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1.
Christopher Woll P. Brian Smith James Walter Fox 《The American journal of emergency medicine》2018,36(1):33-37
Objective
To assess frequency of preoperative hematologic testing in a tertiary care pediatric emergency department (PED) and how often these values predict clinical outcome or change management decisions.Methods
Single-center retrospective cohort study in a tertiary-care children's hospital PED. Patients 0–18 years old, presenting between July 1, 2009-July 1, 2011, ultimately undergoing a surgical procedure within 48 h of presentation were included. Patients were defined as having “preoperative” hematologic assessment if these studies were performed solely because the child was going to the operative suite. Patients who met trauma team activation criteria, underwent neurosurgical procedures, or had laboratory studies performed prior to PED arrival were excluded. The primary outcome was the prevalence of preoperative laboratory assessment.Results
528 children were included, of whom 301 (57%) underwent preoperative hematologic laboratory evaluations. Of these 301 patients, 115 (38%) had abnormal hematologic parameters, and only 3 (1%) of these patients had their perioperative management changed. One additional child had intraoperative bleeding that required blood products but did not undergo preoperative hematologic assessment. All four children had medical histories that would have identified their risk for perioperative bleeding events.Conclusion
Preoperative hematologic laboratory assessment occurs frequently in children initially cared for in a tertiary care pediatric emergency department who subsequently undergo operative interventions. Although age-based abnormal hematologic values are often found, rarely are these abnormalities clinically significant. This study suggests that children cared for in a PED without a history concerning for an increased risk of perioperative bleeding does not require preoperative hematologic assessment. 相似文献2.
Evan H. Allie Henry E. Dingle William N. Johnson Jeffrey R. Birnbaum Melissa A. Hilmes Sudha P. Singh Donald H. Arnold 《The American journal of emergency medicine》2018,36(5):769-773
Background
Acute asthma exacerbations (AAE) account for many Pediatric Emergency Department (PED) visits. Chest radiography (CXR) is often performed in these patients to identify practice-changing findings such as pneumonia (PNA). Limited knowledge exists to balance the cost and radiation dose of CXR with expected yield of clinically meaningful information.Objective
To determine in children with AAE with CXR, whether patient characteristics are associated with radiographic PNA; and significant practice change by initiation of antibiotic.Design/Methods
Retrospective chart review of AAE patients with CXR performed in a PED in 2014. We examined univariate associations between patient characteristics and PNA on CXR and administration of antibiotic. Multiple logistic regression models then subsequently examined adjusted associations between patient characteristics and both outcomes.Results
Of 288 patients, 43 (15%) had PNA on CXR and 51 (17.8%) received antibiotics. There were no statistically significant univariate associations between either outcome and age, race, gender, insurance status, mode of PED arrival, fever or hypoxia (all p > 0.11). Crackles were associated with antibiotic administration (p = 0.03), but not PNA on CXR (p = 0.07). Only previous antibiotic use within 7 days had both significant univariate associations (p = 0.002) and adjusted associations with both PNA on CXR (aOR 3.6) and antibiotic administration (aOR 3.3).Conclusion
CXR infrequently adds valuable information in children with AAE. Patients treated with antibiotic within 7 days are more likely to have PNA identified on CXR and receive antibiotics. A larger study is needed to examine potential significance of hypoxia and crackles. 相似文献3.
Jennica Siddle Peter S. Pang Christopher Weaver Elizabeth Weinstein Daniel O&#x;Donnell Thomas P. Arkins Charles Miramonti 《The American journal of emergency medicine》2018,36(5):843-845
Background
Mobile Integrated Health (MIH) leverages specially trained paramedics outside of emergency response to bridge gaps in local health care delivery.Study objective
To evaluate the efficacy of a MIH led transitional care strategy to reduce acute care utilization.Methods
This was a retrospective cohort analysis of a quality improvement pilot of patients from an urban, single county EMS, MIH transitional care initiative. We utilized a paramedic/social worker (or social care coordinator) dyad to provide in home assessments, medication review, care coordination, and improve access to care. The primary outcome compared acute care utilization (ED visits, observation stays, inpatient visits) 90 days before MIH intervention to 90 days after.Results
Of the 203 patients seen by MIH teams, inpatient utilization decreased significantly from 140 hospitalizations pre-MIH to 26 post-MIH (83% reduction, p = 0.00). ED and observation stays, however, increased numerically, but neither was significant. (ED 18 to 19 stays, p = 0.98; observation stays 95 to 106, p = 0.30) Primary care visits increased 15% (p = 0.11).Conclusion
In this pilot before/after study, MIH significantly reduces acute care hospitalizations. 相似文献4.
