We had our January journal club at Vines, discussing 3 articles on different topics.

1- The first was an editorial on legal cases related to use of medical stents. The authors highlight the inter-rater difference in assessment of coronary blockages between even advanced interventional cardiologists. This has legal implications as cardiologists are prosecuted for unnecessary procedures. This article is important to EM no as much for the medical content (we don’t place stents), but for the precedent of the legal system prosecuting physicians for doing what they were trained to do.

2- The second article in Annals EM looked at 24,459 ED patients with chest pain who were deemed to require outpatient stress testing. The conclusion: “Less than one third of patients completed outpatient stress testing within the guideline-recommended 3 days after initial evaluation. More important, the low adverse event rates suggest that selective outpatient stress testing is safe. In this cohort of patients selected for outpatient cardiac stress testing in a well-integrated health system, there does not appear to be any associated benefit of stress testing within 3 days, nor within 30 days, compared with those who never received testing at all. The lack of benefit of obtaining timely testing, in combination with low rates of objective adverse events, may warrant reassessment of the current guidelines.” Notice that this does not change guidelines, but ads to the conversation on proper use of resources and how aggressively we should work up chest pain in low risk patients.

3- The final article, the 2018 flu guidelines, sound similar to prior years, with focus of testing and treatment on patients at risk for complications. They do throw in the recommendation to test “if the results might influence antiviral treatment decisions or reduce use of unnecessary antibiotics, further diagnostic testing, and time in the emergency department, or if the results might influence antiviral treatment or chemoprophylaxis decisions for high-risk household contacts.” Physicians should start treatment right away for

• Persons of any age who are hospitalized with influenza, regardless of illness duration prior to hospitalization (A-II).
• Outpatients of any age with severe or progressive illness, regardless of illness duration (A-III).
• Outpatients who are at high risk of complications from influenza, including those with chronic medical conditions and immunocompromised patients (A-II).
• Children younger than 2 years and adults ≥65 years (A-III).
• Pregnant women and those within 2 weeks postpartum (A-III).

And we can consider treatment for

• Outpatients with illness onset ≤2 days before presentation (C-I).
• Symptomatic outpatients who are household contacts of persons who are at high risk of developing complications from influenza, particularly those who are severely immunocompromised (C-III).
• Symptomatic healthcare providers who care for patients who are at high risk of developing complications from influenza, particularly those who are severely immunocompromised (C-III).

Hope everyone enjoyed Journal Club, looking forward to the February articles