Relapse after Emergency Department Discharge for Acute Asthma

Objectives:  The objectives were to determine patient and treatment-response factors associated with relapse after emergency department (ED) treatment for acute asthma.
Methods:  Subjects aged 18–55 years who were treated for acute asthma in 20 Canadian EDs prospectively underwent a structured ED interview and telephone contact 2 weeks later.
Results:  Of 695 enrolled patients, 604 (86.9%) were discharged from the ED; follow-up was available in 529 (87.5%); 63% were female and the median age was 29 years. Most patients were discharged on oral (70.8%) and inhaled (60.1%) corticosteroids (CS); 2-week treatment adherences were 93.3 and 80.9%, respectively. Relapse occurred in 9.2% at 1 week (95% confidence interval [CI] = 7.1% to 12.0%) and 13.9% (95% CI = 11% to 17%) at 2 weeks. In multivariable modeling, factors associated with relapse were ethnicity (risk ratio [RR] white = 0.66; 95% CI = 0.52 to 0.83); female gender (RR = 1.57; 95% CI = 1.14 to 2.09); any ED visits in the past 2 years (RR = 1.47; 95% CI = 1.18 to 1.80); ever admitted for asthma treatment (RR = 1.83; 95% CI = 1.09 to 2.84); use of combined inhaled CS plus long-acting β₂-agonists (RR = 1.39; 95% CI = 1.07 to 1.78) and of oral CS (RR = 1.35; 95% CI = 1.12 to 1.59) at the time of ED presentation.
Conclusions:  Ethnicity (white), female gender, prior ED visits and admissions for asthma, and recent treatments (especially oral CS) were associated with asthma relapse, which remains relatively common. Future research is required to target this high-risk group.     

The Association between Emergency Department Crowding and Analgesia Administration in Acute Abdominal Pain Patients

Objectives:  The authors assessed the effect of emergency department (ED) crowding on the nontreatment and delay in treatment for analgesia in patients who had acute abdominal pain.
Methods:  This was a secondary analysis of prospectively enrolled nonpregnant adult patients presenting to an urban teaching ED with abdominal pain during a 9-month period. Each patient had four validated crowding measures assigned at triage. Main outcomes were the administration of and delays in time to analgesia. A delay was defined as waiting more than 1 hour for analgesia. Relative risk (RR) regression was used to test the effects of crowding on outcomes.
Results:  A total of 976 abdominal pain patients (mean [±standard deviation] age = 41 [±16.6] years; 65% female, 62% black) were enrolled, of whom 649 (67%) received any analgesia. Of those treated, 457 (70%) experienced a delay in analgesia from triage, and 320 (49%) experienced a delay in analgesia after room placement. After adjusting for possible confounders of the ED administration of analgesia (age, sex, race, triage class, severe pain, final diagnosis of either abdominal pain not otherwise specified or gastroenteritis), increasing delays in time to analgesia from triage were independently associated with all four crowding measures, comparing the lowest to the highest quartile of crowding (total patient-care hours RR = 1.54, 95% confidence interval [CI] = 1.32 to 1.80; occupancy rate RR = 1.64, 95% CI = 1.42 to 1.91; inpatient number RR = 1.57, 95% CI = 1.36 to 1.81; and waiting room number RR = 1.53, 95% CI = 1.31 to 1.77). Crowding measures were not associated with the failure to treat with analgesia.
Conclusions:  Emergency department crowding is associated with delays in analgesic treatment from the time of triage in patients presenting with acute abdominal pain.     

Measuring the effect of Family Medicine Group enrolment on avoidable visits to emergency departments by patients with diabetes in Quebec,Canada

The Family Medicine Group (FMG) model of primary care in Quebec, Canada, was driven by the voluntary implementation of family physicians. Our main objective was to measure the effect of FMG enrolment on avoidable use of the emergency department (ED) by diabetic patients. We also sought to determine if effects differed according to whether patients were infrequent or frequent users of the ED and according to high‐ versus low‐regional levels of enrolment. We used data from provincial health administrative databases to identify the diabetic patient population over the age of 20 years for each fiscal year between 2003‐2004 and 2011‐2012. We used fixed effects and marginal structural models to estimate the effect of enrolment in FMGs on avoidable use of the ED. Our results indicated that for every 10‐percentage point increase in the population enrolled with an FMG in the year prior to an event, there was a 3% reduction in avoidable visits to the ED made by an individual (RR = 0.97; 95% CI = 0.95, 0.99). We found a significant reduction among diabetic patients who had at most 1 visit to the ED per year (RR = 0.97; 95% CI = 0.95, 0.99) and nonsignificant effects among more frequent users. Within low‐enrolment regions, a 10‐percentage point increase in enrolment in FMG practices at t ? 1 led to an 18% decrease in the number of avoidable ED visits (RR = 0.82; 95% CI = 0.78, 0.87). The effect disappeared when the analyses were restricted to the high‐enrolment regions (RR = 1.00; 95% CI = 0.92, 1.09). The design and implementation of the incentive to promote team‐based practice may not have borne much influence on early adopters who may have been overrepresented by physicians from high‐performing practices before the introduction of the reform.     

