ECG Predictors of Cardiac Arrhythmias in Older Adults With Syncope

STUDY OBJECTIVE

Cardiac arrhythmia is a life-threatening condition in older adults who present to the emergency department (ED) with syncope. Previous work suggests the initial ED ECG can predict arrhythmia risk; however, specific ECG predictors have been variably specified. Our objective is to identify specific ECG abnormalities predictive of 30-day serious cardiac arrhythmias in older adults presenting to the ED with syncope.

METHODS

We conducted a prospective, observational study at 11 EDs in adults aged 60 years or older who presented with syncope or near syncope. We excluded patients with a serious cardiac arrhythmia diagnosed during the ED evaluation from the primary analysis. The outcome was occurrence of 30-day serous cardiac arrhythmia. The exposure variables were predefined ECG abnormalities. Independent predictors were identified through multivariate logistic regression. The sensitivities and specificities of any predefined ECG abnormality and any ECG abnormality identified on adjusted analysis to predict 30-day serious cardiac arrhythmia were also calculated.

RESULTS

After exclusion of 197 patients (5.5%; 95% confidence interval [CI] 4.7% to 6.2%) with serious cardiac arrhythmias in the ED, the study cohort included 3,416 patients. Of these, 104 patients (3.0%; 95% CI 2.5% to 3.7%) had a serious cardiac arrhythmia within 30 days from the index ED visit (median time to diagnosis 2 days [interquartile range 1 to 5 days]). The presence of nonsinus rhythm, multiple premature ventricular conductions, short PR interval, first-degree atrioventricular block, complete left bundle branch block, and Q wave/T wave/ST-segment abnormalities consistent with acute or chronic ischemia on the initial ED ECG increased the risk for a 30-day serious cardiac arrhythmia. This combination of ECG abnormalities had a similar sensitivity in predicting 30-day serious cardiac arrhythmia compared with any ECG abnormality (76.9% [95% CI 67.6% to 84.6%] versus 77.9% [95% CI 68.7% to 85.4%]) and was more specific (55.1% [95% CI 53.4% to 56.8%] versus 46.6% [95% CI 44.9% to 48.3%]).

CONCLUSION

In older ED adults with syncope, approximately 3% receive a diagnosis of a serious cardiac arrhythmia not recognized on initial ED evaluation. The presence of specific abnormalities on the initial ED ECG increased the risk for 30-day serious cardiac arrhythmias.

Minimizing Attrition for Multisite Emergency Care Research

Loss to follow-up of enrolled patients (a.k.a. attrition) is a major threat to study validity and power. Minimizing attrition can be challenging even under ideal research conditions, including the presence of adequate funding, experienced study personnel, and a refined research infrastructure. Emergency care research is shifting toward enrollment through multisite networks, but there have been limited descriptions of approaches to minimize attrition for these multicenter emergency care studies. This concept paper describes a stepwise approach to minimize attrition, using a case example of a multisite emergency department prospective cohort of over 3,000 patients that has achieved a 30-day direct phone follow-up attrition rate of <3%. The seven areas of approach to minimize attrition in this study focused on patient selection, baseline contact data collection, patient incentives, patient tracking, central phone banks, local enrollment site assistance, and continuous performance monitoring. Appropriate study design, including consideration of these methods to reduce attrition, will be time well spent and may improve study validity.

Evaluation of the sensitivity and specificity of serum level of prostasin, CA125, LDH, AFP, and hCG+β in epithelial ovarian cancer patients

OBJECTIVES

The aim of this work was to compare and analyze the diagnostic value of serum prostasin, cancer antigen 125 (CA125), lactate dehydrogenase (LDH), alpha-fetoprotein (AFP), and human chorionic gonadotropin (hCG+β) in epithelial ovarian cancer (EOC) and evaluate if their serum levels could be used as a potential diagnostic markers of EOC from benign tumors and healthy women.

MATERIALS AND METHODS

Preoperative serum samples of 110 women (24 healthy controls, 66 ovarian benign tumors, and 20 EOC) were tested for prostasin, CA125, AFP, and hCG+β. The level of CA125, AFP, and hCG+β serum tumor markers were determined by electro-chemiluminescence immunoassay (ECLIA) and the serum level of prostasin was measured using enzyme-linked immunosorbent assay (ELISA) and LDH activity was measured by spectrophotometer and analyzed using SPSS version.

