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1.
Xi Zhang Nicole Rowan Bethann Mangel Pflugeisen Sanjin Alajbegovic 《The American journal of emergency medicine》2017,35(4):594-598
Background
Antibiotics are overprescribed for abnormal urine tests including asymptomatic bacteriuria (AB), contributing to rising antimicrobial resistance rates. Pharmacists reviewed urine cultures daily from emergency department (ED) encounters to assess antibiotic appropriateness. We studied antibiotic prescribing practices and assessed compliance to national guidelines, correlations with urine analysis (UA) components, and opportunities for antimicrobial stewardship in the ED.Methods
This quality improvement project (QIP) was a prospective cohort study at a community hospital ED, with data collected from finalized urine cultures resulting October 30, 2014 through January 5, 2015. Analyses were conducted using Chi-squared and Fisher Exact tests and stepwise multiple logistic regression.Results
Urine cultures from 457 encounters were reviewed, of which 136 met the inclusion criteria as non-pregnant and asymptomatic for urinary tract infection (UTI). 43% of 136 patients were treated with antibiotics, for a total of 426 antibiotic days. Pharmacist interventions for these patients resulted in 122/426 (29%) of potential antibiotic days saved. Factors found to significantly increase the odds of antibiotic prescribing in asymptomatic patients included presence of leukocyte esterase (OR = 4.5, 95% CI: 1.2–17.2; p = 0.03) or nitrites (OR = 10.8, 95% CI: 1.7–68.1; p = 0.01) in the urine and age ≥ 75 (OR = 3.5, 95% CI: 1.2-9.6, p = 0.02).Discussion
Pharmacist intervention in discontinuing or modifying antibiotics for asymptomatic patients with urine cultures reduced unnecessary antibiotic exposure and was a first step in antimicrobial stewardship efforts in the ED. Future work includes limiting urine tests and subsequent antibiotic therapy for non-pregnant asymptomatic patients. 相似文献2.
Gregory Gafni-Pappas Susanne D. DeMeester Michael A. Boyd Arun Ganti Adam M. Nicholson Jeremy Albright Juan Wu 《The American journal of emergency medicine》2018,36(10):1825-1831
Objective
The HAS-Choice pathway utilizes the HEART Score, an accelerated diagnostic protocol (ADP), and shared decision-making using a visual aid in the evaluation of chest pain patients. We seek to determine if our intervention can improve resource utilization in a community emergency department (ED) setting while maintaining safe patient care.Methods
This was a single-center prospective cohort study with historical that included ED patients ≥21 years old presenting with a primary complaint of chest pain in two time periods. The primary outcome was patient disposition. Secondary outcomes focused on 30-day ED bounce back and major adverse cardiac events (MACE). We used multivariate logistic regression to estimate the odds ratio (OR) and its 95% confidence interval (CI).Results
In the pre-implementation period, the unadjusted disposition to inpatient, observation and discharge was 6.5%, 49.1% and 44.4%, respectively, whereas in the post period, the disposition was 4.8%, 41.5% and 53.7%, respectively (chi-square p < 0.001). The adjusted odds of a patient being discharged was 40% higher (OR = 1.40; 95% CI, 1.30, 1.51; p < 0.001) in the post-implementation period. The adjusted odds of patient admission was 30% lower (OR = 0.70; 95% CI, 0.60, 0.82; p < 0.001) in the post-implementation period. The odds of 30-day ED bounce back did not statistically differ between the two periods. MACE rates were <1% in both periods, with a significant decrease in mortality in the post-implementation period.Conclusion
Our study suggests that implementation of a shared decision-making tool that integrates an ADP and the HEART score can safely decrease hospital admissions without an increase in MACE. 相似文献3.
