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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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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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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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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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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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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Co-ingestion of Benzodiazepines and Opioids Contributes to Overdose and Death

MedicalResearch.com Interview with:
Christopher M. Jones, Pharm D., M.P.H
Senior advisor, Office of Public Health Strategy and Analysis
Office of the Commissioner, Food and Drug Administration

Medical Research: What is the background for this study?

Dr. Jones: Opioid analgesics and benzodiazepines are the two most common drug classes involved in prescription drug overdose deaths. In 2010, 75% of prescription drug overdose deaths involved opioid analgesics and 29% involved benzodiazepines. Opioid analgesics and benzodiazepines are also the most common drugs associated with emergency department visits due to nonmedical use of prescription drugs.

Combined opioid and benzodiazepine use has been suggested as a risk factor for overdose death.

Opioids and benzodiazepines have complex drug interactions and in combination can result in synergistic respiratory depression, but the exact mechanisms by which benzodiazepines worsen opioid-related respiratory depression are not fully understood.

Widespread co-use of benzodiazepines and opioids has been documented in both chronic pain and addiction treatment settings. Studies suggest that among patients who receive long-term opioids for chronic non-cancer pain, 40% or more also use benzodiazepines. Among patients who abuse opioids, benzodiazepine abuse also is prevalent, and co-users report using benzodiazepines to enhance opioid intoxication.

This study builds on the prior literature by analyzing trends on how the combined use of opioids and benzodiazepines in the U.S. contributes to the serious adverse outcomes of nonmedical use–related ED visits and drug overdose deaths. A better understanding of the consequences of co-use of these medications will help identify at-risk populations, inform prevention efforts, and improve the risk–benefit balance of these medications.

Medical Research: What are the main findings?

Dr. Jones: From 2004 to 2011, the rate of nonmedical use–related Emergency Department visits involving both opioid analgesics and benzodiazepines increased from 11.0 to 34.2 per 100,000 population. During the same period, drug overdose deaths involving both drugs increased from 0.6 to 1.7 per 100,000. Statistically significant increases in Emergency Department visits occurred among males and females, non-Hispanic whites, non-Hispanic blacks, and Hispanics, and all age groups except 12–17-year-olds. For overdose deaths, statistically significant increases were seen in males and female, all three race/ethnicity groups, and all age groups except 12–17-year-olds. Benzodiazepine involvement in opioid analgesic overdose deaths increased each year, increasing from 18% of opioid analgesic overdose deaths in 2004 to 31% in 2011.

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Low Risk Of Adverse Cardiac Events in Patients With Negative ER Evaluation For Chest Pain

Michael B. Weinstock, MD Professor of Emergency Medicine, Adjunct Department of Emergency Medicine, The Ohio State University College of Medicine Emergency Department Chairman and Director of Medical Education, Mt. Carmel St. Ann's Dept. of Emergency Medicine Columbus, OhioMedicalResearch.com Interview with:
Michael B. Weinstock, MD
Professor of Emergency Medicine, Adjunct
Department of Emergency Medicine, The Ohio State University College of Medicine
Emergency Department Chairman and Director of Medical Education, Mt. Carmel St. Ann’s Dept. of Emergency Medicine
Columbus, Ohio

Medical Research: What is the background for this study?

Response: Patients with potential cardiac ischemia are often admitted to the hospital even after a negative evaluation in the emergency department due to concern about missed MI, unstable angina, or potential for cardiac arrhythmia.

Medical Research: What are the main findings?

Response: Our study was different than previous studies and clinical decision rules; instead of looking at a 30 day marker, which is important to the cardiologist, ours looked at the risk of a Clinically Relevant Adverse Cardiac Event (CRACE) occurring during hospitalization. These events included inpatient STEMI, life-threatening arrhythmia, cardiac or respiratory arrest, or death. The study found only 4 of these events out of 7266 patients studied and of the 4, two were possibly iatrogenic, suggesting that after a negative ED evaluation (including 2 negative serial cardiac enzyme tests, non-ischemic and interpretable ECG, and nonconcerning vital signs) a patient can be safely sent home for an expedited cardiac outpatient evaluation.

