Eddy Lang

Variation in management of recent-onset atrial fibrillation and flutter among academic hospital emergency departments.

STUDY OBJECTIVEnAlthough recent-onset atrial fibrillation and flutter are common arrhythmias managed in the emergency department (ED), there is insufficient evidence to help physicians choose between 2 competing treatment strategies, rate control and rhythm control. We seek to evaluate variation in ED management practices for recent-onset atrial fibrillation and flutter patients at multiple Canadian sites and to determine whether hospital site was an independent predictor of attempted cardioversion.nnnMETHODSnWe conducted a cross-sectional survey by health records review on an observational cohort of all eligible adult recent-onset atrial fibrillation and flutter cases, with onset of symptoms less than 48 hours, treated at 8 academic hospital EDs during a 12-month period, and evaluated the variation in practice among sites for important management strategies.nnnRESULTSnAmong the 1,068 study patients, 88.3% had atrial fibrillation and 11.7% had atrial flutter. The proportion of cases managed with rhythm control was 59.4% (interhospital range 42% to 85%) and, among these, electrocardioversion was attempted first for 44.2% (range 7% to 69%). There was variation in most management strategies, including use of rate control drugs 54.9% (range 37% to 65%), choice of procainamide as rhythm control drug 62.1% (range 15% to 89%), referral to cardiology in the ED 30.7% (range 16% to 64%), use of heparin 13.7% (range 1% to 29%), and outpatient cardiology referral 43.0% (range 30% to 65%). Adverse events were relatively uncommon and transient for patients undergoing attempts at pharmacologic (13.0%) or electrocardioversion (12.1%). Overall, 83.3% of patients were discharged home from the ED (range 73% to 90%). After controlling for 12 covariates, multivariate logistic regression found that factors independently associated with attempted cardioversion were age (odds ratio [OR] 0.97; 95% confidence interval [CI] 0.95 to 0.98), history of electrocardioversion (OR 2.73; 95% CI 1.56 to 4.80), associated heart failure (OR 0.29; 95% CI 0.09 to 0.95), and hospital site (ORs ranged from 0.38 to 3.05).nnnCONCLUSIONnWe demonstrated a high degree of variation in management approaches for recent-onset atrial fibrillation and flutter patients treated in academic hospital EDs. Individual hospital site, age, previous cardioversion, and associated heart failure were independent predictors for the use of rhythm control.

The prognostic significance of moderate hyperamylasemia in the evaluation of the emergency department patient.

Hyperamylasemia of greater than five times the upper limit of the normal range (200 IU/L) is highly specific for the diagnosis of pancreatitis, but the meaning of lower values is unclear. The purpose of this study was to evaluate the prognostic significance of amylase values > 200 and < 1000 IU/L. A controlled historical cohort study was conducted to determine whether moderate hyperamylasemia is associated with an increased severity of outcome compared to patients with normal amylase values. Subjects met certain inclusion criteria and had a serum amylase of > 200 and < 1000 IU/L (normal < 200 IU/L). The case group consisted of 44 patients (medium serum amylase = 307.5 IU/L) and resembled the control group of 77 patients (median serum amylase = 117.5 IU/L) with regard to sex distribution and presenting complaint. However, the case group was older, was on more medications, and had a shorter duration of symptoms prior to the ED visit (< 72 h). Analysis of clinically important outcomes revealed that the groups were similar in terms of 6-month mortality, general admission rate, ICU admission rate, and rate of surgical intervention. The proportion of patients who had radiologically or endoscopically documented gastrointestinal pathology was also similar. The results demonstrate that patients with moderate hyperamylasemia (i.e. amylase < 1000 IU/L), notwithstanding the fact that they are older, are on more medications, and have more acute symptomatology, did not have a worse outcome than patients with the same complaints and normal amylases.

Finding One's Way In Translating Evidence Into Practice

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Intravenous proton pump inhibitors prior to endoscopy in suspected upper gastrointestinal bleeding.

