R&R In The FASTLANE 069

Welcome to the 69th 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 6 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

Blum et al. Adjunct prednisone therapy for patients with community-acquired pneumonia: a multicentre, double-blind, randomised, placebo-controlled trial. Lancet 2015. PMID: 25608756

• In this large Swiss trial patients aged 18 years or older with community-acquired pneumonia were randomised to receiving either prednisone 50 mg daily for 7 days or placebo within 24h of presentation. The median time to clinical stability was shorter in the prednisone group with no difference in pneumonia associated complications. The patients who were randomised to receiving prednisone had a higher incidence of in-hospital hyperglycaemia needing insulin treatment but other than that there were no complications associated with steroid use. Certainly something to consider. (Nudrat Rashid)
• The literature for the use of steroids in pneumonia is inconsistent. This RDCT of 785 patients found that community acquired pneumonia (CAP) patients who received steroids had a shorter time stabilization of symptoms as defined by vital signs, mental status and oral intake. The authors and the accompanying editorial believe that these findings support routine use of steroids in all patients with CAP. The study is compromised by issues of unblinding (hyperglycemia in the steroid group and the bitter taste of prednisone may unblind patients). More importantly, the primary outcome is not as robust as we’d like to see. Decreased length of stay would have been a more robust finding. (Anand Swaminathan)
• Recommended by: Nudrat Rashid, Anand Swaminathan
• Read More: Prednisone . . . for Pneumonia (EM Lit of Note)

Roland D et al. Are you a SCEPTIC? SoCial mEdia Precision & uTility In Conferences. Emerg Med J 2014. PMID: 25504658

• Live tweeting medical conferences is becoming increasingly common and has provoked discussions on the value of these tweets compared with the distraction. In this tiny study, the authors compared the speakers’ intended message with the tweets during the presentations. They found that 43.2% (16/37) tweets represented, 43.2% (16/37) partly represented and 8.1% (3/37) misrepresented what the speaker was trying to say. This study is an interesting step in analyzing the value of conference tweeting and, perhaps, ways in which Twitter can: (1)Provide feedback to speakers about how to present their messages clearly (2)Engage speakers to clarify or interact with twitter (3)Potentially disseminate messages more widely.
• Recommended by: Lauren Westafer

Shah K et al. Magnitude of D-dimer matters for diagnosing pulmonary embolus. Am J Emerg Med 2013; 31(6):942-5. PMID: 23685058

• We work up too many patients for PE, we diagnose too many patients for PE, but we have few answers. This paper doesn’t solve everything, but helps support what seems intuitively true: the higher the d-dimer, the more likely the patient has a PE. Hopefully someday soon we will have some better cutoffs for the d-dimer, tailored to the patient.
• Recommended by: Seth Trueger

Ecochard-Dugelay E. et al. Clinical predictors of radiographic abnormalities among infants with bronchiolitis in a paediatric emergency department. BMC Pediatr 2014. PMID: 24906343

• Chest x-rays are often needlessly ordered for kids with wheeze. This prospective cohort study sought to determine the clinical predictors of an abnormal chest x-ray in children under 2 years of age with suspected bronchiolitis. They found that less than 5% of these kids had abnormal x-rays as assessed by 2 blinded experts. The ONLY independent clinical predictor of an abnormal x-ray of the 9 variables studied was the presence of fever. A validated clinical decision rule would make this a slam dunk practice changer and help improve resource utilization while minimizing radiation risk.
• Recommended by: Anton Helman

McNab S et al. 140 mmol/L of sodium versus 77 mmol/L of sodium in maintenance intravenous fluid therapy for children in hospital (PIMS): a randomised controlled double-blind trial. Lancet 2014. PMID: 25472864

• The ideal fluid for pediatric maintenance infusion is unclear. This study was an RDCT comparing isotonic (140 mmol/L sodium) and 1/2 normal saline. This group found a higher rate of hyponatremia in kids getting 1/2 normal solution. There was no significant difference in serious adverse events. These results call in to question the use of hypotonic solutions in kids.
• Recommended by: Anand Swaminathan

Woller SC, Stevens SM et al. Assessment of the Safety and Efficiency of Using an Age-Adjusted D-dimer Threshold to Exclude Suspected Pulmonary Embolism. Chest 2014; 146(6):1444-51. PMID: 24831769.

• Very interesting study using revised Geneva Score and age-adjusted D-dimer. The study looked into 923 patients who underwent a CT pulmonary angiogram. For 104 with a negative D-dimer and a rGS < 10 (low risk + moderate risk) no PE was observed in 30 days; from the 293 with a negative age-adjusted D-dimer and rGS <10, 4 PE were observed (1.5% false-negative rate) with 2.3% false negative in patients older than 75 years. The potential decrease in imaging was about 18.3%. This paper offers fresh evidence about the use of age-adjusted population in low-medium risk patients older than 50, assuming a false-negative between 1.5-2.3%.
• Recommended by: Daniel Cabrera