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Frequent ER Visits Linked To Prescription Drug Overdose

MedicalResearch.com Interview with:
Joanne Brady, PhD candidate
Department of Anesthesiology, College of Physicians and Surgeons
Department of Epidemiology, Mailman School of Public Health
Columbia University, New York, NY

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

Response: Prescription drug overdose is a major public health problem in the United States. Prescription drug overdose mortality has increased dramatically over the past twenty five years. Frequent emergency department utilization may be a marker for risk of prescription drug overdose death. The current study assessed how frequency of emergency department visits in the past year related to risk of subsequent prescription drug overdose death. In a cohort of patients visiting the emergency department, patients with four or more visits to the emergency department in the past year were at substantially higher risk for prescription drug overdose death than patients who visited the emergency department one or fewer times. As the number of visits to the emergency department increased from 0 – 1 to 4 or more for any reason the risk of dying from prescription drug overdose also increased.

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Frequent Emergency Department Users More Likely To Die Or Be Admitted

dr-brian-roweMedicalResearch.com Interview with:
Dr. Brian Rowe, MD, MSc, CCFP(EM), FCCP
Professor, Department of Emergency Medicine
University of Alberta, Edmonton, Alberta, Canada

MedicalResearch: What is the background for this study?

Dr. Rowe: Frequent users are also called “familiar faces” or “heavy users” and they represent an important sub-group of patients in the emergency setting, with often complex needs that contribute to overcrowding and excess health care costs. The evidence suggests that frequent users account for up to one in 12 patients seeking emergency care, and for around one in four of all visits.

MedicalResearch: What are the main findings?

Dr. Rowe: Frequent users of emergency department care are more than twice as likely to die, be admitted to hospital, or require other outpatient treatment as infrequent users, concludes an analysis of the available evidence, published in Emergency Medicine Journal.

These conclusions are based on a thorough search of seven electronic databases of relevant research relating to the frequency and outcomes of emergency department use by adults. Out of a total of more than 4000 potential studies, 31 relevant research reports published between 1990 and 2013 were included in the final analysis. Frequent users were variably defined as visiting emergency care departments from four or more times up to 20 times a year.

Among the seven studies looking at deaths, the analysis showed that frequent attenders at emergency care departments were more than twice as likely to die as those who rarely sought emergency care. Most of the studies included hospital admission as an outcome, and these showed that frequent users were around 2.5 times as likely to be admitted as infrequent users. Ten studies looked at use of other hospital outpatient care, and these showed that frequent users were more than 2.5 times as likely to require at least one outpatient clinic after their visit to the emergency care department.

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Connecting Chronically Ill Patients To Safety Net Clinics Reduced ER Visits

Karoline Mortensen, Ph.D. Assistant Professor Department of Health Services Administration University of Maryland College Park, MDMedicalResearch.com Interview with:
Karoline Mortensen, Ph.D.
Assistant Professor
Department of Health Services Administration
University of Maryland
College Park, MD

Medical Research: What is the background for this study?

Dr. Mortensen: For twenty years, use of hospital emergency departments has been on the rise in the United States, particularly among low-income patients who face barriers to accessing health care outside of hospitals including not having an identifiable primary health care provider. Almost half of emergency room visits are considered “avoidable.” The Emergency Department-Primary Care Connect Initiative of the Primary Care Coalition, which ran from 2009 through 2011, linked low-income uninsured and Medicaid patients to safety-net health clinics.

Medical Research: What are the main findings?

