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Capsey M, Ryan C, Mankelow J, Martin D. Utilisation and experience of emergency medical services by patients with back pain: A scoping review. Musculoskelet Sci Pract 2024; 71:102928. [PMID: 38574578 DOI: 10.1016/j.msksp.2024.102928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 01/16/2024] [Accepted: 03/07/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Back pain is recognised as a common reason for people to access emergency medical services (EMS). EMS focus on identifying and treating serious and life-threatening conditions. Back pain frequently has a non-specific cause, however back pain is also a symptom for potentially serious pathology best suited for management by EMS. OBJECTIVES This scoping review explores how and why patients with back pain access EMS, the care provided, and patients' and clinicians' perceptions of EMS. METHODS The established methodology advocated by the Joanna Briggs Institute was followed. Literature was identified via a comprehensive search of six databases as well as grey literature searching. Data was extracted to form a narrative review supported by summary tables and figures. RESULTS The review included 144 papers across the last 36 years, with half the papers published since 2018, the majority from the USA and Australia. Rates of back pain presentation range from 1 to 9% depending on the definition used, with the rate of serious pathology higher than in primary care. Patients present due to concerns about their condition, positive perceptions of the care provided by EMS and difficulty in accessing primary care. Imaging and opioids are widely used, blood markers may aid diagnosis of serious pathology, whilst physiotherapists in Emergency Departments may support management of patients without serious pathology. CONCLUSIONS Back pain is a common reason for EMS presentation. Whilst non-specific back pain is the most common diagnosis further research to support the recognition and care of serious cases would be beneficial.
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Affiliation(s)
- Matt Capsey
- Institute of Health, University of Cumbria, Bowerham Road, Lancaster, LA1 3JD, UK; School of Health and Life Sciences, Teesside University, Middlesbrough, Tees Valley, TS1 3BX , UK.
| | - Cormac Ryan
- Centre for Rehabilitation, School of Health and Life Sciences, Teesside University, Middlesbrough, Tees Valley, TS1 3BX, UK.
| | - Jagjit Mankelow
- School of Health and Life Sciences, Teesside University, Middlesbrough, Tees Valley, TS1 3BX , UK.
| | - Denis Martin
- Centre for Rehabilitation, School of Health and Life Sciences, Teesside University, Middlesbrough, Tees Valley, TS1 3BX, UK.
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Ali M, van Etten ES, Akoudad S, Schaafsma JD, Visser MC, Ali M, Cordonnier C, Sandset EC, Klijn CJM, Ruigrok YM, Wermer MJH. Haemorrhagic stroke and brain vascular malformations in women: risk factors and clinical features. Lancet Neurol 2024; 23:625-635. [PMID: 38760100 DOI: 10.1016/s1474-4422(24)00122-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/18/2024] [Accepted: 03/14/2024] [Indexed: 05/19/2024]
Abstract
Haemorrhagic stroke is a severe condition with poor prognosis. Biological sex influences the risk factors, presentations, treatment, and patient outcomes of intracerebral haemorrhage, aneurysmal subarachnoid haemorrhage, and vascular malformations. Women are usually older at onset of intracerebral haemorrhage compared with men but have an increased risk of aneurysmal subarachnoid haemorrhage as they age. Female-specific factors such as pregnancy, eclampsia or pre-eclampsia, postmenopausal status, and hormone therapy influence a woman's long-term risk of haemorrhagic stroke. The presence of intracranial aneurysms, arteriovenous malformations, or cavernous malformations poses unique clinical dilemmas during pregnancy and delivery. In the absence of evidence-based guidelines for managing the low yet uncertain risk of haemorrhagic stroke during pregnancy and delivery in women with vascular malformations, multidisciplinary teams should carefully assess the risks and benefits of delivery methods for these patients. Health-care providers should recognise and address the challenges that women might have to confront when recovering from haemorrhagic stroke.
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Affiliation(s)
- Mariam Ali
- Department of Neurology, Leiden University Medical Centre, Leiden, Netherlands.
| | - Ellis S van Etten
- Department of Neurology, Leiden University Medical Centre, Leiden, Netherlands
| | - Saloua Akoudad
- Department of Neurology, University Medical Centre Groningen, Groningen, Netherlands
| | - Joanna D Schaafsma
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Marieke C Visser
- Department of Neurology, Amsterdam University Medical Centre, Location AMC, Amsterdam, Netherlands
| | - Mahsoem Ali
- Department of Surgery, Amsterdam University Medical Centre, Location VUmc, Amsterdam, Netherlands
| | - Charlotte Cordonnier
- University Lille, Inserm, CHU Lille, UMR-S1172, Lille Neuroscience and Cognition, Lille, France
| | - Else Charlotte Sandset
- Department of Neurology, Stroke Unit, Oslo University Hospital, Oslo, Norway; The Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Catharina J M Klijn
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Ynte M Ruigrok
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Marieke J H Wermer
- Department of Neurology, University Medical Centre Groningen, Groningen, Netherlands
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Candelaresi P, Di Monaco C, Pisano E. Stroke chameleons: Diagnostic challenges. Eur J Radiol Open 2023; 11:100533. [PMID: 38028188 PMCID: PMC10652115 DOI: 10.1016/j.ejro.2023.100533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 10/20/2023] [Indexed: 12/01/2023] Open
Affiliation(s)
- P Candelaresi
- Neurology and Stroke Unit, AORN Antonio Cardarelli, Naples, Italy
| | - C Di Monaco
- Neurology and Stroke Unit, AORN Antonio Cardarelli, Naples, Italy
- Department of Neuroscience, Reproductive Science and Odontostomatology, Federico II University, Naples, Italy
| | - E Pisano
- Neurology and Stroke Unit, AORN Antonio Cardarelli, Naples, Italy
- Department of Neuroscience, Reproductive Science and Odontostomatology, Federico II University, Naples, Italy
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Herasevich S, Soleimani J, Huang C, Pinevich Y, Dong Y, Pickering BW, Murad MH, Barwise AK. Diagnostic error among vulnerable populations presenting to the emergency department with cardiovascular and cerebrovascular or neurological symptoms: a systematic review. BMJ Qual Saf 2023; 32:676-688. [PMID: 36972982 DOI: 10.1136/bmjqs-2022-015038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 03/10/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Diagnostic error (DE) is a common problem in clinical practice, particularly in the emergency department (ED) setting. Among ED patients presenting with cardiovascular or cerebrovascular/neurological symptoms, a delay in diagnosis or failure to hospitalise may be most impactful in terms of adverse outcomes. Minorities and other vulnerable populations may be at higher risk of DE. We aimed to systematically review studies reporting the frequency and causes of DE in under-resourced patients presenting to the ED with cardiovascular or cerebrovascular/neurological symptoms. METHODS We searched EBM Reviews, Embase, Medline, Scopus and Web of Science from 2000 through 14 August 2022. Data were abstracted by two independent reviewers using a standardised form. The risk of bias (ROB) was assessed using the Newcastle-Ottawa Scale, and the certainty of evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation approach. RESULTS Of the 7342 studies screened, we included 20 studies evaluating 7436,737 patients. Most studies were conducted in the USA, and one study was multicountry. 11 studies evaluated DE in patients with cerebrovascular/neurological symptoms, 8 studies with cardiovascular symptoms and 1 study examined both types of symptoms. 13 studies investigated missed diagnoses and 7 studies explored delayed diagnoses. There was significant clinical and methodological variability, including heterogeneity of DE definitions and predictor variable definitions as well as methods of DE assessment, study design and reporting.Among the studies evaluating cardiovascular symptoms, black race was significantly associated with higher odds of DE in 4/6 studies evaluating missed acute myocardial infarction (AMI)/acute coronary syndrome (ACS) diagnosis compared with white race (OR from 1.18 (1.12-1.24) to 4.5 (1.8-11.8)). The association between other analysed factors (ethnicity, insurance and limited English proficiency) and DE in this domain varied from study to study and was inconclusive.Among the studies evaluating DE in patients with cerebrovascular/neurological symptoms, no consistent association was found indicating higher or lower odds of DE. Although some studies showed significant differences, these were not consistently in the same direction.The overall ROB was low for most included studies; however, the certainty of evidence was very low, mostly due to serious inconsistency in definitions and measurement approaches across studies. CONCLUSIONS This systematic review demonstrated consistent increased odds of missed AMI/ACS diagnosis among black patients presenting to the ED compared with white patients in most studies. No consistent associations between demographic groups and DE related to cerebrovascular/neurological diagnoses were identified. More standardised approaches to study design, measurement of DE and outcomes assessment are needed to understand this problem among vulnerable populations. TRIAL REGISTRATION NUMBER The study protocol was registered in the International Prospective Register of Systematic Reviews PROSPERO 2020 CRD42020178885 and is available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020178885.
