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1.
Pediatr Emerg Care ; 2020 Jan 21.
Artigo em Inglês | MEDLINE | ID: mdl-31977768

RESUMO

OBJECTIVES: The Academy of Administrators in Academic Emergency Medicine Benchmark Survey of academic emergency departments (EDs) was conducted in 2017. We compared operational measures between pediatric and adult (defined as fewer than 5% pediatric visits) EDs based on survey data. Emergency departments in dedicated pediatric hospitals were not represented. METHODS: Measures included: (1) patient volumes, length of stay, and acuity; and 2) faculty staffing, productivity, and percent effort in academics. t Tests were used to compare continuous measures and inferences for categorical variables were made using Pearson χ test. RESULTS: The analysis included 17 pediatric and 52 adult EDs. We found a difference in the number of annual visits between adult (median, 66,275; interquartile range [IQR], 56,184-77,702) and pediatric EDs (median, 25,416; IQR, 19,840-29,349) (P < 0.0001). Mean "arrivals per faculty clinical hour" and "total arrivals per treatment space" showed no differences. The proportion of visits (1) arriving by emergency medical services and (2) for behavioral health were significantly higher in adult EDs (both P < 0.0001). The mean length of stay in hours for "all" patients was significantly longer in adult (5.4; IQR, 5.0-6.6) than in pediatric EDs (3.5; IQR, 2.9-4.3; P = 0.017). A similar difference was found for "discharged" patients (P = 0.004). Emergency severity indices, professional evaluation and management codes, and hospitalization rates all suggest higher acuity in adult EDs (all P < 0.0001). There were no differences in mean work relative value units per patient or in the distribution of full time equivalent effort dedicated to academics. CONCLUSIONS: In this cohort, significant differences in operational measures exist between academic adult and pediatric EDs. No differences were found when considering per unit measures, such as arrivals per faculty clinical hour or per treatment space.

2.
Pain ; 160(3): 670-675, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30507783

RESUMO

Obesity has been found to increase the risk of musculoskeletal pain (MSP) in other settings, but to our knowledge, the influence of increased body mass index on pain outcomes after common trauma exposures such as motor vehicle collision (MVC) has not been assessed. In addition, obesity results in biomechanical changes, as well as physiologic changes including reduced hypothalamic pituitary adrenal axis negative feedback inhibition, but mechanisms by which obesity may result in worse post-traumatic outcomes remain poorly understood. In this study, we evaluated the influence of body mass index on axial and overall MSP severity (0-10 numeric rating scale) 6 weeks, 6 months, and 1 year after MVC among 917 European Americans who presented to the emergency department for initial evaluation. After adjusting for an array of sociodemographic factors, obesity (particularly morbid obesity) was an independent risk factor for worse MSP after MVC (eg, RR 1.41 [95% CI 1.11, 1.80] for moderate or severe MSP 6 months after MVC among morbidly obese vs normal weight MVC survivors). Interestingly, substantial effect modification was observed between obesity risk and a genetic variant known to reduce hypothalamic pituitary adrenal axis negative feedback inhibition (FKBP5 rs9380526). (eg, 41% vs 16% increased risk of moderate or severe MSP at 6 months among obese individuals with and without the risk allele.) Further studies are needed to elucidate mechanisms underlying chronic pain development in obese trauma survivors and to develop interventions that will reduce chronic pain severity among this common, at-risk group.


Assuntos
Acidentes de Trânsito/estatística & dados numéricos , Dor Crônica/epidemiologia , Dor Crônica/etiologia , Obesidade/epidemiologia , Adolescente , Adulto , Distribuição por Idade , Idoso , Índice de Massa Corporal , Dor Crônica/genética , Feminino , Genótipo , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Obesidade/genética , Polimorfismo de Nucleotídeo Único/genética , Proteínas de Ligação a Tacrolimo/genética , Proteínas de Ligação a Tacrolimo/metabolismo , Adulto Jovem
4.
J Emerg Nurs ; 44(2): 123-131, 2018 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-29223696

RESUMO

BACKGROUND: The percentage of patients who leave the emergency department without being seen by a provider is a measure of efficiency and presents risk-management concerns. The number of patients actually "seen" by a provider is a measure of productivity. The opening of our new emergency department in December 2012, resulted in increases in both demand and the percentage of patients who left without being seen. Operational nursing leadership managed ED patient flow, but the structure was loosely organized on an ad hoc basis. METHODS: Operational nursing leadership roles were re-assigned to personnel with management aptitude and interest. The charge nurse coordinated care throughout all sections (pods) of the department while the pod lead nurse coordinated care in each pod. The flow coordinator nurse accepted transfers and emergency medical services arrivals. Nursing and physician staffing remained unchanged, and measures were calculated over a 3-year period (December 3, 2012, to December 2, 2015). The number of patients seen per day was analyzed using simple linear regression. The percentage of patients who left without being seen was analyzed using fractional logistic regression; P< 0.05 was considered statistically significant. RESULTS: The weekly mean number of patients seen per day rose 13% from 265 to 299 patients. The weekly mean percentage of patients who left without being seen declined 45% from 8.2% to 4.5%. The regression lines for both measures were significant at P < 0.001. CONCLUSION: Measures of efficiency and productivity can be improved significantly with a dedicated operational nursing leadership structure without adding nursing or physician staffing.


