Clinical Characteristics, Management, and Outcomes of Patients Diagnosed With Acute Pulmonary Embolism in the Emergency Department

Objectives In a large U.S. sample, this study measured the presentation features, testing, treatment strategies, and outcomes of patients diagnosed with pulmonary embolism (PE) in the emergency department (ED). Background No data have quantified the demographics, clinical features, management, and outcomes of outpatients diagnosed with PE in the ED in a large, multicenter U.S. study. Methods Patients of any hemodynamic status were enrolled from the ED after confirmed acute PE or with a high clinical suspicion prompting anticoagulation before imaging for PE. Exclusions were inability to provide informed consent (where required) or unavailability for follow-up. Results A total of 1,880 patients with confirmed acute PE were enrolled from 22 U.S. EDs. Diagnosis of PE was based upon positive results of computerized tomographic pulmonary angiogram in most cases (n = 1,654 [88%]). Patients represented both sexes equally, and racial and ethnic composition paralleled the overall U.S. ED population. Most (79%) patients with PE were employed, and one-third were older than age 65 years. The mortality rate directly attributed to PE was 20 in 1,880 (1%; 95% confidence interval [CI]: 0% to 1.6%). Mortality from hemorrhage was 0.2%, and the all-cause 30-day mortality rate was 5.4% (95% CI: 4.4% to 6.6%). Only 3 of 20 patients with major PE that ultimately proved fatal had systemic anticoagulation initiated before diagnostic confirmation, and another 3 of these 20 received a fibrinolytic agent. Conclusions Patients diagnosed with acute PE in U.S. EDs have high functional status, and their mortality rate is low. These registry data suggest that appropriate initial medical management of ED patients with severe PE with anticoagulation is poorly standardized and indicate a need for research to determine the appropriate threshold for empiric treatment when PE is suspected before diagnostic confirmation

Prognostic utility of plasma neutrophil gelatinase-associated lipocalin in patients with acute heart failure: The NGAL EvaLuation Along with B-type NaTriuretic Peptide in acutely decompensated heart failure (GALLANT) trial

Neutrophil gelatinase-associated lipocalin (NGAL) is a measure of acute kidney injury. Renal dysfunction portends significant risk after discharge from acute heart failure (AHF). Thus, a sensitive marker of renal injury might also help to risk stratify HF patients

Quality of care in elder emergency department patients with pneumonia: a prospective cohort study

<p>Abstract</p> <p>Background</p> <p>The goals of the study were to assess the relationship between age and processes of care in emergency department (ED) patients admitted with pneumonia and to identify independent predictors of failure to meet recommended quality care measures.</p> <p>Methods</p> <p>This was a prospective cohort study of a pre-existing database undertaken at a university hospital ED in the Midwest. ED patients ≥18 years of age requiring admission for pneumonia, with no documented use of antibiotics in the 24 hours prior to ED presentation were included. Compliance with Pneumonia National Quality Measures was assessed including ED antibiotic administration, antibiotics within 4 hours, oxygenation assessment, and obtaining of blood cultures. Odds ratios were calculated for elders and non-elders. Logistic regression was used to identify independent predictors of process failure.</p> <p>Results</p> <p>One thousand, three hundred seventy patients met inclusion criteria, of which 560 were aged ≥65 years. In multiple variable logistic regression analysis, age ≥65 years was independently associated with receiving antibiotics in the ED (odds ratio [OR] = 2.03, 95% CI 1.28–3.21) and assessment of oxygenation (OR = 2.10, 95% CI, 1.18–3.32). Age had no significant impact on odds of receiving antibiotics within four hours of presentation (OR 1.10, 95% CI 0.84–1.43) or having blood cultures drawn (OR 1.02, 95%CI 0.78–1.32). Certain other patient characteristics were also independently associated with process failure.</p> <p>Conclusion</p> <p>Elderly patients admitted from the ED with pneumonia are more likely to receive antibiotics while in the ED and to have oxygenation assessed in the ED than younger patients. The independent association of certain patient characteristics with process failure provides an opportunity to further increase compliance with recommended quality measures in admitted patients diagnosed with pneumonia.</p

Comparison of balance assessment modalities in emergency department elders: a pilot cross-sectional observational study