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Affiliation(s)
- Svetlana Herasevich
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jalal Soleimani
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Chanyan Huang
- Department of Anaesthesiology, Sun Yat-sen University First Affiliated Hospital, Guangzhou, Guangdong, China
| | - Yuliya Pinevich
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Yue Dong
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Brian W Pickering
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohammad H Murad
- Center for Science of Healthcare Delivery, Division of Preventive Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Amelia K Barwise
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Bioethics Research Program, Mayo Clinic, Rochester, MN, USA
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Bakradze E, Shu L, Henninger N, Prabhakaran S, Siegler JE, De Marchis GM, Giles JA, Dittrich T, Heldner MR, Antonenko K, Kam W, Liebeskind DS, Simpkins AN, Nguyen TN, Yaghi S, Liberman AL. Delayed Diagnosis in Cerebral Venous Thrombosis: Associated Factors and Clinical Outcomes. J Am Heart Assoc 2023; 12:e030421. [PMID: 37753785 PMCID: PMC10727263 DOI: 10.1161/jaha.123.030421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 08/04/2023] [Indexed: 09/28/2023]
Abstract
Background Identifying factors associated with delayed diagnosis of cerebral venous thrombosis (CVT) can inform future strategies for early detection. Methods and Results We conducted a retrospective cohort study including all participants from ACTION-CVT (Anticoagulation in the Treatment of Cerebral Venous Thrombosis) study who had dates of neurologic symptom onset and CVT diagnosis available. Delayed diagnosis was defined as CVT diagnosis occurring in the fourth (final) quartile of days from symptom onset. The primary study outcome was modified Rankin Scale score of ≤1 at 90 days; secondary outcomes included partial/complete CVT recanalization on last available imaging and modified Rankin Scale score of ≤2. Logistic regression analyses were used to identify independent variables associated with delayed diagnosis and to assess the association of delayed diagnosis and outcomes. A total of 935 patients were included in our study. Median time from symptom onset to diagnosis was 4 days (interquartile range, 1-10 days). Delayed CVT diagnosis (time to diagnosis >10 days) occurred in 212 patients (23%). Isolated headache (adjusted odds ratio [aOR], 2.36 [95% CI, 1.50-3.73]; P<0.001), older age (aOR by 1 year, 1.02 [95% CI, 1.004-1.03]; P=0.01), and papilledema (aOR, 2.00 [95% CI, 1.03-3.89]; P=0.04) were associated with diagnostic delay, whereas higher National Institutes of Health Stroke Scale score was inversely associated with diagnostic delay (aOR by 1 point, 0.95 [95% CI, 0.89-1.00]; P=0.049). Delayed diagnosis was not associated with modified Rankin Scale score of ≤1 at 90 days (aOR, 1.08 [95% CI, 0.60-1.96]; P=0.79). Conclusions In a large multicenter cohort, a quarter of included patients with CVT were diagnosed >10 days after symptom onset. Delayed CVT diagnosis was associated with the symptom of isolated headache and was not associated with adverse clinical outcomes.
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Affiliation(s)
- Ekaterina Bakradze
- Department of NeurologyUniversity of Alabama at BirminghamBirminghamALUSA
| | - Liqi Shu
- Department of NeurologyBrown UniversityProvidenceRIUSA
| | - Nils Henninger
- Department of NeurologyUniversity of Massachusetts Chan Medical SchoolWorcesterMAUSA
- Department of PsychiatryUniversity of Massachusetts Chan Medical SchoolWorcesterMAUSA
| | | | | | - Gian Marco De Marchis
- Department of NeurologyUniversity Hospital Basel and University of BaselBaselSwitzerland
| | - James A. Giles
- Department of NeurologyYale University School of MedicineNew HavenCTUSA
| | - Tolga Dittrich
- Department of NeurologyUniversity Hospital Basel and University of BaselBaselSwitzerland
| | - Mirjam R. Heldner
- Department of NeurologyUniversity Hospital and University of BernBernSwitzerland
| | - Kateryna Antonenko
- Department of NeurologyUniversity Hospital and University of BernBernSwitzerland
| | - Wayneho Kam
- Department of NeurologyDuke University HospitalDurhamNCUSA
| | - David S. Liebeskind
- Department of NeurologyUniversity of California at Los AngelesLos AngelesCAUSA
| | - Alexis N. Simpkins
- Department of NeurologyUniversity of FloridaGainesvilleFLUSA
- Department of NeurologyCedars‐Sinai Medical CenterLos AngelesCAUSA
| | - Thanh N. Nguyen
- Department of NeurologyBoston University Chobanian and Avedisian School of MedicineBostonMAUSA
| | - Shadi Yaghi
- Department of NeurologyBrown UniversityProvidenceRIUSA
| | - Ava L. Liberman
- Clinical and Translational Neuroscience Unit, Department of NeurologyFeil Family Brain and Mind Research Institute, Weill Cornell MedicineNew YorkNYUSA
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Liberman AL, Wang Z, Zhu Y, Hassoon A, Choi J, Austin JM, Johansen MC, Newman-Toker DE. Optimizing measurement of misdiagnosis-related harms using symptom-disease pair analysis of diagnostic error (SPADE): comparison groups to maximize SPADE validity. Diagnosis (Berl) 2023; 10:225-234. [PMID: 37018487 PMCID: PMC10659025 DOI: 10.1515/dx-2022-0130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 03/06/2023] [Indexed: 04/07/2023]
Abstract
Diagnostic errors in medicine represent a significant public health problem but continue to be challenging to measure accurately, reliably, and efficiently. The recently developed Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) approach measures misdiagnosis related harms using electronic health records or administrative claims data. The approach is clinically valid, methodologically sound, statistically robust, and operationally viable without the requirement for manual chart review. This paper clarifies aspects of the SPADE analysis to assure that researchers apply this method to yield valid results with a particular emphasis on defining appropriate comparator groups and analytical strategies for balancing differences between these groups. We discuss four distinct types of comparators (intra-group and inter-group for both look-back and look-forward analyses), detailing the rationale for choosing one over the other and inferences that can be drawn from these comparative analyses. Our aim is that these additional analytical practices will improve the validity of SPADE and related approaches to quantify diagnostic error in medicine.