Upper gastrointestinal bleeding is a common presentation to the emergency department (ED) and can require intensive treatment and resources. Management is often carried out in concert with gastroenterologists, who perform diagnostic and therapeutic endoscopy, and rarely with surgeons, who manage patients whose bleeding cannot be controlled with medical therapy. The use of IV PPIs is well supported in the scientific literature for use in upper gastrointestinal bleeds (UGIBs) demonstrating high-risk stigmata at the time of endoscopy. In a Cochrane systematic review, Leontiadis and colleagues amassed 24 randomized controlled trials with over 4300 patients to show that PPIs are associated with a reduced risk of rebleeding or the need for surgical intervention in patients with UGIBs related to peptic ulcer disease. Selective analyses suggest that in the setting of high-risk lesions at endoscopy (i.e., active bleeding, nonbleeding visible vessel) and for studies performed in Asia, there is even an effect on all cause mortality. Emergency physicians often encounter patients with UGIBs who may experience significant delays before undergoing endoscopy. Furthermore, one expects that only a small proportion of all patients with UGIBs will have highrisk lesions on endoscopy that would mandate the use of IV PPIs. This raises uncertainty as to whether it is beneficial to institute IV PPIs in all patients with suspected UGIBs before they undergo endoscopy.

Should survivors of out-of-hospital cardiac arrest be treated with hypothermia?

Background Out-of-hospital cardiac arrest is a major cause of death in developed countries. The estimated incidence in the United States is about 1/1000 population per year (15%–20% of all deaths). Survival rates are estimated to be from 5% to 35%. In patients who survive the initial resuscitation, residual neurologic damage has been estimated as between 10% and 70%. In order to decrease cerebral damage and the ischemia that occurs during and after initial resuscitation, the use of therapeutic hypothermia has been proposed. Human studies using moderate hypothermia in the late 1950s showed promise but had high complication rates. Using mild hypothermia, both animal studies and uncontrolled retrospective pilot studies with human subjects have demonstrated favourable neurologic outcomes. While the mechanism is not certain, it has been postulated that hypothermia decreases cerebral oxygen consumption and modifies other biochemical mechanisms, including calcium shifts, excitotoxicity, lipid peroxidation and other free-radical reactions, DNA damage and inflammation. Until now, no randomized controlled trials have shown mild hypothermia to be a feasible and effective treatment for cardiac arrest patients.

CJEM Debate Series: #ChoosingWisely – The Choosing Wisely campaign will not impact physician behaviour and choices – CORRIGENDUM

This series of editorials will provide CJEM readers with the opportunity to hear differing perspectives on topics pertinent to the practice of emergency medicine. The debaters have allocated opposing arguments on topics where there is some controversy or perhaps scientific equipoise. We continue the series with the topic of Choosing Wisely (CW), a high profile campaign backed by several medical associations, including the Canadian Association of Emergency Physicians (CAEP). Is the CW campaign simply a re-branding of common sense and the currently followed best practice in consumer organization style? Or is it a novel evidencebased program that will both save money and improve the quality of care that we deliver? Is it an attempt to remove clinical judgment from patient care, replacing it with simplistic rules that do not recognize variability in populations? Or is the aim of the campaign to empower patients to facilitate improved communication with care providers and ultimately better choices? Does the campaign seek to cut cost as its bottom line? Or will CW help prompt clinicians to challenge old habits and follow best evidence? Dr. Eddy Lang and his team make the argument that the CW campaign is well intentioned; however, due to weak methodology, it will not impact physician behaviour and choices as they argue for the motion with Dr. Heather Murray and her team responding to back the campaign, arguing that it is okay not to order all of those tests, and that ultimately CW will change practice. Join the CJEM debate: Follow @CJEMOnline or go to www.facebook.com/CJEMonline to participate in the online poll and to see the results!

