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: Early Rhythm Control for A-fib | EAST-AFNET 4 Trial

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Early rhythm control of atrial fibrillation was associated with a lower risk of cardiovascular outcomes, including cardiovascular-related death as well as stroke and hospitalization for worsening heart failure or acute coronary syndrome.

Why does this matter?
Patients with atrial fibrillation are diagnosed with stroke, ACS, CHF or cardiovascular-related deaths at a rate of 5% per year.  The risk of cardiovascular complications seems to be highest during the first year following diagnosis, a period referred to “early atrial fibrillation.”  Would early rhythm control reduce this risk?

I can no longer AFFIRM prior studies…
Patients diagnosed with atrial fibrillation within the past 12 months were randomized to receive either usual care or rhythm control therapy; all patients received treatment of cardiovascular conditions, anticoagulation and rate control.  Patients assigned to the rhythm control arm received a combination of pharmacotherapy, cardioversion or ablation.  Flecainide was the most commonly use anti-arrhythmic (35.9%) followed by amiodarone (19.6%).  The first primary outcome was a composite of death from cardiovascular causes, stroke, or hospitalization with worsening CHF or ACS. The first primary outcome occurred in 249 patients (3.9 per 100 person-years) in the rhythm control group and 316 patients (5.0 per 100 person-years) in the usual care group resulting in an absolute difference in risk of 1.1 events per 100 person-years.  Interestingly, this study included a secondary primary outcome that looked at the number of nights spent in the hospital per year, which did not differ among the treatment groups.  Patients assigned to the treatment arm had a higher incidence of adverse events related to drug toxicity and ablation (pericardial tamponade and bleeding, known complications of this procedure).  Prior studies showed no advantage of rhythm control, most notably, the AFFIRM trial published in 2002.  In contrast to previous studies, this study included ablation as a rhythm control strategy and kept patients in both the usual care group and rhythm control group on anticoagulation throughout the follow-up period.  All patients that were enrolled in this study were deemed eligible for randomization to both the usual care and rhythm control group.  Therefore, this probably excluded patients that were symptomatic and may not be generalizable to the acute care setting.

Early Rhythm-Control Therapy in Patients with Atrial Fibrillation. N Engl J Med. 2020 Aug 29. doi: 10.1056/NEJMoa2019422. Online ahead of print.

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#2: Best Tests for Septic Arthritis

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The best predictors of septic arthritis in the knee were synovial WBC and Gram stain. Synovial lactate and PCR performed poorly, and no features of the history or exam were helpful.

Why does this matter?
Septic arthritis (SA) is high on the differential diagnosis for monoarticular arthritis. Prior studies have shown history and inflammatory markers to be inaccurate. Synovial WBC >50,000 increased the probability of SA. Synovial lactate and PCR have also been considered as possible aids in the diagnosis, though each has gotten mixed reviews.

If you suspect septic arthritis, tap the joint.
This was a prospective study that included 71 adults with monoarticular knee arthritis. Prevalence of SA was 7% (prior studies had prevalence rates of 27%). Again, history and physical was unable to rule SA in or out. Synovial L-lactate was inaccurate (D-lactate wasn’t detected at all in 8 samples). PCR was also disturbingly inaccurate. I won’t show the table for history and exam, because no aspects were helpful. But here is the table comparing various tests. The best predictors were synovial WBC and Gram stain.

Screen Shot 2020-10-18 at 3.39.32 PM.png

This was a small, single center study with predominately older African American adults, and it only considered monoarticular arthritis of the knee. Only 5 patients had SA. Performance of these markers in a larger, different population may be different.

Diagnostic Accuracy of Synovial Lactate, Polymerase Chain Reaction, or Clinical Examination for Suspected Adult Septic Arthritis. J Emerg Med. 2020 Aug 17:S0736-4679(20)30671-5. doi: 10.1016/j.jemermed.2020.06.068. Online ahead of print.

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#3: RCT – Droperidol, Ziprasidone, and Lorazepam Walk Into a Bar…

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Droperidol 5mg IM was a safe, rapid way to sedate agitated patients and was more effective than IM ziprasidone 10 or 20mg and lorazepam 2mg.

Why does this matter?
Treatment of agitated patients in the ED is important for their own safety and the safety of the staff. This study was performed in 2004-2005 and was presented as an abstract but then went unpublished. Then droperidol got a black box warning followed by a nationwide shortage. Now that it’s back, the authors decided they should publish the full study.

Droperidol, ziprasidone, and lorazepam walk into a bar
This was a randomized trial comparing IM droperidol 5mg, ziprasidone 10mg, ziprasidone 20mg, and lorazepam 2mg. For the primary outcome of adequate sedation at 15 minutes, droperidol was best at 64%; compared to ziprasidone 10mg, 25%; ziprasidone 20mg, 35%, and lorazepam 2mg, 29%. The original primary outcome was difference in sedation score, which was also best with droperidol. Droperidol lasted the longest before redosing, 90 minutes. It was also just behind ziprasidone 20mg in need for additional sedation. Most of these patients were agitated because they were drunk. This study took place before K2 and bath salts, and methamphetamine use was not as common then. Mild respiratory depression, defined as a dip in SpO2 <90% or alteration of EtCO2, was common with all agents, ranging from 12-48%, but was lowest with droperidol (12%). No one needed intubation except one patient who was later found to have a subdural hematoma. None of the agents caused prolonged QTc. This study is old and out of date, but it still adds value and shows that droperidol is a safe, effective, rapid way to sedate patients with agitation.

Randomized Double-Blind Trial of Intramuscular Droperidol, Ziprasidone and Lorazepam for Acute Undifferentiated Agitation in the Emergency Department. Acad Emerg Med. 2020 Sep 5. doi: 10.1111/acem.14124. Online ahead of print.

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