User login
Three lab tests predict serious bacterial infections in infants
BY JENNIE SMITH
AT SAEM 2015
SAN DIEGO – A simple three-variable prediction rule can accurately predict which febrile infants younger than age 2 months with fever who present to the ED have serious bacterial infections. Bacterial meningitis, urinary tract infections, and bacteremia are considered serious bacterial infections; many young infants with these infections are difficult to identify, and current laboratory protocols for identifying them include urinalysis, white blood cell counts, band counts, and sometimes cerebrospinal fluid.
Vitals Key clinical point: A rule comprising three lab measurements allows for the prediction of serious bacterial infections in infants under age 2 months presenting to the ED. Major finding: Positive urinalysis, ANC of 4.09 x 1,000/mm3 or higher, and serum procalcitonin of 1.71 ng/mL or greater are between 98% and 99% sensitive in predicting SBIs. Data source: A prospective observational cohort of 1,821 infants at 21 centers forming a pediatric emergency research network. Disclosures: The study was funded by federal government grants. The authors disclosed no conflicts of interest. |
In a presentation at the annual meeting of the Society for Academic Emergency Medicine, Dr Nathan Kuppermann of the University of California, Davis, demonstrated results from a large prospective cohort study of 1,821 febrile infants 60 days old and younger conducted at 21 EDs. Infants with underlying congenital anomalies or critical illness were excluded from the study.
The investigators evaluated 8 variables as potential predictors: age, temperature, Yale Observation Scale score, and clinician suspicion of SBI, along with 4 laboratory variables (urinalysis, white blood cell count, absolute neutrophil count [ANC], and procalcitonin). Band counts were available at some, but not all of the study centers, and therefore were not evaluated.
Dr Kuppermann and his colleagues found that positive urinalysis, ANC of 4.09 x 1,000/mm3 or higher, and serum procalcitonin of 1.71 ng/mL or higher were, taken together, 98% to 99% sensitive and about 60% specific, in predicting SBI in the cohort. Negative predictive values approached 100%. The rate of SBI was 9.3% of the cohort, in keeping with expected rates.
“The SBI positive group was more likely to have higher clinician suspicion of SBI, and all of the lab markers were more elevated in the SBI positive group than the SBI negative group,” Dr Kuppermann said at the meeting. However, after the researchers considered all of the predictors as a group, only the urinalysis, the ANC, and the procalcitonin remained important. Only 3 of 1,821 (0.2%) infants with SBIs were missed when the three-variable prediction tool was used.
To make the prediction rule easier to remember and use, the investigators evaluated lower, more standard, and easier to remember thresholds for the three variables. They reanalyzed their data using a lower cutoff point for ANC of 4.00 x 1,000/mm3, and a lowered procalcitonin cutoff of 0.5 ng/mL. The rule performed almost identically as the original rule, and did not miss any more patients with SBIs beyond the original three.
Dr Kuppermann described the three-variable rule as “simple, objective, and highly accurate” in predicting or ruling out SBI. Nonetheless, it requires external validation in a large cohort, he acknowledged. He said he would continue to routinely perform lumbar punctures in infants younger than 30 days with fever until the findings could be further validated.
“But personally, in that second month of life, I would use these data to decide who actually needs a lumbar puncture and hospitalization,” he said.
Dr Kuppermann also noted as a limitation of the study that the cohort included few infants with bacterial meningitis.
ED revisits twice as frequent as expected
BY MARY ANN MOON
FROM ANNALS OF INTERNAL MEDICINE
The rate of adult revisits to EDs is more than twice as high as has been reported previously – 8% at 3 days and 20% at 30 days – in large part because until now researchers have failed to account for revisits to different hospitals, according to a report published online June 2 in Annals of Internal Medicine.
Vitals Key clinical point: Revisits to the emergency department were twice as frequent as previously reported: 8% at 3 days and 20% at 30 days. Major finding: At 3 days after an initial ED visit, the overall revisit rate was 8.2%, and at 30 days it was 20%, with one-third of these revisits occurring at a medical facility different from that of the initial visit. Data source: A longitudinal, population-based study of adult revisits to the ED after 57,530,239 initial visits in six states during 2006-2010. Disclosures: This study was supported by the US Agency for Healthcare Research and Quality. The researchers’ financial disclosures are available at www.acponline.org. |
Little is known about returns to an emergency department following an index ED visit because most studies have assessed only visits to a single institution or to hospitals within a single state or insurance plan. Now researchers have performed a broader examination of the issue by analyzing newly available multistate longitudinal data from the Healthcare Cost and Utilization Project, which allowed them to identify returns to any ED or acute-care hospital. They focused on acute-care revisits after 57,530,239 initial ED visits by adults in six states (Arizona, California, Florida, Nebraska, Utah, and Hawaii) during 2006-2010.
At 3 days after an initial ED visit, the overall revisit rate was 8.2%, with one-third of these revisits occurring at a medical facility different from that of the initial visit. Previously, estimates of 3-day revisits have ranged from 2.7% to 3.4%. At 30 days, the revisit rate was 20%, and approximately one-third of these revisits involved a different facility. Revisits to different institutions “may have special clinical and financial implications because fragmentation of care increases the likelihood of duplication of services and problems with care transitions,” said Dr Reena Duseja of the department of emergency medicine, University of California, San Francisco, and her associates.
Views on the News Highlighting an underappreciated problem The findings of Duseja et al highlight an underappreciated problem and also raise important questions. To what extent do ED revisits represent gaps in quality as opposed to reasonable strategies that prevent admissions? How often are revisits due to failures of transitional care, suboptimal patient education, or lack of timely follow-up? And why do patients so often seek care at different institutions? Are they dissatisfied with their initial encounter, exercising greater discretion in choosing a facility the second time around, or doing something else? Dr Kumar Dharmarajan and Dr Harlan M. Krumholz are at the Center for Outcomes Research and Evaluation, Yale University, New Haven, Connecticut. Dr Dharmarajan reported receiving grant support from the National Institute on Aging and the American Federation for Aging Research. Dr Krumholz reported receiving grant support from the National Heart, Lung, and Blood Institute and the Center for Cardiovascular Outcomes Research at Yale. The investigators made these remarks in an editorial accompanying Dr Duseja’s report (Ann Intern Med. 2015;162(11):793-794. doi:10.7326/M15-0878). |
“The scope of revisits to outside institutions is much greater than previously suspected, which suggests that improving communication infrastructure across institutions (such as health information exchanges) may improve care and allow individual institutions to get a more accurate picture of their revisit rates,” they noted (Ann Intern Med. 2015;162(11):750-756. doi:10.7326/M14-1616).
Revisit rates varied substantially according to diagnosis. “Skin and subcutaneous tissue infection” accounted for 23% of revisits. “Abdominal pain” was the diagnosis with the next highest revisit rate (10%). The most frequent diagnosis among patients who revisited a different hospital was back pain (2.6%), and nonspecific chest pain was the diagnosis with the
highest rate of later admission to a different hospital (1.1%).