Ralph C. Wang Robert M. Rodriguez Jahan Fahimi M. Kennedy Hall Stephen Shiboski Tom Chi Rebecca Smith-Bindman 《The American journal of emergency medicine》2017,35(4):554-563
Objective
Routine CT for patients with acute flank pain has not been shown to improve patient outcomes, and it may unnecessarily expose patients to radiation and increased costs. As preliminary steps toward the development of a guideline for selective CT, we sought to determine the prevalence of clinically important outcomes in patients with acute flank pain and derive preliminary decision rules.Methods
We analyzed data from a randomized trial of CT vs. ultrasonography for patients with acute flank pain from 15 EDs between October 2011 and February 2013. Clinically important outcomes were defined as inpatient admission for ureteral stones and alternative diagnoses. Clinically important stones were defined as stones requiring urologic intervention. We sought to derive highly sensitive decision rules for both outcomes.Results
Of 2759 participants, 236 (8.6%) had a clinically important outcome and 143 (5.2%) had a clinically important stone. A CDR including anemia (hemoglobin < 13.2 g/dl), WBC count > 11 000/μl, age > 42 years, and the absence of CVAT had a sensitivity of 97.9% (95% CI 94.8–99.2%) and specificity of 18.7% (95% 17.2–20.2%) for clinically important outcome. A CDR including hydronephrosis, prior history of stone, and WBC count < 8300/μl had a sensitivity of 98.6% (95% CI 94.5–99.7%) and specificity of 26.0% (95% 24.2–27.7%) for clinically important stone.Conclusions
We determined the prevalence of clinically important outcomes in patients with acute flank pain, and derived preliminary high sensitivity CDRs that predict them. Validation of CDRs with similar test characteristics would require prospective enrollment of 2100 patients. 相似文献5.
Amir A. Kimia Scotty Williams Peter N. Hadar Assaf Landschaft John Porter Richard G. Bachur 《The American journal of emergency medicine》2018,36(6):931-934
Background
Currant jelly stool is a late manifestation of intussusception and is rarely seen in clinical practice. Other forms of GI bleeding have not been thoroughly studied and little is known about their respective diagnostic values.Objective
To assess the predictive value of GI bleeding (positive guaiac test, bloody stool and rectal bleeding in evaluation of intussusception.Methods
We performed a retrospective cross-sectional study cohort of all children, ages 1 month-6 years of age, who had an abdominal ultrasound obtained evaluating for intussusception over 5 year period. We identified intussusception if diagnosed by ultrasound, air-contrast enema or surgery. Univariate and a multivariate logistic regression analysis were performed.Results
During the study period 1258 cases met the study criteria; median age was 1.7 years (IQR 0.8, 2.9) and 37% were females. Overall 176 children had intussusception; 153 (87%) were ileo-colic and 23 were ileo-ileal. Univariate risk ratio and adjusted Odds ratio were 1.3 (95% CI, 0.8, 2.0) and 1.3 (0.7, 2.4) for positive guaiac test, 1.1 (0.6, 2.1) and 0.9 (0.3, 3.0) for bloody stool, and 1.7 (1.02, 2.8) and 1.3 (0.5, 3.1) for rectal bleeding .Conclusion
Blood in stool, whether visible or tested by guaiac test has poor diagnostic performance in the evaluation of intussusception and is not independently predictive of intussusception. If the sole purpose of a rectal exam in these patients is for guaiac testing it should be reconsidered. 相似文献6.
