R&R In The FASTLANE 110

Welcome to the 110th 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

Pelaccia T et al. From Context Comes Expertise: How Do Expert Emergency Physicians Use Their Know-How to Make Decisions? Ann Emerg Med 2015. PMID: 26298449

• The authors utilize the innovative approach of lapel mounted cameras on emergency physicians as they study “expert” practitioner decision making. Using the video as an aid to recall their thoughts at the time during interviews, this article briefly details one of the factors which came out on multiple occasions: that of the “context” in which the patient was seen. Specifically, the physicians discuss how co-workers’ input impacted their view of the patient, biasing (or cuing?) them to believe the patient more or less severely ill. A fascinating read and I look forward to seeing more reports from these authors as they provide more information on physician thought processes at the time of patient encounters.
• Recommended by: Jeremy Fried

Siegal DM et al. Andexanet Alfa for the Reversal of Factor Xa Inhibitor Activity. NEJM 2015. PMID: 26559317

• Andexanet Alfa is here to reverse the Factor Xa inhibitors – which it seems to do, at least, in healthy volunteers. Its use may be hindered by its quite short effective half-life, however. (Radecki)
• Do you remember when the New England Journal of Medicine was a reputable source of medical information? Me neither. The authors investigated a new reversal agent for two of the oral Xa inhibitors rivaroxaban and apixaban by loading healthy patients and then administering the antidote and checking activity of anti-factor Xa. Where is the patient centered outcome? Who cares. The antidote markedly decreased anti-factor Xa activity (a marker of a surrogate outcome) in comparison to placebo – a straw man comparison to say the least. Is this research an important step in the process of drug development? Yes. Does it deserve publication in the hallowed NEJM? Yes . . . if selling reprints is your major concern. (Swaminathan)
• Recommended by: Ryan Radecki, Anand Swaminathan
• Read More: The Great Reveal of Andexanet Alfa (EM Lit of Note)

Lee HM et al. What are the adverse effects associated with the combined use of intravenous lipid emulsion and extracorporeal membrane oxygenation in the poisoned patient? Clin Toxicol. 2015;53:145-150. PMID: 25634667

• Intravenous lipid emulsion (ILE) and extracorporeal membrane oxygenation (ECMO) are used in cases of severe drug poisonings unresponsive to standard treatment. There is concern that ILE may cause adverse effects when administered in combination with ECMO. This is a literature review of in vitro and clinical cases in which ILE and ECMO were used together or in succession. In vitro data suggests that complications are possible, however available clinical data is too limited to make any conclusions.
• Recommended by: Meghan Spyres

Antoon JW et al. Pediatric Fever of Unknown Origin. Pediatr Rev. 2015; 36(9):380-91. PMID: 26330472

• Fever of unknown origin is different than fever without a source. This is a nice review that reminds us of the thought process. Sick Appearing? Cover for all Badness! Looks Well? Be mindful… like Sherlock Holmes and don’t just give random antibiotics.
• Recommended by: Sean Fox
• Read More: Fever of Unknown Origin (Pediatric EM Morsels)

Sherbino J et al. Criteria for social media-based scholarship in health professions education. Postgrad Med J 2015. PMID: 26275426

• Not all social media activities meet the standard of education scholarship. This paper clarifies the criteria, championing social media-based scholarship as a legitimate academic activity in health professions education.
• Recommended by: Salim Rezaie

Fanari Z et al. Aggressive Measures to Decrease “Door to Balloon” Time and Incidence of Unnecessary Cardiac Catheterization: Potential Risks and Role of Quality Improvement. Mayo Clin Proc 2015. PMID: 26549506

• Reducing the door to balloon (DTB) time results in increased mortality. That’s the headline from this paper. In this cohort study, the authors found that institution of an aggressive protocol to reduce DTB time resulted in NO significant change in STEMI mortality. However, false-positive STEMIs went up from 7.7% to 16.5% and there was a significant increase in mortality in this group. The rush to reduce DTB time (by a whopping 15 minutes in this study) rushes the clinician leading to early diagnostic closure and a patient in the wrong doctors hands thus leading to increased bad outcomes. Time to slow down a bit and think.
• Recommended by: Anand Swaminathan