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Affiliation(s)
- Ava L. Liberman
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine
| | - Zheyu Wang
- The Johns Hopkins University School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Division of Biostatistics and Bioinformatics
- The Johns Hopkins Bloomberg School of Public Health, Department of Biostatistics
| | - Yuxin Zhu
- The Johns Hopkins University School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Division of Biostatistics and Bioinformatics
- The Johns Hopkins University School of Medicine, Department of Neurology and the Armstrong Institute Center for Diagnostic Excellence
| | - Ahmed Hassoon
- The Johns Hopkins Bloomberg School of Public Health, Department of Biostatistics
| | - Justin Choi
- Department of Internal Medicine, Weill Cornell Medicine
| | - J. Matthew Austin
- The Johns Hopkins University School of Medicine, Department of Anesthesiology and Critical Care Medicine and the Armstrong Institute Center for Diagnostic Excellence
| | - Michelle C. Johansen
- The Johns Hopkins University School of Medicine, Department of Neurology and the Armstrong Institute Center for Diagnostic Excellence
| | - David E. Newman-Toker
- The Johns Hopkins University School of Medicine, Department of Neurology and the Armstrong Institute Center for Diagnostic Excellence
- The Johns Hopkins Bloomberg School of Public Health, Departments of Epidemiology and Health Policy & Management
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Miyagami T, Watari T, Harada T, Naito T. Medical Malpractice and Diagnostic Errors in Japanese Emergency Departments. West J Emerg Med 2023; 24:340-347. [PMID: 36976599 PMCID: PMC10047720 DOI: 10.5811/westjem.2022.11.55738] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 11/02/2022] [Indexed: 03/29/2023] Open
Abstract
INTRODUCTION Emergency departments (ED) are unpredictable and prone to diagnostic errors. In addition, non-emergency specialists often provide emergency care in Japan due to a lack of certified emergency specialists, making diagnostic errors and associated medical malpractice more likely. While several studies have investigated the medical malpractice related to diagnostic errors in EDs, only a few have focused on the conditions in Japan. This study examines diagnostic error-related medical malpractice lawsuits in Japanese EDs to understand how various factors contribute to diagnostic errors. METHODS We retrospectively examined data on medical lawsuits from 1961-2017 to identify types of diagnostic errors and initial and final diagnoses from non-trauma and trauma cases. RESULTS We evaluated 108 cases, of which 74 (68.5%) were diagnostic error cases. Twenty-eight of the diagnostic errors were trauma-related (37.8%). In 86.5% of these diagnostic error cases, the relevant errors were categorized as either missed or diagnosed incorrectly; the others were attributable to diagnostic delay. Cognitive factors (including faulty perception, cognitive biases, and failed heuristics) were associated with 91.7% of errors. Intracranial hemorrhage was the most common final diagnosis of trauma-related errors (42.9%), and the most common initial diagnoses of non-trauma-related errors were upper respiratory tract infection (21.7%), non-bleeding digestive tract disease (15.2%), and primary headache (10.9%). CONCLUSION In this study, the first to examine medical malpractice errors in Japanese EDs, we found that such claims are often developed from initial diagnoses of common diseases, such as upper respiratory tract infection, non-hemorrhagic gastrointestinal diseases, and headaches.
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Affiliation(s)
- Taiju Miyagami
- Juntendo University, Department of General Medicine, Bunkyō, Tokyo, Japan
| | - Takashi Watari
- Shimane University Hospital, General Medicine Center, Department of General Medicine, Izumo City, Shimane, Japan
- University of Michigan Medical School, Department of Medicine, Ann Arbor, Michigan, United States of America
| | - Taku Harada
- Nerima Hikarigaoka Hospital, Division of General Medicine, Tokyo, Japan
- Dokkyo Medical University Hospital, Department of Diagnostic and Generalist Medicine, Mibu, Shimotsuga, Tochigi, Japan
| | - Toshio Naito
- Juntendo University, Department of General Medicine, Bunkyō, Tokyo, Japan
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Freund O, Azolai L, Sror N, Zeeman I, Kozlovsky T, Greenberg SA, Epstein Weiss T, Bornstein G, Tchebiner JZ, Frydman S. Diagnostic delays among COVID-19 patients with a second concurrent diagnosis. J Hosp Med 2023; 18:321-328. [PMID: 36779316 DOI: 10.1002/jhm.13063] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/22/2023] [Accepted: 02/02/2023] [Indexed: 02/14/2023]
Abstract
BACKGROUND Little is known about the effect of a new pandemic on diagnostic errors. OBJECTIVE We aimed to identify delayed second diagnoses among patients presenting to the emergency department (ED) with COVID-19. DESIGNS An observational cohort Study. SETTINGS AND PARTICIPANTS Consecutive hospitalized adult patients presenting to the ED of a tertiary referral center with COVID-19 during the Delta and Omicron variant surges. Included patients had evidence of a second diagnosis during their ED stay. MAIN OUTCOME AND MEASURES The primary outcome was delayed diagnosis (without documentation or treatment in the ED). Contributing factors were assessed using two logistic regression models. RESULTS Among 1249 hospitalized COVID-19 patients, 216 (17%) had evidence of a second diagnosis in the ED. The second diagnosis of 73 patients (34%) was delayed, with a mean (SD) delay of 1.5 (0.8) days. Medical treatment was deferred in 63 patients (86%) and interventional therapy in 26 (36%). The probability of an ED diagnosis was the lowest for Infection-related diagnoses (56%) and highest for surgical-related diagnoses (89%). Evidence for the second diagnosis by physical examination (adjusted odds ratios [AOR] 2.35, 95% confidence interval [CI] 1.20-4.68) or by imaging (AOR 2.10, 95% CI 1.16-3.79) were predictors for ED diagnosis. Low oxygen saturation (AOR 0.38, 95% CI 0.18-0.79) and cough or dyspnea (AOR 0.48, 95% CI 0.25-0.94) in the ED were predictors of a delayed second diagnosis.
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Affiliation(s)
- Ophir Freund
- Internal Medicine B, Tel-Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Lee Azolai
- Internal Medicine B, Tel-Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Neta Sror
- Internal Medicine B, Tel-Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Idan Zeeman
- Internal Medicine B, Tel-Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tom Kozlovsky
- Internal Medicine B, Tel-Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sharon A Greenberg
- Emergency Department, Tel-Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Tali Epstein Weiss
- Internal Medicine B, Tel-Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gil Bornstein
- Internal Medicine B, Tel-Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Joseph Zvi Tchebiner
- Internal Medicine B, Tel-Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shir Frydman
- Internal Medicine B, Tel-Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Kartavykh RA, Yusupova AR, Gushcha AO. [Modern aspects to the diagnosis and non-surgical treatment of low back pain]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2023; 87:106-113. [PMID: 38054234 DOI: 10.17116/neiro202387061106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
Low back pain is one of the most common complaints in primary care. This pain is usually nonspecific and musculoskeletal. However, identification and exclusion of specific causes of pain as early as possible are important for specialists since their underestimation can sometimes lead to life-threatening consequences. The authors analyze literature data on the key facts of anamnesis («red flags»), management of patients with low back pain with emphasis on modern concepts and recommendations for diagnostics, identifying the dominant nature and cause of pain, differential diagnosis, and diagnostic significance of neuroimaging. Special attention is paid to existing options for conservative (drug and non-drug therapy) and interventional treatment methods, which have become increasingly popular in recent years.