Sex-specific, high-sensitivity cardiac troponin T cut-off concentrations for ruling out acute myocardial infarction with a single measurement

OBJECTIVEnSex-specific diagnostic cut-offs may improve the test characteristics of high-sensitivity troponin assays for the diagnosis of myocardial infarction (MI). The objective of this study was to quantify test characteristics of sex-specific cut-offs of a single, high-sensitivity cardiac troponin T (hs-cTnT) assay for 7-day MI in patients with chest pain.nnnMETHODSnThis observational cohort study included consecutive emergency department (ED) patients with suspected cardiac chest pain from four Canadian EDs who had an hs-cTnT assay performed within 60 minutes of ED arrival. The primary outcome was MI at 7 days. We quantified test characteristics (sensitivity, negative predictive value [NPV], likelihood ratios and proportion of patients ruled out) for multiple combinations of sex-specific, rule-out cut-offs. We calculated the net reclassification index compared to universal rule-out cut-offs.nnnRESULTSnIn 7,130 patients (3,931 men and 3,199 women), the 7-day MI incidence was 7.38% among men and 3.78% among women. Optimal sex-specific cut-offs (<8 ng/L for men and <7 ng/L for women) had a 98.5% sensitivity for MI and ruled out MI in 55.8% of patients. This would enable an absolute increase in the proportion of patients who were able to be ruled out with a single hs-cTnT of 13.2% to 22.2%, depending on the universal rule-out concentration used as a comparator.nnnCONCLUSIONSnSex-specific hs-cTnT cut-offs for ruling out MI at ED arrival may improve classification performance, enabling more patients to be safely ruled out at ED arrival. However, differences between sex-specific and universal cut-off concentrations are within the variation of the assay, limiting the clinical utility of this approach. These findings should be confirmed in other data sets.

Age-adjusted D-dimer thresholds in the investigation of suspected pulmonary embolism: A retrospective evaluation in patients ages 50 and older using administrative data

OBJECTIVESnD-dimer testing is an important component of the workup for pulmonary embolism (PE). However, age-related increases in D-dimer concentrations result in false positives in older adults, leading to potentially unnecessary imaging utilization. The objective of this study was to quantify the test characteristics of an age-adjusted D-dimer cut-off for ruling out PE in older patients investigated in actual clinical practice.nnnMETHODSnThis observational study used administrative data from four emergency departments from July 2013 to January 2015. Eligible patients were ages 50 and older with symptoms of PE who underwent D-dimer testing. The primary outcome was 30-day diagnosis of PE, confirmed by imaging reports. Test characteristics of the D-dimer assay were calculated using the standard reference value (500 ng/ml), the local reference value (470 ng/ml), and an age-adjusted threshold (10 ng/ml × patient’s age).nnnRESULTSnThis cohort includes 6,655 patients ages 50 and older undergoing D-dimer testing for a possible PE. Of these, 246 (3.7%) were diagnosed with PE. Age-adjusted D-dimer cut-offs were more specific than standard cut-offs (75.4% v. 63.8%) but less sensitive (90.3% v. 97.2%). The false-negative risk in this population was 0.49% using age-adjusted D-dimer cut-offs compared with 0.15% with traditional cut-offs.nnnCONCLUSIONnAge-adjusted D-dimer cut-offs are substantially more specific than traditional cut-offs and may reduce CT utilization among older patients with suspected PE. We observed a loss of sensitivity, with an increased risk of false-negatives, using age-adjusted cut-offs. We encourage further evaluation of the safety and accuracy of age-adjusted D-dimer cut-offs in actual clinical practice.

Slow or swift, your patients' experience won't drift: absence of correlation between physician productivity and the patient experience.

Absract OBJECTIVES: To evaluate the relationship between Emergency Physician (EP) productivity and patient satisfaction with Emergency Department (ED) care.nnnMETHODSnThis retrospective observational study linked administrative and patient experience databases to measure correlations between the patient experience and EP productivity. The study was performed across three Calgary EDs (from June 2010 to July 2013). Patients>16 years old with completed Health Quality Council of Alberta (HQCA) ED Patient Experience Surveys were included. EP productivity was measured at the individual physician level and defined as the average number of patients seen per hour. The association between physician productivity and patient experience scores from six composite domains of the HQCA ED Patient Experience Survey were examined using Pearson correlation coefficients, linear regression modelling, and a path analysis.nnnRESULTSnWe correlated 3,794 patient experience surveys with productivity data for 130 EPs. Very weak non-significant negative correlations existed between productivity and survey composites: Staff Care and Communication (r=-0.057, p=0.521), Discharge Communication (r=-0.144, p=0.102), and Respect (r=-0.027, p=0.760). Very weak, non-significant positive correlations existed between productivity and the composite domains: Medication Communication (r=0.003, p=0.974) and Pain management (r=0.020, p=0.824). A univariate general linear model yielded no statistically significant correlations between EP productivity and patient experience, and the path analysis failed to show a relationship between the variables.nnnCONCLUSIONnWe found no correlation between EP productivity and the patient experience.

