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1.
Mol Psychiatry ; 25(2): 283-296, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31745239

RESUMO

Adverse posttraumatic neuropsychiatric sequelae (APNS) are common among civilian trauma survivors and military veterans. These APNS, as traditionally classified, include posttraumatic stress, postconcussion syndrome, depression, and regional or widespread pain. Traditional classifications have come to hamper scientific progress because they artificially fragment APNS into siloed, syndromic diagnoses unmoored to discrete components of brain functioning and studied in isolation. These limitations in classification and ontology slow the discovery of pathophysiologic mechanisms, biobehavioral markers, risk prediction tools, and preventive/treatment interventions. Progress in overcoming these limitations has been challenging because such progress would require studies that both evaluate a broad spectrum of posttraumatic sequelae (to overcome fragmentation) and also perform in-depth biobehavioral evaluation (to index sequelae to domains of brain function). This article summarizes the methods of the Advancing Understanding of RecOvery afteR traumA (AURORA) Study. AURORA conducts a large-scale (n = 5000 target sample) in-depth assessment of APNS development using a state-of-the-art battery of self-report, neurocognitive, physiologic, digital phenotyping, psychophysical, neuroimaging, and genomic assessments, beginning in the early aftermath of trauma and continuing for 1 year. The goals of AURORA are to achieve improved phenotypes, prediction tools, and understanding of molecular mechanisms to inform the future development and testing of preventive and treatment interventions.

2.
Acad Emerg Med ; 27(1): 54-60, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31599043

RESUMO

BACKGROUND: Hyperkalemia is common and potentially life threatening. Patiromer is a Food and Drug Administration (FDA)-cleared oral potassium binder effective in the chronic treatment of hyperkalemia. OBJECTIVE: The objective was to investigate the potential efficacy and safety of oral patiromer in treating acute hyperkalemia in the emergency department (ED). METHODS: This is a single-center, randomized, open-label convenience sample pilot study in an inner-city ED. Adult patients with end-stage renal disease and a serum potassium level of ≥ 6.0 mEq/L were randomized to standard of care (SOC) or one dose of 25.2 g oral patiromer plus SOC (PAT). Blood samples and electrocardiograms were collected at enrollment and at 1, 2, 4, and 6 hours thereafter. The primary outcome was the difference in potassium between groups at 6 hours. Secondary outcomes were the amount and number of times insulin and albuterol were given. RESULTS: Thirty patients were included in the final analysis, 15 in each group. There were no differences in age, sex, or baseline serum potassium. There was no difference in mean serum potassium between SOC and PAT groups at 6 hours (6.32 mEq/L, confidence interval [CI] = 6.0 to 6.63 mEq/L vs. 5.81 mEq/L, CI = 5.48 to 6.14 mEq/L). However, 2 hours posttreatment the serum potassium of the PAT group was lower than SOC group (5.90 mEq/L, CI = 5.63 to 6.17 mEq/L vs. 6.51 mEq/L, CI = 6.25 to 6.78 mEq/L) and also 0.61 mEq/L lower than baseline. There were no differences in the amount or number of administrations of insulin or albuterol between groups, although the amount of albuterol used in the PAT group at 6 hours was lower but not significant (median, 0 mg vs. 12.5 mg; p = 0.097). There were no differences in adverse events between groups. CONCLUSION: In this open-label pilot study of severe hyperkalemia, a single dose of 25.2 g of oral patiromer reduced serum potassium within 2 hours but did not show a difference at 6 hours. This is the first study showing that patiromer may have a role in the acute management of hyperkalemia; however, more rigorous studies are needed.

3.
Am J Emerg Med ; 2019 Dec 10.
Artigo em Inglês | MEDLINE | ID: mdl-31884025

RESUMO

BACKGROUND: Hyperkalemia (HK) is common and associated with mortality. Our purpose was to determine if the rapid correction of elevated serum potassium level (K+) was associated with reduced mortality in emergency department (ED) patients. METHODS: Design: We reviewed the electronic medical records (EMR) of ED patients with HK (K+ ≥ 5.5 mEq/L) from 10/2016-10/2017. SETTING: Large, academic ED. PARTICIPANTS: Adult ED patients presenting with hyperkalemia. Main outcomes and measures: The main outcome was in-hospital mortality. We compared outcomes of patients whose K+ normalized (dropped below 5.5 mEq/L) with those whose K+ did not normalize using chi-square and multivariate analyses to determine the associations between predictor variables and outcomes. RESULTS: From 114,977 ED visits, 1033 patients (0.9%, 95%CI 0.85-0.95%) had HK. Their mean (SD) age was 60 (26) years and 58% were male. Of these, 884 had a second K+ measured within a median (IQR) of 5 (3-8) hours. Mortality and admission rates were higher in patients with HK vs. those with normal K+ (8.5% vs. 0.8%, P < 0.001 and 80% vs. 39%, P < 0.001, respectively). Mortality was lower in patients whose HK normalized compared with those whose K+ remained elevated (6.3% vs. 12.7%, P = 0.001). After adjusting for age, creatinine, comorbidities, and initial K+, normalization of K+ was associated with reduced mortality (OR 0.47, 95%CI 0.28 to 0.80). CONCLUSIONS: Normalization of K+ during the ED stay in patients with HK is associated with a 50% mortality reduction. Efforts to rapidly identify and treat HK in the ED are needed.