Distances to Emergency Department and to Primary Care Provider's Office Affect Emergency Department Use in Children

Objectives:  Patients of all ages use emergency departments (EDs) for primary care. Several studies have evaluated patient and system characteristics that influence pediatric ED use. However, the issue of proximity as a predictor of ED use has not been well studied. The authors sought to determine whether ED use by pediatric Medicaid enrollees was associated with the distance to their primary care providers (PCPs), distance to the nearest ED, and distance to the nearest children's hospital.
Methods:  This historical cohort study included 26,038 children age 18 and under, assigned to 332 primary care practices affiliated with a Medicaid health maintenance organization (HMO). Predictor variables were distance from the child's home to his or her PCP site, distance from home to the nearest ED, and distance from home to the nearest children's hospital. The outcome variable was each child's ED use. A negative binomial model was used to determine the association between distance variables and ED use, adjusted for age, sex, and race, plus medical and primary care site characteristics previously found to influence ED use. Distance variables were divided into quartiles to test for nonlinear associations.
Results:  On average, children made 0.31 ED visits/person/year. In the multivariable model, children living greater than 1.19 miles from the nearest ED had 11% lower ED use than those living within 0.5 miles of the nearest ED (risk ratio [RR] = 0.89, 95% CI = 0.81 to 0.99). Children living between 1.54 and 3.13 miles from their PCPs had 13% greater ED use (RR = 1.13, 95% CI = 1.03 to 1.24) than those who lived within 0.7 miles of their PCP.
Conclusions:  Geographical variables play a significant role in ED utilization in children, confirming the importance of system-level determinants of ED use and creating the opportunity for interventions to reduce geographical barriers to primary care.     

Acceptance of Rapid HIV Screening in a Southeastern Emergency Department

Objectives:  The objective was to assess the acceptance of an emergency department (ED) human immunodeficiency virus (HIV) screening program based on the Centers for Disease Control and Prevention (CDC) recommendations for routine HIV screening in health care settings.
Methods:  Rapid HIV screening was offered on an opt-out basis to patients aged 13 to 64 years presenting to the ED by trained HIV counselors. Patients were excluded if they had a history of HIV, were physically or mentally incapacitated, did not understand their right to opt-out, or did not speak English or Spanish. Statistical analyses, including logistic regression, were performed to assess the associations between the demographics of patients offered testing and their test acceptance or refusal.
Results:  From March 2008 to January 2009, a total of 5,080 (91%) of the 5,585 patients offered the HIV test accepted, and 506 (9%) refused. White and married patients were less likely to accept testing than those who were African American and unmarried (p < 0.001). Adult patients were almost twice as likely to accept testing as pediatric patients (odds ratio [OR] = 1.95; 95% confidence interval [CI] = 1.50 to 2.53). As age increased among pediatric patients, testing refusal decreased (OR = 0.71; 95% CI = 0.59 to 0.85), and as age increased among adult patients, testing refusal increased (OR = 1.17; 95% CI = 1.12 to 1.22). Two percent of persons accepting the test were considered high risk. Males were more likely to report high-risk behavior than females (OR = 1.83; 95% CI = 1.23 to 2.72).
Conclusions:  The opt-out approach results in high acceptance of routine HIV screening. Widespread adoption of the CDC's recommendations, although feasible, will require significant increases in resources.     