Assuntos
Eficiência Organizacional/estatística & dados numéricos , Enfermagem em Emergência/métodos , Serviço Hospitalar de Emergência/normas , Admissão e Escalonamento de Pessoal/estatística & dados numéricos , Avaliação de Programas e Projetos de Saúde/métodos , Aglomeração , Humanos , Tempo de Internação/estatística & dados numéricos , Massachusetts , Fatores de Tempo
5.
Clin J Pain ; 34(4): 366-374, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-28915155

RESUMO

OBJECTIVES: Certain forms of social support have been shown to improve pain-coping behaviors and pain outcomes in older adults with chronic pain, but little is known about the effect of social support on pain outcomes in older adults following trauma exposure. METHODS: We analyzed data from a prospective longitudinal study of adults aged 65 years and older presenting to an emergency department after a motor vehicle collision (MVC) to characterize the relationship between perceived social support and MVC-related pain after trauma overall and by subgroups based on sex, depressive symptoms, and marital status. RESULTS: In our sample (N=176), patients with low perceived social support had higher pain severity 6 weeks after MVC than patients with high perceived social support after adjustment for age, sex, race, and education (4.2 vs. 3.2, P=0.04). The protective effect of social support on pain severity at 6 weeks was more pronounced in men and in married individuals. Patients with low social support were less likely to receive an opioid prescription in the emergency department (15% vs. 32%, P=0.03), but there was no difference in opioid use at 6 weeks (22% vs. 20%, P=0.75). DISCUSSION: Among older adults experiencing trauma, low perceived social support was associated with higher levels of pain at 6 weeks.


Assuntos
Acidentes de Trânsito , Depressão/psicologia , Dor/psicologia , Apoio Social , Ferimentos e Lesões/psicologia , Idoso , Feminino , Humanos , Estudos Longitudinais , Masculino , Estado Civil , Dor/fisiopatologia , Medição da Dor , Estudos Prospectivos , Fatores Sexuais , Ferimentos e Lesões/fisiopatologia
6.
West J Emerg Med ; 18(6): 982-992, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-29085527

RESUMO

INTRODUCTION: Patient progress, the movement of patients through a hospital system from admission to discharge, is a foundational component of operational effectiveness in healthcare institutions. Optimal patient progress is a key to delivering safe, high-quality and high-value clinical care. The Baystate Patient Progress Initiative (BPPI), a cross-disciplinary, multifaceted quality and process improvement project, was launched on March 1, 2014, with the primary goal of optimizing patient progress for adult patients. METHODS: The BPPI was implemented at our system's tertiary care, academic medical center, a high-volume, high-acuity hospital that serves as a regional referral center for western Massachusetts. The BPPI was structured as a 24-month initiative with an oversight group that ensured collaborative goal alignment and communication of operational teams. It was organized to address critical aspects of a patient's progress through his hospital stay and to create additional inpatient capacity. The specific goal of the BPPI was to decrease length of stay (LOS) on the inpatient adult Hospital Medicine service by optimizing an interdisciplinary plan of care and promoting earlier departure of discharged patients. Concurrently, we measured the effects on emergency department (ED) boarding hours per patient and walkout rates. RESULTS: The BPPI engaged over 300 employed clinicians and non-clinicians in the work. We created increased inpatient capacity by implementing daily interdisciplinary bedside rounds to proactively address patient progress; during the 24 months, this resulted in a sustained rate of discharge orders written before noon of more than 50% and a decrease in inpatient LOS of 0.30 days (coefficient: -0.014, 95% CI [-0.023, -0.005] P< 0.005). Despite the increase in ED patient volumes and severity of illness over the same time period, ED boarding hours per patient decreased by approximately 2.1 hours (coefficient: -0.09; 95% CI [-0.15, -0.02] P = 0.007). Concurrently, ED walkout rates decreased by nearly 32% to a monthly mean of 0.4 patients (coefficient: 0.4; 95% CI [-0.7, -0.1] P= 0.01). CONCLUSION: The BPPI realized significant gains in patient progress for adult patients by promoting earlier discharges before noon and decreasing overall inpatient LOS. Concurrently, ED boarding hours per patient and walkout rates decreased.


Assuntos
Centros Médicos Acadêmicos/organização & administração , Assistência à Saúde/organização & administração , Serviço Hospitalar de Emergência/organização & administração , Tempo de Internação , Melhoria de Qualidade , Eficiência Organizacional , Hospitalização , Humanos , Admissão do Paciente , Equipe de Assistência ao Paciente , Alta do Paciente , Pacientes Desistentes do Tratamento , Fatores de Tempo
7.
Am J Geriatr Psychiatry ; 25(9): 953-963, 2017 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-28506605