RESULTS

The Area Under the Curve (AUC) values of prostasin, CA125, LDH, AFP, and hCG+β for the discrimination of EOC from benign and healthy controls were, respectively, 0.89, 0.91, 0.77, 0.54, and 0.65, and significant increase in serum levels of prostasin, CA125, and LDH were observed for EOC compared with benign and control groups.

CONCLUSION

The present study showed that CA 125 and LDH levels of serum increased in high stages, while prostasin level was decreased in high stages. The present results indicate that prostasin, CA125, and LDH are differentially expressed in EOC than in benign and healthy control population, that may be an indicative of a better diagnostic value, with higher sen- sitivity and specificity. Here the authors used a multimarker approach, consisting of CA125, AFP, beta hCG, prostasin, and LDH that could provide a more accurate tool for a differential diagnosis of patients with EOC.

Reliability of Clinical Assessments in Older Adults With Syncope or Near Syncope

OBJECTIVES

Clinical prediction models for risk stratification of older adults with syncope or near syncope may improve resource utilization and management. Predictors considered for inclusion into such models must be reliable. Our primary objective was to evaluate the inter-rater agreement of historical, physical examination, and electrocardiogram (ECG) findings in older adults undergoing emergency department (ED) evaluation for syncope or near syncope. Our secondary objective was to assess the level of agreement between clinicians on the patient's overall risk for death or serious cardiac outcomes.

METHODS

We conducted a cross-sectional study at 11 EDs in adults 60 years of age or older who presented with unexplained syncope or near syncope. We excluded patients with a presumptive cause of syncope (e.g., seizure) or if they were unable or unwilling to follow-up. Evaluations of the patient's past medical history and current medication use were completed by treating provider and trained research associate pairs. Evaluations of the patient's physical examination and ECG interpretation were completed by attending/resident, attending/advanced practice provider, or attending/attending pairs. All evaluations were blinded to the responses from the other rater. We calculated the percent agreement and kappa statistic for binary variables. Inter-rater agreement was considered acceptable if the kappa statistic was 0.6 or higher.

RESULTS

We obtained paired observations from 255 patients; mean (±SD) age was 73 (±9) years, 137 (54%) were male, and 204 (80%) were admitted to the hospital. Acceptable agreement was achieved in 18 of the 21 (86%) past medical history and current medication findings, none of the 10 physical examination variables, and three of the 13 (23%) ECG interpretation variables. There was moderate agreement (Spearman correlation coefficient, r = 0.40) between clinicians on the patient's probability of 30-day death or serious cardiac outcome, although as the probability increased, there was less agreement.

CONCLUSIONS

Acceptable agreement between raters was more commonly achieved with historical rather than physical examination or ECG interpretation variables. Clinicians had moderate agreement in assessing the patient's overall risk for a serious outcome at 30 days. Future development of clinical prediction models in older adults with syncope should account for variability of assessments between raters and consider the use of objective clinical variables.

Screening electroencephalograms are feasible in the emergency department

We investigated the feasibility and quality of a wireless, four-channel screening electroencephalogram (EEG) device on patients presenting to the emergency department (ED) with a possible seizure disorder. A convenience sample was used of ED patients presenting with a preliminary diagnosis of syncope, potential partial-complex or generalized seizure disorder, head injury with prolonged symptoms or acute undiagnosed altered mental status. Study patients had a screening EEG in the ED, but the emergency physician and patient were blinded to the results of the EEG so that neither patient care nor disposition were affected by inclusion in the study. A total of 227 patients were enrolled, with a mean age of 56 years. EEG quality was acceptable, i.e. a screening interpretation was able to be provided, in 208 of 227 cases (92%). The EEG interpretation was normal in 65%, identified generalized or focal slowing in 24% and identified sub-clinical epileptiform activity in 12% of patients. Screening EEGs performed in the ED are feasible, can be acquired with acceptable quality, and may identify sub-clinical seizure activity in a significant number of patients.

An ED scribe program is able to improve throughput time and patient satisfaction

INTRODUCTION

At our institution, we previously described the detrimental effect of computerized physician order entry (CPOE) on throughput time and patient satisfaction (Ann of Emer Med, Vol 56, P S83-S84). To address these quality metrics, we conducted a pilot program using scribes in the emergency department (ED).

