Your browser doesn't support javascript.
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 97
Filtrar
Mais filtros










Base de dados
Intervalo de ano de publicação
1.
Prehosp Emerg Care ; : 1-16, 2020 Jan 21.
Artigo em Inglês | MEDLINE | ID: mdl-31961753

RESUMO

OBJECTIVES: Although life-threatening emergencies for cancer patients are relatively rare, cancer patients often seek care in the emergency department. The use of emergency medical service (EMS) by these patients is not well studied. The aim of this study was to investigate the characteristics of cancer patients who present to the emergency department (ED) for care, and; compare characteristics of patients transported by EMS versus those transported by private vehicle. METHODS: Our retrospective cohort study was conducted in an EMS system with 21,070 annual transports and an academic ED with 129,263 annual visits. Our study consisted of patients with a new diagnosis of cancer between January 1 and July 1, 2015 who subsequently presented to the ED between January 1, 2015 and July 1, 2017. Study variables included patient demographics, mode of ED arrival, cancer type and treatment, patient clinical characteristics and disposition. To describe differences in patient characteristics of EMS vs. private vehicle transport, we report variable frequencies and stratified them by mode of transport. RESULTS: Of the 2,727 patients with a new diagnosis of cancer, 1,303 (47.8%) presented to the ED with a total of 3,590 visits in 30 months. EMS transported 22% of cancer patients to the ED versus 78% transported by private vehicle. Thus, cancer patients would make up approximately 1.5% (781/52,675) of all EMS transports during the study period. For those transported by EMS, the most common chief complaints were respiratory distress (16.0%), pain (15.4%), and neurological symptoms (12.6%). Patients with cancer of the lung/respiratory tract (21.5%), upper GI (12.4%), and CNS (11.0%) were most frequently transported by EMS. Older age, presence of CNS cancer, presentation with neurological or cardiovascular complaints, and higher acuity were significantly associated with EMS transport to ED, while gender and pain severity were not. Patients transported by EMS were more likely to be hospitalized and for greater than 2 days (p < 0.0001). CONCLUSIONS: Cancer patients frequently seek emergency care after initial diagnosis, most commonly present for symptom relief, and are often admitted. Patients transported by EMS are more likely to be admitted and for longer periods of time.

2.
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.

3.
Prehosp Emerg Care ; : 1-6, 2019 Nov 13.
Artigo em Inglês | MEDLINE | ID: mdl-31613657

RESUMO

AbstractIntroduction: Telecommunicator Assisted Cardiopulmonary Resuscitation (T-CPR) is independently associated with improved survival and improved functional outcome after adult Out of Hospital Cardiac Arrest (OHCA). The objective of this study was to evaluate whether there are racial and socioeconomic disparities in the provision of T-CPR instruction and subsequent CPR performance. Methods: We performed a retrospective review of a convenience sample of EMS agencies throughout the United States that utilized the Cardiac Arrest Registry to Enhance Survival (CARES) dispatch registry during the period 1/2014-12/2017. Data were collected by dispatch agencies after review of 9-1-1 OHCA audio recordings. Elements related to dispatcher CPR instruction, barriers to bystander CPR (BCPR) performance, patient race (White, Black, Hispanic-Latino, or other) and Utstein data were captured from the CARES database. These data were merged with census tract data from incident locations. The effects of race and income (Socioeconomic status, SES) on outcome were analyzed using multilevel logistic regression. Results: A total of 3,807 cases were identified from 37 dispatch agencies in 6 states. The sample was predominantly White (57.5%) and male (64.9%) with an average age of 60.3 ± 19.9. In the adjusted analysis, there were no differences in the odds of receiving CPR instruction by race (black vs white), OR = 0.96 (95% CI. 0.70, 1.32) or for increased income, (OR = 1.00, 95% CI 0.99, 1.02). There was a significant difference in receipt of T-CPR instruction by patient age, OR = 0.99 (95% CI, 0.98, 0.99). Subsequent utilization of T-CPR instruction to perform BCPR was less likely for patients that had a lower income, OR = 1.03 (95% CI 1.01, 1.05). There was also a decreased rate of BCPR provision by patient age OR = 0.99 (95% CI, 0.99, 1.00), but there was no difference in rate of BCPR provision by race, OR = 0.86 (95% CI 0.61, 1.23). Conclusion: We identified differences in age but not race or SES in the provision of T-CPR instruction by dispatch centers. We also identified decreased CPR provision by age and income after receipt of T-CPR instructions. In this sample, we found no evidence of racial disparities in the provision of T-CPR instruction or subsequent provision of BCPR.