RESUMO

OBJECTIVE: To characterize risk factors for and consequences of post-traumatic stress disorder (PTSD) among older adults evaluated in the emergency department (ED) following motor vehicle collision (MVC). DESIGN: Prospective multicenter longitudinal study (2011-2015). SETTING: 9 EDs across the United States. PARTICIPANTS: Adults aged 65 years and older who presented to an ED after MVC without severe injuries. MEASUREMENTS: PTSD symptoms were assessed 6 months after the ED visit using the Impact of Event Scale-Revised. RESULTS: Of 223 patients, clinically significant PTSD symptoms at 6 months were observed in 21% (95% CI 16%-26%). PTSD symptoms were more common in patients who did not have a college degree, had depressive symptoms prior to the MVC, perceived the MVC as life-threatening, had severe ED pain, and expected their physical or emotional recovery time to be greater than 30 days. Three factors (ED pain severity [0-10 scale], perceived life-threatening MVC [0-10 scale], and pre-MVC depressive symptoms [yes to either of two questions]), predicted 6-month PTSD symptoms with an area under the curve of 0.76. Compared to patients without PTSD symptoms, those with PTSD symptoms were at higher risk for persistent pain (72% versus 30%), functional decline (67% versus 42%), and new disability (49% versus 18%). CONCLUSIONS: Among older adults treated in the ED following MVC, clinically significant PTSD symptoms at 6 months were present in 21% of patients and were associated with adverse health outcomes. Increased risk for PTSD development can be identified with moderate accuracy using information readily available in the ED.


Assuntos
Acidentes de Trânsito/estatística & dados numéricos , Envelhecimento , Atitude Frente a Saúde , Depressão/epidemiologia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Dor/epidemiologia , Transtornos de Estresse Pós-Traumáticos/epidemiologia , Acidentes de Trânsito/psicologia , Idoso , Envelhecimento/psicologia , Depressão/psicologia , Feminino , Seguimentos , Humanos , Masculino , Dor/etiologia , Dor/psicologia , Fatores de Risco , Transtornos de Estresse Pós-Traumáticos/psicologia
8.
Pain ; 158(2): 289-295, 2017 02.
Artigo em Inglês | MEDLINE | ID: mdl-28092325

RESUMO

Each year millions of Americans present to the emergency department (ED) for care after a motor vehicle collision (MVC); the majority (>90%) are discharged to home after evaluation. Acute musculoskeletal pain is the norm in this population, and such patients are typically discharged to home with prescriptions for oral opioid analgesics or nonsteroidal antiinflammatory drugs (NSAIDs). The influence of acute pain management on subsequent pain outcomes in this common ED population is unknown. We evaluated the effect of opioid analgesics vs NSAIDs initiated from the ED on the presence of moderate to severe musculoskeletal pain and ongoing opioid use at 6 weeks in a large cohort of adult ED patients presenting to the ED after MVC (n = 948). The effect of opioids vs NSAIDs was evaluated using an innovative quasi-experimental design method using propensity scores to account for covariate imbalances between the 2 treatment groups. No difference in risk for moderate to severe musculoskeletal pain at 6 weeks was observed between those discharged with opioid analgesics vs NSAIDs (risk difference = 7.2% [95% confidence interval: -5.2% to 19.5%]). However, at follow-up participants prescribed opioids were more likely than those prescribed NSAIDs to report use of prescription opioids medications at week 6 (risk difference = 17.5% [95% confidence interval: 5.8%-29.3%]). These results suggest that analgesic choice at ED discharge does not influence the development of persistent moderate to severe musculoskeletal pain 6 weeks after an MVC, but may result in continued use of prescription opioids. Supported by NIAMS R01AR056328 and AHRQ 5K12HS022998.


Assuntos
Acidentes de Trânsito/estatística & dados numéricos , Analgésicos Opioides/uso terapêutico , Anti-Inflamatórios não Esteroides/uso terapêutico , Serviço Hospitalar de Emergência/estatística & dados numéricos , Dor/tratamento farmacológico , Dor/epidemiologia , Adolescente , Adulto , Idoso , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Autorrelato , Adulto Jovem
9.
Pain ; 158(4): 682-690, 2017 04.
Artigo em Inglês | MEDLINE | ID: mdl-28030471

RESUMO

Posttraumatic stress disorder (PTSD) symptoms and pain after traumatic events such as motor vehicle collision (MVC) have been proposed to be mutually promoting. We performed a prospective multicenter study that enrolled 948 individuals who presented to the emergency department within 24 hours of MVC and were discharged home after evaluation. Follow-up evaluations were completed 6 weeks, 6 months, and 1 year after MVC. Path analysis results supported the hypothesis that axial pain after MVC consistently promotes the maintenance of hyperarousal and intrusive symptoms, from the early weeks after injury through 1 year. In addition, path analysis results supported the hypothesis that one or more PTSD symptom clusters had an influence on axial pain outcomes throughout the year after MVC, with hyperarousal symptoms most influencing axial pain persistence in the initial months after MVC. The influence of hyperarousal symptoms on pain persistence was only present among individuals with genetic vulnerability to stress-induced pain, suggesting specific mechanisms by which hyperarousal symptoms may lead to hyperalgesia and allodynia. Further studies are needed to better understand the specific mechanisms by which pain and PTSD symptoms enhance one another after trauma, and how such mechanisms vary among specific patient subgroups, to better inform the development of secondary preventive interventions.