Natalie Bresee Mary Aglipay Alexander Sasha Dubrovsky Andrée-Anne Ledoux Franco Momoli Jocelyn Gravel Stephen B. Freedman Karen Barlow Lawrence Richer Nicholas J. Barrowman Roger Zemek 《The American journal of emergency medicine》2018,36(12):2225-2231
Objective
There is a lack of definitive pediatric literature on effective pharmacotherapy for persistent post-concussion headache symptoms. This study assessed whether acute metoclopramide treatment in the Emergency Department (ED) was associated with a reduction in persistent headache in children at 1- and 4-weeks post-concussion.Methods
Children aged 8–17 years with acute concussion presenting to 9-Canadian Pediatric EDs were enrolled in a prospective cohort study, from August 2013–June 2015. Primary and secondary outcomes were persistent headache at 1- and 4-week post-injury respectively. Headache persistence was based on the one and four-week headache scores minus recalled pre-injury score using the Post-Concussion Symptom Inventory. The association between metoclopramide and headache persistence at 1- and 4-weeks were examined using unadjusted and adjusted regression and 1:4 propensity score matching model.Results
Baseline assessments were completed in 2095 participants; 65 (3.1%) received metoclopramide within 48-hours of injury. At 1- and 4-weeks, 54% (963/1808) and 26% (456/1780) of participants had persistent headache relative to baseline respectively. In unadjusted analysis, no association between metoclopramide and headache persistence at 1-week was found [treated vs. untreated: 1-week (53% vs. 53%; relative risk (RR) = 1.0 (95%CI: 0.8, 1.3); 4-weeks (27.3% vs. 25.6%; RR = 1.0 (95% CI: 0.9, 1.2)]. Metoclopramide was not associated with lower headache risk on propensity score matching [treated vs. untreated: 1-week, n = 220 (52% vs. 59.4%; RR = 0.8 (95%CI: 0.6, 1.2) and 4-weeks, n = 225 (27.1% vs. 32.8%; RR = 0.9 (95%CI: 0.8, 1.1)].Conclusion
Metoclopramide administration was not associated with a reduction in headache persistence in children seeking ED care due to a concussion. Further research is necessary to determine which pharmacotherapies may be effective for acute and persistent post-concussive headache. 相似文献4.
Corrie E. Chumpitazi Chris A. Rees Elizabeth A. Camp Erin B. Henkel Karina L. Valdez Bruno P. Chumpitazi 《The American journal of emergency medicine》2017,35(10):1490-1493
Objectives
Constipation is a common cause of abdominal pain in children presenting to the emergency department (ED). The objectives of this study were to determine the diagnostic evaluation undertaken for constipation and to assess the association of the evaluation with final ED disposition.Methods
A retrospective chart review of children presenting to the pediatric ED of a quaternary care children's hospital with abdominal pain that received a soap suds enema therapy.Results
A total of 512 children were included, 270 (52.7%) were female, and the median age was 8.0 (IQR: 4.0–11.0). One hundred and thirty eight patients (27%) had a digital rectal exam (DRE), 120 (22.8%) had bloodwork performed, 218 (43%) had urinalysis obtained, 397 (77.5%) had abdominal radiographs, 120 (23.4%) had abdominal ultrasounds, and 18 (3.5%) had computed tomography scans. Children who had a DRE had a younger median age (6.0, IQR: 3.0–9.25 vs. 8.0, IQR: 4.0–12.0; p < 0.001) and were significantly less likely to have radiologic imaging (OR = 0.50, 95% CI 0.32–0.78; p = 0.002), but did not have an increased odds of being discharged home. After adjusting for gender, ethnicity, and significant past medical history those with an abdominal radiograph were less likely to be discharged to home (aOR = 0.56, 95% CI 0.31–1.01; p = 0.05).Conclusions
The diagnostic evaluation of children diagnosed with fecal impaction in the ED varied. Abdominal imaging may be avoided if children receive a DRE. When children presenting to the ED with abdominal pain had an abdominal radiograph, they were more likely to be admitted. 相似文献5.