Takayuki Otani Hirotaka Sawano Tomoaki Natsukawa Reiko Matsuoka Tetsufumi Nakashima Motonori Takahagi Yasuyuki Hayashi 《The American journal of emergency medicine》2018,36(6):1003-1008
Purpose
In out-of-hospital cardiac arrest (OHCA) patients resuscitated with veno-arterial extracorporeal membrane oxygenation (VA-ECMO), known as extracorporeal cardiopulmonary resuscitation (ECPR), bleeding is a common complication. The purpose of this study was to assess the risk factors for bleeding complications in ECPR patients.Methods
We retrospectively analyzed the data for OHCA patients admitted to our hospital and resuscitated with ECPR between October 2009 and December 2016. We compared patients with and without major bleeding (i.e. the Bleeding Academic Research Consortium class ≥ 3 bleeding) within 24 h of hospital admission. Patients, whose bleeding complication was not evaluated, were excluded.Results
During the study period, 133 OHCA patients were resuscitated with ECPR, of whom 102 (77%) were included. In total, 71 (70%) patients experienced major bleeding. There were significant differences in age (median 65 vs. 50 years, P < 0.001), prior antiplatelet therapy (25% vs. 3%, P = 0.008), hemoglobin (median 11.6 vs. 12.6 g/dL, P = 0.003), platelet count (median 125 vs. 155 × 103/μL, P = 0.001), and D-dimer levels on admission (median 18.8 vs. 6.7 μg/mL, P < 0.001) among patients with and those without major bleeding. Multivariate analysis showed significant associations between major bleeding and D-dimer levels (odds ratio, 1.066; 95% confidence interval, 1.018–1.116). Area under receiver-operating characteristic curve, which describes the accuracy of D-dimer levels in predicting major bleeding, was 0.76 (95% confidence interval, 0.66–0.87).Conclusion
D-dimer levels may predict major bleeding in ECPR patients, suggesting that hyperfibrinolysis may be related to bleeding. 相似文献7.
Lucas Oliveira J. e Silva M. Fernanda Bellolio Elisa M. Smith David J. Daniels Christine M. Lohse Ronna L. Campbell 《The American journal of emergency medicine》2017,35(10):1485-1489
Background
Motor vehicle–related injuries (including off-road) are the leading cause of traumatic brain injury (TBI) and acute traumatic spinal cord injury in the United States.Objectives
To describe motocross-related head and spine injuries of adult patients presenting to an academic emergency department (ED).Methods
We performed an observational cohort study of adult ED patients evaluated for motocross-related injuries from 2010 through 2015. Electronic health records were reviewed and data extracted using a standardized review process.Results
A total of 145 motocross-related ED visits (143 unique patients) were included. Overall, 95.2% of patients were men with a median age of 25 years. Sixty-seven visits (46.2%) were associated with head or spine injuries. Forty-three visits (29.7%) were associated with head injuries, and 46 (31.7%) were associated with spine injuries. Among the 43 head injuries, 36 (83.7%) were concussions. Seven visits (16.3%) were associated with at least 1 head abnormality identified by computed tomography, including skull fracture (n = 2), subdural hematoma (n = 1), subarachnoid hemorrhage (n = 4), intraparenchymal hemorrhage (n = 3), and diffuse axonal injury (n = 3). Among the 46 spine injuries, 32 (69.6%) were acute spinal fractures. Seven patients (4.9%) had clinically significant and persistent neurologic injuries. One patient (0.7%) died, and 3 patients had severe TBIs.Conclusion
Adult patients evaluated in the ED after motocross trauma had high rates of head and spine injuries with considerable morbidity and mortality. Almost half had head or spine injuries (or both), with permanent impairment for nearly 5% and death for 0.7%. 相似文献8.
Joonsung Choi Jun Hyun Baik Chi Hong Kim So Hyang Song Sung Kyung Kim Myeongjong Kim Sungeun Yun 《The American journal of emergency medicine》2018,36(7):1160-1165
Objective
The aim of this retrospective study was to observe the long-term outcomes of conservative treatment and bronchial artery embolization (BAE) in patients with mild hemoptysis and to analyze the risk factors associated with hemoptysis recurrence.Methods
Patients with mild hemoptysis from January 2005 to January 2016 were enrolled in this study. The patients' medical records, including smoking history, etiologic diseases, bronchoscopic findings, mortality, BAE information, and follow-up data of recurrent hemoptysis, were reviewed and analyzed.Results
A total of 288 patients with mild hemoptysis were included in this study. Of them, 71 patients (24.7%) underwent BAE and 217 patients (75.3%) were treated conservatively. The clinical success rate of BAE was 98.6%, with a low minor complication rate of 5.6%. Bronchoscopy before treatments was performed in 237 patients (82.3%). Fifty-five patients (19.1%) experienced recurrent hemoptysis during a median follow-up period of 2.4 years (interquartile range: 1.0–4.4 years). Patients who showed active bleeding or blood clots on bronchoscopy had a significantly lower recurrence-free survival rate than patients with no bronchoscopic evidence of bleeding or blood clots (p = 0.012). The risk factors affecting recurrence were heavy smoking (p = 0.002, hazard ratio [HR]: 3.57), aspergillosis (p = 0.035, HR: 6.01), and bronchoscopic findings of active bleeding (p = 0.016, HR: 3.29) or blood clots (p = 0.012, HR: 2.77).Conclusions
The recurrence rate of hemoptysis was not negligible in patients with mild hemoptysis. BAE can be considered in patients with a high risk of recurrence. 相似文献9.
