Canadian Headache Society criteria for the diagnosis of acute migraine headache in the ED—do our patients meet these criteria?

INTRODUCTION: We previously reported that many patients who present to the ED with "migraine" headache do not meet the International Headache Society criteria (IHSC) for the diagnosis of acute migraine. Objective The aim of the study was to compare the frequency for which ED patients with migraine headache meet the Canadian Headache Society criteria (CHSC) vs the IHSC. METHODS: This was a prospective, observational study, performed at a community ED. Consecutive patients who presented to study authors with a chief complaint of headache were enrolled. Historical/clinical data were collected on a standardized form. Ninety-five percent confidence intervals (95% CIs) were calculated and Fisher exact test was used as appropriate. RESULTS: One hundred eighty-nine patients were enrolled in this study. Mean age was 38 years. Females comprised 69% of patients. Thirty-seven percent of patients had prior ED visits for headaches. A positive family history of migraines was present in 35% of patients. Diagnostic imaging was previously performed in 44 of the enrollees to evaluate the cause of their headaches. A total of 43 (23%) patients had a prior diagnosis of migraine. Overall CHSC was met in 18% of patients, compared with 15% of patients who met IHSC. Discharge diagnosis of migraine was made in 41% of patients. Of these patients, 33% met CHSC and 28% met IHSC (P=.30). For patients with discharge diagnosis of migraine, 33% of females and 36% of males fit CHSC (P=.53), whereas 26% and 36% met IHSC (P=.34), respectively. For patients with a prior diagnosis of migraine, 32% met CHSC and 26% met IHSC (P=.24). Patients with a prior diagnosis of migraine and/or a discharge diagnosis of migraine met CHSC 31% (95% CI, 22%-40%) of the time vs 25% for the IHSC (95% CI, 16%-34%) (P=.26). Four patients without a discharge and/or previous diagnosis of migraine met CHSC; 3 met IHSC. CONCLUSIONS: In our study population, only a minority of patients with headache who have prior diagnosis and/or ED diagnosis of migraine headache met CHSC. The utility of CHSC and/or IHSC to standardize ED patients for headache research may be limited.     

Does adherence to the guideline recommendation for active treatments improve the quality of care for patients with acute low back pain delivered by physical therapists?

BACKGROUND: Numerous practice guidelines have been developed for patients with low back pain in an attempt to reduce inappropriate variations and improve the cost-effectiveness of care. Guideline implementation has received more research attention than the impact of adherence to guideline recommendations on outcomes and costs of care. OBJECTIVE: Examine the association between adherence to the guideline recommendation to use active versus passive treatments with clinical outcomes and costs for patients with acute low back pain receiving physical therapy. RESEARCH DESIGN: Retrospective review of patients with acute low back pain receiving physical therapy in 2004-2005. Adherence to the recommendation for active treatment was determined from billing records. Clinical and financial outcomes were compared between patients receiving adherent or nonadherent care. SUBJECTS: A total of 1190 patients age 18-60 years old with low back pain of less than 90 days duration in 10 clinics in 1 geographic region. MEASURES: Clinical outcomes included the numeric pain rating and Oswestry disability questionnaire taken initially and at the completion of treatment. Financial outcomes included the number of sessions and charges for physical therapy care. RESULTS: Adherence rate was 40.4%. Adherence was greater for patients receiving workers' compensation (P < 0.05). Patients receiving adherent care had fewer visits and lower charges (P < 0.05), and showed more improvement in disability [adjusted mean difference for percentage improvement 25.8%, 95% confidence interval (CI): 21.3-30.4, P < 0.001] and pain (adjusted mean difference for percentage improvement 22.4%, 95% CI: 17.5-27.3, P < 0.001). Patients receiving adherent care were more likely to have a successful physical therapy outcome (64.7% vs. 36.5%, P < 0.001). CONCLUSIONS: Adherence to the guideline recommendation for active care was associated with better clinical outcomes and reduced cost.     

Patients admitted to the emergency department with acute chest pain--is there a difference between patients in an urban and a rural area?

