851 e-Letters

  • The Prognostic Value of the Quick Walk Test during COVID-19 Outbreaks: the Experience of the Fenice Network

    We read with great interest the study by Goodacre et al. [1], where post-exertion oxygen saturation adds modest prognostic information to clinical assessment of suspected COVID-19 in the ED.

    This is partially in contrast with the findings of our study [2], performed within the Fenice Network (Italian group for clinical research in Emergency Medicine). In consecutive ED patients with SpO2 ≥ 95%, the most promising version of a standardised quick walk test (QWT) yielded a sensitivity of 83.3% (95% confidence interval [CI] = 35.9% to 99.6%), and specificity of 93.4% (95% CI = 91.5% to 95.0%). The positive and negative predictive values (PPVs and NPVs) were 8.6% (95% CI = 2.9% to 19.0%) and 99.9% (95% CI = 99.3% to 100.0%).

    This difference is probably due to 3 factors:

    1. The test standardisation. In our case series, the test was standardised for all centres and consists of a 30-40 metres walk at the maximun possible speed for each patient. Conversely, in the study by Goodacre et al., exertion SpO2 was either recorded after different, not standardised, intentional tests or could have made opportunistically after a spontaneous patient’s effort. The latter condition is particularly worrisome for the purpose of a thorough assessment of the prognostic value of the post-exertion oxygen saturation.

    2. The outcome definition. Goodacre et al. considered patients who died or required respiratory, cardiovascular or renal support within 30 days after initial p...

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  • Training for Major Incidents-mind the (COVID) gap?

    Dear Editor,

    The collated experiences and lessons from recent Major Incidents experienced in the UK is now juxtaposed with the ‘new normal’ of the healthcare community and emergency services operating with the threat of COVID-19 and the associated considerations of PPE against Aerosol Generating Procedures.

    Emergency service personnel and hospital clinicians will have trained with ‘universal precautions’ and risk-specific personal protective equipment for Health Emergency Preparation Exercises (HEPE) previously. COVID-19 has resulted in wide-spread adoption of single-use coveralls and respiratory protective equipment (facemask and powered hoods) beyond the specialist responders who would have normally exercised for major incidents whilst operating with these.

    With a return to a new normality of service provision and emergency preparedness, the clinical and logistical challenges of operating in AGP PPE need to be factored into MI plans and future practical exercises across the emergency services and acute hospital care. These range from those issues at the operational level such as dynamic risk assessment, identification and communication between clinicians and commanders at scene, record keeping and identifying the need to use COVID PPE (or when no longer needed, keeping in mind its exertional toll) and don and doff areas with ancillary staff.

    Tactical issues include conveyance platforms and options for patients from scenes to hospital – some of...

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  • Telehealth impact pre-COVID

    There is no question that SARS-CoV-2 has dramatically increased the utilization of telehealth services in the US and elsewhere. However, the claim that telehealth was not a significant factor pre-COVID is simply not true. Here is the quote from the article: "Prior to the severe acute respiratory syndrome coronavirus 2 or COVID-19 pandemic, telehealth generally had little overall engagement in the US healthcare system."

    In 2009 during the H1N1 epidemic, Kaiser Permanente-Northern California's (KP-NCAL) appointment and advice call centers (AACC) scheduled 900,000 telehealth visits. In 2010 in my capacity as Clinical Director of the KP-NCAL Sacramento AACC I organized a regional program employing telehealth to address the after hours needs of adults. That program over the next 8 years averaged 50,000 encounters per year on nights and weekends and backed up an additional 200,000+ locally managed afterhours telehealth visits per year. 24% of the total encounters in KP-NCAL's Adult and Family Medicine departments by 3.8 million adults in 2017 were delivered through virtual telehealth. I would say these efforts definitely qualify as substantial "overall engagement".

  • Takotsubo cardiomyopathy-related cardiogenic shock might be a contraindication

    The use of Angiotensin II for cardiogenic shock(1) might be counterproductive in patients who have cardiogenic shock attributable to Takotsubo cardiomyopathy(TTC) characterised by left ventricular outflow tract(LVOT) obstruction. The following are the reasons justifying non-use of that treatment modality:-
    Angiotensin II induces catecholamine release(2), thereby potentially exacerbating the catecholamine surge which characterises TTC. This catecholamine surge is mimicked by exogenous administration of epinephrine, the latter well documented as a trigger for de novo TTC in 22 patients reviewed in the literature search by Madisa et al(2). In another literature review, dobutamine(also a catecholamine ) triggered the onset of TTC in 22 patients(3). A typical example of the latter was a 61 year old woman who developed chest pain at 70% of her age-predicted heart rate, when she was on a 40 mcg/min infusion of dobutamine. Her electrocardiogram(ECG) then showed inferolateral ST segment elevation. Transthoracic echocardiography showed severe akinesia of the apical, anteroseptal, and apicolateral segments at peak dobutamine infusion. Coronary angiography disclosed normal epicardial vasculature(5).
    When LVOT obstruction occurs in TTC it can give rise to severe hypotension, exemplified by a 60 year old woman with a nadir systolic blood pressure(SBP) of 80 mm Hg in association with a gradient of 58 mm Hg across the LVOT. After landiolol( a beta blocker) inf...

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  • Traffic lights for a storm?

    I enjoyed reading this article, however, the reference to a cytokine storm warrants clarification. An editorial in JAMA Internal Medicine doi:10.1001/jamainternmed.2020.3313 suggested little evidence for such a storm and this has been supported by more recent studies by Remy et al in JCI Insight (10.1172/jci.insight.140329) who demonstrated severe immunosuppression and Kox et al in JAMA (doi:10.1001/jama.2020.17052) who found multiple cytokines were reduced in severe COVID-19.