<p>Abstract</p> <p>Background</p> <p>More than one-third of US adults 65 and over fall every year. These falls may cause serious injury including substantial long-term morbidity (due declines in activities of daily living) and death. The emergency department (ED) visit represents an opportunity for identifying high risk elders and potentially instituting falls-related interventions. The unique characteristic of the ED environment and patient population necessitate that risk-assessment modalities be validated in this specific setting. In order to better identify elders at risk of falls, we examined the relationship between patient-provided history of falling and two testing modalities (a balance plate system and the timed up-and-go [TUG] test) in elder emergency department (ED) patients.</p> <p>Methods</p> <p>We conducted a cross-sectional observational study of patients ≥ 60 years old being discharged from the ED. Patient history of falls in the past week, month, 6 months, and year was obtained. Balance plate center of pressure excursion (COP) measurements and TUG testing times were recorded. COP was recorded under four conditions: normal stability eyes open (NSEO) and closed (NSEC), and perturbed stability eyes open and closed. Correlation between TUG and COP scores was measured. Univariate logistic regression was used to identify the relationship between patient-provided falls history and the two testing modalities. Proportions, likelihood ratios, and receiver-operating-characteristic (ROC) curves for prediction of previous falls were reported.</p> <p>Results</p> <p>Fifty-three subjects were enrolled, 11% had fallen in the previous week and 42% in the previous year. There was no correlation between TUG and any balance plate measurements. In logistic regression, neither testing modality was associated with prior history of falls (<it>p </it>> 0.05 for all time periods). Balance plate NSEO and NSEC testing cutoffs could be identified which were 83% sensitive and had a negative likelihood ratio (LR-) of 0.3 for falls in the past week. TUG testing was not useful for falls in the past week, but performed best for more distant falls in the past month, 6 months, or year. TUG cutoffs with sensitivity over 80% and LR(-) of 0.17-0.32 could be identified for these time periods.</p> <p>Conclusion</p> <p>Over 40% of community-dwelling elder ED patients report a fall within the past year. Balance plate and TUG testing were feasibly conducted in an ED setting. There is no relationship between scores on balance plate and TUG testing in these patients. In regression analysis, neither modality was significantly associated with patient provided history of falls. These modalities should not be adopted for screening purposes in elders in the ED setting without validation in future studies or as part of multi-factorial risk assessment.</p

Finding acute coronary syndrome with serial troponin testing for rapid assessment of cardiac ischemic symptoms (FAST-TRAC): a study protocol.

ObjectiveTo determine the utility of a highly sensitive troponin assay when utilized in the emergency department.MethodsThe FAST-TRAC study prospectively enrolled >1,500 emergency department patients with suspected acute coronary syndrome within 6 hours of symptom onset and 2 hours of emergency department presentation. It has several unique features that are not found in the majority of studies evaluating troponin. These include a very early presenting population in whom prospective data collection of risk score parameters and the physician's clinical impression of the probability of acute coronary syndrome before any troponin data were available. Furthermore, two gold standard diagnostic definitions were determined by a pair of cardiologists reviewing two separate data sets; one that included all local troponin testing results and a second that excluded troponin testing so that diagnosis was based solely on clinical grounds. By this method, a statistically valid head-to-head comparison of contemporary and high sensitivity troponin testing is obtainable. Finally, because of a significant delay in sample processing, a unique ability to define the molecular stability of various troponin assays is possible.Trial registrationClinicalTrials.gov Identifier NCT00880802

Combined Versus Detailed Evaluation Components in Medical Student Global Rating Indexes

Introduction: To determine if there is any correlation between any of the 10 individual components of a global rating index on an emergency medicine (EM) student clerkship evaluation form. If there is correlation, to determine if a weighted average of highly correlated components loses predictive value for the final clerkship grade.Methods: This study reviewed medical student evaluations collected over two years of a required fourth-year rotation in EM. Evaluation cards, comprised of a detailed 10-part evaluation, were completed after each shift. We used a correlation matrix between evaluation category average scores, using Spearman’s rho, to determine if there was any correlation of the grades between any of the 10 items on the evaluation form.Results: A total of 233 students completed the rotation over the two-year period of the study. There were strong correlations (&gt;0.80) between assessment components of medical knowledge, history taking, physical exam, and differential diagnosis. There were also strong correlations between assessment components of team rapport, patient rapport, and motivation. When these highly correlated were combined to produce a four-component model, linear regression demonstrated similar predictive power in terms of final clerkship grade (R2=0.71, CI95=0.65–0.77 and R2=0.69, CI95=0.63–0.76 for the full and reduced models respectively).Conclusion: This study revealed that several components of the evaluation card had a high degree of correlation. Combining the correlated items, a reduced model containing four items (clinical skills, interpersonal skills, procedural skills, and documentation) was as predictive of the student’s clinical grade as the full 10-item evaluation. Clerkship directors should be aware of the performance of their individual global rating scales when assessing medical student performance, especially if attempting to measure greater than four components.

