This is a bit of a fascinating article with a great deal to unpack – and rightly published in a prominent journal. The brief summary – this is a “pragmatic”, open-label, cluster-randomized trial in which a set of interventions designed to increase guideline-concordant care were rolled out via electronic health record tools. These interventions were further supported by “facilitators”, persons assigned to each practice in the intervention cohort to support uptake of the EHR tools. In this specific study, the underlying disease state was the triad of chronic kidney disease, hypertension, and typ ..read more

A brief post collating a few bits of my various work published across the interwebs …. The Annals of Emergency Medicine Podcast continues to summarise the meatiest articles from each month, featuring a cycle of new co-hosts, as well: Apple Podcasts Google Podcasts Soundcloud Naturally, there are continuing Journal Club features, covering the following articles:  Zone 1 endovascular balloon occlusion of the aorta vs resuscitative thoracotomy for patient resuscitation after severe hemorrhagic shock Video versus direct laryngoscopy for tracheal intubation of critically ill adult ..read more

And, most importantly, if you put the symptoms related to your fever into ChatGPT, it will generate a reasonable differential diagnosis. “So?” This brief report in Annals describes a retrospective experiment in which 30 written case summaries lifted from the electronic documentation system were fed to either clinician teams or ChatGPT. The clinician teams (either an internal medicine or emergency medicine resident, plus a supervising specialist) and ChatGPT were asked to generate a “top 5” of differential diagnoses, and then settle upon one “most likely” diagnosis. Each case was tested both so ..read more

Well, PRISMS demonstrated unfavorable results. MARISS tried to ascertain predictors of poor outcome in mild stroke, and intravenous thrombolysis was not associated with an effect on the primary outcome. Now, again, we examine thrombolysis in “mild” stroke, in this case, NIHSS ≤3 – and fail. Like MARISS, this is a retrospective dredge of patients selected by the treating clinicians to receive either intravenous thrombolysis or, in this case, dual-antiplatelet therapy with clopidogrel and aspirin. The population included for analysis is the Austrian Stroke Unit Registry from 2018 until 2019, an ..read more

It’s a trick question – in the end, all of us have already lost. This is a short retrospective report evaluating, primarily, the Epic Sepsis Prediction Model, and the mode in which is deployed. The Epic SPM generates a “prediction of sepsis score”, calculated at 15 minute intervals, providing a continuous risk score for the development of sepsis. Of course, in modern medicine, this is usually reduced to a trigger threshold at which point an alert is fired. Alerts, alerts, alerts – what are they good for? In this study, the Epic SPM was evaluated at several difference SPS score thresholds rangi ..read more

In a world of doors, truck beds, furniture, and other finger-crushing nuisances, emergency department visits for injuries involving the distal digits are common. Injuries range from tuft fractures, to degloving injuries, to all manner of nail and nailbed derangement. Perusing any textbook or online resource will typically advise some manner of repair, including, but not limited to, replacing an avulsed nail back into the proximal nail fold and securing it in place. If the avulsed nail is not available, recommendations include placing a bit of foil into the proximal nail fold. The general idea ..read more

We do love to give out opiates in the emergency department. Kidney stone? Opiates. Broken arm? Opiates. Gunshot wound? Opiates. Sore throat? Dexamethasone. And opiates. So of course we’re here with opiates for your back pain. In this modern day, we are far, far more judicious than in times of yore, back when pharma had lobbied for pain to become the “fifth vital sign”. But, nonetheless, those patients who are struggling to manage despite non-opiate analgesia frequently end up with some sort of small supply to try and resolve an acutely painful condition. The OPAL trial, published in The Lancet ..read more

In case you missed this beautiful little article, it’s worth re-highlighting regarding the paradoxical “cost” of “quality”. In theory, high-quality care is its own reward. Timely actions and interventions, thoughtful and thorough evaluations, and appropriate guideline adherence when applicable are all goals with reasonable face validity for healthcare delivery. Competing incentives, however, coupled with time pressures, erode some of the natural inclination towards ideal care. Thus, “quality” metrics and goals, created with the best of intentions to nudge clinicians and health systems towards ..read more

Platelets are the good little minions of hemostasis. In their absence, invasive procedures develop additional risk, ranging from minimal to clinically important, and the mitigation strategy ranges from avoidance, the alternative procedural techniques, to prophylactic platelet transfusions. Platelets, like any blood product, are associated significant risks, not limited to acute lung injury, transfusion-related circulatory overload, allergic reactions, and more. This prospective, randomized trial evaluated whether, in patients with thrombocytopenia, a platelet transfusion was necessary before c ..read more

It is safe to say the honeymoon phase of large language models has started to fade a bit. Yes, they can absolutely pass a medical licensing examination when given carefully constructed prompts. The focus now turns to practical applications – like, in this example, using ChatGPT to write an entire scientific paper for you! There is no reason to go through the details of the paper, the content, the findings, or any aspect of fruit and vegetable consumption. It is linked only to prove that it exists, and was written in its entirety by an LLM. To create the article, the authors used prompts contai ..read more