Rapid Increase in ER Visits For Young Girls With Self-Inflicted Injuries

MedicalResearch.com Interview with:

Dr. Melissa C. Mercado PhD, MSc, MA Behavioral scientist Division of Violence Prevention National Center for Injury Prevention and Control CDC

Dr. Mercado

Dr. Melissa C. Mercado PhD, MSc, MA
Behavioral scientist
Division of Violence Prevention
National Center for Injury Prevention and Control
CDC

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Suicide ranks as the 10th leading cause of death for all age groups combined and has been among the top 12 leading causes of death since 1975 in the U.S. In 2015, across all age groups, suicide was responsible for 44,193 deaths in the U.S., which is approximately one suicide every 12 minutes.

Suicide was the second leading cause of death among U.S. youth aged 10-24 years in 2015. Self-inflicted injury is one of the strongest risk factors for suicide.

This study examined trends in non-fatal self-inflicted injuries treated in hospital emergency departments (EDs) among youth aged 10 to 24 years in the United States from 2001-2015.  The overall weighted age-adjusted rate for this group increased by 5.7% annually during the 2008 to 2015 period.  Age-adjusted trends for males overall and across age groups remained stable throughout 2001-2015.  However, rates among females increased significantly, by 8.4% annually. The largest increase among females was observed among those aged 10-14 years, with an increase of 18.8% annually from 2009 to 2015.

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How Much Non-Invasive Testing Is Necessary In ER To Rule Out Heart Attack?

MedicalResearch.com Interview with:

David L. Brown, MD, FACC Professor of Medicine Cardiovascular Division Washington University School of Medicine St. Louis, MO 63110

Dr. Brown

David L. Brown, MD, FACC
Professor of Medicine
Cardiovascular Division
Washington University School of Medicine
St. Louis, MO 63110

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Approximately 10 million patients present to emergency rooms in the US annually for evaluation of acute chest pain.

The goal of that evaluation is to rule out the diagnosis of an acute heart attack. Imaging with coronary CT angiography and stress testing are not part of the diagnostic algorithm for acute heart attack.  Nevertheless many chest pain patients undergo some form of noninvasive cardiac testing in the ER. We found that CCTA or stress testing adding nothing to the care of chest pain patients beyond what is achieved by a history, physical examination, ECG and troponin test.

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Thunderclap Headache: Ottawa Rule To Exclude Subarachnoid Bleeding

MedicalResearch.com Interview with:

Jeff Perry, MD, MSc, CCFP-EM Professor, Department of Emergency Medicine Senior Scientist, Ottawa Hospital Research Institute Research Chair in Emergency Neurological Research, University of Ottawa Emergency Physician and Epidemiology Program The Ottawa Hospital Ottawa, Ontario

Dr. Perry

Jeff Perry, MD, MSc, CCFP-EM
Professor, Department of Emergency Medicine
Senior Scientist, Ottawa Hospital Research Institute
Research Chair in Emergency Neurological Research, University of Ottawa
Emergency Physician and Epidemiology Program
The Ottawa Hospital
Ottawa, Ontario

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Headache accounts for about 1-2% of all emergency department visits.  One of the most feared diagnosis within these patients is subarachnoid hemorrhage. While investigations are clearly warranted for patients with a diminished level of consciousness or new focal neurological deficits, approximately 50% of patients with subarachnoid hemorrhage (SAH) have no focal or global neurological findings. Deciding whether to image headache patients with no deficits is difficult, especially since timely diagnosis and treatment results in substantially better outcomes.

The desire to never miss a subarachnoid hemorrhage, however, contributes to escalating neuroimaging rates and a dogmatic adherence to lumbar puncture, even if the scan is negative, despite the very high sensitivity of computed tomography. However, a recent population-based study suggested that over 5% of confirmed subarachnoid hemorrhages were missed at initial presentation, especially in smaller hospitals. Therefore, identifying which headache patients require investigations to rule-out SAH is of great importance.

We have previously derived (N=1,999) and refined (N=2,131) the Ottawa SAH Rule. In this study, we conducted an multicenter prospective cohort study at six tertiary care hospitals, and found that the Ottawa SAH Rule performed well, with an 100% sensitivity, and specificity of 13.6%.

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Teaching Hospitals See Largest Number of Homeless Emergency Room Patients

MedicalResearch.com Interview with:

Ruirui Sun, Ph.D. AHRQ

Dr. Sun

Ruirui Sun, Ph.D.
AHRQ

MedicalResearch.com: What is the background for this study?

Response: Homeless people are more likely than the members of the general public to use emergency department (ED) services, and it is usually at teaching hospitals when they seek medical care (Kushel et al., 2001; Bowdler and Barrell, 1987). This Healthcare Cost and Utilization Project (HCUP) Statistical Brief studies patient characteristics, insurance coverage and clinical profile of the ED visits among homeless individuals by hospital teaching status, during 2014 from eight States (AZ, FL, GA, MA, MD, MO, NY, and WI).

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Nearly Half of All US Medical Care is Delivered by Emergency Departments

MedicalResearch.com Interview with:

David Marcozzi, MD, MHS-CL, FACEP Associate Professor  Director of Population Health Department of Emergency Medicine Adjunct Associate Professor Co-Director of the Program in Health Disparities and Population Health Department of Epidemiology and Public Health University of Maryland School of Medicine Assistant Chief Medical Officer for Acute Care University of Maryland Medical Center

Dr. Marcozzi

David Marcozzi, MD, MHS-CL, FACEP
Associate Professor
Director of Population Health
Department of Emergency Medicine
Adjunct Associate Professor
Co-Director of the Program in Health Disparities and Population Health
Department of Epidemiology and Public Health
University of Maryland School of Medicine
Assistant Chief Medical Officer for Acute Care
University of Maryland Medical Center

MedicalResearch.com: What is the background for this study?

Response: Nearly half of all US medical care is delivered by emergency departments, according to a new study by researchers at the University of Maryland School of Medicine (UMSOM). And in recent years, the percentage of care delivered by emergency departments has grown. The study highlights what many experts argue is a major flaw in American health care: the use of emergency care in non-urgent cases, where clinics and doctor’s offices would be more appropriate.

“I was shocked by this result. This really helps us understand health care in this country. This research underscores the fact that emergency departments are critical to our nation’s healthcare delivery system, particularly for Americans who have no access to care.” said David Marcozzi, MD, MHS-CL, FACEP, an associate professor in the UMSOM Department of Emergency Medicine, and co-director of the UMSOM Program in Health Disparities and Population Health. “Patients seek care delivered in emergency departments for many reasons, and we need to face this fact this is a significant segment of healthcare and actually it may be delivering the type of care that individuals want and need—24/7, 365 days.”  Although he now focuses on population health and hospital throughput, Dr. Marcozzi is an emergency room doctor himself, and works one or two days a week in the University of Maryland Medical Center emergency department, treating patients.

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Coordination Program Reduced ER Visits and Readmissions in Medicaid Population

MedicalResearch.com Interview with:

Roberta Capp MD Assistant Professor Director for Care Transitions in the Department of Emergency Medicine University of Colorado School of Medicine Medical Director of Colorado Access Medicaid Aurora Colorado

Dr. Capp

Roberta Capp MD
Assistant Professor
Director for Care Transitions in the Department of Emergency Medicine
University of Colorado School of Medicine
Medical Director of Colorado Access Medicaid
Aurora Colorado

 

 

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Medicaid clients are at highest risk for utilizing the hospital system due to barriers in accessing outpatient services and social determinants.

We have found that providing care management services improves primary care utilization, which leads to better chronic disease management and reductions in emergency department use and hospital admissions.

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Does Pre-Hospital Advanced Life Support Improve Survival in Out-of-Hospital Cardiac Arrest?

MedicalResearch.com Interview with:
Alexis Cournoyer MD
Université de Montréal
Hôpital du Sacré-Cœur de Montréal
Institut de Cardiologie de Montréal,
Montréal, Québec, Canada. 

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Out-of-hospital advanced cardiac life support (ACLS) is frequently provided to patients suffering from cardiac arrest.  This was shown to improve rates of return of spontaneous circulation, but there was no good evidence that it improved any patient-oriented outcomes.  Given the progress of post-resuscitation care, it was important to reassess if ACLS improved survival in out-of-hospital cardiac arrest.  Also, with the advent of extracorporeal resuscitation, a promising technique that needs to be performed relatively early in the course of the resuscitation and which seems to improve patients’ outcome, we wanted to evaluate if prolonged prehospital resuscitation with ACLS was effective in extracorporeal resuscitation candidates.