“Financial data from the Florida facilities showed that revisits accounted for more of the total costs of ED care than initial visits did. This demonstrates that revisits are a major, and unaccounted for, component of emergency care costs,” Dr Duseja and her associates said.
Because of insufficient data, they could not determine whether these revisits reflected inadequate access to primary care, patient nonadherence to treatment recommendations, poor quality of care at the initial visit, or other factors, the researchers noted.
Cefazolin ranks sixth as cause of drug-induced liver injury
BY AMY KARON
FROM CLINICAL GASTROENTEROLOGY AND HEPATOLOGY
| A single intravenous infusion of cefazolin can cause drug-induced liver injury (DILI), and the antibiotic ranked sixth among pharmacologic causes of hepatic injury in an analysis of 1,212 patients. “Cephalosporins appear to be a relatively common cause of antibiotic-associated liver injury,” said Dr Saleh Alqahtani at the University of Texas Southwestern in Dallas and his associates. “The latency period is typically 1 to 3 weeks after exposure, and patients may not become symptomatic until after the antibiotic is stopped – this is particularly true in the unique clinical syndrome in which a single infusion of cefazolin leads to drug-induced liver injury.” |
Vitals Key clinical point: A single dose of cefazolin can cause drug-induced liver injury (DILI), and the agent is implicated more often than previously thought. Major finding: Cefazolin ranked sixth among causes of DILI, and signs and symptoms began 1 to 3 weeks after initial exposure. Data source: Registry-based study of 1,212 cases of DILI. Disclosures: The study was funded by the National Institute of Diabetes and Digestive and Kidney Diseases, the National Institutes of Health, the National Cancer Institute, and by Clinical and Translational Science Award grants. The investigators reported having no conflicts of interest. |
“Cephalosporins have been reported as rare causes of DILI, but most data come from single case reports,” the researchers said. To study causes of DILI, they analyzed cases from the Drug-Induced Livery Injury Network, an ongoing prospective study at 8 US medical centers. Enrolled patients had strong clinical suspicion for liver injury caused by a drug or an herbal agent. Liver injury was defined based on specific criteria for liver enzymes, alkaline phosphatase (ALP), or total bilirubin levels, or as an international normalized ratio greater than 1.5 that was accompanied by elevated liver enzymes or ALP. Patients were followed for at least 6 months after their baseline visit (Clin Gastroenterol Hepatol. Published January 26, 2015. doi: 10.1016/j.cgh.2015.01.010).
Among the 1,212 cases of DILI in the analysis, one-third were linked to antimicrobial therapies, including 41 (3.3%) in which cephalosporins were implicated, the investigators reported. Nineteen of the cases were tied to a single dose of intravenous cefazolin given before surgery. These patients developed cholestatic or mixed hepatocellular-cholestatic injury 1 to 3 weeks after the cefazolin infusion. They almost always had jaundice and pruritus, and usually also had fever and nausea. Signs and symptoms were self-limiting, resolving within a few days to a few weeks.
“Because of confusion about the specific diagnosis, patients underwent substantial diagnostic testing (including multiple computed tomography scans, magnetic resonance imaging scans, endoscopic retrograde cholangiopancreatography exams, liver biopsies, and others), which often were unnecessary, and in some cases led to severe complications,” the investigators said.
“The study also identified barriers to identifying cefazolin as a cause of DILI,” they said. Patients often did not know they had received the antibiotic, and clinicians, including study investigators, often did not know that cefazolin could cause DILI. In more than half of cases, DILI was linked to cefazolin only after careful medical record reviews. “For these reasons, we speculate that cefazolin is and has been underappreciated as a cause of DILI,” the researchers noted. “The appearance of jaundice and pruritus 1 to 3 weeks after minor surgery should lead to a search of surgical records and medications that might have been given during surgery. These results also imply that the merits of routine use of cefazolin at the time of uncomplicated surgery should be reconsidered carefully.”
“Two patients died after receiving cephalosporins other than cefazolin, and another patient developed severe liver injury,” the researchers said. “However, in each of the fatal cases, patients had a complicated clinical course, with a severe hypersensitivity reaction on top of an underlying liver disease. Therefore, we urge caution in concluding that non-cefazolin cephalosporin-induced DILI may be severe or fatal,” they said. “Because cephalosporins are used commonly in clinical practice, it is likely that the overall mortality rate associated with cephalosporin use is low, but not nil, and it may be more likely in patients with underlying disorders.”
The study was funded by the National Institute of Diabetes and Digestive and Kidney Diseases, the National Institutes of Health, the National Cancer Institute, and by six Clinical and Translational Science Award grants. The investigators reported having no conflicts of interest.
Pelvic CT may not be needed to diagnose intra-abdominal injury in children
BY JENNIE SMITH
FROM SAEM 2015
| San DIEGO – Children who have suffered blunt trauma are routinely screened in EDs for intra-abdominal injury (IAI) via computed tomography of the abdomen and pelvis. |
Vitals Key clinical point: Abdominal CT scans without a pelvic portion may diagnose intra-abdominal injury in children as well as do full abdominopelvic scans, with less radiation exposure to patients. Major finding: Abdominal CT alone was 85% sensitive (95% CI, 65%-96%) and 99% specific (95% CI, 97%-100%) in identifying IAIs. The four missed injuries were solid organ injuries within the radiographic abdomen. Data source: A retrospective cohort study of 313 patients aged 3 to 17 years presenting to 12 EDs. Disclosures: The study was funded by the Carolinas Trauma Network Research Center of Excellence. None of the investigators disclosed conflicts of interest. |
But concerns about excess exposure to CT radiation, particularly to the gonads, led one group of researchers to question whether it’s necessary to scan the entire abdominopelvic region in all of these patients to identify IAI.
Dr Stacy Reynolds and her colleagues at the Carolinas Medical Center in Charlotte, North Carolina, hypothesized that CT limited to the radiographic abdomen – the region between the dome of the diaphragm to the top of the iliac crest – can capture the vast majority of IAIs in this population.
At the Society for Academic Emergency Medicine annual meeting, Dr Reynolds presented results from a retrospective cohort study enrolling 313 hemodynamically stable pediatric patients (median age 14 years, 64% male) presenting to 12 EDs after blunt trauma. Patients with known pelvic fractures or hip dislocation were excluded, as they would have had a clear indication for a full abdominopelvic CT.
All subjects underwent axial abdominopelvic CT imaging. Researchers created matched pairs of images comprising the original scans and those that had been altered with software that truncated the pelvic portion of the study to create CT abdomen-only studies. Study radiologists were blinded to the results of the original scans.
In all, 26 IAI’s were diagnosed in 24 patients: 8 hepatic injuries, 12 splenic injuries, 5 renal injuries, and 1 retroperitoneal hemorrhage. Abdominal CT alone was 85% sensitive (95% CI, 65%-96%) and 99% specific (95% CI, 97%-100%) in identifying IAIs. The four missed injuries were solid organ injuries within the radiographic abdomen. False positives occurred in two of the complete scans, both involving free fluid prompting suspicion of small bowel injury later ruled out by clinical observation.