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Affiliation(s)
| | | | - A O Gushcha
- Research Center of Neurology, Moscow, Russia
- Russian Medical Academy of Continuing Professional Education, Moscow, Russia
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10
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Patrick L. Headache and acute cerebrovascular disease: How do we differentiate primary and secondary headache disorders in the emergency setting? Headache 2022; 62:1073-1074. [DOI: 10.1111/head.14409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 09/21/2022] [Indexed: 11/07/2022]
Affiliation(s)
- Lauren Patrick
- Neurovascular Division University of California San Francisco San Francisco California USA
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11
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Liberman AL, Zhang C, Lipton RB, Kamel H, Parikh NS, Navi BB, Segal AZ, Razzak J, Newman-Toker DE, Merkler AE. Short-term stroke risk after emergency department treat-and-release headache visit. Headache 2022; 62:1198-1206. [PMID: 36073865 PMCID: PMC10041409 DOI: 10.1111/head.14387] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 08/02/2022] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To evaluate whether patients discharged to home after an emergency department (ED) visit for headache face a heightened short-term risk of stroke. BACKGROUND Stroke hospitalizations that occur soon after ED visits for headache complaints may reflect diagnostic error. METHODS We conducted a retrospective cohort study using statewide administrative claims data for all ED visits and admissions at nonfederal hospitals in Florida 2005-2018 and New York 2005-2016. Using standard International Classification of Diseases (ICD) codes, we identified adult patients discharged to home from the ED (treat-and-release visit) with a benign headache diagnosis (cohort of interest) as well as those with a diagnosis of renal colic or back pain (negative controls). The primary study outcome was hospitalization within 30 days for stroke (ischemic or hemorrhagic) defined using validated ICD codes. We assess the relationship between index ED visit discharge diagnosis and stroke hospitalization adjusting for patient demographics and vascular comorbidities. RESULTS We identified 1,502,831 patients with an ED treat-and-release headache visit; mean age was 41 (standard deviation: 17) years and 1,044,520 (70%) were female. A total of 2150 (0.14%) patients with headache were hospitalized for stroke within 30 days. In adjusted analysis, stroke risk was higher after headache compared to renal colic (hazard ratio [HR]: 2.69; 95% confidence interval [CI]: 2.29-3.16) or back pain (HR: 4.0; 95% CI: 3.74-4.3). In the subgroup of 26,714 (1.78%) patients with headache who received brain magnetic resonance imaging at index ED visit, stroke risk was only slightly elevated compared to renal colic (HR: 1.47; 95% CI: 1.22-1.78) or back pain (HR: 1.49; 95% CI: 1.24-1.80). CONCLUSION Approximately 1 in 700 patients discharged to home from the ED with a headache diagnosis had a stroke in the following month. Stroke risk was three to four times higher after an ED visit for headache compared to renal colic or back pain.
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Affiliation(s)
- Ava L Liberman
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Cenai Zhang
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Richard B Lipton
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Neal S Parikh
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Alan Z Segal
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Junaid Razzak
- Department of Emergency Medicine, Weill Cornell Medicine, New York, New York, USA
| | - David E Newman-Toker
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Epidemiology and Health Policy & Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Department of Otolaryngology and Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Alexander E Merkler
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
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12
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Alfaleh A, Alkattan A, Alageel A, Salah M, Almutairi M, Sagor K, Alabdulkareem K. The role of telemedicine services in changing users’ intentions for presenting to the emergency departments in Saudi Arabia. Digit Health 2022; 8:20552076221091358. [PMID: 35694122 PMCID: PMC9185009 DOI: 10.1177/20552076221091358] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 03/15/2022] [Indexed: 11/16/2022] Open
Abstract
Background Emergency department (ED) overcrowding is described as one of the main issues
in any hospital. In Saudi Arabia, the ministry of health applied new
telemedicine technology to serve patients by using the mobile application,
including the Sehha application and 937 medical call center. The main aim of
this study is to determine the role of different telemedicine services in
changing the intention users’ intentions for visiting the emergency
departments in Saudi Arabia. Methods A cross-sectional study was conducted during August 2020 to May 2021 among
319 patients using two telemedicine services in Saudi Arabia, including the
medical call center and Sehha smartphone application. The primary endpoint
of this study was to determine the number of patients intended to visit ER
before and after contacting one of the two telemedicine services and the
frequency of people who changed their opinion to visit an ED. Results This study analyzed the data from 319 patients who completed the survey
provided by the Saudi Ministry of Health concerning information related to
their health status and ED visits. Among patients that had the intention to
visit the ED (N = 159), 53 of them did not go to EDs after
using telemedicine services (p < 0.01). Regarding the
medical call center and Sehha application, 9.6% and 24.4%, respectively, of
the patients who used these telemedicine services changed their minds
concerning visiting ED after taking the medical advice
(p < 0.01). Conclusions The implemented telemedicine services in Saudi Arabia, namely the Sehha
application and medical call center, could reduce those intended to visit ED
and consequently reduce the overload of EDs by providing medical advice to
patients concerning their minor medical issues.
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Affiliation(s)
- Amjad Alfaleh
- Department of Research and Development, General Directorate of Medical Consultations, Ministry of Health, Riyadh, Saudi Arabia
- General Director Office, General Directorate of School Health, Ministry of Health, Riyadh, Saudi Arabia
| | - Abdullah Alkattan
- Department of Research and Development, General Directorate of Medical Consultations, Ministry of Health, Riyadh, Saudi Arabia
| | - Alaa Alageel
- Department of Research and Development, General Directorate of Medical Consultations, Ministry of Health, Riyadh, Saudi Arabia
| | - Mohammed Salah
- Department of Health Statistics, General Directorate of Primary Health Centers, Ministry of Health, Riyadh, Saudi Arabia
| | - Mona Almutairi
- Department of Research and Development, General Directorate of Medical Consultations, Ministry of Health, Riyadh, Saudi Arabia
| | - Khlood Sagor
- Department of Research and Development, General Directorate of Medical Consultations, Ministry of Health, Riyadh, Saudi Arabia
| | - Khaled Alabdulkareem
- Research Department, Assistant Deputy Minister for Primary Healthcare, Ministry of Health, Riyadh, Saudi Arabia
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13
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Liberman AL, Hassoon A, Fanai M, Badihian S, Rupani H, Peterson SM, Sebestyen K, Wang Z, Zhu Y, Lipton RB, Newman-Toker DE. Cerebrovascular disease hospitalizations following emergency department headache visits: A nested case-control study. Acad Emerg Med 2022; 29:41-50. [PMID: 34309135 PMCID: PMC8766867 DOI: 10.1111/acem.14353] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 07/08/2021] [Accepted: 07/13/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Delayed diagnosis of cerebrovascular disease (CVD) among patients can result in substantial harm. If diagnostic process failures can be identified at emergency department (ED) visits that precede CVD hospitalization, interventions to improve diagnostic accuracy can be developed. METHODS We conducted a nested case-control study using a cohort of adult ED patients discharged from a single medical center with a benign headache diagnosis from October 1, 2015 to March 31, 2018. Hospitalizations for CVD within 1 year of index ED visit were identified using a regional health information exchange. Patients with subsequent CVD hospitalization (cases) were individually matched to patients without subsequent hospitalization (controls) using patient age and visit date. Demographic, clinical, and ED process characteristics were assessed via detailed chart review. McNemar's test for categorical and paired t-test for continuous variables were used with statistical significance set at ≤0.05. RESULTS Of the 9157 patients with ED headache visits, 57 (0.6%, 95% confidence interval [CI] = 0.5-0.8) had a subsequent CVD hospitalization. Median time from ED visit to hospitalization was 107 days. In 25 patients (43.9%, 25/57) the CVD hospitalization and the index ED visit were at different hospitals. Fifty-three cases and 53 matched controls were included in the final study analysis. Cases and controls had similar baseline demographic and headache characteristics. Cases more often had a history of stroke (32.1% vs. 13.2%, p = 0.02) and neurosurgery (13.2% vs. 1.9%, p = 0.03) prior to the index ED visit. Cases more often had less than two components of the neurologic examination documented (30.2% vs. 11.3%, p = 0.03). CONCLUSION We found that 0.6% of patients with an ED headache visit had subsequent CVD hospitalization, often at another medical center. ED visits for headache complaints among patients with prior stroke or neurosurgical procedures may be important opportunities for CVD prevention. Documented neurologic examinations were poorer among cases, which may represent an opportunity for ED process improvement.