Multicenter Study of Limited Health Literacy in Emergency Department Patients

Objectives:  The objective was to evaluate the prevalence of limited health literacy and its association with sociodemographic variables in emergency department (ED) patients.
Methods:  This was a cross-sectional survey in three Boston EDs. The authors enrolled consecutive adult patients during two 24-hour periods at each site. They measured health literacy by the short version of the Test of Functional Health Literacy in Adults (S-TOFHLA). Using multivariate logistic regression, the authors evaluated associations between sociodemographic variables and limited health literacy, as classified by S-TOFHLA scores.
Results:  The authors enrolled 300 patients (77% of eligible). Overall, 75 (25%; 95% confidence interval [CI] = 20% to 30%) of participants had limited health literacy. Limited health literacy was independently associated with older age (compared to 18–44 years, odds ratio [OR] 4.3 [95% CI = 2.0 to 9.2] for 45–64 years and OR 3.4 [95% CI = 1.4 to 8.5] for ≥65 years), less education (compared to high school graduates, OR 2.7 [95% CI = 1.1 to 7.3] for some high school or lower and OR 0.43 [95% CI = 0.21 to 0.88] for some college or higher), and lower income (OR 2.8 [95% CI = 1.2 to 6.6] for ≤$40,000 compared to >$40,000). Although ethnicity, race, and language were associated with limited health literacy in unadjusted analyses, the associations were not significant on multivariate analysis.
Conclusions:  In this sample, one-quarter of ED patients would be expected to have difficulty understanding health materials and following prescribed treatment regimens. Advanced age and low socioeconomic status were independently associated with limited health literacy. The ability of a significant subgroup of ED patients to understand health information, especially during illness or injury, requires further study.     

Untreated Hypertension and the Emergency Department: A Chance to Intervene?

Objectives:  Untreated hypertension (HTN) is a major public health problem. Screening for untreated HTN in the emergency department (ED) may lead to appropriate treatment of more patients. The authors investigated the accuracy of identifying HTN in the ED, the proportion of ED patients with untreated HTN, patient characteristics predicting untreated HTN, and provider documentation of untreated HTN.
Methods:  The authors performed a retrospective cross-sectional study on a random sample of 2,061 adults treated at an urban academic ED. The validity of six candidate definitions of HTN in the ED was assessed in a subsample using outpatient clinic records as the reference standard. "Untreated HTN" was HTN without a HTN medication listed in the ED history. "Documentation of untreated HTN was documentation of HTN as a visit problem, specific referral for HTN, or ED discharge with a HTN" information sheet or a HTN medication. Multivariable logistic regression was used to determine associations.
Results:  The preferred definition of HTN in the ED had sensitivity of 86% (95% confidence interval [CI] = 80% to 90%), specificity of 78% (95% CI = 69% to 85%), and accuracy of 83% (95% CI = 78% to 87%). Of the 42% (95% CI = 40% to 44%) of ED patients with HTN, 43% (95% CI = 39% to 46%) had untreated HTN. Patients who were younger and male, without primary care physicians, with fewer prior ED visits, and without cardiovascular comorbidities, had higher odds of untreated HTN. Of those with untreated HTN, 8% (95% CI = 5% to 11%) had their untreated HTN documented.
Conclusions:  Untreated HTN was common in the ED but rarely documented. Providers can use ED blood pressures along with patient characteristics to identify those with untreated HTN for referral to primary care.     

Evaluation of a violence risk assessment system (the Alert System) for reducing violence in an acute hospital: a before and after study

Objectives

To investigate the effectiveness of a risk assessment system in reducing the risk of violence in an acute care hospital in the Canadian province of British Columbia.

Methods

Hospital violence incident rates (number of incidents/100,000 work hours) were calculated and compared pre, during and post implementation of the Alert System, a violence risk assessment system, at one acute care hospital. Poisson regression models were used to examine the effect of the Alert System on hospital-level violent incident rates. Multivariable, conditional logistic regression was used to examine the effect of the Alert System on the individual-level risk of violent incidence using a case-control study.

Results

The violent incident rate decreased during the Alert System implementation period only, but subsequently returned to pre-implementation levels. In the case-control analyses, the Alert flag was associated with an increased risk for a patient violent incident (odds ratio = 7.74, 95% CI = 4.81-12.47).

Conclusions

Although useful at identifying violent patients, the Alert System even though offered in conjunction with violence prevention training, does not appear to provide the resources or procedures needed by healthcare workers to prevent a patient from progressing to a violent incident once flagged. Violence in healthcare should be studied and prevented using a multifaceted approach.     

