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The Top 10 Most Important Articles of 2016 (and some from 2015)

This is a summary of a talk given by Drs. Krishan Yadav and Maggie Kisilewicz at the National Capital Conference in Emergency Medicine. Below are brief summaries and a bottom line, but of course you'll have to read the literature yourself to make your own decisions!

1) Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage ATACH-2 

Qureshi et al. N Engl J Med 2016; 375: 1033 – 1043.
DOI: 10.1056/NEJMoa1603460.

• RCT to assess if aggressive SBP reduction within 4.5 hours of spontaneous intracranial hemorrhage results in decreased death or disability at 3 months.
• Main Finding: No difference in death or disability at 3 months for Intensive BP (110 – 139 mmHg) vs. Standard BP (140 – 179 mmHg) group.
o Caution: this trial really compared SBP targets of 129 mmHg vs. 141 mmHg (see Figure 1)

• Bottom Line: BP reduction to 140 mmHg is safe. Aim for a SBP target of 160 mmHg in 
spontaneous ICH – if the patient continues to deteriorate, revise target to 140 mmHg.

2) An Age-Adjusted D-dimer Threshold of Emergency Department patients with Suspected Pulmonary Embolus: Accuracy and Clinical Implications. 

Sharp et al. Ann Emerg Med. 2016 Feb;67(2):249-57. 
DOI: 10.1016/j.annemergmed.2015.07.026

• Retrospective chart review to assess the sensitivity and specificity of using an age-adjusted D-dimer threshold to aid in diagnosing PE in patients 50 years or older.
• Main Finding: In older adults, the age-adjusted D-dimer threshold is more accurate. It is more specific (64% versus 54%) but less sensitive (93% versus 98%) than the standard threshold of 500 ng/dL resulting in less low value imaging.

• Bottom Line: Start using age adjusted D-dimer to evaluate older adults suspected of PE.

3) Discharge Glucose Is Not Associated With Short-Term Adverse Outcomes in Emergency Department Patients With Moderate to Severe Hyperglycemia. 

Driver et al. Ann Emerg Med. 2016 December; 68(6): 697-705.

• Retrospective cohort study to determine if ED patients with moderate to severe hyperglycemia suffer adverse outcomes at 7 days (return to ED, admission, DKA, or HHS)
• Main Finding: could not find any association between discharge glucose level or treating hyperglycemia (IVF +/- insulin) and 7-day adverse events
o Caution: consider correcting hyperglycemia in the patient being discharged with an infection

• Bottom Line: in uncomplicated hyperglycemia (no DKA/HHS or infection), do not administer IVF or insulin to lower blood glucose to an arbitrary ‘safe’ level. Instead, focus on ensuring appropriate follow-up for long-term glycemic control.

4) Air Versus Oxygen in ST-Segment–Elevation Myocardial Infarction. 

Stub D. et al. Circulation. 2015 Jun16;131(24):2143-50. 
DOI: 0.1161/CIRCULATIONAHA.114.014494.

• Multicenter RCT to determine if administering air or supplemental oxygen to normoxic STEMI patients undergoing PCI affected infarct size as assessed by cardiac enzyme rise and by cardiac MRI 6 months post infarct.
• Main Finding: Supplemental oxygen resulted in statistically higher peak creatinine kinase but not troponin-I. After 6 months, patients receiving supplemental oxygen had larger areas of infarct on cMRI. There was statistical increase in the rates of re-infarction and arrhythmias in patients receiving oxygen, however the study was not powered for these clinical end-points.

• Bottom Line: Supplemental oxygen administered to normoxic STEMI patients has not shown to be beneficial and may, in fact, increase myocardial injury

5) Randomized Clinical Trial of Observation versus Antibiotic Treatment for a First Episode of CT Proven Uncomplicated Acute Diverticulitis (DIABOLO). 

Daniels et al. Br J Surg 2016; 104: 52 – 61.
DOI: 10.1002/bjs.10309.