Assuntos
Acidentes de Trânsito/psicologia , Acidentes de Trânsito/estatística & dados numéricos , Dor/etiologia , Dor/psicologia , Transtornos de Estresse Pós-Traumáticos/etiologia , Adolescente , Adulto , Idoso , Análise Fatorial , Feminino , Técnicas de Genotipagem , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Dor/genética , Medição da Dor , Escalas de Graduação Psiquiátrica , Estudos Retrospectivos , Transtornos de Estresse Pós-Traumáticos/genética , Transtornos de Estresse Pós-Traumáticos/psicologia , Proteínas de Ligação a Tacrolimo/genética , Fatores de Tempo , Adulto Jovem
10.
BMC Geriatr ; 16: 86, 2016 Apr 19.
Artigo em Inglês | MEDLINE | ID: mdl-27094038

RESUMO

BACKGROUND: Restricted physical activity commonly occurs following acute musculoskeletal pain in older adults and may influence long-term outcomes. We sought to examine the relationship between restricted physical activity after motor vehicle collision (MVC) and the development of persistent pain. METHODS: We examined data from a prospective study of adults ≥65 years of age presenting to the emergency department (ED) after MVC without life-threatening injuries. Restricted physical activity 6 weeks after MVC was defined in three different ways: 1) by a ≥25 point decrease in Physical Activity Scale in the Elderly (PASE) score, 2) by the answer "yes" to the question, "during the past two weeks, have you stayed in bed for at least half a day?", and 3) by the answer "yes" to the question, "during the past two weeks, have you cut down on your usual activities as compared to before the accident?" We examined relationships between each definition of restricted activity and pain severity, pain interference, and functional capacity at 6 months with adjustment for confounders. RESULTS: Within the study sample (N = 164), adjusted average pain severity scores at 6 months did not differ between patients with and without restricted physical activity based on decreased PASE score (2.54 vs. 2.07, p = 0.32). In contrast, clinically and statistically important differences in adjusted average pain severity at 6 months were observed for patients who reported spending half a day in bed vs. those who did not (3.56 vs. 1.91, p < 0.01). In adjusted analyses, both decreased PASE score and cutting down on activity were associated with functional capacity at 6 months, but only decreased PASE score was associated with increased ADL difficulty at 6 months (0.70 vs. -0.01, p = 0.02). CONCLUSIONS: Among older adults experiencing MVC, those reporting bed rest or reduced activity 6 weeks after the collision reported higher pain and pain interference scores at 6 months. More research is needed to determine if interventions to promote activity can improve outcomes after MVC in older adults.


Assuntos
Acidentes de Trânsito/tendências , Limitação da Mobilidade , Atividade Motora , Veículos Automotores , Medição da Dor/tendências , Dor/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Serviço Hospitalar de Emergência/tendências , Feminino , Humanos , Estudos Longitudinais , Masculino , Atividade Motora/fisiologia , Dor/epidemiologia , Medição da Dor/métodos , Estudos Prospectivos
11.
Ann Emerg Med ; 67(2): 166-176.e1, 2016 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-26092559

RESUMO

STUDY OBJECTIVE: Motor vehicle crashes are the second most common form of trauma among older adults. We seek to describe the incidence, risk factors, and consequences of persistent pain among older adults evaluated in the emergency department (ED) after a motor vehicle crash. METHODS: We conducted a prospective longitudinal study of patients aged 65 years or older who presented to one of 8 EDs after motor vehicle crash between June 2011 and June 2014 and were discharged home after evaluation. ED evaluation was done through in-person interview; follow-up data were obtained through mail-in survey or telephone call. Pain severity (0 to 10 scale) overall and for 15 parts of the body were assessed at each follow-up point. Principal component analysis was used to assess the dimensionality of the locations of pain data. Participants reporting pain severity greater than or equal to 4 attributed to the motor vehicle crash at 6 months were defined as having persistent pain. RESULTS: Of the 161 participants, 72% reported moderate to severe pain at the ED evaluation. At 6 months, 26% of participants reported moderate to severe motor vehicle crash-related pain. ED characteristics associated with persistent pain included acute pain severity; pain located in the head, neck, and jaw or lower back and legs; poor self-rated health; less formal education; pre-motor vehicle crash depressive symptoms; and patient's expected time to physical recovery more than 30 days. Compared with individuals without persistent pain, those with persistent pain were substantially more likely at 6-month follow-up to have also experienced a decline in their capacity for physical function (73% versus 36%; difference=37%; 95% confidence interval [CI] 19% to 52%), a new difficulty with activities of daily living (42% versus 17%; difference=26%; 95% CI 10% to 43%), a 1-point or more reduction in overall self-rated health on a 5-point scale (54% versus 30%; difference=24%; 95% CI 6% to 41%), and a change in their living situation to obtain additional help (23% versus 8%; difference=15%; 95% CI 2% to 31%). CONCLUSION: Among older adults discharged home from the ED post-evaluation after a motor vehicle crash, persistent pain is common and frequently associated with functional decline and disability.


