Familiarity with radiation exposure dose from diagnostic imaging for acute pulmonary embolism and current patterns of practice

Objective: To assess the current level of knowledge and practice patterns of emergency physicians regarding radiation exposure from diagnostic imaging modalities for investigating acute pulmonary embolism (PE)

The utility of renal ultrasonography in the diagnosis of renal colic in emergency department patients

Objective: Computed tomography (CT) is an imaging modality used to detect renal stones. However, there is concern about the lifetime cumulative radiation exposure attributed to CT. Ultrasonography (US) has been used to diagnose urolithiasis, thereby avoiding radiation exposure. The objective of this study was to determine the ability of US to identify renal colic patients with a low risk of requiring urologic intervention within 90 days of their initial emergency department (ED) visit. Methods: We completed a retrospective medical record review for all adult patients who underwent ED-ordered renal US for suspected urolithiasis over a 1-year period. Independent, double data extraction was performed for all imaging reports and US results were categorized as normal, suggestive of ureterolithiasis, ureteric stone seen or disease unrelated to urolithiasis. Charts were reviewed to determine how many patients underwent subsequent CT and urologic intervention. Results: Of the 817 renal US procedures ordered for suspected urolithiasis during the study period, the results of 352 (43.2%) were classified as normal, and only 2 (0.6%) of these patients required urologie intervention. The results of 177 (21.7%) renal US procedures were suggestive of ureterolithiasis. Of these, 12 (6.8%) patients required urologie intervention. Of the 241 (29.5%) patients who had a ureteric stone seen on US, 15 (6.2%) required urologie intervention. The rate of urologie intervention was significantly lower in those with normal results on US (p \u3c 0.001) than in those with abnormal results on US. Conclusion: A normal result on renal US predicts a low likelihood for urologie intervention within 90 days for adult ED patients with suspected urolithiasis

Normal renal sonogram identifies renal colic patients at low risk for urologic intervention: A prospective cohort study

Introduction: Determining which patients with ureterolithiasis are likely to require urologic intervention is a common challenge in the emergency department (ED). The objective was to determine if normal renal sonogram could identify low-risk renal colic patients, who were defined as not requiring urologic intervention within 90 days of their initial ED visit and can be managed conservatively. Methods: This was a prospective cohort study involving adult patients presenting to the EDs of a tertiary care centre with suspected renal colic over a 20-month period. Renal ultrasonography (US) was performed in the diagnostic imaging department by trained ultrasonographers, and the results were categorized into four mutually exclusive groups: normal, suggestive of ureterolithiasis, visualized ureteric stone, or findings unrelated to urolithiasis. Electronic medical records were reviewed to determine if patients received urologic intervention within 90 days of their ED visit. Results: Of 610 patients enrolled, 341 (55.9%) had US for suspected renal colic. Of those, 105 (30.8%) were classified as normal; none of these patients underwent urologic intervention within 90 days of their ED visit. Ninety (26.4%) US results were classified as suggestive, and nine (10%) patients received urologic intervention. A total of 139 (40.8%) US results were classified as visualized ureteric stone, and 34 (24.5%) patients had urologic intervention. Seven (2.1%) US results were classified as findings unrelated to urolithiasis, and none of these patients required urologic intervention. The rate of urologic intervention was significantly lower in those with normal US results (p \u3c 0.001) than in those with abnormal findings. Conclusion: A normal renal sonogram predicts a low likelihood for urologic intervention within 90 days for adult ED patients with suspected renal colic

Prospective Validation of the Emergency Heart Failure Mortality Risk Grade for Acute Heart Failure: The ACUTE Study

Background: Improved risk stratification of acute heart failure in the emergency department may inform physicians\u27 decisions regarding patient admission or early discharge disposition. We aimed to validate the previously-derived Emergency Heart failure Mortality Risk Grade for 7-day (EHMRG7) and 30-day (EHMRG30-ST) mortality. Methods: We conducted a multicenter, prospective validation study of patients with acute heart failure at 9 hospitals. We surveyed physicians for their estimates of 7-day mortality risk, obtained for each patient before knowledge of the model predictions, and compared these with EHMRG7 for discrimination and net reclassification improvement. We also prospectively examined discrimination of the EHMRG30-ST model, which incorporates all components of EHMRG7 as well as the presence of ST-depression on the 12-lead ECG. Results: We recruited 1983 patients seeking emergency department care for acute heart failure. Mortality rates at 7 days in the 5 risk groups (very low, low, intermediate, high, and very high risk) were 0%, 0%, 0.6%, 1.9%, and 3.9%, respectively. At 30 days, the corresponding mortality rates were 0%, 1.9%, 3.9%, 5.9%, and 14.3%. Compared with physician-estimated risk of 7-day mortality (PER7; c-statistic, 0.71; 95% CI, 0.64-0.78) there was improved discrimination with EHMRG7 (c-statistic, 0.81; 95% CI, 0.75-0.87; P=0.022 versus PER7) and with EHMRG7 combined with physicians\u27 estimates (c-statistic, 0.82; 95% CI, 0.76-0.88; P=0.003 versus PER7). Model discrimination increased nonsignificantly by 0.014 (95% CI, -0.009-0.037) when physicians\u27 estimates combined with EHMRG7 were compared with EHMRG7 alone (P=0.242). The c-statistic for EHMRG30-ST alone was 0.77 (95% CI, 0.73-0.81) and 30-day model discrimination increased nonsignificantly by addition of physician-estimated risk to 0.78 (95% CI, 0.73-0.82; P=0.187). Net reclassification improvement with EHMRG7 was 0.763 (95% CI, 0.465-1.062) when assessed continuously and 0.820 (0.560-1.080) using risk categories compared with PER7. Conclusions: A clinical model allowing simultaneous prediction of mortality at both 7 and 30 days identified acute heart failure patients with a low risk of events. Compared with physicians\u27 estimates, our multivariable model was better able to predict 7-day mortality and may guide clinical decisions. Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02634762