Dr. Mortensen: “Our study found that uninsured patients with chronic health issues – such as those suffering from hypertension, diabetes, asthma, COPD, congestive heart failure, depression or anxiety – relied less on the emergency department after they were linked to a local health clinic for ongoing care,” says Dr. Karoline Mortensen, assistant professor of health services administration at the University of Maryland School of Public Health and senior researcher. “Connecting patients to primary care and expanding the availability of these safety-net clinics could reduce emergency department visits and provide better continuity of care for vulnerable populations.”
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Emergency Room Coding Of Heart Failure Diagnosis Validated

Justin A. Ezekowitz, MBBCh MScAssociate Professor, University of Alberta Co-Director, Canadian VIGOUR Centre Director, Heart Function Clinic Cardiologist, Mazankowski Alberta Heart InstiMedicalResearch.com Interview with:
Justin A. Ezekowitz, MBBCh MSc
Associate Professor, University of Alberta
Co-Director, Canadian VIGOUR Centre
Director, Heart Function Clinic
Cardiologist, Mazankowski Alberta Heart Institute

Medical Research: What is the background for this study?

Dr. Ezekowitz: Heart Failure is a prevalent health issue that carries high morbidity and mortality. Most epidemiologic research derives information from hospital discharge abstracts, but emergency department visits are another source of information. Many have assumed this code is accurate in the emergency department but uncertainty remains.

In our study, we assessed patients at their presentation to Emergency Department, which is usually the first medical contact for acutely ill patients with heart failure.

The objective of our study was to compare administrative codes for acute heart failure (I50.x) in the emergency department against a gold standard of clinician adjudication.

Medical Research: What are the main findings?

Dr. Ezekowitz: Emergency department administrative data is highly correlated with a clinician adjudicated diagnosis. The positive predictive value of acute heart failure as the main diagnosis was 93.3% when compared to clinician adjudication, supported by standardized scoring systems and elevated BNP. Continue reading

Short Cardiac Biomarker Protocols May Underestimate Heart Damage

MedicalResearch.com Interview with:
Anne Vorlat MD

Department of Cardiology
Antwerp University Hospital
Department of Cardiology, Edegem, Belgium

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

Dr. Vorlat: Early diagnosis of myocardial infarction is critical for optimal treatment and prognosis of the patient. The third universal definition of myocardial infarction states that a rise and/or fall of cardiac biomarkers (preferably troponin) with at least one value above the 99th percentile of the upper reference limit is mandatory with symptoms and or ST segment changes on the ECG. Since the development of more sensitive assays for cardiac troponins, myocardial injury can be detected earlier. This has permitted to shorten the timing of the second sampling of cardiac biomarkers from 6h to 3h after the first sampling. Recent studies have tested biomarker protocols with a very short delay (e.g., 1 hour) or with a single measurement of troponin and copeptin (a marker of endogenous stress, not cardiac specific) to rule in or to rule out myocardial injury in a population with chest pain. Although these newer protocols appear to be promising, early presenters (chest pain for less than 2 hours) are underreported. The present study evaluated the usefulness of early rule-in and rule-out biomarker protocols to estimate ischemia-induced myocardial injury in an early presenter model. The “early presenter” model was tested in 107 stable patients after a short period of myocardial ischemia, induced by stenting of a significant coronary artery stenosis. High-sensitivity troponin T (hsTnT), hsTnI and copeptin were measured at the start, and 90, 180 and 360 minutes after stent implantation. We confirmed our hypothesis that short biomarkers protocols underestimate myonecrosis in early presenters.

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ACA: Small Drop In Emergency Room Visits by Young Adults

MedicalResearch.com Interview with:
Asako Moriya Ph.D
School of Public and Environmental Affairs
Indiana University, Bloomington, IN
Center for Financing, Access and Cost Trends
Agency for Healthcare Research and Quality
Rockville, MD

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

Response: Historically, young adults have had the lowest rate of insurance coverage.  They have also frequently sought non-urgent care in emergency departments (EDs). However, ED care, while appropriate for injuries and other true emergencies, is very expensive and inefficient for non-urgent care. The Affordable Care Act (ACA)’s dependent coverage provision requires health plans that offer dependent coverage to allow young adults to stay on their parents’ private health plans until age 26. This insurance expansion had a potential to improve efficiency by reducing inappropriate ED use.