Christopher N. Kaufmann Adam P. Spira G. Caleb Alexander Lainie Rutkow Ramin Mojtabai 《The American journal of emergency medicine》2017,35(10):1414-1419
Objective
Sedative-hypnotic medications (e.g., Benzodiazepines [BZDs] and non-benzodiazepine receptor agonists [nBZRAs]) are associated with adverse events, especially in the elderly, that may require emergency department (ED) treatment. This study assessed outcomes from ED visits attributed to BZDs and/or nBZRAs, and variations in these associations by age group.Methods
Data came from the 2004–2011 waves of the Drug Abuse Warning Network (DAWN). Visits were categorized as involving: (1) BZDs-only, (2) nBZRAs-only, (3) combination of BZDs and nBZRAs, or (4) any other sedative-hypnotic medication. DAWN also recorded the disposition (i.e., outcome) of the visit. Analyses focused on outcomes indicating a serious disposition defined as hospitalization, patient transfer or death. Using logistic regression, the association of BZD and nBZRA use with visit disposition was assessed after applying sample weights so as to be nationally representative of ED visits in the United States involving medications or illicit substances.Results
Nineteen percent of visits involving other sedative-hypnotics, 28% involving BZDs-only, 20% involving nBZRAs-only and 48% involving a combination of BZDs and nBZRAs resulted in a serious disposition. Compared to visits involving other sedative-hypnotics, visits involving BZDs-only had 66% greater odds (Odds Ratio [OR] = 1.66, 95% Confidence Interval [CI] = 1.37–2.01), and visits involving a combination of BZDs and nBZRAs had almost four times increased odds of a serious disposition (OR = 3.91, 95% CI = 2.38–6.41). Results were similar across age groups.Conclusions
Findings highlight the need for clinical and regulatory initiatives to reduce BZD use, especially in combination with nBZRAs, and to promote treatment with safer alternatives to these medications. 相似文献6.
Zardasht Oqab Heather Ganshorn Robert Sheldon 《The American journal of emergency medicine》2018,36(4):551-555
Background
Syncope is a common clinical presentation and establishing an etiology is often challenging. Pulmonary embolism (PE) has been thought to be an uncommon cause but a recent report suggested otherwise.Objective
To establish the prevalence of PE in patients presenting with syncope to the emergency department (ED) and in hospitalized patients.Methods
We systematically searched Medline, CINAHL, EMBASE, LILACS and Web of Science with relevant keywords and MeSH headings for syncope and PE. Inclusion criteria were patients presenting with syncope to ED or hospitalized due to syncope, and etiologies including PE.Results
Of 1329 titles and abstracts, 12 (other than Prandoni et al.) met inclusion criteria. Nine studies included 6608 ED patients and 3 included 975 hospitalized patients. The mean age was 62 (95% CI 54–69) for ED patients and 67 (95% CI 64–70) for hospitalized. The pooled estimate of PE prevalence in ED syncope patients was 0.8% (95% CI 0.5–1.3%, I2 = 0%). The pooled estimate of PE prevalence in hospitalized patients was 1.0% (95% CI 0.5–1.9%, I2 = 0). In contrast, the prevalence of PE in Prandoni et al. were 3.8% and 17.3% for ED and hospitalized patients respectively, both significantly higher than in other relevant studies (p < 0.0001).Conclusion
The estimated prevalence of PE in patients presenting with syncope is low. The Prandoni et al. estimates are significantly higher, suggesting a possible site effect, accrual bias, or investigation strategy. These and the prognostic impact of higher PE prevalence require understanding before changes in practice. 相似文献7.
