis month, Kreindler et al report a review of patient-level predictors of protracted Emergency Department length of stay. These sorts of reports are critical, not solely due to the relative importance of the topic, but also because of the gaps revealed in the current literature. To wit, despite reviewing 30 investigations of Emergency Department length of stay, a partial conclusion of these authors is the available information is insufficient to facilitate its use in service planning.

The value of such predictive tools would be profound. If, based on information readily available during triage, the LOS and resource utilization of a patient might be predicted, the effect spans the entire hospital. Nursing staff needs can be informed for the downstream wards and locations for general and specialty care, not simply for ongoing ED care. The ongoing presence of technical resources might be predicted, such as radiology or laboratory, and staffing maintained in anticipation of future orders. Finally, a prediction of increased LOS may influence models predictive of ED crowding, and prompt additional resources targeted at traditional bottlenecks in care. Clearly, predicting LOS results in a cascade of value.

However, as these authors note, it is simply too challenging to distill simple predictors from these data. Predictors of long LOS include eventual admission, patients with mid-acuity levels, older adults, and certain socioeconomic factors. However, some of these features are colinear with others, and some – like eventual admission – are frequently evident only at the conclusion of an ED stay. Increased intensity of diagnostic testing also predicts increased LOS, which brings to mind another confounding variable: the physicians themselves. Every ED has a range of clinicians, with variable diagnostic skills and risk tolerance, and identical patients with the same complaints may be assessed as immediately safe for discharge by some clinicians, while other clinicians might perform resource-intensive evaluations. This almost certainly ties into the general observation of presenting patient complaint only inconsistently associated with LOS.

What are the ramifications, then, for pursuing models for ED LOS? Essentially, there’s no simple shortcut. And, this is clearly clinically reasonable – as physicians we intrinsically know the vast constellation of patient factors relating to our decision-making process. It does not make sense to suggest a model of reasonable accuracy can be built from such broad brush strokes. Help, however, may yet be on the way from the realm of Clinical Informatics. As EHR data proliferates, the “undifferentiated” ED patient is gradually becoming a thing of the past. No longer would such a model be restricted to the basic triage information, but, perhaps include coded features of the medical history heretofore unavailable to prior models. Alternative analytic approaches, such non-linear, cluster-based techniques – those which best handle “big data” – may also be enabled by access to vastly more robust substrate.

The need for further study is apparent – but it is clear these previously pursued analyses should not be fruitlessly re-replicated. A new approach is necessary.

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Ryan

The Alteplase Controversy Goes Prime Time

19 Sep, 15 | by rradecki

Alteplase & Stroke

Just a few months ago, alteplase for acute ischemic stroke was assaulted in the pages of the BMJ. Academic debate on this subject is hardly novel, as the controversy within the ivory tower has dragged on almost since thrombolytics for stroke received therapeutic approval.

However, as the use of alteplase grows, the number of patients harmed by its use has correspondingly increased. Regardless of the perceived benefits of the treatment, the resulting harms have accumulated into a full public outcry, with family members of those harmed petitioning the government for increased oversight. There are now two ongoing reviews in the United Kingdom – the Medicines and Healthcare products Regulatory Agency review has been joined by the Academy of Medical Sciences. A full 38 minute segment on BBC Radio 4 details several personal stories, and contains snippets of interviews with the renowned David Newman, among others.

In the same vein, the American College of Emergency Physicians has finally released their revision to the highly-conflicted 2012 policy statement regarding treatment of acute ischemic stroke. Substantially altered from the 2012 version, ACEP has dramatically weakened the prior recommendations to reflect the paucity of randomized trial evidence. While two pivotal trials demonstrated significant absolute benefit, such trials enroll simply a few hundred patients in the setting of vastly heterogenous presentations and prognoses for acute stroke.

The new policy statement issues two recommendations for offering alteplase to qualifying patients, both under the “Level B” classification – representing “recommendations” for patient care subject to “moderate clinical certainty”. This is a change from the previous guideline, which provided concise recommendations favoring treatment within three hours as Class A. The new recommendations:

      With a goal to improve functional outcomes, IV tPA should be offered and may be given to selected patients with acute ischemic stroke within 3 hours after symptom onset at institutions where systems are in place to safely administer the medication. The increased risk of sICH should be considered when deciding whether to administer IV tPA to patients with acute ischemic stroke.

Despite the known risk of sICH and the variability in the degree of benefit functional outcomes, IV tPA may be offered and may be given to carefully selected patients with acute ischemic stroke within 3 to 4.5 hours after symptom onset at institutions where systems are in place to safely administer the medication.

It remains to be seen whether these recommendations substantially alter clinical practice or encourage additional investigation. Beyond 3 hours – the timeframe most critiqued by Alpers et al – alteplase remains unapproved for use by the FDA, and by these guidelines need not be offered to patients.

As always, the hope is these developments will spur further, prospective, independent evaluation. We need thousands, not hundreds, of patients in well-designed trials devoid of conflict-of-interest. Otherwise, we continue to place patients at risk, both from the harms of alteplase or the harms of potentially not receiving a truly beneficial therapy.

 

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Ryan

Social Media is Exploding – But is it Effective?

10 May, 15 | by rradecki

About a year ago, I posted about accelerating knowledge translation using Twitter, blogs, and other social media. In some respects, the embrace of social media was still in its infancy – originally, #FOAMed, powered by an independent group of individuals passionate about sharing knowledge and teaching Emergency Medicine. The Emergency Medicine Journal, driven in part by Prof. Carley’s efforts, was one of the first journals to add social media, discussion, and dissemination to their official scope and formally appoint Editors in this domain.

Now, to put it mildly, the scene has exploded.

Each of the major Emergency Medicine journals in the U.S. has at least one social media editor (Annals)(AEM), or an entire social media team. The major conferences, in Emergency Medicine and other specialties, have adopted hashtags (e.g., #ACEP14) and live tweeting by meeting participants as part of knowledge dissemination and promotion. Indeed, an upcoming conference in Chicago, USA, specifically addresses Social Media and Critical Care. Finally, even previously small, individual efforts at knowledge translation, like Academic Life in Emergency Medicine, have gathered momentum and become online clearinghouses of peer-reviewed editorial and educational content, along with their own online Journal Clubs.

The Council of Emergency Medicine Residency Directors (CORD) issued a long statement on the professional use of social media in by training programs, including a statement that “social media can be a powerful tool”. The American Congress of Obstetricians and Gynecologists recently issued guidelines on physicians’ use of social media. The United Kingdom Diabetes Professional Conference broadly covered social media use by endocrinologists to learn from and communicate with patients in a new context. Even other health professional disciplines, such as research nurses, have recognized the power of social media for unexpected viral promotion of clinical topics.

However, despite this enthusiasm, it remains a challenge to measure tangible benefits associated with social media use. Anecdotal stories of professional networking via social media abound – but, ultimately, patient-oriented outcomes as result of knowledge translation ought be the true measure of success. A recent study in Circulation randomized newly published articles to traditional knowledge translation or specific social media promotion – and there was no difference in online views between the two cohorts. The lesson, despite the authors’ conclusion, is not that social media is limited – but the content trumps the distribution method. If a social media stream consists of solely unfiltered noise, rather than useful signal, the entire effort will fail.

While increasing numbers of clinicians and patients are accessing information through alternative digital means, and the potential for education and accelerated knowledge translation through social media exists – individuals and organizations should recognize significant challenges remain. No amount of investment or effort into “social media” replaces useful content, and as more sources contribute to the pool of online information, the more difficult it will be to build a following or measure successful effects.

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