R&R In The FASTLANE 016

Welcome to the 16th edition of Research and Reviews in the Fastlane. R&R in the Fastlane is a free resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature.

This edition contains 8 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Soren Rudolph, Anand Swaminathan and, of course, Chris Nickson. Find more R&R in the Fastlane reviews in the : Overview; Archives and Contributors

This Edition’s R&R Hall of Famer

EINSTEIN–PE Investigators. Oral Rivaroxaban for the Treatment of Symptomatic Pulmonary Embolism. N Engl J Med. 2012 Mar 26. [Epub ahead of print] PubMed PMID: 22449293

• This one is a game-changer.
• A single oral agent is non-inferior to a heparin / warfarin protocol in patients with symptomatic pulmonary embolism. Other –xabans are in the pipeline. Apixaban will probably be even better than rivaroxaban. Now if someone would only be brave enough to compare –xabans to nothing, we would have even more valuable information. (Disclaimer: this study was drug company funded)
• Recommended by: Joe Lex

Colloca L, Miller FG. The Nocebo Effect and Its Relevance for Clinical Practice. Psychosom Med 2011 Sep;73:598-603. Pubmed PMID: 21862825

• In contrast to the beneficial placebo effect, the term “nocebo effect” describes “adverse effects produced by expectations”. For example, a certain number of research subjects will develop described side effects attributed to a study drug, even if they end up in the placebo arm. This interesting paper discusses important clinical and ethical issues related to this phenomenon.
• Recommended by: Leon Gussow

Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malkasian D, Ross JS. Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med. 1994 Jul 14;331(2):69-73. PMID: 8208267 – [Fulltext]

• This is an classic. Lumbar MRI scans 100 hospital employees with no back pain or history of it. Read by two radiologists with clear definitions of what to report. Kappa 0.59. Much more interestingly almost 70% of these asymptomatic people had abnormalities. Most were bulges but a quarter were “protrusions” and almost 10% had facet disease. MR great for cauda equina but maybe not for telling us what causes your patient’s back pain…
• Recommended by: Andy Neill

Schulman S, Crowther MA. How I treat with anticoagulants in 2012: new and old anticoagulants, and when and how to switch. Blood. 2012 Mar 29;119(13):3016-23. Epub 2012 Feb 1. PubMed PMID: 22302737 – [Fulltext]

• Great review of novel oral anticoagulants, from ‘what’ to ‘how to’
• Note: All quoted trials are outpatients or non-ICU in-patients. Lots of pharmacokinetic extrapolation, not so much hard evidence.
• Warfarin still tops for AF and DVTs if stable therapeutic INR, poor compliance, GI (any) bleeding concerns, creatinine clearance <30ml/min, limited budget. 4-factor PCC seems to be the only potential reversal agent and add 6 hours of dialysis for dabigatran.
• Just wonder if rivaroxaban would be a target for intralipid as an antidote!?
• Recommended by: Matthew Mac Partlin

Blom A, Taylor A, Whitehouse S, Orr B, Smith E. A new sign of inappropriate lower back pain. Ann R Coll Surg Engl. 2002 Sep;84(5):342-3. PubMed PMID: 12398129; PubMed Central PMCID: PMC2504150.

• Does your patient’s low back pain pain have an organic cause? Probably not if they react to the heel-tap test: “The patient sits on the examination couch with his hips and knees flexed to 90°. After suggesting that the test may cause lower back pain, the examiner lightly taps the patient’s heel with the base of his hand. If the patient complains of sudden lower back pain, the test is considered to be positive.” The paper also describes Waddell’s signs, with which this simple test compares favourably.
• Recommended by: Chris Nickson

Lewis LM, Banet GA, Blanda M, Hustey FM, Meldon SW, Gerson LW. Etiology and clinical course of abdominal pain in senior patients: a prospective, multicenter study. J Gerontol A Biol Sci Med Sci. 2005 Aug;60(8):1071-6. PubMed PMID: 16127115.

• A great paper to show the surgical registrar who whinges about having to see another ‘constipated’ elderly patient: “Abdominal pain in older patients should be investigated thoroughly as, in this study, nearly 60% of patients were hospitalized, 20% underwent operative or invasive procedures, 10% had return ED visits, and 5% died within a 2-week follow-up period.
• Recommended by: Chris Nickson

Parrish A, Lancaster R.Does the nose know? Amitraz poisoning and olfaction. S Afr Med J 2012 Mar 2;102(4):231-2. PMID: 22464501 – [Fulltext]

• Back to basics… using your senses.
• Recommended by: Sa’ad Lahri

Suzuki T, Smith WR, Moore EE. Pelvic packing or angiography: competitive or complementary? Injury. 2009 Apr;40(4):343-53. Epub 2009 Mar 17. Review. PubMed PMID: 19278678

• A great discussion of the pros and cons of different methods for stemming hemorrhange from pelvic fractures. The authors ultimately advocate going to the OR for preperitoneal packing prior to angiography for hemodynamically unstable patients.
• Recommended by: Chris Nickson