In this study, we observed, as was noted in previous study, that prehospital advanced cardiac life support  did not provide a benefit to patients regarding survival to discharge, but increased the rate of prehospital return of spontaneous circulation.  It also prolonged the delay before hospital arrival of around 15 minutes.  In the patients eligible for extracorporeal resuscitation, we observed the same findings.

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Over One Million Stair-Related Injuries Treated in ERs Each Year

MedicalResearch.com Interview with:

Gary Smith, MD, DrPH Director, Center for Injury Research and Policy Nationwide Children’s Hospital Columbus, OH

Dr. Smith

Gary Smith, MD, DrPH
Director, Center for Injury Research and Policy
Nationwide Children’s Hospital
Columbus, OH

MedicalResearch.com: What is the background for this study?

Response: Previous studies have documented the frequency and characteristics of stair-related injuries among children and older adults. Numerous studies have examined gait characteristics of different age groups and their relationship to falls. In addition, it is estimated that the direct medical and indirect costs of non-fatal stair-related injuries are $92 billion annually in the US.

The current study investigates the epidemiological characteristics of stair-related injuries among all ages using a nationally representative sample over a multi-year period. Our study also expands upon prior research on this topic to investigate the mechanisms of stair-related injuries and examine trends.

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New Assay Can Distinguish Between Viral and Bacterial Infections in Kids

MedicalResearch.com Interview with:
Prof. Alain Gervaix
Head of the Emergency Division
Department of Children and Adolescents
University Hospitals of Geneva
Switzerland

MedicalResearch.com: What is the background for this study?

Response: Many are familiar with the following ‘seemingly’ simple clinical dilemma that occurs on a daily basis across the world. A patient visits the doctor with a fever. Commonly, assigning a diagnosis comes down to deciding whether the infection is bacterial or viral. Accordingly, the doctor decides if to treat or not to treat with antibiotics. The problem is that bacterial and viral infections often present with very similar symptoms, causing uncertainty that leads to antibiotics being used, in many instances, when they are not needed. This antibiotic misuse contributes to the rise of antimicrobial resistance, one of the biggest health threats of the 21st century.

Host biomarkers hold great promise as routine diagnostic tools that can assist doctors in making correct antibiotic treatment decisions, as they overcome key limitations of currently applied pathogen-based tests. Recently, a novel host-assay (ImmunoXpert™) for differentiating bacterial from viral infections was developed and validated to yield high sensitivity and specificity. The three-protein host-assay comprises tumor necrosis factor-related apoptosis-inducing ligand (TRAIL), Interferon gamma-induced protein-10 (IP-10) and C-reactive protein (CRP).

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Morbidity and Financial Costs of Atrial Fibrillation High and Likely to Grow

MedicalResearch.com Interview with:

Sandra L. Jackson, PhD National Center for Chronic Disease Prevention and Health Promotion Centers for Disease Control and Prevention Chamblee GA

Dr. Sandra  Jackson

Sandra L. Jackson, PhD
National Center for Chronic Disease Prevention and Health Promotion
Centers for Disease Control and Prevention
Chamblee GA

MedicalResearch.com: What is the background for this study?

Response: People who have atrial fibrillation are at increased risk for having a heart attack or stroke. While we know that the percentage of the population with atrial fibrillation is increasing in the US, there is no national surveillance system to track the burden of emergency department visits, hospitalizations and deaths related to atrial fibrillation across all ages and health insurance provider types. This study combined data from the Healthcare Cost and Utilization Project and the National Vital Statistics System to provide national estimates for atrial fibrillation-related healthcare service use and deaths from 2006-2014.

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Risk Factors for Adverse Events in Emergency Procedural Pediatric Sedation

MedicalResearch.com Interview with:

Maala Bhatt MD, MSc., FRCPC Director, Pediatric Emergency Research Staff Physician, Emergency Medicine  Children's Hospital of Eastern Ontario

Dr. Bhatt

Maala Bhatt MD, MSc., FRCPC
Director, Pediatric Emergency Research
Staff Physician, Emergency Medicine
Children’s Hospital of Eastern Ontario 

MedicalResearch.com: What is the background for this study?

Response: Procedural sedation, defined as the administration of medications to minimize pain and awareness, has become standard practice in pediatric emergency departments worldwide to facilitate short, painful procedures such as orthopedic reduction and complex laceration repairs. Although emergency department sedation is regarded as safe, serious adverse events have been reported. The incidence of these events has been difficult to determine due to the infrequency of their occurrence and lack of large, multi-center surveillance studies focused on systematic detection of adverse events. Previous studies of emergency department sedation have been limited by single-center design and small sample sizes. These studies have not been able to reliably predict sedation-related adverse events, their severity or impact on patients.

To improve understanding of the safety and comparative effectiveness of ED procedural sedation, we conducted a large multi-center cohort study using standardized outcome measures that are valid and relevant to clinical practice. Our primary objective was to determine which practices lead to the best outcomes in children undergoing emergency department procedural sedation.

MedicalResearch.com: What are the main findings?

Response: We enrolled 6,295 patients undergoing parenteral procedural sedation for a painful procedure in one of six Canadian pediatric emergency departments from July 2010 to February 2015.

The overall incidence of adverse events in our population was 11.7%. Oxygen desaturation (5.6%) and vomiting (5.2%) were the most common events. Serious adverse events and significant interventions in response to an adverse event were rare occurring in only 1.1% and 1.4% of patients respectively.

We found that choice of sedation medication had the biggest impact on the incidence of adverse events and need for significant interventions in response to those events. The incidence of serious adverse events and significant interventions was lowest among patients sedated with ketamine-alone and highest among patients sedated with combination drugs ketamine+propofol and ketamine+fentanyl. We also found that pre-procedural opioid administration was strongly associated with increased odds of oxygen desaturation, vomiting and need for significant interventions, regardless of sedation medication.

Higher doses of ketamine were associated with increased odds of oxygen desaturation and vomiting. These findings are in opposition to the common belief that ketamine does not exhibit a dose-response relationship.

We also found that pre-procedural anti-emetics were associated with a 50% reduction in the odds of vomiting. However, based on published evidence, use in children under five years may not be as advantageous as their baseline risk is much lower.

MedicalResearch.com: What should clinicians and patients take away from your report?

Response: Procedural sedation for children provided by Emergency Physicians in these tertiary care pediatric emergency departments is safe and effective with low rates of serious adverse events (1.1%) and significant interventions (1.4%). Ketamine, Ketamine and Propofol and Propofol alone are all effective and safe in the hands of competent/experienced providers, however using ketamine alone is associated with fewer serious adverse events and significant interventions.

MedicalResearch.com: What recommendations do you have for future research as a result of this study?

Response: Our finding that administering opioids prior to sedation increases the odds of oxygen desaturation, vomiting and the need for significant interventions is interesting. Future work could focus on the timing of opioid administration and the incidence of adverse events. We are also interesting in understanding the longer term effects of sedation medications, controlling for age.

Disclosures: This study was supported by a Canadian Institutes of Health Research Team Grant in Pediatric Emergency Medicine.

MedicalResearch.com: Thank you for your contribution to the MedicalResearch.com community.

Citation:

Bhatt M, Johnson DW, Chan J, Taljaard M, Barrowman N, Farion KJ, Ali S, Beno S, Dixon A, McTimoney CM, Dubrovsky AS, Sourial N, Roback MG, for the Sedation Safety Study Group of Pediatric Emergency Research Canada (PERC). Risk Factors for Adverse Events in Emergency Department Procedural Sedation for Children. JAMA Pediatr. Published online August 21, 2017. doi:10.1001/jamapediatrics.2017.2135

Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.

 

 

 

 

 

 

Limited Benefit To Expedited Stress Testing of Chest Pain In ER Patients

MedicalResearch.com Interview with:
Alexander Sandhu, MD MS

Cardiology Fellow
Stanford University

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Millions of patients present to the emergency department with chest pain but most do not have lab or EKG findings that indicate the patient is having a heart attack. In patients without signs of a heart attack, stress testing is frequently used to determine the need for further workup and treatment. However, there is limited evidence regarding the benefit of stress testing in these patients.

We evaluated how cardiac testing – stress testing and coronary angiography – in these low-risk patients was associated with clinical outcomes. We used a statistical approach that took advantage of the fact that testing is more available on weekdays than weekends. We found that testing was associated with more angiography and revascularization (coronary stenting or coronary artery bypass surgery) but was not associated with a reduction in future heart attacks.

