Effectiveness of the “Timed Up and Go” (TUG) and the Chair Test as Screening Tools for Geriatric Fall Risk Assessment in the ED

OBJECTIVE: We sought to evaluate the effectiveness of the Timed Up and Go (TUG) and the Chair test as screening tools in the Emergency Department (ED), stratified by sex. METHODS: This prospective cohort study was conducted at a Level 1 Trauma center. After consent, subjects performed the TUG and the Chair test. Subjects were contacted for phone follow-up and asked to self-report interim falling. RESULTS: Data from 192 subjects were analyzed. At baseline, 71.4% (n = 137) screened positive for increased falls risk based on the TUG evaluation, and 77.1% (n = 148) scored below average on the Chair test. There were no differences by patient sex. By the six-month evaluation 51 (26.6%) study participants reported at least one fall. Females reported a non-significant higher prevalence of falls compared to males (29.7% versus 22.2%, p = 0.24). TUG test had a sensitivity of 70.6% (95% CI: 56.2%-82.5%), a specificity of 28.4% (95% CI: 21.1%-36.6%), a positive predictive (PP) value 26.3% (95% CI: 19.1%-34.5%) and a negative predictive (NP) value of 72.7% (95% CI: 59.0%-83.9%). Similar results were observed with the Chair test. It had a sensitivity of 78.4% (95% CI: 64.7%-88.7%), a specificity of 23.4% (95% CI: 16.7%-31.3%), a PP value 27.0% (95% CI: 20.1%-34.9%) and a NP value of 75.0% (95% CI: 59.7%-86.8%). No significant differences were observed between sexes. CONCLUSIONS: There were no sex specific significant differences in TUG or Chair test screening performance. Neither test performed well as a screening tool for future falls in the elderly in the ED setting

Sustaining remission of psychotic depression: Rationale, design and methodology of STOP-PD II

Background: Psychotic depression (PD) is a severe disabling disorder with considerable morbidity and mortality. Electroconvulsive therapy and pharmacotherapy are each efficacious in the treatment of PD. Expert guidelines recommend the combination of antidepressant and antipsychotic medications in the acute pharmacologic treatment of PD. However, little is known about the continuation treatment of PD. Of particular concern, it is not known whether antipsychotic medication needs to be continued once an episode of PD responds to pharmacotherapy. This issue has profound clinical importance. On the one hand, the unnecessary continuation of antipsychotic medication exposes a patient to adverse effects, such as weight gain and metabolic disturbance. On the other hand, premature discontinuation of antipsychotic medication has the potential risk of early relapse of a severe disorder.Methods/design: The primary goal of this multicenter randomized placebo-controlled trial is to assess the risks and benefits of continuing antipsychotic medication in persons with PD once the episode of depression has responded to treatment with an antidepressant and an antipsychotic. Secondary goals are to examine age and genetic polymorphisms as predictors or moderators of treatment variability, potentially leading to more personalized treatment of PD. Individuals aged 18-85 years with unipolar psychotic depression receive up to 12 weeks of open-label treatment with sertraline and olanzapine. Participants who achieve remission of psychosis and remission/near-remission of depressive symptoms continue with 8 weeks of open-label treatment to ensure stability of remission. Participants with stability of remission are then randomized to 36 weeks of double-blind treatment with either sertraline and olanzapine or sertraline and placebo. Relapse is the primary outcome. Metabolic changes are a secondary outcome.Discussion: This trial will provide clinicians with much-needed evidence to guide the continuation and maintenance treatment of one of the most disabling and lethal of psychiatric disorders.Trial registration and URL: NCT: NCT01427608. © 2013 Flint et al; licensee BioMed Central Ltd

Research Professionals\u27 Perspectives, Barriers, and Recommendations Regarding Minority Participation in Clinical Trials.

OBJECTIVE: This study aims to investigate research professionals\u27 perspectives regarding minority participation in clinical trials. METHODS: A web-based survey of research professionals at US institutions receiving NIH and/or AHRQ funding to conduct clinical research in 2013. Descriptive statistics, mean, standard deviation (SD), and the Wilcoxon rank-sum test were utilized for analysis. RESULTS: Distributed were 13,041 surveys with 967 (7.4%) responses. Overall and race-stratified analyses included 633 and 521 surveys, respectively. A majority agreed that patients\u27 race (mean, 3.4; SD = 1.0) and primary language (mean, 4.0; SD = 0.9) have an effect on enrollment. They had more success in enrolling those whose primary language was the same as their own (mean, 3.8; SD = 1.0), and that a language barrier and time spent arranging for interpreters had prevented them from offering a study to potential candidates (mean, 3.2; SD = 1.2). Non-Caucasian respondents were more likely to agree that fear of unknown side effects was a deterrent for minorities (p \u3c 0.01), minorities are more likely to be unavailable for follow-up phone calls (p = 0.07), and the unavailability of translated material discourages non-English speakers from participation (p = 0.08). They also were more likely to be neutral or agree with being discouraged from enrolling minorities because of the possibility of their withdrawal or being less likely to be available for phone follow-ups and follow-up visits (all p \u3c 0.01). CONCLUSION: Despite a few subtle racial differences in research professionals\u27 perspectives, a majority expressed no hesitation in enrolling minorities. Patients\u27 race and primary language appeared to influence enrollment. A language barrier appeared to be the strongest barrier for research professionals

Adverse Drug Events and Reactions Managed by Medical Toxicologists: an Analysis of the Toxicology Investigators Consortium (ToxIC) Registry, 2010-2016.

