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BACKGROUND: The opioid epidemic is a serious social, economic and public health problem. This study was designed to evaluate the effectiveness of individual institutional opioid prescriber training on prescriber adherence to the Centers for Disease Control and Prevention (CDC's) guidelines for responsible opioid prescribing practices to treat acute pain. METHODS: Opioid prescribing data were collected from an academic medical centre and its associated outpatient clinics. A baseline for opioid prescribing practices was collected for 2 years and 2 months prior to the planned intervention. Departments responsible for 5% or more of the total institutional opioid prescriptions were chosen to study in detail. A number of opioid prescriptions per department per day and their compliance with the maximum daily dose (MDD) recommendations put out by the CDC were determined. INTERVENTION: The hospital administration implemented a mandatory opioid prescriber training as part of their standard annual provider education for all medical staff, who were all required to attest having read it and pass a quiz by 30 September 2019, which was chosen as the end date for the pre-intervention data. Data were analysed preintervention and postintervention to assess the effect of this intervention on opioid prescribing. RESULTS: Overall opioid prescribing rates decreased by 18.3% and there were significant decreases in opioid prescribing rate in five out of the seven departments/divisions. Overall, there was a statistically significant decrease in the compliance with MDD before (71.3%) and after (67.3%) the intervention (4%, 95% CI 3.13% to 4.87% difference, p<0.001). Additionally, there were statistically significant increases in compliance with CDC guidelines in three departments/divisions. However, there was a statistically significant decrease in compliance with CDC guidelines after intervention in two departments. CONCLUSIONS: The results of this study were largely encouraging for the effectiveness of this institutional mandatory prescriber training.
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Analgésicos Opioides , Melhoria de Qualidade , Humanos , Analgésicos Opioides/uso terapêutico , Padrões de Prática Médica , Centros Médicos AcadêmicosRESUMO
Hyperbaric oxygen (HBO2 ) has been used as an adjunctive treatment for the care of advanced non-healing diabetic foot ulcers (DFUs). A patient's in-chamber transcutaneous oximetry measurement (TCOM) is currently the most effective predictor for response to HBO2 therapy but still excludes close to one in four patients who would benefit out of treatment groups when used for patient selection. Improving selection tools and criteria could potentially help better demonstrate HBO2 therapy's efficacy for such patients. We sought to identify if long-wave infrared thermography (LWIT) measurements held any correlation with a patient's TCOM measurements and if LWIT could be used in a response prediction role for adjunctive HBO2 therapy. To investigate, 24 patients already receiving TCOM measurements were enrolled to simultaneously be imaged with LWIT. LWIT measurements were taken throughout each patient's therapeutic course whether they underwent only standard wound care or adjunctive HBO2 treatments. A significant correlation was found between in-chamber TCOM and post-HBO2 LWIT. There was also a significant difference in the post-HBO2 LWIT measurement from 1st treatment to 6 weeks or the last treatment recorded. These initial findings are important as they indicate a possible clinical use for LWIT in the selection process for patients for HBO2 therapy. Larger studies should be carried out to further articulate the clinical use of LWIT in this capacity.