• Multicenter RCT to determine if antibiotics versus observation leads to decreased time to recovery during 6 months of follow-up.
• Main Finding: antibiotics did not improve time to recovery for first-episode uncomplicated diverticulitis. In addition, there was no benefit for multiple secondary outcomes (readmission rates, development of complicated diverticulitis, need for surgery)
o Caution: 8% of trial participants had an abscess < 5 cm; these patients should still get antibiotics

• Bottom Line: Use shared decision making with carefully selected patients (can get GP follow-up, tolerating PO intake, no fever) regarding outpatient antibiotics for uncomplicated diverticulitis.

6) Characteristics and Outcomes of Patients Presenting With Hypertensive Urgency in the Office Setting. 

Patel et al. JAMA Intern Med. 2016 Jul 1;176(7):981-8. 

• Retrospective cohort looking at whether hospital referral is safer than routine outpatient management for ambulatory patients with asymptomatic hypertension (>180/100).
• Main Finding: In this study of 58 535 patients, emergency department visits for hypertensive urgency were associated with higher rates of hospital admission but not major cardiac events when compared with patients who were sent home. The rate of major adverse cardiac events was less than 1% in all patients. Two-thirds of patients still had uncontrolled hypertension at 6 months.

• Bottom Line: ED visits for hypertensive urgency are associated with more resource utilization but not better CV outcomes.

7) Immediate Total-Body CT Scanning Versus Conventional Imaging and Selective CT Scanning in Patients with Severe Trauma (REACT-2): A Randomized Controlled Trial. 

Sierink et al. Lancet 2016; 388(10045): 673 – 683. 
DOI: 10.1016/S0140-6736(16)30932-1.

• Published data to date suggests pan-can is associated with improved survival – but all studies have been retrospective. This is the first RCT to determine if pan-scan for trauma is associated with decreased in-hospital mortality.
• Main Finding: No difference between pan-scan versus selective-scan groups for in-hospital mortality.
o Caution: 46% of patients in selective-scan group ended up with the equivalent of a pan-scan during hospital stay

• Bottom Line: There is still no consensus on which trauma patients actually benefit from a pan-scan.

8) Immediate Discharge and Home Treatment With Rivaroxaban of Low Risk Venous Thromboembolism Diagnosed in Two U.S. Emergency Departments: A One-year Preplanned Analysis. 

Beam et al. Acad Emerg Med. 2015 Jul;22(7):788-95. 
DOI: 10.1111/acem.12711.

• In this prospective observational study, 106 low-risk PE and DVT patients were started on rivaroxaban and sent home directly from the ED. Outpatient clinic follow up occurred within 36h of discharge. Outcomes included VTE recurrence, bleeding complications and medication compliance over a 6 month period. Patient and physician satisfaction was not measured.
• Main Findings: No patients developed recurrent or new VTE while on treatment and there were no major bleeding events. Overall patient compliance was 92%.

• Bottom Line: Selected low-risk patients diagnosed with VTE can be safely started on DOAC therapy and discharged from the ED to close outpatient follow up.

9) A randomized trial of intraarterial treatment for acute ischemic stroke. 

Berhamer et al. N Engl J Med. 2015 Jan 1;372(1):11-20. 
DOI: 10.1056/NEJMoa1411587.

• In this pragmatic, multicenter RCT, 500 patients with disabling ischemic stroke localized to the anterior circulation artery were randomized to intra-arterial treatment plus usual care or usual care alone.
• Main Finding: Absolute difference of 13.5 percentage points in good neurologic outcome (modified Rankin Score 0 – 2) favouring the intervention group. This corresponds to an NNT = 8. No increase in mortality or symptomatic ICH was seen.

• Bottom Line: Intra-arterial therapy within 6 hours of symptom onset improved functional independence at 90days.

10) Prevalence of Pulmonary Embolism Among Patients Hospitalized for Syncope (PESIT). 

Prandoni et al. N Engl J Med 2016; 375: 1542 – 1531.
DOI: 10.1056/NEJMoa1602172.

• Cross-sectional multicenter study to determine the prevalence of pulmonary embolism (PE) among patients hospitalized for syncope.
• Main Finding: overall prevalence for PE = 17.3% (“approximately 1 in 6 patients hospitalized for syncope had a PE”)
o Caution: cause and effect not established. This does not mean 1 in 6 patients had syncope because of a PE.

• Bottom Line: Do not change current clinical practice. Patients with syncope should be worked up for PE when it is felt to be clinically warranted.


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