Dr Reynolds said in an interview that the findings, while promising, were limited by the study’s small numbers, and its use of axial images alone, when sagittal images also would be required for the most accurate diagnoses. Also, physician suspicion of IAI prior to imaging was not captured because of the study’s retrospective design, she said. “The real key to whether or not this hypothesis is valuable is if physicians are able to target the right population of patients for application.”
Dr Reynolds cautioned that the findings would need to be validated in a larger trial before any changes could be made to clinical practice. “Some of the outcomes that we need to make sure whether we’re missing are still rare,” she said. “You couldn’t feel confident that this is the right way to go with a study this small, but it establishes that we can safely and ethically pursue a multicenter trial that would examine the issue with bigger numbers.”
Other groups of investigators, including members of the Pediatric Emergency Care Applied Research Network (PECARN), also have taken up the question of identifying children at low risk of IAI who may not need CT screening after blunt trauma. In 2013, PECARN published a prediction rule using only patient history and physical examination findings intended to obviate use of CT in the lowest-risk patients (Ann Emerg Med. 2013;62:107-116.e2).
Dr Reynolds said that while overuse of CT was a worrisome trend that could have long-term implications for patients, and that it was important to identify ways it might be limited, there is a reason it remains the go-to technology in the ED for detecting IAI. “It’s got very high sensitivity and specificity. If you’re a busy trauma surgeon who’s admitting 20 injured patients in a night, there’s no faster or more efficient way to determine whether the patient in front of you is injured.”
The ‘sad truth’ about suicide risk assessment scales
BY BRUCE JANCIN
EXPERT ANALYSIS FROM THE ANNUAL AAS CONFERENCE
ATLANTA – “Don’t – repeat, don’t – use risk assessment tools and scales in an effort to predict future suicide in patients who’ve committed intentional self-harm,” Dr Keith Hawton urged at the annual conference of the American Association of Suicidology.
He noted this isn’t simply a matter of his personal opinion; it’s also a strongly worded recommendation in the current UK NICE (National Institute for Health and Care Excellence) guidelines on the long-term management of patients who’ve committed self-harm. The various NICE guidelines, which address numerous areas of medical practice and are used to determine what’s reimbursable through the UK’s National Health Service, are famously evidence based and concerned with cost-effectiveness.
The NICE guidelines on management of self-harm further advise: “Do not use risk assessment tools and scales to determine who should and should not be offered treatment or who should be discharged from hospital.”
“Those are some fairly contentious statements about risk assessment scales. But those statements are based upon review of the evidence about the effectiveness of risk assessment scales,” according to Dr Hawton, professor of psychiatry and director of the Centre for Suicide Research at the University of Oxford (England).
“In our country, hospitals have become obsessed with risk assessment. And usually, it seems to be about protecting the organization rather than the patient, because so often the results aren’t linked to risk management, which is what we should be talking about,” he observed.
Dr Hawton and his colleagues provided some of the evidence that led to the NICE guideline committee’s thumbs-down on the use of suicide risk assessment scales in patients who’ve engaged in intentional self-harm. In a study provocatively titled “The sad truth about the SADPERSONS scale,” he and his coinvestigators essentially dismantled SADPERSONS, a widely used screening tool for suicide risk, concluding that it is without value.
The acronym stands for Sex (male), Age (<19 or >45), Depression, Previous attempts, Ethanol abuse, Rational thinking loss, Social supports lacking, Organized plan, No spouse, and Sickness. One point is given for each. Patients who score 7-10 are to be hospitalized, and those with a total of 5 or 6 points should be strongly considered for hospitalization.
Dr Hawton and coinvestigators tracked 126 consecutive patients who were evaluated for self-harm using the SADPERSONS scale in a general hospital emergency department and then followed them for 6 months. SADPERSONS performed miserably in predicting clinical management outcomes, such as admission to a psychiatric hospital or repetition of self-harm within 6 months. Indeed, the test failed to identify 4 of the 5 patients admitted to a psychiatric hospital, 65 of 70 who were referred from the ED to community psychiatric aftercare, and 28 of 31 who repeated self-harm within 6 months. Thus, its sensitivity as a predictor of repetition of self-harm was a lowly 6.6% (Emerg Med J. 2014;31:796-798).
And yet, a 32-hospital UK national study conducted by Dr Hawton and others found that SADPERSONS was the most widely used scale in EDs for risk assessment following self-harm (BMJ Open. 2014;4(5):e004732. doi:10.1136/bmjopen-2013-004732). “It’s a very crude tool,” Dr Hawton said. “How it found its way into common use in clinical practice is beyond me.”
bjancin@frontlinemedcom.com
Three lab tests predict serious bacterial infections in infants
BY JENNIE SMITH
AT SAEM 2015
SAN DIEGO – A simple three-variable prediction rule can accurately predict which febrile infants younger than age 2 months with fever who present to the ED have serious bacterial infections. Bacterial meningitis, urinary tract infections, and bacteremia are considered serious bacterial infections; many young infants with these infections are difficult to identify, and current laboratory protocols for identifying them include urinalysis, white blood cell counts, band counts, and sometimes cerebrospinal fluid.
Vitals Key clinical point: A rule comprising three lab measurements allows for the prediction of serious bacterial infections in infants under age 2 months presenting to the ED. Major finding: Positive urinalysis, ANC of 4.09 x 1,000/mm3 or higher, and serum procalcitonin of 1.71 ng/mL or greater are between 98% and 99% sensitive in predicting SBIs. Data source: A prospective observational cohort of 1,821 infants at 21 centers forming a pediatric emergency research network. Disclosures: The study was funded by federal government grants. The authors disclosed no conflicts of interest. |
In a presentation at the annual meeting of the Society for Academic Emergency Medicine, Dr Nathan Kuppermann of the University of California, Davis, demonstrated results from a large prospective cohort study of 1,821 febrile infants 60 days old and younger conducted at 21 EDs. Infants with underlying congenital anomalies or critical illness were excluded from the study.
The investigators evaluated 8 variables as potential predictors: age, temperature, Yale Observation Scale score, and clinician suspicion of SBI, along with 4 laboratory variables (urinalysis, white blood cell count, absolute neutrophil count [ANC], and procalcitonin). Band counts were available at some, but not all of the study centers, and therefore were not evaluated.
Dr Kuppermann and his colleagues found that positive urinalysis, ANC of 4.09 x 1,000/mm3 or higher, and serum procalcitonin of 1.71 ng/mL or higher were, taken together, 98% to 99% sensitive and about 60% specific, in predicting SBI in the cohort. Negative predictive values approached 100%. The rate of SBI was 9.3% of the cohort, in keeping with expected rates.
“The SBI positive group was more likely to have higher clinician suspicion of SBI, and all of the lab markers were more elevated in the SBI positive group than the SBI negative group,” Dr Kuppermann said at the meeting. However, after the researchers considered all of the predictors as a group, only the urinalysis, the ANC, and the procalcitonin remained important. Only 3 of 1,821 (0.2%) infants with SBIs were missed when the three-variable prediction tool was used.
