Time to Treatment and Mortality during Mandated Emergency Care for Sepsis (NEJM, via G Johnson)

Time to Treatment and Mortality during Mandated Emergency Care for Sepsis.

Christopher W. Seymour, M.D., Foster Gesten, M.D., Hallie C. Prescott, M.D., Marcus E. Friedrich, M.D., Theodore J. Iwashyna, M.D., Ph.D., Gary S. Phillips, M.A.S., Stanley Lemeshow, Ph.D., Tiffany Osborn, M.D., M.P.H., Kathleen M. Terry, Ph.D., and Mitchell M. Levy, M.D.

N Engl J Med 2017; 376:2235-2244June 8, 2017DOI: 10.1056/NEJMoa1703058

https://www.ncbi.nlm.nih.gov/pubmed/28528569
https://doi.org/10.1056/NEJMoa1703058

Journal Club Articles for 4/26/2017

Correlation of Venous Blood Gas and Pulse Oximetry With Arterial Blood Gas in the Undifferentiated Critically Ill Patient.
J Intensive Care Med. 2016 Jun 9.
Zeserson E, Goodgame B, Hess JD, Schultz K, Hoon C, Lamb K, Maheshwari V, Johnson S, Papas M, Reed J, Breyer M.
PMID: 27283009
DOI: 10.1177/0885066616652597

Propofol or Ketofol for Procedural Sedation and Analgesia in Emergency Medicine-The POKER Study: A Randomized Double-Blind Clinical Trial.
Ann Emerg Med. 2016 Nov;68(5):574-582.e1.
Ferguson I, Bell A, Treston G, New L, Ding M5, Holdgate A.
PMID: 27460905
DOI: 10.1016/j.annemergmed.2016.05.024
Full text via NYSL: http://www.sciencedirect.com.dbgateway.nysed.gov/science/article/pii/S0196064416302049

 

Recommended NEJM Reading (via G. Johnson)

Recommended reading from the new NEJM, via Dr. Gary Johnson

Acute Spinal Cord Compression
Alexander E. Ropper, M.D., and Allan H. Ropper, M.D.
N Engl J Med. 2017 Apr 6;376(14):1358-1369.
doi: 10.1056/NEJMra1516539.
PMID: 28379788

Two-Year Outcome after Endovascular Treatment for Acute Ischemic Stroke
Lucie A. van den Berg, M.D., Marcel G.W. Dijkgraaf, Ph.D., Olvert A. Berkhemer, M.D., Ph.D., Puck S.S. Fransen, M.D., Debbie Beumer, M.D., Hester F. Lingsma, Ph.D., Charles B.L.M. Majoie, M.D., Ph.D., Diederik W.J. Dippel, M.D., Ph.D., Aad van der Lugt, M.D., Ph.D., Robert J. van Oostenbrugge, M.D., Ph.D., Wim H. van Zwam, M.D., Ph.D., and Yvo B.W.E.M. Roos, M.D., Ph.D., for the MR CLEAN Investigators*
N Engl J Med. 2017 Apr 6;376(14):1341-1349.
doi: 10.1056/NEJMoa1612136.
PMID: 28379802

Initial prescription associated with long term opioid usage (via Paolo)

Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use – United States, 2006-2015.
Shah A, Hayes CJ, Martin BC.
MMWR Morb Mortal Wkly Rep.
2017 Mar 17;66(10):265-269.
doi: 10.15585/mmwr.mm6610a1.
PubMed: https://www.ncbi.nlm.nih.gov/pubmed/28301454
Full text PDF: https://www.cdc.gov/mmwr/volumes/66/wr/pdfs/mm6610a1.pdf

Rothman adds:

The study has gotten some attention in the popular media as well- here’s what your patients may have read:

Ars Technica’s Beth Mole: With a 10-day supply of opioids, 1 in 5 become long-term users
https://arstechnica.com/science/2017/03/with-a-10-day-supply-of-opioids-1-in-5-become-long-term-users/

Vox: The risk of a single 5-day opioid prescription, in one chart
http://www.vox.com/2017/3/18/14954626/one-simple-way-to-curb-opioid-overuse-prescribe-them-for-3-days-or-less

CNN: Prescriptions may hold clues to who gets hooked on opioids, study says
http://www.cnn.com/2017/03/20/health/opioid-prescriptions-predict-chronic-use-study/

Valium for acute back pain…

“….added nothing above and beyond Naproxen (which we can presume based upon very little distinction within the NSAID class is equivalent to Motrin).
http://www.annemergmed.com/article/S0196-0644(16)31214-8/abstract
[PubMed]

In previous studies this held true for opiates as well.