Erratum: This Article Corrects: Trends in NRMP Data from 2007-2014 for U.S. Seniors Matching into Emergency Medicine .

[This corrects the article on p. 105 in vol. 18, PMID: 28116018.]

Trends in NRMP Data from 2007-2014 for U.S. Seniors Matching into Emergency Medicine.

INTRODUCTION: Since 1978, the National Residency Matching Program (NRMP) has published data demonstrating characteristics of applicants who have matched into their preferred specialty in the NRMP main residency match. These data have been published approximately every two years. There is limited information about trends within these published data for students matching into emergency medicine (EM). Our objective was to investigate and describe trends in NRMP data to include the following: the ratio of applicants to available EM positions; United State Medical Licensing Examination (USMLE) Step 1 and Step 2 scores (compared to the national means); number of programs ranked; and Alpha Omega Alpha Honor Medical Society (AOA) membership among U.S. seniors matching into EM. METHODS: This was a retrospective observational review of NRMP data published between 2007 and 2016. We analyzed the data using analysis of variance (ANOVA) or Kruskal-Wallis testing, and Fischer\u27s exact or chi-squared testing, as appropriate to determine statistical significance. RESULTS: The ratio of applicants to available EM positions remained essentially stable from 2007 to 2014 but did increase slightly in 2016. We observed a net upward trend in overall Step 1 and Step 2 scores for EM applicants. However, this did not outpace the national trend increase in Step 1 and 2 scores overall. There was an increase in the mean number of programs ranked by EM applicants over the years studied from 7.8 (SD4.2) to 9.2 (SD5.0, p0.001), driven predominantly by the cohort of U.S. students successful in the match. Among time intervals, there was a difference in the number of EM applicants with AOA membership (p=0.043) due to a drop in the number of AOA students in 2011. No sustained statistical trend in AOA membership was identified over the seven-year period studied. CONCLUSION: NRMP data demonstrate trends among EM applicants that are similar to national trends in other specialties for USMLE board scores, and a modest increase in number of programs ranked. AOA membership was largely stable. EM does not appear to have become more competitive relative to other specialties or previous years in these categories

Trends in NRMP Data from 2007-2014 for US Seniors Matching into Emergency Medicine

INTRODUCTION: Since 1978, the National Residency Matching Program (NRMP) has published data demonstrating characteristics of applicants who have matched into their preferred specialty in the NRMP main residency match. These data have been published approximately every two years. There is limited information about trends within these published data for students matching into emergency medicine (EM). Our objective was to investigate and describe trends in NRMP data to include the following: the ratio of applicants to available EM positions; United State Medical Licensing Examination (USMLE) Step 1 and Step 2 scores (compared to the national means); number of programs ranked; and Alpha Omega Alpha Honor Medical Society (AOA) membership among U.S. seniors matching into EM. METHODS: This was a retrospective observational review of NRMP data published between 2007 and 2016. We analyzed the data using analysis of variance (ANOVA) or Kruskal-Wallis testing, and Fischer’s exact or chi-squared testing, as appropriate to determine statistical significance. RESULTS: The ratio of applicants to available EM positions remained essentially stable from 2007 to 2014 but did increase slightly in 2016. We observed a net upward trend in overall Step 1 and Step 2 scores for EM applicants. However, this did not outpace the national trend increase in Step 1 and 2 scores overall. There was an increase in the mean number of programs ranked by EM applicants over the years studied from 7.8 (SD4.2) to 9.2 (SD5.0, p<0.001), driven predominantly by the cohort of U.S. students successful in the match. Among time intervals, there was a difference in the number of EM applicants with AOA membership (p=0.043) due to a drop in the number of AOA students in 2011. No sustained statistical trend in AOA membership was identified over the seven-year period studied. CONCLUSION: NRMP data demonstrate trends among EM applicants that are similar to national trends in other specialties for USMLE board scores, and a modest increase in number of programs ranked. AOA membership was largely stable. EM does not appear to have become more competitive relative to other specialties or previous years in these categories