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: Top Ten Pearls for Right Care in the Emergency Department

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These are the top ten pearls to help us do the right thing for our patients in the ED. These are broader and complement Choosing Wisely for EM.

Why does this matter?
Choosing Wisely attempts to reduce overuse of certain procedures or diagnostics, but it left some of the more controversial points unsaid in many of its top 5 lists, according to the authors. The Right Care Alliance is a response. Here is what they deemed the top 10 in EM, “to identify not merely interventions that are overused but also others that need to be used more widely, if we are to achieve both better and more equitable health outcomes and financial savings.” The senior author is Jerry Hoffman, of EMA and NEXUS acclaim.

Doing the right thing
The EM Right Care Alliance group had two guiding principles. 1. There is a “quixotic search for certainty.” We can’t achieve perfection and never miss. In doing so, overtesting often harms as many patients as might be helped. 2. “Medical care is not the sole, or even most important, determinant of health outcomes.” In other words, social determinants, such as homelessness or addiction are often more important. With that, here are the top ten for EM, quoted below.

  1. “Avoid further testing beyond history, physical exam, clinical gestalt and ECG in patients who are at minimal risk of an acute coronary syndrome.” Comment: There are some patients at minimal risk based on H&P + ECG alone. These authors advocate for not drawing labs or testing such patients. I say – be careful here. I use decision tools for this, like HEART.

  2. “Avoid further testing beyond history, physical exam and clinical gestalt in patients who are at minimal risk of pulmonary embolus (PE).” Comment: Love me some PERC. I am all on board with this.

  3. “Be judicious with the use of imaging, especially advanced imaging, in trauma patients.” Comment: Well, yeah… REACT-2, NEXUS, Canadian C-spine Rule,

  4. “Avoid routine laboratory testing.” Comment: With this caveat – if you don’t know what is wrong with the patient, err on the side of doing more. Also, in cancer patients or immunocompromised patients, this is super bad advice.

  5. “Consider non-medical reasons for a patient’s presentation to the ED.” Comment: Asking yourself why the patient is really back again for the 7th time this month is important. Also, asking the patient how you can best serve them today will often help you focus the workup.

  6. “Tailor the intensity of care to the goals of the patient.” Comment: This is good advice. Explicitly ask your patient what is most important to them and if you have done that during their visit. You will be surprised what you learn.

  7. “Employ shared decision-making (SDM) where appropriate.” Comment: My only concern with the SDM movement is when docs won’t give advice or recommendations. If my financial adviser just said to pick the funds I thought were best, what good would they be? It is OK to advise and offer your informed opinion to help the patient or family decide.

  8. “When prescribing an intervention, make an effort to ensure that the patient is capable of accomplishing what is recommended.” Comment: Having an ED-based social worker can be a game-changer here.

  9. “Tailor discharge instructions and follow-up recommendations to the individual patient.” Comment: It means a lot to patients when you type in a sentence or two specific to them on the discharge paperwork. Also, I like to circle in ink the most important parts. And make sure it is in their language.

  10. “Be an advocate.” Comment: We are uniquely positioned to see the effects of failures in our social safety net and healthcare systems. As such, we need to speak up outside the ED for the voiceless. The authors didn’t mention it, but this also means being an advocate for our own patients. If a consultant/hospitalist/administrator/etc. won’t do the right thing – you must have the moral compass and clear understanding of what excellence demands to make sure your patient gets what they need.

Bringing value, balance and humanity to the emergency department: The Right Care Top 10 for emergency medicine. Emerg Med J. 2019 Dec 24. pii: emermed-2019-209031. doi: 10.1136/emermed-2019-209031. [Epub ahead of print]

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#2: COVID-19 – Coronavirus Deep Dive

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Huang and colleagues have described the clinical presentation and course of illness for the 41 admitted patients who were identified as having lab-confirmed 2019-nCoV infection by January 2, 2020 to a designated hospital in Wuhan, China. At this point, be concerned in patients who have fever, cough, fatigue/myalgia, and pneumonia (particularly bilateral pneumonia).

Why does this matter?
Yesterday, we scratched the surface. Today we dive deep into the clinical aspects of COVID-19. We need to use this descriptive information to help us build our understanding of the virus so that we can do our best to identify and care for patients with potential cases. This post is longer than usual but needed for a worldwide public health threat.


Important Information:

What is 2019-nCoV (aka COVID-19)?

