Evaluation of an emergency department buprenorphine induction and medication-assisted treatment referral program.

BACKGROUND: Emergency departments are struggling to manage the increasing number of patients seen for opioid use disorders and opioid overdose. With opioid overdose deaths rising at alarming rates, emergency physicians are beginning to induce patients with long-acting opioids such as buprenorphine and referring patients to outpatient medication-assisted treatment facilities. The objective of this study was to describe a pragmatic approach to buprenorphine induction, referral to treatment, and assess follow-up rates. METHODS: Single center, retrospective analysis of emergency department patients undergoing buprenorphine induction and referral to outpatient medication-assisted treatment. Patients were identified by an ongoing log of induced patients, between May 2017 and October 2018. The data is analyzed using descriptive statistics, with means and associated standard deviations, medians and interquartile ranges for continuous variables, and frequencies as percentages for categorical data. RESULTS: Overall, 219 patients were seen and induced with buprenorphine in the emergency department. Mean age was 35 years old (SD 10.3) and 56% were male. Intravenous opioids were most commonly abused at 75%. Our primary outcome of interest was the percentage of patients enrolled in MAT at 30 days, which occurred in 49.3% of our population. Patients were in moderate withdrawal based on initial COWS scores of 13.1(SD 5.8), and received mean total doses of 7.7 mg (SD 3.3). Median ED length of stay decreased by 40% between May 2017 and October 2018. CONCLUSION: Emergency department initiated buprenorphine induction using a structured pragmatic approach is effective at maintaining patients in medication-assisted therapy.

Addition of the electrocardiogram to the preparticipation examination of college athletes.

OBJECTIVE: Although the use of standardized cardiovascular (CV) system-focused history and physical examination is recommended for the preparticipation examination (PPE) of athletes, the addition of the electrocardiogram (ECG) has been controversial. Because the impact of ECG screening on college athletes has rarely been reported, we analyzed the findings of adding the ECG to the PPE of Stanford athletes. DESIGN: For the past 15 years, the Stanford Sports Medicine program has mandated a PPE questionnaire and physical examination by Stanford physicians for participation in intercollegiate athletics. In 2007, computerized ECGs with digital measurements were recorded on athletes and entered into a database. SETTING: Although the use of standardized CV-focused history and physical examination are recommended for the PPE of athletes, the addition of the ECG has been controversial. Because the feasibility and outcomes of ECG screening on college athletes have rarely been reported, we present findings derived from the addition of the ECG to the PPE of Stanford athletes. For the past 15 years, the Stanford Sports Medicine program has mandated a PPE questionnaire and physical examination by Stanford physicians for participation in intercollegiate athletics. In 2007, computerized ECGs with digital measurements were recorded on athletes and entered into a database. MAIN OUTCOME MEASURES: Six hundred fifty-eight recordings were obtained (54% men, 10% African-American, mean age 20 years) representing 24 sports. Although 68% of the women had normal ECGs, only 38% of the men did so. Incomplete right bundle branch block (RBBB) (13%), right axis deviation (RAD) (10%), and atrial abnormalities (3%) were the 3 most common minor abnormalities. Sokolow-Lyon criteria for left ventricular hypertrophy (LVH) were found in 49%; however, only 27% had a Romhilt-Estes score of >or=4. T-wave inversion in V2 to V3 occurred in 7%, and only 5 men had abnormal Q-waves. Sixty-three athletes (10%) were judged to have distinctly abnormal ECG findings possibly associated with conditions including hypertrophic cardiomyopathy or arrhythmogenic right ventricular dysplasia/cardiomyopathy. These athletes were offered further testing but this was not mandated according to the research protocol. RESULTS: Six hundred fifty-three recordings were obtained (54% men, 7% African American, mean age 20 years), representing 24 sports. Although 68% of the women had normal ECGs, only 38% of the men did so. Incomplete RBBB (13%), RAD (10%), and atrial abnormalities (3%) were the 3 most common minor abnormalities. Sokolow-Lyon criteria for LVH were found in 49%; however, only 27% had a Romhilt-Estes score of >or=4. T-wave inversion in V2 to V3 occurred in 7% and only 5 men had abnormal Q-waves. Sixty-five athletes (10%) were judged to have distinctly abnormal ECG findings suggestive of arrhythmogenic right ventricular dysplasia, hypertrophic cardiomyopathy, and/or biventricular hypertrophy. These athletes will be submitted to further testing. CONCLUSIONS: Mass ECG screening is achievable within the collegiate setting by using volunteers when the appropriate equipment is available. However, the rate of secondary testing suggests the need for an evaluation of cost-effectiveness for mass screening and the development of new athlete-specific ECG interpretation algorithms.