4.
J Emerg Med ; 57(3): 354-361, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31353265

RESUMO

BACKGROUND: Patients with active cancer account for a growing percentage of all emergency department (ED) visits and have a unique set of risks related to their disease and its treatments. Effective triage for this population is fundamental to facilitating their emergency care. OBJECTIVES: We evaluated the validity of the Emergency Severity Index (ESI; version 4) triage tool to predict ED-relevant outcomes among adult patients with active cancer. METHODS: We conducted a prespecified analysis of the observational cohort established by the National Cancer Institute-supported Comprehensive Oncologic Emergencies Research Network's multicenter (18 sites) study of ED visits by patients with active cancer (N = 1075). We used a series of χ2 tests for independence to relate ESI scores with 1) disposition, 2) ED resource use, 3) hospital length of stay, and 4) 30-day mortality. RESULTS: Among the 1008 subjects included in this analysis, the ESI distribution skewed heavily toward high acuity (>95% of subjects had an ESI level of 1, 2, or 3). ESI was significantly associated with patient disposition and ED resource use (p values < 0.05). No significant associations were observed between ESI and the non-ED based outcomes of hospital length of stay or 30-day mortality. CONCLUSION: ESI scores among ED patients with active cancer indicate higher acuity than the general ED population and are predictive of disposition and ED resource use. These findings show that the ESI is a valid triage tool for use in this population for outcomes directly relevant to ED care.

5.
JAMA Netw Open ; 2(3): e190979, 2019 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-30901049

RESUMO

Importance: Better understanding of the emergency care needs of patients with cancer will inform outpatient and emergency department (ED) management. Objective: To provide a benchmark description of patients who present to the ED with active cancer. Design, Setting, and Participants: This multicenter prospective cohort study included 18 EDs affiliated with the Comprehensive Oncologic Emergencies Research Network (CONCERN). Of 1564 eligible patients, 1075 adults with active cancer were included from February 1, 2016, through January 30, 2017. Data were analyzed from February 1 through August 1, 2018. Main Outcomes and Measures: The proportion of patients reporting symptoms (eg, pain, nausea) before and during the ED visit, ED and outpatient medications, most common diagnoses, and suspected infection as indicated by ED antibiotic administration. The proportions observed, admitted, and with a hospital length of stay (LOS) of no more than 2 days were identified. Results: Of 1075 participants, mean (SD) age was 62 (14) years, and 51.8% were female. Seven hundred ninety-four participants (73.9%; 95% CI, 71.1%-76.5%) had undergone cancer treatment in the preceding 30 days; 674 (62.7%; 95% CI, 59.7%-65.6%) had advanced or metastatic cancer; and 505 (47.0%; 95% CI, 43.9%-50.0%) were 65 years or older. The 5 most common ED diagnoses were symptom related. Of all participants, 82 (7.6%; 95% CI, 6.1%-9.4%) were placed in observation and 615 (57.2%; 95% CI, 54.2%-60.2%) were admitted; 154 of 615 admissions (25.0%; 95% CI, 21.7%-28.7%) had an LOS of 2 days or less (median, 3 days; interquartile range, 2-6 days). Pain during the ED visit was present in 668 patients (62.1%; 95% CI, 59.2%-65.0%; mean [SD] pain score, 6.4 [2.6] of 10.0) and in 776 (72.2%) during the prior week. Opioids were administered in the ED to 228 of 386 patients (59.1%; 95% CI, 18.8%-23.8%) with moderate to severe ED pain. Outpatient opioids were prescribed to 368 patients (47.4%; 95% CI, 3.14%-37.2%) of those with pre-ED pain, including 244 of 428 (57.0%; 95% CI, 52.2%-61.8%) who reported quite a bit or very much pain. Nausea in the ED was present in 336 (31.3%; 95% CI, 28.5%-34.1%); of these, 160 (47.6%; 95% CI, 12.8%-17.1%) received antiemetics in the ED. Antibiotics were administered in the ED to 285 patients (26.5%; 95% CI, 23.9%-29.2%). Of these, 209 patients (73.3%; 95% CI, 17.1%-21.9%) were admitted compared with 427 of 790 (54.1%; 95% CI, 50.5%-57.6%) not receiving antibiotics. Conclusions and Relevance: This initial prospective, multicenter study profiling patients with cancer who were treated in the ED identifies common characteristics in this patient population and suggests opportunities to optimize care before, during, and after the ED visit. Improvement requires collaboration between specialists and emergency physicians optimizing ED use, improving symptom control, avoiding unnecessary hospitalizations, and appropriately stratifying risk to ensure safe ED treatment and disposition of patients with cancer.