Mauro Giordano Tiziana Ciarambino Pietro Castellino Lorenzo Malatino Alessandro Cataliotti Luca Rinaldi Giuseppe Paolisso Luigi Elio Adinolfi 《The American journal of emergency medicine》2017,35(5):749-752
Study objective
We investigated seasonal prevalence of hyponatremia in the emergency department (ED).Design
A cross-sectional study using clinical chart review.Setting
University Hospital ED, with approximately 28 000 patient visits a year.Type of participants
We reviewed 15 049 patients, subdivided in 2 groups: the adult group consisting of 9822 patients aged between 18 and 64 years old and the elderly group consisting of 5227 patients aged over 65 years presenting to the ED between January 1st, 2014 and December 31st, 2015.Intervention
Emergency patients were evaluated for the presence of hyponatremia by clinical chart review.Measurements and main results
Hyponatremia was defined as a serum sodium level < 135 mmol/l. Mean monthly prevalence of hyponatremia was of 3.74 ± 0.5% in the adult group and it was significantly increased to 10.3 ± 0.7% in the elderly group (p < 0.05 vs adults). During the summer, hyponatremia prevalence was of 4.14 ± 0.2% in adult and markedly increased to 12.52 ± 0.7% (zenith) in elderly patients (p < 0.01 vs adult group; p < 0.05 vs other seasons in elderly group). In the elderly group, we reported a significant correlation between weather temperature and hyponatremia prevalence (r: 0.491; p < 0.05).Conclusion
We observed a major influence of climate on the prevalence of hyponatremia in the elderly in the ED. Decline in renal function, salt loss, reduced salt intake and increased water ingestion could all contribute to developing hyponatremia in elderly patients during the summer. These data could be useful for emergency physicians to prevent hot weather-induced hyponatremia in the elderly. 相似文献10.
Payman Moharamzadeh Seyedhossein Ojaghihaghighi Mohsen Amjadi Farzad Rahmani Arezoo Farjamnia 《The American journal of emergency medicine》2017,35(12):1922-1925
Objective
Local forms of the tranexamic acid have been effective in treating many haemorrhagic cases. So that the aim of the current study is to assess the effectiveness of local tranexamic acid in controlling painless hematuria in patients referred to the emergency department.Methods
This is a randomized, double-blind clinical trial study, which was conducted on 50 patients with complaints of painless lower urinary tract bleeding during June 2014 and August 2015. The patients were randomly divided into two groups of 25 people each, one group receiving tranexamic acid and the other given a placebo. During bladder irrigation, local tranexamic acid and the placebo were injected into the bladder via Foley catheter. Patients were examined over 24 h in terms of the amount of normal saline serum used for irrigation, level of hemoglobin, and blood in urine.Results
In this study it was observed that consumption of tranexamic acid significantly decreased the volume of used serum for bladder irrigation (P = 0.041) and the microscopic status of urine decreased significantly in terms of the hematuria after 24 h (P = 0.026). However, the rate of packed cell transfusion and drop in hemoglobin levels showed no significant difference in both groups of patients (P ? 0.05).Conclusion
The results of this study showed that tranexamic acid could significantly reduce the volume of required serum for bladder irrigation to clear urine, but it had no significant effect on the drop in serum hemoglobin levels. 相似文献11.
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12.
