ACEP NowACEP Now https://www.acepnow.com Wed, 14 Nov 2018 15:31:08 +0000 en-US hourly 1 https://wordpress.org/?v=4.9.8 Tips for Updating Your Approach to Pediatric Seizures https://www.acepnow.com/article/tips-for-updating-your-approach-to-pediatric-seizures/ https://www.acepnow.com/article/tips-for-updating-your-approach-to-pediatric-seizures/#respond Wed, 14 Nov 2018 15:31:08 +0000 https://www.acepnow.com/?post_type=article&p=20440 Seizures and epilepsy are common, serious neurologic diseases in children and adolescents.1,2 Convulsions can be a manifestation...

The post Tips for Updating Your Approach to Pediatric Seizures appeared first on ACEP Now.

]]>
Seizures and epilepsy are common, serious neurologic diseases in children and adolescents.1,2 Convulsions can be a manifestation of epilepsy or occur secondary to a complication of a systemic or central nervous system disorder. The emergency physician is usually the first provider to evaluate and stabilize children with suspected seizures. Here, we will review recent literature and share our personal experience in the approach to a seizing child in the emergency department.

Epilepsy is defined as the predisposition to generate seizures.3,4 While generalized or focal shaking in a child readily raises a concern for seizure in caregivers and doctors alike, subtle manifestations, such as brief episodes of lip smacking in temporal lobe epilepsy or head bobbing in infantile spasms, can be challenging to correctly detect as signs of a serious neurologic disorder.

As with any other patient presenting to the emergency department, assessment of seizing children starts with determining stability and urgently addressing the ABCs. Careful attention should be given to the possibility of continuous seizure activity even if no apparent convulsions are seen. It’s helpful to consider the possibility that seizures were provoked so that their causes can be diagnosed and addressed.3 Table 1 enumerates causes of provoked seizures in patients without epilepsy.

Table 1: Select Causes of Provoked Seizures8

(click for larger image) Table 1: Select Causes of Provoked Seizures8

Published guidelines on imaging in children with new-onset seizures note that in only approximately 2 to 4 percent of cases, the results altered immediate medical management.5 While MRI is the most accurate diagnostic modality in pediatric patients, for unstable patients in whom space-occupying lesions need to be excluded, a noncontrast CT scan of brain is the modality of choice as it is rapid, is readily available, and generally does not require sedation.5,6 It is unusual to find an acute abnormality on imaging of a normally developed child (not an infant) with a completely normal neurological examination after a brief, nonlocalizing seizure.5 In these patients, imaging can be done on an outpatient basis as necessary. The same can be said for laboratory testing.

It is important to note that there are few studies prospectively evaluating timing of imaging in children with new-onset epilepsy. Some high- and low-risk characteristics are based on electroencephalogram (EEG) results. Most guidelines also exclude neonatal seizures.5 A seizure in a neonate almost always requires expeditious imaging and an EEG.6 An otherwise healthy and developmentally normal child older than 24 months after a brief first-time generalized seizure who quickly returns to normal can be discharged without medications with follow-up by pediatric neurology.3,4,7,8 All of these patients will ultimately need an EEG, and most will require an MRI of the head.5,6

As in adults, most children suffering a first unprovoked seizure do not have another one, especially if their EEG is normal. The risk is higher in children with autistic spectrum disorders and if the seizure happens during sleep.7 If it occurs, recurrent seizure is most common in the first six months after the first one.7 While sudden unexpected death in epilepsy (SUDEP) is a known and feared entity that is currently impossible to predict in any given patient, most excess mortality in children with epilepsy is not caused by a seizure itself.9 Great care should be taken when evaluating infants. Sepsis, meningitis, or disseminated herpes infection can manifest initially with a seizure with or without an abnormal temperature. Appropriate discharge instructions related to trauma and burn prevention, avoiding driving and taking care of babies, and not swimming or lying in a bath without close supervision are of paramount importance.

Febrile Seizures

Febrile seizures are most commonly defined as those occurring in children of defined age (6 to 60 months, per the American Academy of Pediatrics 2008 guideline) without prior afebrile seizures or neurological abnormalities and occurring in association with acute febrile illness when no other precipitating condition is identified.10 Complex febrile seizures have focal onset, have lateralizing signs, last longer than 15 minutes, are associated with prolonged postictal deficits, or occur more than once in a given acute febrile illness. These represent approximately 40 percent of all febrile seizure presentations.10 Febrile seizures that are not complex are defined as simple. Children typically are highly febrile if presenting soon after the seizure; low-grade fever is unusual with febrile seizures unless antipyretics were already given. Seizures lasting more than five minutes currently meet criteria for status epilepticus (SE).11

Management of patients with simple febrile seizures in the emergency department is similar to the management of children presenting with fever without a seizure and focuses on exclusion of serious illness such as meningitis or sepsis. The 2011 guidelines from the American Academy of Pediatrics do not recommend routine imaging, EEG, lumbar puncture, blood work, or urinalysis solely because of a simple or complex febrile seizure. Unimmunized young children (less than one year old), those on antibiotics, or those with sick appearance warrant a more extensive workup. Children seizing in the emergency department can be given benzodiazepines with intramuscular (IM), IV, intranasal, and rectal routes described.3,10,12 The decision to prescribe rectal diazepam for use in subsequent febrile seizure episodes is controversial and must be balanced with potential of apnea after its administration.10 As the seizure typically occurs when fever spikes, antipyretics do not help to prevent first or subsequent febrile seizures.

SE is defined as seizure activity lasting more than five minutes or recurrent seizures without recovery in between.11,13 It is the most common neurological emergency in childhood.13 Prolonged seizure activity can permanently damage neurons; the longer a seizure lasts, the less likely it is to stop spontaneously and the less likely it is to respond to standard antiepileptic drugs (AEDs).3 SE appears to increase expression of drug efflux proteins in the brain, thus decreasing AED levels there.13 As it is impossible to predict how long a given seizure will last, it’s best to administer appropriate medications without delay by the fastest reliable route available and escalate therapy as necessary. Intramuscular midazolam administration has been shown to be safe and effective for prehospital SE.12 IV access can be challenging in seizing children, especially if the veins were extensively used in the past. An intraosseous line can be lifesaving in this situation. Early cardiorespiratory monitoring and supplemental oxygen are recommended for all patients.