Technology-driven or Patient Outcome–driven Use of Emergency Department Ultrasound for Deep Vein Thrombosis Assessment

T he recent explosion and now widespread use of ultrasound (US) technology in the hands of the emergency physician (EP) represents both an exciting and a remarkable transformation in the practice of our specialty. The accuracy and benefits of bedside US are firmly established in the domains of free fluid detection for trauma, aortic aneurysm screening in patients with abdominal pain, and central line insertion. These indications have successfully spearheaded the introduction of US in many centers because their early performance at the bedside is supported by evidence and can inform urgent surgical decision-making and patient safety considerations. In other words, bedside US makes a difference in these conditions. The emergency department (ED) applications of US are also continuing to rapidly expand and now include, among others, biliary imaging, echocardiography, firsttrimester emergencies, and, germane to this commentary, the evaluation of suspected deep vein thrombosis (DVT). Momentum is clearly on the side of increasing the indications for ED US. However, to what extent are these developments driven by the technology itself and professional satisfaction, as opposed to proven benefit or cost-effectiveness that is cognizant of patient-important outcomes and impact on ED throughput? Is there a point at which the growing list of indications for EP performed US (EPPU) will begin to include items that no longer meet criteria for having a worthwhile impact on emergency care? Before closing in on answers to these questions as they relate to EPPU for DVT assessment, a number of issues merit consideration. The well-done systematic review by Burnside et al. in this issue of Academic Emergency Medicine is an important addition to the emergency medicine literature, providing a synthesis of the diagnostic properties of EPPU for suspected DVT. The problem, however, is that despite the cautionary language that the authors employ in describing the implications of their research, it is likely that proponents of EPPU will use the impressive measures of accuracy that are reported in this work to substantiate the incorporation of this diagnostic strategy both in training and in practice. After all, with the use of Bayesian principles and a Fagen nomogram (http://araw.mede.uic.edu/cgi-bin/testcalc.pl), the likelihood ratios (LR) inferred by the reported sensitivity of 95% and the specificity of 96% (+LR = 24, )LR = 0.05) suggest that the posttest probability of DVT in a patient at low or moderate pretest probability of DVT falls to 1% or less if the EPPU is negative and is greater than 95% if their pretest probability is high (50%) and the EPPU demonstrates a noncompressible deep vein. These would meet action thresholds (disposition or treatment decisions) for most EPs and in nearly all clinical contexts. Burnside et al. emphasize the methodologic limitations of the six studies included in their systematic review as the primary justification for considering EPPU as not being ready for ‘‘prime time.’’ These limitations are well laid out using the QUADAS criteria for the quality assessment of diagnostic studies. Of note, the threats to validity, both internal and external, that Burnside et al. focus on would likely serve to inflate their reported measures of test performance and paint a rosier picture than might actually be the case if more rigorous standards for performing and reporting this research were employed. Not directly included in the QUADAS criteria is the issue of selection bias, which is particularly relevant to this review, since at least five and possibly all of the studies included enrolled patients through convenience sampling techniques. As a result of this selection process, it is possible that patients with challenging anatomy were less likely to be enrolled in these studies for fear of a technically difficult examination. By focusing primarily on thighs that were going to be easier to evaluate, these studies may have further inflated measures of test performance yielding implications on generalizability as well. There are yet additional aspects of applicability to consider before contemplating the use of EPPU for DVT assessment in routine practice. A key question is whether US in the hands of a qualified and trained EP would eliminate the need for patients to have to undergo an additional timely US in the hospital’s vascular imaging department. A related question is how much additional training and testing is necessary for an EP to achieve sufficient proficiency for this to be true. Also important is a consideration of the diagnostic utility of EPPU; that is, will the information derived from EPPU allow us to reach important action thresholds (disposition and treatment decisions) that we would have otherwise refrained from crossing? To explore these issues, I will consider the clinical implications of this technology in two kinds of patients. While