Journal Feed Weekly Wrap-Up

We always work hard, but we may not have time to read through a bunch of journals. It’s time to learn smarter. 

Originally published at JournalFeed, a site that provides daily or weekly literature updates. 

Follow Dr. Clay Smith at @spoonfedEM, and sign up for email updates here.

#1: Measles Spoon Feed – What You Need to Know

Spoon Feed
The U.S. is currently in a measles outbreak.  So, don’t miss this quick spoon-feed refresher.  You will learn something new.

Why does this matter?
Measles is a mild, self-limited illness in most people.  It was temporarily eradicated in the U.S. as of 2000, but more and more cases are being seen as families choose not to vaccinate.  There have been nearly 800 cases in the U.S. already in 2019.

You need to know about measles
Given the recent outbreak, someone who reads JournalFeed is likely to see a case.  We need to be ready.  Especially review the images at the end.

How does measles present?

  • Peak incidence is in the spring and summer, highest in March, but may occur year round.

  • Unvaccinated populations, travelers to an endemic area, or immunocompromised patients are most at risk.

  • Incubation period is 6-21 days, median 13.

  • Fever starts first, up to 40°C by day 5.

  • Conjunctivitis, cough, coryza (copious nasal drainage) begins next (Image 1).

  • Koplik spots on the buccal mucosa, usually opposite the molars, appear 48h prior to rash (Image 2).  Spots may be anywhere on the oropharyngeal mucosa, such as the soft palate.  Cervical adenopathy is common.

  • Rash appears last, starting on the face, especially along the hairline behind the ears, spreading across the face, down the neck, onto the trunk; spares palms and soles, morbilliform in appearance (of course), blanching at first, then non-blanching.  Rash resolves over the next 6 days.  Images 3 and 4.

  • Labs may show eosinophilia or elevated transaminases.

What are the complications of measles?

  • Complications occur in 30%.

  • Diarrhea occurs in 8%.

  • Global immunosuppression and secondary bacterial infections are common, i.e. otitis media – 7% of all patients; also staphylococcal, streptococcal, or H. influenzae infections.

  • Pneumonia occurs in 6% and is the most common cause of death.

  • Encephalitis occurs in 1/1000.  Read this heartbreaking account of measles encephalitis by Roald Dahl about his 7-year-old daughter and his plea for vaccination.  “In an hour, she was unconscious.  In twelve hours she was dead.”

  • Acute demyelinating encephalomyelitis (ADEM) occurs in 1/1000, with 10-20% mortality rate.

  • Rarely, delayed onset subacute sclerosing panencephalitis occurs (5-10/million cases per this review but far more common per the Lancet review), which is a progressive neurological decline that is universally fatal.

Where does measles occur in the world?

  • Measles occurs around the world.  India has the highest incidence.

  • “In many parts of the world, including Europe, Central and South America, Asia, the Pacific and Africa, the disease remains endemic.”

  • Indonesia had a drop in vaccination rates and subsequent spike in cases.

  • The U.S. is currently in its worst outbreak in decades, due to undervaccination.

How is measles diagnosed?

  • The initial diagnosis is clinical, as above.

  • Confirmation is by saliva, mouth, throat, or blood samples with PCR-based testing.  My state (TN) recommends a throat swab sent in viral transport media.

How is measles managed in the ED?

  • Patients should be placed in isolation using airborne precautions.  An N-95 mask, gown, and gloves are needed.

  • Patients should be thoroughly examined and treated for bacterial superinfection or other complications.  Most treatment is symptomatic and done at home.

  • “Given that vitamin A deficiency predisposes to severe and complicated measles, two oral doses [given over two consecutive days] of vitamin A 200,000 IU (100,000 IU if age 6–11 months, 50 000 IU if under 6 months) is recommended for all children with acute measles and to all cases of severe infection with measles. A third dose is given 2–4 weeks later.”

