Depression is associated with repeat emergency department visits in patients with non-specific abdominal pain

Introduction: Patients with abdominal pain often return multiple times despite no definitive diagnosis. Our objective was to determine if repeat emergency department (ED) use among patients with non-specific abdominal pain might be associated with a diagnosis of moderate to severe depressive disorder. Methods: We screened 987 ED patients for major depression during weekday daytime hours from June 2011 through November 2011 using a validated depression screening tool, the PHQ-9. Each subject was classified as either no depression, mild depression or moderate/ severe depression based on the screening tool. Within this group, we identified 83 patients with non-specific abdominal pain by either primary or secondary diagnosis. Comparing depressed patients versus non-depressed patients, we analyzed demographic characteristics and number of prior ED visits in the past year. Results:In patients with non-specific abdominal pain, 61.9% of patients with moderate or severe depression (PHQ9≥10) had at least one visit to our ED for the same complaint within a 365-day period, as compared to 29.2% of patients with no depression (PHQ9 Conclusion: Repeat ED use among patients with non-specific abdominal pain is associated with moderate to severe depressive disorder. Patients with multiple visits for abdominal pain may benefit from targeted ED screening for depression. [West J Emerg Med. 2014;15(3):325–328.

Psychiatric Boarding in U.S. EDs: A Multifactorial Problem that Requires Multidisicplinary Solutions

ED visits for psychiatric conditions make up an ever-increasing share of all ED visits. Patients with psychiatric complaints have a significantly greater length-of-stay in the ED than patients with non-psychiatric complaints. Prolonged boarding in the ED for psychiatric patients is associated with lower quality care for psychiatric patients and further contributes to overall ED crowding

Severity of Pain is not associated with Urgency of Diagnosis in ED Patients with Abdominal Pain

Background Abdominal Pain is the most common cause of visits to US Emergency Departments (EDs) and the causes range from urgent to non-urgent diagnoses. Distinguishing urgent versus non-urgent causes of abdominal pain is done through the use of clinical exam, lab studies and diagnostic imaging such as CT scans. There are no validated clinical decision rules to assist physicians in discriminating urgent from non-urgent causes of abdominal pain or which patient needs a CT scan. There is controversy regarding the use of CT scans for patients with abdominal pain due to the increased cost, radiation exposure and length of stay. Objective The objective of this study is to compare the demographics, pain score and CT utilization for patients with urgent versus non-urgent causes of abdominal pain. Methods At an academic ED, a convenience sample of patients with abdominal pain was prospectively enrolled by research assistants during the ED visit. Research assistants abstracted treatment information from the electronic medical record for the ED and hospitalization if applicable. Finally, enrollees were telephoned 2 weeks after the index ED visit to ascertain symptom resolution and treatment outcomes. Following establishment of final diagnosis, patients were classified as having an urgent or non-urgent diagnosis based upon published peer-reviewed criteria. Risk differences in pain severity, CT scan utilization and demographics were compared to urgency of diagnosis and a paired t-test was used to estimate differences in initial clinical characteristics. Results In a model of 725 patients, 144 had urgent diagnoses and 561 had non-urgent diagnoses. There was no distinction in insurance type, income level, mean age or pain score in the two groups. Ct scan utilization was higher in patients with urgent diagnoses (42.4% versus 16.4%.) Conclusion 20.4% of patients had an urgent diagnosis for the abdominal pain. There was no difference in the pain score for patients with urgent versus non-urgent diagnosis. While work-up bias is a potential limitation, CT scan utilization was higher in patients with an urgent diagnosis suggesting appropriate clinical judgement. Future studies will need to look at ways to target the testing to more high-risk patients who present with undifferentiated abdominal pain

Bimodal release ondansetron for acute gastroenteritis among adolescents and adults: A randomized clinical trial