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Oxigenoterapia Hiperbárica , Humanos , Monitorização Transcutânea dos Gases Sanguíneos , Projetos Piloto , Termografia , Cicatrização/fisiologiaRESUMO
OBJECTIVES: Emergency departments (EDs) could play an important role in the COVID-19 pandemic response by reaching patients who would otherwise not seek vaccination in the community. Prior to expanding COVID-19 vaccination to the acute care setting, we assessed ED patients' COVID-19 vaccine status, perspectives, and hypothetical receptivity to ED-based vaccination. METHODS: From January 11 through March 31, 2021, we conducted a multisite (Albany Medical Center, Boston Medical Center, Buffalo General Hospital, University of Cincinnati Medical Center, and Upstate Medical Center), cross-sectional survey of ED patients, with embedded randomization for participants to receive 1 of 4 vignette vaccination messages (simple opt-in message, recommendation by the hospital, community-oriented message, and acknowledgment of vaccine hesitancy). Main outcomes included COVID-19 vaccination status, prior intention to be vaccinated, and receptivity to randomized hypothetical vignette messages. RESULTS: Of 610 participants, 122 (20.0%) were vaccinated, 234 (38.4%) had prior intent to be vaccinated, 111 (18.2%) were unsure as to prior intent, and 143 (23.4%) had no prior intent to be vaccinated. Vaccine hesitancy (participants who were vaccine unsure or did not intend to receive the vaccine) was associated with the following: age <45 years, female, non-Hispanic Black, no primary health care, and no prior influenza vaccination. Overall, 364 of 565 (64.4%; 95% CI, 60.3%-68.4%) were willing to accept a hypothetical vaccination in the ED. Among participants with prior vaccine hesitancy, a simple opt-in message resulted in the highest acceptance rates to hypothetical vaccination (39.7%; 95% CI, 27.6%-52.8%). CONCLUSIONS: EDs have appropriate patient populations to initiate COVID-19 vaccination programs as a supplement to community efforts. A simple opt-in approach may offer the best messaging to reach vaccine-hesitant ED patients.
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Vacinas contra COVID-19 , COVID-19 , Adulto , COVID-19/epidemiologia , COVID-19/prevenção & controle , Estudos Transversais , Serviço Hospitalar de Emergência , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias/prevenção & controle , VacinaçãoRESUMO
INTRODUCTION: The 2019 novel coronavirus pandemic has caused significant disruptions in the clinical operations of hospitals as well as clinical education, training, and research at academic centers. New York State was among the first and largest epicenters of the pandemic, resulting in significant disruptions across its 29 emergency medicine (EM) residency programs. We conducted a cross-sectional observational study of EM residency programs in New York State to assess the impact of the pandemic on resident education and training programs. METHODS: We surveyed a cross-sectional sample of residency programs throughout New York State in June 2020, in the timeframe immediately after the state's first "wave" of the pandemic. The survey was distributed to program leadership and elicited information on pandemic-prompted curricular modifications and other educational changes. The survey covered topics related to disruptions in medical education and sought details on solutions to educational issues encountered by programs. RESULTS: Of the 29 accredited EM residency programs in New York State, leadership from 22 (76%) responded. Of these participating programs, 11 (50%) experienced high pandemic impact on clinical services, 21 (95%) canceled their own trainees' off-service rotations, 22 (100%) canceled or postponed visiting medical student rotations, 22 (100%) adopted virtual conference formats (most within the first week of the pandemic wave), and 11 (50%) stopped all prospective research (excluding COVID-19 research), while most programs continued retrospective research. CONCLUSION: This study highlights the profound educational impact of the pandemic on residency programs in one of the hardest- and earliest-hit regions in the United States. Specifically, it highlights the ubiquity of virtual conferencing, the significant impact on research, and the concerns about canceled rotations and missed training opportunities for residents, as well as prehospital and non-physician practitioner trainees. This data should be used to prompt discussion regarding the necessity of alternate educational modalities for pandemic times and the sequelae of implementing these plans.
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COVID-19 , Medicina de Emergência , Internato e Residência , COVID-19/epidemiologia , Estudos Transversais , Medicina de Emergência/educação , Humanos , New York/epidemiologia , Estudos Prospectivos , Estudos Retrospectivos , Estados Unidos/epidemiologiaRESUMO
INTRODUCTION: Opioid withdrawal due to opioid use disorder (OUD) is an increasing health emergency and complaint in emergency departments (EDs) across the United States. As a response to the increased need for OUD treatment, a low threshold buprenorphine program, or Bridge Clinic, was established within our hospital system. Patients are primarily connected to the Bridge Clinic through the ED, and are able to complete their consultation appointment reliably within 1-3 days of referral. This program also serves to connect patients to community resources for continued treatment of OUD. METHODS: A retrospective chart review was performed to identify ED-based referrals to the Bridge Clinic in the period from January 1, 2017 - December 31, 2018. Outcomes of interest included: (1) ED utilization in the six months before and after consultation at the Bridge Clinic and (2) adherence to buprenorphine therapy at 2-year follow-up. RESULTS: A total of 269 patients were included in the study, with 167 males (62%) and a mean age of 37.8 years. There were 654 total visits to the ED six months before referral to the Bridge Clinic and 381 visits in the six-month period after the initial appointment. There was a high adherence to buprenorphine treatment at 2 year follow up (56%). CONCLUSIONS: These early results suggest that prompt referral to a buprenorphine treatment program significantly reduces ED utilization and connects patients to community resources for continued buprenorphine treatment for OUD.