A simplified clinical electrocardiogram score for the prediction of cardiovascular mortality.

BACKGROUND: Electrocardiogram (ECG) scores have been demonstrated to predict CV mortality but they are rarely utilized clinically. OBJECTIVE: Develop a simple score consisting of adding classical ECG abnormalities to make the ECG a more convenient prognostic tool. METHODS: Resting ECGs of 29,320 outpatient male veterans from the Palo Alto Veteran Affairs Healthcare System (PAVHS) collected between 1987 and 2000 were computer analyzed with an average follow-up of 7.5 y. Twelve classic ECG abnormalities were chosen on the basis of prevalence and corresponding relative risks, including left and right bundle branch block, diagnostic Q waves, intraventricular conduction defect, atrial fibrillation, left atrial abnormality, left and right axis deviation, left and right ventricular hypertrophy, ST depression, and abnormal QTc interval. A simple score derived from the summation of these criteria was then entered into an age and heart rate adjusted Cox analysis. RESULTS: There was a progressive increase in risk of death as the number of ECG abnormalities increased. The relative risks for 1, 2, 3, 4, and 5 ECG abnormalities were 1.8 (CI 1.6-2.0), 2.4 (CI 2.2-2.7), 3.6 (CI 3.2-4.1), 4.5 (CI 3.8-5.4), and 6.0 (CI 4.7-7.8) respectively (p < 0.001). The age-adjusted hazard ratio for CV mortality was 6.0 when there were five or more ECG abnormalities present. CONCLUSION: Summing the number of classical ECG abnormalities provides a powerful predictor of CV mortality independent of age, standard risk factors, and clinical status.

Ineffectiveness of surveillance to control community-acquired methicillin-resistant Staphylococcus aureus in a professional football team.

OBJECTIVES: Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infection is an increasing problem in athletic populations, with outbreaks spreading among team members. Due to this elevated risk, several strategies have been adopted from nonsports settings to avoid and to control CA-MRSA outbreaks within athletic teams, including the use of surveillance nasal cultures to identify CA-MRSA carriers for decolonization. We sought to assess the effectiveness of such a surveillance program in reducing CA-MRSA infections over 1 season in a professional football team. In addition, we measured the prevalence of CA-MRSA carriage in players with active CA-MRSA infections and conducted a review of the literature for studies, including CA-MRSA nasal carriage surveys in athletic teams. DESIGN: Prospective cohort. SETTING: Professional football team, San Francisco 49ers. PARTICIPANTS: Players and staff of the 2007 San Francisco 49ers (n = 108). INTERVENTIONS: Preseason nasal cultures for CA-MRSA were obtained on players and staff of the San Francisco 49ers. Wound and nasal cultures were performed for all participants with suspected CA-MRSA infections throughout the season. MAIN OUTCOME MEASURES: Nasal and wound cultures positive for CA-MRSA. RESULTS: Of 108 total subjects screened on the first day of the 2007 season, 0 cultures were positive for methicillin-resistant Staphylococcus aureus (MRSA). A total of 5 culture-confirmed CA-MRSA infections occurred during the course of the season. Zero of these 5 players had positive MRSA nasal cultures at the time of infection. CONCLUSIONS: Despite the success of surveillance nasal screening in controlling MRSA outbreaks in hospital settings, this strategy is ineffective in athletic populations.

An analysis of four ulnar collateral ligament reconstruction procedures with cyclic valgus loading.