Katherinne Ferro Moura Franco Yuri Rafael dos Santos Franco Naiane Teixeira Bastos de Oliveira Rosimeire Simprini Padula Cristina Maria Nunes Cabral 《Revista brasileira de fisioterapia (S?o Carlos (S?o Paulo, Brazil))》2018,22(6):512-518
Background
The progression through the difficulty levels of Pilates exercises is a subjective criterion, that depends on the therapist's experience and ability to identify the best moment to progress to the next level.Objective
To identify the factors that interfere in the progression through the difficulty levels of the Pilates exercises in patients with chronic nonspecific low back pain.Methods
Data from 139 patients with chronic nonspecific low back pain from a randomized controlled trial were used for statistical analysis using binary logistic regression. The dependent variable was the progression through the difficulty levels, and the independent variables were age, gender, educational level, low back pain duration, pain intensity, general disability, kinesiophobia, previous physical activity, and number of absences.Results
The factors that interfered in the progression through the difficulty levels were previous physical inactivity (odds ratio [OR] = 5.14, 95% confidence interval [CI]: 1.53–17.31), low educational level (OR = 2.62, 95% CI: 1.12–6.10), more advanced age (OR = 0.95, 95% CI: 0.92–0.98) and more absences (OR = 0.63, 95% CI: 0.50–0.79). These variables explain 41% of the non-progression through the difficulty level of the exercises.Conclusion
Physical inactivity, low educational level, more advanced age and greater number of absences can be interfering factors in the progression through the difficulty levels of the Pilates exercises in patients with chronic nonspecific low back pain. 相似文献8.
Matthieu Marchetti Antoine Benedetti Olivier Mimoz Jean-Yves Lardeur Jérémy Guenezan Nicolas Marjanovic 《The American journal of emergency medicine》2017,35(3):444-447
Objectives
Acute heart failure (AHF) is a leading cause of admission in emergency departments (ED). It is associated with significant in-hospital mortality, suggesting that there is room for improvement of care. Our aims were to investigate clinical patterns, biological characteristics and determinants of 30-day mortality.Methods
We conducted a single site, retrospective review of adult patients (≥ 18 years) admitted to ED for AHF over a 12-month period. Data collected included demographics, clinical, biological and outcomes data. Epidemiologic data were collected at baseline, and patients were followed up during a 30-day period.Results
There were a total of 322 patients. Mean age was 83.9 ± 9.1 years, and 47% of the patients were men. Among them, 59 patients (18.3%) died within 30 days of admission to the ED. The following three characteristics were associated with increased mortality: age > 85 years (OR = 1.5[95%CI:0.8–2.7], p = 0.01), creatinine clearance < 30 mL/min (OR = 2.6[95%CI:1.4–5], p < 0.001) and Nt-proBNP > 5000 pg/mL (OR = 2.2[95%CI:1.2–4], p < 0.001). The best Nt-proBNP cut-off value to predict first-day mortality was 9000 pg/mL (area under the curve (AUC) [95%CI] of 0.790 [0.634–0.935], p < 0.001). For 7-day mortality, it was 7900 pg/mL (0.698 [0.578–0.819], p < 0.001) and for 30-day mortality, 5000 pg/mL (0.667 [0.576–0.758], p < 0.001).Conclusions
Nt-proBNP level on admission, age and creatinine clearance, are predictive of 30-day mortality in adult patients admitted to ED for AHF. 相似文献9.
Laurent Puy Chantal Lamy Sandrine Canaple Audrey Arnoux Nicolas Laine Ella Iacob Jean-Marc Constans Olivier Godefroy 《The American journal of emergency medicine》2017,35(5):716-719
Background and purpose
Following the reorganization of a University Medical Center onto a single campus, an Intensive Care Unit was created within the adult Emergency Department (ED ICU). We assessed the effects of these organizational changes on acute stroke management and the intravenous administration of recombinant tissue plasminogen activator (IV rtPA), as characterized by the thrombolysis rate, door-to-needle time (DNT) and outcome at 3 months.Methods
Between October 2013 and September 2015, we performed a retrospective, observational, single-center, comparative study of patients admitted for ischemic stroke and treated with IV rtPA during two 321-day periods (before and after the creation of the ED ICU). All patients with ischemic stroke were included. Multivariable logistic regression models were performed. The DNT was stratified according to a threshold of 60 min. A favorable long-term outcome was defined as a modified Rankin score ≤ 2 at 3 months.Results
A total of 1334 ischemic stroke patients were included. Among them, 101 patients received IV rtPA. The frequency of IV rtPA administration was 5.8% (39 out of 676) before the creation of the ED ICU, and 9.3% (62 out of 668) afterwards (odds ratio (OR) [95% confidence interval (CI)]: 1.67 [1.08–2.60]; p = 0.02). Additionally, the DNT was shorter (OR [95%CI]: 4.30 [1.17–20.90]; p = 0.04) and there was an improvement in the outcome (OR [95%CI] = 1.30 [1.01–2.10]; p = 0.045).Conclusion
Our results highlight the benefits of a separate ED ICU within conventional ED for acute stroke management, with a higher thrombolysis rate, reduced intrahospital delays and better safety. 相似文献10.
