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: Risk of Epilepsy with Febrile Seizure

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Febrile seizures happened in 3.6% of all Danish children, with about 25% having a second. Risk of long-term epilepsy was 16% after a third febrile seizure and risk of psychiatric disorder went up to 29%.

Why does the matter?
Febrile seizures are common – roughly 5% of all children ages 6 months to 5 years. Do they portend a bad prognosis?

Seize the moment to educate families
In this large population database from Denmark, following over 2.1 million children over a 35 year period, the overall rate of febrile seizure in children 3 months to 5 years was 3.6%. They were more common in boys. Peak risk for boys and girls was at 16 months of age. Risk of subsequent febrile seizure after the first was 23%; after the second, 36%; and after the third, 44%. Risk of long-term epilepsy was 2.2% at baseline for the population and went up to 6.4% after the first febrile seizure, 10.8% after the second, and 15.8% after the third. In other words, there was a roughly 3-fold, 5-fold, and 7-fold increase in risk. Risk of developing a psychiatric disorder was 17% at baseline and went up to 29% after a third febrile seizure. Risk of mortality went up in children with third febrile seizure who went on to develop epilepsy: 1% baseline to 1.9%. This is helpful and important information for families. We can tell them with confidence that febrile seizures are common: 2-5% of all children. Roughly one-quarter will have a second febrile seizure. And about 1 in 6 will develop long-term epilepsy after a third febrile seizure.

Evaluation of Long-term Risk of Epilepsy, Psychiatric Disorders, and Mortality Among Children With Recurrent Febrile Seizures: A National Cohort Study in Denmark. JAMA Pediatr. 2019 Oct 7. doi: 10.1001/jamapediatrics.2019.3343. [Epub ahead of print]

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#2: Is 5 Days of Penicillin For Strep Pharyngitis Enough?

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A 5-day course of penicillin was non-inferior to a 10-day course for group A streptococcal pharyngitis (GASP).

Why does this matter?
Ten days of penicillin is typical for GASP. This duration was chosen because it was shown effective in reducing acute rheumatic fever (ARF). Currently, ARF is extremely rare in higher-income countries. Treatment is largely to reduce the burden of symptoms. So, would a shorter course be effective?

GASP! Just 5 days?
This was a multicenter, open-label RCT in Sweden that included 433 patients over age 6 with 3 out of 4 Centor criteria plus a positive rapid strep test. They were randomized to receive either penicillin V 800mg po QID x 5 days (16g total dose) or 1000mg po TID x 10 days (30g total dose). The lower dose regimen was non-inferior to the higher dose regimen for the primary outcome of clinical cure: 89.6% vs. 93.3%, respectively (95%CI -9.7 to 2.2). Secondary outcomes were similar with two possible areas of interest. First, bacterial eradication was a bit higher in the longer duration group. But there were more minor adverse events in the longer duration group. Time to symptom improvement was better in the shorter duration group.

Penicillin V four times daily for five days versus three times daily for 10 days in patients with pharyngotonsillitis caused by group A streptococci: randomised controlled, open label, non-inferiority study. BMJ. 2019 Oct 4;367:l5337. doi: 10.1136/bmj.l5337.

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#3: PrePARE – Fluid Bolus Before Intubation and Cardiovascular Collapse

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A 500mL fluid bolus prior to intubation of critically ill ICU patients did not reduce the rate of cardiovascular (CV) collapse.

Why does this matter?
Intubation, with use of powerful induction agents, positive pressure, and decreased preload may result in CV collapse in up to one-quarter of patients. Would giving a fluid bolus prior to intubation help?