For suggested diagnostic workup of SE, see Table 2. For medication sequence in treating SE, refer to Table 3. Both seizure activity and medications used to terminate it can cause respiratory failure. Bag-valve-mask ventilation can sometimes stave off the need for endotracheal intubation unless emergent imaging or other diagnostic procedures are immediately needed. In case of ongoing seizure activity or altered mental status, EEG monitoring is recommended early.11,13

(click for larger image) Table 2: Important Diagnostic Tests for Patients in Status Epilepticus<sup>11,13</sup>

(click for larger image) Table 2: Important Diagnostic Tests for Patients in Status Epilepticus11,13

Nonconvulsive SE (NCSE)

Prolonged brain seizure activity on EEG in a patient with altered mental status but without convulsions defines NCSE. It can present separately as an acute confusional state or develop following an observed seizure.11 A wide variety of symptoms have been described, ranging from aphasia to severe agitation or coma.11 It appears to have a similar incidence in children and adults and is not rare.14,15 In settings where immediate EEG is not available, its recognition can be quite challenging. In our experience, in unclear cases, cautious administration of a weight-appropriate benzodiazepine dose can, at times, result in dramatic improvement in mental status aiding in diagnosis. Similarly to patients with convulsive SE, these patients need emergent workup focusing on diagnosing life-threatening etiologies, continuous EEG monitoring, and expeditious AED administration. As is the case with convulsive SE, the prognosis mostly depends on etiology and the degree of neurological impairment.13

Table 3: Suggested Intervention Sequence in Treatment of Pediatric Status Epilepticus3,11–14,18,19

(click for larger image) Table 3: Suggested Intervention Sequence in Treatment of Pediatric Status Epilepticus3,11–14,18,19

Psychogenic Nonepileptic Seizure (PNES) and Other Seizure Mimics

PNES is defined as repeated and frequently intractable seizure activity in the absence of epileptogenic changes on concurrently recorded EEG.16 Video EEG is necessary to firmly establish the diagnosis, and psychiatric comorbidities are common in both PNES and epilepsy.16 As many as a quarter of children thought to be suffering from seizures are ultimately found to have PNES.17 Misdiagnosis leads to inappropriate use of antiepileptic drugs with corresponding side effects up to and including the need for mechanical ventilation. Appropriate referral and treatment achieved an 80 percent remission rate in one study.17

Special Populations

Table 4: Select Antiepileptic Drugs (AEDs)2,3,8,20 While numerous new AEDs are now available, it’s unknown if they are any more effective and safer than the old ones.21 While AEDs can lower the chance of a seizure occurrence, they do not treat epilepsy or prevent the development of it.

(click for larger image) Table 4: Select Antiepileptic Drugs (AEDs)2,3,8,20
While numerous new AEDs are now available, it’s unknown if they are any more effective and safer than the old ones.21 While AEDs can lower the chance of a seizure occurrence, they do not treat epilepsy or prevent the development of it.
NOTE: AEDs with US Food and Drug Administration boxed warnings are carbamazepine, felbamate, lamotrigine, perampanel, and valproic acid

There are new imaging techniques such as diffusion tensor images and MRI fused with specialized PET imaging that have improved detection of epileptogenic foci amenable to surgery in children with intractable epilepsy.6

Conclusion

Seizures are a common complaint in children presenting to the emergency department. The initial focus should be on stabilization of vital functions as well as rapid diagnostic workup to exclude treatable secondary causes. Febrile seizures are a unique pediatric pathology where management now mostly focuses on the concurrent, acute febrile illness. Convulsive and nonconvulsive SE are true neurological emergencies and should be stabilized as soon as possible. PNES is common, and video EEG monitoring is required to firmly establish the diagnosis.


Dr. GarberDr. Garber is assistant professor of emergency medicine at Case Western Reserve University in Cleveland.

Dr. GlauserDr. Glauser is professor of emergency medicine at Case Western Reserve University.

References

  1. Dörks M, Langner I, Timmer A, et al. Treatment of paediatric epilepsy in Germany: antiepileptic drug utilisation in children and adolescents with a focus on new antiepileptic drugs. Epilepsy Res. 2013;103(1):45-53.
  2. O’Connell BK, Gloss D, Devinsky O. Cannabinoids in treatment-resistant epilepsy: a review. Epilepsy Behav. 2017;70(Pt B):341-348.
  3. Abend NS, Huh JW, Helfaer MA, et al. Anticonvulsant medications in the pediatric emergency room and intensive care unit. Pediatr Emerg Care. 2008;24(10):705-718.
  4. Fisher RS, Acevedo C, Arzimanoglou A, et al. ILAE official report: a practical clinical definition of epilepsy. Epilepsia. 2014;55(4):475-482.
  5. Gaillard WD, Chiron C, Cross JH, et al. Guidelines for imaging infants and children with recent-onset epilepsy. Epilepsia. 2009;50(9):2147-2153.
  6. Rastogi S, Lee C, Salamon N. Neuroimaging in pediatric epilepsy: a multimodality approach. Radiographics. 2008;28(4):1079-1095.
  7. Maia C, Moreira AR, Lopes T, et al. Risk of recurrence after a first unprovoked seizure in children. J Pediatr (Rio J). 2017;93(3):281-286.
  8. Shorvon SD. The etiologic classification of epilepsy. Epilepsia 2011;52(6):1052-1057.
  9. Berg AT, Nickels K, Wirrell EC, et al. Mortality risks in new-onset childhood epilepsy. Pediatrics. 2013;132(1):124-131.
  10. Kimia AA, Bachur RG, Torres A, et al. Febrile seizures: emergency medicine perspective. Curr Opin Pediatr. 2015;27(3):292-297.
  11. Brophy GM, Bell R, Claassen J, et al. Guidelines for the evaluation and management of status epilepticus. Neurocrit Care. 2012;17(1):3-23.
  12. Silbergleit R, Durkalski V, Lowenstein D, et al. Intramuscular versus intravenous therapy for prehospital status epilepticus. N Engl J Med. 2012;366(7):591-600.
  13. Mastrangelo M, Celato A. Diagnostic work-up and therapeutic options in management of pediatric status epilepticus. World J Pediatr. 2012;8(2):109-115.
  14. Greiner HM, Holland K, Leach JL, et al. Nonconvulsive status epilepticus: the encephalopathic pediatric patient. Pediatrics. 2012;129(3):e748-755.
  15. Glass HC, Kan J, Bonifacio SL, et al. Neonatal seizures: treatment practices among term and preterm infants. Pediatr Neurol. 2012;46(2):111-115.
  16. Scévola L, Teitelbaum J, Oddo S, et al. Psychiatric disorders in patients with psychogenic nonepileptic seizures and drug-resistant epilepsy: a study of an Argentine population. Epilepsy Behav. 2013;29(1):155-160.
  17. Sawchuk T, Buchhalter J. Psychogenic nonepileptic seizures in children—psychological presentation, treatment, and short-term outcomes. Epilepsy Behav. 2015;52(Pt A):49-56.
  18. Kossoff EH, Nabbout R. Use of dietary therapy for status epilepticus. J Child Neurol. 2013;28(8):109-1051.
  19. Rosati A, L’Erario M, Ilvento L, et al. Efficacy and safety of ketamine in refractory status epilepticus in children. Neurology. 2012;79(24):2355-2358.
  20. Tzadok M, Uliel-Siboni S, Linder I, et al. CBD-enriched medical cannabis for intractable pediatric epilepsy: the current Israeli experience. Seizure. 2016;35:41-44.
  21. Rosati A, De Masi S, Guerrini R. Antiepileptic drug treatment in children with epilepsy. CNS Drugs. 2015;29(10):847-863.