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Health Care Personnel Have Poor Understanding of Costs of ER Care

MedicalResearch.com Interview with:

Kevin Hoffman, DO Emergency medicine resident Lakeland Health in Saint Joseph, Michigan

Dr. Hoffman

Kevin Hoffman, DO
Emergency medicine resident
Lakeland Health in Saint Joseph, Michigan

MedicalResearch.com: What is the background for this study?

Response: In this study, we researched emergency department providers’ understanding of the costs of care for three routine patient presentations. Our study differed from the majority of previous studies with the use of clinical vignettes and cost determination for the entire visit. This is in contrast to previous research which focused on cost assessment of individual tests or medications. We wanted to use a study design that was more realistic and applicable to the way we work in the emergency department (ED). The hope is that with this research based on clinical scenarios that the data will be more easily translated back into potential changes and ways to improve efficiency in the ED.
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Fore! Most Common Golf Injuries Result From Getting Hit By Club or Ball

MedicalResearch.com Interview with:

Gary Smith, MD, DrPH</strong> Director, Center for Injury Research and Policy Nationwide Children’s Hospital Columbus, OH

Dr. Smith

Gary Smith, MD, DrPH
Director, Center for Injury Research and Policy
Nationwide Children’s Hospital
Columbus, OH

MedicalResearch.com: What is the background for this study?

Response: Golf is enjoyed worldwide as a leisure activity and competitive sport. While golf is viewed as a low-risk sport, acute traumatic and overuse injuries do occur. Previous studies have generally focused on the clinical aspects of golf-related injuries. Few studies examine injuries that occurred during practice at home or school, or due to conditions or hazards on a golf course.

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Rory’s Regulations: Faster Is Better When It Comes To Sepsis Care

MedicalResearch.com Interview with:

Christopher W. Seymour, M.D., M.Sc. Assistant professor of Critical Care Medicine and Emergency Medicine, and member of Clinical Research Investigation and Systems Modeling of Acute Illness University of Pittsburgh

Dr. Seymour

Christopher W. Seymour, M.D., M.Sc.
Assistant professor of Critical Care Medicine and Emergency Medicine, and member of Clinical Research Investigation and Systems Modeling of Acute Illness
University of Pittsburgh

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Following the tragic and widely publicized death of Rory Staunton, 12, from undiagnosed sepsis in 2012, New York became the first state to require that hospitals follow a protocol to quickly identify and treat the condition. The mandate led to widespread controversy in the medical community as to whether such steps would have saved Rory or anyone else’s life.

Rory’s Regulations require hospitals to follow protocols for early identification and treatment of sepsis, and submit data on compliance and outcomes. The hospitals can tailor how they implement the protocols, but must include a blood culture to test for infection, measurement of blood lactate (a sign of tissue stress) and administration of antibiotics within three hours of diagnosis—collectively known as the “three-hour bundle.”

We analyzed data from nearly 50,000 patients from 149 New York hospitals to scientifically determine if  Rory’s Regulations worked. We found that they did – 83 percent of the hospitals completed the bundle within the required three hours, overall averaging 1.3 hours for completion. For every hour that it took clinicians to complete the bundle, the odds of the patient dying increased by 4 percent.

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Efficient Protocol Allows Primary Stroke Centers To Ensure Access To Thrombectomies

MedicalResearch.com Interview with:

Ryan A. McTaggart M.D. Assistant Professor of Diagnostic Imaging, Neurology, and Neurosurgery @mobilestroke4U Warren Alpert School of Medicine at Brown University Rhode Island Hospital

Dr. Ryan  McTaggart

Ryan A. McTaggart M.D.
Assistant Professor of Diagnostic Imaging, Neurology, and Neurosurgery
@mobilestroke4U
Warren Alpert School of Medicine
Brown University
Rhode Island Hospital

MedicalResearch.com: What is the background for this study?

Response: Stroke is the #1 cause of disability and 5th leading cause of death. Mechanical thrombectomy (direct mechanical removal of the obstructing blood clot) is a dramatically effective treatment for the most devastating of all acute ischemic strokes – emergency large vessel occlusion (ELVO).

Access to this treatment can be optimized with the use of

1) mobile stroke unit technology,

2) changing our Emergency medical services triage algorithms so that stroke matches that of trauma (using field severity to transport the right patient, to the right hospital, the first time, whenever possible), and

3) improving in-hospital processes at Primary Stroke Centers (PSCs) so that patients with suspected ELVO who present to a PSC (a hospital that does not offer mechanical thrombectomy) do not get left behind and untreated.

This study reflects an effort to address and improve the third item.

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Use of HEART Score in ER Can Help Evaluate Low Risk Chest Pain

MedicalResearch.com Interview with:

Judith Poldervaart MD, PhD Assistant professor Julius Center for Health Sciences and Primary Care University Medical Center  Utrecht

Dr.Poldervaart

Judith Poldervaart MD, PhD
Assistant professor
Julius Center for Health Sciences and Primary Care
University Medical Center
Utrecht

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Since its development in 2008, interest in the HEART score is increasing and several research groups around the world have been publishing on the HEART score. After validation of any risk score for cardiac events, there is a concern about the safety when used in daily practice.

We were able to show the HEART score is just as safe as the usual care currently used at EDs, which has not been shown yet in previous research. That we did not find a decrease in costs, is probably due to the hesitance of physicians to discharge low-risk patients from the ED without further testing. But extrapolation of the findings of a cost-effectiveness analysis (including nonadherence) suggests that HEART care could lead to annual savings of €40 million in the Netherlands. Hopefully, in time (and more publications of the HEART score now appearing almost weekly from all over the world) this effect on use of health care resources will become more apparent.

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Youth With Autism Use Emergency Rooms At Markedly Increased Rate

MedicalResearch.com Interview with:

Guodong Liu, PhD  Assistant Professor Division of Health Services and Behavioral Research Department of Public Health Sciences, A210 Penn State University College of Medicine Hershey, PA 17033

Dr. Guodong Liu

Guodong Liu, PhD 
Assistant Professor
Division of Health Services and Behavioral Research
Department of Public Health Sciences, A210
Penn State University College of Medicine
Hershey, PA 17033

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Adolescents with autism spectrum disorder (ASD) use emergency department services four times as often as their peers without autism, according to Penn State College of Medicine researchers. The findings suggest that youth with autism may need better access to primary care and specialist services.

MedicalResearch.com: What should readers take away from your report?

Response: Although there was no significant increase in autism rates among adolescents in the study over the nine-year period, emergency department use in adolescents with autism increased five-fold, from 3 percent in 2005 to 16 percent in 2013. During the same time period, emergency department use in adolescents without an autism diagnosis remained steady at around 3 percent.  there could be a link between this underutilization of preventive care services and overuse of emergency department services.

On average, adolescents with autism had a four-time higher risk of visiting the emergency department than adolescents without ASD.  Older adolescents with autism also visited the emergency department more often than their younger counterparts. A third of middle and late adolescents in this group had medical emergencies, compared to just one-tenth of early adolescents.  Females and individuals living in rural areas were more likely to visit the emergency room than males and those living in urban areas.

MedicalResearch.com: What recommendations do you have for future research as a result of this study?

Response: We want to see more data on adolescents with ASD to confirm his findings. We are planning a similar study of emergency department use in adolescent Medicaid patients with autism. Our goal is to plot an unbiased nationally representative picture of how this special population fares in terms of their emergency department usage and, in related work, hospitalizations.

We are also searching for modifiable factors that could be addressed to reduce emergency visits and resulting hospitalizations in adolescents with autism. 

MedicalResearch.com: Is there anything else you would like to add?

Response: These Young ASD patients need to be actively taken care of and monitored. There should be better communication between these adolescents and their caregivers and with their regular pediatricians and specialists. If we can do those kinds of things we may help them have less frequent emergencies. This study was published by the Journal of Autism and Developmental Disorders.

I have no disclosures.

Lead author: Dr. Guodong Liu, assistant professor of public health sciences, Penn State University College of Medicine.

Other researchers on this study were Amanda M. Pearl, PhD and Michael J. Murray, MD, Department of Psychiatry; Lan Kong, PhD, Division of Biostatistics and Bioinformatics, Department of Public Health Sciences; and Douglas L. Leslie, PhD, Division of Health Services and Behavioral Research, Department of Public Health Sciences, all at Penn State College of Medicine.

Penn State College of Medicine Junior Faculty Development Program funded this research.

MedicalResearch.com: Thank you for your contribution to the MedicalResearch.com community.