Predictors of Mortality in Patients with Delirium Tremens

Objectives:  The objectives were to identify factors that may help predict mortality for patients with delirium tremens (DT).
Methods:  The authors conducted a 1:1 gender- and age-matched case–control study of patients hospitalized for DT. Using McNemar chi-square tests and conditional logistic regression (CLR), risk factors for death, including demographics, location of diagnosis, vital sign derangements, treatment methods, and comorbid conditions, were evaluated. Crude and adjusted odds ratios (OR) and 95% confidence intervals (CI) are reported.
Results:  Thirty-five patients with DT died between January 2000 and June 2006. The majority (31; 88.6%) were male with a mean (±standard deviation [SD]) age of 51.7 (±7.6) years. Hyperthermia in the first 24 hours of DT diagnosis (OR = 10.0, 95% CI = 2.3 to 42.7), persistent tachycardia (OR = 24.0, 95% CI = 3.3 to 177.4), and use of restraints (OR = 7.50, 95% CI = 1.7 to 32.8) were associated with increased mortality by univariate analysis, while an emergency department (ED) diagnosis of DT (OR = 0.18, 95% CI = 0.05 to 0.6) and use of clonidine (OR = 0.10, 95% CI = 0.01 to 0.78) were associated with decreased mortality. In the CLR model, restraint use and hyperthermia were the only variables that remained significant (OR = 5.8, 95% CI = 1.0 to 32.2; and OR = 6.1, 95% CI = 1.2 to 30.4, respectively).
Conclusions:  The use of restraints and hyperthermia is associated with increased odds of death for patients with DT. This study highlights the need for further research into modifiable factors influencing mortality from DT.     

Derivation of a Triage Algorithm for Chest Radiography of Community-acquired Pneumonia Patients in the Emergency Department

Background:  Community-acquired pneumonia (CAP) accounts for 1.5 million emergency department (ED) patient visits in the United States each year.
Objectives:  To derive an algorithm for the ED triage setting that facilitates rapid and accurate ordering of chest radiography (CXR) for CAP.
Methods:  The authors conducted an ED-based retrospective matched case–control study using 100 radiographic confirmed CAP cases and 100 radiographic confirmed influenzalike illness (ILI) controls. Sensitivities and specificities of characteristics assessed in the triage setting were measured to discriminate CAP from ILI. The authors then used classification tree analysis to derive an algorithm that maximizes sensitivity and specificity for detecting patients with CAP in the ED triage setting.
Results:  Temperature greater than 100.4°F (likelihood ratio = 4.39, 95% confidence interval [CI] = 2.04 to 9.45), heart rate greater than 110 beats/minute (likelihood ratio = 3.59, 95% CI = 1.82 to 7.10), and pulse oximetry less than 96% (likelihood ratio = 2.36, 95% CI = 1.32 to 4.20) were the strongest predictors of CAP. However, no single characteristic was adequately sensitive and specific to accurately discriminate CAP from ILI. A three-step algorithm (using optimum cut points for elevated temperature, tachycardia, and hypoxemia on room air pulse oximetry) was derived that is 70.8% sensitive (95% CI = 60.7% to 79.7%) and 79.1% specific (95% CI = 69.3% to 86.9%).
Conclusions:  No single characteristic adequately discriminates CAP from ILI, but a derived clinical algorithm may detect most radiographic confirmed CAP patients in the triage setting. Prospective assessment of this algorithm will be needed to determine its effects on the care of ED patients with suspected pneumonia.     

The health of children with cerebral palsy and stress in their parents

Title.  The health of children with cerebral palsy and stress in their parents.
Aim.  This paper is a report of a study conducted to describe the health of children with cerebral palsy and investigate predictors of stress in their parents.
Background.  Children with severe cerebral palsy tend to have poorer health than their able-bodied peers, and their parents are more likely to be stressed and have poorer health.
Method.  A cross-sectional survey with home visits using standard questionnaires was administered to parents in 2004–05. A total of 102/199 (51%) children and parents participated. The children were compared with a normative sample.
Results.  Children with cerebral palsy had poorer physical health, and 79% of parents reported that their child had moderate to severe pain. Their poorer health, in comparison with the normal sample and measured by the Child Health Questionnaire, was related to feeding problems and seizures, general health perceptions to intellectual and feeding impairment, and family activities with severe motor, intellectual and feeding impairment. Poorer psychological well-being on the hyperactivity domain of the Strengths & Difficulties Questionnaire was related to feeding difficulties, on the prosocial domain to more severe forms of all child impairments, and on the social impairment scale to intellectual impairment. Children with psychological problems had statistically significantly increased odds (OR = 7·2, 95% CIs 2·6–20·3) of having parents with high stress.
Conclusion.  Children with cerebral palsy and associated impairments are at higher risk of poorer health and family well-being. A family-centred approach to the care of children with cerebral palsy and their families is essential to ensure both receive adequate care and support.     