We used data from the Agency for Healthcare Research and Quality and found that the quarterly ED-visit rate decreased by a small, but statistically significant amount (1.6 per 1,000 population) among adults age 19-25 after the implementation of the ACA’s dependent coverage provision. The decrease was concentrated among women, weekday visits, non-urgent conditions, and conditions that could be treated in other settings. We found no effect among visits due to injury, weekend visits, and urgent conditions.

The findings suggest that the ACA’s dependent coverage provision has increased the efficiency of medical care delivery by reducing non-urgent ED use. Having access to their parents’ health insurance appears to be prompting young adults to use medical care more appropriately.

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Insurance Study Evaluates ER Imaging For Low Back Pain

MedicalResearch.com Interview with:
Erin R. Schlemmer, MPH
Health Care Manager / Epidemiologist
Department of Clinical Epidemiology & Biostatistics
Blue Cross Blue Shield of Michigan

MedicalResearch: What is the background for this study?

Response: Low back pain (LBP) is a common reason for emergency department (ED) visits. Usually, uncomplicated acute LBP is a benign, self-limited condition that can be managed without the need for imaging studies. However, national data have shown that a substantial proportion of ED patients with LBP receive imaging studies, and that the use of advanced imaging has increased considerably for this population in recent years.

A number of groups (including specialty societies, a consortium of health plan medical directors, and an expert panel of emergency medicine physicians) have offered recommendations for the appropriate use of imaging for Low back pain. Within these guidelines, there are a number of “red flag” conditions that serve as indications for Low back pain imaging, and it is generally accepted that most patients do not require imaging to inform treatment of their Low back pain unless they have one or more red flags.

Our objective was to use claims data from a large commercial insurer to describe the imaging indications and imaging status of patients presenting to the ED with Low back pain, and to describe demographic and healthcare use characteristics associated with non-indicated imaging.

MedicalResearch: What are the main findings?

Response: We found that over half (51.9%) of all patients presenting to the ED with low back pain had no claims-based evidence of indications for imaging. Overall, 36.5% of patients received imaging, and 10.2% received advanced imaging (CT or MRI). Among patients with imaging indications, the most common indication was trauma (71.6%), followed by cancer (24.0%). Although nearly a third of non-indicated patients received imaging, this population had a lower prevalence of imaging compared to patients with imaging indications (30.1% vs. 43.5%), and were also less likely to have prior healthcare use (such as ED visits) in the past year. Among non-indicated patients who received imaging, 26.2% received advanced imaging (CT or MRI) and 4.3% had >1 type of imaging.

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Emergency Room Visits Related to Indoor Tanning

Gery P. Guy Jr., PhD, MPH Health economist Division of Cancer Prevention and Control’s Epidemiology and Applied Research Branch CDCMedicalResearch.com Interview with:
Gery P. Guy Jr., PhD, MPH
Health economist
Division of Cancer Prevention and Control’s Epidemiology and Applied Research Branch CDC

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

Dr. Guy: Indoor tanning exposes users to intense UV radiation and is associated with an increased risk of skin cancer. However, little is known about the more immediate adverse outcomes of indoor tanning. This study provides the first national estimates of visits to emergency departments related to indoor tanning. We examined cases from the Consumer Product Safety Commission’s National Electronic Injury Surveillance System (NEISS), a national probability sample of hospitals in the U.S. and its territories. Patient information is collected from each NEISS hospital for every emergency visit involving an injury associated with consumer products. From this sample, the total number of product-related injuries treated in hospital emergency rooms nationwide can be estimated.