4.
Clin Infect Dis ; 2019 Dec 17.
Artigo em Inglês | MEDLINE | ID: mdl-31844888
7.
Ann Emerg Med ; 2019 Nov 13.
Artigo em Inglês | MEDLINE | ID: mdl-31732375

RESUMO

Bleeding is the most common complication of anticoagulant use. The evaluation and management of the bleeding patient is a core competency of emergency medicine. As the prevalence of patients receiving anticoagulant agents and variety of anticoagulants with different mechanisms of action, pharmacokinetics, indications, and corresponding reversal agents increase, physicians and other clinicians working in the emergency department require a current and nuanced understanding of how best to assess, treat, and reverse anticoagulated patients. In this project, we convened an expert panel to create a consensus decision tree and framework for assessment of the bleeding patient receiving an anticoagulant, as well as use of anticoagulant reversal or coagulation factor replacement, and to address controversies and gaps relevant to this topic. To support decision tree interpretation, the panel also reached agreement on key definitions of life-threatening bleeding, bleeding at a critical site, and emergency surgery or urgent invasive procedure. To reach consensus recommendations, we used a structured literature review and a modified Delphi technique by an expert panel of academic and community physicians with training in emergency medicine, cardiology, hematology, internal medicine/thrombology, pharmacology, toxicology, transfusion medicine and hemostasis, neurology, and surgery, and by other key stakeholder groups.

8.
J Emerg Med ; 57(4): 575, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31739914
9.
Clin Biochem ; 2019 Oct 26.
Artigo em Inglês | MEDLINE | ID: mdl-31669511

RESUMO

BACKGROUND: Cardiac troponin (cTn) is the keystone for diagnosis of acute myocardial infarction (AMI). We examined the analytical and diagnostic accuracy of the Atellica IM TnIH assay to determine high-sensitivity performance and appropriate diagnostic performance for clinical use. METHODS: Sex-specific 99th percentile upper reference limits (URLs) were determined for a healthy cohort of 1007 women and 1000 men using non-parametric statistics. High-sensitivity performance was assessed by examining if imprecision was ≤10% at sex-specific URLs and if ≥50% of cTnI values for each sex exceeded the assay's limit of detection (LoD) with the AACC Universal Sample Bank. Precision, high-dose hook effect, endogenous/exogenous interferences were examined with CLSI guidance. Clinical characterization was with 2494 suspected AMI subjects presenting to emergency departments across the United States. AMI was adjudicated by expert cardiologists and emergency medicine physicians. There were no comorbidity exclusions. RESULTS: 99th percentile URLs were 34 ng/L, 53 ng/L and 45 ng/L for the female, male and overall populations, respectively. Total imprecision was <5% from 12 ng/L to 16,000 ng/L; ≥55% of cTnI values for each sex exceeded the LoD. No high-dose hook or endogenous/exogenous interferences were identified. After 2.5-3.5 h post presentation the sensitivity and specificity were >90%; negative and positive predictive value were ≥98% and >60%, respectively. Non-AMI subjects with comorbidities and values exceeding 99th percentile URLs had absolute and percent change at 2-4 h that were lower than AMI patients with comorbidities (p = 0.001). CONCLUSION: The Atellica IM TnIH assay is a high-sensitivity method and demonstrates clinical performance appropriate for AMI diagnosis.