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Affiliation(s)
- Ava L. Liberman
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA, Department of Neurology
| | - Ahmed Hassoon
- The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA, Departments of Epidemiology,The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA, Departments of Neurology
| | - Mehdi Fanai
- The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA, Departments of Neurology
| | - Shervin Badihian
- The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA, Departments of Neurology
| | - Hetal Rupani
- The Johns Hopkins University School of Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Susan M. Peterson
- The Johns Hopkins University School of Medicine, Department of Emergency Medicine, Baltimore, Maryland, USA
| | - Krisztian Sebestyen
- The Johns Hopkins University School of Medicine, Department of Surgery, Baltimore, Maryland, USA
| | - Zheyu Wang
- The Johns Hopkins University School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Division of Biostatistics and Bioinformatics, Baltimore, Maryland, USA,The Johns Hopkins Bloomberg School of Public Health, Departments of Biostatistics, Baltimore, Maryland, USA
| | - Yuxin Zhu
- The Johns Hopkins University School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Division of Biostatistics and Bioinformatics, Baltimore, Maryland, USA,The Johns Hopkins Bloomberg School of Public Health, Departments of Biostatistics, Baltimore, Maryland, USA
| | - Richard B. Lipton
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA, Department of Neurology
| | - David E. Newman-Toker
- The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA, Departments of Epidemiology,The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA, Departments of Neurology,The Johns Hopkins University School of Medicine, Armstrong Institute Center for Diagnostic Excellence, Baltimore, Maryland, USA
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14
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Zhou AZ, Marin JR, Hickey RW, Lam SK, Ramgopal S. Serious diagnoses at revisits in children discharged from the emergency department with back pain. Acad Emerg Med 2021; 28:1299-1307. [PMID: 34245643 DOI: 10.1111/acem.14336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 06/17/2021] [Accepted: 06/26/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Back pain is often benign but can be a harbinger for serious pathology. Little is known about the outcome in children with back pain but no serious diagnoses detected at the initial visit. We sought to estimate the rate of serious diagnoses at revisits among children initially discharged from the emergency department (ED) with back pain. METHODS We performed a multicenter retrospective cohort study of patients from 45 pediatric hospitals in the Pediatric Health Information System database from October 1, 2015, to March 31, 2019. We included patients discharged from the ED with a principal diagnosis of back pain and excluded patients with trauma and concurrent or previously known serious diagnoses. We identified the rates and types of serious diagnoses made within 30 days of the index visit. We examined the rates of diagnostic tests at the index visit in patients with and without serious diagnoses. RESULTS Of the 25,130 patients with back pain, 88 (0.4%, 95% confidence interval = 0.3% to 0.4%) had serious pathology diagnosed within 30 days. The most common diagnoses were anatomic (40%) and nonneurologic (39%) categories such as vertebral fracture and nephrolithiasis; infectious (19%) and neoplastic etiologies (3%) were less common. Diagnoses requiring acute interventions such as cauda equina syndrome (n = 2) and intraspinal abscess (n = 3) were rare. Patients with serious diagnoses at revisits underwent more blood tests and back ultrasound at the index visit compared to patients without serious diagnoses. CONCLUSIONS In pediatric patients discharged from the ED with a diagnosis of back pain and no serious or trauma diagnoses, there is a low rate of serious pathology on revisits. Of the serious diagnoses identified, high-acuity diseases were rare. For the subset of patients with clinical suspicion for serious pathology but none identified at the index visit, this represents an opportunity for further research to optimize their management.
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Affiliation(s)
- Amy Z. Zhou
- Division of Emergency Medicine Ann & Robert H. Lurie Children's Hospital of ChicagoNorthwestern University Feinberg School of Medicine Chicago Illinois USA
| | - Jennifer R. Marin
- Division of Pediatric Emergency Medicine Department of Pediatrics UPMC Children’s Hospital of PittsburghUniversity of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
- Department of Emergency Medicine University of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
| | - Robert W. Hickey
- Division of Pediatric Emergency Medicine Department of Pediatrics UPMC Children’s Hospital of PittsburghUniversity of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
| | - Sandi K. Lam
- Department of Neurosurgery Ann & Robert H. Lurie Children's Hospital of ChicagoNorthwestern University Feinberg School of Medicine Chicago Illinois USA
| | - Sriram Ramgopal
- Division of Emergency Medicine Ann & Robert H. Lurie Children's Hospital of ChicagoNorthwestern University Feinberg School of Medicine Chicago Illinois USA
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15
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Shroyer SR, Davis WT, April MD, Long B, Boys G, Mehta SG, Mercaldo SF. A Clinical Prediction Tool for MRI in Emergency Department Patients with Spinal Infection. West J Emerg Med 2021; 22:1156-1166. [PMID: 34546893 PMCID: PMC8463051 DOI: 10.5811/westjem.2021.5.52007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/15/2021] [Indexed: 11/11/2022] Open
Abstract
Introduction Patients with pyogenic spinal Infection (PSI) are often not diagnosed at their initial presentation, and diagnostic delay is associated with increased morbidity and medical-legal risk. We derived a decision tool to estimate the risk of spinal infection and inform magnetic resonance imaging (MRI) decisions. Methods We conducted a two-part prospective observational cohort study that collected variables from spine pain patients over a six-year derivation phase. We fit a multivariable regression model with logistic coefficients rounded to the nearest integer and used them for variable weighting in the final risk score. This score, SIRCH (spine infection risk calculation heuristic), uses four clinical variables to predict PSI. We calculated the statistical performance, MRI utilization, and model fit in the derivation phase. In the second phase we used the same protocol but enrolled only confirmed cases of spinal infection to assess the sensitivity of our prediction tool. Results In the derivation phase, we evaluated 134 non-PSI and 40 PSI patients; median age in years was 55.5 (interquartile range [IQR] 38–70 and 51.5 (42–59), respectively. We identified four predictors for our risk score: historical risk factors; fever; progressive neurological deficit; and C-reactive protein (CRP) ≥ 50 milligrams per liter (mg/L). At a threshold SIRCH score of ≥ 3, the predictive model’s sensitivity, specificity, and positive predictive value were, respectively, as follows: 100% (95% confidence interval [CI], 100–100%); 56% (95% CI, 48–64%), and 40% (95% CI, 36–46%). The area under the receiver operator curve was 0.877 (95% CI, 0.829–0.925). The SIRCH score at a threshold of ≥ 3 would prompt significantly fewer MRIs compared to using an elevated CRP (only 99/174 MRIs compared to 144/174 MRIs, P <0.001). In the second phase (49 patient disease-only cohort), the sensitivities of the SIRCH score and CRP use (laboratory standard cut-off 3.5 mg/L) were 92% (95% CI, 84–98%), and 98% (95% CI, 94–100%), respectively. Conclusion The SIRCH score provides a sensitive estimate of spinal infection risk and prompts fewer MRIs than elevated CRP (cut-off 3.5 mg/L) or clinician suspicion.