Carolinna M. Garcia Sandra J. Cunningham 《The American journal of emergency medicine》2018,36(1):105-109
Objectives
In adult patients with blunt trauma, severe mechanism of injury leads to routine pan-computed tomography (CT). Due to concerns about the risk of radiation, we sought to determine whether clinical suspicion could identify children requiring radiographic imaging.Methods
A prospective study was conducted in a pediatric emergency department of a Level 1 trauma center. Patients ≤ 14 years presenting with blunt trauma due to predefined severe mechanisms were eligible. Physicians recorded their suspicions for clinically significant injury (CSI). Imaging was obtained at the physician's discretion. CSI was defined as injury requiring intervention or hospital admission ≥ 24 h. Both admitted and discharged patients were contacted ≥ 2 weeks after presentation to document undetected injuries.Results
837 patients were eligible; 753 were enrolled. 159 patients were excluded because the mechanism did not meet severity criteria. Follow-up was completed for 529/594 remaining patients. Physicians were suspicious of all injuries in 71/75 patients with CSI and had no suspicions in 382/454 without CSI. The 75 injured patients had 153 CSIs; positive suspicion of CSI was recorded for 149 injuries. The four patients who sustained unsuspected injuries had multiple other suspected injuries. Of the 594 patients, 42 received focused CT and 14 underwent pan-CT. No patient had previously undetected injuries on follow-up.Conclusion
In our study, clinical suspicion was able to identify children with CSI. If further studies support our findings, using clinical suspicion rather than mechanism alone to guide radiographic imaging may avoid unnecessary radiation exposure. 相似文献13.
F. Moustafa L. Poujol N. Vincent J. Saint-Denis N. Dublanchet N. Breuil S. Heuser A. Lebreton F. Dutheil J. Schmidt 《The American journal of emergency medicine》2018,36(7):1257-1261
Background
According to the International Society on Thrombosis and Haemostasis (ISTH), intramuscular hematoma without other severity criteria is not considered a major bleeding. Objectives: In a large cohort of reversed vitamin K antagonist (VKA) patients admitted to the emergency unit for muscular hematoma, we assess frequency, severity, and anticoagulation management based on whether ISTH criteria were met or not.Materials and methods
We performed a retrospective single-center study involving patients admitted to an emergency unit for VKA-induced intramuscular hematoma whose bleeding was reversed with prothrombin complex concentrates.Results
During the study period, 631 VKA-induced bleeding events occurred in our emergency unit, of which 73 (11.6%) were intramuscular hematomas and half met ISTH criteria. The mean age was 75.5 years (95% CI = 72.6–78.3). Admission blood tests showed that patients with ISTH criteria had higher international normalized ratio (7.0 ± 4.6 vs. 4.1 ± 3.0, p = 0.002) and lower hemoglobin (8.1 ± 1.8 vs. 11.9 ± 2.2, p < 0.001) than those without. Patients with ISTH criteria were more likely to have intramuscular hematoma in the iliopsoas, gluteal, and pectoral muscles than those without. Interestingly, two-thirds of rectus sheath hematomas involved patients without ISTH criteria. However, patients with or without ISTH criteria exhibited a similar hospitalization duration and rate of re-bleeding.Conclusion
We showed that half of the patients admitted with intramuscular hematoma could not be qualified as having ISTH-criteria major bleeding. Interestingly, these patients displayed a similar hospitalization duration and rate of re-bleeding to those with ISTH-criteria major bleeding. 相似文献14.
Chun Tat Lui Oi Fung Wong Kwok Leung Tsui Chak Wah Kam Siu Man Li Mina Cheng Ka Kit Gilberto Leung 《The American journal of emergency medicine》2018,36(8):1444-1450
Background
Currently existing predictive models for massive blood transfusion in major trauma patients had limitations for sequential evaluation of patients and lack of dynamic parameters.Objective
To establish a predictive model for predicting the need of massive blood transfusion major trauma patients, integrating dynamic parameters.Design
Multi-center retrospective cohort study.Setting
Four designated trauma centers in Hong Kong.Methods
Trauma patients aged > 12 years were recruited from the trauma registries from 2005 to 2012. MBT was defined as delivery of ≥ 10 units of packed red cells within 24 h. Split sampling method was adopted for model building and validation. Multivariate logistic regression was adopted for model building, with weight assigned based on logarithmic of adjusted odds ratios. The performance of the dynamic MBT score (DMBT) was compared with the PWH score and the Trauma Associated Severe Hemorrhage (TASH) score in the validation data set.Results
4991 patients were included in the study. The DMBT was established with 8 parameters: systolic blood pressure, heart rate, hemoglobin, hemoglobin drop within the first 2 h, INR, base deficit, unstable pelvic fracture and hemoperitoneum in radiological imaging. At cut-off score of 6 the DMBT achieved sensitivity of 78.2% and specificity of 89.2%. In the validation set, the AUCs of the DMBT, PWH score, and TASH score were 0.907, 0.844, and 0.867 respectively.Conclusions
The DMBT score allows both snapshot and sequential activation along the trauma care pathway and has better performance than the PWH score and TASH score. 相似文献15.