Assuntos
Acidentes de Trânsito , Dor/epidemiologia , Dor/etiologia , Idoso , Idoso de 80 Anos ou mais , Avaliação da Deficiência , Serviço Hospitalar de Emergência , Feminino , Avaliação Geriátrica , Humanos , Incidência , Escala de Gravidade do Ferimento , Entrevistas como Assunto , Estudos Longitudinais , Masculino , Medição da Dor , Alta do Paciente , Estudos Prospectivos , Fatores de Risco
12.
Psychosom Med ; 78(1): 68-78, 2016 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-26588823

RESUMO

OBJECTIVES: To determine the influence of epidemiologic factors and the influence of genetic variants affecting FKBP5, a protein known to modulate hypothalamic-pituitary-adrenocortical axis function, on the severity of somatic symptoms commonly termed "postconcussive" 6 and 12 months after motor vehicle collision (MVC). METHODS: European Americans 18 to 65 years of age who presented to one of eight emergency departments (EDs) after MVC were enrolled. Exclusion criteria included hospital admission. Blood samples were collected in the ED for genotyping. Participants completed evaluations including an adapted Rivermead Post-Concussive Symptoms Questionnaire in the ED and at 6 weeks, 6 months, and 1 year. Repeated-measures analysis of covariance was used to evaluate the association between epidemiologic factors (sociodemographic, pre-MVC health, collision characteristics, head injury, peritraumatic pain, and stress), FKBP5 genetic variants, and postconcussive symptom severity. RESULTS: Among 943 patients recruited in the ED, follow-up was completed on 835 (88%) at 6 months and 857 (90%) at 1 year. Self-reported head impact during collision was not associated with chronic postconcussive symptom severity. After correction for multiple testing, three FKBP5 single-nucleotide polymorphisms (rs3800373, rs7753746, and rs9380526) predicted chronic postconcussive symptom severity, with an average symptom severity of 1.10 (95% confidence interval = 0.96-1.24), 1.36 (1.21-1.51), and 1.55 (1.23-1.88) for one, two, or three copies of minor allele at rs3800373 (p = .001). Similar effect sizes were observed for the minor alleles of rs7753746 and rs9380526. CONCLUSIONS: Postconcussive symptoms after minor MVC are not generally related to the severity of mild brain injury. This study shows that neurobiologic stress systems may play a role in the pathogenesis of postconcussive symptoms.


Assuntos
Sistema Hipotálamo-Hipofisário/fisiopatologia , Sistema Hipófise-Suprarrenal/fisiopatologia , Polimorfismo de Nucleotídeo Único , Síndrome Pós-Concussão/genética , Proteínas de Ligação a Tacrolimo/genética , Acidentes de Trânsito , Adolescente , Adulto , Idoso , Traumatismos Craniocerebrais/epidemiologia , Traumatismos Craniocerebrais/etiologia , Serviço Hospitalar de Emergência , Feminino , Genótipo , Humanos , Masculino , Pessoa de Meia-Idade , Dor/epidemiologia , Dor/etiologia , Síndrome Pós-Concussão/epidemiologia , Síndrome Pós-Concussão/fisiopatologia , Síndrome Pós-Concussão/psicologia , Estresse Psicológico/epidemiologia , Estresse Psicológico/etiologia , Proteínas de Ligação a Tacrolimo/sangue , Adulto Jovem
13.
Clin J Pain ; 31(9): 768-775, 2015 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-25370144

RESUMO

OBJECTIVES: Dopaminergic signaling is implicated in nociceptive pathways. These effects are mediated largely through dopamine receptors and modulated in part by dopamine transporters. This study tested the hypothesis that genetic variants in the genes encoding dopamine receptor 2 (DRD2) and the dopamine active transporter (SLC6A3) influence acute pain severity after motor vehicle collision. MATERIALS AND METHODS: European Americans presenting to the emergency department after motor vehicle collision were recruited. Overall pain intensity in emergency department was assessed using a 0 to 10 numeric rating scale. DNA was extracted from blood samples and genotyping of single-nucleotide polymorphisms (SNPs) in the DRD2 and SLC6A3 gene was performed. RESULTS: A total of 948 patients completed evaluation. After correction for multiple comparisons, SNP rs6276 at DRD2 showed significant association with pain scores, with individuals with the A/A genotype reporting lower mean pain scores (5.3; 95% confidence interval [CI], 5.1-5.5) than those with A/G (5.9; 95% CI, 5.6-6.1) or G/G (5.7; 95% CI, 5.2-6.2) genotypes (P=0.0027). Secondary analyses revealed an interaction between sex and DRD2 SNPs rs4586205 and rs4648318 on pain scores: females with 2 minor alleles had increased pain intensity, whereas males with 2 minor alleles had less pain than individuals with a major allele (interaction P=0.0019). DISCUSSION: Genetic variants in DRD2 are associated with acute pain after a traumatic stressful event. These results suggest that dopaminergic agents may be useful for the treatment of individuals with acute posttraumatic pain as part of a multimodal opioid-sparing analgesic regimen.