  • Pain is a central consideration

    A timely and interesting read if for no other reason colleagues and I were discussing / bemoaning recurrent abdominal pain presentations only last week. Many of the features that act as obstacles were well recognised and omnipresent.

    The solutions are an excellent mixture of skills and I can see much utility, I can also foresee the care pathways being highly personalised in our healthcare institutions (Daniels et al allude to this by describing one the ED consultants with an interest in HIU) and once that person moves job the pathway crumbles.

    To an extent excluding medical emergency (the 1st E in ERROR) does require medicalisation whether it be vitals being taken or the initial bloods including lactate. I can see the purpose and benefit of not repeating unnecessary blood tests and I suspect not doing tests will be a feat more easily achieved with seniority, There is benefit in letting HIUs be seen exclusively by such.

    I was surprised that Daniels and the other authors claim that "pain is not a central consideration in RCEM guidelines...". The college guidelines page (https://www.rcem.ac.uk/RCEM/Quality_Policy/Clinical_Standards_Guidance/R...) lists at east 3 where pain is most certainly the central consideration, or was this in relation to abdominal pain only?


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  • Methodological issues on the sample size used to compare the efficacy of ketamine–propofol and sodium thiopental–fentanyl.

    Dear Editor,

    We read with great interest the EMJ article by Bahreini and colleagues (published August 2020).1 The authors aimed to compare the relative efficacy and side effect profiles of sodium thiopental–fentanyl (TF) and ketamine–propofol (KP) when used for procedural sedation of 96 adult patients prior to undergoing a painful procedure in the emergency department setting. This randomised double-blind clinical trial quantitatively compared recovery time and both patient and provider satisfaction between the two treatment groups. Additionally, the study aimed to assess the prevalence of adverse effects occurring during recovery and patient recall of the procedure. The authors concluded that there was a statistically significant improvement in both patient and provider satisfaction and degree of procedure recall when using KP compared to TF. However, there was no statistically significant difference in recovery time or adverse effects between the treatment groups.

    The authors discussed that the study was not adequately powered to assess the side effect profiles. However, using a systematic review of the effects of KP and propofol, it is possible to make comparisons with the current study regarding the KP side effect profile.2 In all cases, the occurrence of adverse events was greater in those studies included in the systemic review. For example, the POKER study reported that 14% of patients sedated with KP required an airway intervention 3 compared to only...

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  • Triage portals in to A&E departments

    What this proposed reset does not describe is a reorganisation of 'at the door' triage based on the type of presentation.
    The need for effective patient throughput (patient flow); the major problem in contemporary A&E (at least pre Covid19) has not been addressed.
    I propose triaging 'at the door' carried out by nurse practitioners (assisted by paramedic crews bringing patients in) and admin staff to access medical information rapidly (for example via the Great North Care Record). These insights were gained from camp Bastion in Afghanistan.

    There should be 4 key portals and pathways thereafter.
    a) The seriously ill (Major Trauma, Sepsis, Stroke, Cardiac Infarcts, Acute Abdomens etc.)
    b) Cases of frailty (mainly elderly people, including delirium / dementia, minor trauma)
    c) mental Health presentations (of all ages, including learning disability)
    d) overspill from General Practice

    These pathways would be staffed by specialist nurse practitioners, pharmacists and speciality doctors, working on prearranged algorithms with electronic prescribing and discharge / handover templates (ideally in a SBAR format) to assist patient flow. cross referral (called scaffolding in mental health) should be possible on occasion. Overall, a duty matron should keep overall control of activity through an electronic dashboard. Paramedic / ambulance crews should have access to this matron remotely to make crucial d...

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  • Public and Political Influence on Frontline Practice

    Dear Editor,

    I read with interest the recent article by Carley et al., “Evidence-based medicine and COVID-19: what to believe and when to change”1. The authors pay homage to the challenges of keeping pace with a pandemic growing at unprecedented speeds, forcing the hand of clinicians to make therapeutic decisions on the basis of weak, often unvalidated evidence. They also note the influence of political opinion, referencing Donald Trump’s infamous declaration on the efficacy of hydroxychloroquine as a treatment for COVID-192. In their concluding statements, the authors eloquently present the need to follow science rather than emotions or politics.

    Having worked in a large critical care unit over the pandemic, I question how easy this is in practice. Clinicians, nurses and Allied Health Professionals do not exist in a vacuum, but rather their opinions and knowledge are inevitably shaped by social and cultural rhetoric. I use the example of Personal Protective Equipment (PPE), an acronym once reserved to select professions yet now colloquially used by the lay person. Information regarding the appropriate PPE to be worn was disseminated in multiple formats, from news broadcasts to social media platforms such as Twitter. As knowledge developed about how the SARS-COV-2 virus was transmitted, recommendations on PPE changed accordingly. As of July 23rd, it was recommended that double gloving was not necessary3, and in fact increased the risk of transmitting e-coli...

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  • Erratum in Article Citations Noted on July 13, 2020

    This article draws its evidence from two citations, one by Madsen et al., and the other from a systematic review, which has been mis-cited as a duplicate of the Madsen reference. The correct citation to the systematic review is not Madsen et al., but Tarnutzer et al., PubMed ID 28356464 (Tarnutzer AA, Lee SH, Robinson KA, Wang Z, Edlow JA, Newman-Toker DE. ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: A meta-analysis. Neurology. 2017;88(15):1468-1477. doi:10.1212/WNL.0000000000003814.).