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More CT Scans Done For Minor Head Trauma Than Guidelines Recommend

Dr. Jennifer Marin MD MSc Director of Emergency Ultrasound, Division of Pediatric Emergency Medicine Assistant Professor of Pediatrics and Emergency Medicine University of Pittsburgh School of MedicineMedicalResearch.com Interview with:
Dr. Jennifer Marin MD MSc

Director of Emergency Ultrasound
Division of Pediatric Emergency Medicine
Assistant Professor of Pediatrics and Emergency Medicine
University of Pittsburgh School of Medicine

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

Dr. Marin: Overuse of diagnostic imaging in the emergency department has become a focus of concern from policy makers, patients, and physicians. There are evidence-based clinical decision rules and policy recommendations published in order to optimize the use of such imaging. However, physicians don’t necessarily use these tools in their decision-making. Head computed tomography (CT) imaging for patients with minor head trauma is a common CT performed in the emergency setting. Our study sought to evaluate how often physicians adhered to the American College of Emergency Physicians (ACEP) Clinical Policy on Neuroimaging. The policy outlines which patients warrant a CT in the setting of minor head trauma based on certain factors, such as age, mechanism of injury, and signs and symptoms of head trauma. What we found is that when the policy recommends that a head CT be performed, it is obtained more than 90% of the time. However, when a head CT is not recommended, it is actually obtained in nearly half of those patients. We hope this will draw attention to decision rules and clinical policies, such as that from ACEP, and remind physicians that using these tools can assist in appropriate imaging practices.
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Acute Coronary Syndrome: How Do Patients Without Critical Stenosis Do?

Dr. Marc-Alexander Ohlow, MD, adjunct Professor of Medicine Cardiology Department Zentralklinik Bad Berka, GermanyMedicalResearch.com Interview with:
Dr. Marc-Alexander Ohlow, MD,
Adjunct Professor of Medicine
Cardiology Department
Zentralklinik Bad Berka, Germany

MedicalResearch.com: What are the main findings of the study?

Dr. Ohlow: This paper reports the finding of a retrospective study including 4.311 consecutive patients with suspected acute coronary syndrome (ACS). Out of them 272 patients with acute onset of chest pain and elevated levels of cardiac necrosis markers did not have significant (≥50% diameter stenosis) coronary artery stenosis on coronary angiography. Aim of this study was to provide further information and understanding of the clinical characteristics and outcome of patients with acute coronary syndrome without critical stenosis, and comparing those with a consecutive series of patients with ACS requiring percutaneous coronary intervention (non-ST-elevation myocardial infarction patients).

Patients presenting without significant coronary stenosis, but with chest pain and elevated troponin level were younger, had less severe angina symptoms, were more likely to be women, had lower level of myocardial necrosis markers (troponin and creatine kinase), and had higher left ventricular ejection fraction compared to patients undergoing angioplasty due to significant coronary obstruction.
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Pharmacist Intervention Reduced Emergency Room ReVisits

Anna Alassaad Pharmacist, PhD Student, Department of Medical Sciences, Uppsala University Uppsala, Sweden, Uppsala University Hospital, Uppsala, SwedenMedicalResearch.com Interview with:
Anna Alassaad
Pharmacist, PhD Student,
Department of Medical Sciences, Uppsala University
Uppsala, Sweden, Uppsala University Hospital, Uppsala, Sweden

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

Response: The main findings from our study are that patients with a low number of prescribed drugs benefited more from a comprehensive clinical pharmacist intervention than patients with a higher number of drugs. There was no difference in effect between the patients with higher and lower levels of inappropriate prescribing, as measured by two validated tools for inappropriate prescribing.

Clinical pharmacist interventions have in several studies shown positive effects on inappropriate prescribing and clinical outcomes. Since the concomitant use of a large number of drugs is associated with an increased risk of adverse drug events, it is often assumed that patients receiving a larger number of drugs would benefit most from interventions aiming to improve the quality of drug use. However, differences in the effects of clinical pharmacist intervention between different subgroups of patients have rarely been analyzed.

We have, in a randomized controlled trial, previously demonstrated that a clinical pharmacist intervention at an acute internal medicine hospital ward reduces emergency department visits by 47%, revisits to hospital by 16%, and drug-related readmissions by 80% for patients aged 80 years or older. We aimed to investigate whether there was any difference in treatment effect of the clinical pharmacist interventions on number of subsequent revisits to the emergency department between the patients with less than five drugs and those with five or more drugs on admission to hospital. We also explored whether the effect of the intervention was consistent for patients with a high or low level of inappropriate prescribing.

