JournalFeed 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: Predicting Outpatient Failure for Cellulitis

Spoon Feed
Tachypnea, chronic ulcers, prior MRSA colonization, and prior cellulitis in the past 12 months were all associated with an increased risk of oral antibiotic failure for treatment of non-purulent cellulitis.

Why does this matter?
At our institution, we are looking for ways to reduce admission, and cellulitis is a target illness.  This adds a few more items to the possible list of exclusions when considering whether it is safe to treat as an outpatient.

When PO antibiotics are more likely to fail
This was a retrospective study of patients presenting to the ED with non-purulent cellulitis.  They found 288 who failed oral antibiotics.  The risk factors for failure were respiratory rate >20 at triage (OR 6.31), chronic ulcers (OR 4.90), history of MRSA colonization or infection (OR 4.83), and cellulitis in the past 12 months (OR 2.23).  Surprisingly, diabetes and chronic kidney disease were not associated with increased risk.

Source
Predictors of Oral Antibiotic Treatment Failure for Non-Purulent Skin and Soft Tissue Infections in the Emergency Department.  Acad Emerg Med. 2018 Jun 5. doi: 10.1111/acem.13492. [Epub ahead of print]
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Another Spoonful


#2: New S-Sign for SCFE + Klein’s Line

Spoon Feed
Combining Klein’s line for the AP view and the new S-sign for the frog-leg lateral view increased the diagnostic accuracy for detecting slipped capital femoral epiphysis (SCFE).

Why does this matter?
SCFE may be subtle on radiographs.  Early detection allows children the best chance for surgery and functional recovery.  Classically, Klein’s line is taught.  The S-sign adds another tool to Klein’s line to increase diagnostic yield of x-ray.

Klein’s line and S-sign
A heterogeneous group of 20 orthopedic surgeons, radiologists, and pediatricians viewed 35 radiographs of SCFE using Klein’s line on the AP view and the S-sign on frog-leg lateral view to make the diagnosis.  They found the overall diagnostic accuracy was better with the S-sign than Klein’s line, 92% vs 79%.  Sensitivity of the S-sign was 89%, specificity 95%.  Sensitivity of Klein’s line was 68%, specificity 89%.  Combined S-sign + Klein’s line sensitivity was 96%, specificity 85%.  Take a look and review Klein’s line for the AP view and the new S-sign for the frog-leg lateral.

Another Spoonful
CORE EM and Ped EM Morsels both have great posts to learn more about SCFE.

Source
The S Sign: A New Radiographic Tool to Aid in the Diagnosis of Slipped Capital Femoral Epiphysis.  J Emerg Med. 2018 Jun;54(6):835-843. doi: 10.1016/j.jemermed.2018.01.023. Epub 2018 Mar 15.
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#3: Midazolam Beat Haloperidol for Agitation

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Midazolam 5mg IM beat haloperidol 5 mg, ziprasidone 20 mg, olanzapine 10 mg, and haloperidol 10 mg (all also given IM), with 71% sedated at 15 minutes.  Olazapine came in second.

Why does this matter?
Sedating an agitated patient is important for their own safety and that of the staff.  Agents need to be rapid onset, safe, and effective.  This was a study of four agents in the ED.

Midazolam with the KO
This was a prospective study that enrolled 737 patients.  They had an every 3-week rotating regimen of agents set prior to study onset, and agitated patients would get one of the five IM drug regimens: haloperidol 5 mg, ziprasidone 20 mg, olanzapine 10 mg, midazolam 5 mg, or haloperidol 10 mg.  They found midazolam was best at 15 minutes, with 71% of patients adequately sedated.  Olanzapine 10mg was a close second at 61%, beating out both haloperidol doses (each about 40%) and ziprasidone (50%).  All were equally safe, with rare adverse outcomes equally distributed among the groups.  Now that droperidol is off the market, it looks like midazolam is a reasonable, safe drug to choose.

Source
Intramuscular Midazolam, Olanzapine, Ziprasidone, or Haloperidol for Treating Acute Agitation in the Emergency Department.  Ann Emerg Med. 2018 Jun 6. pii: S0196-0644(18)30373-1. doi: 10.1016/j.annemergmed.2018.04.027. [Epub ahead of print]
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Another Spoonful


#4: Fluconazole Safety in Pregnancy

Spoon Feed
Oral fluconazole appears to be safe to use in pregnancy.

Why does this matter?
Vaginal candidiasis is common in pregnancy.  Oral fluconazole 150mg once is an effective, simple, and non-messy treatment.  However, in 2016, JAMA published an article that found increased risk of stillbirth and miscarriage in women who received fluconazole.  This research letter in JAMA Internal Medicine was even bigger and was reassuring.

To the relief of pregnant women everywhere…
This small research letter included over 10,000 pregnant women exposed to fluconazole compared to unexposed pregnant women.  They found no increased risk of stillbirth or neonatal death, even at doses over 300mg.  This study was over three times larger than the original JAMA article in 2016.  It appears that fluconazole 150mg is safe to use for yeast infection during pregnancy.  This is preferable to the messy topical preparations requiring several days of therapy.

Source
Oral Fluconazole in Pregnancy and Risk of Stillbirth and Neonatal Death.  JAMA. 2018 Jun 12;319(22):2333-2335. doi: 10.1001/jama.2018.6237.
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