Assuntos
Serviço Hospitalar de Emergência , Hospitalização/estatística & dados numéricos , Neoplasias , Idoso , Dor do Câncer/etiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Náusea/etiologia , Neoplasias/complicações , Neoplasias/epidemiologia , Neoplasias/terapia , Estudos Prospectivos
6.
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
7.
Prehosp Emerg Care ; 22(6): 743-752, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29624088

RESUMO

OBJECTIVE: Our objective was to analyze and compare out-of-hospital cardiac arrest (OHCA) system of care performance and outcomes at the Medical Control Authority (MCA) level in the state of Michigan. We hypothesized that clinically and statistically significant variations in treatment and outcomes of OHCA exists within a single U.S. state. METHODS: We performed a retrospective, observational study of all non-traumatic EMS-treated OHCA from the state of Michigan CARES registry for 2014-2015. Geocoding of the OHCA incident address was used to assign records to individual MCAs. MCA-based demographics, arrest characteristics, system of care performance and outcomes were quantified and compared. Associations between demographics, system of care parameters, and outcomes were examined at the MCA level. RESULTS: A total of 8,115 records with complete data were available for analysis. Eleven MCAs met study inclusion criteria of >100 cases, producing a final sample size of 7,788 records (96%). Statistically significant variations in survival to hospital discharge ranged from 4.5% to 15% (p < 0.001) (Adjusted odds ratio [AOR] range 0.6-2.0) and survival with good neurologic outcome 2.7-12.5% (p < 0.001; AOR range 0.5-2.2,) were observed across MCAs. Bystander CPR ranged from 32% to 53% (p < 0.001) and bystander AED application ranged from 3.5% 11.5% (p < 0.05). Of patients admitted to the hospital alive, 29-68% received targeted temperature management. In hospital mortality ranged from 53.1% to 73.9% (p < 0.05). CONCLUSION: Significant intrastate variability in OHCA system of care performance and outcomes currently exist and are similar to what has been previously reported across North America almost a decade ago. This degree of variability highlights the opportunity to optimize modifiable factors within local systems of care to improve OHCA outcomes.


Assuntos
Parada Cardíaca Extra-Hospitalar/terapia , Padrões de Prática Médica , Adulto , Idoso , Idoso de 80 Anos ou mais , Reanimação Cardiopulmonar/mortalidade , Serviços Médicos de Emergência , Feminino , Hospitalização , Humanos , Masculino , Michigan/epidemiologia , Pessoa de Meia-Idade , Razão de Chances , Estudos Prospectivos , Sistema de Registros , Estudos Retrospectivos , Resultado do Tratamento
8.
Clin Ther ; 40(2): 204-213.e2, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-29371004