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Who Relapses After Emergency Room Visit For Asthma?

Brian H. Rowe, MD, MSc, CCFP(EM), FCCP Tier I Canada Research Chair in Evidence-based Emergency Medicine Scientific Director, Emergency Strategic Clinical Network Professor, Department of Emergency Medicine University of AlbertaMedicalResearch.com Interview with:
Brian H. Rowe, MD, MSc, CCFP(EM), FCCP
Tier I Canada Research Chair in Evidence-based Emergency Medicine
Scientific Director, Emergency Strategic Clinical Network
Professor, Department of Emergency Medicine
University of Alberta

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

Dr. Rowe​: The study was designed to evaluate non-pharmacological issues associated with relapse following discharge from the emergency department with acute asthma. Many years of high-quality research have shown that systemic and inhaled corticosteroids (ICS) in combination are required to reduce relapse. In this study all patients received systemic corticosteroids and the majority received inhaled corticosteroids (either as mono-therapy or in combination with long-acting beta-agonists​ {LABA}).

This study ​ design permitted us to evaluate other factors associated with relapse as a guide for clinicians to use in planning discharge.

The main findings include identifying the key factors independently associated with relapse: female sex (OR = 1.9; 95% confidence interval [CI]: 1.2, 3.0), symptom duration of > 24 hours prior to emergency department visit (OR = 1.7; 95% CI: 1.3, 2.3), ever using oral corticosteroids (OR = 1.5; 95% CI: 1.1, 2.0), current use of an ICS/LABA combination product (OR = 1.9; 95% CI: 1.1, 3.2), and owning a spacer device (OR = 1.6; 95% CI: 1.3, 1.9). Continue reading

Nursing Home Patients: Cognitive Function Linked To Emergency Room Visits

Dr. Caroline E Stephens PhD Department of Community Health Systems University of California, San FranciscoMedicalResearch.com Interview with:
Dr. Caroline E Stephens PhD
Department of Community Health Systems
University of California, San Francisco

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

Dr. Stephens: In our national random sample of nursing home residents, we found that mild cognitive impairment (CI) predicted higher rates of ED visits compared to no CI, but interestingly, ED visit rates decreased as severity of cognitive impairment increased.  However, after nursing home residents were evaluated in the ED, severity of CI was not significantly associated with higher odds of hospitalization.

Another important finding was that the proportion of nursing home residents using feeding tubes more than tripled in advanced or end-stage dementia, from 9.9% to 33.8%.  Moreover, tube-fed nursing home residents had 73% higher rates of total ED visits, but once evaluated in the ED, they were no more likely to be hospitalized than those without feeding tubes.  This finding is particularly striking given the numerous existing studies that have questioned the utility and appropriateness of using feeding tubes in people with advanced dementia.

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How Safe Is Ketamine For Sedation in the ER?

MedicalResearch.com Interview with:
Lindsay Cohen MD
Department of Emergency Medicine
University of British Columbia

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

Dr. Cohen: In our systematic review of the literature, we sought to synthesize the available evidence on the effect of ketamine on clinical outcomes as compared to other sedative agents in intubated patients. Our outcomes of interest included intracranial and cerebral perfusion pressures, neurologic outcomes, ICU length of stay, and mortality. We included only randomized controlled trials and prospective controlled studies, and identified a total of ten studies that met our inclusion criteria. Due to the lack of homogeneity in the studies, data was analyzed in a qualitative manner. None of the studies reported significant differences between ketamine and other sedative agents for any of our outcomes of interest.