The post Tips for Updating Your Approach to Pediatric Seizures appeared first on ACEP Now.

]]>
https://www.acepnow.com/article/tips-for-updating-your-approach-to-pediatric-seizures/feed/ 0
Case Report: Man Presents with Foul-Smelling Leg Wound https://www.acepnow.com/article/case-report-man-presents-with-foul-smelling-leg-wound/ https://www.acepnow.com/article/case-report-man-presents-with-foul-smelling-leg-wound/#respond Wed, 14 Nov 2018 15:31:07 +0000 https://www.acepnow.com/?post_type=article&p=20451 The Case A 30-year-old man presented to the emergency department with a left leg wound that had...

The post Case Report: Man Presents with Foul-Smelling Leg Wound appeared first on ACEP Now.

]]>
Large ulcers with undermined borders and erythematous edges on the patient’s left lateral leg.

The Case

A 30-year-old man presented to the emergency department with a left leg wound that had been present for five years and “worsening over the past four months.” The patient presented because he was on the verge of losing his job because of the odor from the wound. The patient described the lesion as painful, making it difficult to ambulate. He denied recent trauma to the area. However, he had a remote history of a car accident years ago but didn’t remember any injury to the leg. He reported subjective fevers, nausea, and vomiting over the past few weeks. His past medical history was significant for smoking and nephrotic syndrome. No family history of autoimmune disorders was reported, and he denied any prior dermatological conditions.

Figure 2 (BELOW): Large ulcers with undermined borders and erythematous edges on the patient’s left medial leg.

Figure 2: Large ulcers with undermined borders and erythematous edges on the patient’s left medial leg.
GINA VENTO, MATTHEW ROEHRS, DAVID EFFRON

Upon entering the patient’s room, an intense, putrid odor was noted. The patient appeared in no acute distress, and his vital signs were normal. The patient had large ulcers with undermined borders and erythematous edges on the entire aspect of his left lateral and medial leg (see Figures 1 and 2). The leg was diffusely tender to palpation, with distal strength and sensation intact. No edema was noted. Dorsalis pedis and posterior tibial pulses were intact.

Workup for the patient included basic labs and a wound culture. Radiographs of the tibia showed a large soft tissue defect overlying the medial aspect of the proximal and mid tibia with no periosteal reaction to suggest osteomyelitis. The patient’s labs were significant for a leukocytosis of 13.7, hemoglobin of 9.7, normal lactate, and renal dysfunction with a creatinine of 2.67. The patient was started on vancomycin and Zosyn (piperacillin and tazobactam) and admitted to the medicine service. Dermatology and general surgery were consulted once the patient was admitted.

Background

Skin complaints are common reasons for visits to the emergency department, with skin infections, such as cellulitis, being one of the most common. Differentiating toxic skin conditions from benign skin conditions is essential. This patient’s condition could be concerning for a necrotizing infection, but that possibility is less likely given the time frame. Initial concern was for a chronic infection. The patient’s wound cultures grew Staph, which could have been a contaminant versus infection. Punch biopsy revealed acute and chronic inflammation. Dermatology concluded that this presentation was consistent with pyoderma gangrenosum.

The incidence of pyoderma gangrenosum is estimated to be three to 10 cases per million people per year. It is often associated with systemic disease such as inflammatory bowel disease, arthropathies, and hematologic diseases. The pathogenesis is thought to be related to neutrophil dysfunction with a component related to abnormal immune system response. Treatment is dependent on the severity of the disease. Local pyoderma gangrenosum is treated with a barrier cream and wound care to try to prevent infection. Topical steroids can also be used. If the disease is more severe, systemic corticosteroid therapy should be considered. If this does not seem to be helping, cyclosporine should be considered. Systemic steroids can result in improvement in as little as one week. It is also important to address underlying systemic disease that may be contributing to the condition.

Case Resolution

This patient was discharged on prednisone 50 mg twice a day, with a plan to taper over several weeks. It was also recommended that the patient use Vaseline with Xeroform and Kerlix for dressing changes. Cyclosporine could not be considered for this patient as he had renal disease. The patient was discharged from the hospital and was told to follow up closely with dermatology. The patient did not show up for his follow-up visits and was lost to follow-up.


Dr. Vento is an emergency medicine resident at MetroHealth in Cleveland.

Dr. Roehrs and Dr. Effron are emergency physicians at MetroHealth.

Resources for Further Reading

The post Case Report: Man Presents with Foul-Smelling Leg Wound appeared first on ACEP Now.

]]>
https://www.acepnow.com/article/case-report-man-presents-with-foul-smelling-leg-wound/feed/ 0
ACEP Submits Comments in Response to PFS Schedule and QPP Rule https://www.acepnow.com/article/acep-submits-comments-in-response-to-pfs-schedule-and-qpp-rule/ https://www.acepnow.com/article/acep-submits-comments-in-response-to-pfs-schedule-and-qpp-rule/#respond Wed, 14 Nov 2018 15:31:07 +0000 https://www.acepnow.com/?post_type=article&p=20449 ACEP submitted a robust set of comments responding to the calendar year 2019 Medicare Part B physician...