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Affiliation(s)
- Steven R Shroyer
- Methodist Hospital System, Greater San Antonio Emergency Physicians, San Antonio, Texas
| | - William T Davis
- Uniformed Services University of the Health Sciences, Department of Military and Emergency Medicine, Bethesda, Maryland
| | - Michael D April
- Uniformed Services University of the Health Sciences, Department of Military and Emergency Medicine, Bethesda, Maryland.,Massachusetts General Hospital, Department of Radiology, Boston, Massachusetts
| | - Brit Long
- Uniformed Services University of the Health Sciences, Department of Military and Emergency Medicine, Bethesda, Maryland
| | - Greg Boys
- Methodist Hospital System, Department of Radiology, San Antonio, Texas
| | - Sumeru G Mehta
- Methodist Hospital System, Greater San Antonio Emergency Physicians, San Antonio, Texas
| | - Sarah F Mercaldo
- Massachusetts General Hospital, Department of Radiology, Boston, Massachusetts
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16
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Dunn HP, Browning SD, Thomson D, Yates WB, McCluskey P, Keay L, White AJ, Fraser CL. Impact on patient management of non-mydriatic fundus photography compared to direct ophthalmoscopy in a regional Australian emergency department. Emerg Med Australas 2021; 34:186-193. [PMID: 34448357 DOI: 10.1111/1742-6723.13845] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 07/27/2021] [Accepted: 08/02/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To investigate the management impact of non-mydriatic fundus photography (NMFP) implementation for appropriate ED patients; compare the diagnostic accuracy of direct ophthalmoscopy (DO) and NMFP, and determine the prevalence of fundus pathology in a regional Australian ED. METHODS This before/after crossover study prospectively enrolled patients presenting with headache, neurological deficit, visual disturbance and/or hypertensive urgency. Patients received DO examination, then separate NMFP examination. Emergency clinicians (ECs) were surveyed on their patient management plans following both DO examination and NMFP imaging. Telemedicine review of NMFP images was performed by an ophthalmologist within 48 h, and any additional management changes were documented. RESULTS The use of NMFP influenced changes in management in 52 (39%) of 133 enrolled patients (95% confidence interval 31-48%). Of these, 65% were escalations of management due to acute fundus pathology, while 35% were de-escalating changes following normal fundus findings. ECs diagnostic accuracy for acute fundus pathology improved from 0% to 29% sensitivity, and 59% to 84% specificity using DO and NMFP respectively, and telemedicine registrar review increased this to 50% sensitivity and 86% specificity. The period prevalence of acute fundus pathology was 10.5% (95% confidence interval 6-17%). CONCLUSION The addition of NMFP images can significantly impact the management of ED patients requiring fundus examination, facilitating expedited and optimised patient care. NMFP improves ECs diagnostic acumen for fundus pathology over DO examination and telehealth specialist review is important for diagnostic accuracy. There is a clinically important prevalence of fundus pathology in this regional ED setting.
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Affiliation(s)
- Hamish P Dunn
- Faculty of Medicine, The University of New South Wales, Port Macquarie, New South Wales, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Department of Ophthalmology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Samuel D Browning
- Faculty of Medicine, The University of New South Wales, Port Macquarie, New South Wales, Australia
| | - David Thomson
- Faculty of Medicine, The University of New South Wales, Port Macquarie, New South Wales, Australia
| | - William B Yates
- Faculty of Medicine, The University of New South Wales, Port Macquarie, New South Wales, Australia.,Save Sight Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Peter McCluskey
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Save Sight Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Lisa Keay
- School of Optometry and Vision Science, The University of New South Wales, Sydney, New South Wales, Australia.,The George Institute for Global Health, The University of New South Wales, Sydney, New South Wales, Australia
| | - Andrew J White
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Department of Ophthalmology, Westmead Hospital, Sydney, New South Wales, Australia.,The George Institute for Global Health, The University of New South Wales, Sydney, New South Wales, Australia
| | - Clare L Fraser
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Save Sight Institute, The University of Sydney, Sydney, New South Wales, Australia
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17
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Liberman AL, Wang C, Friedman BW, Prabhakaran S, Esenwa CC, Rostanski SK, Cheng NT, Erdfarb A, Labovitz DL, Lipton RB. Head Computed tomography during emergency department treat-and-release visit for headache is associated with increased risk of subsequent cerebrovascular disease hospitalization. Diagnosis (Berl) 2021; 8:199-208. [PMID: 33006951 DOI: 10.1515/dx-2020-0082] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 08/14/2020] [Indexed: 12/26/2022]
Abstract
OBJECTIVES The occurrence of head computed tomography (HCT) at emergency department (ED) visit for non-specific neurological symptoms has been associated with increased subsequent stroke risk and may be a marker of diagnostic error. We evaluate whether HCT occurrence among ED headache patients is associated with increased subsequent cerebrovascular disease risk. METHODS We conducted a retrospective cohort study of consecutive adult patients with headache who were discharged home from the ED (ED treat-and-release visit) at one multicenter institution. Patients with headache were defined as those with primary ICD-9/10-CM discharge diagnoses codes for benign headache from 9/1/2013-9/1/2018. The primary outcome of cerebrovascular disease hospitalization was identified using ICD-9/10-CM codes and confirmed via chart review. We matched headache patients who had a HCT (exposed) to those who did not have a HCT (unexposed) in the ED in a one-to-one fashion using propensity score methods. RESULTS Among the 28,121 adult patients with ED treat-and-release headache visit, 45.6% (n=12,811) underwent HCT. A total of 0.4% (n=111) had a cerebrovascular hospitalization within 365 days of index visit. Using propensity score matching, 80.4% (n=10,296) of exposed patients were matched to unexposed. Exposed patients had increased risk of cerebrovascular hospitalization at 365 days (RR: 1.65: 95% CI: 1.18-2.31) and 180 days (RR: 1.62; 95% CI: 1.06-2.49); risk of cerebrovascular hospitalization was not increased at 90 or 30 days. CONCLUSIONS Having a HCT performed at ED treat-and-release headache visit is associated with increased risk of subsequent cerebrovascular disease. Future work to improve cerebrovascular disease prevention strategies in this subset of headache patients is warranted.
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Affiliation(s)
- Ava L Liberman
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Cuiling Wang
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Benjamin W Friedman
- Department of Emergency Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Charles C Esenwa
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Sara K Rostanski
- Department of Neurology, New York University School of Medicine, New York, NY, USA
| | - Natalie T Cheng
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Amichai Erdfarb
- Department of Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Daniel L Labovitz
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Richard B Lipton
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
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18
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Sharp AL, Baecker A, Nassery N, Park S, Hassoon A, Lee MS, Peterson S, Pitts S, Wang Z, Zhu Y, Newman-Toker DE. Missed acute myocardial infarction in the emergency department-standardizing measurement of misdiagnosis-related harms using the SPADE method. Diagnosis (Berl) 2021; 8:177-186. [PMID: 32701479 DOI: 10.1515/dx-2020-0049] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 06/03/2020] [Indexed: 12/02/2023]
Abstract
OBJECTIVES Diagnostic error is a serious public health problem. Measuring diagnostic performance remains elusive. We sought to measure misdiagnosis-related harms following missed acute myocardial infarctions (AMI) in the emergency department (ED) using the symptom-disease pair analysis of diagnostic error (SPADE) method. METHODS Retrospective administrative data analysis (2009-2017) from a single, integrated health system using International Classification of Diseases (ICD) coded discharge diagnoses. We looked back 30 days from AMI hospitalizations for antecedent ED treat-and-release visits to identify symptoms linked to probable missed AMI (observed > expected). We then looked forward from these ED discharge diagnoses to identify symptom-disease pair misdiagnosis-related harms (AMI hospitalizations within 30-days, representing diagnostic adverse events). RESULTS A total of 44,473 AMI hospitalizations were associated with 2,874 treat-and-release ED visits in the prior 30 days. The top plausibly-related ED discharge diagnoses were "chest pain" and "dyspnea" with excess treat-and-release visit rates of 9.8% (95% CI 8.5-11.2%) and 3.4% (95% CI 2.7-4.2%), respectively. These represented 574 probable missed AMIs resulting in hospitalization (adverse event rate per AMI 1.3%, 95% CI 1.2-1.4%). Looking forward, 325,088 chest pain or dyspnea ED discharges were followed by 508 AMI hospitalizations (adverse event rate per symptom discharge 0.2%, 95% CI 0.1-0.2%). CONCLUSIONS The SPADE method precisely quantifies misdiagnosis-related harms from missed AMIs using administrative data. This approach could facilitate future assessment of diagnostic performance across health systems. These results correspond to ∼10,000 potentially-preventable harms annually in the US. However, relatively low error and adverse event rates may pose challenges to reducing harms for this ED symptom-disease pair.