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Tool Identifies ER Patients With Substance Abuse Issues

Wendy Macias Konstantopoulos, MD, MPH Department of Emergency Medicine Division of Global Health & Human Rights Massachusetts General Hospital Harvard Medical SchoolMedicalResearch.com Interview with:
Wendy Macias Konstantopoulos, MD, MPH
Department of Emergency Medicine
Division of Global Health & Human Rights
Massachusetts General Hospital
Harvard Medical School

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

Dr. Macias-Konstantopoulos: Nearly two-thirds (64%) of 3240 emergency department (ED) patients who endorsed using drugs in the last 30 days, met criteria for problematic drug use (DAST-10 score ≥3). Of patients who identified their primary drug of use as being a substance other than cannabis, approximately 91% met criteria for problematic drug use, including nearly 94% of those using illicit drugs and 76% of those using pharmaceuticals. Compared to those who used cannabis primarily, primary non-cannabis users had an almost 15 times higher odds of meeting criteria for problematic drug use. Finally, we know from previous studies that drug-using individuals are more likely to access medical care through the ED and more likely to require hospitalization than their non-drug using counterparts. Our study found that drug-using ED patients who met criteria for problematic drug use tended to have ED triage levels associated with higher levels of severity or resource utilization when compared to drug-using ED patients who did not meet criteria for a drug problem.

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How Can Doctors Tell When A Patient “Looks Sick” ?

MedicalResearch.com Interview with: Jeffrey Allen Kline Vice Chair of Research Department of Emergency Medicine
MedicalResearch.com Interview with:
Jeffrey Allen Kline
Vice Chair of Research
Department of Emergency Medicine
Indiana University Health

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

Dr. Kline: We believe that clinicians use information from their patients’ faces to make decisions about diagnostic testing.

This is particularly relevant in emergency medicine, where the clinicians make decisions rapidly with limited information. We videotaped patients’ faces who had chest pain and dyspnea and used the most well-known facial scoring system to assess their facial expression variability in response to seeing visual stimuli. We found that patients who ultimately had emergent problems tended to hold their faces in a neutral position and be less likely to show the expression of surprise. The investigators were not surprised at this, but we did find that patients with emergent problems also tended to have less negative affect as well as less positive affect. In other words, patients who were sickest even tended to frown less than patients with no medical problem.
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Psychiatric Medications Linked To High Number of ER Visits

MedicalResearch.com interview with:
Lee M. Hampton, MD, MSc:
Division of Healthcare Quality Promotion
Centers for Disease Control and Prevention
Atlanta, Georgia

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

Dr. Hampton: The study, which used CDC’s national outpatient adverse drug event surveillance system (NEISS-CADES), found that there are almost 90,000 estimated annual emergency department visits by adults for adverse drug events from therapeutic use of antipsychotics, antidepressants, sedatives and anxiolytics, lithium salts or stimulants between 2009 and 2011. Almost one in five of those emergency department visits (19.3%) resulted in hospitalization. Sedatives and anxiolytics, antidepressants, and antipsychotics each caused 20,000 to 30,000 emergency department visits annually. However, relative to how often each of these types of medications was prescribed at outpatient visits, antipsychotics and lithium salts were more likely to cause emergency department visits for adverse drug events than were sedatives, stimulants, and antidepressants. Antipsychotics caused 3.3 times more emergency department visits for adverse drug events than sedatives, 4.0 times more emergency department visits than stimulants, and 4.9 times more emergency department visits than antidepressants relative to their outpatient use.

Out of the 83 specific drugs the study looked at, ten drugs were implicated in nearly 60% of the emergency department visits for ADEs from therapeutic use of antipsychotics, antidepressants, sedatives and anxiolytics, lithium salts or stimulants. Zolpidem was implicated in nearly 12% of all such emergency department visits and 21% of such emergency department visits involving adults aged 65 years or older, more than any other antipsychotic, antidepressant, sedative or anxiolytic, lithium salt or stimulant.
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Chest Pain in the Emergency Room: Clinical Decision Strategy

Dr. Richard Body Emergency Department Manchester Royal Infirmary Manchester UKMedicalResearch.com Interview with: 
Dr. Richard Body
Emergency Department
Manchester Royal Infirmary
Manchester UK

 

MedicalResearch.com: What are the main findings of the study?