To make the prediction rule easier to remember and use, the investigators evaluated lower, more standard, and easier to remember thresholds for the three variables. They reanalyzed their data using a lower cutoff point for ANC of 4.00 x 1,000/mm3, and a lowered procalcitonin cutoff of 0.5 ng/mL. The rule performed almost identically as the original rule, and did not miss any more patients with SBIs beyond the original three.
Dr Kuppermann described the three-variable rule as “simple, objective, and highly accurate” in predicting or ruling out SBI. Nonetheless, it requires external validation in a large cohort, he acknowledged. He said he would continue to routinely perform lumbar punctures in infants younger than 30 days with fever until the findings could be further validated.
“But personally, in that second month of life, I would use these data to decide who actually needs a lumbar puncture and hospitalization,” he said.
Dr Kuppermann also noted as a limitation of the study that the cohort included few infants with bacterial meningitis.
ED revisits twice as frequent as expected
BY MARY ANN MOON
FROM ANNALS OF INTERNAL MEDICINE
The rate of adult revisits to EDs is more than twice as high as has been reported previously – 8% at 3 days and 20% at 30 days – in large part because until now researchers have failed to account for revisits to different hospitals, according to a report published online June 2 in Annals of Internal Medicine.
Vitals Key clinical point: Revisits to the emergency department were twice as frequent as previously reported: 8% at 3 days and 20% at 30 days. Major finding: At 3 days after an initial ED visit, the overall revisit rate was 8.2%, and at 30 days it was 20%, with one-third of these revisits occurring at a medical facility different from that of the initial visit. Data source: A longitudinal, population-based study of adult revisits to the ED after 57,530,239 initial visits in six states during 2006-2010. Disclosures: This study was supported by the US Agency for Healthcare Research and Quality. The researchers’ financial disclosures are available at www.acponline.org. |
Little is known about returns to an emergency department following an index ED visit because most studies have assessed only visits to a single institution or to hospitals within a single state or insurance plan. Now researchers have performed a broader examination of the issue by analyzing newly available multistate longitudinal data from the Healthcare Cost and Utilization Project, which allowed them to identify returns to any ED or acute-care hospital. They focused on acute-care revisits after 57,530,239 initial ED visits by adults in six states (Arizona, California, Florida, Nebraska, Utah, and Hawaii) during 2006-2010.
At 3 days after an initial ED visit, the overall revisit rate was 8.2%, with one-third of these revisits occurring at a medical facility different from that of the initial visit. Previously, estimates of 3-day revisits have ranged from 2.7% to 3.4%. At 30 days, the revisit rate was 20%, and approximately one-third of these revisits involved a different facility. Revisits to different institutions “may have special clinical and financial implications because fragmentation of care increases the likelihood of duplication of services and problems with care transitions,” said Dr Reena Duseja of the department of emergency medicine, University of California, San Francisco, and her associates.
Views on the News Highlighting an underappreciated problem The findings of Duseja et al highlight an underappreciated problem and also raise important questions. To what extent do ED revisits represent gaps in quality as opposed to reasonable strategies that prevent admissions? How often are revisits due to failures of transitional care, suboptimal patient education, or lack of timely follow-up? And why do patients so often seek care at different institutions? Are they dissatisfied with their initial encounter, exercising greater discretion in choosing a facility the second time around, or doing something else? Dr Kumar Dharmarajan and Dr Harlan M. Krumholz are at the Center for Outcomes Research and Evaluation, Yale University, New Haven, Connecticut. Dr Dharmarajan reported receiving grant support from the National Institute on Aging and the American Federation for Aging Research. Dr Krumholz reported receiving grant support from the National Heart, Lung, and Blood Institute and the Center for Cardiovascular Outcomes Research at Yale. The investigators made these remarks in an editorial accompanying Dr Duseja’s report (Ann Intern Med. 2015;162(11):793-794. doi:10.7326/M15-0878). |
“The scope of revisits to outside institutions is much greater than previously suspected, which suggests that improving communication infrastructure across institutions (such as health information exchanges) may improve care and allow individual institutions to get a more accurate picture of their revisit rates,” they noted (Ann Intern Med. 2015;162(11):750-756. doi:10.7326/M14-1616).
Revisit rates varied substantially according to diagnosis. “Skin and subcutaneous tissue infection” accounted for 23% of revisits. “Abdominal pain” was the diagnosis with the next highest revisit rate (10%). The most frequent diagnosis among patients who revisited a different hospital was back pain (2.6%), and nonspecific chest pain was the diagnosis with the
highest rate of later admission to a different hospital (1.1%).
“Financial data from the Florida facilities showed that revisits accounted for more of the total costs of ED care than initial visits did. This demonstrates that revisits are a major, and unaccounted for, component of emergency care costs,” Dr Duseja and her associates said.
Because of insufficient data, they could not determine whether these revisits reflected inadequate access to primary care, patient nonadherence to treatment recommendations, poor quality of care at the initial visit, or other factors, the researchers noted.
Cefazolin ranks sixth as cause of drug-induced liver injury
BY AMY KARON
FROM CLINICAL GASTROENTEROLOGY AND HEPATOLOGY
| A single intravenous infusion of cefazolin can cause drug-induced liver injury (DILI), and the antibiotic ranked sixth among pharmacologic causes of hepatic injury in an analysis of 1,212 patients. “Cephalosporins appear to be a relatively common cause of antibiotic-associated liver injury,” said Dr Saleh Alqahtani at the University of Texas Southwestern in Dallas and his associates. “The latency period is typically 1 to 3 weeks after exposure, and patients may not become symptomatic until after the antibiotic is stopped – this is particularly true in the unique clinical syndrome in which a single infusion of cefazolin leads to drug-induced liver injury.” |
Vitals Key clinical point: A single dose of cefazolin can cause drug-induced liver injury (DILI), and the agent is implicated more often than previously thought. Major finding: Cefazolin ranked sixth among causes of DILI, and signs and symptoms began 1 to 3 weeks after initial exposure. Data source: Registry-based study of 1,212 cases of DILI. Disclosures: The study was funded by the National Institute of Diabetes and Digestive and Kidney Diseases, the National Institutes of Health, the National Cancer Institute, and by Clinical and Translational Science Award grants. The investigators reported having no conflicts of interest. |
“Cephalosporins have been reported as rare causes of DILI, but most data come from single case reports,” the researchers said. To study causes of DILI, they analyzed cases from the Drug-Induced Livery Injury Network, an ongoing prospective study at 8 US medical centers. Enrolled patients had strong clinical suspicion for liver injury caused by a drug or an herbal agent. Liver injury was defined based on specific criteria for liver enzymes, alkaline phosphatase (ALP), or total bilirubin levels, or as an international normalized ratio greater than 1.5 that was accompanied by elevated liver enzymes or ALP. Patients were followed for at least 6 months after their baseline visit (Clin Gastroenterol Hepatol. Published January 26, 2015. doi: 10.1016/j.cgh.2015.01.010).