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Buprenorfina , Transtornos Relacionados ao Uso de Opioides , Adulto , Buprenorfina/uso terapêutico , Serviço Hospitalar de Emergência , Humanos , Masculino , Antagonistas de Entorpecentes/uso terapêutico , Tratamento de Substituição de Opiáceos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Estudos Retrospectivos , Estados UnidosRESUMO
Introduction: Limitations of urine drug-screening (UDS) by immunoassay include false-positive results. Pantoprazole, a proton-pump inhibitor (PPI), is reported to cause false-positive results for THC on UDS. The objective of this study was to determine if oral PPIs cause false-positive THC results using the THC One Step Marijuana Test Strip®.Methods: Eligible healthy volunteers completed a 5-day course of a PPI followed by urine testing using the THC One Step Marijuana Test Strip®. Phase one included 3 subjects taking pantoprazole 40 mg once daily for 5 days. On day 5, urine specimens underwent THC screening. Phase two included 9 subjects randomized to 5-day supply of once-daily oral esomeprazole 20 mg, lansoprazole 15 mg, or omeprazole 20 mg. All study methods and testing mirrored those in phase one.Results: All 12 subjects completed the study protocol. All urine samples collected on day 5 were negative for THC in all subjects.Discussion: Our results demonstrate that oral PPIs did not cause a false-positive THC using the THC One Step Marijuana Test Strip®. Limitations include small sample size, use of a single commercial immunoassay, and inability to confirm medication compliance. Further, large-scale research using other commercial urine immunoassays is warranted.
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Dronabinol/urina , Pantoprazol/administração & dosagem , Inibidores da Bomba de Prótons/administração & dosagem , Detecção do Abuso de Substâncias/métodos , Administração Oral , Interações Medicamentosas , Reações Falso-Positivas , Voluntários Saudáveis , Humanos , Imunoensaio , Detecção do Abuso de Substâncias/normasRESUMO
INTRODUCTION: To determine if hyperbaric oxygen (HBO2) therapy has an effect on diabetic blood glucose levels (BGL) and, if so, the extent of this effect. Also, to examine factors that exacerbate any observed effect. METHODS: This was a retrospective review of prospectively collected quality data on diabetics undergoing HBO2. Pre- and post-treatment BGL were recorded. Pre-treatment BGL ⟨120 mg/dL received glucose supplementation. Hypoglycemia was defined as BGL ⟨70 mg/dL. BGL ⟨90 mg/dL was included as an elevated hypoglycemia threshold. RESULTS: 77 patients representing 1,825 treatments were included for analysis. No patient had deleterious side effects or required emergency care. BGL decreased in 75.4% of treatments in this group, with a median decrease of 25 mg/dL (IQR=54 mg/dL; range of decreased 374 mg/dL to increased 240 mg/dL). A statistically significant greater percentage of treatments of patients with type 2 diabetes resulted in a decrease in BGL (1598 or 77.5%) compared to treatments of patients with type 1 diabetes (169 or 51.5%) (χ2(1, N=1767) =55.37, p⟨0.001). 1.1% of treatments had post-HBO2 serum glucose ⟨90 mg/dL, and 0.2% of treatments had post-HBO2 serum glucose ⟨70 mg/dL. The majority (70%) of patients with post-HBO2 BGL ⟨90 mg/dL were maintained on insulin alone (χ2(2, N=20) =12.4, p=0.002). Well-controlled diabetics (i.e., those with all BGLs within 50 mg/dL over all pre-HBO2 treatments) had no post-HBO2 BGL ⟨70 mg/dL or ⟨90 mg/dL. CONCLUSION: Our results suggest that HBO2 does not cause a clinically significant decrease in diabetic patient BGL. No patient in our study had deleterious side effects or required emergency care. We found that glucose level of ⟨90 mg/dL occurred more often in those who use insulin. Hyperbaric patients who exhibit consistent BGL values may represent a group who could be managed similarly to the non-diabetic population.