Citation:

Guodong Liu, Amanda M. Pearl, Lan Kong, Douglas L. Leslie, Michael J. Murray. A Profile on Emergency Department Utilization in Adolescents and Young Adults with Autism Spectrum Disorders. Journal of Autism and Developmental Disorders, 2016; 47 (2): 347 DOI: 10.1007/s10803-016-2953-8

Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.

More Medical Research Interviews on MedicalResearch.com

 

 

Risk Factors for Unplanned Transfer to the ICU after ED Admission

MedicalResearch.com Interview with:
Marleen Boerma MD
Department of Emergency Medicine
Elisabeth-Tweesteden Hospital
Tilburg, The Netherlands

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Unplanned Intensive Care Unit (ICU) admission has been used as a surrogate marker of adverse events, and is used by the Australian Council of Healthcare Accreditation as a reportable quality indicator. If we can identify independent variables predicting deterioration which require ICU transfer within 24 hours after emergency department (ED) admission, direct ICU admission should be considered. This may improve patient safety and reduce adverse events by appropriate disposition of patients presenting to the ED.

This study shows that there were significantly more hypercapnia patients in the ICU admission group (n=17) compared to the non-ICU group (n=5)(p=0.028). There were significantly greater rates of tachypnea in septic patients (p=0.022) and low oxygen saturation for patients with pneumonia (p=0.045). The level of documentation of respiratory rate was poor.

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Fentanyl Laced Heroin Contributing To Spike In Heroin Overdoses in Miami-Dade County

MedicalResearch.com Interview with:
Alexander Diaz Bode

M.D. Candidate
University of Miami Leonard M. Miller School of Medicine
Miami, FL

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Our country is in the midst of an opiate epidemic. This is particularly evident in the emergency department (ED), which continues to see an alarmingly large number heroin overdose. With the shutdown of “pill-mills”, where opioid prescriptions would be prescribed indiscriminately, Florida has seen particularly large increases in opiate use and overdose. In Miami, we noticed that during the summer of 2016, there was a disproportionate increase in heroin overdose being treated at our hospital relative to previous years. Our recently published study showed that fentanyl or fentanyl analog laced heroin likely contributed to this massive spike in heroin overdose observed during the summer of 2016.

Fentanyl and its synthetic analogs are opioid receptor agonists that bind with hundreds of times higher affinity than diamorphine, aka heroin. Naloxone, better known by the brand name Narcan®, is used to reverse heroin overdose in the ED. This drug works by competitively inhibiting the opioid receptor, effectively “knocking off” the bound heroin. Using naloxone dosing as a surrogate marker of heroin purity, our study found that during the investigated spike there was a disproportionate increase in the amount of naloxone used in our ED to reverse overdose relative to the increase in opiate overdose. This indicated that a stronger opioid receptor agonist, such as fentanyl or fentanyl analogs, likely was involved in the massive spike in overdose observed during the summer of 2016.

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How Does Emergency Room Crowding Affect Care of Septic Patients?

MedicalResearch.com Interview with:

Anish Agarwal, MD, MPH The Hospital of the University of Pennsylvania Department of Emergency Medicine Philadelphia, PA

Dr. Anish Agarwal

Anish Agarwal, MD, MPH
The Hospital of the University of Pennsylvania
Department of Emergency Medicine
Philadelphia, PA

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: The morbidity and mortality of severe sepsis has been well studied and documented. An aggressive approach to protocolized care for patients suffering from severe sepsis and septic shock has been shown to improve mortality and should be started as early in the time course of a patient’s presentation. Emergency departments (ED) are designed to deliver time-sensitive therapies, however, they also may suffer from crowding due to multiple factors.

This study aimed to assess the impact of ED crowding upon critical interventions in the treatment of severe sepsis including time to intravenous fluids, antibiotics, and overall delivery of a protocolized bundle of care. The study found that as ED crowding increased, time to critical therapies significantly increased and the overall implementation of procotolized care decreased. More specifically as ED occupancy and total patient hours within the ED increased, time to intravenous fluids decreased and time to antibiotics increased as occupancy, hours, and boarding increased.

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Many CT Scans Can Be Avoided During ER Evaluation of Head Trauma

MedicalResearch.com Interview with:

Adam L. Sharp MD MS Research Scientist/Emergency Physician Kaiser Permanente Southern California Kaiser Permanente Research Department of Research & Evaluation Pasadena, CA 91101

Dr. Adam Sharp

Adam L. Sharp MD MS
Research Scientist/Emergency Physician
Kaiser Permanente Southern California
Kaiser Permanente Research
Department of Research & Evaluation
Pasadena, CA 91101

MedicalResearch.com: What is the background for this study?

Response: Millions of head computed tomography (CT) scans are ordered annually in U.S. emergency Departments (EDs), but the extent of avoidable imaging is poorly defined. Ensuring appropriate use is important to ensure patient outcomes and limited resources are optimized. A large number of stake holders have highlighted the need to reduce “unnecessary” CT scanning as part of their recommendations for the Choosing Wisely campaign. However, despite calls for improved stewardship, the extent of avoidable CT use among adults with minor trauma in community EDs is not known.

The Canadian CT Head Rule (CCHR) is perhaps the most studied of many validated decision instruments designed to assist providers in evaluating patients with minor head trauma. This study aims to describe the scope of overuse of CT imaging by ED providers in cases where application of the CCHR could have avoided imaging.

Secondarily, we sought to describe the extent to which avoidable CTs, if averted, would have resulted in “missed” intracranial hemorrhages requiring a neurosurgical intervention.

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tPA Plus Mechanical Thrombectomy in Acute Ischemic Stroke?

MedicalResearch.com Interview with:

Vitor Mendes Pereira MD MSc Division of Neuroradiology - Joint Department of Medical Imaging Division of Neurosurgery - Department of Surgery Toronto Western Hospital - University Health Network Associate Professor of Radiology and Surgery University of Toronto

Dr. Vitor Mendes Pereira

Vitor Mendes Pereira MD MSc
Division of Neuroradiology – Joint Department of Medical Imaging
Division of Neurosurgery – Department of Surgery
Toronto Western Hospital – University Health Network
Associate Professor of Radiology and Surgery
University of Toronto 

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Our study is a pooled analysis of two large prospective stroke studies that evaluated the effectiveness of mechanical thrombectomy (MT) using one of the stent retrievers (Solitaire device ) in patients with acute ischemic stroke related to large vessel occlusion(LVO). It is known (after 5 randomized controlled trials in 2015) that IV rtPA alone failed to demonstrated benefit when compared to MT associated or not to rtPA. A question is still open: what it is the real benefit of IV rtPA in the context of LVO, particularly in centres that can offer mechanical thrombectomy within 60 minutes after qualifying imaging?

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Children Can Choke to Death on Grapes

MedicalResearch.com Interview with:
Dr Jamie G Cooper

Consultant in Emergency Medicine
Aberdeen Royal Infirmary
Aberdeen UK

MedicalResearch.com: What is the background for this study?

MedicalResearch.com Interview with: Jamie Cooper Consultant in Emergency Medicine Aberdeen Royal Infirmary Aberdeen MedicalResearch.com: What is the background for this study? Response: Choking in children can be fatal and regularly grapes can be the cause. We believe that public awareness of the choking hazard posed by grapes (and other similarly shaped foods, such as cherry tomatoes) is not wide spread. By publishing this article we aimed to highlight the problem to health professionals who look after children and also to the public at large in an attempt to reduce the number of future episodes. MedicalResearch.com: What are the main findings? Response: With parental consent we published the cases of three small children who suffered choking episodes as a result of whole grapes, two of whom died as a result. In each case it was not possible to dislodge the grape using first aid techniques. MedicalResearch.com: What should readers take away from your report? Response: Small children are at risk from choking because they have smaller airways, reduced ability to chew foods, underdeveloped swallowing coordination and can be easily distracted when eating. Grapes are a healthy and popular snack but are ideally suited to cause airway obstruction, particularly if inhaled whole. Small children (up to 5 years) should always be supervised by adults while eating; and grapes should be halved, or ideally quartered, before consumption. We hope that by drawing attention to this issue that consideration will be given at a political level to wider dissemination of this information so as to prevent further occurrences. MedicalResearch.com: Thank you for your contribution to the MedicalResearch.com community. Citation: BMJ The choking hazard of grapes: a plea for awareness Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions. More Medical Research Interviews on MedicalResearch.com

Grapes
Wikipedia image

Response: Choking in children can be fatal and regularly grapes can be the cause.  We believe that public awareness of the choking hazard posed by grapes (and other similarly shaped foods, such as cherry tomatoes) is not wide spread.  By publishing this article we aimed to highlight the problem to health professionals who look after children and also to the public at large in an attempt to reduce the number of future episodes.