14.
BMC Emerg Med ; 14: 25, 2014 Dec 30.
Artigo em Inglês | MEDLINE | ID: mdl-25547869

RESUMO

BACKGROUND: Motor vehicle collisions (MVCs) are the second most common injury mechanism resulting in emergency department (ED) visits by older adults. MVCs result in substantial pain and psychological distress among younger individuals, but little is known about the occurrence of these symptoms in older individuals. We describe the frequency of and characteristics associated with pain, distress, and anticipated time for physical and emotional recovery for older adults presenting to the ED after MVC in comparison to younger adults. METHODS: In-person interviews were conducted for adults presenting to one of eight EDs after MVC without an obvious fracture or injury requiring admission as part of two prospective studies. Pain severity was assessed using a 0-10 verbal scale. Distress was assessed using the Peritraumatic Distress Inventory (range 0-52). Patients were asked to estimate their expected time for physical and emotional recovery; these responses were dichotomized to <30 or ≥30 days. ED pain and distress and associations between patient and collision characteristics and ED pain and distress were examined for patients age 65 years and older and patients age 18 to 64. RESULTS: Older (n = 96) and younger (n = 943) adults had the same mean pain scores (5.5, SD 2.5 vs. 5.5, SD 2.4). Distress scores were lower in older than in younger adults (15.5, SD 9 vs. 19.2, SD 10). A higher percentage of older adults than younger adults had an anticipated time to physical recovery ≥30 days (41%, 95% confidence interval [CI] 28%-55% vs. 11%, 95% CI 9%-13%). Similarly, older adults were more likely to have an anticipated time for emotional recovery ≥30 days (45%, 95% CI 35%-55% vs. 17%, 95% CI 15%-20%). Older adults were less likely than younger adults to have moderate or severe neck pain (score ≥4) (25%, 95% CI 23% to 41% vs. 54%, 95% CI 48% to 60%) or back pain (31%, 95% CI 23% to 46% vs. 56%, 95% CI 51 to 62%) but more likely to have moderate or severe chest pain (42%, 95% CI 32% to 50% vs. 20%, 95% CI 16 to 23%). Pre-MVC depressive symptoms and pain catastrophizing were positively associated with pain and distress in both older and younger adults. CONCLUSIONS: In our cohort, older adults who presented to the ED after MVC experienced similar pain severity as younger patients and less distress but were more likely to estimate their times for physical and emotional recovery to be 30 days or more. Increased emergency provider awareness of acute pain and distress symptoms among older patients experiencing MVC may improve outcomes for these patients.


Assuntos
Acidentes de Trânsito/psicologia , Dor/epidemiologia , Dor/psicologia , Estresse Psicológico/epidemiologia , Estresse Psicológico/psicologia , Adolescente , Adulto , Fatores Etários , Idoso , Estudos de Coortes , Serviço Hospitalar de Emergência , Feminino , Florida/epidemiologia , Fraturas Ósseas/epidemiologia , Humanos , Entrevistas como Assunto , Masculino , Massachusetts , Michigan/epidemiologia , Pessoa de Meia-Idade , Veículos Automotores , New York/epidemiologia , Medição da Dor , Resultado do Tratamento , Adulto Jovem
15.
West J Emerg Med ; 15(6): 687-92, 2014 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-25247044

RESUMO

INTRODUCTION: Because lack of inpatient capacity is associated with emergency department (ED) crowding, more efficient bed management could potentially alleviate this problem. Our goal was to assess the impact of involving a patient placement manager (PPM) early in the decision to hospitalize ED patients. The PPMs are clinically experienced registered nurses trained in the institution-specific criteria for correct unit and bed placement. METHODS: We conducted two pilot studies that included all patients who were admitted to the adult hospital medicine service: 1) 10/24 to 11/22/2010 (30 days); and 2) 5/24 to 7/4/2011 (42 days). Each pilot study consisted of a baseline control period and a subsequent study period of equal duration. In each pilot we measured: 1) the number of "lateral transfers" or assignment errors in patient placement, 2) median length of stay (LOS) for "all" and "admitted" patients and 3) inpatient occupancy. In pilot 2, we added as a measure code 44s, i.e. status change from inpatient to observation after patients are admitted, and also equipped all emergency physicians with portable phones in order to improve the efficiency of the process. RESULTS: In pilot 1, the number of "lateral transfers" (incorrect patient placement assignments) during the control period was 79 of the 854 admissions (9.3%) versus 27 of 807 admissions (3.3%) during the study period (P<0.001). We found no statistically significant differences in inpatient occupancy or ED LOS for "all" or for "admitted" patients. In pilot 2, the number of "lateral transfers" was 120 of 1,253 (9.6%) admissions in the control period and 42 of 1,229 (3.4%) admissions in the study period (P<0.001). We found a 49-minute (352 vs. 401 minutes) decrease in median LOS for "admitted" ED patients during the study period compared with the control period (P=0.04). The code 44 rates, median LOS for "all" patients and inpatient occupancy did not change. CONCLUSION: Inclusion of the PPM in a three-way handoff conversation between emergency physicians and hospitalist providers significantly decreased the number of "lateral transfers." Moreover, adding status determination and portable phones for emergency physicians improved the efficiency of the process and was associated with a 49 (12%) minute decrease in LOS for admitted patients.