The post ACEP Submits Comments in Response to PFS Schedule and QPP Rule appeared first on ACEP Now.

]]>
ACEP submitted a robust set of comments responding to the calendar year 2019 Medicare Part B physician fee schedule (PFS) and Quality Payment Program (QPP) proposed rule. This rule included numerous policies that impact physician payments under Medicare, most notably a proposal that would streamline documentation requirements and create a blended payment rate for office/outpatient evaluation and management (E/M) level 2 through 5 codes. However, the proposal does not initially impact the emergency medicine E/M code set. The rule also proposes a set of policies related to the third year of the QPP, the performance program established by the Medicare Access and CHIP Reauthorization Act.

The post ACEP Submits Comments in Response to PFS Schedule and QPP Rule appeared first on ACEP Now.

]]>
https://www.acepnow.com/article/acep-submits-comments-in-response-to-pfs-schedule-and-qpp-rule/feed/ 0
Lessons Learned from Court Case that Weakened Peer-Review Protection https://www.acepnow.com/article/lessons-learned-from-court-case-that-weakened-peer-review-protection/ https://www.acepnow.com/article/lessons-learned-from-court-case-that-weakened-peer-review-protection/#respond Wed, 14 Nov 2018 15:31:06 +0000 https://www.acepnow.com/?post_type=article&p=20456 On March 27, 2018, the the Supreme Court of Pennsylvania sent every emergency medicine contracting group scrambling...

The post Lessons Learned from Court Case that Weakened Peer-Review Protection appeared first on ACEP Now.

]]>
shutterstock.com

On March 27, 2018, the the Supreme Court of Pennsylvania sent every emergency medicine contracting group scrambling to ensure their peer-review processes were comporting with the laws in their respective states. Taking a very strict interpretation of the Pennsylvania Peer Review Protection Act (PRPA), the court held that the emergency medicine contracting group, UPMC Emergency Medicine, Inc. (ERMI), did not qualify as a “professional health care provider” under the PRPA and was thus not given the evidentiary privilege afforded by the state’s peer-review statute.

The court ruling stems from the medical malpractice action of Reginelli v Boggs. The clinical story is a seemingly familiar one in emergency medicine, whereby a patient presents to the emergency department with epigastric discomfort, returning later with a misdiagnosed myocardial infarction. The issues soon turned from the basic elements of a negligence claim to the discoverability of peer-review material. During a deposition, it became apparent that Brenda Walther, MD, the ED director, maintained a “performance file” on the physicians in the group, including the defendant, Marcellus Boggs, MD. The plaintiffs filed a motion to compel production of the performance file, which was allowed by virtue that “ERMI, as an independent contractor, is not an entity enumerated in the PRPA as being protected by peer review privilege.”

The PRPA articulates that “peer review” is undertaken and protected by “professional health care providers,” which are defined as those “individuals or organizations who are approved, licensed, or otherwise regulated to practice or operate in the health care field under the laws of the Commonwealth.”1 Among the 12 protected individuals or organizations listed in the act, two are “a physician and a corporation or other organization operating as a hospital.”1

The Supreme Court of Pennsylvania affirmed the appellate court’s assertion that ERMI did not “qualify as a health care provider under the PRPA, because it is not approved, licensed, or otherwise regulated to practice or operate in the health care field in Pennsylvania, and it did not become one because one of its employees (Walther) conducted an evaluation of another of its employees (Boggs).”

The court suggested that peer-review protections would have been afforded to ERMI and Dr. Boggs had Dr. Walther been a designated and documented member of the hospital’s peer-review committee. Alternatively, the court asserted that the evidentiary privilege could have been afforded had the staffing hospital established a formal written affiliation with ERMI as an outside entity to conduct its peer-review processes for the emergency department. Although the court record alluded to an existing quasi-contractual peer-review arrangement at the trial phase of the proceedings, the agreement was not provided in a timely fashion to the court and thus became inadmissible on appellate review.

While it is a tough pill to swallow, the ruling in this case should prompt the majority of emergency medicine groups to reassess the protections their peer-review processes have in the context of the statutes in the states where they operate.

Lessons Learned

  1. Review your state’s peer-review statute to ensure strict compliance.
  2. Confirm written affiliation between the hospital and the ED group/director to specifically perform the peer-review process.
  3. Consider making the ED director or other group designee a member of the hospital peer-review process/committee.
  4. Identify all peer-review personnel, materials, and processes as affirmatively falling within the peer-review statutory authority.
  5. Periodically update the hospital/group agreement using language commensurate with that of the protecting peer-review statute.
  6. Mark all peer-review correspondences in any form (written, oral, electronic, etc.) as protected peer-review material.

Dr. Totz is facility medical director at First Choice Emergency Room at Adeptus Health in Texas.

Reference

  1. 63 Pa Stat § 425.2.

The post Lessons Learned from Court Case that Weakened Peer-Review Protection appeared first on ACEP Now.

]]>
https://www.acepnow.com/article/lessons-learned-from-court-case-that-weakened-peer-review-protection/feed/ 0
Dr. Christina Maslach Discusses the Roots of Burnout, Part 2 https://www.acepnow.com/article/dr-christina-maslach-discusses-the-roots-of-burnout-part-2/ https://www.acepnow.com/article/dr-christina-maslach-discusses-the-roots-of-burnout-part-2/#respond Tue, 23 Oct 2018 17:58:49 +0000 https://www.acepnow.com/?post_type=article&p=20342 When Christina Maslach, PhD, started her psychology research career in the early 1970s, she didn’t know her...

The post Dr. Christina Maslach Discusses the Roots of Burnout, Part 2 appeared first on ACEP Now.

]]>
When Christina Maslach, PhD, started her psychology research career in the early 1970s, she didn’t know her work would lead to the Maslach Burnout Inventory, a measure for professional burnout still being used today. She first published the inventory with coauthor Susan E. Jackson in 1981. Dr. Maslach, who is professor of psychology at the University of California, Berkeley, has researched and published extensively about burnout throughout her career and has helped to define the way we discuss and understand the combination of stress, exhaustion, and powerlessness that endangers the careers—and lives—of many emergency physicians.

ACEP Now Medical Editor-in-Chief Kevin Klauer, DO, EJD, FACEP, recently sat down with Dr. Maslach to discuss the early research that led to her developing the Maslach Burnout Inventory, and what she’s learned from decades of talking to people about burnout. Here is Part 2 of their conversation. Part 1 appeared in the September issue.