Among the 1,212 cases of DILI in the analysis, one-third were linked to antimicrobial therapies, including 41 (3.3%) in which cephalosporins were implicated, the investigators reported. Nineteen of the cases were tied to a single dose of intravenous cefazolin given before surgery. These patients developed cholestatic or mixed hepatocellular-cholestatic injury 1 to 3 weeks after the cefazolin infusion. They almost always had jaundice and pruritus, and usually also had fever and nausea. Signs and symptoms were self-limiting, resolving within a few days to a few weeks.
“Because of confusion about the specific diagnosis, patients underwent substantial diagnostic testing (including multiple computed tomography scans, magnetic resonance imaging scans, endoscopic retrograde cholangiopancreatography exams, liver biopsies, and others), which often were unnecessary, and in some cases led to severe complications,” the investigators said.
“The study also identified barriers to identifying cefazolin as a cause of DILI,” they said. Patients often did not know they had received the antibiotic, and clinicians, including study investigators, often did not know that cefazolin could cause DILI. In more than half of cases, DILI was linked to cefazolin only after careful medical record reviews. “For these reasons, we speculate that cefazolin is and has been underappreciated as a cause of DILI,” the researchers noted. “The appearance of jaundice and pruritus 1 to 3 weeks after minor surgery should lead to a search of surgical records and medications that might have been given during surgery. These results also imply that the merits of routine use of cefazolin at the time of uncomplicated surgery should be reconsidered carefully.”
“Two patients died after receiving cephalosporins other than cefazolin, and another patient developed severe liver injury,” the researchers said. “However, in each of the fatal cases, patients had a complicated clinical course, with a severe hypersensitivity reaction on top of an underlying liver disease. Therefore, we urge caution in concluding that non-cefazolin cephalosporin-induced DILI may be severe or fatal,” they said. “Because cephalosporins are used commonly in clinical practice, it is likely that the overall mortality rate associated with cephalosporin use is low, but not nil, and it may be more likely in patients with underlying disorders.”
The study was funded by the National Institute of Diabetes and Digestive and Kidney Diseases, the National Institutes of Health, the National Cancer Institute, and by six Clinical and Translational Science Award grants. The investigators reported having no conflicts of interest.
Pelvic CT may not be needed to diagnose intra-abdominal injury in children
BY JENNIE SMITH
FROM SAEM 2015
| San DIEGO – Children who have suffered blunt trauma are routinely screened in EDs for intra-abdominal injury (IAI) via computed tomography of the abdomen and pelvis. |
Vitals Key clinical point: Abdominal CT scans without a pelvic portion may diagnose intra-abdominal injury in children as well as do full abdominopelvic scans, with less radiation exposure to patients. Major finding: Abdominal CT alone was 85% sensitive (95% CI, 65%-96%) and 99% specific (95% CI, 97%-100%) in identifying IAIs. The four missed injuries were solid organ injuries within the radiographic abdomen. Data source: A retrospective cohort study of 313 patients aged 3 to 17 years presenting to 12 EDs. Disclosures: The study was funded by the Carolinas Trauma Network Research Center of Excellence. None of the investigators disclosed conflicts of interest. |
But concerns about excess exposure to CT radiation, particularly to the gonads, led one group of researchers to question whether it’s necessary to scan the entire abdominopelvic region in all of these patients to identify IAI.
Dr Stacy Reynolds and her colleagues at the Carolinas Medical Center in Charlotte, North Carolina, hypothesized that CT limited to the radiographic abdomen – the region between the dome of the diaphragm to the top of the iliac crest – can capture the vast majority of IAIs in this population.
At the Society for Academic Emergency Medicine annual meeting, Dr Reynolds presented results from a retrospective cohort study enrolling 313 hemodynamically stable pediatric patients (median age 14 years, 64% male) presenting to 12 EDs after blunt trauma. Patients with known pelvic fractures or hip dislocation were excluded, as they would have had a clear indication for a full abdominopelvic CT.
All subjects underwent axial abdominopelvic CT imaging. Researchers created matched pairs of images comprising the original scans and those that had been altered with software that truncated the pelvic portion of the study to create CT abdomen-only studies. Study radiologists were blinded to the results of the original scans.
In all, 26 IAI’s were diagnosed in 24 patients: 8 hepatic injuries, 12 splenic injuries, 5 renal injuries, and 1 retroperitoneal hemorrhage. Abdominal CT alone was 85% sensitive (95% CI, 65%-96%) and 99% specific (95% CI, 97%-100%) in identifying IAIs. The four missed injuries were solid organ injuries within the radiographic abdomen. False positives occurred in two of the complete scans, both involving free fluid prompting suspicion of small bowel injury later ruled out by clinical observation.
Dr Reynolds said in an interview that the findings, while promising, were limited by the study’s small numbers, and its use of axial images alone, when sagittal images also would be required for the most accurate diagnoses. Also, physician suspicion of IAI prior to imaging was not captured because of the study’s retrospective design, she said. “The real key to whether or not this hypothesis is valuable is if physicians are able to target the right population of patients for application.”
Dr Reynolds cautioned that the findings would need to be validated in a larger trial before any changes could be made to clinical practice. “Some of the outcomes that we need to make sure whether we’re missing are still rare,” she said. “You couldn’t feel confident that this is the right way to go with a study this small, but it establishes that we can safely and ethically pursue a multicenter trial that would examine the issue with bigger numbers.”
Other groups of investigators, including members of the Pediatric Emergency Care Applied Research Network (PECARN), also have taken up the question of identifying children at low risk of IAI who may not need CT screening after blunt trauma. In 2013, PECARN published a prediction rule using only patient history and physical examination findings intended to obviate use of CT in the lowest-risk patients (Ann Emerg Med. 2013;62:107-116.e2).
Dr Reynolds said that while overuse of CT was a worrisome trend that could have long-term implications for patients, and that it was important to identify ways it might be limited, there is a reason it remains the go-to technology in the ED for detecting IAI. “It’s got very high sensitivity and specificity. If you’re a busy trauma surgeon who’s admitting 20 injured patients in a night, there’s no faster or more efficient way to determine whether the patient in front of you is injured.”
The ‘sad truth’ about suicide risk assessment scales
BY BRUCE JANCIN
EXPERT ANALYSIS FROM THE ANNUAL AAS CONFERENCE
ATLANTA – “Don’t – repeat, don’t – use risk assessment tools and scales in an effort to predict future suicide in patients who’ve committed intentional self-harm,” Dr Keith Hawton urged at the annual conference of the American Association of Suicidology.
He noted this isn’t simply a matter of his personal opinion; it’s also a strongly worded recommendation in the current UK NICE (National Institute for Health and Care Excellence) guidelines on the long-term management of patients who’ve committed self-harm. The various NICE guidelines, which address numerous areas of medical practice and are used to determine what’s reimbursable through the UK’s National Health Service, are famously evidence based and concerned with cost-effectiveness.