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Affiliation(s)
- Adam L Sharp
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
- Department of Health System Science, Kaiser Permanente School of Medicine, Pasadena, CA, United States
| | - Aileen Baecker
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Najlla Nassery
- Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Stacy Park
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Ahmed Hassoon
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Ming-Sum Lee
- Kaiser Permanente Southern California, Los Angeles Medical Center, Division of Cardiology, Los Angeles, CA, United States
| | - Susan Peterson
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Samantha Pitts
- Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Zheyu Wang
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Yuxin Zhu
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - David E Newman-Toker
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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19
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Ramgopal S, Zhou AZ, Hickey RW, Marin JR. Rates of Presentation, Treatments and Serious Neurologic Disorders Among Children and Young Adults Presenting to US Emergency Departments With Headache. J Child Neurol 2021; 36:475-481. [PMID: 33356803 DOI: 10.1177/0883073820979137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate rates of presentation, neuroimaging, therapies, and serious neurologic disorders (SNDs) among children and young adults presenting to the emergency department with headache. METHODS We performed a cross-sectional study of a nationally representative sample survey of visits to US emergency departments between 2002 and 2017. We identified encounters of patients ≤25 years old with chief complaint of headache. We report the rates of presentation, imaging, and treatments and report proportions having concomitant diagnoses of serious neurologic disorders. RESULTS Among encounters ≤25 years, 2.0% had a chief complaint of headache, with no change in the yearly rates of encounters (P = .98). Overall, 20.8% had a head computed tomography (CT), with a reduction in performance between 2007 and 2016 (P < .01). One-quarter (25.2%, 95% confidence interval [CI] 22.2%-28.3%) were given narcotics and 2.5% (95% CI 1.7%-3.2%) had serious neurologic disorders. CONCLUSION Overall, 2.0% of emergency department encounters among patients ≤25 years were for headache, with low rates of serious neurologic disorders. CT use appeared to be declining.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, 2429Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Amy Z Zhou
- Division of Emergency Medicine, 2429Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Robert W Hickey
- Division of Pediatric Emergency Medicine, Department of Pediatrics, 6619UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jennifer R Marin
- Division of Pediatric Emergency Medicine, Department of Pediatrics, 6619UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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20
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Wallace EJC, Liberman AL. Diagnostic Challenges in Outpatient Stroke: Stroke Chameleons and Atypical Stroke Syndromes. Neuropsychiatr Dis Treat 2021; 17:1469-1480. [PMID: 34017173 PMCID: PMC8129915 DOI: 10.2147/ndt.s275750] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 04/08/2021] [Indexed: 12/14/2022] Open
Abstract
Failure to diagnose transient ischemic attack (TIA) or stroke in a timely fashion is associated with significant patient morbidity and mortality. In the outpatient or clinic setting, we suspect that patients with minor, transient, and atypical manifestations of cerebrovascular disease are most prone to missed or delayed diagnosis. We therefore detail common stroke chameleon symptoms as well as atypical stroke presentations, broadly review new developments in the study of diagnostic error in the outpatient setting, suggest practical clinical strategies for diagnostic error reduction, and emphasize the need for rapid consultation of stroke specialists when appropriate. We also address the role of psychiatric disease and vascular risk factors in the diagnostic evaluation and treatment of suspected stroke/TIA patients. We advocate incorporating diagnostic time-outs into clinical practice to assure that the diagnosis of TIA or stroke is considered in all relevant patient encounters after a detailed history and examination are conducted in the outpatient setting.
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Affiliation(s)
- Emma J C Wallace
- Montefiore Medical Center, Albert Einstein College of Medicine, Department of Neurology, Bronx, NY, USA
| | - Ava L Liberman
- Montefiore Medical Center, Albert Einstein College of Medicine, Department of Neurology, Bronx, NY, USA
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Kim HS, Ciolino JD, Lancki N, Strickland KJ, Pinto D, Stankiewicz C, Courtney DM, Lambert BL, McCarthy DM. A Prospective Observational Study of Emergency Department-Initiated Physical Therapy for Acute Low Back Pain. Phys Ther 2020; 101:6044310. [PMID: 33351942 PMCID: PMC7970627 DOI: 10.1093/ptj/pzaa219] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 07/29/2020] [Accepted: 11/11/2020] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Low back pain accounts for nearly 4 million emergency department (ED) visits annually and is a significant source of disability. Physical therapy has been suggested as a potentially effective nonopioid treatment for low back pain; however, no studies to our knowledge have yet evaluated the emerging resource of ED-initiated physical therapy. The study objective was to compare patient-reported outcomes in patients receiving ED-initiated physical therapy and patients receiving usual care for acute low back pain. METHODS This was a prospective observational study of ED patients receiving either physical therapy or usual care for acute low back pain from May 1, 2018, to May 24, 2019, at a single academic ED (>91,000 annual visits). The primary outcome was pain-related functioning, assessed with Oswestry Disability Index (ODI) and Patient-Reported Outcomes Measurement Information System pain interference (PROMIS-PI) scores. The secondary outcome was use of high-risk medications (opioids, benzodiazepines, and skeletal muscle relaxants). Outcomes were compared over 3 months using adjusted linear mixed and generalized estimating equation models. RESULTS For 101 participants (43 receiving ED-initiated physical therapy and 58 receiving usual care), the median age was 40.5 years and 59% were women. Baseline outcome scores in the ED-initiated physical therapy group were higher than those in the usual care group (ODI = 51.1 vs 36.0; PROMIS-PI = 67.6 vs 62.7). Patients receiving ED-initiated physical therapy had greater improvements in both ODI and PROMIS-PI scores at the 3-month follow-up (ODI = -14.4 [95% CI = -23.0 to -5.7]; PROMIS-PI = -5.1 [95% CI = -9.9 to -0.4]) and lower use of high-risk medications (odds ratio = 0.05 [95% CI = 0.01 to 0.58]). CONCLUSION In this single-center observational study, ED-initiated physical therapy for acute low back pain was associated with improvements in functioning and lower use of high-risk medications compared with usual care; the causality of these relationships remains to be explored. IMPACT ED-initiated physical therapy is a promising therapy for acute low back pain that may reduce reliance on high-risk medications while improving patient-reported outcomes. LAY SUMMARY Emergency department-initiated physical therapy for low back pain was associated with greater improvement in functioning and lower use of high-risk medications over 3 months.
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Affiliation(s)
- Howard S Kim
- Address all correspondence to Dr Kim at: , @theNNTweet
| | - Jody D Ciolino
- Division of Biostatistics, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Nicola Lancki
- Division of Biostatistics, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Kyle J Strickland
- Department of Rehabilitation Services, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Daniel Pinto
- Department of Physical Therapy, Marquette University College of Health Sciences, Milwaukee, Wisconsin, USA,Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Christine Stankiewicz
- Department of Rehabilitation Services, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - D Mark Courtney
- Department of Emergency Medicine, University of Texas Southwestern Medical School, Dallas, Texas, USA
| | - Bruce L Lambert
- Department of Communication Studies, Center for Communication and Health, Northwestern University School of Communication, Chicago, Illinois, USA
| | - Danielle M McCarthy
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA,Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Liberman AL, Lu J, Wang C, Cheng NT, Moncrieffe K, Lipton RB. Factors associated with hospitalization for ischemic stroke and TIA following an emergency department headache visit. Am J Emerg Med 2020; 46:503-507. [PMID: 33191047 DOI: 10.1016/j.ajem.2020.10.082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 10/06/2020] [Accepted: 10/31/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Misdiagnosis of cerebrovascular disease among Emergency Department (ED) patients with headache has been reported. We hypothesized that markers of substandard diagnostic processes would be associated with subsequent ischemic cerebrovascular events among patients discharged from the ED with a headache diagnosis even after adjusting for demographic variables and medical history. METHODS We conducted a case-control study of adult ED patients diagnosed with a primary headache disorder at Montefiore Medical Center from 9/1/2013-9/1/2018. Cases were defined as patients hospitalized for an ischemic stroke or TIA within 365 days of their index ED visit. Control patients were defined as those who lacked a subsequent hospitalization for cerebrovascular disease. Pre-specified demographic, clinical, and diagnostic process factors were compared between groups; conditional logistic regression was used to assess the separate and joint influence of baseline features on risk of cerebral ischemia. RESULTS A total of 93 consecutive headache patients with a subsequent ischemic stroke/TIA hospitalization were matched to 93 controls (n = 186). Cases were older than controls and more likely to have traditional cerebrovascular risk factors. Neurological consultation was obtained more often for cases (13% vs. 4%; P = 0.03), cases were in the ED for longer (6 vs. 5 h, P = 0.03), and more frequently received neuroimaging (80% vs. 48%; P < 0.0001). Rates of neurological examination, documented differential diagnoses, and clear discharge follow up plans were similar between cases and controls. In our conditional logistic regression model, only history of prior stroke/TIA was associated with increased odds of subsequent cerebral ischemia. CONCLUSION Factors associated with diagnostic process failures did not increase the odds of subsequent ischemic stroke/TIA hospitalization following ED headache visit in our study.
