Acetaminophen in Pregnancy, HD for Methanol, Risk Score for Rhabdo

Dr. Bob Hoffman was our guest during our last Journal Club, on 1/7/15, and it was great.  Dr. Hoffman had some great insight.

First Article:
http://www.ncbi.nlm.nih.gov/pubmed/24566677
Acetaminophen use during pregnancy, behavioral problems, and hyperkinetic disorders.
Bottom Line: This is a really well done study done in Denmark.  There's no way this study could have been done in the US, we don't have the medical infrastructure to pull it off.  This was in the media a lot, and led many to question the role of acetaminophen for pain and/or fever relief in pregnancy.  In short, the conclusion was that there is an association between acetaminophen use in pregnancy and ADHD by age 7.  This was an observational study, and in no way implies causation.  It is, however, provocative and will likely prompt more research.  Not practice changing, though.  Pregnant women should still use acetaminophen until convincing data states otherwise.

Second Article:
http://www.ncbi.nlm.nih.gov/pubmed/24000014
A risk prediction score for kidney failure or mortality in rhabdomyolysis.
Bottom Line: The authors of this study derived and validated a risk prediction score for mortality and renal failure in patients with rhabdomyolysis using retrospective data.  Not a bad tool for predicting risk in patients that are to be admitted for rhabdomyolysis.  Not reasonable to use, however, for the young athletic patient with a little CK elevation but otherwise normal renal function and labs that you indistinctly know will do well on discharge.  This tool was not derived on outpatients, and should not be used to justify a discharge - the lowest possible risk using this tool is like 1.6% for the primary outcome, anyway.  And, who wants to put that in a chart?

Third Article:
http://www.ncbi.nlm.nih.gov/pubmed/24621917
Intermittent hemodialysis is superior to continuous veno-venous hemodialysis/hemodiafiltration to eliminate methanol and formate during treatment for methanol poisoning.
Bottom Line: You have to accept that the surrogate marker of elimination half life leads to better outcomes.  Once you do, then you'll accept the findings.  Basically, intermittent HD is better at elimination methanol and the deleterious byproduct formate.  If unable to use intermittent HD (possibly for hemodynamic reasons), and continuous dialysis is chosen, then two factors matter in terms of methanol and formate elimination - the dialysate flow rate, and the membrane surface.

BP in Sepsis, Abx for COPD, and Fever in SSD

We had our last Journal Club on September 17, and it was great.  Much great discussion.

First Article:
http://www.ncbi.nlm.nih.gov/pubmed/22923662
Efficacy of antibiotic therapy for acute exacerbations of mild to moderate chronic obstructive pulmonary disease.
Bottom Line: Antibiotics may be useful in mild to moderate COPD exacerbations; whereas we already know it's beneficial (mortality benefit) in severe COPD.  Gerenalizability is limited by choice of antibiotics, and infrequent use of steroids.

Second Article:
http://www.ncbi.nlm.nih.gov/pubmed/24635770
High versus low blood-pressure target in patients with septic shock.
Bottom Line: This is a good one that was overshadowed by the Process Trial.  No benefit for MAP goal of 85 vs 65.  However, in patient's with hypertension, the high target group required less renal replacement therapy.  So, you may consider a higher target in those with chronic hypertension, but no strong, compelling evidence to do so.  Also, probably doesn't matter in the ED.

Third Article:
http://www.ncbi.nlm.nih.gov/pubmed/23669523
Bacteremia risk and outpatient management of febrile patients with sickle cell disease.
Bottom Line: In pediatric patients with good follow up, it is safe to discharge a febrile sickle cell patient after a shot of ceftriaxone - less than 1% of these patients had bacteremia.  I think the key here is that this was Boston Children's, and they all had good follow up.  So, if that's your scenario, discharge away (unless they look ill, of course).  Great comment from one of our community docs - "I've never gone home and thought dang, I wish I wouldn't have given that rocephin."

52 Articles 2014

Here's my attempt at 52 articles in 52 weeks.  Our residency will be reading all of these over the next year.  Disclaimer: subject to change.

Airway	Preoxygenation and prevention of desaturation during emergency airway management.	Weingart SD	2012	Ann Emerg Med	PubMed
Airway	The importance of first pass success when performing orotracheal intubation in the emergency department.	Sakles JC	2013	Acad Emerg Med	PubMed
Airway	Does end-tidal carbon dioxide monitoring detect respiratory events prior to current sedation monitoring practices?	Burton JH	2006	Acad Emerg Med	PubMed

NOAC Reversal

Ok, we all know warfarin sucks.  Patients hate it because it has to be monitored, and if they eat too many collard greens or you prescribe bactrim or cipro they're going to bleed and die.  Invariably, we've all had the patient with hematuria and an INR of 10, but totally stable and with a normal hematocrit.  You consult "the chart" on uptodate and end up more confused.  So, you make something up...um...let's stop taking the warfarin for the next two days, and decrease your dose from 5 mg to 4 mg...and, um...here's 2.5 mg of vitamin K...now, go check in at your coumadin clinic...

Lane's Top Ten

I can't claim credit for this, but Lane Blankenship recently gave his Senior Grand Rounds, and it was excellent!  Here are his top ten articles:

Transfusion Strategies in UGIB

Villanueva C, et al.  Transfusion Strategies for Acute Upper Gastrointestinal Bleeding.  2013 Jan 3;368(1):11-21.
Recently, I presented the landmark article for promoting a restrictive transfusion strategy in upper GI bleeding (UGIB) at our journal club.  I spent a fair amount of time researching the background to this study.  Suffice it to say, there's been a lot of nerds manufacturing non-evidenced based guidelines for decades regarding this issue.  They usually met in Italy, so I can understand the draw to convene.  This study aimed to set the record straight on transfusion strategy for undifferentiated UGIB.