R&R In The FASTLANE 148

Welcome to the 148th 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

Taylor RA et al. Determination of a Testing Threshold for Lumbar Puncture in the Diagnosis of Subarachnoid Hemorrhage after a Negative Head CT: A Decision Analysis. Academic emergency medicine. 2016. PMID: 27378053

• Test thresholds are an essential concept in emergency medicine, but have really only taken hold in PE workups so far. This group attempts to weigh the harms and benefits of LP after negative CT for subarachnoid haemorrhage and come up with a test threshold of 4.3%. This means that we are doing more harm than good by testing anyone with a pre-LP likelihood of disease less than 4.3% – which is almost everyone after a negative CT. (Look at figure 3 in the paper for more detail.) That being said, there are a lot of assumptions that go into a number like this, so don’t expect it to be exact. Interestingly, another team published on the same topic in the same issue, and also came up with a test threshold of 5%:
• Carpenter CR et al. Spontaneous Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis Describing the Diagnostic Accuracy of History, Physical Exam, Imaging, and Lumbar Puncture with an Exploration of Test Thresholds. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2016. PMID: 27306497
• Recommended by Justin Morgenstern

Rubin LG, Schaffner W. Clinical practice. Care of the asplenic patient. The New England journal of medicine. 371(4):349-56. 2014. PMID: 25054718

• A great review and reminder to us all that asplenic patients (whether surgical, functional, or congenital) are at VERY high risk when they present with fever. According to the authors, they should ALL be antibiosed and brought into the hospital as their presenting symptoms may be isolated to fever alone, or otherwise mild. These are the well appearing patients who can deteriorate rapidly. The authors also remind us that sickle cell patients are functionally asplenic after age 1 and anatomically asplenic due to autoinfarction after age 6-8.
• Recommended by Jeremy Fried

Berg R. The hardships of being a Sith Lord: implications of the biopsychosocial model in a space opera. Advances in Physiology Education 2016 Vol. 40 no. 2, 234-236 PMID: 27105743

• Have you ever wondered about the cause of Darth Vader’s progressive decline in pulmonary function? In this paper the authors consider the mental and physical impact of the severe psychosocial stress that Darth Vader is exposed to as a high-ranking official in the Galactic Empire. Just wonderful nerdy reading….by the way, did you know that the estimated cost of the Death Star is at least $850 quadrillion in steel alone!
• Recommended by Soren Rudolph

Chauny JM et al. Risk of Delayed Intracranial Hemorrhage in Anticoagulated Patients with Mild Traumatic Brain Injury: Systematic Review and Meta-Analysis. J Emerg Med 2016. PMID: 27473443

• Do we need to observe and re-scan patients with minor head trauma on anticoagulants who have negative initial NCHCTs? This systematic review and meta-analysis says probably not. The authors identified 7 studies with about 1600 patients and found that the incidence of new ICH 24 hours later was 0.60% with resulting neurosurgical intervention occurring in just 0.13% of patients. Admitting and observing all these patients doesn’t make sense but consider it in patients who can’t get back to the hospital quickly if they get worse, those who are over-anticoagulated, those with multiple comorbidities and those on multiple antiplatelet/anticoagulant medications.
• Recommended by Anand Swaminathan

Kaplan RM, Irvin VL. Likelihood of Null Effects of Large NHLBI Clinical Trials Has Increased over Time. PLoS ONE. 2015;10(8):e0132382. PMID: 26244868

• Once NIH-funded trials needed to register their primary outcomes with ClinicalTrials.gov, suddenly, all these studies with pharma co-sponsors stopped being universally positive.
• Recommended by Ryan P Radecki
• Read more:  ClinicalTrial.gov registration & cleaning up primary outcomes (EM lit of note)

Morrow DS et al. Versatile, Reusable, and Inexpensive Ultrasound Phantom Procedural Trainers. Journal of ultrasound in medicine. 35(4):831-41. 2016. PMID:26969595

• Medical training equipment is often ridiculous expensive, but hands on training is important and real patients are in short supply. This is a great paper that describes the use of ballistic gel to cheaply create a ultrasound trainers for vascular access, lumbar puncture, and abscess I&D
• Recommended by Justin Morgentern