PrePARE yourself for a let down
This was a RCT of critically ill adult patients who were being intubated in the ICU. It was open label and randomized 337 patients to either a 500mL fluid bolus just prior to and during intubation or no fluid bolus. For the composite outcome of CV collapse (hypotension – SBP ≤65, new or increased vasopressor within 2 minutes of intubation, or arrest /death within an hour of intubation), there was no difference in the fluid bolus vs no bolus groups, 20% vs 18%, respectively – not statistically different. The study was stopped early due to futility. Most subgroups and other exploratory outcomes also did not benefit from a fluid bolus. A fluid bolus was not associated with any adverse events. Interestingly, this trial allowed co-enrollment in the PreVent trial, in which some patients received positive pressure via bag mask ventilation (BMV). There was a suggestion that patients receiving BMV may have a lower rate of CV collapse with fluid, and those not receiving BMV might actually have greater risk of CV collapse with a fluid bolus. This is an interesting observation at this point but is not conclusive.

Another Spoonful

Effect of a fluid bolus on cardiovascular collapse among critically ill adults undergoing tracheal intubation (PrePARE): a randomised controlled trial. Lancet Respir Med. 2019 Oct 1. pii: S2213-2600(19)30246-2. doi: 10.1016/S2213-2600(19)30246-2. [Epub ahead of print]

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#4: Acute Headache – ACEP Policy Statment

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This ACEP clinical policy presents evidence-based recommendations on the management of patients presenting to the ED with acute headache.

Why does this matter?
Headaches are a common complaint in the ED, and etiologies can range from potentially life-threatening to benign. This clinical policy presents answers to several key questions in the evaluation and management of adult patients with acute headache. Recommendations are graded as follows:
Level A – generally accepted patient care principles based on high quality evidence
Level B – recommendations based on moderate quality evidence
Level C – recommendations based on lower quality evidence or consensus recommendations because no good data exists

These were the questions they addressed:

1. In the adult ED patient presenting with acute headache, are there risk-stratification strategies that reliably identify the need for emergent neuroimaging?

The Ottawa Subarachnoid Hemorrhage Rule is the only risk stratification tool that has been validated and identifies the need for neuroimaging in acute headache. It has a high sensitivity but lacks specificity for SAH.

Patients with a normal neurologic examination and peak headache intensity within 1 hour of pain onset require investigation if one or more of the following is present:

  • Symptoms of neck pain or stiffness

  • Age ≥40 years old

  • Witnessed loss of consciousness

  • Onset during exertion

  • Thunderclap headache (peak intensity immediately)

  • Limited neck flexion on exam

Level B recommendation

2. In the adult ED patient treated for acute primary headache, are nonopioids preferred to opioid medications?

Nonopioid medications are strongly preferred for treatment of acute primary headaches in the ED patients.

Level A recommendation

 3. In the adult ED patient presenting with acute headache, does a normal noncontrast head CT scan performed within 6 hours of headache onset preclude the need for further diagnostic workup for SAH?

A normal noncontrast head CT performed within 6 hours of symptom onset in an ED headache patient with a normal neurologic exam can be used to rule out a nontraumatic SAH without performing an LP.

Level B recommendation

4. In the adult ED patient who is still considered to be at risk for SAH after a negative noncontrast head CT, is CTA of the head as effective as LP to safely rule out SAH?

In patients considered to be at risk for SAH after negative noncontrast head CT, CTA is a reasonable alternative to LP for safely ruling out SAH. ACEP recommends using shared decision making to select the best diagnostic test with regard to pros and cons of CT/LP versus CT/CTA.

  • Lumbar puncture is a time-intensive procedure with a low diagnostic yield, a high rate of traumatic taps, high rate of uninterpretable test results, and a risk of post-LP headache.

  • CTA avoids many of the negative aspects of performing an LP. However, it may identify incidental cerebral aneurysms leading to unnecessary invasive procedures, is associated with a higher radiation dose, and risks missing an alternative diagnosis through LP.

Level C recommendation

Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Headache: Approved by the ACEP Board of Directors June 26, 2019 Clinical Policy Endorsed by the Emergency Nurses Association (July 31, 2019). Ann Emerg Med. 2019 Oct;74(4):e41-e74. doi: 10.1016/j.annemergmed.2019.07.009.

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