RESUMO

PURPOSE: Little is known about gender differences in the treatment of pain after motor vehicle collisions (MVCs) in an emergency department (ED). We aimed to describe gender differences in pain experiences and treatment, specifically the use of opioids and benzodiazepines after ED discharge, for MVC-related pain. METHODS: This was a secondary analysis of previously collected data from the CRASH Injury studies. We included patients who were seen and discharged from an ED after an MVC and who were enrolled in 1 of 2 multicenter longitudinal prospective cohort studies (1 black/non-Hispanic and 1 white/non-Hispanic). First, we compared the experience of pain as defined by self-reported moderate-to-severe axial pain, widespread pain, number of somatic symptoms, pain catastrophizing, and peritraumatic distress between women and men using bivariate analyses. We then determined whether there were gender differences in the receipt of prescription medications for post-MVC pain symptoms (opioids and benzodiazepines) using multivariate logistic regression adjusting for demographic characteristics, pain, and collision characteristics. FINDINGS: In total, 1878 patients were included: 61.4% were women. More women reported severe symptoms on the pain catastrophizing scale (36.8% vs 31.0%; P = 0.032) and peritraumatic distress following the MVC (59.7% vs 42.5%; P < 0.001), and women reported more somatic symptoms than men (median, 3.9; interquartile range, 3.7-4.0 vs median, 3.3; interquartile range, 3.1-3.5; P < 0.001). Unadjusted, similar proportions of women and men were given opioids (29.2% vs 29.7%; P = 0.84). After adjusting for covariates, women and men remained equally likely to receive a prescription for opioids (relative risk = 0.83; 95% confidence interval, 0.58-1.19). Women were less likely than men to receive a benzodiazepine at discharge from an ED (relative risk = 0.53; 95% confidence interval, 0.32-0.88). IMPLICATIONS: In a large, multicenter study of ED patients treated for MVC, there were gender differences in the acute psychological response to MVC with women reporting more psychological and somatic symptoms. Women and men were equally likely to receive opioid prescriptions at discharge. Future research should investigate potential gender-specific interventions to reduce both posttraumatic distress and the risk of developing negative long-term outcomes like chronic pain.


Assuntos
Acidentes de Trânsito , Analgésicos Opioides/uso terapêutico , Serviço Hospitalar de Emergência , Dor/epidemiologia , Adulto , Estudos de Coortes , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Dor/tratamento farmacológico , Medição da Dor , Alta do Paciente , Estudos Prospectivos , Autorrelato , Adulto Jovem
9.
Circulation ; 137(1): e7-e13, 2018 01 02.
Artigo em Inglês | MEDLINE | ID: mdl-29114008

RESUMO

Cardiopulmonary resuscitation is a lifesaving technique for victims of sudden cardiac arrest. Despite advances in resuscitation science, basic life support remains a critical factor in determining outcomes. The American Heart Association recommendations for adult basic life support incorporate the most recently published evidence and serve as the basis for education and training for laypeople and healthcare providers who perform cardiopulmonary resuscitation.


Assuntos
American Heart Association , Reanimação Cardiopulmonar/normas , Serviços Médicos de Emergência/normas , Parada Cardíaca/terapia , Massagem Cardíaca/normas , Indicadores de Qualidade em Assistência à Saúde/normas , Respiração Artificial/normas , Reanimação Cardiopulmonar/efeitos adversos , Reanimação Cardiopulmonar/mortalidade , Consenso , Educação em Saúde/normas , Pessoal de Saúde/educação , Pessoal de Saúde/normas , Parada Cardíaca/diagnóstico , Parada Cardíaca/mortalidade , Parada Cardíaca/fisiopatologia , Massagem Cardíaca/efeitos adversos , Massagem Cardíaca/mortalidade , Humanos , Respiração Artificial/efeitos adversos , Respiração Artificial/mortalidade , Fatores de Risco , Resultado do Tratamento , Estados Unidos
10.
Prehosp Emerg Care ; 22(2): 222-228, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29220603