KK: I’m noticing people moving away from the term “burnout” and moving toward “resiliency.” What are your thoughts on that?

Dr. Christina Maslach

Dr. Christina Maslach

CM: On the one hand, I think it’s a good strategy to focus on what are the positive goals we could move toward. People are going to be more highly motivated to make things better—let’s improve the situation—rather than simply focusing on the negative. In fact, we did that in our research earlier when we started focusing on what we were calling engagement as the opposite of what we were seeing in terms of burnout.

Where I would disagree a little bit is that resilience is really focusing on individual characteristics such as how well you cope, how well you take care of yourself, etc. The biggest challenge I find right now is that people keep thinking of burnout as a personal problem, and how do we get people to fix themselves? What that means is, we’re not paying attention to all of the causes of the problem.

Years ago, there was a cartoon showing a medical doctor in a white lab coat running on a treadmill really fast, with a huge fire and flames licking at his heels. Resiliency is directed at how to make you run faster, be stronger, last longer, etc., but it’s not doing a thing about the fire. At some point, we really need to make sure that we’re looking at both, but being healthy, getting enough rest, meditating, and doing yoga aren’t going to solve the problem. I’m a believer in what’s happening upstream is causing this problem.

KK: Do you recall either a specific time or a specific individual where you thought your interaction with somebody saved a life?

ABOVE: Image from the cover of the issue of Human Behavior magazine where Dr. Maslach published her first article in 1976. LEFT: Cover of Burnout: The Cost of Caring, published in 1982.

ABOVE: Image from the cover of the issue of Human Behavior magazine where Dr. Maslach published her first article in 1976.
LEFT: Cover of Burnout: The Cost of Caring, published in 1982.

CM: I will go back to that very first article based on all the interviews I did, where I spoke with people. The reaction that I got to that paper was huge, and people would write or call and say, “I read your article, and now I realize I have a different understanding of what’s happening and what I need to do.”

KK: Do you have any suggestions for emergency physicians to avoid burnout, recognize it, manage it?

CM: Everybody thinks of burnout primarily in terms of workload. The demands are way too high combined with too few resources, etc. That is a predictor of the exhaustion part of burnout. The research is showing us that there are at least five other areas between people and the job that can predict burnout, or greater engagement with work.

  1. The workload issue.
  2. The extent to which you have some sort of control, autonomy, or discretion over how you do your job.
  3. Reward, which is positive feedback, getting positive feedback when you’ve done good work. What we’re finding is that it’s not so much salary or benefits; it’s social reward and recognition.
  4. Community, which is the workplace community (eg, your colleagues, bosses, the people you supervise, any­body who you come in contact with on a regular basis). If there is a toxic work environment where people don’t trust each other, don’t feel that everybody has their back and they have theirs, there’s no support. There’s destructive competition—it is deadly.
  5. Fairness. Whatever the rules are, there should be a fair way in which they are administered to avoid issues of discrimination and not treating people fairly and well.
  6. Values. It’s what is driving you to do that kind of work, your passion. I see that in health care when we get into how many minutes can you spend with each patient, getting the beds turned, the financial pressure that is eating into the quality of care that they’re providing. That can also be a great source of burnout.

KK: Absolutely, and knowing those domains is critically important. Some call it health care reform, but I think it’s really payment reform. Spending less time with patients and providing less value, that sixth component, is putting a lot of pressure on us, which is weakening our resilience, and making burnout worse. Thank you so much for your time and your wonderful work. You truly have benefited emergency medicine.

The post Dr. Christina Maslach Discusses the Roots of Burnout, Part 2 appeared first on ACEP Now.

]]>
https://www.acepnow.com/article/dr-christina-maslach-discusses-the-roots-of-burnout-part-2/feed/ 0
A Quick Guide to Buprenorphine Products https://www.acepnow.com/article/a-quick-guide-to-buprenorphine-products/ https://www.acepnow.com/article/a-quick-guide-to-buprenorphine-products/#respond Tue, 23 Oct 2018 17:56:39 +0000 https://www.acepnow.com/?post_type=article&p=20377 There are multiple forms for buprenorphine (commonly called bupe), and this can prove confusing. Although we may...

The post A Quick Guide to Buprenorphine Products appeared first on ACEP Now.

]]>
Dr P. Marazzi/Science Source

Dr P. Marazzi/Science Source
Hailshadow/iStock/Getty Images
Shutterstock.com

There are multiple forms for buprenorphine (commonly called bupe), and this can prove confusing. Although we may never use most of these formulations in the emergency department, we should be familiar with them.

Sublingual Tablets and Film Strips

This is the primary formulation used in the emergency department and hospital as well as the most common form for those prescribed bupe for the treatment of opioid use disorder (OUD) and for patients who are prescribed bupe for pain. The film strips are preferred by my patients because they dissolve fast and tend to not taste too bitter.

The naloxone is included to prevent drug abusers from crushing the tab or strip and inhaling it or dissolving and injecting the medication. Naloxone has a very poor sublingual (SL) and oral bioavailability (less than 2 percent). However, naloxone has a very high intranasal and IV bioavailability, which is a deterrent to misuse of the medication. Patients and health care providers are often confused by the combination of bupe and naloxone because buprenorphine can precipitate withdrawal in opioid-dependent patients. However, buprenorphine-precipitated withdrawal is a feature of the pharmacology of bupe itself and has nothing to do with the naloxone component of Suboxone. When Suboxone is taken sublingually as intended, the naloxone has no bioavailability and no effect.

Bupe also has poor oral bioavailability—only about 15 percent if swallowed. Furthermore, it is important to remember that bupe tabs or strips must be placed sublingually, not anywhere else in the mouth; it’s not an oral dissolving tablet like ondansetron.

There is also a SL bupe mono-product, the most common brand name of which is Subutex, produced by Indivior, the same company that makes Suboxone. Subutex is only produced in tablet form. It is generally available in 2 mg and 8 mg strengths. Most generic forms are in the same dose formulations as the Suboxone or Subutex products (eg, 8 mg/2 mg or simply 8 mg, respectively).