Rossana Rosa Lilian M. Abbo Kenley Raney Hansel E. Tookes Mark Supino 《The American journal of emergency medicine》2017,35(3):397-401
Objective
To calculate the emergency department (ED)-level Escherichia coli percentage of isolates susceptible to commonly used antibiotics and to determine the risk factors associated with inadequate empiric antibiotic therapy among patients treated for urinary tract infections (UTIs) in our ED.Methods
Retrospective cohort study conducted at a large tertiary teaching hospital. Participants included patients older than 18 years of age who had a urine culture with growth of > 100,000 colonies of E. coli. Demographic and therapeutic choices associated with inadequate empiric antibiotic therapy were explored. Antimicrobial susceptibility pattern of E. coli isolates recovered from ED patients were calculated, and stratified by gender and age.Results
A total of 300 unique patients had E. coli bacteriuria during the study period. Among patients who received at least one dose of antibiotic in the ED, variables independently associated with an increased risk of inadequate empiric therapy were age (relative risk [RR] 1.016; 95% confidence interval [CI] 1.001–1.031; P = 0.032), male gender (RR 2.507; 95% CI 1.470–4.486; P = 0.001), and use of fluoroquinolones (RR 2.128; 95% CI 1.249–3.624 P = 0.005). Sub-group analysis of patients discharged from the ED showed that definitive therapy with nitrofurantoin decreased the risk of inadequate empiric antibiotic therapy by 80% (RR 0.202; CI 0.065–0.638; P = 0.006). ED-level antibiograms showed differences in antimicrobial susceptibility of E. coli by age and gender.Conclusions
Development of ED-level antimicrobial susceptibility data and consideration of patients' clinical characteristics can help better guide selection of empiric antibiotic therapy for the treatment of UTIs. 相似文献11.
12.
AIM
To explore the effect of relaxation therapy applied to people with anxiety disorders.METHODS
Systematic review with meta-analysis.RESULTS
Sixteen Randomized Control Trials (RCTs) were included for meta-analysis to determine the effect of relaxation therapy. The overall effect of relaxation therapy on symptom of anxiety was significant with Hedges' g = 0.62 (95% CI: 0.42–0.81), which indicates a medium-high effect; heterogeneity was statistically significant with I2 = 48.84. Subgroup analysis exploring the possible causes of heterogeneity found that types of comparison of TAU and CBT was significant (Q = 4.20, p = 0.04). The effect of relaxation therapy on symptoms of depression, phobia, and worry was significant; Hedges' g = 0.44 (95% CI: 0.30–0.59), 0.40 (95% CI: 0.06–0.75), 0.54 (95% CI: 0.28–0.79), respectively.CONCLUSION
The results of this study provide evidence for the effectiveness of relaxation therapy for people with anxiety disorders. Therefore, relaxation therapy can be selected as a useful intervention for reducing negative emotions in people with anxiety disorders. 相似文献13.