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Emergency Department Use High Among CKD Patients, Primarily for Heart Failure

MedicalResearch.com Interview with:

Paul E Ronksley, PhD Assistant Professor Department of Community Health Sciences Cumming School of Medicine University of Calgary Calgary Canada

Dr. Paul E Ronksley

Paul E Ronksley, PhD
Assistant Professor
Department of Community Health Sciences
Cumming School of Medicine
University of Calgary
Calgary Canada

MedicalResearch.com: What is the background for this study?

Response: Prior studies have observed high resource use among patients with chronic kidney disease (CKD), which is related to the medical complexity of this patient population. However, there has been limited exploration of how patients with CKD use the emergency department (ED) and whether utilization is associated with disease severity. While the ED is essential for providing urgent or emergent care, identifying ways of improving ED efficiency and decreasing wait times has been recognized as a priority in multiple countries. Improving coordination and management of care for patients with multiple chronic conditions (the norm for CKD) in an outpatient setting may meet health care needs and ultimately improve patient experience and outcomes while reducing the burden currently placed on the ED. However, this requires an understanding of ED use among patients with CKD and the proportion of use that is amenable to outpatient care. Using a large population-based cohort we explored how rates of ED use vary by kidney disease severity and the proportion of these events that are potentially preventable by high quality ambulatory care.

We identified all adults (≥18 years) with eGFR<60 mL/min/1.73m2 (including dialysis-dependent patients) in Alberta, Canada between April 1, 2010 and March 31, 2011. Patients with CKD were linked to administrative data to capture clinical characteristics and frequency of ED encounters, and followed until death or end of study (March 31, 2013). Within each CKD category we calculated adjusted rates of overall  emergency departmentt use, as well as rates of potentially preventable ED encounters (defined by 4 CKD-specific ambulatory care sensitive conditions (ACSCs); heart failure, hyperkalemia, volume overload, malignant hypertension).

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High Treatment Failure Rates Among Elderly With Purulent Skin Infections

MedicalResearch.com Interview with:

John P. Haran, MD Assistant Professor Department of Emergency Medicine University of Massachusetts Medical School UMass Memorial Medical Group Worcester, MA

Dr. John P. Haran

John P. Haran, MD
Assistant Professor
Department of Emergency Medicine
University of Massachusetts Medical School
UMass Memorial Medical Group
Worcester, MA

MedicalResearch.com: What is the background for this study?

Response: In 2014, the Infectious Disease Society of America (IDSA) updated their guidelines for the management of skin and soft tissue infection in response to high MRSA infection rates as well as high treatment failure rates for skin and soft tissue infections. Greater than 1 in 5 patients treated for a skin abscess will fail initial treatment.

Historically antibiotics have been shown to be unnecessary in the treatment of uncomplicated purulent infections. This notion has been recently challenges when authors published a randomized control trial using trimethoprim-sulfamethoxazone in the NEJM that demonstrated a minimal increase in cure rates for outpatient treatment of uncomplicated skin purulent skin infections. In this study they did not follow IDSA-guidelines nor model or stratify their analysis. It is possible their findings may be due to at-risk patient groups that did not receive antibiotics. Many widely used clinical decision rules incorporate age into their decision algorithms, however the IDSA did not do this with their recent guidelines.

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Tamsulosin (Flomax) Improves Passage of Some Kidney Stones

MedicalResearch.com Interview with:
Ralph Wang, MD, MAS

Associate Clinical Professor, Department of Emergency Medicine
University of California, San Francisco

MedicalResearch.com: What is the background for this study?

Response: Medical expulsive therapy, most notably tamsulosin, has been studied extensively to improve stone passage in patients diagnosed with ureteral stone. Prior trials and meta-analyses have identified a benefit. In fact, tamsulosin is
recommended by the American Urologic Association for patients diagnosed with ureteral stones < 10mm that do not require intervention. However, recent well-conducted multi-center randomized trials have not found any improvement in stone passage.

Thus we conducted a systematic review and meta-analysis of all double blinded, placebo controlled randomized trials of tamsulosin to determine whether it improves stone passage.

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Uninsured Kids More Likely To Be Transferred From Emergency Departments

MedicalResearch.com Interview with:

Yunru Huang Ph.D. Candidate in epidemiology Department of Pediatrics University of California Davis, Sacramento, CA

Yunru Huang and Dr. James Marcin (left)

Yunru Huang
Ph.D. Candidate in epidemiology
Department of Pediatrics
University of California
Davis, Sacramento, CA

MedicalResearch.com: What is the background for this study?

Response: Each year, more than 27 million children seek care in emergency departments (EDs) in the United States. Many EDs, however, are not fully equipped with the recommended pediatric supplies and may not have access to the pediatric specialists and resources needed to provide definitive care. As a result, many children receiving treatment in EDs of hospitals with limited pediatric resources are transferred to another hospital’s ED or inpatient unit for admission.

The Emergency Medical Treatment and Active Labor Act (EMTALA) requires hospitals to make decisions on patient transfer and admission independent of insurance status. That is, the decision to transfer a patient to another hospital for admission should only depend upon clinical factors or the need for specialty services. However, patterns observed in the medical literatures have suggested that a child’s insurance status could be associated with transfer and admission decisions. These studies have been limited to single institutions and/or have been limited to specific conditions._ENREF_14 Whether or not transfer decisions among pediatric patients are related to insurance status has yet to be studied on a national level and across a variety of diagnoses.

We used Healthcare Cost and Utilization Project 2012 Nationwide Emergency Department Sample data and sought to investigate the relationships between insurance status and odds of transfer relative to local admission among pediatric patients receiving care in the ED.

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Nurse-Initiated Protocols Can Improve Timeliness of Care in an Urban Emergency Department

MedicalResearch.com Interview with
Mathew Douma, RN BSN ENC(C) CNCC(C)
Emergency Department, Royal Alexandra Hospital
Edmonton, Alberta, Canada; Masters of Nursing Student
University of Toronto, Toronto

MedicalResearch.com: What is the background for this study?

Response: Many emergency departments experience crowding, which is typically defined as a situation where demands for service exceed the ability of the emergency department to provide quality care in a timely fashion. Typically when patients are waiting in a waiting room they do not undergo diagnostics or treatments. In an effort to speed the process up and reduce the amount of time the patient spends in the emergency department, some facilities have created protocols for diagnostics or treatments typically outside the traditional scope of practice of nursing staff.

Our emergency department had protocols like this for almost 15 years, though we had never evaluated their effectiveness. So an interdisciplinary group in our emergency department updated them and then we set out to evaluate them.

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Opportunities for Improvement in Pediatric Resuscitation Across US EDs

MedicalResearch.com Interview with:
Marc Auerbach, MD, FAAP, MSc
Associate Professor of Pediatrics (Emergency Medicine) and of Emergency Medicine
Co-chair INSPIRE (International Network for Simulation Based Pediatric Innovation Research and Education)
Director, Pediatric Simulation
Yale Center for Medical Simulation;

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Severely ill infants and children present to any of over 5000 United States Emergency Departments every day. A direct comparison of the quality of resuscitative care across EDs is challenging due to the low frequency of these high stakes events in individual EDs. This study utilized in-situ simulation-based measurement to compare the quality of resuscitative care delivered to two infants and one child by 58 distinct interprofessional teams across 30 EDs. Composite quality scores correlated with annual pediatric patient volume, with higher volume departments demonstrating higher scores.

The pediatric readiness score measures compliance with guidelines created by the American Academy of Pediatrics, the American College of Emergency Physicians and the Emergency Nurses Association. The pediatric readiness score correlated with composite quality scores measured by simulation.

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Dialysis Patients Use Emergency Rooms At Six Times Rate of General Population

MedicalResearch.com Interview with:

Rachel Patzer, PhD, MPH Director of Health Services Research, Emory Transplant Center Assistant Professor Emory University School of Medicine Department of Surgery Division of Transplantation

Dr. Rachel Patzer

Rachel Patzer, PhD, MPH
Director of Health Services Research,
Emory Transplant Center
Assistant Professor
Emory University School of Medicine
Department of Surgery
Division of Transplantation

MedicalResearch.com: What is the background for this study?

Response: Patients with End Stage Renal Disease (ESRD) make up less than 1% of all Medicare patients, but account for more than 7% of all Medicare expenses. Patients with ESRD have the highest risk of hospitalization of any patient with a chronic disease, and while hospital admissions have decreased over the last several years, emergency department utilization for this patient population has increased by 3% in the last 3 years. The purpose of the study we conducted was to describe the clinical and demographic characteristics associated with emergency department utilization.