Brief Screening for Adolescent Depressive Symptoms in the Emergency Department

Background:  Depression is the most common psychiatric disorder among adolescents and is more prevalent among those seeking care in the emergency department (ED). However, adolescents are rarely screened for depressive symptoms in the pediatric emergency department (PED).
Objectives:  To evaluate the sensitivity and specificity of one- and two-item screens for depressive symptoms compared to the 20-question Center for Epidemiologic Studies Depression Scale (CESD) among adolescents seeking care in a PED.
Methods:  This was a cross-sectional study of a convenience sample of adolescents 12–17 years old presenting to an urban PED with subcritical illness or injury. Participants completed three screening instruments: the two-question screen, the single-question screen, and the CESD.
Results:  A total of 321 patients were approached to enter the study, of whom 212 (66%) agreed to participate. Seventy-eight (37%) of the study participants screened positive for depression on the CESD using a cutoff score of ≥16. The two-question screen had a sensitivity of 78% (95% confidence interval [CI] = 73% to 84%) and specificity of 82% (95% CI = 77% to 87%) for depressive symptoms compared with the CESD. The single-question screen had a sensitivity of 56% (95% CI = 50% to 63%) and specificity of 93% (95% CI = 90% to 96%) compared with the CESD.
Conclusions:  The two-question screen is a sensitive and specific initial screen for depressive symptoms in adolescents being seen in the PED. This quick, simple instrument would be ideal for use in the busy PED setting and would allow clinicians to identify adolescents who require more extensive psychiatric evaluation.     

Common CX3CR1 alleles are associated with a reduced risk of headaches

Objectives.— The aim of this study was to investigate the role of the chemokine receptor CX3CR1 in headaches and migraine.
Methods.— Distribution of 2 polymorphisms of the chemokine receptor CX3CR1 (V249I and T280M) was determined in a population-based sample of 1179 elderly individuals.
Results.— Heterozygotes for both CX3CR1 polymorphisms had a reduced risk of recurrent headaches, with an odds ratio (OR) of 0.64 (95% confidence interval [CI] = 0.46-0.90) for the I249 allele and 0.55 (95% CI = 0.38-0.81) for the M280 allele. Haplotype analysis showed that carriers of the rarer CX3CR1 I249-M280 haplotype had a reduced risk of recurrent headaches, with an OR of 0.57 (95% CI = 0.41-0.80, P = .001). This association was seen for both nonmigraine headaches (OR = 0.47, 95% CI = 0.28-0.79, P = .004) and migraine (OR = 0.65, 95% CI = 0.43-0.98, P = .041).
Conclusions.— These results need to be replicated but suggest that the chemokine receptor CX3CR1 may play a role in recurrent headaches.     

Identifying abuse among women: use of clinical guidelines by nurses and midwives

Title.  Identifying abuse among women: use of clinical guidelines by nurses and midwives.
Aim.  This aim of this study to identify the incidence of violence against women seeking healthcare services and evaluate the use of clinical guidelines to identify interpersonal violence.
Methods.  A cross-sectional survey was carried out. Data were collected over a period of 7 months in 2005 and 2006. The samples consisted of 14 nurses, 10 midwives and 208 women in Iceland (101 women visiting the Emergency Department and 107 receiving prenatal care at the High Risk Prenatal Care Clinic).
Results.  Twenty women (19·6%) who visited the Emergency Department and 21 women (19·8%) who came to the High Risk Prenatal Care Clinic had been sexually abused at some point in their lives by close family members. Within the preceding 12 months, 18 women at the Emergency Department (19·1%) and eight at the High Risk Prenatal Care Clinic (7·5%) reported physical abuse, and 22 women (22·2%) at the Emergency Department and 12 (11·5%) at the High Risk Prenatal Care Clinic reported emotional abuse. A majority of the nurses and midwives indicated that the guidelines were efficient for assessing/screening for gender violence in emergency and high risk clinical settings.
Conclusion.  Screening for abuse of women at emergency and high risk clinics is crucial, not only to offer the women the immediate interventions they might need, but also to ensure the future provision of appropriate healthcare services.     