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Glicemia/análise , Diabetes Mellitus Tipo 1/sangue , Diabetes Mellitus Tipo 2/sangue , Oxigenoterapia Hiperbárica , Idoso , Diabetes Mellitus/induzido quimicamente , Diabetes Mellitus Tipo 1/tratamento farmacológico , Diabetes Mellitus Tipo 2/tratamento farmacológico , Feminino , Humanos , Oxigenoterapia Hiperbárica/efeitos adversos , Oxigenoterapia Hiperbárica/estatística & dados numéricos , Hipoglicemia/sangue , Hipoglicemia/induzido quimicamente , Hipoglicemiantes/uso terapêutico , Insulina/uso terapêutico , Masculino , Estudos Retrospectivos , Esteroides/efeitos adversosRESUMO
INTRODUCTION: Hyperbaric oxygen (HBO2) therapy is used to promote healing in select problem wounds. Transcutaneous oxygen measurement (TCOM) can be used to predict the response of these wounds to HBO2, with in-chamber TCOM values shown to be the most predictive. We evaluated the use of in-chamber TCOM values to determine optimal treatment pressure. METHODS: A retrospective review was completed of patients undergoing HBO2 therapy for a lower-extremity wound and who had in-chamber TCOM. Data collected included TCOM values, treatment profile, and patient outcome. RESULTS: A total of 142 patients were identified. The overall results demonstrated healing in 59%, minor amputation (below ankle) in 11.3%, and major amputation (above ankle) in 16.2% of patients. 79.3% of patients at 2 atmospheres absolute (ATA) and 86.6% of patients at 2.4 ATA had transcutaneous oxygen pressure (TcPO2) values ≥250 mmHg. Among those with TcPO2 ⟨250 mmHg at 2 ATA, 41% attained TcPO2 ⟩250 mmHg at 2.4 ATA. Among those treated at 2 ATA the healing rate was 70.6% if TcPO2 ⟩250 mmHg, and 11.8% if TcPO2 ⟨250 mmHg (P⟨0.001). Among those treated at 2.4 ATA the healing rate was 33.3% if TcPO2 ⟩250 mmHg and 14.3% if TcPO2 ⟨250 mmHg (P⟨0.001). DISCUSSION: Determining optimal therapeutic pressure for patients undergoing HBO2 is important to maximize benefit and minimize risk. This study indicates that in-chamber TCOM can be used to select an individualized optimal treatment pressure in patients undergoing HBO2 for lower-extremity wounds, including diabetic foot ulcers. This may result in better utilization of HBO2 and better outcomes.
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Amputação Cirúrgica , Monitorização Transcutânea dos Gases Sanguíneos/métodos , Oxigenoterapia Hiperbárica/métodos , Cicatrização/fisiologia , Amputação Cirúrgica/métodos , Amputação Cirúrgica/estatística & dados numéricos , Pressão Atmosférica , Feminino , Humanos , Falência Renal Crônica/complicações , Úlcera da Perna/terapia , Masculino , Pessoa de Meia-Idade , Pressão Parcial , Estudos RetrospectivosRESUMO
INTRODUCTION: Hyperbaric oxygen (HBO2) therapy is generally safe and well tolerated. However, known side effects do exist. Elevation in the blood pressure of patients undergoing HBO2 therapy is a less defined potential side effect. We sought to better quantify effects of HBO2 on blood pressure (BP) in patients undergoing HBO2. METHODS: A retrospective chart review was performed on quality assurance data captured on all patients undergoing HBO2 between March 2012 and October 2015 at a large tertiary referral university hospital hyperbaric center. RESULTS: We identified 155 patients who received 3,147 hyperbaric oxygen treatments. For all treatments there was an overall increase in the median systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) following treatment. No statistically significant difference was found when comparing patients with and without hypertension. Calcium channel blockers (CCB) and beta-blockers (BB) were found to have an agonizing effect while ACE inhibitors (ACEI) were found to have a protective effect. The change in SBP was less with each additional treatment in patients undergoing more than one treatment. DISCUSSION: The current study demonstrates that absolute rises in blood pressure do occur as a result of HBO2 therapy. However, the extent of this effect is not large. BB and CCB had agonizing effects while ACEI had a protective effect. Finally, there was a protective effect with more treatments.
