- Light Exercise and mTBI
- Asymptomatic Hypertension—What’s the Risk?
- Racial Factors in Pain Treatment
- Supplemental Oxygen in ACS
- Shorter Courses of Antibiotics for Pediatric CAP
- Who’s Behind that COVID-19 Mask?
- COVID-19 Infection in Healthcare Workers
Light Exercise for Patients with Mild Traumatic Brain Injury (mTBI)
Take-home point: There is no benefit for recovery in patients with mTBI randomized to light exercise compared with standard care.
Citation: Varner C, Thompson C, de Wit K, et al. A randomized trial comparing prescribed light exercise to standard management for emergency department patients with acute mild traumatic brain injury. Acad Emerg Med. January 22 201. [Epub ahead of print]
Relevance: Evidence for postconcussion recommendations has been rapidly evolving, especially with regard to the role of physical activity.
Study summary: This was a multicenter, randomized controlled trial conducted in three tertiary care EDs in Ontario, Canada. Adults who sustained a mTBI in the 48 hours prior to presentation were eligible for enrollment. The enrolled participants’ baseline function was assessed using the Rivermead Post-concussion Symptom Questionnaire (RPQ). Patients were then randomized to 30 minutes of light exercise (ie, walking) daily (intervention group) or graduated return to usual activities with cognitive rest (control group).
A total of 367 patients were initially enrolled into the study, with 241 patients completing the 30-day follow-up protocol (115 intervention, 126 control). The authors found no difference in the proportion of patients with postconcussion syndrome between the groups (13.4% intervention vs 14.6% control) and no difference in the median change of RPQ scores (13 intervention vs 14 control).
Limitation: Many patients were lost to follow-up in the study. The study design precluded blinding.
Incidental Asymptomatic Hypertension
Take-home point: Patients with asymptomatically elevated blood pressure do not appear to be at a significantly elevated risk of adverse events in subsequent months and years.
Citation: McAlister FA, Youngson E, Howe BH. Elevated blood pressures are common in the emergency department but are they important? A retrospective cohort study of 30,278 adults. Ann Emerg Med. 2021;7 7(4):425-432.
Relevance: The incidental finding of asymptomatic hypertension among patients in the urgent care and emergency settings presents an extremely common clinical dilemma. This study suggests that this finding likely demands no urgent or immediate management.
Study summary: This was a retrospective cohort study of all patients presenting to the University of Alberta (Canada) Hospital ED. The authors analyzed data from 30,278 consecutive patients that presented to the ED and who were ultimately discharged home. The authors found that 48.6% of patients had a BP of >140/90 mmHg and that 72.9% of this group did not have a known history of hypertension. Among these patients, the most common chief complaints were trauma (25.7%), followed by abdominal symptoms (12.6%), and chest pain (11.1%).
Of the patients with an elevated blood pressure reading without a known history of hypertension, 65.8% were treated within a month in an outpatient setting. Patients with BP measurements of ≥160/100 without a history of hypertension were only slightly more likely to suffer stroke, transient ischemic attack (TIA), acute coronary syndrome (ACS), heart failure, or death in the subsequent year (3.3% vs 2.5%) or 2 years (5.9% vs 3.8%) than those without. Most importantly, this difference was no longer significant after adjusting for patient age, gender, and comorbidities.
Limitation: This was a single-center study with retrospective design. Admitted patients were not included in the analysis.
Does Patient Race Affect How We Treat Pain?
Take-home point: African American and Hispanic patients with renal colic received significantly lower doses of opioids than White patients.
Citation: Berger A, Wang Y, Rowe C, et al. Racial disparities in analgesic use amongst patients presenting to the emergency department for kidney stones in the United States. Am J Emerg Med. 2021;39:71–74.
Relevance: Disparate treatment of pain due to racial bias may be an underappreciated social determinant of health (SDH).
Study summary: This was a retrospective review of 266,210 ED patients presenting for renal colic from the Premier Hospital Database (which accounts for 20% of total hospitals in the U.S.). Patient data analyzed included age, gender, insurance status (Medicare, Medicaid, private, or other/unknown) and substance-use history. Race and/or ethnicity was categorized as White, Black, or Hispanic. Patients of unknown race/ethnicity were excluded.
The authors found that White patients received the highest total doses of opioid: 3.3 mg more morphine mg equivalents (MME) than Black patients and 6.0 mg more MME than Hispanic patients. Black patients were less likely to receive ketorolac but there was no difference in ketorolac administration between Whites and Hispanics. Racial and ethnic differences in the cohort persisted even when controlling for regional and urban/rural variations, insurance type, hospital size, teaching hospital status, age, and history of substance abuse.
Limitation: The patients included in the analysis were predominantly White (84%) and only 6% were Black. Administrative data retrospectively evaluated are subject to multiple forms of bias.
High-Flow Oxygen in Patients with Suspected Acute Coronary Syndrome (ACS)
Take-home point: Patients with suspected ACS and normal saturation levels are unlikely to benefit from supplemental oxygen therapy.
Citation: Stewart R, Jones P, Dicker B, et al. High flow oxygen and risk of mortality in patients with suspected acute coronary syndrome: pragmatic, cluster randomized, crossover trial. BMJ. 2021;372:n355.
Relevance: Current guidelines recommend supplementary oxygen for patients with suspected ACS only in the setting of low SpO2 levels. This study investigates the effects administering high-flow oxygen to patients with suspected ACS and normal SpO2.