Timothy Johnson Peter Richman John R. Allegra Barnet Eskin James Seger 《The American journal of emergency medicine》2018,36(11):1964-1966
Background
Advances in pharmacologic therapy, non-invasive positive pressure ventilation (NIPPV) and advanced directives may have decreased the intubations of dyspneic elderly (≥65 years old) patients in the emergency department (ED).Objective
To determine if the percentage of elderly ED patients intubated has decreased in recent years.Methods
Design: Retrospective multihospital cohort. Setting: Consecutive ED patients in nine NJ hospitals (1/1/1999 to 9/30/2014). Protocol: We identified patients intubated in the ED by CPT codes. Data analysis: We calculated the annual percentage of patients ≥65 intubated and the percentage intubated by diagnosis along with 95% confidence intervals (CIs).Results
Of the 5,693,380 total patients in the database there were 1,065,371 visits for patients ≥ 65. Their average age was 80 ± 8 years; 54% were female. Of these, 6297 were intubated (0.59%). From 1999 to 2014 the percent intubated decreased from 0.73% to 0.52%, a relative decrease of 29% (95% CI: 17%, 38%). The specific diagnoses with >500 intubations were congestive heart failure (CHF), pneumonia and cardiac arrest, accounting for 37% of the total. Of these three, CHF was the only diagnosis with a statistically significant change from 1999 to 2014: a relative decrease of 70% (95% CI: 53%, 81%). If all diagnoses without CHF are analyzed the overall relative decrease is 14% (95% CI: 3%, 24%).Conclusion
Intubation rates for patients ≥ 65 decreased from 1999 through 2014, particularly in CHF patients. We speculate that these findings reflect wider implementation of NIPPV, other therapeutic modalities and advanced directives. 相似文献14.
Qiang Zhang Bo Liu Lianxing Zhao Zhijiang Qi Huan Shao Le An Chunsheng Li 《The American journal of emergency medicine》2017,35(10):1555-1560
Objective
The aim of this study was to conduct a meta-analysis to evaluate the efficacy of vasopressin-epinephrine compared to epinephrine alone in patients who suffered out-of-hospital cardiac arrest (OHCA).Methods
Relevant studies up to February 2017 were identified by searching in PubMed, EMBASE, the Cochrane Library, Wanfang for randomized controlled trials(RCTs) assigning adults with cardiac arrest to treatment with vasopressin-epinephrine (VEgroup) vs adrenaline (epinephrine) alone (E group). The outcome point was return of spontaneous circulation (ROSC) for patients suffering from OHCA. Heterogeneity, subgroup analysis, sensitivity analysis and publication bias were explored.Results
Individual patient data were obtained from 5047 participants who experienced OHCA in nine studies. Odds ratios (ORs) were calculated using a random-effects model and results suggested that vasopressin-epinephrine was associated with higher rate of ROSC (OR = 1.67, 95% CI = 1.13–2.49, P < 0.00001, and total I2 = 83%). Subgroup showed that vasopressin-epinephrine has a significant association with improvements in ROSC for patients from Asia (OR = 3.30, 95% CI = 1.30–7.88); but for patients from other regions, there was no difference between vasopressin-epinephrine and epinephrine alone (OR = 1.07, 95% CI = 0.72–1.61).Conclusion
According to the pooled results of the subgroup, combination of vasopressin and adrenaline can improve ROSC of OHCA from Asia, but patients from other regions who suffered from OHCA cannot benefit from combination of vasopressin and epinephrine. 相似文献15.
Lee M. Flowers Kayse T. Maass Gabrielle J. Melin Ronna L. Campbell Paul J. Novotny Jessica J. Westphal David M. Nestler Kalyan S. Pasupathy 《The American journal of emergency medicine》2018,36(11):2029-2034
Objective
Psychiatric patient boarding in emergency department (ED) is a severe and growing problem. In July 2013, Minnesota implemented a law requiring jailed persons committed to state psychiatric facilities be transferred within 48-h of commitment. This study aims to quantify the effect of this law on a large ED's psychiatric patient flow.Methods
A pre- and post- comparison of 2011–2015 ED length of stay (LOS) for adult psychiatric patients was performed using electronic medical record data. Comparisons of the median LOS were assessed using a segmented regression model with time series error, and risk differences (RD) were used to determine changes in the proportion of patients with LOS ≥3 and ≥5 days. Changes in patient disposition proportions were assessed using risk ratios.Results
The median ED LOS for patients admitted for psychiatric care increased by 5.22 h from 2011 to 2015 (95% CI: (4.33, 7.15)), while the frequency of patient encounters remained constant. Although no significant difference in the rate of ED LOS increase was found pre- and post- implementation, the proportion of adults with LOS ≥3 days and ≥15 days increased (RD 0.017 (95% CI: (0.013, 0.021)); 0.002 (95% CI: (0.001,0.004)), respectively).Conclusions
The proportion of ED adult psychiatric patients experiencing prolonged LOS increased following the implementation of a statewide law requiring patients committed through the criminal justice system be transferred to a state psychiatric hospital within 48 h. Identifying characteristics of subsets of psychiatric patients disproportionally affected could suggest focused healthcare system improvements to improve ED psychiatric care. 相似文献16.