METHODS

We conducted a before-and-after study of ED throughput at our 320-bed suburban community hospital with a census of 70000 annual visits. Our primary outcome measure was the effect of scribes on ED throughput as measured by the effect on (1) door-to-room time; (2) room-to-doc time; (3) door-to-doc time; (4) doc-to-dispo time; and (5) length of stay for discharged/admitted patients, between pre-CPOE and post-CPOE cohorts. Our secondary outcome measure was patient satisfaction as provided by Press Ganey surveys. Data were analyzed using descriptive statistics, and means were compared using a standard t test.

RESULTS

Patient data from a total of 11729 patients in the before cohort were compared with data from 12609 patients in the after cohort. Despite a 7.5 % increase in volume between the post-CPOE and post-scribe cohorts, all throughput metrics improved in the post-scribe cohort. This process improved the overall door-to-doc time to 61 minutes in the after cohort from 74 minutes in the before cohort. Furthermore, patient and physician satisfaction was improved from the 58th and 62nd percentile to 75th and 92nd percentile, respectively.

Randomized clinical trial of an emergency department observation syncope protocol versus routine inpatient admission

STUDY OBJECTIVE

Older adults are frequently hospitalized from the emergency department (ED) after an episode of unexplained syncope. Current admission patterns are costly, with little evidence of benefit. We hypothesize that an ED observation syncope protocol will reduce resource use without adversely affecting patient-oriented outcomes.

METHODS

This randomized trial at 5 EDs compared an ED observation syncope protocol to inpatient admission for intermediate-risk adults (≥50 years) presenting with syncope or near syncope. Primary outcomes included inpatient admission rate and length of stay. Secondary outcomes included 30-day and 6-month serious outcomes after hospital discharge, index and 30-day hospital costs, 30-day quality-of-life scores, and 30-day patient satisfaction.

RESULTS

Study staff randomized 124 patients. Observation resulted in a lower inpatient admission rate (15% versus 92%; 95% confidence interval [CI] difference -88% to -66%) and shorter hospital length of stay (29 versus 47 hours; 95% CI difference -28 to -8). Serious outcome rates after hospital discharge were similar for observation versus admission at 30 days (3% versus 0%; 95% CI difference -1% to 8%) and 6 months (8% versus 10%; 95% CI difference -13% to 9%). Index hospital costs in the observation group were $629 (95% CI difference -$1,376 to -$56) lower than in the admission group. There were no differences in 30-day quality-of-life scores or in patient satisfaction.

CONCLUSION

An ED observation syncope protocol reduced the primary outcomes of admission rate and hospital length of stay. Analyses of secondary outcomes suggest reduction in index hospital costs, with no difference in safety events, quality of life, or patient satisfaction. Our findings suggest that an ED observation syncope protocol can be replicated and safely reduce resource use.

a-tDCS differential modulation of corticospinal excitability: the effects of electrode size

BACKGROUND

Novel noninvasive brain stimulation techniques such as transcranial direct current stimulation (tDCS) have been developed in recent years. tDCS-induced corticospinal excitability changes depend on two important factors: current density and electrodes size. Despite clinical success with existing tDCS parameters; optimal protocols are still not entirely set.

OBJECTIVE

The current study aimed to investigate the effects of anodal tDCS (a-tDCS) with three electrode sizes on corticospinal excitability.

METHODS

a-tDCS was applied with three active electrode sizes of 12, 24 and 35 cm(2) with a constant current density of 0.029 mA/cm(2) on twelve right handed healthy individuals (mean age: 34.5 ± 10.32 years) in different sessions at least 48 h apart. a-tDCS was applied continuously for 10 min, with a constant reference electrode size of 35 cm(2). The corticospinal excitability of extensor carpi radialis muscle (ECR) was measured before and immediately after the intervention and at 10, 20 and 30 min thereafter.

RESULTS

We found that smaller electrode may produce more focal current density and could lead to more effective and localized neural modulation than the larger ones. Post hoc comparisons showed that active electrode of 12 cm(2) size induces the biggest increase in the corticospinal excitability compared to bigger electrode sizes, 24 cm(2) (P = 0.002) and 35 cm(2) (P = 0.000). There was no significant difference between two larger electrode sizes (24 cm(2) and 35 cm(2)) (P = 0.177). a-tDCS resulted in significant excitability enhancement lasting for 30 min after the end of stimulation in the 12 and 24 cm(2) electrode size conditions (P < 0.005). However, in 35 cm(2) electrode size condition, the MEP amplitudes of the ECR did not differ significantly from baseline value in 20 and 30 min post stimulation (P > 0.005).