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Pressão Sanguínea , Oxigenoterapia Hiperbárica/efeitos adversos , Hipertensão/etiologia , Antagonistas Adrenérgicos beta/farmacologia , Idoso , Inibidores da Enzima Conversora de Angiotensina/farmacologia , Pressão Arterial/fisiologia , Pressão Sanguínea/efeitos dos fármacos , Bloqueadores dos Canais de Cálcio/farmacologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Centros de Atenção TerciáriaRESUMO
The United States has the highest rate of incarceration in the world. Many correctional facilities have outsourced the medical care for this population that often presents with complex health issues. This study evaluates the reasons that inmates present to an emergency department (ED) and compares them to the general population ED visits. The most common presenting complaints were trauma (16.8%), abdominal pain (13.5%), chest pain (9.0%), and self-injury (8.7%). These presenting complaints differed significantly from those of the general population (abdominal pain [8.1%] and chest pain [5.2%]). Inmate-patients seen in the ED presented with a significantly higher frequency of trauma, 16.8% versus approximately 1.5%.
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Serviço Hospitalar de Emergência , Prisioneiros , Adulto , Feminino , Humanos , Masculino , Auditoria Médica , New York/epidemiologia , Estudos Retrospectivos , Ferimentos e Lesões/epidemiologiaAssuntos
Serviços Médicos de Emergência/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde , Gravidade do Paciente , Classe Social , Adulto , Idoso , Idoso de 80 Anos ou mais , Serviços Médicos de Emergência/economia , Feminino , Pesquisas sobre Atenção à Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Cidade de Nova Iorque , Aceitação pelo Paciente de Cuidados de Saúde/psicologia , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Fatores de TempoRESUMO
INTRODUCTION: Whole bowel irrigation (WBI) is a management option for overdose of medications poorly adsorbed to activated charcoal, with modified release properties, or for body packers. Polyethylene glycol (PEG) is a mixture of ethylene oxide polymers of varying molecular weight. PEG with an average molecular weight of 3350 g/mol is used for WBI. PEG electrolyte lavage solution has been shown in vitro to hasten the dissolution of acetaminophen. The impact of PEG on the pharmacokinetics of extended release pharmaceuticals is unknown. Lower average molecular weight PEG mixtures are used as solvents and excipients. We sought to investigate the impact of PEG on the release of morphine from several extended release morphine formulations. METHODS: An in vitro gastric model was developed. To test the validity of our model, we first investigated the previously described interaction of ethanol and Avinza®. Once demonstrated, we then investigated the effect of PEG with several extended release morphine formulations. RESULTS: In the validation portion of our study, we confirmed an ethanol Avinza® interaction. Subsequently, we did not observe accelerated release of morphine from Avinza® or generic extended release morphine in the presence of PEG. CONCLUSION: The use of PEG for gastric decontamination following ingestion of these extended release morphine formulations is unlikely to accelerate morphine release and aggravate intoxication.
