Journal of Emergency Medicine最新文献

{"title":"Single Intravenous Dose Dalbavancin Pathway for the Treatment of Acute Bacterial Skin and Skin Structure Infections: Considerations for Emergency Department Implementation and Cost Savings","authors":"","doi":"10.1016/j.jemermed.2024.03.003","DOIUrl":"10.1016/j.jemermed.2024.03.003","url":null,"abstract":"<div><h3>Background</h3><p>A pathway for the treatment of acute bacterial skin and skin structure infections (ABSSSI) with a single intravenous (IV) dose of dalbavancin was previously shown to reduce hospital admissions and shorten inpatient length of stay (LOS).</p></div><div><h3>Objectives</h3><p>To describe pathway implementation at the emergency department (ED) and evaluate cost-effectiveness of a single-dose dalbavancin administered to ED patients who would otherwise be hospitalized to receive usual care with multidose IV antibiotics.</p></div><div><h3>Methods</h3><p>The dalbavancin pathway was previously implemented at 11 U.S. EDs (doi:10.1111/acem.14258). Patients with ABSSSI, without an unstable comorbidity or infection complication requiring complex management, were treated with a single dose of dalbavancin. At the emergency physicians’ discretion, patients were either discharged and received outpatient follow-up or were hospitalized for continued management. A decision analytic cost-effectiveness model was developed from the U.S. healthcare's perspective to evaluate costs associated with the dalbavancin pathway compared with inpatient usual care. Costs (2021 USD) were modeled over a 14-day horizon and included ED visits, drug costs, inpatient stay, and physician visits. One-way and probabilistic sensitivity analyses examined input parameter uncertainty.</p></div><div><h3>Results</h3><p>Driven largely by the per diem inpatient cost and LOS for usual care, the dalbavancin pathway was associated with savings of $5133.20 per patient and $1211.57 per hospitalization day avoided, compared with inpatient usual care. The results remained robust in sensitivity and scenario analyses.</p></div><div><h3>Conclusion</h3><p>The new single-dose dalbavancin ED pathway for ABSSSI treatment, which was previously implemented at 11 U.S. EDs, offers robust cost savings compared to inpatient usual care.</p></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":"67 2","pages":"Pages e217-e229"},"PeriodicalIF":1.2,"publicationDate":"2024-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S0736467924000714/pdfft?md5=f641f301f7b9ad697d3513c2fea77c9f&pid=1-s2.0-S0736467924000714-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140272209","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Frequency of Persistent Opioid Use 6 Months After Exposure to IV Opioids in the Emergency Department: A Prospective Cohort Study","authors":"","doi":"10.1016/j.jemermed.2024.03.018","DOIUrl":"10.1016/j.jemermed.2024.03.018","url":null,"abstract":"<div><h3>Background</h3><p>As rates of opioid use disorder in the general population have increased, some have questioned whether IV opioids should be used routinely for treatment of acute severe pain in the emergency department (ED).</p></div><div><h3>Objectives</h3><p>We determined the incidence of persistent opioid use among opioid-naïve patients exposed to IV opioids in the ED.</p></div><div><h3>Methods</h3><p>This was a prospective observational cohort study conducted in two EDs in the Bronx, NY. Opioid-naïve adults with severe pain who received IV opioids in the ED were followed-up 6 months later by telephone interview and review of the state opioid prescription database. We defined persistent opioid use as filling 6 or more prescriptions for opioids in the 6 months following the ED visit or an average of one prescription per month.</p></div><div><h3>Results</h3><p><span>We screened 1555 patients. Of these, 506 patients met entry criteria and provided analyzable data. Morphine was the IV opioid most frequently administered in the ED (478, 94%), followed by hydromorphone<span> (20, 4%). Of the 506, 8 (2%) received both IV morphine and hydromorphone and 63 (12%) participants were prescribed an opioid for use after the ED visit. One patient/506 (0%) met our </span></span><em>apriori</em> criteria for persistent opioid use within 6 months.</p></div><div><h3>Conclusion</h3><p>Among 506 opioid naïve ED patients administered IV opioids for acute severe pain, only one used opioids persistently during the subsequent 6 months.</p></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":"67 2","pages":"Pages e119-e127"},"PeriodicalIF":1.2,"publicationDate":"2024-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140283413","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Navigating Care Refusal and Noncompliance in Patients with Opioid Use Disorder","authors":"","doi":"10.1016/j.jemermed.2024.03.008","DOIUrl":"10.1016/j.jemermed.2024.03.008","url":null,"abstract":"<div><h3>Background</h3><p>For many emergency physicians (EPs), deciding whether or not to allow a patient suffering the ill effects of opioid use to refuse care is the most frequent and fraught situation in which they encounter issues of decision-making capacity, informed refusal, and autonomy. Despite the frequency of this issue and the well-known impacts of opioid use disorder on decision-making, the medical ethics community has offered little targeted analysis or guidance regarding these situations.