Assuntos
Serviço Hospitalar de Emergência/organização & administração , Admissão do Paciente , Transferência da Responsabilidade pelo Paciente , Adulto , Aglomeração , Serviço Hospitalar de Emergência/normas , Humanos , Tempo de Internação/estatística & dados numéricos , Admissão do Paciente/normas , Transferência da Responsabilidade pelo Paciente/organização & administração , Transferência da Responsabilidade pelo Paciente/normas , Projetos Piloto
16.
Pain ; 155(10): 2116-23, 2014 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-25107859

RESUMO

Living in a lower socioeconomic status neighborhood has been shown to alter stress system function and is associated with a number of adverse health outcomes, but its influence on musculoskeletal pain (MSP) outcomes after traumatic stress exposures such as motor vehicle collision (MVC) has not been assessed. We performed a multicenter, prospective study that enrolled 948 European-American individuals within 24 hours of MVC who were discharged home after emergency department evaluation. Follow-up evaluations were completed via telephone or Internet survey 6 weeks, 6 months, and 1 year after MVC on 91%, 89%, and 91% of participants, respectively. A robust aggregate measure of census tract neighborhood disadvantage was derived, and individual-level characteristics assessed included socioeconomic and demographic characteristics, pain prior to MVC, litigation status, and opioid use. MSP was assessed in the emergency department; MSP and pain interference with daily activity were assessed at 6 weeks, 6 months, and 1 year. After adjustment for individual-level factors, living in more disadvantaged neighborhoods was associated with increased MSP (P=0.0009) and increased pain interference with daily function (P<0.0001). The relationship between neighborhood disadvantage and MSP was moderated by a common single nucleotide polymorphism, rs2817038, 5' of the gene encoding FKBP5, a functional regulator of glucocorticoid receptor sensitivity (interaction P-value=0.0015). These data support the hypothesis that low neighborhood socioeconomic status increases the likelihood of worse MSP outcomes after traumatic stress exposures such as MVC, and that this influence is mediated in part via its influence on stress system function.


Assuntos
Acidentes de Trânsito , Dor Crônica/diagnóstico , Características de Residência , Meio Social , Atividades Cotidianas , Adolescente , Adulto , Idoso , Dor Crônica/genética , Interação Gene-Ambiente , Genótipo , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Polimorfismo de Nucleotídeo Único , Estudos Prospectivos , Fatores de Risco , Fatores Socioeconômicos , Proteínas de Ligação a Tacrolimo/genética , Populações Vulneráveis , Adulto Jovem
17.
Pain ; 155(9): 1836-45, 2014 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-24972071

RESUMO

Persistent musculoskeletal pain is common after motor vehicle collision (MVC) and often results in substantial disability. The objective of this study was to identify distributions of post-MVC pain that most interfere with specific life functions and that have the greatest interference with aggregate life function. Study data were obtained from a prospective longitudinal multicenter emergency department-based cohort of 948 European Americans experiencing MVC. Overall pain (0-10 numeric rating scale [NRS]), pain in each of 20 body regions (0-10 NRS), and pain interference (Brief Pain Inventory, 0-10 NRS) were assessed 6 weeks, 6 months, and 1 year after MVC. After adjustment for overall pain intensity, an axial distribution of pain caused the greatest interference with most specific life functions (R(2)=0.15-0.28, association P values of <.001) and with overall function. Axial pain explained more than twice as much variance in pain interference as other pain distributions. However, not all patients with axial pain had neck pain. Moderate or severe low back pain was as common as neck pain at week 6 (prevalence 37% for each) and overlapped with neck pain in only 23% of patients. Further, pain across all body regions accounted for nearly twice as much of the variance in pain interference as neck pain alone (60% vs 34%). These findings suggest that studies of post-MVC pain should not focus on neck pain alone.


Assuntos
Acidentes de Trânsito , Atividades Cotidianas , Dor Musculoesquelética/fisiopatologia , Qualidade de Vida , Adolescente , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Estudos Prospectivos , Adulto Jovem
18.
Pain ; 155(2): 309-21, 2014 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-24145211

RESUMO

Debate continues regarding the influence of litigation on pain outcomes after motor vehicle collision (MVC). In this study we enrolled European Americans presenting to the emergency department (ED) in the hours after MVC (n=948). Six weeks later, participants were interviewed regarding pain symptoms and asked about their participation in MVC-related litigation. The incidence and predictors of neck pain and widespread pain 6weeks after MVC were compared among those engaged in litigation (litigants) and those not engaged in litigation (nonlitigants). Among the 859 of 948 (91%) participants completing 6-week follow-up, 711 of 849 (83%) were nonlitigants. Compared to nonlitigants, litigants were less educated and had more severe neck pain and overall pain, and a greater extent of pain at the time of ED evaluation. Among individuals not engaged in litigation, persistent pain 6weeks after MVC was common: 199 of 711 (28%) had moderate or severe neck pain, 92 of 711 (13%) had widespread pain, and 29 of 711 (4%) had fibromyalgia-like symptoms. Incidence of all 3 outcomes was significantly higher among litigants. Initial pain severity in the ED predicted pain outcomes among both litigants and nonlitigants. Markers of socioeconomic disadvantage predicted worse pain outcomes in litigants but not nonlitigants, and individual pain and psychological symptoms were less predictive of pain outcomes among those engaged in litigation. These data demonstrate that persistent pain after MVC is common among those not engaged in litigation, and provide evidence for bidirectional influences between pain outcomes and litigation after MVC.