An Alternative Hemostatic Dressing: Comparison of CELOX, HemCon, and QuikClot

Objectives:  Uncontrolled hemorrhage remains a leading cause of traumatic death. Several topical adjunct agents have been shown to be effective in controlling hemorrhage, and two, chitosan wafer dressing (HemCon [HC]) and zeolite powder dressing (QuikClot [QC]), are being utilized regularly on the battlefield. However, recent literature reviews have concluded that no ideal topical agent exists. The authors compared a new chitosan granule dressing (CELOX [CX]) to HC, QC and standard dressing in a lethal hemorrhagic groin injury.
Methods:  A complex groin injury with transection of the femoral vessels and 3 minutes of uncontrolled hemorrhage was created in 48 swine. The animals were then randomized to four treatment groups (12 animals each). Group 1 included standard gauze dressing (SD); Group 2, CX; Group 3, HC; and Group 4, QC. Each agent was applied with 5 minutes of manual pressure followed by a standard field compression dressing. Hetastarch (500 mL) was infused over 30 minutes. Hemodynamic parameters were recorded over 180 minutes. Primary endpoints included rebleed and death.
Results:  CX reduced rebleeding to 0% (p < 0.001), HC to 33% (95% CI = 19.7% to 46.3%, p = 0.038), and QC to 8% (95% CI = 3.3% to 15.7%, p = 0.001), compared to 83% (95% CI = 72.4% to 93.6%) for SD. CX improved survival to 100% compared to SD at 50% (95% CI = 35.9% to 64.2%, p = 0.018). Survival for HC (67%) (95% CI = 53.7% to 80.3%) and QC (92%; 95% CI = 84.3% to 99.7%) did not differ from SD.
Conclusions:  In this porcine model of uncontrolled hemorrhage, CX improved hemorrhage control and survival. CELOX is a viable alternative for the treatment of severe hemorrhage.     

Evaluation of Risk Score Algorithms for Detection of Chlamydial and Gonococcal Infections in an Emergency Department Setting

Objectives:  To develop and evaluate screening algorithms to predict current chlamydial and gonococcal infections in emergency department (ED) settings and assess their performance.
Methods:  Between 2002 and 2005, adult patients aged 18 to 35 years attending an urban ED were screened for Chlamydia trachomatis (Ct) and Neisseria gonorrhoeae (GC) and completed a brief demographic and behavioral questionnaire. Using multiple unconditional logistic regressions, the authors developed four separate predictive models and applicable clinical risk scores to screen for infection. They developed models for females and males separately, for Ct and GC infections combined, and for Ct infection alone. The sensitivities and specificities of the clinical risk scores at different cutoffs were used to examine performance of the algorithms.
Results:  Among 5,537 patients successfully screened for Ct and GC, the overall prevalence of infection was 9.6%. Age was the strongest predictor of infection. Adjusting for other predictors, the prevalence odds ratio (POR) was 2.2 (95% confidence interval [CI] = 1.7 to 2.8) for Ct and GC combined and 2.9 (95% CI = 2.1 to 4.1) for Ct alone comparing females 25 years and younger to females older than 25 years. Among males, the association was stronger with an adjusted POR of 3.3 (95% CI = 2.3 to 4.7) for Ct and GC combined and 3.2 (95% CI = 2.1 to 4.7) for Ct infection alone.
Conclusions:  If the decision to incorporate Ct and GC screening into routine ED care is made, age alone appears to be a sufficient screening criterion.     

The Six-item Screener to Detect Cognitive Impairment in Older Emergency Department Patients

