COMMENTARY

Amal Mattu's Top Non-COVID Studies in 2020

Amal Mattu, MD

Disclosures

March 01, 2021

2020 is finally over. Although the COVID-19 pandemic hasn't ended yet, 2021 has brought some light to the end of the dark tunnel we've all been traveling through. While we might like to completely forget about the past year, it did bring us some excellent emergency medicine literature. The research on SARS-CoV-2 definitely occupied the bulk of our attention, but many other publications unrelated to the virus are worthy of mention as well.

In this annual recap of my favorite articles of the past year, I will focus your attention on three simple but practice-changing articles from 2020, which you may have missed while you were busy treating patients with COVID. Note that these serve as brief summaries only, and I encourage interested readers to peruse the actual articles for further details.

Update to CDC Treatment Guidelines for Gonococcal Infection, 2020

It seems only fitting that we begin this year's summary with a discussion of another infection, Neisseria gonorrhoeae. The authors of this report indicate that gonococcal infections have increased by 63% since 2014. The Centers for Disease Control and Prevention (CDC) have continued to closely monitor prevalence and resistance patterns for N gonorrhoeae, and they have updated their treatment recommendations.

Rather than a single 250-mg intramuscular (IM) dose of ceftriaxone, the CDC now recommend a single 500-mg IM dose for patients weighing < 150 kg. For patients weighing ≥ 150 kg, they recommend a 1-g IM dose. This recommendation applies for uncomplicated gonococcal infections of the cervix, urethra, pharynx, or rectum.

The alternative recommended regimen for all but pharyngeal gonorrhea is gentamicin 240 mg IM as a single dose plus azithromycin 2 g orally as a single dose. There is no reliable alternative treatment for pharyngeal gonorrhea. Treatment for potential concurrent chlamydial infection is still recommended with doxycycline 100 mg orally taken twice per day for 7 days. During pregnancy, the CDC recommends 1 g of azithromycin as a single oral dose instead of doxycycline.

Thrombolysis With Alteplase After Acute Ischemic Stroke

The use of thrombolytics for acute ischemic stroke in patients presenting between 3 and 4.5 hours after onset has been adopted as reasonable practice (if not the standard of care) by most clinicians who treat stroke. The data that underpin this practice are based on the Third European Cooperative Acute Stroke Study (ECASS III), published in 2008. However, baseline differences in history of prior stroke and stroke severity scores in the study populations were identified as a potential confounder in the results.

In a more recent paper, Alper and colleagues reanalyzed the trial data and adjusted for these baseline imbalances to assess whether patients in the alteplase group did in fact have better outcomes. After adjusting for the imbalances, the researchers found no evidence of benefit but significant risks to the use of alteplase in the 3 to 4.5-hour window after ischemic stroke. Given that ECASS III was the only study that had shown benefit in this time period, the researchers concluded that the use of thrombolytics during the 3- to 4.5-hour window warrants reconsideration. It would be prudent for clinicians that treat stroke to consider these findings in their decision-making process for stroke patients presenting in the 3- to 4.5-hour time period.

Outpatient Treatment of Low-Risk Pulmonary Embolism

Pulmonary embolism (PE) is one of the "can't miss" causes of chest pain and dyspnea in emergency medicine ─ a condition we think of and work up every day. Our diagnostic approaches to this condition have become increasingly more sensitive, and so it's probably not uncommon for high-volume, high-acuity emergency departments (EDs) to diagnose a patient with PE every day.

But as hospital overcrowding continues to worsen, it is increasingly important to identify patients who can be safely discharged for outpatient therapy. There are currently three validated risk stratification tools ─ the Pulmonary Embolism Severity Index (PESI), the Simplified PESI (sPESI), and the Hestia criteria ─ that are often used to identify patients with PE who have a very low risk for short-term adverse outcomes.

The American College of Emergency Physicians, the American College of Chest Physicians, and the European Society of Cardiology all endorse outpatient management of low-risk PE with oral anticoagulants. However, data indicate that outpatient management is being utilized in a very low percentage of patients with PE, probably owing to physician fear of adverse outcomes.

Maughan and colleagues performed a systematic review of studies evaluating outcomes for patients with PE who were treated as outpatients. In total, they included 12 studies incorporating a total of over 1800 outpatients with PE in the review. They found that the 90-day rate of major adverse outcomes (all-cause mortality, PE-related mortality, recurrent venous thromboembolism, or major bleeding) was less than 1%. They found no significant difference in outcome between the class of anticoagulant (vitamin K antagonists vs direct oral anticoagulants) that was used.

I will admit that I am one of the more than 90% of physicians who have been hesitant to discharge patients in whom I have diagnosed PE. This study and other similar studies are certainly making me much more comfortable with the idea of discharging these patients, knowing that their risk for adverse events is extremely low.

My Final Thoughts

There you have it ─ my favorite three practice-changing non–COVID-19 articles of 2020. I am up to date on current guidelines for treatment of sexually transmitted infections; I'm pushing back a bit more on treating stroke patients with thrombolytics when they present in the 3- to 4.5-hour window (and our neurologists have been receptive to these discussions and concerns); and within the past month, I've sent home two low-risk patients with PE. I hope readers give serious consideration to these articles.

There were several other articles in 2020 that I found practice-changing as well. I will simply list them here as "honorable mentions" and encourage readers to peruse the following:

  • Lee and colleagues discussed the use of various versions of the shock index to predict postintubation hypotension in the ED.

  • Dmitriew and colleagues evaluated the utility of the HINTS (head impulse, nystagmus, test of skew) exam in the ED for patients with dizziness and reported how often this exam is being performed inaccurately and inappropriately.

  • Hatten and colleagues from the American College of Emergency Physicians published a clinical policy related to the use of opioids in the ED and the management of patients with opioid withdrawal.

Please be sure to include in the comments section if you have a favorite article of 2020. Best wishes to all for a safe and happy 2021.

Amal Mattu, MD, is a professor, vice chair of education, and co-director of the emergency cardiology fellowship in the Department of Emergency Medicine at the University of Maryland School of Medicine in Baltimore.

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