  • Local infection control should be notified, as well as state public health officials.  This is a reportable illness.

  • Susceptible family contacts or other known contacts should be vaccinated with two doses of MMR a month apart as soon as possible.

How contagious is measles?

  • Measles is one of the most contagious pathogens, able to cause disease via airborne particles up to two hours after an infected patient has left the room, with a 90% attack rate.

  • In other words, if you are susceptible and exposed, there is a 90% chance you will get it.

How effective is the measles vaccine?

  • It is 90% effective after one dose of MMR and essentially 100% effective with two, spaced a month apart.

  • It is usually given at 12-15 months and then 4-6 years.

How should measles exposure be managed if vaccine status is uncertain?

  • It is safe to give MMR even if vaccine status is unknown.

  • It does not have proven safety in pregnancy and is usually avoided.  It is important to be vaccinated prior to pregnancy, as transplacental antibody protection is strong.

What precautions are needed if traveling to a high incidence area?

  • Special caution is needed, “in Africa, especially in Nigeria, in China, the Philippines and the Middle East, including Yemen.”

  • Unvaccinated people should get two MMR vaccines a month apart.

Another Spoonful

Could this be measles? Emerg Med J. 2019 Apr 3. pii: emermed-2019-208490. doi: 10.1136/emermed-2019-208490. [Epub ahead of print]

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#2: Early or Delayed Cardioversion for Atrial Fibrillation

Spoon Feed
In patients who presented with recent onset atrial fibrillation (AFib) < 36h, delayed cardioversion (DC) at 48h compared to early cardioversion (EC) was non-inferior (91% vs 94%; -2.9 percentage points, 95%CI -8.2 to 2.2).

Why does this matter?
There is a significant variation in practice between how recent-onset AFib is treated in the US compared to other countries. In general, physicians in the US are more likely to utilize rate-control and have a much higher admission rate.

Better late than never?
This was a multi-center, randomized, open-label, noninferiority trial performed in the Netherlands. A total of 437 patients were randomized to either early or delayed cardioversion. EC consisted of pharmacologic conversion (flecainide was preferred) or electrical cardioversion in those who had contraindications. DC consisted of rate control with beta-blockers, non-dihydropyridine calcium channel blockers, or digoxin until HR < 110 and discharge with next-day follow-up (around 48h from onset) for re-evaluation. No TEEs were performed, and patients who had a high risk of stroke were started on anticoagulation and continued based on CHA2DS2-VASc scores. The primary outcome was sinus rhythm at the 4-week follow-up visit. Secondary outcomes included ED length of stay at the index visit, ED visits related to AFib, cardiovascular complications, and time until recurrence of Afib. A total of 335 patients had telemetric monitoring at home 3 times daily or with symptoms.

In the DC group, 91% were in sinus rhythm at the 4 week mark compared to 94% in the EC group. This resulted in a between-group difference of -2.9 percentage points (95%CI -8.2 to 2.2), which did not meet the lower 95%CI inferiority mark of 10 percentage points. In the DC group, spontaneous conversion occurred in 69% at 48h. In the EC group, 16% had spontaneous conversion (some received rate-control meds). In terms of cardiovascular complications, both groups had 1 ischemic stroke or TIA; 3 patients in both groups had unstable angina or ACS during the 4-week follow-up.

While there were similar adverse outcomes in both groups, this study was not powered to detect a difference. It seems that the majority of patients in the DC group had spontaneous conversion with rate-control and this approach is non-inferior to early cardioversion. This supports the current rate-control practice. It is also unlikely that most patients will be able to obtain follow-up so closely after being discharged. I anticipate that many of these patients will continue to get admitted in the US after rate-control.

For more on Afib, see these emDocs posts:

EM Educator

More AF Management


Management Do’s and Don’ts 

Early or Delayed Cardioversion in Recent-Onset Atrial Fibrillation. N Engl J Med. 2019 Apr 18;380(16):1499-1508. doi: 10.1056/NEJMoa1900353. Epub 2019 Mar 18.