Dr. Body: This paper actually reports the findings of two consecutive, separate studies.  We aimed to derive and then externally validate a clinical decision rule to risk stratify patients with suspected acute coronary syndromes in the Emergency Department (ED).  This rule could then be used to reduce unnecessary hospital admissions while also making judicious use of specialist high dependency resources.

In the first study we derived a clinical decision rule that incorporates 8 variables: high sensitivity troponin T, heart-type fatty acid binding protein; ECG ischaemia; worsening angina; hypotension (systolic blood pressure <100mmHg on arrival); sweating observed in the ED; pain associated with vomiting; and pain radiating to the right arm or shoulder.  When we validated the rule at a different centre, we found that its use could have avoided hospital admission for over a quarter of patients while effectively risk stratifying others.  Of the 10% of patients who were identified as ‘high risk’, approximately 95% had a major adverse cardiac event within 30 days.  The findings suggest that the Manchester Acute Coronary Syndromes (MACS) decision rule could be used to ‘rule in’ and ‘rule out’ acute coronary syndromes immediately, using information gathered at the time of initial presentation to the ED.  Before clinical implementation, we recommend that effect of using the MACS rule in practice should first be evaluated in a trial setting.  This will enable us to determine:
(a) whether physicians and patients are likely to comply with (and be satisfied with) the MACS rule;
(b) the safety of the MACS rule when used in practice; and
(c) whether use of the MACS rule leads to cost savings for the health service.

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Biphasic Allergic Reactions in ER Patients

MedicalResearch.com Interview with:
Brian Grunau MD
Emergency Physician, St. Paul’s Hospital
Clinical Assistant Professor, UBC Department of Emergency Medicine

MedicalResearch.com: What are the main findings of the study?

Dr. Grunau: Among 2819 consecutive Emergency Department visits of patients with allergic reactions or anaphylaxis, five clinically important biphasic reactions were identified (0.18%; 95% confidence interval [CI] 0.07% to 0.44%), with two occurring during the ED visit and three post-discharge. There were no fatalities.  When examining patients who satisfied the definition for anaphylaxis and those who did not separately, clinically important biphasic reactions occurred in 2 patients (0.40%; 95% CI 0.07% to 1.6%) and 3 patients (0.13%; 95% CI 0.03% to 0.41%), respectively.
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Emergency Room Reimbursements: Potential Mixed Impact of ACA

MedicalResearch.com Interview with:
Jessica E. Galarraga, MD, MPH Resident Physician Department of Emergency Medicine George Washington University Hospital 2120 L. St. N.W. Suite 475 Washington D.C. Jessica E. Galarraga, MD, MPH
Resident Physician
Department of Emergency Medicine
George Washington University Hospital
2120 L. St. N.W. Suite 475
Washington D.C.

 

MedicalResearch.com: What are the main findings of the study?

Dr. Galarraga: This study examined how emergency department (ED) reimbursements for outpatient visits may be impacted by the insurance coverage expansion of the Patient Protection and Affordable Care Act as newly eligible patients gain coverage either through the Medicaid expansion or through health insurance exchanges. We conducted our analyses using the Medical Expenditure Panel Survey, a nationally representative survey managed by the Agency for Healthcare Research and Quality. We found that ED reimbursements for outpatient encounters by the previously uninsured who gain Medicaid insurance may increase by  17 percent and moving Medicaid-expansion ineligible patients to the private insurance market through insurance exchanges may increase reimbursements as high as 39 percent after the act is implemented.
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Cost-Effectiveness of Helicopter Versus Ground Emergency Medical Services for Trauma Scene Transport in the US

Sridhar Sri SeshadriMedicalResearch.com eInterview with: M. Kit Degado, MD, MS

Instructor, Emergency Medicine
Affiliated Faculty, Centers for Health Policy/Primary Care and Outcomes Research
Stanford University School of Medicine
kdelgado@stanford.edu

MedicalResearch.com: What are the main findings of the study?

Dr. Degado:

  • We found that if an additional 1.6% of patients flown by helicopter survive or if there is any improvement in disability outcomes, then helicopter EMS should be considered cost-effective over transporting patients by ground EMS.
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