The aim of this study was to compare the characteristics and outcome for patients coming to the emergency department with acute chest pain in a city university hospital, representing an urban area, and a county hospital, representing a rural area. This was a retrospective survey of all chest pain patients at Sahlgrenska University Hospital, G?teborg, covering an area with 706 inhabitants/km2, and at Uddevalla County Hospital, Uddevalla, covering an area with 34 inhabitants/km2, over a period of 6 months. In all 2,297 patients were registered at Sahlgrenska University Hospital and 1062 at Uddevalla Hospital (per 100,000 inhabitants and year 1,502 and 1,342 patients, respectively). The patients in the urban area were more frequently sent home from the emergency department than in the rural area (30% versus 23%; p < 0.0001). Patients in the urban area had a lower prevalence of previous cardiovascular diseases. An obvious acute myocardial infarction (AMI) or a strong suspicion of AMI at initial evaluation was less frequent in the urban area whereas no suspicion of AMI was twice as common (46% versus 24%; p < 0.0001). Furthermore, there was a difference in the use of medications; various cardiovascular drugs were more frequently used in the rural area. Despite these differences at baseline the 30-day mortality was similar (3.5% in the urban area and 3.6% in the rural area; NS), as well as the 2-year mortality (14.0% and 12.7%, respectively; NS). It is concluded that the number of patients admitted to the emergency department with acute chest pain/100,000 was slightly higher in the urban than in the rural area. Patients in the urban area differed from those in the rural area having a lower prevalence of previous cardiovascular diseases, a lower initial suspicion of AMI, they were less frequently hospitalized and less frequently prescribed various cardiovascular drugs. Mortality did not differ between the two cohorts.     

Review of dyspnoea quantification in the emergency department: Is a rating scale for breathlessness suitable for use as an admission prediction tool?

Acute shortness of breath is a potential marker of serious cardiopulmonary disease and requires rapid assessment. In our current health-care system, increasing pressure on the ED to limit costs and waiting times has resulted in the development of many clinical decision aids and admission prediction tools designed to assist ED physicians in meeting these demands. However, most of these tools are disease specific, and none are currently available for application to patients presenting to the ED with shortness of breath. Although somewhat limited, current evidence supports the utilization of a simple dyspnoea rating scale, to assist in the streamlining of clinical severity assessments and urgency evaluations, and to potentially provide useful information to facilitate rapid and accurate site-of-care decisions in this setting.     

Is a specific oncological scoring system better at predicting the prognosis of cancer patients admitted for an acute medical complication in an intensive care unit than general gravity scores?

Objective To evaluate the effectiveness of a specific oncologic scoring system—the ICU Cancer Mortality model (ICM)—in predicting hospital mortality in comparison to two general severity scores—the Acute Physiology and Chronic Health Evaluation (APACHE II) and the Simplified Acute Physiology Score (SAPS II).Patients and methods All 247 patients admitted for a medical acute complication over an 18-month period in an oncological medical intensive care unit were prospectively registered. Their data, including type of complication, vital status at discharge and cancer characteristics as well as other variables necessary to calculate the three scoring systems were retrospectively assessed.Results Observed in-hospital mortality was 34%. The predicted in-hospital mortality rate for APACHE II was 32%; SAPS II, 24%; and ICM, 28%. The goodness of fit was inadequate except for the ICM score. Comparison of the area under the ROC curves revealed a better fit for ICM (area 0.79). The maximum correct classification rate was 72% for APACHE II, 74% for SAPS II and 77% for ICM. APACHE II and SAPS II were better at predicting outcome for survivors to hospital discharge, although ICM was better for non-survivors. Two variables were independently predicting the risk of death during hospitalisation: ICM (OR=2.31) and SAPS II (OR=1.05).Conclusions Gravity scores were the single independent predictors for hospital mortality, and ICM was equivalent to APACHE II and SAPS II.     

Pro/con clinical debate: is high-frequency oscillatory ventilation useful in the management of adult patients with respiratory failure?

In neonatal and pediatric intensive care units, high-frequency oscillatory ventilation (HFOV) has become an increasingly common therapy. This may not have been the case if researchers had not persisted in investigating the therapy after early disappointing clinical trials. Devices capable of providing this therapy to adults have become commercially available relatively recently. However, there are many questions that need to be answered regarding HFOV in adults: Is HFOV in adults superior to conventional mechanical ventilation? Who is the ideal candidate for HFOV? When should it be applied? What is the best technique with which to apply it? When should a patient on HFOV be converted back to conventional ventilation? What is the safety and efficacy of the device? As outlined in the following debate, there are several compelling arguments for and against the use of HFOV at this point in adults.     

How effective is the acute low back pain screening questionnaire for predicting 1-year follow-up in patients with low back pain?