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#3: Counterpoint: Pelvic Exam Is Necessary

Spoon Feed
This letter to the editor presents compelling reasons why a pelvic exam is needed to diagnose cervicitis or pelvic inflammatory disease (PID).

Why does this matter?
Recently, Annals of EM published an article that questioned the utility of routine pelvic exam for adolescent STI diagnosis in the ED. This is a counterpoint to the original paper.

Bad news for interns across the country…
We rarely, if ever, cover a letter to the editor, but since the original article was such a controversial topic with high associated morbidity, it is important to show the other side. The letter advocates that a pelvic exam is needed to diagnose cervicitis or PID based on the following:

  • PID and cervicitis are clinical diagnoses that cannot be made without a pelvic exam.

  • The CDC recommends it; in fact, the diagnostic criteria for PID are based on cervical, uterine or adnexal tenderness. Diagnostic specificity is enhanced with presence of mucopurulent discharge or WBCs on saline wet mount, which requires a pelvic exam.

  • Relying solely on positive testing for N. gonorrhea, chlamydia, or trichomoniasis as determinative for the diagnosis of STI will miss cases, as PID may be caused by other organisms, is often polymicrobial, and is a clinical not microbiological diagnosis.

  • Skipping the exam will also miss genital herpes, other vaginitis, or foreign body.

  • The authors of the original article state that ACOG, AAP, and CDC do not recommend pelvic exam in asymptomatic patients, which is true. But that was not the population they studied. The patients in the original article were symptomatic, and all three organizations recommend pelvic exam in such patients.

  • Failing to detect PID risks complications of worsening infection, abscess, scarring, and infertility.

For more, see this emDocs post.

Why a Pelvic Exam is Needed to Diagnose Cervicitis and Pelvic Inflammatory Disease. Ann Emerg Med. 2019 Apr;73(4):424-425. doi: 10.1016/j.annemergmed.2018.11.028.

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#4: PE in Pregnancy – YEARS Algorithm

Spoon Feed
The Pregnancy-Adapted YEARS Algorithm safely and accurately ruled out pulmonary embolism (PE) for pregnant patients and reduced the rate of CT pulmonary angiography (CTPA) across all trimesters.

Why does this matter?
PE is one of the leading causes of maternal death during pregnancy. However, making the diagnosis can be challenging. The d-dimer test has decreased specificity and accuracy during pregnancy, and imaging modalities such as CTPA and ventilation-perfusion (VQ) scanning expose both the fetus and mother to radiation. But what if there was a clinical decision rule that could safely rule out PE in pregnant patients and reduce the rate of CTPA or VQ imaging?

Pregnant with Anticipation: We have been waiting YEARS for this algorithm
This was a prospective international study of 498 pregnant women with suspected PE. The pregnancy-adapted YEARS algorithm (Figure below) was used to guide diagnostic testing and management.

Using this protocol, PE was diagnosed in 4% of patients. CTPA was avoided in 39% of all patients. Only one patient not initially diagnosed with venous thromboembolism was diagnosed with DVT during the 3-month follow-up, and no patients were diagnosed with subsequent PE during follow-up.  The efficiency of the algorithm was highest during the first trimester (when radiation is potentially most detrimental to the developing fetus) and lowest during the third trimester. In total, CTPA was avoided in 65% of patients in the first trimester, 46% in the second trimester, and 32% in the third trimester.  This seems to be a viable clinical decision tool to rule out PE in pregnant patients and safely reduce CTPA use.

Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism.  N Engl J Med. 2019 Mar 21;380(12):1139-1149. doi: 10.1056/NEJMoa1813865.

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One thought on “Journal Feed Weekly Wrap-Up”

  1. Thank you for sharing an important Letter to the Editor in referring to the necessity for pelvic exam in symptomatic patients

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