RESUMO

OBJECTIVES: Dispatch-assisted cardiopulmonary resuscitation (DA-CPR) has been shown to improve cardiac arrest survival. Recent literature has proposed dispatch metrics for provision of this intervention. Our objectives are to: use the Cardiac Arrest Registry to Enhance Survival (CARES) to compare current practice to proposed DA-CPR guidelines; describe barriers to DA-CPR; and assess the association of DA-CPR with out-of-hospital cardiac arrest (OHCA) survival. METHODS: We reviewed data from structured dispatch reviews of 911 OHCA calls from 1/1/14-12/31/15. Dispatch data including whether dispatch CPR instruction was given, and time intervals to CPR instruction and provision were linked with OHCA data elements from field cardiac arrest process and outcome data. Descriptive data on barriers to dispatch-caller instruction and measures of dispatcher performance were calculated. We compared outcome of patients who received bystander CPR prior to the 911 call (BCPR), after dispatcher CPR instructions (DA-CPR), and not until Emergency Medical Services (EMS) arrival (no BCPR). RESULTS: We identified 3335 cases from 32 dispatch agencies in 9 states that had dispatch and outcome data. CPR was performed prior to the 911 call by a bystander in 496 (14.9%) cases. Of all calls where the dispatcher talked to a bystander, dispatchers recognized cardiac arrest in 82.9% cases (1514/1827), with 31.6% calls recognized in <60 seconds. DA-CPR instructions were initiated in most (1320/1514, 87.2%) cases, and cardiac compressions were initiated in 73.7% (973/1320). DA-CPR was performed < two minutes in 21.4% of cases. In a multivariable analysis, BCPR (CPR prior to EMS arrival without instructions given) was associated with significantly improved patient survival (OR = 1.49, 95% CI 1.09, 2.04), and DA-CPR a non-significant improvement in survival to discharge (OR = 1.19, 95% CI 0.91, 1.56). CONCLUSIONS: Temporal measures of dispatch performance were substantially below proposed national standards. In this population, OHCA was frequently recognized and DA-CPR performed but was not associated with a significant improvement in survival.


Assuntos
Reanimação Cardiopulmonar , Despacho de Emergência Médica , Parada Cardíaca Extra-Hospitalar , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Serviços Médicos de Emergência , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Parada Cardíaca Extra-Hospitalar/mortalidade , Alta do Paciente , Sistema de Registros , Análise de Sobrevida , Adulto Jovem
11.
Am J Emerg Med ; 36(5): 834-837, 2018 May.
Artigo em Inglês | MEDLINE | ID: mdl-29146417

RESUMO

INTRODUCTION: The role of circulatory support in the post-cardiac arrest period remains controversial. Our objective was to investigate the association between treatment with a percutaneous hemodynamic support device and outcome after admission for cardiac arrest. METHODS: We performed a retrospective study of adult patients with admission diagnosis of cardiac arrest or ventricular fibrillation (VF) from the Michigan Inpatient Database, treated between July 1, 2010, and June 30, 2013. Patient demographics, clinical characteristics, treatments, and disposition were electronically abstracted based on ICD-9 codes at the hospital level. Mixed-effects logistic regression models were fit to test the effect of percutaneous hemodynamic support device defined as either percutaneous left ventricular assist device (pLVAD) or intra-aortic balloon pump (IABP) on survival. These models controlled for age, sex, VF, myocardial infarction (MI), and cardiogenic shock with hospital modeled as a random effect. RESULTS: A total of 103 hospitals contributed 4393 patients for analysis, predominately male (58.8%) with a mean age of 64.1years (SD 15.5). On univariate analysis, younger age, male sex, VF as the initial rhythm, acute MI, percutaneous coronary intervention, percutaneous hemodynamic support device, and absence of cardiogenic shock were associated with survival to discharge (each p<0.001). Mixed-effects logistic regressions revealed use of percutaneous hemodynamic support device was significantly associated with survival among all patients (OR 1.8 (1.28-2.54)), and especially in those with acute MI (OR 1.95 (1.31-2.93)) or cardiogenic shock (OR 1.96 (1.29-2.98)). CONCLUSION: Treatment with percutaneous hemodynamic support device in the post-arrest period may provide left ventricular support and improve outcome.