The NICE guidelines on management of self-harm further advise: “Do not use risk assessment tools and scales to determine who should and should not be offered treatment or who should be discharged from hospital.”
“Those are some fairly contentious statements about risk assessment scales. But those statements are based upon review of the evidence about the effectiveness of risk assessment scales,” according to Dr Hawton, professor of psychiatry and director of the Centre for Suicide Research at the University of Oxford (England).
“In our country, hospitals have become obsessed with risk assessment. And usually, it seems to be about protecting the organization rather than the patient, because so often the results aren’t linked to risk management, which is what we should be talking about,” he observed.
Dr Hawton and his colleagues provided some of the evidence that led to the NICE guideline committee’s thumbs-down on the use of suicide risk assessment scales in patients who’ve engaged in intentional self-harm. In a study provocatively titled “The sad truth about the SADPERSONS scale,” he and his coinvestigators essentially dismantled SADPERSONS, a widely used screening tool for suicide risk, concluding that it is without value.
The acronym stands for Sex (male), Age (<19 or >45), Depression, Previous attempts, Ethanol abuse, Rational thinking loss, Social supports lacking, Organized plan, No spouse, and Sickness. One point is given for each. Patients who score 7-10 are to be hospitalized, and those with a total of 5 or 6 points should be strongly considered for hospitalization.
Dr Hawton and coinvestigators tracked 126 consecutive patients who were evaluated for self-harm using the SADPERSONS scale in a general hospital emergency department and then followed them for 6 months. SADPERSONS performed miserably in predicting clinical management outcomes, such as admission to a psychiatric hospital or repetition of self-harm within 6 months. Indeed, the test failed to identify 4 of the 5 patients admitted to a psychiatric hospital, 65 of 70 who were referred from the ED to community psychiatric aftercare, and 28 of 31 who repeated self-harm within 6 months. Thus, its sensitivity as a predictor of repetition of self-harm was a lowly 6.6% (Emerg Med J. 2014;31:796-798).
And yet, a 32-hospital UK national study conducted by Dr Hawton and others found that SADPERSONS was the most widely used scale in EDs for risk assessment following self-harm (BMJ Open. 2014;4(5):e004732. doi:10.1136/bmjopen-2013-004732). “It’s a very crude tool,” Dr Hawton said. “How it found its way into common use in clinical practice is beyond me.”
bjancin@frontlinemedcom.com
Three lab tests predict serious bacterial infections in infants
BY JENNIE SMITH
AT SAEM 2015
SAN DIEGO – A simple three-variable prediction rule can accurately predict which febrile infants younger than age 2 months with fever who present to the ED have serious bacterial infections. Bacterial meningitis, urinary tract infections, and bacteremia are considered serious bacterial infections; many young infants with these infections are difficult to identify, and current laboratory protocols for identifying them include urinalysis, white blood cell counts, band counts, and sometimes cerebrospinal fluid.
Vitals Key clinical point: A rule comprising three lab measurements allows for the prediction of serious bacterial infections in infants under age 2 months presenting to the ED. Major finding: Positive urinalysis, ANC of 4.09 x 1,000/mm3 or higher, and serum procalcitonin of 1.71 ng/mL or greater are between 98% and 99% sensitive in predicting SBIs. Data source: A prospective observational cohort of 1,821 infants at 21 centers forming a pediatric emergency research network. Disclosures: The study was funded by federal government grants. The authors disclosed no conflicts of interest. |
In a presentation at the annual meeting of the Society for Academic Emergency Medicine, Dr Nathan Kuppermann of the University of California, Davis, demonstrated results from a large prospective cohort study of 1,821 febrile infants 60 days old and younger conducted at 21 EDs. Infants with underlying congenital anomalies or critical illness were excluded from the study.
The investigators evaluated 8 variables as potential predictors: age, temperature, Yale Observation Scale score, and clinician suspicion of SBI, along with 4 laboratory variables (urinalysis, white blood cell count, absolute neutrophil count [ANC], and procalcitonin). Band counts were available at some, but not all of the study centers, and therefore were not evaluated.
Dr Kuppermann and his colleagues found that positive urinalysis, ANC of 4.09 x 1,000/mm3 or higher, and serum procalcitonin of 1.71 ng/mL or higher were, taken together, 98% to 99% sensitive and about 60% specific, in predicting SBI in the cohort. Negative predictive values approached 100%. The rate of SBI was 9.3% of the cohort, in keeping with expected rates.
“The SBI positive group was more likely to have higher clinician suspicion of SBI, and all of the lab markers were more elevated in the SBI positive group than the SBI negative group,” Dr Kuppermann said at the meeting. However, after the researchers considered all of the predictors as a group, only the urinalysis, the ANC, and the procalcitonin remained important. Only 3 of 1,821 (0.2%) infants with SBIs were missed when the three-variable prediction tool was used.
To make the prediction rule easier to remember and use, the investigators evaluated lower, more standard, and easier to remember thresholds for the three variables. They reanalyzed their data using a lower cutoff point for ANC of 4.00 x 1,000/mm3, and a lowered procalcitonin cutoff of 0.5 ng/mL. The rule performed almost identically as the original rule, and did not miss any more patients with SBIs beyond the original three.
Dr Kuppermann described the three-variable rule as “simple, objective, and highly accurate” in predicting or ruling out SBI. Nonetheless, it requires external validation in a large cohort, he acknowledged. He said he would continue to routinely perform lumbar punctures in infants younger than 30 days with fever until the findings could be further validated.
“But personally, in that second month of life, I would use these data to decide who actually needs a lumbar puncture and hospitalization,” he said.
Dr Kuppermann also noted as a limitation of the study that the cohort included few infants with bacterial meningitis.
ED revisits twice as frequent as expected
BY MARY ANN MOON
FROM ANNALS OF INTERNAL MEDICINE
The rate of adult revisits to EDs is more than twice as high as has been reported previously – 8% at 3 days and 20% at 30 days – in large part because until now researchers have failed to account for revisits to different hospitals, according to a report published online June 2 in Annals of Internal Medicine.
Vitals Key clinical point: Revisits to the emergency department were twice as frequent as previously reported: 8% at 3 days and 20% at 30 days. Major finding: At 3 days after an initial ED visit, the overall revisit rate was 8.2%, and at 30 days it was 20%, with one-third of these revisits occurring at a medical facility different from that of the initial visit. Data source: A longitudinal, population-based study of adult revisits to the ED after 57,530,239 initial visits in six states during 2006-2010. Disclosures: This study was supported by the US Agency for Healthcare Research and Quality. The researchers’ financial disclosures are available at www.acponline.org. |
Little is known about returns to an emergency department following an index ED visit because most studies have assessed only visits to a single institution or to hospitals within a single state or insurance plan. Now researchers have performed a broader examination of the issue by analyzing newly available multistate longitudinal data from the Healthcare Cost and Utilization Project, which allowed them to identify returns to any ED or acute-care hospital. They focused on acute-care revisits after 57,530,239 initial ED visits by adults in six states (Arizona, California, Florida, Nebraska, Utah, and Hawaii) during 2006-2010.
