Oct 20, 2017
A day late and a dollar short, but here it is, the Ercast summer Journal Club. As per usual, boy genius Adam Rowh, MD is in the house to give his take on the medical literature. In this episode, we discuss
Also mentioned in this show
The answer for much of the antibiotic era has been no. I and D is sufficient treatment. But with the rise of MRSA, that thinking has been questioned. A paper by Talan in 2016 investigating TMP-Sulfa vs placebo for uncomplicated skin abscess suggested that TMP-Sulfa conferred a higher cure rate after I and D. Now comes a study of similar ilk but an additional treatment arm.
Looking under the hood (examining the details)
An intoxicated patient with moderate trauma has a pristine looking, completely normal, CT of the cervical spine. Do we need them to continue wearing their cervical collar until clinical sobriety? Enter our next study
This conclusion mirrors the EAST guidelines on cervical spine collar clearance in the obtunded adult blunt trauma patient:
In obtunded adult blunt trauma patients, we conditionally recommend cervical collar removal after a negative high-quality C-spine CT scan result alone. This conditional recommendation is based on very low-quality evidence but places a strong emphasis on the high negative predictive value of high quality CT imaging in excluding the critically important unstable C-spine injury.
The lament for droperidol's absence from our pharmacopeia continues unabated, yet there is another shining star: haloperidol. What's old is new when it comes to treating severe nausea and vomiting. Long recognized in the palliative care world as the cat's pajamas for management of nausea, haloperidol is finally getting the recognition it deserves.
The study: Ramirez, R., et al. "Haloperidol undermining gastroparesis symptoms (HUGS) in the emergency department." The American journal of emergency medicine (2017). PMID:28320545
The patients: Retrospective study of 52 patients with diabetic gastroparesis treated with 5mg IM haloperidol.
The comparator group: The SAME PATIENTS on ED visits when they didn’t get haloperidol! You can't get better matching characteristics than that.
The results: Using haloperidol in this group of patients decreased amount of opiates given and admissions but not ED or hospital length of stay. There were no complications seen in patients given haloperidol
This has been a subject of much debate over the past decade and there has been signal that there may be a benefit in function outcome when thrombolytics are given to so-called intermediate risk pulmonary emboli- not hypotensive but right ventricular dysfunction and a positive biomarker. The biggest research article to date says lytics don't improve outcome.
The study: Konstantinides, Stavros V., et al. "Impact of thrombolytic therapy on the long-term outcome of intermediate-risk pulmonary embolism." Journal of the American College of Cardiology 69.12 (2017): 1536-1544. PMID:28335835
The patients: About 700 patients with intermediate risk PE given either Tenecteplase of placebo. Intermediate risk PE defined as RV dysfunction confirmed by echocardiography or spiral computed tomography of the chest. Myocardial injury confirmed by a positive troponin I or T test result.
The results: At 3 year follow up, there was no significant difference in mortality, functional limitations, pulmonary HTN, or RV dysfunction.
Our take home: When we first saw this paper, we were giddy because here was evidence that would show, once and for all, that lytics were an effective treatment for this cohort. The cold hard data says quite the opposite: lytics don’t make a difference in long term outcome. The best evidence we have to date suggests that there is no justification to give systemic thrombolysis to a stable patient with intermediate risk PE. Will catheter directed lysis prove any better, or are there certain high risk groups under the 'intermediate' umbrella who would benefit? Time will tell.
The study: Hay, Alastair D., et al. "Effect of oral prednisolone on symptom duration and severity in nonasthmatic adults with acute lower respiratory tract infection: a randomized clinical trial." Jama 318.8 (2017): 721-730. PMID:28829884
The patients: 400 patients with cough for less than a month and at least 1 lower tract symptom like phlegm, chest pain, wheezing or SOB in the past day. Patients received either 40 mg of prednisolone or placebo daily for 5 days. The primary outcomes were duration of cough and mean severity of symptoms on days 2 to 4.
The results: Steroids did not make a difference
Our take home: WTF!? Of course steroids didn’t work! Only 6 percent of patients had wheezing and only a handful had crackles. Does a patient with an undifferentiated acute viral respiratory infection benefit from steroids? Apparently not. We tend to prescribe patients to these patients who DO have wheezing, but this supports our practice of not using them in patients who don't.