</p></div><div><h3>Discussion</h3><p>As a result, EPs demonstrate significant variability in how they evaluate and respond to them, with highly divergent understandings and application of concepts such as decision-making capacity, informed consent, autonomy, legal repercussions, and strategies to resolve the clinical dilemma. In this paper, we seek to provide more clarity to this issue for the EPs.</p></div><div><h3>Conclusions</h3><p>Successfully navigating this issue requires that EPs understand the specific effects that opioid use disorder has on decision-making, and how that in turn bears on the ethical concepts of autonomy, capacity, and informed refusal. Understanding these concepts can lead to helpful strategies to resolve these commonly-encountered dilemmas.</p></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":"67 2","pages":"Pages e233-e242"},"PeriodicalIF":1.2,"publicationDate":"2024-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140766310","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Incidental Renal Cysts Found by Point-of-Care Ultrasound: A Retrospective Chart Review","authors":"","doi":"10.1016/j.jemermed.2024.03.020","DOIUrl":"10.1016/j.jemermed.2024.03.020","url":null,"abstract":"<div><h3>Background</h3><p>Incidental findings are unrelated to a patient's complaint, found on diagnostic imaging, such as point-of-care ultrasound (POCUS). Incidental findings represent potential harms to patients and may lead to increased patient anxiety and health care costs related to downstream testing and surveillance.</p></div><div><h3>Study Objectives</h3><p>In this study, we aimed to calculate the rate of incidental renal cysts found by POCUS. Further, we hoped to describe how emergency physicians relay the findings to patients. Lastly, we hoped to examine if patients suffered harms in the 12 months following identification of an incidental renal cyst.</p></div><div><h3>Methods</h3><p>From our single-center, academic emergency department (ED), we reviewed renal POCUS images from 1000 consecutive adult ED patients to determine if there was a renal cyst. Next, we performed manual chart review to determine if patients were informed of the incidental renal cyst or suffered any patient harms.</p></div><div><h3>Results</h3><p>We found the prevalence of renal cysts to be 6.5% (95% confidence interval: 4.9%–8.4%). Those with cysts were more likely to be older compared to those without (63 ± 14 vs. 49 ± 15 years of age). Only 8% of patients had evidence that they were informed of their incidental renal cyst. No patients received a biopsy or were diagnosed with renal cell carcinoma or polycystic kidney disease.</p></div><div><h3>Conclusion</h3><p>Incidental renal cysts are common and are more likely to be found in older adults. In our study, physicians infrequently informed patients of their incidental finding.</p></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":"67 2","pages":"Pages e209-e216"},"PeriodicalIF":1.2,"publicationDate":"2024-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140277773","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Grey-to-White Matter Ratio Values in Early Head Computed Tomography (CT) as a Predictor of Neurologic Outcomes in Survivors of Out-of-Hospital Cardiac Arrest Based on Severity of Hypoxic-Ischemic Brain Injury","authors":"","doi":"10.1016/j.jemermed.2024.03.037","DOIUrl":"10.1016/j.jemermed.2024.03.037","url":null,"abstract":"<div><h3>Background</h3><p>Hypoxic-ischemic brain injury (HIBI) is a common complication of out-of-hospital cardiac arrest (OHCA).</p></div><div><h3>Objectives</h3><p>We investigated whether grey-to-white matter ratio (GWR) values, measured using early head computed tomography (HCT), were associated with neurologic outcomes based on the severity of HIBI in survivors of OHCA.</p></div><div><h3>Methods</h3><p>This retrospective multicenter study included adult comatose OHCA survivors who underwent an HCT scan within 2 h after the return of spontaneous circulation. HIBI severity was assessed using the revised post-Cardiac Arrest Syndrome for Therapeutic hypothermia (rCAST) scale (low, moderate, and severe). Poor neurologic outcomes were defined as Cerebral Performance Categories 3 to 5 at 6 months after OHCA.</p></div><div><h3>Results</h3><p>Among 354 patients, 27% were women and 224 (63.3%) had poor neurologic outcomes. The distribution of severity was 19.5% low, 47.5% moderate, and 33.1% severe. The area under the receiver operating curves of the GWR values for predicting rCAST severity (low, moderate, and severe) were 0.52, 0.62, and 0.79, respectively. The severe group had significantly higher predictive performance than the moderate group (<em>p</em> = 0.02). Multivariate logistic regression analysis revealed a significant association between GWR values and poor neurologic outcomes in the moderate group (adjusted odds ratio = 0.012, 95% CI 0.0–0.54, <em>p</em> = 0.02).