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Interventions To Decrease Frequent ED Use May Be Effective But Best Strategies Not Clear

MedicalResearch.com Interview with:
Jessica Moe MD, MA, PGY5 FRCPC
Emergency Medicine, University of Alberta
MSc (Candidate) Clinical Epidemiology

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Frequent visitors are common in many urban emergency departments (ED). They represent high resource-utilizing patients; additionally, existing literature demonstrates that they experience higher mortality and adverse health outcomes than non-frequent ED users. Interventions targeting frequent ED users therefore may potentially prevent adverse outcomes in this high risk patient group. The purpose of this study was to provide an up-to-date review of the existing literature on the effectiveness of interventions for adult frequent ED users.

This systematic review summarizes evidence from 31 interventional studies. The majority evaluated case management and care plans; a smaller number of studies examined diversion strategies, printout case notes, and social work visits. Overall, the studies were considered to have moderate to high risk of bias; however, 84% of before-after studies found that ED visits significantly decreased after the intervention. Additionally, studies examining interventions for homelessness consistently found that interventions improved stable housing. Overall, effects on hospital admissions and outpatient visits were unclear.

In summary, the available evidence is encouraging and suggests interventions targeted towards frequent ED users may be effective in decreasing ED visit frequency and improving housing stability.

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NYU Neurologist Comments On New Guidelines For Emergency Room Treatment of Migraines

MedicalResearch.com Interview with:

Dr. Mia T. Minen, MD, MPH Director, Headache Services at NYU Langone Medical Center Assistant professor, Department of Neurology

Dr. Mia T. Minen

Mia Minen, MD, MPH
Assistant Professor of Neurology
NYU Langone Medical Center

MedicalResearch.com Editor’s note: The American Headache Society has issued new guidelines on “The Management of Adults With Acute Migraine in the Emergency Department” (1,2)

Dr. Minen, Director of Headache Services at NYU Langone Medical Center, discusses these new guidelines below.

MedicalResearch.com: What is the background for these new guidelines?
How common/severe is the issue of migraine or headache presentation to the ER?

Dr. Minen: These guidelines were needed because previous research shows that there are about 1.2. million visits to the emergency department (ED) each year for migraine, and over 25 different medications are sometimes used for treatment. Many of these medications don’t have evidence-based data to back their usage, and opioids are especially likely to be prescribed in between 60 and 70 percent of these cases, despite their lack of efficacy and risks. The American Headache Society convened an expert panel to review the existing evidence on all the medications used to treat migraines in the ED, and we developed these new treatment guidelines.

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Unlike Car Accidents, Gun Injuries Are Becoming More Lethal

MedicalResearch.com Interview with:

Angela Sauaia MD PhD Professor of Public Health, Medicine, and Surger University of Colorado Denver

Dr. Angela Sauaia

Angela Sauaia MD PhD
Professor of Public Health, Medicine, and Surgery
University of Colorado Denver

MedicalResearch.com: What is the background for this study? What are the main findings?

Authors: Americans mourn firearm related fatalities every day. Mass shootings are just the tip of the iceberg of the daily tragedy witnessed by trauma surgeons in emergency rooms. Industries strive to reduce the perils associated with motor vehicles, pedestrian and bicycles accidents, just to cite a few, through technology and education. Firearms move in the exact opposite direction. They are becoming progressively more dangerous and we have done little in terms of education to prevent accidents. The same trend is true for monitoring statistics. It is not difficult to obtain statistics on which type of car was associated with more accidents or fatalities. Conversely, trying to obtain data on which type of firearms are more likely to result in accidents or death is extremely difficult. We used the best data we could find and found that, contrary to every other injury mechanism, firearm injuries are becoming more lethal. In simple words, if you get into a car accident today, you are more likely to survive it due to improvements in trauma care and safety of vehicles than 10 years ago. On the other hand, if you get shot today, you are more likely to die than if you were shot 10 years ago, despite our excellent trauma care.

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Over-the-Counter Diarrhea Medication is an Opioid That Can Cause Cardiac Death

MedicalResearch.com Interview with:

William Eggleston, PharmD Fellow in Clinical Toxicology/Emergency Medicine Upstate Medical University Upstate New York Poison Center

Dr. William Eggleston

William Eggleston, PharmD
Fellow in Clinical Toxicology/Emergency Medicine
Upstate Medical University
Upstate New York Poison Center

MedicalResearch.com: What is the background for this study? What are the main findings?

Dr. Eggleston: The case series describes two deaths associated with loperamide abuse with supportive post-mortem findings. It adds to the growing body of literature reporting cardiac toxicity after loperamide abuse and demonstrates the deadly consequences. It also highlights the growing trend of loperamide abuse amongst opioid addicted patients looking to get high or stave off withdrawal symptoms.

MedicalResearch.com: What should readers take away from your report?

Dr. Eggleston: Readers should recognize that loperamide is an OTC opioid medication that acts similarly to morphine or heroin in the body after high doses. The drug is easily abused due to its low cost, ease of accessibility, legal status, and lack of social stigma associated with its possession. Most importantly, loperamide is a cardiac toxin that causes conduction disturbances in high doses and can produce deadly dysrhythmias.

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Oxygen Saturation Poor Predictor of Return Visits For Infant Respiratory Infections

MedicalResearch.com Interview with:

Suzanne Schuh, MD, FRCP(C), ABPEM The Hospital for Sick Children affiliated with the University of Toronto

Dr. Suzanne Schuh

Suzanne Schuh, MD, FRCP(C), ABPEM
The Hospital for Sick Children affiliated with the
University of Toronto

Medical Research: What is the background for this study?

Dr. Schuh: Routine measurement of oxygen saturation in bronchiolitis is sometimes used as a proxy for illness severity, despite poor correlation between these parameters. This focus on oximetry may in part relate to lack of evidence on the natural history of desaturations in bronchiolitis which are often transient, and frequently not accompanied by increased respiratory distress. Desaturations occurring in infants with mild bronchiolitis in an ED often result in hospitalizations or prolonged hospital stay. They occur in healthy infants and may also occur in infants with mild bronchiolitis at home.

The main objective of this study of infants with acute bronchiolitis was to determine if there is a difference in the proportion of unscheduled medical visits within 72 hours of ED discharge in infants who desaturate during home oximetry monitoring versus those without desaturations. Our study shows that the majority of infants with mild bronchiolitis experience desaturations after discharge home.

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Steroids An Option to NSAIDS for Treatment of Acute Gout

MedicalResearch.com Interview with:

Professor Timothy H Rainer MD MBBCh Director, Accident & Emergency Medicine Academic Unit The Chinese University of Hong Kong

Prof. Timothy Rainer

Professor Timothy H Rainer  MD MBBCh
Director, Accident & Emergency Medicine Academic Unit
The Chinese University of Hong Kong 

Medical Research: What is the background for this study? What are the main findings?

Prof. Rainer: Gout is a type of arthritis characterised by periodic attacks of acute joint swelling and severe pain, and  often treated with colchicine or nonsteroidal anti-inflammatory drugs (NSAIDs).  Two recent randomized, controlled trials showed that oral prednisolone, a corticosteroid, was as effective as NSAIDs in the treatment of acute gout, but these studies involved small numbers of patients.  The researchers investigatedwhether oral prednisolone was as effective and safe as indomethacin (a NSAID) in a larger sample of patients who had acute gout symptoms and who were seen in the emergency department (ED) setting. Patients in both the prednisolone and indomethacin groups had clinically meaningful decreases in their pain levels during the 2 hours they were observed in the ED as well as during the 14-day follow-up period. Both groups had a similar decrease in pain levels. No major adverse events were reported in either group although there were more minor adverse events in the indomethacin group.

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ER Visits Rise in Three Years Following Bariatric Surgery

MedicalResearch.com Interview with:

Junaid A. Bhatti, MBBS, MSc, PhD Sunnybrook Health Sciences Centre Research Institute Toronto, Canada

Dr. Junaid Bhatti

Junaid A. Bhatti, MBBS, MSc, PhD
Sunnybrook Health Sciences Centre Research Institute
Toronto, Canada 

Medical Research: What is the background for this study? What are the main findings?