INTRODUCTION: Adverse drug events/reactions (ADE/ADRs) cost more than $30 billion annually and are among the leading causes of death in the USA. Little is known about patients treated at the bedside for ADE/ADR by medical toxicologists. METHODS: We conducted a retrospective study of ADE/ADR cases reported to the Toxicology Investigators Consortium (ToxIC) registry between January 1, 2010, and December 31, 2016. Clinical and demographic data were collected including age, sex, circumstances surrounding exposure, suspected offending substance, clinical manifestations, treatment, disposition, and outcome. RESULTS: Among 51,440 ToxIC cases during this time period, 673 ADE/ADR cases were reported (337 females). By age, ADE/ADRs were seen most commonly among adults age 19-65 years (442/673, 65.7% of ADE/ADR) and older adults age 65-89 years (134/673, 19.9% of ADE/ADR). 222/673 (33%) of consults for ADE/ADR were seen in the emergency department (ED); 181/673 (26.9%) were seen in the hospital ward; and 160/673 (23.8%) were seen in the intensive care unit (ICU). The most commonly reported sign for ADE/ADR was tachycardia: 51/673 (7.6%), followed by bradycardia: 49/673 (7.3%). Most commonly reported agents associated with ADE/ADR were as follows: 97/673 (14.4%) due to cardiovascular medications; 76/673 (11.3%) due to antipsychotic medications; and 61/673 (9.1%) due to antidepressants. 429/673 (63.7%) of ADE/ADR were reported as due to a single agent, and 212/673 (31.5%) were reported as due to multiple agents. CONCLUSIONS: 4.2% of cases managed at the bedside by a consulting toxicologist and reported to the ToxIC registry between 2010 and 2016 had ADE/ADR as the reason for consultation. Agents most commonly involved in ADE/ADRs included cardiovascular medications, antipsychotic medications, and antidepressants

Effectiveness of the Timed Up and Go (TUG) and the Chair test as screening tools for geriatric fall risk assessment in the ED.

OBJECTIVE: We sought to evaluate the effectiveness of the Timed Up and Go (TUG) and the Chair test as screening tools in the Emergency Department (ED), stratified by sex. METHODS: This prospective cohort study was conducted at a Level 1 Trauma center. After consent, subjects performed the TUG and the Chair test. Subjects were contacted for phone follow-up and asked to self-report interim falling. RESULTS: Data from 192 subjects were analyzed. At baseline, 71.4% (n = 137) screened positive for increased falls risk based on the TUG evaluation, and 77.1% (n = 148) scored below average on the Chair test. There were no differences by patient sex. By the six-month evaluation 51 (26.6%) study participants reported at least one fall. Females reported a non-significant higher prevalence of falls compared to males (29.7% versus 22.2%, p = 0.24). TUG test had a sensitivity of 70.6% (95% CI: 56.2%-82.5%), a specificity of 28.4% (95% CI: 21.1%-36.6%), a positive predictive (PP) value 26.3% (95% CI: 19.1%-34.5%) and a negative predictive (NP) value of 72.7% (95% CI: 59.0%-83.9%). Similar results were observed with the Chair test. It had a sensitivity of 78.4% (95% CI: 64.7%-88.7%), a specificity of 23.4% (95% CI: 16.7%-31.3%), a PP value 27.0% (95% CI: 20.1%-34.9%) and a NP value of 75.0% (95% CI: 59.7%-86.8%). No significant differences were observed between sexes. CONCLUSIONS: There were no sex specific significant differences in TUG or Chair test screening performance. Neither test performed well as a screening tool for future falls in the elderly in the ED setting

Factors Influencing Participation in Clinical Trials: Emergency Medicine vs. Other Specialties.

INTRODUCTION: This study investigated factors that influence emergency medicine (EM) patients\u27 decisions to participate in clinical trials and whether the impact of these factors differs from those of other medical specialties. METHODS: A survey was distributed in EM, family medicine (FM), infectious disease (ID), and obstetrics/gynecology (OB/GYN) outpatient waiting areas. Eligibility criteria included those who were 18 years of age or older, active patients on the day of the survey, and able to complete the survey without assistance. We used the Kruskal-Wallis test and ordinal logistic regression analyses to identify differences in participants\u27 responses. RESULTS: A total of 2,893 eligible subjects were approached, and we included 1,841 surveys in the final analysis. Statistically significant differences (p≤0.009) were found for eight of the ten motivating factors between EM and one or more of the other specialties. Regardless of a patient\u27s gender, race, and education, the relationship with their doctor was more motivating to patients seen in other specialties than to EM patients (FM [odds ratio {OR}:1.752, 95% confidence interval {CI}{1.285-2.389}], ID [OR:3.281, 95% CI{2.293-4.695}], and OB/GYN [OR:2.408, 95% CI{1.741-3.330}]). EM\u27s rankings of how well the research was explained and whether the knowledge learned would benefit others as their top two motivating factors were similar across other specialties. All nine barriers showed statistically significant differences (p≤0.008) between EM and one or more other specialties. Participants from all specialties indicated risk of unknown side effects as their strongest barrier. Regardless of the patients\u27 race, time commitment was considered to be more of a barrier to other specialties when compared to EM (FM [OR:1.613, 95% CI{1.218-2.136}], ID [OR:1.340, 95% CI{1.006-1.784}], or OB/GYN [OR:1.901, 95% CI{1.431-2.526}]). Among the six resources assessed that help patients decide whether to participate in a clinical trial, only one scored statistically significantly different for EM (p CONCLUSION: There are significant differences between EM patients and those of other specialties in the factors that influence their participation in clinical trials. Providing material in the patient\u27s own language, explaining the study well, and elucidating how their participation might benefit others in the future may help to improve enrollment in EM-based clinical trials