At 3 days after an initial ED visit, the overall revisit rate was 8.2%, with one-third of these revisits occurring at a medical facility different from that of the initial visit. Previously, estimates of 3-day revisits have ranged from 2.7% to 3.4%. At 30 days, the revisit rate was 20%, and approximately one-third of these revisits involved a different facility. Revisits to different institutions “may have special clinical and financial implications because fragmentation of care increases the likelihood of duplication of services and problems with care transitions,” said Dr Reena Duseja of the department of emergency medicine, University of California, San Francisco, and her associates.
Views on the News Highlighting an underappreciated problem The findings of Duseja et al highlight an underappreciated problem and also raise important questions. To what extent do ED revisits represent gaps in quality as opposed to reasonable strategies that prevent admissions? How often are revisits due to failures of transitional care, suboptimal patient education, or lack of timely follow-up? And why do patients so often seek care at different institutions? Are they dissatisfied with their initial encounter, exercising greater discretion in choosing a facility the second time around, or doing something else? Dr Kumar Dharmarajan and Dr Harlan M. Krumholz are at the Center for Outcomes Research and Evaluation, Yale University, New Haven, Connecticut. Dr Dharmarajan reported receiving grant support from the National Institute on Aging and the American Federation for Aging Research. Dr Krumholz reported receiving grant support from the National Heart, Lung, and Blood Institute and the Center for Cardiovascular Outcomes Research at Yale. The investigators made these remarks in an editorial accompanying Dr Duseja’s report (Ann Intern Med. 2015;162(11):793-794. doi:10.7326/M15-0878). |
“The scope of revisits to outside institutions is much greater than previously suspected, which suggests that improving communication infrastructure across institutions (such as health information exchanges) may improve care and allow individual institutions to get a more accurate picture of their revisit rates,” they noted (Ann Intern Med. 2015;162(11):750-756. doi:10.7326/M14-1616).
Revisit rates varied substantially according to diagnosis. “Skin and subcutaneous tissue infection” accounted for 23% of revisits. “Abdominal pain” was the diagnosis with the next highest revisit rate (10%). The most frequent diagnosis among patients who revisited a different hospital was back pain (2.6%), and nonspecific chest pain was the diagnosis with the
highest rate of later admission to a different hospital (1.1%).
“Financial data from the Florida facilities showed that revisits accounted for more of the total costs of ED care than initial visits did. This demonstrates that revisits are a major, and unaccounted for, component of emergency care costs,” Dr Duseja and her associates said.
Because of insufficient data, they could not determine whether these revisits reflected inadequate access to primary care, patient nonadherence to treatment recommendations, poor quality of care at the initial visit, or other factors, the researchers noted.
Cefazolin ranks sixth as cause of drug-induced liver injury
BY AMY KARON
FROM CLINICAL GASTROENTEROLOGY AND HEPATOLOGY
| A single intravenous infusion of cefazolin can cause drug-induced liver injury (DILI), and the antibiotic ranked sixth among pharmacologic causes of hepatic injury in an analysis of 1,212 patients. “Cephalosporins appear to be a relatively common cause of antibiotic-associated liver injury,” said Dr Saleh Alqahtani at the University of Texas Southwestern in Dallas and his associates. “The latency period is typically 1 to 3 weeks after exposure, and patients may not become symptomatic until after the antibiotic is stopped – this is particularly true in the unique clinical syndrome in which a single infusion of cefazolin leads to drug-induced liver injury.” |
Vitals Key clinical point: A single dose of cefazolin can cause drug-induced liver injury (DILI), and the agent is implicated more often than previously thought. Major finding: Cefazolin ranked sixth among causes of DILI, and signs and symptoms began 1 to 3 weeks after initial exposure. Data source: Registry-based study of 1,212 cases of DILI. Disclosures: The study was funded by the National Institute of Diabetes and Digestive and Kidney Diseases, the National Institutes of Health, the National Cancer Institute, and by Clinical and Translational Science Award grants. The investigators reported having no conflicts of interest. |
“Cephalosporins have been reported as rare causes of DILI, but most data come from single case reports,” the researchers said. To study causes of DILI, they analyzed cases from the Drug-Induced Livery Injury Network, an ongoing prospective study at 8 US medical centers. Enrolled patients had strong clinical suspicion for liver injury caused by a drug or an herbal agent. Liver injury was defined based on specific criteria for liver enzymes, alkaline phosphatase (ALP), or total bilirubin levels, or as an international normalized ratio greater than 1.5 that was accompanied by elevated liver enzymes or ALP. Patients were followed for at least 6 months after their baseline visit (Clin Gastroenterol Hepatol. Published January 26, 2015. doi: 10.1016/j.cgh.2015.01.010).
Among the 1,212 cases of DILI in the analysis, one-third were linked to antimicrobial therapies, including 41 (3.3%) in which cephalosporins were implicated, the investigators reported. Nineteen of the cases were tied to a single dose of intravenous cefazolin given before surgery. These patients developed cholestatic or mixed hepatocellular-cholestatic injury 1 to 3 weeks after the cefazolin infusion. They almost always had jaundice and pruritus, and usually also had fever and nausea. Signs and symptoms were self-limiting, resolving within a few days to a few weeks.
“Because of confusion about the specific diagnosis, patients underwent substantial diagnostic testing (including multiple computed tomography scans, magnetic resonance imaging scans, endoscopic retrograde cholangiopancreatography exams, liver biopsies, and others), which often were unnecessary, and in some cases led to severe complications,” the investigators said.
“The study also identified barriers to identifying cefazolin as a cause of DILI,” they said. Patients often did not know they had received the antibiotic, and clinicians, including study investigators, often did not know that cefazolin could cause DILI. In more than half of cases, DILI was linked to cefazolin only after careful medical record reviews. “For these reasons, we speculate that cefazolin is and has been underappreciated as a cause of DILI,” the researchers noted. “The appearance of jaundice and pruritus 1 to 3 weeks after minor surgery should lead to a search of surgical records and medications that might have been given during surgery. These results also imply that the merits of routine use of cefazolin at the time of uncomplicated surgery should be reconsidered carefully.”
“Two patients died after receiving cephalosporins other than cefazolin, and another patient developed severe liver injury,” the researchers said. “However, in each of the fatal cases, patients had a complicated clinical course, with a severe hypersensitivity reaction on top of an underlying liver disease. Therefore, we urge caution in concluding that non-cefazolin cephalosporin-induced DILI may be severe or fatal,” they said. “Because cephalosporins are used commonly in clinical practice, it is likely that the overall mortality rate associated with cephalosporin use is low, but not nil, and it may be more likely in patients with underlying disorders.”
The study was funded by the National Institute of Diabetes and Digestive and Kidney Diseases, the National Institutes of Health, the National Cancer Institute, and by six Clinical and Translational Science Award grants. The investigators reported having no conflicts of interest.