</p></div><div><h3>Conclusions</h3><p>In this cohort study, GWR values measured using early HCT demonstrated variations in predicting neurologic outcomes based on HIBI severity. Furthermore, GWR in the moderate group was associated with poor neurologic outcomes.</p></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":"67 2","pages":"Pages e177-e187"},"PeriodicalIF":1.2,"publicationDate":"2024-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141293458","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Shock Index among Children Presenting to the Emergency Department: Analysis of Nationally Representative Sample","authors":"","doi":"10.1016/j.jemermed.2024.03.022","DOIUrl":"10.1016/j.jemermed.2024.03.022","url":null,"abstract":"<div><h3>Background</h3><p>The Shock Index (SI) is emerging as a potentially useful measure among children with injury or suspected sepsis.</p></div><div><h3>Objective</h3><p>The aim of this study was to evaluate the distribution of the SI and evaluate its association with clinical outcomes among all children presenting to the emergency department (ED).</p></div><div><h3>Methods</h3><p>A complex survey of nonfederal U.S. ED encounters from 2016 through 2021 was analyzed. Among children, the Pediatric Age-Adjusted Shock Index (SIPA), Pediatric Shock Index (PSI), and the Temperature- and Age-Adjusted Shock Index (TAMSI) were analyzed. The association of these criteria with disposition, acuity, medication administration, diagnoses and procedures was analyzed.</p></div><div><h3>Results</h3><p>A survey-weighted 81.5 million ED visits were included for children aged 4–16 years and 117.2 million visits were included for children aged 1–12 years. SI could be calculated for 78.6% of patients aged 4–16 years and 57.9% of patients aged 1–12 years. An abnormal SI was present in 15.9%, 11.1%, and 31.7% when using the SIPA, PSI, and TAMSI, respectively. With all criteria, an elevated SI was associated with greater hospitalization. The SIPA and PSI were associated with triage acuity. All criteria were associated with medical interventions, including provision of IV fluids and acquisition of blood cultures.</p></div><div><h3>Conclusions</h3><p>An elevated SI is indicative of greater resource utilization needs among children in the ED. When using any criteria, an elevated SI was associated with clinically important outcomes. Further research is required to evaluate the distribution of the SI in children and to investigate its potential role within existing triage algorithms for children in the ED.</p></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":"67 2","pages":"Pages e146-e156"},"PeriodicalIF":1.2,"publicationDate":"2024-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140759751","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Traumatic Pseudoaneurysm of the Temporal Artery","authors":"","doi":"10.1016/j.jemermed.2024.03.035","DOIUrl":"10.1016/j.jemermed.2024.03.035","url":null,"abstract":"","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":"67 2","pages":"Pages e230-e232"},"PeriodicalIF":1.2,"publicationDate":"2024-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141293459","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Effect of Contrast Rationing on the Development of Acute Kidney Injury During the Global Contrast Shortage","authors":"","doi":"10.1016/j.jemermed.2024.04.009","DOIUrl":"10.1016/j.jemermed.2024.04.009","url":null,"abstract":"<div><h3>Background</h3><p>In April of 2022, the COVID-19 pandemic resulted in a global shortage of intravenous contrast media<span> (ICM), which led our health care system to implement rationing measures.</span></p></div><div><h3>Study Objectives</h3><p>We set out to determine if the reduction in ICM use was associated with a change in the incidence of acute kidney injury (AKI).</p></div><div><h3>Methods</h3><p><span>We conducted a multicenter retrospective cohort analysis to compare the incidence of AKI in patients who presented before and after ICM rationing. Adult patients who had a </span>CT of the abdomen performed who had at least 2 creatinine measurements, at least 24 h apart, were included. The maximum increase in creatinine was determined by subtracting the maximal creatinine obtained within 7 days with the initial creatinine. The primary outcome was the development of AKI.</p></div><div><h3>Results</h3><p>A total of 2168 patients met inclusion criteria (1082 before; 1086 after). There was no significant difference in age, gender, comorbid conditions, disposition, or initial estimated glomerular filtration rate between groups. In the prerationing group, 87.7% of patients received ICM compared to 42.7% after. There was no significant difference in the development of AKI between groups (11.1% vs. 11.0%), including when stratified by baseline renal function and adjusted for age, sex, race, comorbid conditions, and emergency severity index.</p></div><div><h3>Conclusions</h3><p>The dramatic reduction in ICM use that resulted from the global shortage was not associated with a change in the incidence of AKI. This reinforces the results of previous studies which have failed to find evidence of a relationship between ICM administration and AKI.