Yuedong Tang Jie Shen Feng Zhang Xiaoyong Zhou Zhongyan Tang Tingting You 《The American journal of emergency medicine》2018,36(1):27-32
Objective
Acute upper gastrointestinal bleeding (UGIB) is a potentially life-threatening condition that requires rapid assessment in the emergency department (ED). We aimed to compare the performance of the AIMS65, Glasgow-Blatchford (Blatchford), preendoscopic Rockall (pre-Rockall), and preendoscopic Baylor bleeding (pre-Baylor) scores in predicting 30-day mortality in patients with acute UGIB in the ED setting.Methods
Consecutive patients with acute UGIB who were admitted to the ED ward during 2012–2016 were retrospectively recruited. Data were retrieved from the admission list of the ED using international classification of disease codes via computer registration. The predictive accuracy of these four scores was compared using the area under the receiver operating characteristic curve (AUC) method.Results
Among the 395 patients included during the study period, the total 30-day mortality rate was 10.4% (41/395). The AIMS65 and Glasgow-Blatchford scores performed better with an AUC of 0.907 (95% confidence interval (CI), 0.852–0.963; P < 0.001) and 0.870 (95% confidence interval, 0.833–0.902; P < 0.001) compared with other scoring systems (preendoscopic Rockall score: AUC, 0.709; 95% CI, 0.635–0.784; P < 0.001; preendoscopic Baylor score: AUC, 0.523; 95% CI, 0.472–0.573; P > 0.05).Conclusion
In patients with acute UGIB in the ED, the AIMS65 and Glasgow–Blatchford scores are clinically more useful for predicting 30-day mortality than the preendoscopic Rockall and preendoscopic Baylor scores. The AIMS65 score might be more ideal for risk stratification in the ED setting. 相似文献17.
Michael D. April Chase Donaldson Lloyd I. Tannenbaum Tyler Moore Jose Aguirre Alexander Pingree James H. Lantry 《The American journal of emergency medicine》2017,35(10):1474-1479
Background
Our objective was to compare in-hospital mortality among emergency department (ED) patients meeting trial-based criteria for septic shock based upon whether presenting with refractory hypotension (systolic blood pressure < 90 mm Hg after 1 L intravenous fluid bolus) versus hyperlactatemia (initial lactate ≥ 4 mmol/L).Methods
We conducted a retrospective cohort analysis by chart review of ED patients admitted to an intensive care unit with suspected infection during 1 August 2012–28 February 2015. We included all patients with body fluid cultures sampled either during their ED stay without antibiotic administration or within 24 h of antibiotic administration in the ED. We excluded patients not meeting criteria for either refractory hypotension or hyperlactatemia. Trained chart abstractors blinded to the study hypothesis double entered data from each patient's record including demographics, clinical data, treatments, and in-hospital mortality. We compared in-hospital mortality among patients with isolated refractory hypotension, isolated hyperlactatemia, or both. We also calculated odds ratios (ORs) via logistic regression for in-hospital mortality based on presence of refractory hypotension or hyperlactatemia.Results
Of 202 patients included in the analysis, 38 (18.8%) died during hospitalization. Mortality was 10.9% among 101 patients with isolated refractory hypotension, 24.4% among 41 patients with isolated hyperlactatemia, and 28.3% among 60 patients with both (p = 0.01). Logistic regression analyses yielded in-hospital mortality OR for refractory hypotension of 1.3 (95% CI 0.5–3.8) versus OR for hyperlactatemia of 2.9 (95% CI 1.2–7.4).Conclusions
Hyperlactatemia appears associated with higher in-hospital mortality compared to refractory hypotension among ED patients with septic shock. 相似文献18.