Pelvic CT may not be needed to diagnose intra-abdominal injury in children
BY JENNIE SMITH
FROM SAEM 2015
| San DIEGO – Children who have suffered blunt trauma are routinely screened in EDs for intra-abdominal injury (IAI) via computed tomography of the abdomen and pelvis. |
Vitals Key clinical point: Abdominal CT scans without a pelvic portion may diagnose intra-abdominal injury in children as well as do full abdominopelvic scans, with less radiation exposure to patients. Major finding: Abdominal CT alone was 85% sensitive (95% CI, 65%-96%) and 99% specific (95% CI, 97%-100%) in identifying IAIs. The four missed injuries were solid organ injuries within the radiographic abdomen. Data source: A retrospective cohort study of 313 patients aged 3 to 17 years presenting to 12 EDs. Disclosures: The study was funded by the Carolinas Trauma Network Research Center of Excellence. None of the investigators disclosed conflicts of interest. |
But concerns about excess exposure to CT radiation, particularly to the gonads, led one group of researchers to question whether it’s necessary to scan the entire abdominopelvic region in all of these patients to identify IAI.
Dr Stacy Reynolds and her colleagues at the Carolinas Medical Center in Charlotte, North Carolina, hypothesized that CT limited to the radiographic abdomen – the region between the dome of the diaphragm to the top of the iliac crest – can capture the vast majority of IAIs in this population.
At the Society for Academic Emergency Medicine annual meeting, Dr Reynolds presented results from a retrospective cohort study enrolling 313 hemodynamically stable pediatric patients (median age 14 years, 64% male) presenting to 12 EDs after blunt trauma. Patients with known pelvic fractures or hip dislocation were excluded, as they would have had a clear indication for a full abdominopelvic CT.
All subjects underwent axial abdominopelvic CT imaging. Researchers created matched pairs of images comprising the original scans and those that had been altered with software that truncated the pelvic portion of the study to create CT abdomen-only studies. Study radiologists were blinded to the results of the original scans.
In all, 26 IAI’s were diagnosed in 24 patients: 8 hepatic injuries, 12 splenic injuries, 5 renal injuries, and 1 retroperitoneal hemorrhage. Abdominal CT alone was 85% sensitive (95% CI, 65%-96%) and 99% specific (95% CI, 97%-100%) in identifying IAIs. The four missed injuries were solid organ injuries within the radiographic abdomen. False positives occurred in two of the complete scans, both involving free fluid prompting suspicion of small bowel injury later ruled out by clinical observation.
Dr Reynolds said in an interview that the findings, while promising, were limited by the study’s small numbers, and its use of axial images alone, when sagittal images also would be required for the most accurate diagnoses. Also, physician suspicion of IAI prior to imaging was not captured because of the study’s retrospective design, she said. “The real key to whether or not this hypothesis is valuable is if physicians are able to target the right population of patients for application.”
Dr Reynolds cautioned that the findings would need to be validated in a larger trial before any changes could be made to clinical practice. “Some of the outcomes that we need to make sure whether we’re missing are still rare,” she said. “You couldn’t feel confident that this is the right way to go with a study this small, but it establishes that we can safely and ethically pursue a multicenter trial that would examine the issue with bigger numbers.”
Other groups of investigators, including members of the Pediatric Emergency Care Applied Research Network (PECARN), also have taken up the question of identifying children at low risk of IAI who may not need CT screening after blunt trauma. In 2013, PECARN published a prediction rule using only patient history and physical examination findings intended to obviate use of CT in the lowest-risk patients (Ann Emerg Med. 2013;62:107-116.e2).
Dr Reynolds said that while overuse of CT was a worrisome trend that could have long-term implications for patients, and that it was important to identify ways it might be limited, there is a reason it remains the go-to technology in the ED for detecting IAI. “It’s got very high sensitivity and specificity. If you’re a busy trauma surgeon who’s admitting 20 injured patients in a night, there’s no faster or more efficient way to determine whether the patient in front of you is injured.”
The ‘sad truth’ about suicide risk assessment scales
BY BRUCE JANCIN
EXPERT ANALYSIS FROM THE ANNUAL AAS CONFERENCE
ATLANTA – “Don’t – repeat, don’t – use risk assessment tools and scales in an effort to predict future suicide in patients who’ve committed intentional self-harm,” Dr Keith Hawton urged at the annual conference of the American Association of Suicidology.
He noted this isn’t simply a matter of his personal opinion; it’s also a strongly worded recommendation in the current UK NICE (National Institute for Health and Care Excellence) guidelines on the long-term management of patients who’ve committed self-harm. The various NICE guidelines, which address numerous areas of medical practice and are used to determine what’s reimbursable through the UK’s National Health Service, are famously evidence based and concerned with cost-effectiveness.
The NICE guidelines on management of self-harm further advise: “Do not use risk assessment tools and scales to determine who should and should not be offered treatment or who should be discharged from hospital.”
“Those are some fairly contentious statements about risk assessment scales. But those statements are based upon review of the evidence about the effectiveness of risk assessment scales,” according to Dr Hawton, professor of psychiatry and director of the Centre for Suicide Research at the University of Oxford (England).
“In our country, hospitals have become obsessed with risk assessment. And usually, it seems to be about protecting the organization rather than the patient, because so often the results aren’t linked to risk management, which is what we should be talking about,” he observed.
Dr Hawton and his colleagues provided some of the evidence that led to the NICE guideline committee’s thumbs-down on the use of suicide risk assessment scales in patients who’ve engaged in intentional self-harm. In a study provocatively titled “The sad truth about the SADPERSONS scale,” he and his coinvestigators essentially dismantled SADPERSONS, a widely used screening tool for suicide risk, concluding that it is without value.
The acronym stands for Sex (male), Age (<19 or >45), Depression, Previous attempts, Ethanol abuse, Rational thinking loss, Social supports lacking, Organized plan, No spouse, and Sickness. One point is given for each. Patients who score 7-10 are to be hospitalized, and those with a total of 5 or 6 points should be strongly considered for hospitalization.
Dr Hawton and coinvestigators tracked 126 consecutive patients who were evaluated for self-harm using the SADPERSONS scale in a general hospital emergency department and then followed them for 6 months. SADPERSONS performed miserably in predicting clinical management outcomes, such as admission to a psychiatric hospital or repetition of self-harm within 6 months. Indeed, the test failed to identify 4 of the 5 patients admitted to a psychiatric hospital, 65 of 70 who were referred from the ED to community psychiatric aftercare, and 28 of 31 who repeated self-harm within 6 months. Thus, its sensitivity as a predictor of repetition of self-harm was a lowly 6.6% (Emerg Med J. 2014;31:796-798).
And yet, a 32-hospital UK national study conducted by Dr Hawton and others found that SADPERSONS was the most widely used scale in EDs for risk assessment following self-harm (BMJ Open. 2014;4(5):e004732. doi:10.1136/bmjopen-2013-004732). “It’s a very crude tool,” Dr Hawton said. “How it found its way into common use in clinical practice is beyond me.”
bjancin@frontlinemedcom.com