When is the bupe mono-product indicated instead of the dual product? The most common clinical indication is pregnancy because the safety of routine naloxone exposure during pregnancy remains somewhat in question. However, recent small studies suggest the dual product is safe in pregnancy.1,2

The other common use of Subutex is in clinics, hospitals, etc., where the medication is administered by a nurse and there is no worry it will be crushed and injected. In my clinic and emergency department, we use only the generic mono-product bupe (administered by a nurse) because it is less expensive. We stock 8 mg and 2 mg SL tablets.

Many patients buy bupe, administering their own medication-assisted treatment. When patients speak of treating their symptoms or self-medicating with “strips,” they are usually speaking of 8 mg/2 mg bupe/naloxone film strips. Clearly, bupe does have street value. However, the street value of bupe is far less than that of other prescription opioids.

Injectable Buprenorphine

Buprenex, the common brand of injectable bupe, comes in 0.3 mg/1 mL vials. Bupe is a potent analgesic, and as an analgesic, bupe 0.3 mg IV is equivalent to about 7.5 mg of IV morphine. However, it has a much longer half-life. Of note, although the half-life of bupe as an analgesic is only about eight hours, its half-life when treating OUD is much longer (about 36 hours) but is dose-dependent.

The IV form of bupe is not commonly used in the United States but has been used as an IV analgesic in other parts of the world since the 1980s. The use of injectable bupe is growing in American veterinary medicine. Due to its much higher affinity for the mu receptor, IV bupe has also been used in some emergency departments to reverse acute opioid overdoses.3

Transdermal Buprenorphine Patches

Butrans is the brand name of the transdermal bupe patches used to treat chronic pain. While Butrans may be effective in treating OUD, it is not usually prescribed for OUD, and it has a U.S. Food and Drug Administration (FDA) indication only for chronic pain in the “opioid-experienced” patient. Generally, patients are switched to Butrans patches after developing a tolerance to traditional opioids.

The patches come in dosing strengths of 5, 7.5, 10, 15, and 20 mcg/hour and are changed every seven days. The 10 mcg/hour patch is approximately equianalgesic to 80 mg/day of oral morphine. Note that bupe patches, intended for the opioid-dependent patient, release much fewer mcg/hour of buprenorphine than fentanyl patches do of fentanyl.

Implantable Buprenorphine

Probuphine is a long-term implantable form of buprenorphine that delivers a continuous, stable blood level of bupe for the treatment of OUD. Four implants inserted subdermally in the upper arm (in an office procedure) release a total dose of bupe similar to a daily sublingual 8 mg dose for six months. The dose equivalent of only 8 mg/day SL is lower than the effective dose for most patients treated for OUD with bupe SL. This low equivalent dose along with the cost and the need to obtain insurance approval are factors that prevent more widespread use.

Depot Subcutaneous Buprenorphine

Sublocade is the newest long-acting form of bupe on the market, FDA-approved in late 2017 for treating OUD. This depot form of bupe is injected monthly in 100 mg and 300 mg doses into the abdominal subcutaneous tissue to continuously release a dosage equivalent to 8–24 mg/day of SL bupe. Although more patients with OUD could more easily remain compliant in bupe medication-assisted treatment, the number of patients receiving Sublocade remains low. The cost and the need to obtain insurance approval are factors that prevent more widespread use.

There may be a future role for depot injectable forms of bupe in the emergency department to ensure sustained opioid withdrawal management for patients after discharge from the emergency department or to serve as a longer bridge of sobriety for referral to an opioid addiction treatment clinic.


Read the drug summary for Suboxone.


Dr. Ketcham is medical director of the opioid addiction treatment service via New Mexico Treatment Services in Farmington, co-medical director of EMS agencies of San Juan County, and a staff emergency physician at San Juan Regional Medical Center in Farmington and Los Alamos Medical Center

References

  1. Debelak K, Morrone WR, O’Grady KE, et al. Buprenorphine + naloxone in the treatment of opioid dependence during pregnancy-initial patient care and outcome data. Am J Addict. 2013;22(3):252-254.
  2. Nguyen L, Lander LR, O’Grady KE, et al. Treating women with opioid use disorder during pregnancy in Appalachia: initial neonatal outcomes following buprenorphine + naloxone exposure. Am J Addict. 2018;27(2):92-96.
  3. Zamani N, Hassanian-Moghaddam H. Intravenous buprenorphine: a substitute for naloxone in methadone-overdosed patients? Ann Emerg Med. 2017;69(6):737-739.

The post A Quick Guide to Buprenorphine Products appeared first on ACEP Now.

]]>
https://www.acepnow.com/article/a-quick-guide-to-buprenorphine-products/feed/ 0
Suboxone 101: The Skinny on This Opioid-Dependence Drug https://www.acepnow.com/article/suboxone-101-the-skinny-on-this-opioid-dependence-drug/ https://www.acepnow.com/article/suboxone-101-the-skinny-on-this-opioid-dependence-drug/#respond Tue, 23 Oct 2018 17:55:07 +0000 https://www.acepnow.com/?post_type=article&p=20373 Suboxone is a sublingual (SL) film dosage form containing a partial opioid agonist (buprenorphine) and an opioid antagonist (naloxone) for treating opioid dependence.1...

The post Suboxone 101: The Skinny on This Opioid-Dependence Drug appeared first on ACEP Now.

]]>
Shutterstock.com

Suboxone is a sublingual (SL) film dosage form containing a partial opioid agonist (buprenorphine) and an opioid antagonist (naloxone) for treating opioid dependence.1 It is a Schedule III Controlled Substance that was originally approved by the U.S. Food and Drug Administration (FDA) in August 2010. It should be used as part of a complete treatment plan that includes psychosocial support and counseling.

Prescribing Suboxone is limited under the Drug Addiction Treatment Act (DATA), which states that prescription use of Suboxone to manage opioid dependence is limited to health care providers who meet certain qualifying requirements, have notified the Secretary of Health and Human Services (HHS) of their intent to prescribe this product for the treatment of opioid dependence, and have been assigned a unique identification number that must be included on every prescription.2,3

Administration

Suboxone is administered sublingually or buccally as a single daily dose, which should not be cut, chewed, or swallowed. One film should be placed under the tongue close to the base on the left or right side and allowed to completely dissolve. For buccal administration, the film should be placed on the inside of the left or right cheek and allowed to completely dissolve.

Dosing

To avoid precipitating withdrawal, induction with Suboxone should be undertaken when clear and objective withdrawal signs are evident.1,4 Whether the patient’s opioid dependence is with long-acting or short-acting drugs should be considered.