Assuntos
Serviços Médicos de Emergência , Parada Cardíaca/terapia , Balão Intra-Aórtico/estatística & dados numéricos , Intervenção Coronária Percutânea/estatística & dados numéricos , Choque Cardiogênico/terapia , Idoso , Feminino , Parada Cardíaca/mortalidade , Parada Cardíaca/fisiopatologia , Hemodinâmica , Humanos , Balão Intra-Aórtico/mortalidade , Masculino , Michigan , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/mortalidade , Estudos Retrospectivos , Choque Cardiogênico/mortalidade , Choque Cardiogênico/fisiopatologia , Taxa de Sobrevida , Resultado do Tratamento
12.
Prehosp Emerg Care ; 22(2): 208-213, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-28910207

RESUMO

BACKGROUND: To improve survival of patients resuscitated from out of hospital cardiac arrest (OCHA), data is needed to assess and improve inpatient post-resuscitation care. Our objective was to apply probabilistic linkage methodology to link EMS and inpatient databases and evaluate whether it may be used to describe post-arrest care in Michigan. METHODS: We performed a retrospective study to describe post-cardiac arrest care in adult OHCA patients who were transported to Michigan hospitals from July 1, 2010, to June 30, 2013. Using probabilistic linkage methodology we linked two databases, the Michigan EMS Information System (MI_EMSIS) and the Michigan Inpatient Database (MIDB), which describes inpatient care and outcome of all admissions. Rates of case incidence and survival were compared to published literature. We compared the linked dataset to existing cardiac arrest databases from three counties to evaluate the quality of this linkage. RESULTS: Multiple iterations of match strategies were used to create a linked EMS-inpatient dataset. There were 12,838 MI_EMSIS cardiac arrest records of which 1,977 were matched with MIDB records, identifying them as surviving to hospital admission. Of these 590 (30.0%) survived to hospital discharge. The annual survival incidence/100,000 population to admission was 6.93/100,000 and survival incidence to discharge was 2.1/100,000. The matched dataset was compared to county databases identified a limited sensitivity [48.2%, 95% CI 42.1%-55.3%)] and positive predictive value [64.4%, 95% CI 56.8%-71.3%)]. CONCLUSION: Use of the MI_EMSISEMS database and the Michigan Inpatient database was feasible and produced rates of cardiac arrest admission and survival rates similar to published literature. This process yielded a limited match compared to existing county cardiac arrest databases. We conclude that such a linked dataset is useful for descriptive purposes but not as a population based dataset to evaluate statewide post-cardiac arrest care.


Assuntos
Reanimação Cardiopulmonar/normas , Serviços Médicos de Emergência , Parada Cardíaca Extra-Hospitalar/terapia , Melhoria de Qualidade , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Feminino , Humanos , Masculino , Michigan , Pessoa de Meia-Idade , Alta do Paciente , Estudos Retrospectivos , Taxa de Sobrevida , Adulto Jovem
13.
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
14.
J Am Coll Cardiol ; 70(12): 1467-1476, 2017 Sep 19.
Artigo em Inglês | MEDLINE | ID: mdl-28911510

RESUMO

BACKGROUND: Gasping is a natural reflex that enhances oxygenation and circulation during cardiopulmonary resuscitation (CPR). OBJECTIVES: This study sought to assess the relationship between gasping during out-of-hospital cardiac arrest and 1-year survival with favorable neurological outcomes. METHODS: The authors prospectively collected incidence of gasping on all evaluable subjects in a multicenter, randomized, controlled, National Institutes of Health-funded out-of-hospital cardiac arrest clinical trial from August 2007 to July 2009. The association between gasping and 1-year survival with favorable neurological function, defined as a Cerebral Performance Category (CPC) score ≤2 was estimated using multivariable logistic regression. RESULTS: The rates of 1-year survival with a CPC score of ≤2 were 5.4% (98 of 1,827) overall, and 20% (36 of 177) and 3.7% (61 of 1,643) for individuals with and without spontaneous gasping or agonal respiration during CPR, respectively. In multivariable analysis, 1-year survival with CPC ≤2 was independently associated with younger age (odds ratio [OR] for 1 SD increment 0.57; 95% confidence interval [CI]: 0.43 to 0.76), gasping during CPR (OR: 3.94; 95% CI: 2.09 to 7.44), shockable initial recorded rhythm (OR: 16.50; 95% CI: 7.40 to 36.81), shorter CPR duration (OR: 0.31; 95% CI: 0.19 to 0.51), lower epinephrine dosage (OR: 0.47; 95% CI: 0.25 to 0.87), and pulmonary edema (OR: 3.41; 95% CI: 1.53 to 7.60). Gasping combined with a shockable initial recorded rhythm had a 57-fold higher OR (95% CI: 23.49 to 136.92) of 1-year survival with CPC ≤2 versus no gasping and no shockable rhythm. CONCLUSIONS: Gasping during CPR was independently associated with increased 1-year survival with CPC ≤2, regardless of the first recorded rhythm. These findings underscore the importance of not terminating resuscitation prematurely in gasping patients and the need to routinely recognize, monitor, and record data on gasping in all future cardiac arrest trials and registries.