Assuntos
Acidentes de Trânsito/legislação & jurisprudência , Serviço Hospitalar de Emergência/legislação & jurisprudência , Cervicalgia/diagnóstico , Cervicalgia/epidemiologia , Traumatismos em Chicotada/diagnóstico , Traumatismos em Chicotada/epidemiologia , Acidentes de Trânsito/psicologia , Acidentes de Trânsito/tendências , Adolescente , Adulto , Idoso , Serviço Hospitalar de Emergência/tendências , Feminino , Seguimentos , Humanos , Incidência , Jurisprudência , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Cervicalgia/psicologia , Dor/diagnóstico , Dor/epidemiologia , Dor/psicologia , Valor Preditivo dos Testes , Estudos Prospectivos , Estados Unidos/epidemiologia , Traumatismos em Chicotada/psicologia , Adulto Jovem
19.
Pain ; 154(8): 1419-26, 2013 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-23707272

RESUMO

Individual vulnerability factors influencing the function of the hypothalamic-pituitary-adrenal axis may contribute to the risk of the development of persistent musculoskeletal pain after traumatic stress exposure. The objective of the study was to evaluate the association between polymorphisms in the gene encoding FK506 binding protein 51, FKBP5, a glucocorticoid receptor co-chaperone, and musculoskeletal pain severity 6 weeks after 2 common trauma exposures. The study included data from 2 prospective emergency department-based cohorts: a discovery cohort (n=949) of European Americans experiencing motor vehicle collision and a replication cohort of adult European American women experiencing sexual assault (n=53). DNA was collected from trauma survivors at the time of initial assessment. Overall pain and neck pain 6 weeks after trauma exposure were assessed using a 0-10 numeric rating scale. After adjustment for multiple comparisons, 6 FKBP5 polymorphisms showed significant association (minimum P<0.0001) with both overall and neck pain in the discovery cohort. The association of rs3800373, rs9380526, rs9394314, rs2817032, and rs2817040 with neck pain and/or overall pain 6 weeks after trauma was replicated in the sexual assault cohort, showing the same direction of the effect in each case. The results of this study indicate that genetic variants in FKBP5 influence the severity of musculoskeletal pain symptoms experienced during the weeks after motor vehicle collision and sexual assault. These results suggest that glucocorticoid pathways influence the development of persistent posttraumatic pain, and that such pathways may be a target of pharmacologic interventions aimed at improving recovery after trauma.


Assuntos
Dor Musculoesquelética/etiologia , Dor Musculoesquelética/genética , Polimorfismo de Nucleotídeo Único/genética , Transtornos de Estresse Traumático/complicações , Proteínas de Ligação a Tacrolimo/genética , Acidentes de Trânsito/psicologia , Adolescente , Adulto , Idoso , Estudos de Coortes , Análise Mutacional de DNA , Feminino , Predisposição Genética para Doença , Genótipo , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Delitos Sexuais/psicologia , Transtornos de Estresse Traumático/classificação , Adulto Jovem
20.
Am J Emerg Med ; 31(6): 967-9, 2013 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-23623236

RESUMO

INTRODUCTION: In the United States, institutional review boards (IRBs) oversee the scientific, ethical, and regulatory aspects of research conducted on human subjects. Institutional variations in the interpretation and application of federal and local regulations concerning genetic testing can have significant impact on the implementation of such studies. OBJECTIVE: We assessed variability in IRB review of a multi-center Emergency Department-based study examining genotypic and phenotypic predictors of pain and psychological outcomes after minor motor vehicle collision (Project CRASH). This is one of the first multi-center genetic research protocols based solely in the Emergency Department (ED). METHODS: We performed an observational study of sites participating in Project CRASH. We collected IRB information and correspondence from each site. We collected data that included information regarding institution demographics, original IRB application characteristics, subsequent IRB correspondence, and time interval between submission and approval. Descriptive statistics were used in analysis. RESULTS: All sites that initially agreed to participate in Project CRASH also participated in this study (n = 7). The time interval in receiving IRB approval varied between 20-760 days (median 105, IQR 21-225). One site appeared to be an outlier (760 days). The most commonly requested changes were changes to the consent form. CONCLUSION: Institutional interpretation of regulations regarding our ED-based genetic study was highly variable. Although the majority of our results are consistent with other similar published studies, the mean time interval for approval for this genetic study is far greater than other reported studies.


Assuntos
Serviço Hospitalar de Emergência , Comitês de Ética em Pesquisa/estatística & dados numéricos , Pesquisa em Genética/ética , Acidentes de Trânsito/psicologia , Termos de Consentimento/ética , Termos de Consentimento/normas , Comitês de Ética em Pesquisa/normas , Estudos de Associação Genética/ética , Estudos de Associação Genética/normas , Humanos , Estudos Multicêntricos como Assunto , Fatores de Tempo , Estados Unidos , Ferimentos e Lesões/genética , Ferimentos e Lesões/psicologia
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