Dr. Bhatti: Weight loss surgeries are consistently increasing in the US. While the positive impact of surgery on patient’s health are undebatable, limited information is available about long-term healthcare utilization, especially, emergency care utilization in bariatric surgery patients. This study compared emergency care utilization in bariatric patients three years following surgery to that of three years prior to surgery. Overall, we found that emergency care utilization increased by about 17% following surgery compared to the before surgery period. While complaints related to cardiovascular, ear, respiratory, and dermatology decreased, the complaints related to gastrointestinal, genitourinary, mental health, and substance misuse increased following surgery.  Continue reading

Mentally Ill, Homeless Patients Are High Intensity Emergency Department Users

MedicalResearch.com Interview with:

Paul E Ronksley, PhD Assistant Professor Department of Community Health Sciences Cumming School of Medicine University of Calgary Calgary, AB Canada

Dr. Paul Ronksley

Paul E Ronksley, PhD
Assistant Professor
Department of Community Health Sciences
Cumming School of Medicine
University of Calgary
Calgary, AB Canada

Medical Research: What is the background for this study?

Response: Numerous studies have shown that high users of the emergency department (ED) are often patients with complex medical needs and limited personal and social resources. It is also recognized that high users are a heterogeneous group driven by variability in the operational definition used to define this patient population. “High use” of ED services is often defined by the number of visits per year (namely ≥3 or ≥4 visits to the ED in a 1-year period) with little exploration of the distribution/pattern of these visits over time. The purpose of our study was to examine patient and encounter-level factors and costs related to periods of short-term resource intensity (clustered ED visits) among high users of the ED within a tertiary-care teaching facility. This is important as it may inform interventions that can focus on a more defined group with the goal of providing the needed care in a setting outside of the ED.

Medical Research: What are the main findings?

Response: Our main findings demonstrate that among high  emergency department users (i.e. patients with 3 or more ED visits in a 1-year period), approximately 1 in 7 patients had a period of high-intensity ED use (3 or more visits clustered within a week). These patients with clustered visits were more likely to be homeless, require psychiatric emergency services, and revisit the  emergency department for the same presenting complaints. The high-intensity users were also less likely to be admitted, more likely to leave without being seen and had lower costs per encounter, although their total ED cost across all visits was higher.

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Avoidable Acute Admissions From Emergency Room Driven By Time and Space Pressures

MedicalResearch.com Interview with:

Jonathan Pinkney MD FRCP Professor of Medicine Plymouth University and Peninsula Schools of Medicine and Dentistry Centre for Clinical Trials and Population Studies Plymouth Science Park Phase 1 Honorary Consultant Physician Diabetes and Endocrinology University Medicine Derriford Hospital Plymouth Hospitals NHS Trust Plymouth UK

Prof. Jonathan Pinkney

Jonathan Pinkney MD FRCP
Professor of Medicine
Plymouth University and Peninsula Schools of Medicine and Dentistry
Centre for Clinical Trials and Population Studies
Plymouth Science Park Phase 1
Honorary Consultant Physician Diabetes and Endocrinology
University Medicine Derriford Hospital
Plymouth Hospitals NHS Trust
Plymouth UK


Medical Research: What is the background for this study?

Dr. Pinkney: The background is that the study was funded by the National Institute for Health Research in response to a call for research on the problem of unscheduled emergency admissions to hospitals in the UK. The rates of patient attendance at emergency departments and subsequent acute admissions to hospitals have risen year on year. Rising numbers of admissions have significant knock-on effects for acute hospitals including crowding in emergency departments, pressures on staffing, and disruption of elective treatment because of high rates of bed occupancy. The increase in admissions has been associated largely with increased short stay admissions. As a result, there has been an increasing view that a significant proportion of acute medical admissions may not be necessary, and in this respect may be said to be avoidable. There had been relatively limited research on how hospitals can best reduce these avoidable admissions.

The main aims of the study were to investigate how senior staff in four major acute hospitals in south west England endeavour to avoid unnecessary acute admissions, and to examine a range of different systems in place in different hospitals to avoid unnecessary admissions. We called this project the “3A” or Avoidable Acute Admissions study. The 3A study was a mixed methods study with a strong emphasis on the narrative experience of patients, carers and healthcare professionals in the emergency departments and associated units of these four acute hospitals. The quantitative component of the study was an application of Value Stream Mapping (VSM), a technique from lean theory, and this was used to identify and measure points of delay in the patient journey.

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Patients Who Leave the ER Prematurely: They Are Not All the Same

MedicalResearch.com Interview with:
Jessica Moe MD, MA, PGY4 FRCPC Emergency Medicine
MSc (Candidate) Clinical Epidemiology
RCPS Emergency Medicine Residency Program
University of Alberta
Edmonton, Alberta

Medical Research: What is the background for this study? What are the main findings?

Dr. Moe: Patients who leave the emergency department (ED) prior to completing their care account for a substantial number of annual visits; some of these patients are at high medical risk. We used the National Hospital Ambulatory Medical Care Survey from 2009-2011 to examine a nationally representative sample of patients who left the ED prior to completing care.

Our work suggests that, among patients who leave the ED prematurely, the degree of medical risk may be related to whether or not these patients saw a medical professional prior to leaving the ED. Patients who leave prior to medical evaluation are generally younger and present with lower acuity visits, whereas patients who leave after medical evaluation tend to be older, are more likely to arrive by ambulance and have higher acuity visits.

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All Baby Boomers Should Be Screened At Least Once For Hepatitis C

Dr Waridibo Allison MD PhD Department of Medicine, Division of Infectious Diseases and Immunology New York Langone University School of Medicine New York, NY 10016MedicalResearch.com Interview with:
Dr Waridibo Allison MD PhD
Department of Medicine, Division of Infectious Diseases and Immunology
New York Langone University School of Medicine
New York, NY 10016

Medical Research: What is the background for this study? What are the main findings?

Dr. Allison: It was found that among 383 baby boomers presenting to a large urban emergency department in New York City the prevalence of HCV antibody reactivity was 7.3%. Only four patients were successfully linked to care and only one patient was started on HCV treatment. The study highlights the possibility that there may be problems in linking patients to care from the ED compared to other clinical settings such as primary care and inpatient settings. It was concluded that only with strategies to improve linkage to care could a screening program for baby boomers be recommended in the ED where the study was carried out.

The study additionally had a qualitative component and, via structured interviews, evaluated knowledge about HCV infection amongst baby boomers presenting to the ED. Overall knowledge was good but some misconceptions about transmission persisted and many patients mistakenly believed that there is a vaccine for hepatitis C.

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Most Patients Receive Another Opioid Prescription After Overdose

Dr. Marc LaRochelle MD MPH

Dr. LaRochelle

MedicalResearch.com Interview with:
Marc R. Larochelle, MD, MPH
Assistant Professor of Medicine
Boston Medical Center
Boston, MA 

Medical Research: What is the background for this study? What are the main findings?

Dr. Larochelle: More than 16 thousand people in the United States die from prescription opioid overdose each year. However, morbidity extends well beyond fatal overdose – nearly half a million emergency department visits each year are related to prescription opioid-related harms. Emergency department visits for misuse of opioids represent an opportunity to identify and intervene on opioid use disorders, particularly for patients who receive prescriptions for opioids to treat pain. We examined a cohort of nearly 3000 commercially insured individuals prescribed opioids for chronic pain who were treated for a nonfatal opioid overdose in an emergency department or inpatient setting. We were interested in examining rates of continued prescribing after the overdose and the association of that prescribing with risk of repeated overdose. We found that 91% of individuals received another prescription for opioids after the overdose. Those continuing to receive opioids at high dosages were twice as likely as those whose opioids were discontinued to experience repeated overdose.

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Combined Biomarkers Copeptin and hsTroponin Help Exclude Severe Coronary Stenosis

Florence Leclercq, MD, PhD Department of Cardiology Arnaud de Villeneuve Hospital University hospital of Montpellier Montpellier,France

Dr. Leclercq

MedicalResearch.com Interview with:
Florence Leclercq, MD, PhD

Department of Cardiology
Arnaud de Villeneuve Hospital
University hospital of Montpellier
Montpellier,France

Medical Research: What is the background for this study? What are the main findings?

Response: Patients with history of coronary artery disease (CAD) are considered as a population with high risk of further coronary eventsHowever, frequent pre-existing ECG changes observed in these patients result in difficulty interpreting new ECG aspects in case of chest discomfort. Furthermore, anxiety frequently induced non-cardiac causes of chest pain in these patients, leading to unjustified admission to cardiology units.  Moreover, levels of troponin are usually higher in patients with previous CAD compared to patients without history of angina, resulting in difficulty interpreting baseline values in this population.  Conversely, copeptin may be influenced by the severity of myocardial ischemia and resulting endogenous stress, and could be a useful additional marker to exclude severe coronary stenosis in high-risk patients with recent chest pain.
This propective monocentric study evaluates the incremental value of copeptin associated with high-sensitivity cardiac T troponin (hs-cTnT) to exclude severe coronary stenosis in 96 patients with coronary artery disease  (CAD) and acute chest pain.  