Initially, Suboxone should be given in divided doses. In patients dependent on short-acting opioids, start with up to 8 mg/2 mg (buprenorphine/naloxone) on Day 1 in divided doses. On Day 2, give a single dose of up to 16 mg/4 mg. For methadone or long-acting opioid dependence products, induction onto SL buprenorphine monotherapy is initially recommended for Days 1 and 2.

For maintenance treatment, the target Suboxone dosage is usually a single dose of 16 mg/4 mg. From Day 3 onward, doses should be progressively adjusted in increments/decrements of 2 mg/0.5 mg or 4 mg/1 mg to a level that suppresses withdrawal.

Provision of multiple refills is not advised early in treatment or without appropriate patient follow-up. Patients should be monitored at least weekly for the first month. Once the patient has achieved a stable dosage and their assessment (eg, urine drug screening) does not indicate illicit drug use, less frequent follow-up visits may be appropriate. There is no maximum recommended duration of maintenance treatment. Patients may need to remain on treatment indefinitely.

Drug Safety

Buprenorphine-containing transmucosal products for the treatment of opioid dependence (BTOD) for the risk evaluation and mitigation strategy (REMS) program is an FDA-required program designed to ensure informed risk-benefit decisions prior to beginning treatment and during treatment with BTOD drugs.5 This product’s REMS is to decrease the risk of abuse, addiction, misuse, overdose, and drug interactions leading to respiratory depression. Other adverse reactions include transaminitis, hypotension, hypersensitivity reactions, and central nervous system (CNS) depression.

Additionally, it is extremely dangerous to self-administer non-prescribed benzodiazepines or other CNS depressants (including alcohol) while taking BTODs.

Buprenorphine/Naloxone Products List4

Buprenorphine/naloxone products include:

  • Suboxone SL film in strengths of buprenorphine 2 mg/naloxone 0.5 mg, buprenorphine 4 mg/naloxone 1 mg, buprenorphine 8 mg/naloxone 2 mg, and buprenorphine 12 mg/naloxone 3 mg
  • Bunavail buccal film in strengths of buprenorphine 2.1 mg/naloxone 0.3 mg, buprenorphine 4.2 mg/naloxone 0.7 mg, and buprenorphine 6.3 mg/naloxone 1 mg
  • Zubsolv SL tablet in strengths of buprenorphine 0.7 mg/naloxone 0.18 mg, buprenorphine 1.4 mg/naloxone 0.36 mg, buprenorphine 2.9 mg/naloxone 0.71 mg, buprenorphine 5.7 mg/naloxone 1.4 mg, buprenorphine 8.6 mg/naloxone 2.1 mg, and buprenorphine 11.4 mg/naloxone 2.9 mg
  • Buprenorphine/naloxone generic SL tablet, in strengths of buprenorphine 2 mg/naloxone 0.5 mg, buprenorphine 8 mg/naloxone 2 mg, buprenorphine 12 mg/naloxone 3 mg, and buprenorphine 16 mg/naloxone 4 mg

Price4

Sixty pouches of Suboxone SL film cost approximately $328 (2 mg/0.5 mg), $587 (4 mg/1 mg and 8 mg/2 mg), and $1,174 (12 mg/3 mg), according to Lexi-Drugs. Thirty generic SL tablets of buprenorphine/naloxone cost approximately $175 (2 mg/0.5 mg) and $313 (8 mg/2 mg).


Read the emergency medicine commentary on Suboxone.


Dr. Kaufman is a board-certified geriatric pharmacist, a pharmacist at NewYork-Presbyterian/Lower Manhattan Hospital, and a freelance medical writer and editor.

References

  1. Drugs @ FDA, Suboxone prescribing information. U.S. Food and Drug Administration website. Accessed September 28, 2018.
  2. Controlled Substances Act, 21 USC §823(g) (1974).
  3. Buprenorphine. Substance Abuse and Mental Health Services Administration website. Accessed September 28, 2018.
  4. Buprenorphine/naloxone products. Lexicomp Online [database online]. Hudson, OH: Wolters Kluwer Clinical Drug Information. Updated May 3, 2018. Accessed May 15, 2018.
  5. Office-based buprenorphine therapy for opioid dependence: important information for prescribers. BTOD REMS website. Accessed September 28, 2018.

The post Suboxone 101: The Skinny on This Opioid-Dependence Drug appeared first on ACEP Now.

]]>
https://www.acepnow.com/article/suboxone-101-the-skinny-on-this-opioid-dependence-drug/feed/ 0
Determining a Fair Price for Health Care https://www.acepnow.com/article/determining-a-fair-price-for-health-care/ https://www.acepnow.com/article/determining-a-fair-price-for-health-care/#respond Tue, 23 Oct 2018 13:31:59 +0000 https://www.acepnow.com/?post_type=article&p=20389 Editor’s Note: Read Dr. Cedric Dark’s commentary on this EMRA + PolicyRx Health Policy Journal Club article....

The post Determining a Fair Price for Health Care appeared first on ACEP Now.

]]>
Editor’s Note: Read Dr. Cedric Dark’s commentary on this EMRA + PolicyRx Health Policy Journal Club article.

There is no standard for how much health care services should cost nationally, so it is difficult to determine if and how much hospitals and clinics “overcharge.” Insurers do not reimburse the full charges, and health care bills may be inflated to adjust for the reduced reimbursement.

A recent study in JAMA Internal Medicine compared Medicare reimbursement to billed services.1 Medicare provides health insurance for the elderly and reimburses hospitals with predetermined and fixed prices. These reimbursements are called “allowed charges.” Allowed charges were used as a proxy for the true price of health care services.

To determine the excess markup of health care services, this retrospective study analyzed Medicare Part B claims submitted in 2013. The study included services provided by 12,337 emergency physicians and 57,607 internal medicine physicians who were affiliated with thousands of hospitals. Markup was defined as the ratio of charges billed to Medicare compared to Medicare allowable charges. The study then compared markup between hospitals and between specialties.

The study determined that services delivered by emergency physicians were billed at 4.4 times the allowable Medicare payment, while services delivered by internists were billed at 2.1 times the allowable Medicare payment. Hospitals ranged greatly in terms of markup, with emergency services varying from 1 to 12.6 times the allowable amount. For-profit hospitals, hospitals with a high proportion of uninsured patients, and hospitals in the Southeast had greater markups.