Acute Management and Outcomes of Patients with Diabetes Mellitus Presenting to Canadian Emergency Departments with Hypoglycemia

Objectifs: Cette vérification rétrospective des dossiers a permis d\u27examiner les données démographiques, les examens, la prise en charge et les résultats des patients adultes souffrant de diabète sucré qui se sont présentés aux services des urgences (SU) au Canada. Méthodes: Tous les sites ont mené une recherche dans leurs dossiers médicaux électroniques à l\u27aide des codes de la Classification internationale des maladies, dixième révision, pour relever les visites aux SU entre 2008 et 2010 qui étaient liées à l\u27hypoglycémie. Les caractéristiques des patients, les données démographiques, la prise en charge aux SU, les ressources des SU et les résultats sont rapportés. Résultats: Un total de 1039 patients de plus de 17 ans ont été inclus dans l\u27étude; 347 (33,4 %) ont été classifiés comme étant des cas de diabète de type 1 et 692 (66,6 %) ont été classifiés comme étant des cas de diabète de type 2. Les patients souffrant du diabète de type 2 étaient beaucoup plus âgés (73 ans vs 49 ans; p\u3c0,0001) et avaient plus d\u27affections chroniques inscrites à leur dossier (tous p\u3c0,001). La plupart des sujets arrivaient par ambulance, et 39 % des cas montraient des scores de triage qui révélaient des tableaux cliniques graves. Les traitements contre l\u27hypoglycémie étaient fréquents (75,7 %) durant le transport préhospitalier; 38,5 % recevaient du glucose et 40,1 % recevaient du glucagon par voie intraveineuse. Les traitements administrés dans les SU contre l\u27hypoglycémie comprenaient le glucose par voie orale (76,8 %), le glucose par voie intraveineuse (29,6 %) et en perfusion continue (27,7 %). Les examens diagnostiques (81,9 %) comprenaient fréquemment les électrocardiogrammes (51,9 %), la radiographie thoracique (37,5 %) et la tomodensitométrie crânienne (14,5 %). La plupart des patients (73,5 %) recevaient leur congé. Cependant, plus de sujets souffrant du diabète de type 2 nécessitaient une admission (30,3 vs 8,8 %). Les instructions de congé étaient étayées chez seulement 55,5 % des patients, et l\u27orientation vers des services de diabète se rencontrait chez moins de 20 % des cas. Une variation considérable dans la prise en charge de l\u27hypoglycémie existait entre les SU. Conclusions: Les patients souffrant de diabète qui se présentaient à un SU en raison d\u27une hypoglycémie consomment considérablement de ressources en soins de santé, puis une variation est observée dans la pratique. Les SU devraient élaborer des protocoles de prise en charge de l\u27hypoglycémie en portant une attention à la planification du congé pour réduire la récurrence

Prospective Validation of the Emergency Heart Failure Mortality Risk Grade for Acute Heart Failure

Background: Improved risk stratification of acute heart failure in the emergency department may inform physicians\u27 decisions regarding patient admission or early discharge disposition. We aimed to validate the previously-derived Emergency Heart failure Mortality Risk Grade for 7-day (EHMRG7) and 30-day (EHMRG30-ST) mortality. Methods: We conducted a multicenter, prospective validation study of patients with acute heart failure at 9 hospitals. We surveyed physicians for their estimates of 7-day mortality risk, obtained for each patient before knowledge of the model predictions, and compared these with EHMRG7 for discrimination and net reclassification improvement. We also prospectively examined discrimination of the EHMRG30-ST model, which incorporates all components of EHMRG7 as well as the presence of ST-depression on the 12-lead ECG. Results: We recruited 1983 patients seeking emergency department care for acute heart failure. Mortality rates at 7 days in the 5 risk groups (very low, low, intermediate, high, and very high risk) were 0%, 0%, 0.6%, 1.9%, and 3.9%, respectively. At 30 days, the corresponding mortality rates were 0%, 1.9%, 3.9%, 5.9%, and 14.3%. Compared with physician-estimated risk of 7-day mortality (PER7; c-statistic, 0.71; 95% CI, 0.64-0.78) there was improved discrimination with EHMRG7 (c-statistic, 0.81; 95% CI, 0.75-0.87; P=0.022 versus PER7) and with EHMRG7 combined with physicians\u27 estimates (c-statistic, 0.82; 95% CI, 0.76-0.88; P=0.003 versus PER7). Model discrimination increased nonsignificantly by 0.014 (95% CI, -0.009-0.037) when physicians\u27 estimates combined with EHMRG7 were compared with EHMRG7 alone (P=0.242). The c-statistic for EHMRG30-ST alone was 0.77 (95% CI, 0.73-0.81) and 30-day model discrimination increased nonsignificantly by addition of physician-estimated risk to 0.78 (95% CI, 0.73-0.82; P=0.187). Net reclassification improvement with EHMRG7 was 0.763 (95% CI, 0.465-1.062) when assessed continuously and 0.820 (0.560-1.080) using risk categories compared with PER7. Conclusions: A clinical model allowing simultaneous prediction of mortality at both 7 and 30 days identified acute heart failure patients with a low risk of events. Compared with physicians\u27 estimates, our multivariable model was better able to predict 7-day mortality and may guide clinical decisions. Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02634762