Peter Pruitt Joshua Penn David Peak Pierre Borczuk 《The American journal of emergency medicine》2017,35(2):255-259
Background
Patients with traumatic intracranial hemorrhage and mild traumatic brain injury (mTIH) receive broadly variable care which often includes transfer to a trauma center, neurosurgery consultation and ICU admission. However, there may be a low risk cohort of patients who can be managed without utilizing such significant resources.Objective
Describe mTIH patients who are at low risk of clinical or radiographic decompensation and can be safely managed in an ED observation unit (EDOU).Methods
Retrospective evaluation of patients age ≥ 16, GCS ≥ 13 with ICH on CT. Primary outcomes included clinical/neurologic deterioration, CT worsening or need for neurosurgery.Results
1185 consecutive patients were studied. 814 were admitted and 371 observed patients (OP) were monitored in the EDOU or discharged from the ED after a period of observation. None of the OP deteriorated clinically. 299 OP (81%) had a single lesion on CT; 72 had mixed lesions. 120 patients had isolated subarachnoid hemorrhage (iSAH) and they did uniformly well. Of the 119 OP who had subdural hematoma (SDH), 6 had worsening CT scans and 3 underwent burr hole drainage procedures as inpatients due to persistent SDH without new deficit. Of the 39 OP who had cerebral contusions, 3 had worsening CT scans and one required NSG admission. No patient returned to the ED with a complication. Follow-up was obtained on 81% of OP. 2 patients with SDH required burr hole procedure > 2 weeks after discharge.Conclusions
Patients with mTIH, particularly those with iSAH, have very low rates of clinical or radiographic deterioration and may be safe for monitoring in an emergency department observation unit. 相似文献16.
Ying-Qi Zhang Shui-Lan Zou Hua Zhao Ming-Ming Zhang Cai-Li Han 《The American journal of emergency medicine》2018,36(10):1759-1765
Background
The goal of this study was to investigate whether ceftriaxone combination therapy is associated with better clinical outcomes than respiratory fluoroquinolone monotherapy for adults with community-acquired pneumonia (CAP). We conducted a meta-analysis of published studies.Methods
Using the PubMed, EMBASE, and Cochrane Library databases, we performed a literature search of available randomized controlled trials (RCTs) published as original articles before September 2017.Results
Nine RCTs, involving 1520 patients, were included in the meta-analysis. The pooled relative risks (RRs) for the efficacy of ceftriaxone combination therapy versus respiratory fluoroquinolones monotherapy were 0.96 (95% CI: 0.92–1.01), based on clinically evaluable populations, and 0.93 (95% CI: 0.88–0.99) based on intention-to-treat (ITT) populations. No statistically significant differences were observed in microbiological treatment success (pooled RR = 0.99, 95% CI: 0.90–1.09), although drug-related adverse events were significantly lower with ceftriaxone combination therapy than with respiratory fluoroquinolones monotherapy (pooled RR = 1.27, 95% CI: 1.04–1.55).Conclusions
Current evidence showed that the efficacy of ceftriaxone combination therapy was similar to respiratory fluoroquinolone monotherapy for hospitalized CAP patients, and was associated with lower drug-related adverse events. 相似文献17.
William F. Paolo Rhonaldo Silaban Long Nguyen Susan Wojcik William Grant 《The American journal of emergency medicine》2018,36(11):1986-1992
Objective
Computerized tomography (CT) is often employed to diagnose or rule out certain suspected abdominal pathologies. The aim of this study is to compare emergency physicians' estimated post-test disease probabilities to the probabilities obtained for similar diagnostic tests as reported in the literature.Methods
Physicians were asked to estimate pre and posttest probabilities before and after CT scan results in patients with nontraumatic abdominal and pelvic pain. The actual post-test probability was calculated using published likelihood ratios and compared to physician judgment.Results
210 patient encounters were included. In the negative CT group, physicians' median pre-test probability was 40% with a post-test probability of 0%, while the actual post-test probability is 4.2% (p < 0.001). Physicians' median pre-test probability for a positive CT was 70% with a post-test probability of 100%, while the actual post-test probability is 98% (p < 0.001). The diverticulitis subgroup had no significant differences between physician and actual post-test probabilities. The post-op abscess subgroup had significant differences in post-test probabilities in both the negative CT (30% difference, p = 0.028) and positive CT subgroups (?37% difference, p = 0.003).Conclusions
When applying the probability theory of disease, physicians tend to overestimate the power of CT scanning. The difference in physician and actual post-test probabilities may be small or not clinically significant in diseases with good positive and negative likelihood ratios such as in diverticulitis; however, this difference may be large and clinically significant in diseases with poor likelihood ratios such as in post-op abscess. 相似文献18.