10.
J Emerg Med ; 57(5): 637-645, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31629581

RESUMO

BACKGROUND: Iron deficiency anemia is the most common hematologic disorder in the United States and worldwide. Yet, clinical guidelines for the identification and management of this disorder in the emergency department are lacking. OBJECTIVE OF REVIEW: This clinical review examines strategies for identifying and treating iron deficiency anemia in the emergency department, with a focus on the role of oral iron therapy, intravenous iron therapy, as well as red blood cell transfusion. The article highlights both the available evidence on this topic and the need for future research. DISCUSSION: The diagnosis of iron deficiency anemia has important clinical implications and, although testing is generally straightforward, it may be under-recognized. The scant literature available describing emergency department practice patterns for iron deficiency anemia suggests there is room for improvement. In particular, intravenous iron may be underutilized and red blood cell transfusions administered too liberally. CONCLUSIONS: Iron deficiency anemia is common and many patients can be treated effectively with oral iron. For selected patients with moderate-to-severe iron deficiency anemia, intravenous iron is safe and more effective than oral iron. Red blood cell transfusions should be used rarely for hemodynamically stable patients with iron deficiency irrespective of hemoglobin levels.

11.
J Emerg Med ; 57(6): e167-e173, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31662218

RESUMO

BACKGROUND: Idarucizumab is a humanized, monoclonal antibody fragment used specifically to reverse the anticoagulant effects of dabigatran. CASE REPORTS: We discuss 4 cases of patients who were treated with idarucizumab to reverse dabigatran before early/emergency surgery. Two of the patients had subdural hematomas, 1 had a splenic laceration, and 1 had Fournier gangrene. All patients received 5 g of idarucizumab before surgery. Intraoperative blood loss in all patients was normal, no adverse events were reported, and the patients recovered normally. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The case reports presented provide detailed, practical, real-world experience beyond that reported in other case reports and the Reversal Effects of Idarucizumab on Active Dabigatran study. This can help guide clinicians on how idarucizumab can reverse the anticoagulant effect of dabigatran in emergency situations, including patients with subdural hematoma. Our experience suggests that idarucizumab may be a safe and effective antidote to the effects of dabigatran in real-life bleeding situations involving early or emergency surgeries.

13.
Clin Exp Emerg Med ; 6(3): 226-234, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31474102

RESUMO

OBJECTIVE: Few studies have prospectively evaluated the diagnostic accuracy and temporal impact of ultrasound in the emergency department (ED) in a randomized manner. In this study, we aimed to perform a randomized, standard therapy controlled evaluation of the diagnostic accuracy and temporal impact of a standardized ultrasound strategy, versus standard care, in patients presenting to the ED with acute dyspnea. METHODS: The patients underwent a standardized ultrasound examination that was blinded to the team caring for the patient. Ultrasound results remained blinded in patients randomized to the treating team but were unblinded in the interventional cohort. Scans were performed by trained emergency physicians. The gold standard diagnosis (GSDx) was determined by two physicians blinded to the ultrasound results. The same two physicians reviewed all data >30 days after the index visit. RESULTS: Fifty-nine randomized patients were enrolled. The mean±standard deviation age was 54.4±11 years, and 37 (62%) were male. The most common GSDx was acute heart failure with reduced ejection fraction in 13 (28.3%) patients and airway diseases such as acute exacerbation of asthma or chronic obstructive pulmonary disease in 10 (21.7%). ED diagnostic accuracy, as compared to the GSDx, was 76% in the ultrasound cohort and 79% in the standard care cohort (P=0.796). Compared with the standard care cohort, the final diagnosis was obtained much faster in the ultrasound cohort (mean±standard deviation: 12±3.2 minutes vs. 270 minutes, P<0.001). CONCLUSION: A standardized ultrasound approach is equally accurate, but enables faster ED diagnosis of acute dyspnea than standard care.

15.
J Am Coll Cardiol ; 74(6): 744-754, 2019 Aug 13.
Artigo em Inglês | MEDLINE | ID: mdl-31395124

RESUMO

BACKGROUND: The prevalence of pulmonary embolism (PE) in patients presenting with syncope to the emergency department (ED) is largely unknown. This information, however, is necessary to balance the potential medical benefit or harm of systematic PE screening in patients presenting with syncope to the ED. OBJECTIVES: This study sought to determine the prevalence of PE in patients with syncope. METHODS: Unselected patients presenting with syncope to the ED were prospectively enrolled in a diagnostic multicenter study. Pre-test clinical probability for PE was assessed using the 2-level Wells score and the results of D-dimer testing using age-adapted cutoffs. Presence of PE was evaluated by imaging modalities, when ordered as part of the clinical assessment by the treating ED physician or by long-term follow-up data. RESULTS: Long-term follow-up was complete in 1,380 patients (99%) at 360 days and 1,156 patients (83%) at 720 days. Among 1,397 patients presenting with syncope to the ED, PE was detected at presentation in 19 patients (1.4%; 95% confidence interval [CI]: 0.87% to 2.11%). The incidence of new PEs or cardiovascular death during 2-year follow-up was 0.9% (95% CI: 0.5% to 1.5%). In the subgroup of patients hospitalized (47%), PE was detected at presentation in 15 patients (2.3%; 95% CI: 1.4% to 3.7%). The incidence of new PEs or cardiovascular death during 2-year follow-up was 0.9% (95% CI: 0.4% to 2.0%). CONCLUSIONS: PE seems to be a rather uncommon cause of syncope among patients presenting to the ED. Therefore, systematic PE-screening in all patients with syncope does not seem warranted. (BAsel Syncope EvaLuation Study [BASEL IX]; NCT01548352).

