Cervical Spine Fracture in Ankylosing Spondylitis

[West J Emerg Med. 2009;10(4):267.

Effect of Tamsulosin on Stone Passage for Ureteral Stones: A Systematic Review and Meta-analysis

Study objectiveTamsulosin is recommended for patients receiving a diagnosis of a ureteral stone less than 10 mm who do not require immediate urologic intervention. Because of conflicting results from recent meta-analyses and large randomized controlled trials, the efficacy of tamsulosin is unclear. We perform a systematic review and meta-analysis to investigate the effect of tamsulosin on stone passage in patients receiving a diagnosis of ureteral stone.MethodsMEDLINE, EMBASE, and CENTRAL databases were searched without language restriction through November 2015 for studies assessing the efficacy of tamsulosin and using a double-blind, randomized, controlled trial design. Meta-analysis was conducted with a random-effects model and subgroup analyses were conducted to determine sources of heterogeneity.ResultsEight randomized controlled trials (N=1,384) contained sufficient information for inclusion. The pooled risk of stone passage in the tamsulosin arm was 85% versus 66% in the placebo arm, but substantial heterogeneity existed across trials (I2=80.2%; P<.001). After stratifying of studies by stone size, the meta-analysis of the large stone subgroup (5 to 10 mm; N=514) indicated a benefit of tamsulosin (risk difference=22%; 95% confidence interval 12% to 33%; number needed to treat=5). The meta-analysis of the small stone subgroup (<4 to 5 mm; N=533) indicated no benefit (risk difference=-0.3%; 95% confidence interval -4% to 3%). Neither meta-analysis for the occurrence of dizziness or hypotension showed a significant effect.ConclusionTamsulosin significantly improves stone passage in patients with larger stones, whereas the effect of tamsulosin is diminished in those with smaller stones, who are likely to pass their stone regardless of treatment

Cervical Spine Fracture in Ankylosing Spondylitis

[West J Emerg Med. 2009;10(4):267.

Potential Misdiagnoses of Bell's Palsy in the Emergency Department

Study objectiveWe evaluate the incidence of potentially incorrect emergency department (ED) diagnoses of Bell's palsy and identify factors associated with identification of a serious alternative diagnosis on follow-up.MethodsWe performed a retrospective cohort study from California's Office of Statewide Health Planning and Development for 2005 to 2011. Subjects were adult patients discharged from the ED with a diagnosis of Bell's palsy. Information related to demographics, imaging use, and comorbidities was collected. Our outcome was one of the following diagnoses made within 90 days of the index ED visit: stroke, intracranial hemorrhage, subarachnoid hemorrhage, brain tumor, central nervous system infection, Guillain-Barré syndrome, Lyme disease, otitis media/mastoiditis, or herpes zoster. We report hazard ratios (HRs) and 95% confidence intervals (CIs) for factors associated with misdiagnosis.ResultsA total of 43,979 patients were discharged with a diagnosis of Bell's palsy. Median age was 45 years. On 90-day follow-up, 356 patients (0.8%) received an alternative diagnosis, and 39.9% were made within 7 days. Factors associated with the receiving alternative diagnosis included increasing age (HR 1.11, 95% CI 1.01 to 1.21, every 10 years), black race (HR 1.68; 95% CI 1.13 to 2.48), diabetes (HR 1.46; 95% CI 1.10 to 1.95), and computed tomography or magnetic resonance imaging use (HR 1.43; 95% CI 1.10 to 1.85). Private insurance was negatively associated with an alternative diagnosis (HR 0.65; 95% CI 0.46 to 0.93). Stroke, herpes zoster, Guillain-Barré, and otitis media accounted for 85.4% of all alternative diagnoses.ConclusionEmergency providers have a very low rate of misdiagnosing Bell's palsy. The association between imaging use and misdiagnosis is likely confounded by patient acuity. Increasing age and diabetes are modest risk factors for misdiagnosis

Point-of-Care Multi-Organ Ultrasound Improves Diagnostic Accuracy in Adults Presenting to the Emergency Department with Acute Dyspnea

Introduction: Determining the etiology of acute dyspnea in emregency department (ED) patients is often difficult. Point-of-care ultrasound (POCUS) holds promise for improving immediate diagnostic accuracy (after history and physical), thus improving use of focused therapies. We evaluate the impact of a three-part POCUS exam, or “triple scan” (TS) – composed of abbreviated echocardiography, lung ultrasound and inferior vena cava (IVC) collapsibility assessment – on the treating physician’s immediate diagnostic impression.Methods: A convenience sample of adults presenting to our urban academic ED with acute dyspnea (Emergency Severity Index 1, 2) were prospectively enrolled when investigator sonographers were available. The method for performing components of the TS has been previously described in detail. Treating physicians rated the most likely diagnosis after history and physical but before other studies (except electrocardiogram) returned. An investigator then performed TS and disclosed the results, after which most likely diagnosis was reassessed. Final diagnosis (criterion standard) was based on medical record review by expert emergency medicine faculty blinded to TS result. We compared accuracy of pre-TS and post-TS impression (primary outcome) with McNemar’s test. Test characteristics for treating physician impression were also calculated by dichotomizing acute decompensated heart failure (ADHF), chronic obstructive pulmonary disease (COPD) and pneumonia as present or absent.Results: 57 patients were enrolled with the leading final diagnoses being ADHF (26%), COPD/asthma (30%), and pneumonia (28%). Overall accuracy of the treating physician’s impression increased from 53% before TS to 77% after TS (p=0.003). The post-TS impression was 100% sensitive and 84% specific for ADHF.Conclusion: In this small study, POCUS evaluation of the heart, lungs and IVC improved the treating physician’s immediate overall diagnostic accuracy for ADHF, COPD/asthma and pneumonia and was particularly useful to immediately exclude ADHF as the cause of acute dyspnea

Predictors for under-prescribing antibiotics in children with respiratory infections requiring antibiotics.