The findings of this study must be put into context to understand their implications. This study used Medicare allowed charge as a proxy for health care prices, which represents a significant limitation. Medicare reimbursement has increased less than the inflation rate since the mid 1990s and may significantly undervalue true health care costs.

To understand the findings of the study, we need to make health care costs more transparent. The Fair Health claims database (www.fairhealth.org), for example, is dedicated to gathering independent and unbiased health care cost information. The nation should employ databases like this to advocate for less arbitrary reimbursement by insurance companies and to promote health care billing that is consistent with true cost.


Ms. Goldstein is a dual-degree student at NYU School of Medicine and the Wagner School of Public Service in New York City.

References

  1. Xu T, Park A, Bai G, et al. Variation in emergency department vs internal medicine excess charges in the United States. JAMA Intern Med. 2017;177(8):1139-1145.

The post Determining a Fair Price for Health Care appeared first on ACEP Now.

]]>
https://www.acepnow.com/article/determining-a-fair-price-for-health-care/feed/ 0
How Can Health Care Stakeholders Agree on Fair Prices for Our Services? https://www.acepnow.com/article/how-can-health-care-stakeholders-agree-on-fair-prices-for-our-services/ https://www.acepnow.com/article/how-can-health-care-stakeholders-agree-on-fair-prices-for-our-services/#respond Tue, 23 Oct 2018 13:30:32 +0000 https://www.acepnow.com/?post_type=article&p=20382 Emergency medicine, insurance companies, and patients currently exist in what I see as a standoff. The tension...

The post How Can Health Care Stakeholders Agree on Fair Prices for Our Services? appeared first on ACEP Now.

]]>
ILLUSTRATION: Chris Whissen & SHUTTERSTOCK.com

Emergency medicine, insurance companies, and patients currently exist in what I see as a standoff. The tension between the three parties will remain ever present until an outside force, likely governmental, comes in to resolve the conflict. However, why are each of these parties pointing fingers at one another in the first place? The principle reason is that while we all pretend that American health care functions as a market, like many other goods and services in the United States, emergency care certainly does not conform to market principles like Lasik surgery or joint replacements do.

When someone is having a heart attack, they do not have time to comparison shop. When a patient checks into the emergency department, the clinicians cannot determine in advance if the “customer” is willing and able to pay for the services provided. When you throw third-party payers into the mix, you wind up either with price controls (eg, Medicare and Medicaid) or out-of-network billing (for private insurers) wherever it isn’t prohibited. Arguably, the patients are most protected financially in the former situation, least in the latter. Providers, on the other hand, face the opposite financial risks.

Although emergency departments are taking a beating in the media over their billing practices, out-of-network billing is probably less common now than it was just a decade ago.1,2 For many reasons, including the increasing prevalence of high-deductible coverage, patients are finally becoming cost-conscious. The questions that no one seems to be able to answer: What is a fair price in an imperfect market? Should emergency services be a multiple of the Medicare price? Should it be the usual and customary physician charge or a function of the in-network payment agreed to by providers willing to accept the insurer’s reimbursement?

In a marketplace where EMTALA can effectively drive private insurance rates down to zero and where “your money or your life” allows physicians and hospitals to set charges infinitely high, it is imperative that states and/or the federal government establish an actual database where everyone—physicians, insurers, and patients—can see both the charges and the actual reimbursement rates so that a fair price for emergency services can be determined.

Cameron Gettel, MD, in a recent EMRA+PolicyRx Health Policy Journal Club article, articulates why this is high stakes for emergency physicians: “Transparency in how insurance companies provide fair coverage for their beneficiaries and calculate payments to providers is greatly needed as the present one-sided media perspective has misled the public by placing blame solely on physicians.”2 This month’s EMRA+PolicyRx Health Policy Journal Club article anticipates that without a standard for how much health care services should cost, our work will inevitably be compared to Medicare prices.


Cedric Dark, MD, MPHDr. Dark is assistant professor of emergency medicine at Baylor College of Medicine in Houston and executive editor of PolicyRx.org.

References

  1. Kliff S. Emergency rooms are monopolies. Patients pay the price. Vox website. Accessed Sept. 28, 2018.
  2. Gettel C. Nobody likes surprises. EMRA website. Accessed Sept. 28, 2018.

The post How Can Health Care Stakeholders Agree on Fair Prices for Our Services? appeared first on ACEP Now.

]]>
https://www.acepnow.com/article/how-can-health-care-stakeholders-agree-on-fair-prices-for-our-services/feed/ 0
ACEP Responds to The New York Times Opinion by Dr. Glenn Melnick https://www.acepnow.com/article/acep-responds-to-the-new-york-times-opinion-by-dr-glenn-melnick/ https://www.acepnow.com/article/acep-responds-to-the-new-york-times-opinion-by-dr-glenn-melnick/#respond Tue, 16 Oct 2018 18:00:07 +0000 https://www.acepnow.com/?post_type=article&p=20311 ACEP Immediate Past President Paul Kivela, MD, MBA, FACEP, responded to the Sept. 5, 2018, op-ed by...

The post ACEP Responds to <em>The New York Times</em> Opinion by Dr. Glenn Melnick appeared first on ACEP Now.

]]>
ACEP Immediate Past President Paul Kivela, MD, MBA, FACEP, responded to the Sept. 5, 2018, op-ed by Glenn Melnick, PhD, about emergency departments’ contributions to the high cost of health care with corrections on the misinformation presented and hopes for how these issues could be solved. Read the full response at newsroom.acep.org. Here are some highlights from Dr. Kivela’s response:

“Insurance companies are taking advantage of hospital emergency departments, because they have a federal mandate to provide care, regardless of insurance coverage or ability to pay, giving negotiating power to the insurance industry.

“Unfortunately, health insurance companies are ignoring a real solution to ‘surprise’ medical bills and misleading customers and the public when they blame physicians. The Fair Health database, which was developed in response to an insurance company that was fraudulently calculating payments for emergency care, is the best mechanism available to ensure transparency and to make sure insurance companies provide fair payments.”

The post ACEP Responds to <em>The New York Times</em> Opinion by Dr. Glenn Melnick appeared first on ACEP Now.

]]>
https://www.acepnow.com/article/acep-responds-to-the-new-york-times-opinion-by-dr-glenn-melnick/feed/ 0