OBJECTIVES: The aim of this study was to investigate potential associations between the Acute Low Back Pain Screening Questionnaire (ALBPSQ), a biopsychosocial screening instrument for identifying patients at risk of chronicity, and relevant variables at 1-year follow-up in a cohort of patients with low back pain. STUDY DESIGN: A 1-year prospective study was conducted in which patients who had previously received treatment in the Northern Ireland National Health Service (n = 118) were requested to complete a follow-up questionnaire package of pain and functional disability measures and a patient-centered questionnaire of seven variables considered relevant from the patient's perspective. PATIENTS: Ninety patients (76% response rate) returned the completed questionnaire package. RESULTS: The ALBPSQ total score and cutoff score of 112 were significantly positively associated with the pain and functional disability questionnaire scores at follow-up but did not significantly discriminate for difference scores on these measures. Although six of the seven patient-centered variables were significantly associated with the screening questionnaire total score, the cutoff score was strongly predictive of only one variable (work loss) and failed to demonstrate high levels of sensitivity for other variables (i.e., medication use, additional treatment, poor exercise participation). CONCLUSIONS: The findings of this study demonstrate that scores on the ALBPSQ were positively correlated with patients' levels of pain and functional disability at 1-year follow-up and correctly classified all patients reporting some degree of work loss but had minimal predictive strength for the other patient-centered variables evaluated.     

Pulmonary rehabilitation principles in SARS-COV-2 infection (COVID-19): a guideline for the acute and subacute rehabilitation

Coronavirus disease 2019 (COVID-19) is a contagious infection disease, which may cause respiratory, physical, psychological, and generalized systemic dysfunction. The severity of disease ranges from an asymptomatic infection or mild illness to mild or severe pneumonia with respiratory failure and/or death. COVID-19 dramatically affects the pulmonary system. There is a lack of knowledge about the long-term outcomes of the disease and the possible sequelae and rehabilitation. This clinical practic...     

Are emergency medical technician-basics able to use a selective immobilization of the cervical spine protocol? : A preliminary report

Objective

To be a first step in determining whether emergency medicine technician (EMT)-Basics are capable of using a protocol that allows for selective immobilization of the cervical spine. Such protocols are coming into use at an advanced life support level and could be beneficial when used by basic life support providers.

Method

A convenience sample of participants (n = 95) from 11 emergency medical services agencies and one college class participated in the study. All participants evaluated six patients in written scenarios and decided which should be placed into spinal precautions according to a selective spinal immobilization protocol. Systems without an existing selective spinal immobilization protocol received a one-hour continuing education lecture regarding the topic. College students received a similar lecture written so laypersons could understand the protocol.

Results

All participants showed proficiency when applying a selective immobilization protocol to patients in paper-based scenarios. Furthermore, EMT-Basics performed at the same level as paramedics when following the protocol. Statistical analysis revealed no significant differences between EMT-Basics and paramedics. A follow-up group of college students (added to have a non-EMS comparison group) also performed as well as paramedics when making decisions to use spinal precautions. Differences between college students and paramedics were also statistically insignificant.

Conclusions

The results suggest that EMT-Basics are as accurate as paramedics when making decisions regarding selective immobilization of the cervical spine during paper-based scenarios. That laypersons are also proficient when using the protocol could indicate that it is extremely simple to follow. This study is a first step toward the necessary additional studies evaluating the efficacy of EMT-Basics using selective immobilization as a regular practice.     

Do older internists use more hospital resources than younger internists for patients hospitalized with chest pain? A study of patients hospitalized in the coronary care and intermediate care units.

OBJECTIVES: Recent concern about escalating healthcare expenditures has prompted healthcare payers and hospitals to identify physicians whose hospital resource consumption exceeds expected norms. The goals of this study were to determine whether analyses of practice patterns in this manner may a) systematically identify older physicians as big resource "spenders," and b) provide misleading information caused by the failure to adjust utilization data for severity of illness. DESIGN: A prospective, observational study. SETTING: The coronary care and intermediate care unit in an 1,100-bed community hospital. PATIENTS: A total of 217 patients hospitalized for chest pain cared for by noncardiologists. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: On initial inspection, it appeared that the patients of older physicians had longer lengths of stay and greater charge expenditures than the patients of younger physicians. However, further evaluation demonstrated that older physicians cared for older (76 vs. 67 yrs old, p = .0001) and more severely ill patients (judged by risk of complications, risk of acute ischemic heart disease, and disease staging). Older physicians cared for more severely ill myocardial infarction patients than did younger physicians (Killip Classification 2.0 vs. 1.1, p less than .00003). After adjusting for severity of illness, there were fewer differences in hospital charges and consultant use between older and younger physicians, although the patients of older physicians remained hospitalized longer. CONCLUSIONS: There is little difference in resource utilization between patients cared for by older and younger internists after controlling for severity of illness. This investigation highlights the potential hazards of ignoring severity of illness when judging physician efficiency in the coronary care unit.     