Alberto Conti Noemi Renzi Daniele Molesti Simone Bianchi Irene Bogazzi Giada Bongini Giuseppe Pepe Fabiana Frosini Alessio Bertini Massimo Santini 《The American journal of emergency medicine》2017,35(12):1867-1872
Background
Death of patients presenting with bleeding events to the Emergency Department still represent a major problem. We sought to analyze clinical characteristics associated with worse outcomes including short- and long-term death, beyond antithombotic treatment strategy.Methods
Patients presenting with any bleeding events during 2016–2017 years were enrolled. Clinical parameters, site of bleeding, major bleeding, ongoing anti-thrombotic treatment strategy and death were collected. Hard 5:1 propensity score matching was performed to adjust dead patients in baseline characteristics. Endpoints were one-month and one-year death.Results
Out of 166,000 visits to the Emergency Department, 3.050 patients (1.8%) were enrolled and eventually 429 were analyzed after propensity. Overall, anticoagulants or antiplatelets were given to 234(54%). Major bleeding account for 111(26%) patients, without differences between those taking anticoagulants or antiplatelets versus others. Death at one-month and one-year was 26(6%) and 72(17%), respectively. Independent predictors of one-month death were major bleeding (Odds Ratio, OR 26, p < 0.001), female gender (OR 7, p < 0.001) and white blood cells (OR 1.2, p = 0.01); of one-year were major bleeding (OR 7, p < 0.001), age (OR 1.1, p < 0.001) and female gender (OR 2.3, p = 0.043). Of note, death rate of gastrointestinal and intracranial bleeding where higher than others (p < 0.001). Overall mortality was approximately 40% on one-month; 60% in older patients and 80% in female gender with CHA2D2VASC-score ≥ 2. Receiver operator characteristics analysis showed larger areas for major bleeding and age (0.75 and 0.72, respectively) over others; p < 0.05 on C-statistic.Conclusions
In patients with bleeding events, death rate was driven by major bleeding on short-term and older age on long-term. Among dead patients mortality was approximately 40% on one-month; 60% in older patients, and 80% in female gender. 相似文献19.
Matthew J. Binks Rhys S. Holyoak Thomas M. Melhuish Ruan Vlok Elyse Bond Leigh D. White 《The American journal of emergency medicine》2017,35(10):1542-1546
Background
Hypoxemia increases the risk of intubation markedly. Such concerns are multiplied in the emergency department (ED) and during retrieval where patients may be unstable, preparation or preoxygenation time limited and the environment uncontrolled. Apneic oxygenation is a promising means of preventing hypoxemia in this setting.Aim
To test the hypothesis that apnoeic oxygenation reduces the incidence of hypoxemia during endotracheal intubation in the ED and during retrieval.Methods
We undertook a systematic review of six databases for all relevant studies published up to November 2016. Included studies evaluated apneic oxygenation during intubation in the ED and during retrieval. There were no exemptions based on study design. All studies were assessed for level of evidence and risk of bias. The Review Manager 5.3 software was used to perform meta-analysis of the pooled data.Results
Six trials and a total 1822 cases were included for analysis. The study found a significant reduction in the incidence of desaturation (RR = 0.76, p = 0.002) and critical desaturation (RR = 0.51, p = 0.01) when apneic oxygenation was implemented. There was also a significant improvement in first pass intubation success rate (RR = 1.09, p = 0.004).Conclusion
Apneic oxygenation may reduce patient hypoxemia during intubation performed in the ED and during retrieval. It also improves intubation first-pass success rate in this setting. 相似文献20.
Yuan Zhang Kai Sun Yuling Wang Yafei Qin Hui Li 《The American journal of emergency medicine》2018,36(8):1410-1417