Background/objectivePrevious studies showed variability in the use of diagnostic and therapeutic resources for children with febrile acute respiratory tract infections (ARTI), including antibiotics. Unnecessary antibiotic use has important public and individual health outcomes, but missed antibiotic prescribing also has important consequences. We sought to determine factors associated with antibiotic prescribing in pediatric ARTI, specifically those with pneumonia.MethodsWe assessed national trends in the evaluation and treatment of ARTI for pediatric emergency department (ED) patients by analyzing the National Hospital Ambulatory Medical Care Survey from 2002 to 2013. We identified ED patients aged ≤18 with a reason for visit of ARTI, and created 4 diagnostic categories: pneumonia, ARTI where antibiotics are typically indicated, ARTI where antibiotics are typically not indicated, and "other" diagnoses. Our primary outcome was factors associated with the administration or prescription of antibiotics. A multivariate logistic regression model was fit to identify risk factors for underuse of antibiotics when they were indicated.ResultsWe analyzed 6461 visits, of which 10.2% of the population had a final diagnosis of pneumonia and 86% received antibiotics. 41.5% of patients were diagnosed with an ARTI requiring antibiotics, of which 53.8% received antibiotics. 26.6% were diagnosed with ARTI not requiring antibiotics, of which 36.0% received antibiotics. Black race was a predictor for the underuse of antibiotics in ARTIs that require antibiotics (OR: 0.72; 95% CI: 0.58-0.90).ConclusionsFor pediatric patients presenting to the ED with pneumonia and ARTI requiring antibiotics, we found that black race was an independent predictor of antibiotic underuse

More than just meds: National survey of providers’ perceptions of patients’ social, economic, environmental, and legal needs and their effect on emergency department utilization

Introduction: Emergency departments (EDs) are the safety net for millions of patients who need to access care. Many of these patients have social needs that may influence their healthcare. Methods: We sought to understand ED providers’ perceptions of health-related social issues facing their patients by conducting an online survey of emergency medicine physicians nationally. Respondents ranked patients’ most common needs, which needs affected healthcare use, and interest in education on these needs. We also queried when needs are assessed and reasons they are not. Responses are reported as proportions, stratified by training level and program type; the chi-square test was used to assess differences between groups. Results: We broadcast survey links to 168 US emergency medicine training programs, receiving 432 responses from 79 different institutions in 31 states; 45% of the respondents were residents and 49% attendings; 47% identified as academic, 28% as county, 18% as community, and 7% as mixed. Providers’ ranked factors that influenced ED visits; naming lack of health insurance, homelessness, and transportation problems as several of the top non-medical needs they see in the ED. All respondents replied that they care for patients with social needs; all but two felt that social needs move patients to return to the ED. While providers consistently ask about social needs, for any specific social need the number of doctors who routinely ask ranges from 61-100% depending on need. Reasons for not asking included feeling unable to act, lack of time, and lack of knowledge. Only a small minority felt that addressing non-medical needs was not part of their job or that needs were not relevant to patients’ health. Most providers (80%) would like more resources and 70% reported they would attend educational sessions if they were available. We found no difference between attendings and residents in interest in attending educational sessions or in the percentage who ask about needs. Providers from all types of institutions were equally likely to believe social needs caused patients to return and to ask about such needs. Conclusions: This study highlights the fact that emergency department providers around the country see a large number of social needs. They identified specific needs that increase the utilization of healthcare services. These needs would more likely be addressed if greater referral resources were available

Pilot Study of Ultrasound-Guided Corticosteroid Hip Injections by Emergency Physicians

Introduction: Our objective was to assess the efficacy of ultrasound-guided hip injections performed by emergency physicians (EPs) for the treatment of chronic hip pain in an outpatient clinic setting.Methods: Patients were identified on a referral basis from the orthopedic chronic pain clinic. The patient population was either identified as having osteoarthritis of the hip, osteonecrosis of varying etiologies, post-traumatic osteoarthritis of the hip, or other non-infectious causes of chronic hip pain. Patients had an ultrasound-guided hip injection of 4ml of 0.5% bupivacaine and 1ml of triamcinolone acetate (40mg/1ml). Emergency medicine resident physicians under the supervision of an attending EP performed all injections. Pain scores were collected using a Likert pain scale from patients prior to the procedure, and 10 minutes post procedure and at short-term follow-up of one week and one month. The primary outcome was patient-reported pain score on a Likert pain scale at one week.Results: We performed a total of 47 ultrasound-guided intra-articular hip injections on 44 subjects who met inclusion criteria. Three subjects received bilateral injections. Follow-up data were available for 42/47 (89.4%) hip injections at one week and 40/47 (85.1%) at one month. The greatest improvement was at 10 minutes after injection with a mean decrease in Likert pain score from pre-injection baseline of 5.57 (95% CI, 4.76-6.39). For the primary outcome at one week, we found a mean decrease in Likert pain score from pre-injection baseline of 3.85 (95% CI, 2.94-4.75). At one month we found a mean decrease in Likert pain score of 1.8 (95% CI, 1.12-2.53). There were no significant adverse outcomes reported.Conclusion: Under the supervision of an attending EP, junior emergency medicine resident physicians can safely and effectively inject hips for chronic pain relief in an outpatient clinical setting using ultrasound guidance. [West J Emerg Med. 2014;15(7):-0.]