2019-nCoV is a novel betacoronavirus. Two other viruses in the same family are SARS-CoV and MERS-CoV. Although we understand SARS and MERS, there is no current published work about the human infection caused by the 2019-nCoV.

What were the demographics of the forty-one admitted 2019-nCoV patients included in this study?

  • Most were men (30/41 patients; 73%)

  • Median age = 49 years

  • 13/41 patients (32%) had underlying disease (e.g. diabetes, hypertension, cardiovascular disease, COPD, cancer)

What kind of symptoms did the forty-one admitted 2019-nCoV patients included in this study have?

  • Fever (40/41 patients; 98%)

  • Cough (31/41 patients; 76%)

  • Myalgia or Fatigue (18/41 patients; 44%)

  • These three symptoms were the major ones. There were patients who had sputum production, headache, hemoptysis, and diarrhea; however, these symptoms were less common.

  • Dyspnea occurred in 55% later in the course, with mean time to onset of dyspnea at 8 days.

What kind of laboratory abnormalities did the forty-one admitted 2019-nCoV patients included in this study have?

  • Lymphopenia (lymphocyte count < 1.0 x 109/L) (26/41 patients; 63%). [Leukopenia can also be seen.]

  • AST elevation (15/41 patients; 37%)

  • The sicker patients who were admitted to the ICU were more likely to have lymphopenia; AST elevation; elevated D-dimer; elevated AST; elevated cardiac biomarkers; and elevated plasma levels of cytokines and chemokines including levels of  IL2, IL7, IL10, GSCF, IP10, MCP1, MIOP1A, and TNF alpha. Cytokine storm seemed to be associated with disease severity.

What kind of radiology abnormalities did the forty-one admitted 2019-nCoV patients included in this study have?

  • Abnormalities in chest CT images in ALL patients

  • Bilateral involvement on chest CT (40/41 patients; 98%)

  • The sicker patients who were admitted to the ICU were more likely to have bilateral multilobular and subsegmental areas of consolidation (compared to non-ICU patients who tended to have bilateral ground glass opacities and subsegemental areas of consolidation).

What kind of time course did 2019-nCoV infection have in these forty-one admitted patients?

  • Median time from symptom onset to hospital admission = 7 days

  • Median time from symptom onset to dyspnea = 8 days

  • Median time from symptom onset to ARDS = 9 days

  • Median time from symptom onset to ICU admission = 10.5 days

  • Median time from symptom onset to mechanical ventilation = 10.5 days

How many of these forty-one admitted 2019-nCoV patients had complications or death?

  • Once again, all admitted patients had pneumonia.

  • ARDS (12/41 patients; 29%)

  • Acute cardiac injury (5/41 patients; 12%)

  • Secondary infection (4/41 patients; 10%)

  • Invasive mechanical ventilation (4/41 patients; 10%)

  • ECMO (2/41 patients; 5%)

  • ICU admission (13/41 patients; 32%)

  • Death (6/41 patients; 15%) [For comparison, mortality rate is 10% for SARS-CoV and 37% for MERS-CoV.]

What did the authors NOT see with these forty-one admitted 2019-nCoV patients?

  • No children or adolescents were among the 41 admitted, which the authors feel may be due to exposure bias.

  • Not many upper respiratory tract symptoms such as rhinorrhea, sneezing, and sore throat, indicating that the target cells are likely in the lower airway.

  • Not many GI symptoms (particularly less GI symptoms than their MERS and SARS counterparts)

  • No rise in procalcitonin

What do we know about specific treatment for patients with 2019-nCoV thus far?

  • Not much yet.

  • In this study, the forty-one admitted patients received antibiotics and oseltamivir as it was also influenza season. Corticosteroids were given if severe community-acquired pneumonia was diagnosed. Oxygen was administered for hypoxemia. Supportive care measures were administered.

  • In practice, further evidence is needed to determine if systemic corticosteroid treatment is indicated. No antiviral treatment for 2019-nCoV has yet been proven to be effective. The combination of lopinavir and ritonavir showed substantial clinical benefit in SARS-CoV. Remdesivir, which is a broad-spectrum antiviral nucleotide prodrug), has shown some promise with treatment of MERS-CoV and SARS-CoV. Once again, further evidence is needed to guide us in antiviral treatment.

There is a lot more to be discovered about 2019-nCoV. My advice is to stay well-informed using reputable sources of information, like the information from the CDC. Stay tuned…

Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020 Feb 15;395(10223):497-506. doi: 10.1016/S0140-6736(20)30183-5. Epub 2020 Jan 24.

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