Mean age of patients was 60 +/- 13.8 years and the mean time between chest pain onset and blood samples of copeptin was 4.2 +/-2.7 hours. According to clinical decision, coronary angiography was performed in 71 patients (73.9 %) and severe stenosis diagnosed in 14 of them (14.6%). No ischemia was detected on SPECT imaging (n=25). Among the 69 patients with a negative kinetic of hs-cTnT and a negative baseline copeptin, 5 (7.4%) had a severe stenosis (NPV 0.93; 95% CI: 0.87-0.99), 4 of them related to in-stent restenosis (NPV for exclusion of native coronary stenosis: 0.98; 95% CI: 0.93-1).

We can conclude that in patients with preexisting CAD, and once Acute Myocardial Infarction (AMI) is excluded, copeptin increases the NPV of  hs-cTnT  to rule out severe coronary stenosis or significant myocardial ischemia. Coronary stenosis not detected with this strategy concerned exclusively in-stent restenosis or stenosis related to infarcted -related  coronary artery without myocardial viability.

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BNP Testing in Heart Failure Resulted in More ER Admissions But Fewer Repeat Visits

MedicalResearch.com Interview with:
Justin A. Ezekowitz, MBBCh MSc
Associate Professor, University of Alberta
Co-Director, Canadian VIGOUR Centre
Cardiologist  and Director, Heart Function Clinic
Nariman Sepehrvand, MD
Research Fellow & Graduate Student
Mazankowski Alberta Heart Institute
University of Alberta Edmonton, Canada 

Medical Research: What is the background for this study?
Dr. Ezekowitz: Major practice guidelines recommend the use of natriuretic peptide (NP) testing for diagnosing acute heart failure (HF) in emergency departments (ED). Despite these guidelines, the majority of healthcare regions all around the world (except for the United States and New Zealand) have restricted access to NP testing due to concerns over cost to healthcare systems. In the province of Alberta, Canada, however, a province-wide access to NP testing was provided for all EDs in 2012. This study investigates the factors that are related to the utilization of NP testing in EDs.

Medical Research: What are the main findings?

Dr. Ezekowitz: There was a substantial geographic variation in testing for NPs, despite having a single payer system and the universal availability of NP testing in Alberta. Several factors (including male sex, some comorbidities like prior heart failure, urban residence, type of care provider and ED clinical volume) influenced the utilization of testing for NPs in routine ED practice.
Interestingly, patients with heart failure who were tested for NPs at ED, had a higher rate of hospital admission and lower 7 day and 90 day repeat ED visit rates compared to those who were not tested.

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ER Trial of Inhaling Isopropyl Alcohol From Pads Reduced Nausea

Michael D. April, MD, DPhil Department of Emergency Medicine San Antonio Uniformed Services Health Education Consortium San Antonio, TX

Dr. April

MedicalResearch.com Interview with:
Michael D. April, MD, DPhil
Department of Emergency Medicine
San Antonio Uniformed Services Health Education Consortium
San Antonio, TX 

Medical Research: What is the background for this study? What are the main findings?

Dr. April: Anesthesia research studies have found that nasal inhalation of isopropyl
alcohol has efficacy in treating nausea among post-operative patients. We
sought to study this agent among Emergency Department patients with nausea or
vomiting. We found that patients randomized to inhale isopropyl alcohol had
improved self-reported nausea scores compared to patients randomized to inhale
saline (placebo).

MedicalEditor’s note:  Do Not Do This Without Medical Supervision!

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Telemedicine Can Support Rapid Stroke Treatment in Ambulances

Ken Uchino, MD FAHA FANA Director, Vascular Neurology Fellowship Research Director, Cerebrovascular Center, Cleveland Clinic Associate Professor of Medicine (Neurology) Cleveland Clinic Lerner College of Medicine of CWRU Cleveland, OH 44195

Dr. Ken Uchino

MedicalResearch.com Interview with:
Ken Uchino, MD FAHA FANA

Director, Vascular Neurology Fellowship
Research Director, Cerebrovascular Center, Cleveland Clinic
Associate Professor of Medicine (Neurology)
Cleveland Clinic
Lerner College of Medicine of CWRU
Cleveland, OH 44195

Medical Research: What is the background for this study? What are the main findings?

Dr. Uchino: Treatment for acute ischemic stroke is time dependent. Multiple studies have reported strategies to improve time to treatment after arrival in the hospital. Mimicking pre-hospital thrombolysis of acute myocardial infarction pioneered 30 years ago, two groups in Germany have implemented pre-hospital ischemic stroke thrombolysis using mobile stroke unit (“stroke ambulance”) that includes CT scan and laboratory capabilities. These units have been demonstrated to provide stroke treatment earlier than bringing patients to the emergency departments.

Our report extends the concept mobile stroke unit further by using telemedicine for remote physician presence. The other mobile stroke units were designed to have at least one physician on board. This allows potential multiple or geographically distant units to be supported by stroke specialists.

The study demonstrates that after patient arrival in the ambulance, the time to evaluation (CT scanning and blood testing) and to thrombolytic treatment is as quick or better as patient arrival in emergency department door. We are reporting the overall time efficiency after emergency medical service notification (911 call) in a separate paper.

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ER Visits For Hypertension Common and Increasing

Candace D. McNaughton,

Dr. McNaughton

MedicalResearch.com Interview with:
Candace D. McNaughton, MD MPH FACEP
Assistant Professor
Emergency Medicine Research
Department of Emergency Medicine, Research Division
Vanderbilt University Medical Center

Medical Research: What is the background for this study? What are the main findings?

Dr. McNaughton: Hypertension, or high blood pressure, affects 1/3rd of adults in the United States and more than 1 billion people worldwide.  It is also the #1 risk factor for cardiovascular disease such as heart attack and stroke, so it is very important to treat.

The burden of hypertension in the emergency department is not well understood.  The ER is not usually thought of as a place where perhaps we could or should be addressing hypertension; that has traditionally be left up to primary care providers. Through this study, our goals were to gain a better understanding of how many ER visits were either related to hypertension or were solely because of hypertension, and to determine whether this changed from 2006 to 2012.

We found that emergency room visits related to or solely for hypertension were common and that they both rose more than 20% from 2006 to 2012. Visits to the emergency department specifically for hypertension were more common among patients who were younger, healthier, and less likely to have health insurance. Despite increases in the number of ER visits related to hypertension, the proportion of patients who were hospitalized did not increase; this suggests that doctors in emergency departments may be more aware of hypertension and/or may be managing it without having to hospitalize patients.
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Decreased Funding For Mental Health Services Results in Crowded, Strained Emergency Rooms

Dr. Arica Nesper

Dr. Nesper

MedicalResearch.com Interview with:
Arica Nesper, MD, MAS
Resident Physician
Stanford/Kaiser Emergency Medicine Residency
Stanford University Medical Center
Department of Emergency Medicine
Stanford

Medical Research: What is the background for this study? What are the main findings?
Dr. Nesper: Patients with severe mental illness are a distinct demographic in the emergency department. Unfortunately, resources to help these vulnerable patients are frequently the target of funding cuts. We aimed to describe the effect of these cuts on our emergency department and the care provided to our patients. In this study we evaluated data from before our county mental health facility cut its inpatient capacity by half and closed its outpatient unit, and compared this data with data collected after this closure. We found that the mean number of daily psychiatric consultations in our emergency department more than tripled and that the average length of stay for these patients increased by nearly eight hours. These two data combined demonstrate a five-fold increase in daily emergency department bed hours for psychiatric patients, placing a significant strain on the emergency department and demonstrating a delay in definitive care provided to these vulnerable patients.

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Model Predicts Children At High Risk For Asthma Related Acute Care Visits

MedicalResearch.com Interview with:
Jill Hanson, MD
Children’s Mercy Hospital
Kansas City MO 

Background from the American College of Allergy, Asthma & Immunology

“Asthma is the most common chronic disease in children, and one of the most difficult to manage, which is one of the reasons there are so many emergency department visits for asthma sufferers in the US.”

Medical Research: What are the main findings of this study?

Dr. Hanson: Our study of asthmatic children found that the number of historical asthma-related acute care visits (i.e. urgent care, emergency department and inpatient admissions) was predictive of future asthma-related acute care visits. 

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