We describe a new transolecranon fossa ulnar (TOFU) collateral ligament reconstruction technique and compare its response to cyclic valgus loading with the Jobe, Docking, and DANE procedures. TOFU is an arthroscopically assisted, modified all-interference screw technique. A cyclic valgus moment was applied to 32 intact and reconstructed, unembalmed elbows. Valgus angles were measured at 1, 10, 100, and 1000 cycles. At all cycles, there was no difference between intact and TOFU-treated elbows. TOFU resulted in significantly smaller angles than DANE at cycles 10, 100, and 1000; Docking at cycle 1000; and Jobe at cycles 10, 100, and 1000. The TOFU procedure shows superior resistance to valgus loading than DANE and Jobe by cycle 10, and Docking by cycle 1000. Further study is needed to evaluate the clinical value of the TOFU procedure as an arthroscopically assisted technique.

The blood pressure response to dynamic exercise testing: a systematic review.

Although blood pressure (BP) is measured routinely during exercise testing, its clinical significance is not fully understood or appreciated. As the number of studies has increased, conflicting data have emerged, partly due to differences in methodologies, populations studied, testing procedures, and definitions used for an abnormal BP response. This article attempts to review the literature studying the physiology and pathophysiology of the BP response to exercise testing and summarize the evidence for its diagnostic and prognostic applications.

Prognostic value of double product reserve.

BACKGROUND: Although the prognostic power of exercise capacity has been demonstrated, the relative prognostic potential of other hemodynamic responses has not been thoroughly investigated. We aimed to assess the prognostic power of double product (DP) parameters in patients referred for standard exercise testing. DESIGN: A retrospective cohort study. METHODS: Analyses were performed on 1959 patients referred for exercise testing at the Palo Alto Veterans Affairs Medical Center from 1997 to 2006. After removal of female and heart failure patients, 1759 male veterans (mean age 57+/-12 years) remained. DP was calculated by multiplying systolic blood pressure (SBP) and heart rate (HR); variables and their products were subtracted to obtain the differences between rest and maximal exercise (reserve), and recovery. RESULTS: Multivariable Cox survival analysis was performed for 157 all-cause and 53 cardiovascular deaths during a mean follow-up of 5.4+/-2.1 years. Although most of the hemodynamic variables were individually significant in Cox survival analysis, when age, DP reserve, exercise capacity (in metabolic equivalents), and HR recovery were entered together, only age and DP reserve were chosen. Of all hemodynamic measurements considered, DP reserve was the strongest predictor of cardiovascular prognosis after adjustment for age (Wald Z-score,-5.12; P<0.0001) and when considering other potential confounders such as age, beta-blocker use, and the Duke treadmill Score (Wald Z-score,-3.84; P<0.0001). CONCLUSION: In this study population, DP reserve had greater prognostic power than metabolic equivalents, maximal HR or systolic blood pressure, or HR recovery.

Age and double product (systolic blood pressure x heart rate) reserve-adjusted modification of the Duke Treadmill Score nomogram in men.

The Duke Treadmill Score (DTS) is an established clinical tool for risk stratification. Our aim was to determine if other variables could improve the prognostic power of the DTS and if so, to modify the DTS nomogram. From a total of 1,959 patients referred for exercise testing at the Palo Alto VA Medical Center from 1997 to 2006 (a mean follow-up of 5.4 years), we studied 1,759 male veterans (age 57 +/- 12 years) free of heart failure. Double product (DP) was calculated by multiplying systolic blood pressure and heart rate; variables and their products were subtracted to obtain the differences between at rest and maximal exercise (reserve) and recovery. Of all the hemodynamic measurements, DP reserve was the strongest predictor of cardiovascular death (CVD) (Wald Z-score -3.84, p <0.001) after adjustment for potential confounders. When the components of DTS were entered in the Cox hazard model with DP reserve and age, only DP reserve and age were chosen (p <0.00001). Using the Cox coefficients, a score calculated by [age - DTS - 3 x (DP reserve/1,000)] yielded an area under the curve of 0.84 compared with 0.76 for the DTS. Using this equation, a nomogram was constructed by adding age and DP reserve to the original DTS nomogram improving estimation of annual CVD. In conclusion, we propose an age and DP reserve-adjusted DTS nomogram that improves the prognostic estimates of average annual CVD over the DTS alone.