Stacy A. Trent Michael A. Johnson Erica A. Morse Edward P. Havranek Jason S. Haukoos 《The American journal of emergency medicine》2018,36(8):1397-1404
Objectives
Myocardial infarction and stroke are two of the leading causes of death in the U.S. Both diseases have clinical practice guidelines (CPGs) specific to the emergency department (ED) that improve patient outcomes. Our primary objectives were to estimate differences in ED adherence across CPGs for these diseases and identify patient, provider, and environmental factors associated with adherence.Methods
Design: Retrospective study at 3 hospitals in Colorado using standard medical record review. Population: Consecutive adults (≥ 18) hospitalized for acute coronary syndrome (ACS), ST-elevation myocardial infarction (STEMI), or acute ischemic stroke (AIS), who were admitted to the hospital from the ED and for whom the ED diagnosed or initiated treatment. Outcome: ED adherence to the CPG (primary); in-hospital mortality and length-of-stay (secondary). Analysis: Multivariable logistic regression using generalized estimating equations was used.Results
Among 1053 patients, ED care was adherent in 84% with significant differences in adherence between CPGs (p < 0.001) and across institutions (p = 0.04). When patients presented with atypical chief complaints, the odds of receiving adherent care was 0.6 (95% CI 0.4–0.9). When the primary ED diagnosis was associated but not specific to the CPG, the odds of receiving adherent care was 0.5 (95% CI 0.3–0.9) and 0.3 (95% CI 0.2–0.5) for unrelated primary diagnoses.Conclusions
Adherence to ED CPGs for ACS, STEMI and AIS differs significantly between cardiovascular and cerebrovascular diseases and is more likely to occur when the diagnosis is highly suggested by the patient's complaint and acknowledged as the primary diagnosis by the treating ED physician. 相似文献19.
Taeyoung Kong Jong Eun Park Yoo Seok Park Hye Sun Lee Je Sung You Hyun Soo Chung Incheol Park Sung Phil Chung 《The American journal of emergency medicine》2017,35(12):1819-1827
Background
This is the first study to evaluate the association between the serially measured RDW values and clinical severity in patients surviving > 24 h after sustaining trauma. We evaluated the serial measurement and cut-off values of RDW to determine its significance as a prognostic marker of early mortality in patients with suspected severe trauma.Methods
This study retrospectively analyzed prospective data of eligible adult patients who were admitted to the ED with suspected severe trauma. The RDW was determined on each day of hospitalization. The primary outcome was all-cause mortality within 28-days of ED admission.Results
We included 305 patients who met our inclusion criteria. The multivariate Cox regression model demonstrated that higher RDW values on day 1 (hazard ratio [HR], 1.558; 95% confidence interval [CI], 1.09–2.227; p = 0.015) and day 2 (HR, 1.549; 95% CI, 1.046–2.294; p = 0.029) were strong independent predictors of short-term mortality among patients with suspected severe trauma. Considering the clinical course of severe trauma patients, the RDW is an important ancillary test for determining severity. Specifically, we found that RDW values > 14.4% on day 1 (HR, 4.227; 95% CI: 1.672–10.942; p < 0.001) and > 14.7% on day 2 (HR, 6.041; 95% CI: 2.361–15.458; p < 0.001) increased the hazard 28-day all-cause mortality.Conclusion
An increased RDW value is an independent predictor of 28-day mortality in patients with suspected severe trauma. The RDW, routinely obtained as part of the complete blood count without added cost or time, can be serially measured as indicator of severity after trauma. 相似文献20.
Samir Haydar Matthew Spanier Patricia Weems Samantha Wood Tania Strout 《The American journal of emergency medicine》2017,35(11):1730-1733