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Liberação Controlada de Fármacos , Overdose de Drogas/terapia , Dependência de Morfina/terapia , Morfina/farmacocinética , Polietilenoglicóis/uso terapêutico , Cromatografia Gasosa , Preparações de Ação Retardada , Humanos , Concentração de Íons de Hidrogênio , Espectrometria de Massas , Morfina/administração & dosagem , Soluções Farmacêuticas/uso terapêutico , Irrigação TerapêuticaRESUMO
INTRODUCTION: Electroencephalography (EEG) is indicated for diagnosing nonconvulsive status epilepticus (NCSE) in a patient who has altered level of consciousness after a motor seizure. A study in a neonatal population found 94% sensitivity and 78% specificity for detection of seizure using a single-lead device. This study aims to show that a reduced montage EEG would detect 90% of seizures detected on standard EEG. METHODS: A portable Brainmaster EEG device was available in the emergency department (ED) at all times. Patients presenting to the ED with altered mental status and known history of seizure or a witnessed seizure having a standard EEG were eligible for this study. The emergency physician obtained informed consent from the legally authorized representative (LAR), while an ED technician attached the electrodes to the patient, and a research associate attached the electrodes to the wiring routing to the portable EEG module. A board-certified epileptologist interpreted the tracings via the Internet. Simultaneously, the emergency physician ordered a standard 23-lead EEG, which would be interpreted by the neurologist on call to read EEGs. We compared the epileptologist's interpretation of the reduced montage EEG to the results of the 23-lead EEG, which was considered the gold standard for detecting seizures. RESULTS: Twelve of 12 patients or 100% had the same findings on reduced-montage EEG as standard EEG. One of 12 patients or 8% had nonconvulsive seizure activity. CONCLUSION: The results are consistent with prior studies which have shown that 8-48% of patients who have had a motor seizure continue to have nonconvulsive seizure activity on EEG. This study suggests that a bedside reduced-montage EEG can be used to make the diagnosis of NCSE in the ED. Further study will be conducted to see if this technology can be applied to the inpatient neurological intensive care unit setting.
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Eletroencefalografia , Serviço Hospitalar de Emergência , Unidades de Terapia Intensiva , Monitorização Fisiológica/instrumentação , Sistemas Automatizados de Assistência Junto ao Leito , Estado Epiléptico/diagnóstico , Adulto , Idoso , Idoso de 80 Anos ou mais , Eletroencefalografia/instrumentação , Eletroencefalografia/métodos , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Fisiológica/métodos , Reprodutibilidade dos Testes , Sensibilidade e Especificidade , Estado Epiléptico/fisiopatologiaRESUMO
Calcific uremic arteriolopathy, also known as calciphylaxis, is a rare syndrome of small vessel calcification of unknown etiology causing painful, violaceous skin lesions that progress to form chronic non-healing ulcers and gangrene. Hyperbaric oxygen therapy (HBOT) can be used as adjunctive therapy in the treatment of these ulcers. However, due to paucity of cases, there is limited data on the clinical benefit of HBOT and identifying factors associated with healing. The purpose of this study was to determine patient outcomes and factors associated with healing in patients with calciphylaxis undergoing HBOT. A retrospective chart review was completed on patients who were diagnosed with calciphylaxis and had hyperbaric medicine consultation between May 2012 and January 2016. Clinical outcomes, demographics, risk factors, laboratory values, wound distribution, and HBOT profiles were collected and analyzed. We identified 8 patients. Out of 8 patients consulted for calciphylaxis, five were consented and underwent HBOT (2 males and 3 females). All had coexisting ESRD and Diabetes. All males were able to tolerate being in the chamber and received therapeutic treatments (at least 20 HBOT) with complete resolution of ulcers. HBOT was discontinued in one female due to an inconsistent biopsy report and two others due to death secondary to septic shock or respiratory arrest and severe uremia. Calciphylaxis is a devastating disease with a high mortality rate. Our results demonstrated a positive response to HBOT especially when receiving at least 20 treatments. A majority of calciphylaxis cases are females and indeed female gender has been cited as a risk factor for this disease. However, current literature has not conferred a relationship between gender nor the number of HBOT received and outcomes. Our results showed that males had a more favorable outcome provided they received at least twenty HBOT. Further prospective studies are needed to elucidate these outcomes.