16.
Eur J Intern Med ; 70: 24-32, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31451322

RESUMO

OBJECTIVE: To investigate the relationship between length of hospitalisation (LOH) and post-discharge outcomes in acute heart failure (AHF) patients and to ascertain whether there are different patterns according to department of initial hospitalisation. METHODS: Consecutive AHF patients hospitalised in 41 Spanish centres were grouped based on the LOH (<6/6-10/11-15/>15 days). Outcomes were defined as 90-day post-discharge all-cause mortality, AHF readmissions, and the combination of both. Hazard ratios (HRs), adjusted by chronic conditions and severity of decompensation, were calculated for groups with LOH >6 days vs. LOH <6 days (reference), and stratified by hospitalisation in cardiology, internal medicine, geriatrics, or short-stay units. RESULTS: We included 8563 patients (mean age: 80 (SD = 10) years, 55.5% women), with a median LOH of 7 days (IQR 4-11): 2934 (34.3%) had a LOH <6 days, 3184 (37.2%) 6-10 days, 1287 (15.0%) 11-15 days, and 1158 (13.5%) >15 days. The 90-day post-discharge mortality was 11.4%, readmission 32.2%, and combined endpoint 37.4%. Mortality was increased by 36.5% (95%CI = 13.0-64.9) when LOH was 11-15 days, and by 72.0% (95%CI = 42.6-107.5) when >15 days. Conversely, no differences were found in readmission risk, and the combined endpoint only increased 21.6% (95%CI = 8.4-36.4) for LOH >15 days. Stratified analysis by hospitalisation departments rendered similar post-discharge outcomes, with all exhibiting increased mortality for LOH >15 days and no significant increments in readmission risk. CONCLUSIONS: Short hospitalisations are not associated with worse outcomes. While post-discharge readmissions are not affected by LOH, mortality risk increases as the LOH lengthens. These findings were similar across hospitalisation departments.

17.
J Am Coll Cardiol ; 74(3): 271-282, 2019 Jul 23.
Artigo em Inglês | MEDLINE | ID: mdl-31319909

RESUMO

BACKGROUND: Limited data exist on rapid risk-stratification strategies using the U.S. Food and Drug Administration-cleared high-sensitivity cardiac troponin I (hs-cTnI) assays. OBJECTIVES: This study sought to examine single measurement hs-cTnI to identify patients at low and high risk for acute myocardial infarction (MI). METHODS: This was a prospective, multicenter, observational study of patients with suspected acute MI enrolled across 29 U.S. sites with hs-cTnI measured using the Atellica IM TnIH and ADVIA Centaur TNIH (Siemens Healthineers) assays. To identify low-risk patients, sensitivities and negative predictive values (NPVs) for acute MI and MI or death at 30 days were examined across baseline hs-cTnI concentrations. To identify high-risk patients, positive predictive values and specificities for acute MI were evaluated. RESULTS: Among 2,212 patients, acute MI occurred in 12%. The limits of detection or quantitation resulted in excellent sensitivities (range 98.6% to 99.6%) and NPVs (range 99.5% to 99.8%) for acute MI or death at 30 days across both assays. An optimized threshold of <5 ng/l identified almost one-half of all patients as low risk, with sensitivities of 98.6% (95% confidence interval: 97.2% to 100%) and NPVs of 99.6% (95% confidence interval: 99.2% to 99.9%) for acute MI or death at 30 days across both assays. For high-risk patients, hs-cTnI ≥120 ng/l resulted in positive predictive values for acute MI of ≥70%. CONCLUSIONS: Recognizing the continuous relationship between baseline hs-cTnI and risk for adverse events, using 2 Food and Drug Administration-cleared hs-cTnI assays, an optimized threshold of <5 ng/l safely identified almost one-half of all patients as low risk at presentation, with hs-cTnI ≥120 ng/l identifying high-risk patients.