</p></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":"67 2","pages":"Pages e157-e163"},"PeriodicalIF":1.2,"publicationDate":"2024-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141053287","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Increasing Uptake of Lung Cancer Screening Among Emergency Department Patients: A Pilot Study","authors":"","doi":"10.1016/j.jemermed.2024.03.034","DOIUrl":"10.1016/j.jemermed.2024.03.034","url":null,"abstract":"<div><h3>Background</h3><p>Lung cancer is the leading cause of cancer death in the United States. Lung cancer screening (LCS) decreases lung cancer mortality. Emergency department (ED) patients are at disproportionately high risk for lung cancer. The ED, therefore, is an optimal environment for interventions to promote LCS.</p></div><div><h3>Objectives</h3><p>Demonstrate the operational feasibility of identifying ED patients in need of LCS, referring them to LCS services, deploying a text message intervention to promote LCS, and conducting follow-up to determine LCS uptake.</p></div><div><h3>Methods</h3><p>We conducted a randomized clinical trial to determine the feasibility and provide estimates of the preliminary efficacies of 1) basic referral for LCS and 2) basic referral plus a text messaging intervention, grounded in behavioral change theory, to promote uptake of LCS among ED patients. Participants aged 50 to 80, identified as eligible for LCS, were randomized to study arms and followed up at 150 days to assess interval LCS uptake (primary outcome), barriers to screening, and perceptions of the study interventions.</p></div><div><h3>Results</h3><p>A total of 303 patients were surveyed, with 198 identified as eligible for LCS and subsequently randomized. Results indicated that 24% of participants with follow-up data received LCS (11% of the total randomized sample). Rates of screening at follow-up were similar across study arms. The intervention significantly improved normative perceptions of LCS (<em>p</em> = 0.015; Cohen's d = 0.45).</p></div><div><h3>Conclusion</h3><p>This pilot study demonstrates the feasibility of ED-based interventions to increase uptake of LCS among ED patients. A scalable ED-based intervention that increases LCS uptake could reduce lung cancer mortality.</p></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":"67 2","pages":"Pages e164-e176"},"PeriodicalIF":1.2,"publicationDate":"2024-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140400280","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Assessing the Predictive Value of Combining Risk Scoring Systems and Ultrasonography for Short-Term Adverse Outcomes in Syncope: A Prospective Observational Study","authors":"","doi":"10.1016/j.jemermed.2024.03.016","DOIUrl":"10.1016/j.jemermed.2024.03.016","url":null,"abstract":"<div><h3>Background</h3><p><span>In the emergency department (ED), the role of </span>ultrasonography<span><span> (USG) in risk stratification and predicting </span>adverse events in syncope patients is a current research area. However, it is still unclear how ultrasound can be combined with existing risk scores.</span></p></div><div><h3>Objectives</h3><p>In this study, it was aimed to examine the contribution of the use of bedside USG to current risk scores in the evaluation of patients presenting to the ED with syncope. The predictive values of the combined use of USG and risk scores for adverse outcomes at 7 and 30 days were examined.</p></div><div><h3>Methods</h3><p>The Canadian Syncope Risk Score (CSRS), San Francisco syncope rules (SFSR), USG findings of carotid and deep venous structures, and echocardiography results were recorded for patients presenting with syncope. Parameters showing significance in the 7-day and 30-day adverse outcome groups were utilized to create new scores termed CSRS-USG and SFSR-USG. Predictive values were evaluated using receiver operating characteristic (ROC) analysis. The difference between the predictive values was evaluated with the DeLong test.</p></div><div><h3>Results</h3><p><span>The study was carried out with 137 participants. Adverse outcomes were observed in 45 participants (32.8%) within 30 days. 32 (71.7%) of the adverse outcomes were in the first 7 days. For 30-day adverse outcomes, the SFSR-USG (</span><em>p</em> = 0.001) and CSRS-USG (<em>p</em> = 0.038) scores had better predictive accuracy compared to SFSR and CSRS, respectively. However, there was no significant improvement in sensitivity and specificity values.</p></div><div><h3>Conclusion</h3><p>The use of USG in the evaluation of syncope patients did not result in significant improvement in sensitivity and specificity values for predicting adverse events. However, larger sample-sized studies are needed to understand its potential contributions better.</p></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":"67 2","pages":"Pages e198-e208"},"PeriodicalIF":1.2,"publicationDate":"2024-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140280483","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}