So take home points—

1) Low back pain (very probably) does not need benzodiazepines
2) Low back pain (very probably) does not need opiates
3) Low back pain (most certainly) never requires an opiate/benzo combo
4) Low back pain (most likely) really only needs NSAIDs and time (probably mostly the time)
5) Don’t give more than 400mg of Motrin.”

-Dr. William Paolo

“And remember…prescribing benzodiezapines for back pain isn’t necessarily ‘safer.’ National statistics show an increase in benzodiezapine related deaths; perhaps partly attributed to their increased prescribing in response to an overall decrease in opioid prescribing.”

-Dr. Ross Sullivan

Via G. Johnson, NEJM: Opioid-Prescribing Patterns of Emergency Physicians and Risk of Long-Term Use

Opioid-Prescribing Patterns of Emergency Physicians and Risk of Long-Term Use
Michael L. Barnett, M.D., Andrew R. Olenski, B.S., and Anupam B. Jena, M.D., Ph.D.
N Engl J Med 2017; 376:663-673February 16, 2017
DOI: 10.1056/NEJMsa1610524

http://www.nejm.org/doi/full/10.1056/NEJMsa1610524
https://www.ncbi.nlm.nih.gov/pubmed/28199807

Abstract:
Background
Increasing overuse of opioids in the United States may be driven in part by physician prescribing. However, the extent to which individual physicians vary in opioid prescribing and the implications of that variation for long-term opioid use and adverse outcomes in patients are unknown.

Methods
We performed a retrospective analysis involving Medicare beneficiaries who had an index emergency department visit in the period from 2008 through 2011 and had not received prescriptions for opioids within 6 months before that visit. After identifying the emergency physicians within a hospital who cared for the patients, we categorized the physicians as being high-intensity or low-intensity opioid prescribers according to relative quartiles of prescribing rates within the same hospital. We compared rates of long-term opioid use, defined as 6 months of days supplied, in the 12 months after a visit to the emergency department among patients treated by high-intensity or low-intensity prescribers, with adjustment for patient characteristics.

Results
Our sample consisted of 215,678 patients who received treatment from low-intensity prescribers and 161,951 patients who received treatment from high-intensity prescribers. Patient characteristics, including diagnoses in the emergency department, were similar in the two treatment groups. Within individual hospitals, rates of opioid prescribing varied widely between low-intensity and high-intensity prescribers (7.3% vs. 24.1%). Long-term opioid use was significantly higher among patients treated by high-intensity prescribers than among patients treated by low-intensity prescribers (adjusted odds ratio, 1.30; 95% confidence interval, 1.23 to 1.37; P<0.001); these findings were consistent across multiple sensitivity analyses.

Conclusions
Wide variation in rates of opioid prescribing existed among physicians practicing within the same emergency department, and rates of long-term opioid use were increased among patients who had not previously received opioids and received treatment from high-intensity opioid prescribers. (Funded by the National Institutes of Health.).

Journal Club Articles, 2/1/2017

Risk of Acute Kidney Injury After Intravenous Contrast Media Administration
Hinson JS
Annals of Emergency Medicine, Article in Press
http://dx.doi.org/10.1016/j.annemergmed.2016.11.021
https://www.ncbi.nlm.nih.gov/pubmed/28131489
Full text via NYSL: http://www.sciencedirect.com.dbgateway.nysed.gov/science/article/pii/S0196064416313889/pdfft?md5=b2de7b46b233f6c18147311a8bafcc15&pid=1-s2.0-S0196064416313889-main.pdf

Is ketamine a lifesaving agent in childhood acute severe asthma?
Hendaus MA
Ther Clin Risk Manag. 2016 Feb 22;12:273-9.
http://dx.doi.org/10.2147/TCRM.S100389
https://www.ncbi.nlm.nih.gov/pubmed/26955277
Full text: https://www.dovepress.com/getfile.php?fileID=29100