Assuntos
Inalação , Parada Cardíaca Extra-Hospitalar/mortalidade , Parada Cardíaca Extra-Hospitalar/fisiopatologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Parada Cardíaca Extra-Hospitalar/complicações , Prognóstico , Estudos Prospectivos , Taxa de Sobrevida , Taquicardia Ventricular/complicações , Fatores de Tempo , Fibrilação Ventricular/complicações , Adulto Jovem
15.
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
16.
Prehosp Emerg Care ; 21(5): 563-566, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28414559

RESUMO

BACKGROUND: The Michigan Legislature mandated that all public schools stock epinephrine auto-injectors (EAIs). A minimal amount is known regarding the incremental value of EAIs in schools. Our primary objective was to describe the frequency of administration of epinephrine for EMS patients with acute allergic reactions in public schools. Our secondary objective was to estimate the cost of mandating public schools to stock EAIs. METHODS: We performed a retrospective cohort study of EMS cases with an impression of allergic reaction and who received epinephrine recorded in the 2014 Michigan EMS Information System (MI-EMSIS). We abstracted patient demographics, incident location by address to identify public schools, source of epinephrine given, and suspected allergen if known. We calculated advanced life support (ALS) response times to assess temporal impact of school EAIs in communities with ALS systems. We estimated the unsubsidized annual procurement cost of this mandate for Michigan public schools (N = 4,039), using range of costs for the required 2 EAIs (adult and pediatric) as estimated by the legislature ($140/each) and recently reported costs for commercial sources ($1,200). Training costs were not included. Descriptive statistics are reported. RESULTS: During this period, there were 1,550,009 EMS cases in the state with 631 receiving non-cardiac arrest epinephrine for presumed anaphylaxis, of which 23 cases were in public schools. Reported allergens were most often food 12 (51.2%), insect stings 4(22.2%) or unknown 7(30.4%). Among these patients, the source for epinephrine used was from the student, 7 (30.4%), EMS 7 (30.4%), school 7(30.4%), and unknown 2(8.7%). A majority (21, 91.3%) of the public school cases occurred in communities with ALS systems and ALS response was relatively rapid (median response 6 minutes, 90 percentile, 13 minutes). The unsubsidized annual cost of Michigan public schools to stock EAIs ranges from $565,460 to $4,846,800. CONCLUSION: In this study, few public school patients received epinephrine for anaphylaxis and the vast majority occurred in communities with rapid ALS response. The direct annual supply cost of the school EAI mandate is substantial.


Assuntos
Anafilaxia/tratamento farmacológico , Serviços Médicos de Emergência/estatística & dados numéricos , Epinefrina/administração & dosagem , Sistemas de Manutenção da Vida/estatística & dados numéricos , Serviços de Saúde Escolar/economia , Adolescente , Adulto , Alérgenos , Anafilaxia/economia , Criança , Estudos de Coortes , Efeitos Psicossociais da Doença , Serviços Médicos de Emergência/economia , Epinefrina/economia , Feminino , Humanos , Sistemas de Manutenção da Vida/economia , Masculino , Michigan , Estudos Retrospectivos , Serviços de Saúde Escolar/estatística & dados numéricos , Instituições Acadêmicas , Adulto Jovem
17.
J Am Geriatr Soc ; 65(8): 1741-1747, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28322438