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OBJECTIVE: Because free sample of prescription medications have been shown to influence prescribing habits of physicians, we sought to discern if promotional efforts of a retail pharmacy influenced prescriptions filled in our county after a free antibiotic program was initiated. METHODS: Retrospective analysis of prescription antibiotics filled throughout the county was performed. Prescriptions filled during the first 6 months of the year before the program was initiated were compared to prescriptions filled during the first 6 months of the year immediately following initiation of the promotion. RESULTS: A total of 436,372 antibiotic prescriptions were dispensed during that time. The number of antibiotics filled that were included in the promotion increased by 13.4% while the number of antibiotics filled that were excluded from the promotion decreased by 20.4%. CONCLUSION: These data suggest that the promotional pricing of the antibiotics had a significant impact on the number of prescriptions filled in each category. Because a prescription written does not always equate to a prescription filled, further investigation is needed to confirm the relationship between these promotions and actual prescriber habits.
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INTRODUCTION: Traumatic brain injury (TBI) is a significant health concern. While 70-90% of TBI cases are considered mild, decision-making regarding imaging can be difficult. This survey aimed to assess whether clinicians' decision-making was consistent with the most recent American College of Emergency Physicians (ACEP) clinical recommendations regarding indications for a non-contrast head computed tomography (CT) in patients with mild TBI. METHODS: We surveyed 2 academic emergency medicine departments. Six realistic clinical vignettes were created. The survey software randomly varied 2 factors: age (30, 59, or 61 years old) and presence or absence of visible trauma above the clavicles. A single important question was asked: "Would you perform a non-contrast head CT on this patient?" RESULTS: Physician decision-making was consistent with the guidelines in only 62.8% of total vignettes. By age group (30, 59, and 61), decision-making was consistent with the guidelines in 66.7%, 47.4%, and 72.7% of cases, respectively. This was a statistically-significant difference when comparing the 59- and 61-year-old age groups. In the setting of presence/absence of trauma above the clavicles, respondents were consistent with the guidelines in 57.1% of cases. Decision-making consistent with the guidelines was significantly better in the absence of trauma above the clavicles. CONCLUSION: Respondents poorly differentiated the "older" patients from one another, suggesting that respondents either inappropriately apply the guidelines or are unaware of the recommendations in this setting. No particular cause for inconsistency could be determined, and respondents similarly under-scanned and over-scanned in incorrect vignettes. Improved dissemination of the ACEP clinical policy and recommendations is a potential solution to this problem.
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Lesões Encefálicas/diagnóstico por imagem , Serviço Hospitalar de Emergência/normas , Fidelidade a Diretrizes/estatística & dados numéricos , Tomografia Computadorizada por Raios X/normas , Adulto , Tomada de Decisões , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Padrões de Prática Médica/estatística & dados numéricosRESUMO
There is limited data regarding hyperbaric oxygen's effectiveness in the treatment of nonhealing arterial insufficiency ulcers. This study was designed to analyze healing rates and amputation rates in patients who underwent adjunctive hyperbaric oxygen for a nonhealing arterial insufficiency ulcer. A retrospective chart review was completed on patients who underwent hyperbaric oxygen for arterial insufficiency ulcers that failed to heal despite standard treatment. Information collected included complete ulcer healing, amputation, and patient characteristics. There were 82 patients identified. A majority did not have diabetes (84.1%). The overall rate of healing was 43.9%. The overall major amputation rate was 17.1%. The amputation rate among those who healed was 0% compared to 42.4% among those not healed (p < 0.0001). Dialysis was predictive of major amputation (p = 0.03). Our findings suggest hyperbaric oxygen can play a role in management of arterial insufficiency ulcers that have failed standard treatment. The overwhelming majority of these patients did not have diabetes, which allows this study to be translated to patients with a primary arterial insufficiency ulcer. These results support the use of hyperbaric oxygen for select nonhealing arterial insufficiency ulcers that have failed standard therapy and the need for a prospective pilot study.