Study summary: This was a cluster randomized, pragmatic, crossover trial of all patients with suspected ACS treated by the ambulance service in New Zealand and patients that were included in the All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACSQI) Registry. A total of 40,872 patients with suspected or confirmed ACS were enrolled, with 20,304 in the high-oxygen and 20,568 in the low-oxygen group. Patients were randomized to a high-oxygen group that received oxygen with a flow of 6-8 L/min by face mask, irrespective of SpO2. The patients randomized to low oxygen had nasal cannula oxygen flow rate titrated to maintain saturations at 90%-94%.
The authors found neither benefit nor harm in the use of high-flow oxygen as part of routine care in patients presenting with suspected ACS. There was no significant difference found in mortality rates for patients with a final diagnosis of unstable angina, STEMI, or NSTEMI in either group.
Limitation: Study protocol pooling of patients meant that many patients included in the analysis did not have ischemic symptoms when seen.
Shorter Courses of Antibiotics for Pediatric Community-Acquired Pneumonia (CAP)
Take-home point: A 5-day course of antibiotics is as effective as 10 days for the outpatient treatment of CAP in children.
Relevance: Antibiotic stewardship is a key part of prescribing practice within urgent care. The ability to prescribe shorter courses will ensure better compliance and reduce the risk of antimicrobial resistance and adverse reactions.
Study summary: This was a dual-centerd, blinded, noninferiority RCT conducted in Ontario, Canada. Patients aged 6 months to 10 years with CAP not requiring hospital admission were enrolled into the study. Patients were randomized equally to receive either 10 days of amoxicillin or 5 days of amoxicillin followed by 5 days of placebo tablets. The primary outcome for this study was clinical cure at 14 to 21 days postenrollment.
Two hundred eighty-one previously healthy pediatric patients were enrolled into the study, with a total of 126 included in each group for final analysis. The authors found that short-course antibiotic prescribing was noninferior to 10 days of therapy. Additionally, caregivers for the patients with the short-course group reported significantly less absenteeism from work than the caregivers of the standard course group.
Limitation: Most pediatric pneumonia is viral in etiology. The authors acknowledge that they could not definitively establish bacterial infection in the enrolled participants. Ten percent of subjects were lost to follow-up.
COVID-19 Literature Reviews
Mask Use and Masked Facial Expressions
Take-home point: Clear masks improve perceptions of physician-patient communication.
Citation: Kraztke I, Rosenbaum M, Cox C et. al. Effect of clear vs standard covered masks on communication with patients during surgical clinic encounters: a randomized clinical trial. JAMA Surg. March 11, 2021. [Epub ahead of print]
Relevance: With clinician mask use during the COVID-19 pandemic, limiting barriers for physician-patient interactions is more critical than ever.
Study summary: This was a single-center randomized trial in the southern U.S. Fifteen surgeons were randomly assigned to wearing a standard surgical mask or a clear mask with equivalent protection. A survey adapted from the Clinician and Group Assessment of Healthcare Providers and Systems was used to measure the quality of communication in physician─patient interactions. Two hundred patients were enrolled and divided equally between consultations with clear vs standard surgical masks. The authors found that patients in the clear mask group had significantly more positive responses (99%) compared with those in the standard mask group (85%). Similarly, patients in the clear mask group trusted the surgeon’s decisions more frequently (94% vs 72%). Patients perceived higher surgeon empathy in the clear mask group, as well.
Limitation: This was a single-center study and examined only surgeons’ interactions with patients. It is unclear if this would be generalizable to other regions and/or specialties.
Infection Among Healthcare Workers with COVID-19
Take-home point: COVID-19 infection in healthcare workers (HCWs) does not appear to be linked to workplace factors, including roles, environment, or contact with COVID-19 patients
Relevance: Protection of HCWs encountering COVID-19 in the workplace is crucial for their health and wellbeing, as well as function of the healthcare system.
Study summary: This was an infection prevention screening program assessing seroprevalence of COVID-19 in HCWs from a large health care system affiliated with four Prevention Epicenters in Atlanta, (Emory Healthcare), Baltimore, (Johns Hopkins Medicine and University of Maryland Medical System), and Chicago (Rush University System). All badged HCWs were eligible to participate in a voluntary serological survey. The serological test used met the U.S. FDA emergency use criteria, and all measured immunoglobin G (IgG).
The final analysis included 24,749 participants. Most HCWs reported working predominantly in acute care hospitals (87.1%), with smaller proportions working in ambulatory settings (5.3%) or long-term care or inpatient rehabilitation facilities (2.5%). Nurses constituted the most common role among the participants (31.6%) and half of the participants reported caring for patients with COVID-19.
The authors found a low seroprevalence (4.4%) of SARS CoV-2 IgG among HCWs across multiple, geographically diverse health care systems. There was no clear association between workplace contact with patients with COVID-19 and antibody positivity. They also noted that the higher the cumulative community incidence of COVID-19 in the weeks prior to the antibody testing, the higher the risk of the HCW being antibody positive. Therefore, community contact with COVID-19 was most associated with an increased the risk of seropositivity among these HCWs.
Limitation: This study used a convenience sample leading. The authors were also unable to analyze the risk associated with specific activities, such as aerosol-generating procedures based on the lack of granularity in the demographics data.