http://www.nejm.org/doi/pdf/10.1056/NEJMcp064645
A hat tip to Dr. Fuller for an excellent summary article in the New England Journal of Medicine on concussions. While slightly dated at 2007, I have not seen an updated NEJM article on this topic. Please correct me if my search was myopic. For those of you who dislike the NEJM, I do encourage the summary "clinical practice" articles, as they have more a "real world", non-academic, "in the trenches" utility for practitioners like ourselves.
The article can speak for itself, but I would offer the following caveats:
- Special focus should be on Table 1, and be sure to read ALL of the footnotes! Note that the New Orleans criteria has higher sensitivity (in other words, you are less likely to miss an important CT abnormality or a lesion needing neurosurgery) than the Canadian CT Head Rule.
-Note that the Canadian rule excluded children under 16, and as such is invalid for pediatrics.
-Remember that these are screening tests, so the sensitivity should be HIGH, but the specificity should be very LOW. As such, note that even when these rules are met and a CT is performed, a significant issue is present only 5% of the time.
-Woe to all who work in the Express Care New Year's Day. Be very aware that the rules do not apply to intoxicated patients, and remember that if the injury occurred while intoxicated your history is very compromised, to put it nicely.
-The article mentions that the old habit of "waking a person up in the middle of the night" to check on lethargy has not been established. However, if one is concerned enough to ask the family to do this, then one should likely consider going on and getting the CT. Reminds one of the old maxim, "if you think a patient may need intubation, then you probably should have intubated 5 minutes ago."
- In the real world, note that the New Orleans criteria says that if someone has a head injury and is over 60, then since one criteria is met (age over 60), that warrants a CT scan. That is a lot of CT scans (and probably a lot of AMA forms), but that is the price of making the lawyers happy with 99% sensitivity.
Lastly, I think the major reminder here is to be sure to give the patient clear, WRITTEN DISCHARGE INSTRUCTIONS that explains the major symptoms to watch for and the need for urgent emergency room evaluation via 911 or someone else driving. No clinical imaging rule is 100%. The best combo is a well applied, prudent clinical rule and clear, written discharge instructions.
Again, the article is a classic, and please comment below, link, or email me if someone has newer criteria.
Friday, September 7, 2012
"Dogma" is "Am God" Spelled Backwards...
http://www.sciencedirect.com/science/article/pii/S1551714412002030
http://www.nejm.org/doi/full/10.1056/NEJMoa1203378
I will round out this series of Spring/Summer 2012 tick articles with 2 new articles that are a solid reminder of the unclear understanding of tick zoonoses. Please review the 2 earlier blog summary articles on Lyme disease and the other summary article on RMSF and Ehrlichiosis.
Note that the Lyme article was very clearly against persistent/long term, chronic anitbiotic treament for Lyme disease, especially the pseudo-entity of chronic Lyme disease. Most of the strong recommendations were based on expert opinion from the Infectious Disease Society of America, the IDSA. In fact, as readers of the license suspensions in the NC Medical Board newsletter, The Forum, may recall, a few years ago a physician north of Charlotte had his license questioned (and I believe revoked) for chronic ceftriaxone and IV antibiotic therapy for Lyme cases.
Well, as radio host Paul Harvey says, "and then there's the rest of the story". The Medscape referenced first article now questions some of the studies that originally doubted the repeat antibiotic therapy.
I am a believer in science and standing upon the newest and best research as basis for one's therapeutic decisions. However, I cite the Lyme article above to emphasize just how tenuous and evolving the current understanding of Lyme disease is, even when one removes the often confounding variables of vague symptoms and disability compensation payments.
Given that the current understading of Lyme and its treatment options are evolving, and as the previous article mentions the risk of false positive IgM antibodies YEARS after an exposure, I encourage all providers to be very selective in their diagonosis and treatment of Lyme issues, with a paramount focus on proper non urgent care follow up, monitoring, and a written discharge plan in the patient's discharge instructions. I think one can safely say that trying to fully deal with Lyme and its legion issues from an urgent care setting is akin to going to a gunfight with a knife...you lack the continuity to properly monitor and deal with the outcomes.
The second article is another reminder of how little we know about ticks. In this NEJM article, 2 suspected cases of Ehrlichiosis (including the 'trademark' elevated LFTs, thrombocytopenia, and leukopenia) did not improve on doxycycline. Subsequent analysis showed a novel phlebovirus, now dubbed the "Heartland virus", to be the culprit.
In summary, I am reminded of what a grizzled old professor told me my last week of medical school, "Keep reading and stay flexible, because 1/2 of what we have taught you will be wrong in 5 years. The problem is we don't know yet which half....."
Protect yourself with a full awareness of the pros and cons of ordering labs, being leery of false positives and false negatives, and realizing when a situation is best dealt with in a traditional family medicine/internal medicine setting that has continuity, discussion, and better referral ability.
http://www.nejm.org/doi/full/10.1056/NEJMoa1203378
I will round out this series of Spring/Summer 2012 tick articles with 2 new articles that are a solid reminder of the unclear understanding of tick zoonoses. Please review the 2 earlier blog summary articles on Lyme disease and the other summary article on RMSF and Ehrlichiosis.
Note that the Lyme article was very clearly against persistent/long term, chronic anitbiotic treament for Lyme disease, especially the pseudo-entity of chronic Lyme disease. Most of the strong recommendations were based on expert opinion from the Infectious Disease Society of America, the IDSA. In fact, as readers of the license suspensions in the NC Medical Board newsletter, The Forum, may recall, a few years ago a physician north of Charlotte had his license questioned (and I believe revoked) for chronic ceftriaxone and IV antibiotic therapy for Lyme cases.
Well, as radio host Paul Harvey says, "and then there's the rest of the story". The Medscape referenced first article now questions some of the studies that originally doubted the repeat antibiotic therapy.
I am a believer in science and standing upon the newest and best research as basis for one's therapeutic decisions. However, I cite the Lyme article above to emphasize just how tenuous and evolving the current understanding of Lyme disease is, even when one removes the often confounding variables of vague symptoms and disability compensation payments.
Given that the current understading of Lyme and its treatment options are evolving, and as the previous article mentions the risk of false positive IgM antibodies YEARS after an exposure, I encourage all providers to be very selective in their diagonosis and treatment of Lyme issues, with a paramount focus on proper non urgent care follow up, monitoring, and a written discharge plan in the patient's discharge instructions. I think one can safely say that trying to fully deal with Lyme and its legion issues from an urgent care setting is akin to going to a gunfight with a knife...you lack the continuity to properly monitor and deal with the outcomes.
The second article is another reminder of how little we know about ticks. In this NEJM article, 2 suspected cases of Ehrlichiosis (including the 'trademark' elevated LFTs, thrombocytopenia, and leukopenia) did not improve on doxycycline. Subsequent analysis showed a novel phlebovirus, now dubbed the "Heartland virus", to be the culprit.
In summary, I am reminded of what a grizzled old professor told me my last week of medical school, "Keep reading and stay flexible, because 1/2 of what we have taught you will be wrong in 5 years. The problem is we don't know yet which half....."
Protect yourself with a full awareness of the pros and cons of ordering labs, being leery of false positives and false negatives, and realizing when a situation is best dealt with in a traditional family medicine/internal medicine setting that has continuity, discussion, and better referral ability.
Subscribe to:
Posts (Atom)