Importance: Vomiting resulting from acute gastroenteritis is commonly treated with intravenous antiemetics in acute care settings. If oral treatment were beneficial, patients might not need intravenous administered hydration or medication. Furthermore, a long-acting treatment could provide sustained relief from nausea and vomiting. Objective: To determine whether an experimental long-acting bimodal release ondansetron tablet decreases gastroenteritis-related vomiting and eliminates the need for intravenous therapy for 24 hours after administration. Design, Setting, and Participants: This placebo-controlled, double-blind, randomized clinical trial included patients from 19 emergency departments and 2 urgent care centers in the United States from December 8, 2014, to February 17, 2017. Patients 12 years and older with at least 2 vomiting episodes from presumed gastroenteritis in the previous 4 hours and symptoms with less than 36 hours\u27 duration were randomized using a 3:2 active to placebo ratio. Analyses were performed on an intent-to-treat basis and conducted from June 1, 2017, to November 1, 2017. Intervention: Bimodal release ondansetron tablet containing 6 mg of immediate release ondansetron and 18 mg of a 24-hour release matrix for a total of 24 mg of ondansetron. Main Outcomes and Measures: Treatment success was defined as no further vomiting, no need for rescue medication, and no intravenous hydration for 24 hours after bimodal release ondansetron administration. Results: Analysis included 321 patients (mean [SD] age, 29.0 [11.1] years; 195 [60.7%] women), with 192 patients in the bimodal release ondansetron group and 129 patients in the placebo group. Treatment successes were observed in 126 patients in the bimodal release ondansetron group (65.6%) compared with 70 patients in the placebo group (54.3%), with an 11.4% (95% CI, 0.3%-22.4%) absolute probability difference. The proportion of treatment success was 21% higher among patients who received bimodal release ondansetron compared with those who received a placebo (relative risk, 1.21; 95% CI, 1.00-1.46; P = .04). In an analysis including only patients with a discharge diagnosis of acute gastroenteritis and no major protocol violations, there were 123 treatment successes (69.5%) in the bimodal release ondansetron group compared with 67 treatment successes (54.9%) in the placebo group (relative risk, 1.27; 95% CI, 1.05-1.53; P = .01). Adverse effects were infrequent and similar to the known safety profile of ondansetron. Conclusions and Relevance: This randomized clinical trial found that a long-acting bimodal release oral ondansetron tablet was an effective antiemetic among adolescents and adults with moderate to severe vomiting from acute gastroenteritis. The drug benefits extended to 24 hours after administration. Bimodal release ondansetron may decrease the need for intravenous access and emergency department care to manage acute gastroenteritis. Trial Registration: ClinicalTrials.gov identifier: NCT02246439

Rapid 13(c) urea breath test to identify Helicobacter pylori infection in emergency department patients with upper abdominal pain

Introduction: In emergency department (ED) patients with upper abdominal pain, management includes ruling out serious diseases and providing symptomatic relief. One of the major causes of upper abdominal pain is an ulcer caused by Helicobacter pylori (H. pylori), which can be treated and cured with antibiotics. We sought to estimate the prevalence of H. pylori infection in symptomatic patients using a convenience sample at a single urban academic ED and demonstrate the feasibility of ED-based testing. Methods: We prospectively enrolled patients with a chief complaint of pain or discomfort in the upper abdomen for 1 year from February 2011 until February 2012 at a single academic urban ED. Enrolled subjects were tested for H. pylori using a rapid point of care 13C Urea Breath Test (UBT) [Exalenz Bioscience]. We compared patient characteristics between those who tested positive versus negative for the disease. Results: A total of 205 patients with upper abdominal pain were tested over 12 months, and 24% (95% confidence interval: 19% to 30%) tested positive for H. pylori. Black subjects were more likely to test positive than white subjects (28% v. 6%, P \u3c 0.001). Other factors, such as age and sex, were not different between the 2 groups. Conclusion: In our ED, H. pylori infection was present in 1 in 4 patients with epigastric pain, and testing with a UBT was feasible. Further study is needed to determine the risk factors associated with infection, the prevalence of H. pylori in other EDs, the effect of the test on ED length of stay and the cost-effectiveness of an ED-based test-and-treat strategy. [West J Emerg Med. 2013;14(3):278–282.

Do Hospitalists or Physicians with Greater Inpatient HIV Experience Improve HIV Care in the Era of Highly Active Antiretroviral Therapy? Results from a Multicenter Trial of Academic Hospitalists

Background. Little is known about the effect of provider type and experience on outcomes, resource use, and processes of care of hospitalized patients with human immunodeficiency virus (HIV) infection. Hospitalists are caring for this population with increasing frequency. Methods. Data from a natural experiment in which patients were assigned to physicians on the basis of call cycle was used to study the effects of provider type—that is, hospitalist versus non hospitalist—and HIV-specific inpatient experience on resource use, outcomes, and selected measures of processes of care at 6 academic institutions. Administrative data, inpatient interviews, 30-day follow-up interviews, and the National Death Index were used to measure outcomes. Results. A total of 1207 patients were included in the analysis. There were few differences in resource use, outcomes, and processes of care by provider type and experience with HIV-infected inpatients. Patients who received hospitalist care demonstrated a trend toward increased length of hospital stay compared with patients who did not receive hospitalist care (6.0 days vs. 5.2 days; Pp .13). Inpatient providers with moderate experience with HIV-infected patients were more likely to coordinate care with outpatient providers (odds ratio, 2.40; Pp .05) than were those with the least experience with HIV-infected patients, but this pattern did not extend to providers with the highest level of experience. Conclusion. Provider type and attending physician experience with HIV-infected inpatients had minimal effect on the quality of care of HIV-infected inpatients. Approaches other than provider experience, such as the use of multidisciplinary inpatient teams, may be better targets for future studies of the outcomes, processes of care, and resource use of HIV-infected inpatients