RESUMO

BACKGROUND: Among older adults, malnutrition is common, often missed by healthcare providers, and influences recovery from illness or injury. OBJECTIVE: To identify modifiable risk factors associated with malnutrition in older patients. DESIGN: Prospective cross-sectional multicenter study. SETTING: 3 EDs in the South, Northeast, and Midwest. PARTICIPANTS: Non-critically ill, English-speaking adults aged ≥65 years. MEASUREMENTS: Random time block sampling was used to enroll patients. The ED interview assessed malnutrition using the Mini Nutritional Assessment Short-Form. Food insecurity and poor oral health were assessed using validated measures. Other risk factors examined included depressive symptoms, limited mobility, lack of transportation, loneliness, and medication side effects, qualified by whether the patient reported the risk factor affected their diet. The population attributable risk proportion (PARP) for malnutrition was estimated for each risk factor. RESULTS: In our sample (n = 252), the prevalence of malnutrition was 12%. Patient characteristics associated with malnutrition included not having a college degree, being admitted to the hospital, and residence in an assisted living facility. Of the risk factors examined, the PARPs for malnutrition were highest for poor oral health (54%; 95% CI 16%, 78%), food insecurity (14%; 95% CI 3%, 31%), and lack of transportation affecting diet (12%; 95% CI 3%, 28%). CONCLUSION: Results of this observational study identify multiple modifiable factors associated with the problem of malnutrition in older adults.


Assuntos
Serviço Hospitalar de Emergência , Desnutrição/diagnóstico , Desnutrição/epidemiologia , Avaliação Nutricional , Idoso , Estudos Transversais , Depressão/epidemiologia , Feminino , Abastecimento de Alimentos/estatística & dados numéricos , Hospitalização , Humanos , Entrevistas como Assunto , Masculino , Saúde Bucal/estatística & dados numéricos , Prevalência , Estudos Prospectivos , Estados Unidos
18.
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
19.
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
20.
Ther Hypothermia Temp Manag ; 7(2): 95-100, 2017 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-27860555

RESUMO

Post cardiac arrest, neuroprognostication remains a complex and clinically challenging issue for critical care providers. For this reason, our primary objective in this study was to determine the frequency of survival and favorable neurological outcomes in post-cardiac arrest patients with delayed time to awakening. To assess whether early withdrawal of care may adversely impact survival, we also sought to describe the time to withdrawal of care of non-surviving patients. We performed a retrospective study of patients resuscitated after cardiac arrest in two large academic community hospitals. We performed a structured chart review of patients treated with therapeutic hypothermia (TH) at one hospital from 2009 to 2015 and at a second hospital from 2013 to 2015. Demographics and Utstein style variables were recorded on all patients, as well as temporal variables to characterize the time interval from Return of Spontaneous Circulation (ROSC) to awakening as recorded by ICU nurses and defined as Glasgow Coma Scale (GCS) of >8. Descriptive data were also captured regarding time to withdrawal of care. We pre-hoc defined delayed awakening as >72 hours post ROSC or >72 hours post rewarming. Our primary outcome was survival to hospital discharge with a secondary outcome of a favorable cerebral performance category of 1 or 2. During this study period, 321 patients received TH, with 111 (34.6%) discharged alive and, of these, 67 (68.5%) experienced a good neurological outcome. Awakening more than 72 hours after return of circulation was common with 31 patients surviving to discharge. Of these, 16 of 31 (51.6%) were found to have a good neurological outcome on hospital discharge. Of the patients who died before discharge, 54 (29.5%) had care withdrawn less than 72 hours after ROSC. A delayed time to awakening is not infrequently associated with a good neurological outcome after TH in patients resuscitated from cardiac arrest.


Assuntos
Parada Cardíaca , Hipotermia Induzida , Adulto , Idoso , Feminino , Escala de Coma de Glasgow , Parada Cardíaca/epidemiologia , Parada Cardíaca/mortalidade , Parada Cardíaca/terapia , Humanos , Hipotermia Induzida/efeitos adversos , Hipotermia Induzida/mortalidade , Hipotermia Induzida/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Reaquecimento , Fatores de Tempo , Resultado do Tratamento
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA