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RATIONALE & OBJECTIVE: The prevalence of community-acquired acute kidney injury (CA-AKI) in the United States and its clinical consequences are not well described. Our objective was to describe the epidemiology of CA-AKI and the associated clinical outcomes. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: 178,927 encounters by 139,632 adults at 5 US emergency departments (EDs) between July 1, 2017, and December 31, 2022. PREDICTORS: CA-AKI identified using KDIGO (Kidney Disease: Improving Global Outcomes) serum creatinine (Scr)-based criteria. OUTCOMES: For encounters resulting in hospitalization, the in-hospital trajectory of AKI severity, dialysis initiation, intensive care unit (ICU) admission, and death. For all encounters, occurrence over 180 days of hospitalization, ICU admission, new or progressive chronic kidney disease, dialysis initiation, and death. ANALYTICAL APPROACH: Multivariable logistic regression analysis to test the association between CA-AKI and measured outcomes. RESULTS: For all encounters, 10.4% of patients met the criteria for any stage of AKI on arrival to the ED. 16.6% of patients admitted to the hospital from the ED had CA-AKI on arrival to the ED. The likelihood of AKI recovery was inversely related to CA-AKI stage on arrival to the ED. Among encounters for hospitalized patients, CA-AKI was associated with in-hospital dialysis initiation (OR, 6.2; 95% CI, 5.1-7.5), ICU admission (OR, 1.9; 95% CI, 1.7-2.0), and death (OR, 2.2; 95% CI, 2.0-2.5) compared with patients without CA-AKI. Among all encounters, CA-AKI was associated with new or progressive chronic kidney disease (OR, 6.0; 95% CI, 5.6-6.4), dialysis initiation (OR, 5.1; 95% CI, 4.5-5.7), subsequent hospitalization (OR, 1.1; 95% CI, 1.1-1.2) including ICU admission (OR, 1.2; 95% CI, 1.1-1.4), and death (OR, 1.6; 95% CI, 1.5-1.7) during the subsequent 180 days. LIMITATIONS: Residual confounding. Study implemented at a single university-based health system. Potential selection bias related to exclusion of patients without an available baseline Scr measurement. Potential ascertainment bias related to limited repeat Scr data during follow-up after an ED visit. CONCLUSIONS: CA-AKI is a common and important entity that is associated with serious adverse clinical consequences during the 6-month period after diagnosis. PLAIN-LANGUAGE SUMMARY: Acute kidney injury (AKI) is a condition characterized by a rapid decline in kidney function. There are many causes of AKI, but few studies have examined how often AKI is already present when patients first arrive to an emergency department seeking medical attention for any reason. We analyzed approximately 175,000 visits to Johns Hopkins emergency departments and found that AKI is common on presentation to the emergency department and that patients with AKI have increased risks of hospitalization, intensive care unit admission, development of chronic kidney disease, requirement of dialysis, and death in the first 6 months after diagnosis. AKI is an important condition for health care professionals to recognize and is associated with serious adverse outcomes.
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BACKGROUND: Patients who develop acute kidney injury (AKI) have a 2-fold increased risk for major adverse events within 1 year. An estimated 19-26% of all cases of hospital-acquired AKI may be attributable to drug-induced kidney disease (DIKD). Patients evaluated in the emergency department (ED) are often prescribed potentially nephrotoxic drugs, yet the role of ED prescribing in DIKD is unknown. OBJECTIVE: We sought to measure the association between ED medication administration and development of AKI. METHODS: This was a retrospective 5-year cohort analysis at a single center. Patients with a serum creatinine measurement at presentation in the ED and 24-168 h later were included. Outcome was incidence of AKI as defined by Kidney Disease Improving Global Outcomes criteria in the 7 days after ED evaluation. Medication administration risk was estimated using Cox proportional hazards model. RESULTS: There were 46,965 ED encounters by 30,407 patients included in the study, of which 6461 (13.8%) patients met the criteria for AKI. For hospitalized patients, administration of a potentially nephrotoxic medication was associated with increased risk of AKI (hazard ratio [HR] 1.30 [95% confidence interval {CI} 1.20-1.41]). Diuretics were associated with the largest risk of AKI (HR 1.64 [95% CI 1.52-1.78]), followed by angiotensin-converting enzyme inhibitors (HR 1.39 [95% CI 1.26-1.54]) and antibiotics (HR 1.13 [95% CI 1.05-1.22]). For discharged patients, administration of antibiotics was strongly associated with increased risk of AKI (HR 3.19 [95% CI 1.08-9.43]). CONCLUSION: ED administration of potentially nephrotoxic medications was associated with an increased risk of AKI in the following 7 days. Diuretics, angiotensin-converting enzyme inhibitors, and antibiotics were independently associated with increased risk of AKI. Nephroprotective practices in the ED may mitigate kidney injury and long-term adverse outcomes.
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Injúria Renal Aguda , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos , Preparações Farmacêuticas , Injúria Renal Aguda/induzido quimicamente , Injúria Renal Aguda/epidemiologia , Serviço Hospitalar de Emergência , Humanos , Estudos Retrospectivos , Fatores de RiscoRESUMO
Kounis Syndrome is a rare allergic reaction that results in coronary vasospasm and may occur in patients with and without coronary artery disease. A 57-year-old man receiving pre-operative vancomycin for osteomyelitis and gangrene of the foot experienced an episode of anginal symptoms associated with transient ischemic 12-lead electrocardiogram (ECG) changes. The patient's symptoms and ECG changes abated with discontinuation of vancomycin and subsequent coronary angiography revealed no evidence of coronary artery disease. Treatment of Kounis Syndrome begins with cessation of the causative agent. Consensus guidelines for the management of Kounis Syndrome have not been established but treatment should both dilate the coronary vessels and suppress the allergic response. Coronary vasospasm after administration of antibiotics, including vancomycin, is a rare but serious reaction. It is important that Emergency Physicians recognize Kounis Syndrome as an uncommon yet dramatic and consequential reaction to such a commonly-administered antibiotic.
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Antibacterianos/efeitos adversos , Vasoespasmo Coronário/induzido quimicamente , Síndrome de Kounis/etiologia , Vancomicina/efeitos adversos , Administração Intravenosa , Antibacterianos/administração & dosagem , Eletrocardiografia , Gangrena/tratamento farmacológico , Humanos , Masculino , Pessoa de Meia-Idade , Osteomielite/tratamento farmacológico , Vancomicina/administração & dosagemAssuntos
Vacinas contra COVID-19/administração & dosagem , COVID-19/prevenção & controle , Comportamento de Escolha , SARS-CoV-2 , Vacinação/métodos , Vacinação/psicologia , COVID-19/imunologia , Centers for Disease Control and Prevention, U.S. , Comportamento de Escolha/ética , Tomada de Decisões/ética , Disparidades em Assistência à Saúde/ética , Humanos , Pandemias/prevenção & controle , SARS-CoV-2/imunologia , Estados Unidos , United States Food and Drug Administration , Vacinação/éticaRESUMO
STUDY OBJECTIVE: The study objective was to determine whether intravenous contrast administration for computed tomography (CT) is independently associated with increased risk for acute kidney injury and adverse clinical outcomes. METHODS: This single-center retrospective cohort analysis was performed in a large, urban, academic emergency department with an average census of 62,179 visits per year; 17,934 ED visits for patients who underwent contrast-enhanced, unenhanced, or no CT during a 5-year period (2009 to 2014) were included. The intervention was CT scan with or without intravenous contrast administration. The primary outcome was incidence of acute kidney injury. Secondary outcomes included new chronic kidney disease, dialysis, and renal transplantation at 6 months. Logistic regression modeling and between-groups odds ratios with and without propensity-score matching were used to test for an independent association between contrast administration and primary and secondary outcomes. Treatment decisions, including administration of contrast and intravenous fluids, were examined. RESULTS: Rates of acute kidney injury were similar among all groups. Contrast administration was not associated with increased incidence of acute kidney injury (contrast-induced nephropathy criteria odds ratio=0.96, 95% confidence interval 0.85 to 1.08; and Acute Kidney Injury Network/Kidney Disease Improving Global Outcomes criteria odds ratio=1.00, 95% confidence interval 0.87 to 1.16). This was true in all subgroup analyses regardless of baseline renal function and whether comparisons were made directly or after propensity matching. Contrast administration was not associated with increased incidence of chronic kidney disease, dialysis, or renal transplant at 6 months. Clinicians were less likely to prescribe contrast to patients with decreased renal function and more likely to prescribe intravenous fluids if contrast was administered. CONCLUSION: In the largest well-controlled study of acute kidney injury following contrast administration in the ED to date, intravenous contrast was not associated with an increased frequency of acute kidney injury.
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Injúria Renal Aguda/induzido quimicamente , Meios de Contraste/efeitos adversos , Administração Intravenosa , Adulto , Idoso , Estudos de Casos e Controles , Serviço Hospitalar de Emergência , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Tomografia Computadorizada por Raios X/efeitos adversosRESUMO
BACKGROUND: Pneumorrhachis (PR) describes the clinical finding of air within the spinal canal and rarely has been associated with spontaneous pneumomediastinum. There is little medical literature addressing the evaluation and management of these patients in the emergency department. CASE REPORT: We present a series of patients with PR secondary to a spontaneous pneumomediastinum and briefly review the available literature on the topic to discuss reasonable management strategies for patients presenting with this rare finding. In both cases, the patients had excellent outcomes with expectant management despite the worrisome finding of air in the spinal canal. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians must be able to promptly recognize and appropriately assess even uncommon pathology. As with other rare conditions, there are no published guidelines for the ED management of PR, necessitating the use of case presentations to educate providers as to the complications and plan of care of this diagnosis.
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Enfisema Mediastínico/etiologia , Pneumorraque/etiologia , Adulto , Tosse/complicações , Humanos , Masculino , Enfisema Mediastínico/diagnóstico por imagem , Pneumorraque/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Adulto JovemAssuntos
Meios de Contraste , Segurança do Paciente , Administração Intravenosa , Consenso , HumanosRESUMO
PURPOSE: Evidence of an association between intravenous contrast media (CM) and persistent renal dysfunction is lacking for patients with pre-existing acute kidney injury (AKI). This study was designed to determine the association between intravenous CM administration and persistent AKI in patients with pre-existing AKI. METHODS: A retrospective propensity-weighted and entropy-balanced observational cohort analysis of consecutive hospitalized patients ≥ 18 years old meeting Kidney Disease Improving Global Outcomes (KDIGO) creatinine-based criteria for AKI at time of arrival to one of three emergency departments between 7/1/2017 and 6/30/2021 who did or did not receive intravenous CM. Outcomes included persistent AKI at hospital discharge and initiation of dialysis within 180 days of index encounter. RESULTS: Our analysis included 14,449 patient encounters, with 12.8% admitted to the intensive care unit (ICU). CM was administered in 18.4% of all encounters. AKI resolved prior to hospital discharge for 69.1%. No association between intravenous CM administration and persistent AKI was observed after unadjusted multivariable logistic regression modeling (OR 1; 95% CI 0.89-1.11), propensity weighting (OR 0.93; 95% CI 0.83-1.05), and entropy balancing (OR 0.94; 95% CI 0.83-1.05). Sub-group analysis in those admitted to the ICU yielded similar results. Initiation of dialysis within 180 days was observed in 5.4% of the cohort. An association between CM administration and increased risk of dialysis within 180 days was not observed. CONCLUSION: Among patients with pre-existing AKI, contrast administration was not associated with either persistent AKI at hospital discharge or initiation of dialysis within 180 days. Current consensus recommendations for use of intravenous CM in patients with stable renal disease may also be applied to patients with pre-existing AKI.
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Injúria Renal Aguda , Diálise Renal , Humanos , Adolescente , Estudos Retrospectivos , Meios de Contraste/efeitos adversos , Fatores de Risco , Administração IntravenosaRESUMO
OBJECTIVE: The objective was to evaluate the comparative effectiveness and safety of pharmacological and nonpharmacological management options for atrial fibrillation/atrial flutter with rapid ventricular response (AFRVR) in patients with acute decompensated heart failure (ADHF) in the acute care setting. METHODS: This study was a systematic review of observational studies or randomized clinical trials (RCT) of adult patients with AFRVR and concomitant ADHF in the emergency department (ED), intensive care unit, or step-down unit. The primary effectiveness outcome was successful rate or rhythm control. Safety outcomes were adverse events, such as symptomatic hypotension and venous thromboembolism. RESULTS: A total of 6577 unique articles were identified. Five studies met inclusion criteria: one RCT in the inpatient setting and four retrospective studies, two in the ED and the other three in the inpatient setting. In the RCT of diltiazem versus placebo, 22 patients (100%) in the treatment group had a therapeutic response compared to 0/15 (0%) in the placebo group, with no significant safety differences between the two groups. For three of the observational studies, data were limited. One observation study showed no difference between metoprolol and diltiazem for successful rate control, but worsening heart failure symptoms occurred more frequently in those receiving diltiazem compared to metoprolol (19 patients [33%] vs. 10 patients [15%], p = 0.019). A single study included electrical cardioversion (one patient exposed with failure to convert to sinus rhythm) as nonpharmacological management. The overall risk of bias for included studies ranged from serious to critical. Missing data and heterogeneity of definitions for effectiveness and safety outcomes precluded the combination of results for quantitative meta-analysis. CONCLUSIONS: High-level evidence to inform clinical decision making regarding effective and safe management of AFRVR in patients with ADHF in the acute care setting is lacking.
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Fibrilação Atrial , Flutter Atrial , Insuficiência Cardíaca , Adulto , Humanos , Fibrilação Atrial/complicações , Fibrilação Atrial/tratamento farmacológico , Flutter Atrial/complicações , Flutter Atrial/tratamento farmacológico , Diltiazem/uso terapêutico , Metoprolol/uso terapêutico , Antiarrítmicos/uso terapêutico , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/tratamento farmacológico , Ensaios Clínicos Controlados Aleatórios como Assunto , Estudos Observacionais como AssuntoAssuntos
Aorta/anormalidades , Ataxia/etiologia , Acidente Vascular Cerebral/complicações , Carcinoma Papilar/complicações , Carcinoma Papilar/diagnóstico , Serviço Hospitalar de Emergência/organização & administração , Humanos , Imageamento por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade , Acidente Vascular Cerebral/diagnóstico , Ultrassonografia/métodosRESUMO
Racism represents a public health crisis, adversely impacting patient outcomes and health care workplace inclusivity. Dismantling racism requires transforming both racist systems and individual and collective consciousness. Focusing on antiracism in health professions education through the transdisciplinary lens of the health humanities can spur self-reflection, critical thinking, and collaboration among health professions educators and trainees to create more equitable structures of care. This article describes how the health humanities provide a powerful framework for antiracist health professions education. The authors conclude with a snapshot of an existing humanities-based antiracist curriculum, with suggestions to facilitate implementation in other settings.
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Ciências Humanas , Racismo , Currículo , Atenção à Saúde , Ocupações em Saúde , HumanosRESUMO
PURPOSE: Adaptive expertise (AE) has been identified as a critical trait to cultivate in future physicians. The 4-phase master adaptive learner (MAL) conceptual model describes the learning skills and behaviors necessary to develop AE. Though prior work has elucidated skills and behaviors used by MALs in the initial planning phase of learning, most resident learners are not thought to be MALs. In this study, the authors investigated how these majority "typical" learners develop AE by exploring the strategies they used in the planning phase of learning. METHOD: Participants were resident physicians at graduate medical education (GME) training programs located at 4 academic medical centers in the United States. Participants participated in semistructured individual interviews in 2021, and interview transcripts were analyzed using constant comparative analysis of grounded theory. RESULTS: Fourteen subjects representing 8 specialties were interviewed, generating 152 pages of transcripts for analysis. Three themes were identified: "Typical" learners were challenged by the transition from structured undergraduate medical education learning to less-structured GME learning, lacked necessary skills to easily navigate this transition, and relied on trial and error to develop their learning skills. CONCLUSIONS: Participants used trial and error to find learning strategies to help them manage the systemic challenges encountered when transitioning from medical school to residency. The success (or failure) of these efforts was tied to learners' efficacy with the self-regulated learning concepts of agency, metacognitive goal setting, and motivation. A conceptual model is provided to describe the impact of these factors on residents' ability to be adaptive learners, and actionable recommendations are provided to help educators' efforts to foster adaptive learning skills and behaviors. These findings also provided valuable evidence of validity of the MAL model that has thus far been lacking.