18.
Clin Chim Acta ; 495: 522-528, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31152695

RESUMO

BACKGROUND: We report the analytical performance of the Elecsys® Troponin T Gen 5 STAT (TnT Gen 5 STAT; Roche Diagnostics) assay. METHODS: Measuring limits/ranges were determined in lithium-heparin plasma samples per Clinical and Laboratory Standards Institute (CLSI) EP17-A2. Precision was evaluated per CLSI EP05-A2 using lithium-heparin plasma/quality control samples on cobas e 411/cobas e 601 analyzers; two duplicated runs per day for 21 days (n = 84). Cross-reactivity with other troponin forms and interference from endogenous substances/drugs was tested; recovery criterion for no cross-reactivity was within ±10%. RESULTS: Coefficients of variation (CV) for repeatability/intermediate precision were 0.7-5.6%/1.4-10.3% (cobas e 411; mean cardiac troponin T [cTnT]: 7.3-9341 ng/L) and 0.7-3.0%/1.5-6.4% (cobas e 601; mean cTnT: 7.4-9455 ng/L). There was no cross-reactivity with skeletal muscle troponin T (≤ 10,000 ng/L), skeletal muscle troponin I (≤ 100,000 ng/L), cardiac troponin I (≤ 10,000 ng/L), or human troponin C (≤ 80,000 ng/L). No interference was observed with biotin (≤ 20 ng/mL) or 34 drugs. CONCLUSION: The TnT Gen 5 STAT assay demonstrated a CV of <10% at the 99th percentile upper reference limit, meeting precision requirements (Fourth Universal Definition of Myocardial Infarction) for high-sensitivity troponin assays.


Assuntos
Análise Química do Sangue/métodos , Imunoensaio/métodos , Troponina T/sangue , Humanos , Limite de Detecção , Medições Luminescentes , Reprodutibilidade dos Testes
19.
Atherosclerosis ; 286: 142-146, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31170647

RESUMO

BACKGROUND AND AIMS: We aimed to examine the prevalence, demographics, clinical outcomes and economic burden of hospitalizations for patients with PAD. METHODS: Using the National Inpatient Sample, we retrospectively evaluated patients hospitalized with PAD in 2014. Hospitalizations in patients with PAD were identified by the presence of an International Classification of Diseases-9th Revision (ICD-9) diagnosis code of 440.20-440.24. We calculated hospitalization rates/100,000 patients, the proportion of hospitalizations with a major adverse limb event (MALE), as well as minor amputation, mortality, median (interquartile range) length-of-stay (LOS) and treatment costs (in 2017 US$). A separate analysis of hospitalizations of patients with clinical limb ischemia defined as Fontaine class III or IV PAD (440.22, resting pain; 440.23-440.24, ulcers or gangrene) was also performed. RESULTS: We identified 286,160 hospitalizations for patients with PAD. The rate of hospitalizations for PAD was 89.5/100,000, with 137,050 (or 45%) of these having Fontaine class III-IV disease. The proportion of hospitalizations resulting in MALE, major or minor lower extremity amputation or in-hospital death was 45.8%, 8.9%, 8.2% and 3.1%, respectively. Median hospital LOS was 5 (3, 9) days and costs were $15,755 ($8972, $27,800), resulting in an annual cost burden for hospitalization of patients with PAD of ∼$6.31 billion. In hospitalizations of Fontaine class III-IV PAD, MALE, major and minor amputation and death occurred in 60.9%, 16.8%, 15.8% and 3.3% of cases, respectively. Median LOS and costs were 7 (4, 11) days and $18,984 ($10,913, $31,816). CONCLUSIONS: Hospitalizations of patients with PAD represent a substantial medical and financial burden for patients and the US healthcare system.

20.
Curr Heart Fail Rep ; 16(4): 81-88, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31183779

RESUMO

PURPOSE OF REVIEW: To analyze whether the use of morphine, as initial treatment in acute cardiogenic pulmonary edema (ACPE), has an impact in clinical outcomes and mortality. A systematic review of the literature was performed, including all the studies comparing clinical outcomes in patients with ACPE who were treated or not with morphine. RECENT FINDINGS: Seven studies were selected, none of which were a randomized trial focused on answering the aim of this systematic review. The studies consisted of clinical trial secondary analysis assessing non-invasive ventilation in ACPE, one open non-randomized trial, two propensity score evaluations from large registries, and three clinical case reviews. Most of the studies showed unfavorable results with the use of morphine in terms of adverse events and mortality, and many of them were statistically significant. Finally, the ongoing MIdazolam versus MOrphine in acute cardiogenic pulmonary edema (MIMO) trial was specifically designed to compare the results of morphine use versus midazolam. The potential hemodynamic and sedative benefit of the use of morphine for vasodilatation and dyspnea amelioration may be opposed by an increase in mortality, ICU admission, and adverse events. Until there is a randomized clinical trial, the use of morphine for ACPE should be limited.

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