January 14, 2019

Article: Uyeki TM et al. Clinical Practice Guidelines by the Infectious Diseases Society of America: 2018 Update on Diagnosis, Treatment, Chemoprophylaxis, and Institutional Outbreak Management of Seasonal Influenza. Clin Infect Dis 2018. PMID: 30566567

Background: Influenza is an Emergency Department scourge that we deal with every year. The vast majority of patients recover from uncomplicated influenza without anything more than supportive care but, influenza can cause serious complications. Young children, older adults, pregnant and postpartum women, people with neurologic disorders and patients with certain chronic medical conditions (i.e. COPD, CAD, Diabetes, Immunocompromised states) are at increased risk for these complications. Annual vaccination is the best method to reduce the impact of influenza on morbidity and mortality. Though antiviral medications for influenza are far from perfect, the indications for their use must be understood.

January 3, 2019

Introduction: Beyond the Data

The evolution from eminence-based to evidence-based care has come to define bedside emergency medicine, with rigorous skepticism and scholarly consideration accelerated by the power of global connectivity. Where anecdote and opinion once drove therapy, clinicians now approach clinical conundrums with deliberate reflection, expecting—and at times demanding--ever-higher proof of perfection prior to implementing or incorporating therapies, tests, or approaches into their own practice. Such cogitation ensures excellence and safety and avoids pitfalls of over-adoption or confounding. Unfortunately, so many of our daily decisions are made in a space devoid of definitive data, and require a synthesis of relevant literature with our accumulated knowledge and experience—a departure from evidence-based medicine into the pragmatic world of evidence-informed medicine. It is only at this precipice—where studies and statistics simply don’t exist—that we change, where we push forward the boundaries of care, and develop not only experience, but the very questions which will define the next advances in emergency medicine. It’s with this in mind that we present this REBEL post, an entry not so much a look back on manuscripts which dictate our practice, but a treatise to help us look forward. To not inform, but to inspire thought and inquiry.  

December 10, 2018

Background Information: Sepsis is a complex syndrome frequently encountered in the ED. This infection-triggered, multifaceted disorder of life-threatening organ dysfunction is due to the body’s dysregulated response to pathologic and biochemical abnormalities.2-4 There has been significant debate regarding the use of clinical decision tools such as Systemic Inflammatory Response Syndrome (SIRS) and quick Sepsis-related Organ Failure Assessment (qSOFA) in the early recognition of sepsis.2,5-7­ Multiple studies have shown SIRS to not be specific enough for the early detection of sepsis as many non-infectious processes, including exercise, can often meet many of its criteria.8-10 On the other hand, qSOFA has been criticized as having poor sensitivity and moderate specificity for short-term mortality.11,12 Furthermore, qSOFA  has been described as clinically valuable but an imperfect marker of sepsis as some forms of organ dysfunction, such as hypoxemia and renal failure, are not assessed using qSOFA.5 Another severity score known as the National Early Warning Score (NEWS) focuses on inpatient deterioration in detecting patients with increased risk of early cardiac arrest, unanticipated ICU admission and death.13 One study showed that utilization of NEWS in the emergency department (ED) has been shown to be effective in recognizing patients with sepsis who are at a higher risk of adverse outcomes.14  The authors of this study sought to review the use of NEWS as an early sepsis screening score, a predictor of severe sepsis/septic shock, and compare it to SIRS and qSOFA in an ED triage setting.

November 19, 2018

Background: On October 24th, 2018, Roche, the maker of oseltamivir, announced that the US Food and Drug Administration (FDA) approved Xofluza (baloxavir marboxil) for the treatment of acute, uncomplicated influenza in people 12 years of age and older. Historically, there have been two classes of influenza treatment, the M2 ion-channel inhibitors, and the neuraminidase inhibitors, however circulating influenza viruses have become largely resistant to M2 ion-channel inhibitors and the emergence of newer strains of influenza (H1N1) could threaten the utility of neuraminidase inhibitors as well. I have written previously about the Tamiflu Debacle and why this is a medication we should not prescribe to immunocompetent patients. In this post, we attempt to answer a different question: Is baloxavir approval another debacle or does it actually improve patient oriented outcomes?

October 24, 2018

Background:  Oseltamivir (Tamiflu), a neuraminidase inhibitor, was approved by the FDA in 1999.  The majority of the evidence supporting the use of the medication came from trials funded by Roche, the maker of the drug. Safety issues with the drug began sprouting up in 2009, due to case reports in Japan of neuropsychiatric events and these events eventually led to a label warning. The Cochrane collaboration published analyses of the available data in 1999, 2003, and 2006, supporting the use of the drug. However, in 2009, the  Cochrane collaboration began to question Roche about the completeness of the data they were using, which was data from another meta-analysis with 10 RCTs.  Only 2 of those RCTs (Nicholson 2000 and Treanor 2000) were published in peer-reviewed journals.  The other 8 RCTs were presented as proceedings of congress or abstracts in meetings.  Cochrane decided to undertake a complete analysis of full clinical trial data, but had difficulties accessing the data until 2013.  This post will serve as a review of the evidence for and against the use of Oseltamivir (Tamiflu) after the full clinical trial data was finally released.
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