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: Cans We Risk Stratify Febrile Infants 29-60 Days?

Spoon Feed
The modified Philadelphia criteria (mPC) had high enough sensitivity to rule out invasive bacterial infection (IBI) in infants 29-60 days old without obtaining CSF. No infants 29-60 days old who were classified as low risk had bacterial meningitis.

Why does this matter?
Only 1/500 (0.2%) of febrile infants 29-60 days old will have bacterial meningitis. Given this low prevalence, the risk is already low. The risk is higher under 28 days, and most advocate for a full workup that includes LP. The step by step was one approach to this issue, but it requires procalcitonin, which may not be available in some centers and “neonate” was defined as ≤21 days in that study. Would the tried and true Rochester and modified Philadelphia criteria help us risk stratify 29-60-day old infants?

Brotherly love for the babies
This was a multicenter case-control study. The 135 cases were well-appearing, previously healthy, febrile (≥38°C) infants ≤60 days with IBI: 118 bacteremia; 17 bacterial meningitis (7 of these >28 days). Cases were matched with 2 controls (n = 249) from the same time and location and were similar except without IBI. Sensitivity of the mPC surpassed the Rochester criteria overall: 91.9% vs 81.5%; P = .01, but specificity was lower at 34.5% vs 59.8%; P < .001, respectively. Rochester criteria classified 25 children with IBI as low risk, 2 with meningitis; mPC classified 11 as low risk, none with meningitis. In the subgroup 29-60 days old, sensitivity was the same for both criteria at 83.6%. For children > 28 days, the mPC didn’t miss any cases of meningitis.

They gave an example. If we had 300 febrile infants 29-60 days old and assume the rate of IBI is ~2% and bacterial meningitis is 0.2%, 6 of them would have IBI; 0.6 would have meningitis. The mPC misses 1 in 6 (sensitivity 84%); so, we would miss 1 infant with bacteremia and none with meningitis, if this study is correct. See this Facebook video.

Another Spoonful

  • The AAP did a short video with the lead author and an excellent graphic representation of the results.
  • ACEP has a Clinical Policy on well-appearing infant < 2 years with fever.
  • Journal Watch covered this (subscription required) and commented, “Sensitivities of 92% and 82% are not great, but the rarity of invasive bacterial infection in well-appearing infants aged <61 days means that these criteria — or, for that matter, clinical gestalt — will almost always be right when used to send febrile babies home (i.e., poor sensitivity but good negative predictive value). Consensus is emerging that while neonates require lumbar puncture and inpatient care, most older babies can be managed at home and without lumbar puncture.”

Risk Stratification of Febrile Infants ≤60 Days Old Without Routine Lumbar Puncture. Pediatrics. 2018 Nov 13. pii: e20181879. doi: 10.1542/peds.2018-1879. [Epub ahead of print]

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#2: NSTEMI – New ACEP Clinical Policy

Spoon Feed
Be sure you know the formal word on the workup and treatment of NSTEMI for emergency physicians. We want to give patients a quick, safe workup and reduce the risk of short-term major adverse coronary events (MACE).

Why does this matter?
Chest pain leads to 10 million ED visits per year and costs billions. How we manage it in the ED could lead to better care with less expense and hassle for patients. A few definitions:

  • Level A – solid evidence, do it.
  • Level B – moderate quality evidence, recommended
  • Level C – lower quality evidence or expert consensus, meh…

NSTEMI in the ED
This policy was intended to answer these key questions.

  1. In adult patients without evidence of ST-elevation acute coronary syndrome, can initial risk stratification be used to predict a low rate of 30-day major adverse cardiac events?
    • The HEART score is recommended as Level B.
    • Other scores, such as TIMI are recommended as well. Level C.
  2. In adult patients with suspected acute non-ST-elevation acute coronary syndrome, can troponin testing within 3 hours of emergency department presentation be used to predict a low rate of 30-day major adverse cardiac events? All were Level C.
    • A HEART score of 0-3 and negative conventional troponin at zero and 3 hours predicts low rate of MACE.
    • “A single high-sensitivity troponin result below the level of detection on arrival to the ED, or negative serial high-sensitivity troponin result at 0 and 2 hours is predictive of a low rate of MACE.”
    • If, “low risk based on validated ADPs that include a nonischemic ECG result and negative serial high-sensitivity troponin testing results both at presentation and at 2 hours can predict a low rate of 30-day MACE allowing for an accelerated discharge pathway from the ED.”
  3. In adult patients with suspected non-ST-elevation acute coronary syndrome in whom acute myocardial infarction has been excluded, does further diagnostic testing (eg, provocative, stress test, computed tomography angiography) for acute coronary syndrome prior to discharge reduce 30-day major adverse cardiac events?
    • They do not recommend further diagnostic testing in patients who have had MI ruled out (as above) in order to further lower 30-day MACE. Level B. Stress testing or coronary CTA doesn’t seem to impact 30-day MACE and likely leads to more downstream testing without reduction in the rate of MI.
    • Patients should follow up in 1-2 weeks after ED MI rule out. If no follow up is available, consider further ED testing. (Consensus recommendation). Level C
  4. Should adult patients with acute non-ST-elevation myocardial infarction receive immediate antiplatelet therapy in addition to aspirin to reduce 30-day major adverse cardiac events?
    • “P2Y12 inhibitors [i.e. clopidogrel] and glycoprotein IIb/IIIa inhibitors may be given in the ED or delayed until cardiac catheterization.” Level C
    • Personally, I prefer for cardiology to start whatever additional antiplatelet therapy they want and not start it myself in the ED.

Another Spoonful
Do not miss Sanity Returns to ACS, by EMLoN. ACEP now explicitly states that it’s acceptable to not expect a zero miss rate.

Clinical Policy: Critical Issues in the Evaluation and Management of Emergency Department Patients With Suspected Non-ST-Elevation Acute Coronary Syndromes. Ann Emerg Med. 2018 Nov;72(5):e65-e106. doi: 10.1016/j.annemergmed.2018.07.045.

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#3: Can’t See the Appendix on Ultrasound – Now What?

Spoon Feed
Don’t be falsely reassured if the appendix is not visualized on ultrasound in children – especially in boys, those with an elevated total WBC count, or elevated absolute neutrophil count.

Why does this matter?
A non-diagnostic appendix ultrasound is common, occurring in over half of pediatric studies. Prior studies suggested it was safe to send home kids with an incompletely visualized appendix if clinical exam was reassuring or the WBC count was low.

If the appendix ain’t appy, ain’t nobody appy.
This was a retrospective study of 3,245 children with abdominal pain and abdominal ultrasound to rule out appendicitis. In 54%, the appendix could not be visualized. Of these 1,764 children, they pulled out a random sample of 500 for chart review and found 11.9% were ultimately diagnosed with appendicitis. Of those who had additional imaging on the same visit, 21.2% were diagnosed with appendicitis. Of those who were discharged home, 1.5% had an ultimate diagnosis of appendicitis. Risk factors for having appendicitis after non-visualized appendix were, “male sex, leukocytosis, and an elevated absolute neutrophil count.” A major weakness of the study is that all patients were not reviewed. A random sample of 500 patients out of 1,764 means a margin of error of ~4%. Also, they were unable to contact 61% of discharged patients by phone. So, those discharged home who ultimately had appendicitis could be much higher than 1.5%. The real take home point is that if you can’t see the appendix on ultrasound and you clinically suspect appendicitis, you should either get additional imaging or consult surgery.

Another Spoonful
ALiEM has a really helpful post on combining pretest probability with US.

emDocs looks at the literature on US.

Outcomes for Children With a Nonvisualized Appendix on Ultrasound. Pediatr Emerg Care. 2018 Nov 12. doi: 10.1097/PEC.0000000000001672. [Epub ahead of print]

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#4: Do Topical Antibiotics Help Conjunctivitis?

Spoon Feed
Topical antibiotic use for bacterial conjunctivitis was associated with improved rate of clinical cure compared to placebo. For early and late clinical cure with topical antibiotics, the NNT was 9 and 11, respectively.

Why does this matter?
Conjunctivitis is a common complaint encountered in the primary care, urgent care, and emergency care settings. The etiology of conjunctivitis can be bacterial, viral, allergic, or inflammatory, and the exact cause can be difficult to determine. Bacterial conjunctivitis is a clinical diagnosis, and although most cases of bacterial conjunctivitis are self-limiting, topical antibiotics are thought to shorten time to recovery, decrease sight-threatening complications, and reduce the rate of relapse.

Antibiotics speed recovery for conjunctivitis, can’t you see?
This review, which was an update of a 2006 Cochrane review, included 11 randomized controlled trials with a total of 3,673 patients with bacterial conjunctivitis diagnosed either clinically or microbiologically. Topical antibiotics were associated with improved early (2-5 day) clinical cure – RR 1.36 (95% CI 1.15-1.61) and microbiological cure – RR 1.55 (95% CI 1.37-1.76). At 6 to 10 days, topical antibiotics also had clinical benefit – clinical cure: RR 1.21 (95% CI 1.10-1.33) and microbiological cure: RR 1.37 (95% CI 1.24-1.52). The absolute risk difference for early and late clinical cure with topical antibiotics was 11% and 9%, respectively, corresponding to an NNT of 9 and 11. No serious outcomes were reported in the placebo or treatment groups.

Of note, there were significant limitations for many of the studies in this review. The included studies did not have a single standard diagnostic criterion for bacterial conjunctivitis. Also, they used different antibiotic regimens, and many of the included trials were poor quality, with 9 out of 11 trials deemed to have high risk of bias. In addition, no recommendations were made about antibiotic selection or duration.

Nevertheless, though the available evidence is modest, this review shows topical antibiotics are associated with improved cure rates for bacterial conjunctivitis with minimal risk of adverse events.

Topical Antibiotics for Clinical and Microbiological Cure of Bacterial Conjunctivitis. Acad Emerg Med. 2018 Nov 12. doi: 10.1111/acem.13663. [Epub ahead of print]

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