Background:  Cognitive impairment due to delirium or dementia is common in older emergency department (ED) patients. To prevent errors, emergency physicians (EPs) should use brief, sensitive tests to evaluate older patient's mental status. Prior studies have shown that the Six-Item Screener (SIS) meets these criteria.
Objectives:  The goal was to verify the performance of the SIS in a large, multicenter sample of older ED patients.
Methods:  A prospective, cross-sectional study was conducted in three urban academic medical center EDs. English-speaking ED patients ≥65 years old were enrolled. Patients who received medications that could affect cognition, were too ill, were unable to cooperate, were previously enrolled, or refused to participate were excluded. Patients were administered either the SIS or the Mini-Mental State Examination (MMSE), followed by the other test 30 minutes later. An MMSE of 23 or less was the criterion standard for cognitive impairment; the SIS cutoff was 4 or less for cognitive impairment. Standard operator characteristics of diagnostic tests were calculated with 95% confidence intervals (CIs), and a receiver operating characteristic curve was plotted.
Results:  The authors enrolled 352 subjects; 111 were cognitively impaired by MMSE (32%, 95% CI = 27% to 37%). The SIS was 63% sensitive (95% CI = 53% to 72%) and 81% specific (95% CI = 75% to 85%). The area under the receiver operating characteristic curve was 0.77 (95% CI = 0.72 to 0.83).
Conclusions:  The sensitivity of the SIS was lower than in prior studies. The reasons for this lower sensitivity are unclear. Further study is needed to clarify the ideal brief mental status test for ED use.     

Comparison of Nebulized Epinephrine to Albuterol in Bronchiolitis

Objectives:  To compare the effect of nebulized racemic epinephrine to nebulized racemic albuterol on successful discharge from the emergency department (ED).
Methods:  Children up to their 18th month of life presenting to two teaching hospital EDs with a clinical diagnosis of bronchiolitis who were ill enough to warrant treatment but did not need immediate intubation were eligible for this double-blind randomized controlled trial (RCT). Patients received either three doses of racemic albuterol or one dose of racemic epinephrine plus two saline nebulizers. Disposition was decided 2 hours after the first nebulizer. Successful discharge was defined as not requiring additional bronchodilators in the ED after study drug administration and not subsequently admitted within 72 hours. Adjusted relative risks (aRR) were estimated using the modified Poisson regression with successful discharge as the dependent variable and study drug and severity of illness as exposures. Secondary analysis was performed for patients aged less than 12 months and first presentation.
Results:  The authors analyzed 703 patients; 352 patients were given albuterol and 351 epinephrine. A total of 173 in the albuterol group and 160 in the epinephrine group were successfully discharged (crude RR = 1.08, 95% confidence interval [CI] = 0.92 to 1.26). When adjusted for severity of illness, patients who received albuterol were significantly more likely than patients receiving epinephrine to be successfully discharged (aRR = 1.18, 95% CI = 1.02 to 1.36). This was also true among those with first presentation and in those less than 12 months of age.
Conclusions:  In children up to the 18th month of life, ED treatment of bronchiolitis with nebulized racemic albuterol led to more successful discharges than nebulized epinephrine.     

Recent Caffeine Ingestion Reduces Adenosine Efficacy in the Treatment of Paroxysmal Supraventricular Tachycardia

Objectives:  Caffeine, an adenosine receptor blocker, should theoretically reduce adenosine efficacy in the treatment of paroxysmal supraventricular tachycardia (SVT). We aimed to determine the effect of recent caffeine ingestion on the likelihood of reversion of SVT with adenosine.
Methods:  This was a multicenter, case–control study of adult patients with SVT treated with adenosine between September 2007 and July 2008. The primary endpoint was reversion to sinus rhythm (SR) after a 6-mg adenosine bolus, as a function of recent (within 2, 4, 6, and 8 hours) caffeine ingestion. Caffeine ingestion data were collected using a self-administered questionnaire.
Results:  Of 68 patients enrolled, 52 (76.5%, 95% confidence interval [CI] = 64.4% to 85.6%) reverted after a 6-mg adenosine bolus. There were no significant differences in age, sex, or daily caffeine ingestion between patients who did and did not revert (p > 0.05). However, as a group, patients who did not revert had recently ingested significantly more caffeine (p < 0.05). If caffeine had been ingested less than 2 or 4 hours before the adenosine bolus, the odds of reversion to SR were significantly reduced (odds ratio [OR] = 0.18, 95% CI = 0.04 to 0.93; and OR = 0.14, 95% CI = 0.04 to 0.49, respectively). If caffeine had been ingested less than 6 or 8 hours before the adenosine, the odds of reversion were not reduced (OR = 0.31, 95% CI = 0.09 to 1.02; and OR = 0.31, 95% CI = 0.09 to 1.08, respectively).
Conclusions:  Ingestion of caffeine less than 4 hours before a 6-mg adenosine bolus significantly reduces its effectiveness in the treatment of SVT. An increased initial adenosine dose may be indicated for these patients.
ACADEMIC EMERGENCY MEDICINE 2010; 17:44–49 © 2009 by the Society for Academic Emergency Medicine