CONCLUSION

Reducing stimulation electrode size to one third of the conventional one results in spatially more focused stimulation and increases the efficacy of a-tDCS for induction of larger corticospinal excitability. This may be due to the fact that larger electrodes stimulate nearby cortical functional areas which can have inhibitory effects on primary motor cortex.

Wireless brain monitoring in the emergency department

Most hospitals in the world do not perform electroencephalograms in the emergency departments due to space, cost, training, and complexity of the equipment and the test. New miniature, low-cost, simple, digital, wireless EEG machines have been developed that solve all four of these inhibiting factors to allow EEG, to be used in emergency departments to evaluate patients presenting with altered mental status for nonconvulsive seizures. Four-channel wireless EEG used in the ED is feasible, provides good quality screening EEGs, and was able to diagnose underlying seizures or slowing in a significant number of patients.

ED identification of patients with severe sepsis/septic shock decreases mortality in a community hospital

STUDY OBJECTIVES

Our objective was to quantify the mortality difference between patients with severe sepsis/septic shock (SS/SS) identified in the emergency department (EDI) vs those not identified in the emergency department (NEDI) within our community hospital.

METHODS

We conducted a retrospective review of all patients with SS/SS from July 2007 to January 2010 who were admitted to the intensive care unit within our community hospital. Our primary outcome measure was the difference in mortality rates of patients with SS/SS between the EDI and NEDI cohorts. Our secondary outcome measures included the final disposition, the length of stay, and direct cost (DC) for both groups. The data were analyzed using a 2 × 2 contingency table and the Fisher exact test for significance to compare the mortality rates between groups. Lengths of stay and DC between both groups were reported as medians, and significance was calculated using the Mann-Whitney U test.

RESULTS

A total of 267 patients with SS/SS were identified during the 31-month study period. Of these patients, 155 were EDI patients with a mortality rate of 27.7%, and 112 were NEDI patients with a mortality rate of 41.1%. This represents an absolute difference in mortality rates of 13.4% between the 2 groups (P = .0257). The median length of stay between both groups was 7 days for the EDI group and 12.5 days for the NEDI group, translating to median DCs of $9861.01 vs $16 031.07.

CONCLUSIONS

Emergency department identification of patients with SS/SS in the community hospital significantly improves mortality.

Does anodal transcranial direct current stimulation enhance excitability of the motor cortex and motor function in healthy individuals and subjects with stroke: a systematic review and meta-analysis

The primary aim of this review is to evaluate the effects of anodal transcranial direct current stimulation (a-tDCS) on corticomotor excitability and motor function in healthy individuals and subjects with stroke. The secondary aim is to find a-tDCS optimal parameters for its maximal effects. Electronic databases were searched for studies into the effect of a-tDCS when compared to no stimulation. Studies which met the inclusion criteria were assessed and methodological quality was examined using PEDro and Downs and Black (D&B) assessment tools. Data from seven studies revealed increase in corticomotor excitability with a small but significant effect size (0.31 [0.14, 0.48], p=0.0003) in healthy subjects and data from two studies in subjects with stroke indicated significant results with moderate effect size (0.59 [0.24, 0.93], p=0.001) in favor of a-tDCS. Likewise, studies examining motor function demonstrated a small and non-significant effect (0.39 [-0.17, 0.94], p=0.17) in subjects with stroke and a large but non-significant effect (0.92 [-1.02, 2.87], p=0.35) in healthy subjects in favor of improvement in motor function. The results also indicate that efficacy of a-tDCS is dependent on current density and duration of application. A-tDCS increases corticomotor excitability in both healthy individuals and subjects with stroke. The results also show a trend in favor of motor function improvement following a-tDCS. A-tDCS is a non-invasive, cheap and easy-to-apply modality which could be used as a stand-alone technique or as an adds-on technique to enhance corticomotor excitability and the efficacy of motor training approaches. However, the small sample size of the included studies reduces the strength of the presented evidences and any conclusion in this regard should be considered cautiously.