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. 

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#1: Does Ramped Position Impact Intubation Success?

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There was no difference in first pass success with a non-supine (ramped) vs supine intubating position in this retrospective study, and composite adverse events were more common when ramped.  But patients most likely to be ramped were also obese or had predicted difficult airway.

Why does this matter?
Head-up or ramped position may be helpful for some patients when intubating in the ED and is certainly helpful for preoxygnation, especially in obese patients.  Check-UP found it did not help in ICU patients, though there were some issues with their ramping technique.  Whether or not this applies to all-comers is unknown.

NEAR to our hearts
This was a retrospective look at the prospectively collected NEAR study data, an airway registry including 25 EDs.  Of 11,480 intubations, the overwhelming majority were supine, with just 5.8% non-supine.  There was a strong association with obesity and suspected difficult airway and use of non-supine position.  Multivariable logistic regression for factors known to be associated with first-pass success, such as age, initial SpO2, level of experience of the intubator, VL vs DL, etc was used to statistically adjust the odds ratio.  With these adjustments, there was no difference in first pass success between those intubated supine or non-supine, (adjusted OR 1.1, 95% CI 0.9-1.4).  There was also no difference in grade I glottic view.  Adverse events (hypoxia, bradycardia, arrest, etc) were more common in the non-supine group (aOR 1.4, 95% CI 1.1-1.7).  Hypoxia was far and away the most common adverse event.  Interestingly, emesis/aspiration was the only adverse event that was lower in the non-supine group.  This suggests, but does not prove, that non-supine may be a good option for UGI bleeds, massive hemoptysis, or bowel obstruction.  The issue of confounding cannot be overstated in this study.  It shows, at least, there is clinical equipoise, paving the way for more randomized trials.  For now, I think it is reasonable to ramp obese patients, especially during preoxygenation, and to consider it when there is greater aspiration risk.

Source
Multicenter Comparison of Non-supine versus Supine Positioning During Intubation in the Emergency Department: A National Emergency Airway Registry (NEAR) Study.  Acad Emerg Med. 2019 May 22. doi: 10.1111/acem.13805. [Epub ahead of print]

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#2: Lemierre’s Syndrome – Sore Throat Gone Wrong

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Sometimes sore throat isn’t just sore throat – it could be a life threatening complication. Learn about Lemierre’s syndrome with this quick-hitter teaching case from NEJM.

Why does this matter?
We can get lulled to sleep when patients have sore throat – another strep, another virus. Lemierre’s should be on your differential diagnosis when you see patients with pharyngitis. It is rare but devastating if missed.

Sore throat gone wrong
This was an Images in Clinical Medicine summary, publicly available on NEJM.org (just create a free account). Take a minute to look at this this on the NEJM site. The images are fantastic, and the summary is short.

Briefly, Lemierre’s syndrome is an uncommon complication of pharyngitis usually caused by Fusobacterium necrophorum, an anaerobe, that leads to suppurative thrombophlebitis of the internal jugular vein and subsequent disseminated infection, often with septic pulmonary emboli. It usually presents as a prolonged pharyngitis in a patient who is febrile, appears ill, has asymmetric anterior neck swelling, often pleuritic chest pain, shortness of breath, and often tachypnea with abnormal oxygen saturation. It is diagnosed with CT neck (and usually chest) with contrast. It’s treated with broad spectrum antibiotics that cover anaerobes, such as piperacillin-tazobactam or ampicillin-sulbactam, often in an ICU setting.

Another Spoonful

Source
Lemierre’s Syndrome. N Engl J Med. 2019 Mar 21;380(12):e16. doi: 10.1056/NEJMicm1808378.

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#3: Ethics Week – Lost Evidence, Unpublished RCTs

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Nearly 90,000 patients were enrolled in randomized trials that were never published. These patients were enrolled in good faith that their participation would benefit future patients. The key issue: “Large unreported trials threaten the credibility of the available, published evidence.”

Why does this matter?
Failure to publish a trial is considered to be a form or professional misconduct by some. Actual people were enrolled, potentially inconvenienced, or faced unknown risks in some cases; yet, the results of these studies never saw the light of day to inform the scientific community of the results. Loss of evidence is an important ethical issue that is unseen – we don’t notice what’s not published.

What we don’t know may hurt our patients
Researchers found 146 RCTs registered on ClinicalTrials.gov that were completed but long unpublished. Over time, more of these were published, but as of January 2019, 67 trials, with a median enrollment of 765 patients, remained unreported for a median time from completion of 9 years. That’s 83,883 patients, who in good faith allowed themselves to be enrolled in a clinical trial for the greater good of future patients. Yet, the researchers never published the results. This is wrong. Knowledge has been lost in the fields of: “cardiovascular disease (n = 13), infection (n = 12), psychiatric diseases (n = 9), women’s health and obstetrics (n = 6), allergy (n = 5), and neurologic diseases (n = 5).” One may question if this matters, since most of these were negative studies, finding no effect. The authors nailed it: “Large unreported trials threaten the credibility of the available, published evidence. One should be cautious in combining published trials and interpreting them when extensive results remain undisclosed.”

Source
Lost Evidence From Registered Large Long-Unpublished Randomized Controlled Trials: A Survey. Ann Intern Med. 2019 May 7. doi: 10.7326/M19-0440. [Epub ahead of print]

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