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Oxigenoterapia Hiperbárica , Úlcera da Perna/terapia , Salvamento de Membro/métodos , Úlcera por Pressão/terapia , Úlcera Varicosa/terapia , Cicatrização , Idoso , Idoso de 80 Anos ou mais , Amputação Cirúrgica/estatística & dados numéricos , Feminino , Humanos , Úlcera da Perna/fisiopatologia , Masculino , Úlcera por Pressão/fisiopatologia , Estudos Retrospectivos , Resultado do Tratamento , Úlcera Varicosa/fisiopatologiaRESUMO
OBJECTIVE: To identify factors that can predict which emergency department (ED) patients with mTBI are likely to develop persistent post-concussion symptoms (PPCS). DESIGN: A matched case-control study was conducted at a Level 1 trauma centre between June 2006 and July 2009. Patients diagnosed with mTBI in the ED and diagnosed at a concussion management programme with at least one PPCS (85 cases) were compared to patients diagnosed with mTBI in the ED (340 controls) to determine if factors assessed at the time of ED presentation could predict patients likely to develop persistent symptoms. RESULTS: Multivariable hierarchical logistic regression with variables indicating increased risk for PPCS (prior mTBI, history of depression, history of anxiety, multiple injury, forgetfulness/poor memory, noise sensitivity, or light sensitivity) resulted in a final predictive model including prior mTBI, history of anxiety, forgetfulness/poor memory and light sensitivity. The final model had a specificity of 87.9% and a sensitivity of 69.9%. CONCLUSIONS: A strong prediction model to identify those ED patients with mTBI at risk for PPCS was developed and could be easily implemented in the ED; therefore, helping to target those patients who would potentially benefit from close follow-up.
Assuntos
Ansiedade/diagnóstico , Concussão Encefálica/complicações , Transtornos Cognitivos/diagnóstico , Serviço Hospitalar de Emergência , Fotofobia/diagnóstico , Síndrome Pós-Concussão/diagnóstico , Adulto , Ansiedade/fisiopatologia , Concussão Encefálica/fisiopatologia , Estudos de Casos e Controles , Transtornos Cognitivos/fisiopatologia , Feminino , Seguimentos , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Alta do Paciente/estatística & dados numéricos , Fotofobia/fisiopatologia , Síndrome Pós-Concussão/fisiopatologia , Encaminhamento e Consulta , Fatores de Tempo , Centros de Traumatologia , Índices de Gravidade do TraumaRESUMO
OBJECTIVE: To determine the feasibility of using weight change and Borg score as tools for monitoring runner health and safety during a multistage, remote ultramarathon. DESIGN: Observational cohort study of feasibility on nonblinded event participants. SETTING: Six-day, multistage, remote ultramarathon in Utah. PARTICIPANTS: Twenty-seven athletes in the 2012 Desert R.A.T.S. (Race Across the Sand) ultramarathon. ASSESSMENT OF RISK FACTORS: Participant weight, health conditions that limited race participation, such as fatigue or exhaustion, and Borg score were reviewed. MAIN OUTCOME MEASURES: Inability to complete a stage of the race (Did Not Finish status) or development of a clinically significant health condition during the race. Potential prognostic risk factors, such as a high Borg score and weight loss, were analyzed. RESULTS: An overall decrease in weight was observed over the course of the event. Median percent weight changes were losses of 2.96% (day 1), 7.42% (day 2), 2.21% (day 4), and 3.35% (day 6). There was no statistically significant difference in percent weight change between the 14 runners who finished the race and the 13 runners who did not finish the race (U = 73; z = 0.189; P = 0.85). Runners' ability to complete the race was related to the development of adverse health conditions (P = 0.004). Median Borg scores reported were 15 (day 1), 17 (day 2), 13 (day 3), 16 (day 4), and 15 (day 6). Only 2 racers who finished the entire event without adverse events ever gave a Borg score of ≥ 18. CONCLUSIONS: The feasibility of weight change as a tool for monitoring runner health and safety in this setting is limited, but the Borg rating of perceived exertion warrants further study as a potential field expedient tool for monitoring runner health and safety during a multiday, remote ultramarathon.