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Affiliation(s)
- Ava L Liberman
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States of America.
| | - Jenny Lu
- Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, United States of America.
| | - Cuiling Wang
- Department of Biostatistics, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States of America.
| | - Natalie T Cheng
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States of America.
| | - Khadean Moncrieffe
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States of America.
| | - Richard B Lipton
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States of America.
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23
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Abstract
Using an algorithmic approach to acutely dizzy patients, physicians can often confidently make a specific diagnosis that leads to correct treatment and should reduce the misdiagnosis of cerebrovascular events. Emergency clinicians should try to become familiar with an approach that exploits timing and triggers as well as some basic "rules" of nystagmus. The gait should always be tested in all patients who might be discharged. Computed tomographic scans are unreliable to exclude posterior circulation stroke presenting as dizziness, and early MRI (within the first 72 hours) also misses 10% to 20% of these cases.
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Affiliation(s)
- Kiersten L Gurley
- Harvard Medical School, Boston, MA, USA; Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Anna Jaques Hospital, Newburyport, MA, USA.
| | - Jonathan A Edlow
- Harvard Medical School, Boston, MA, USA; Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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24
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Dubosh NM, Edlow JA. Diagnosis and Initial Emergency Department Management of Subarachnoid Hemorrhage. Emerg Med Clin North Am 2020; 39:87-99. [PMID: 33218664 DOI: 10.1016/j.emc.2020.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Atraumatic subarachnoid hemorrhage represents a small proportion of strokes, but is a true medical emergency that results in significant morbidity and mortality. Making the diagnosis can be challenging and misdiagnosis can result in devastating consequences. There are several time-dependent diagnostic and management considerations for emergency physicians and other frontline providers. This article reviews the most up-to-date literature on the diagnostic workup of subarachnoid hemorrhage, avoiding misdiagnosis, and initial emergency department management recommendations.
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Affiliation(s)
- Nicole M Dubosh
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, One Deaconess Road, Rosenburg 2, Boston, MA 02115, USA.
| | - Jonathan A Edlow
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, One Deaconess Road, Rosenburg 2, Boston, MA 02115, USA
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25
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Zhou AZ, Marin JR, Hickey RW, Ramgopal S. Serious Diagnoses for Headaches After ED Discharge. Pediatrics 2020; 146:peds.2020-1647. [PMID: 33008843 DOI: 10.1542/peds.2020-1647] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/20/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Headache is a common complaint among children presenting to the emergency department (ED) and can be due to serious neurologic and nonneurologic diagnoses (SNNDs). We sought to characterize the children discharged from the ED with headache found to have SNNDs at revisits. METHODS We performed a multicenter retrospective cohort study using data from 45 pediatric hospitals from October 1, 2015, to March 31, 2019. We included pediatric patients (≤18 years) discharged from the ED with a principal diagnosis of headache, excluding patients with concurrent or previous SNNDs or neurosurgeries. We identified rates and types of SNNDs diagnosed within 30 days of initial visit and compared these rates with those of control groups defined as patients with discharge diagnoses of cough, chest pain, abdominal pain, and soft tissue complaints. RESULTS Of 121 621 included patients (57% female, median age 12.4 years, interquartile range: 8.8-15.4), 608 (0.5%, 95% confidence interval: 0.5%-0.5%) were diagnosed with SNNDs within 30 days. Most were diagnosed at the first revisit (80.8%); 37.5% were diagnosed within 7 days. The most common SNNDs were benign intracranial hypertension, cerebral edema and compression, and seizures. A greater proportion of patients with SNNDs underwent neuroimaging, blood, and cerebrospinal fluid testing compared with those without SNNDs (P < .001 for each). The proportion of SNNDs among patients diagnosed with headache (0.5%) was higher than for control cohorts (0.0%-0.1%) (P < .001 for each). CONCLUSIONS A total 0.5% of pediatric patients discharged from the ED with headache were diagnosed with an SNND within 30 days. Further efforts to identify at-risk patients remain a challenge.
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Affiliation(s)
- Amy Z Zhou
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago and Feinberg School of Medicine, Northwestern University, Chicago, Illinois;
| | - Jennifer R Marin
- Division of Pediatric Emergency Medicine, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh and School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; and.,Department of Emergency Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Robert W Hickey
- Division of Pediatric Emergency Medicine, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh and School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; and
| | - Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago and Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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26
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Abstract
Low back pain is a frequent complaint of patients seeking care at private offices, ambulatory clinics, and EDs. Key signs and symptoms can guide clinicians in differentiating acute and persistent mechanical low back pain from back pain resulting from a specific cause. Awareness of these findings can reduce the number of missed or incorrect diagnoses that lead to poor patient outcomes. The ability to recognize the red flag findings of serious causes of low back pain ensures prompt diagnosis and initiation of appropriate treatment. This article highlights the history and physical examination findings that will improve identification of red flags associated with emergency or serious causes.
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27
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Abstract
PURPOSE OF REVIEW This review details the frequency of and ways in which migraine can be both an ischemic stroke/transient ischemic attack mimic (false positive) and chameleon (false negative). We additionally seek to clarify the complex relationships between migraine and cerebrovascular diseases with regard to diagnostic error. RECENT FINDINGS Nearly 2% of all patients evaluated emergently for possible stroke have an ultimate diagnosis of migraine; approximately 18% of all stroke mimic patients treated with intravenous thrombolysis have a final diagnosis of migraine. Though the treatment of a patient with migraine with thrombolytics confers a low risk of complication, symptomatic intracerebral hemorrhage may occur. Three clinical prediction scores with high sensitivity and specificity exist that can aid in the diagnosis of acute cerebral ischemia. Differentiating between migraine aura and transient ischemic attacks remains challenging. On the other hand, migraine is a common incorrect diagnosis initially given to patients with stroke. Among patients discharged from an emergency visit to home with a diagnosis of a non-specific headache disorder, 0.5% were misdiagnosed. Further development of tools to quantify and understand sources of stroke misdiagnosis among patients who present with headache is warranted. Both failure to identify cerebral ischemia among patients with headache and overdiagnosis of ischemia can lead to patient harms. While some tools exist to help with acute diagnostic decision-making, additional strategies to improve diagnostic safety among patients with migraine and/or cerebral ischemia are needed.
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Affiliation(s)
- Oleg Otlivanchik
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, 3316 Rochambeau Avenue, Bronx, NY, 10467, USA
| | - Ava L Liberman
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, 3316 Rochambeau Avenue, Bronx, NY, 10467, USA.
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