Poster 2: When are deconditioned patients ready for acute rehabilitation?

Objectives: To assess ability of a medical acuity screening protocol to classify accurately deconditioned patients at risk for medical disruptions of acute rehabilitation. Design: Prospective comparison of 2 equivalent samples of consecutive admissions, 2 months apart, each divided into medically stable and unstable groups before admission. Setting: Acute rehabilitation unit, community hospital. Participants: 30 consecutive adult admissions to acute rehabilitation for deconditioning between September 25, 2000, and November 29, 2000; and 31 between February 1, 2001, and April 30, 2001. Interventions: Deconditioned rehabilitation candidates were screened for medical instability (protocol available), grouped as medically stable or unstable, reviewed with a physiatrist, and tracked prospectively. First sample findings were discussed with admitting physiatrists in multidisciplinary teams before the second sample. Main Outcome Measures: Planned completion of acute rehabilitation versus unplanned discharge due to acute medical setback, and length of rehabilitation stay. Results: Admission medical stability was associated with subsequent acute medical setbacks (Fisher exact test, P=.004). Medically unstable admissions had 6:1 odds of a medical disruption. Predictive success was associated with days from acute hospital to rehabilitation admission (Fisher exact test p=0.01). All predictive errors occurred with patients admitted to rehabilitation in less than 18 days from hospital admission. Medical disruptions of acute rehabilitation declined from the first (38.7%) to the second sample (16.7%). Conclusions: Data-driven team consensus about preadmission medical acuity screening preceded a decline in medical disruptions of acute rehabilitation among deconditioned patients.     

Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Bet 4: is intranasal fentanyl better than parenteral morphine for managing acute severe pain in children?

A short cut review was carried out to establish whether intranasal fentanyl is better than parenteral morphine for managing acute severe pain in children. 51 papers were found using the reported searches, of which 4 presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. It is concluded that intranasal fentanyl is an effective and safe alternative to IV or IM morphine for managing acute pain in children presenting to the Emergency Department.     

Application of cerebral oxygen saturation to prediction of the futility of resuscitation for out-of-hospital cardiopulmonary arrest patients: a single-center,prospective, observational study : Can cerebral regional oxygen saturation predict the futility of CPR?

Background

Cerebral regional oxygen saturation (rSO₂) can be measured immediately and noninvasively just after arrival at the hospital and may be useful for evaluating the futility of resuscitation for a patient with out-of-hospital cardiopulmonary arrest (OHCA). We examined the best practices involving cerebral rSO₂ as an indicator of the futility of resuscitation.

Methods

This study was a single-center, prospective, observational analysis of a cohort of consecutive adult OHCA patients who were transported to the University of Tokyo Hospital from October 1, 2012, to September 30, 2013, and whose cerebral rSO₂ values were measured.

Results

During the study period, 69 adult OHCA patients were enrolled. Of the 54 patients with initial lower cerebral rSO₂ values of 26% or less, 47 patients failed to achieve return of spontaneous circulation (ROSC) in the receiver operating characteristic curve analysis (optimal cutoff, 26%; sensitivity, 88.7%; specificity, 56.3%; positive predictive value, 87.0%; negative predictive value, 60.0%; area under the curve [AUC], 0.714; P = .0033). The AUC for the initial lower cerebral rSO₂ value was greater than that for blood pH (AUC, 0.620; P = .1687) or lactate values (AUC, 0.627; P = .1081) measured upon arrival at the hospital as well as that for initial higher (AUC, 0.650; P = .1788) or average (AUC, 0.677; P = .0235) cerebral rSO₂ values. The adjusted odds ratio of the initial lower cerebral rSO₂ values of 26% or less for ROSC was 0.11 (95% confidence interval, 0.01-0.63; P = .0129).

Conclusions

Initial lower cerebral rSO₂ just after arrival at the hospital, as a static indicator, is associated with non-ROSC. However, an initially lower cerebral rSO₂ alone does not yield a diagnosis performance sufficient for evaluating the futility of resuscitation.