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Internato e Residência , Médicos , Humanos , Estados Unidos , Pesquisa Qualitativa , Aprendizagem , CurrículoRESUMO
OBJECTIVES: In 2008, our emergency medicine (EM) residency program transitioned from a 3-year to a 4-year format. We analyzed the effect that this change had on the scholarly productivity and career choice of graduates, hypothesizing that it would lead residents to be more scholarly productive and graduates to more frequently obtain academic appointments and leadership roles in their first postresidency positions. METHODS: This was a retrospective analysis of graduates (N = 95) from a single residency program that underwent a curriculum change from a 3-year to a 4-year format. Three cohorts prior to (n = 36) and five cohorts after (n = 59) this transition were included. The primary outcome of interest was the setting of graduates' first postresidency position. Secondary outcomes included completion of scholarly activity during training and attaining a leadership role in the first postresidency position. RESULTS: Of the 4-year program graduates, 44% obtained an academic position compared to 28% of 3-year program graduates. After confounders were controlled for, this difference was statistically discernible only if fellowships were excluded (including fellowship, odds ratio [OR] = 2.25, 95% CI = 0.87 to 5.78; excluding fellowship, OR = 3.53, 95% CI = 1.13 to 11.05). Four-year graduates were more likely to obtain a leadership position immediately after graduation (OR = 13.72, 95% CI = 2.45 to 76.99). Compared to residents in the 3-year program, residents in the 4-year format had a similar likelihood of producing any scholarly work by graduation (OR = 1.69, 95% CI = 0.49 to 5.80) but were more likely to publish peer-reviewed manuscripts (OR = 3.92, 95% CI = 2.25 to 6.83). CONCLUSIONS: Compared to 3-year residency graduates, graduates of our 4-year curriculum were more likely to obtain nonfellowship academic appointments and leadership positions immediately after graduation and to publish their scholarly work during residency. This study suggests that residency applicants seeking to be academically productive during residency and leaders in the field of EM should consider training in a 4-year program with similar goals.
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The coronavirus disease 2019 pandemic may require rationing of various medical resources if demand exceeds supply. Theoretical frameworks for resource allocation have provided much needed ethical guidance, but hospitals still need to address objective practicalities and legal vetting to operationalize scarce resource allocation schemata. To develop operational scarce resource allocation processes for public health catastrophes, including the coronavirus disease 2019 pandemic, five health systems in Maryland formed a consortium-with diverse expertise and representation-representing more than half of all hospitals in the state. Our efforts built on a prior statewide community engagement process that determined the values and moral reference points of citizens and health-care professionals regarding the allocation of ventilators during a public health catastrophe. Through a partnership of health systems, we developed a scarce resource allocation framework informed by citizens' values and by general expert consensus. Allocation schema for mechanical ventilators, ICU resources, blood components, novel therapeutics, extracorporeal membrane oxygenation, and renal replacement therapies were developed. Creating operational algorithms for each resource posed unique challenges; each resource's varying nature and underlying data on benefit prevented any single algorithm from being universally applicable. The development of scarce resource allocation processes must be iterative, legally vetted, and tested. We offer our processes to assist other regions that may be faced with the challenge of rationing health-care resources during public health catastrophes.
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COVID-19 , Defesa Civil/organização & administração , Alocação de Recursos para a Atenção à Saúde , Mão de Obra em Saúde , Saúde Pública/tendências , Alocação de Recursos , COVID-19/epidemiologia , COVID-19/prevenção & controle , COVID-19/terapia , Gestão de Mudança , Planejamento em Desastres , Alocação de Recursos para a Atenção à Saúde/métodos , Alocação de Recursos para a Atenção à Saúde/normas , Humanos , Colaboração Intersetorial , Maryland/epidemiologia , Alocação de Recursos/ética , Alocação de Recursos/organização & administração , SARS-CoV-2 , Triagem/ética , Triagem/organização & administraçãoRESUMO
BACKGROUND: Delivering high-quality cardiopulmonary resuscitation (CPR) requires teams to administer highly choreographed care. The American Heart Association recommends audiovisual feedback for real-time optimization of CPR performance. In our Emergency Department (ED) resuscitation bays, ZOLL cardiac resuscitation device visibility was limited. OBJECTIVE: To optimize the physical layout of our resuscitation rooms to improve cardiac resuscitation device visibility for real-time CPR feedback. METHODS: A simulated case of cardiac arrest with iterative ergonomic modifications was performed four times. Variables included the locations of the cardiac resuscitation device and of team members. Participants completed individual surveys and provided qualitative comments in a group debriefing. The primary outcome of interest was participants' perception of cardiac resuscitation device visibility. RESULTS: The highest scoring layout placed the cardiac resuscitation device directly across from the compressor and mirrored the device screen to a television mounted at the head of the bed. Comparing this configuration to our standard configuration on a five-point Likert scale, cardiac resuscitation device visibility increased 46.7% for all team members, 150% for the team leader, and 179% for team members performing chest compressions. CONCLUSION: An iterative, multidisciplinary, simulation-based approach can improve team satisfaction with important clinical care factors when caring for patients suffering cardiac arrest in the ED.