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Akhtar H, Chaudhry SH, Bortolussi-Courval É, Hanula R, Akhtar A, Nauche B, McDonald EG. Diagnostic yield of CT head in delirium and altered mental status-A systematic review and meta-analysis. J Am Geriatr Soc 2023; 71:946-958. [PMID: 36434820 DOI: 10.1111/jgs.18134] [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: 05/05/2022] [Revised: 10/27/2022] [Accepted: 10/30/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND CT head is commonly performed in the setting of delirium and altered mental status (AMS), with variable yield. We aimed to evaluate the yield of CT head in hospitalized patients with delirium and/or AMS across a variety of clinical settings and identify factors associated with abnormal imaging. METHODS We included studies in adult hospitalized patients, admitted to the emergency department (ED) and inpatient medical unit (grouped together) or the intensive care unit (ICU). Patients had a diagnosis of delirium/AMS and underwent a CT head that was classified as abnormal or not. We searched Medline, Embase and other databases (informed by PRISMA guidelines) from inception until November 11, 2021. Studies that were exclusively performed in patients with trauma or a fall were excluded. A meta-analysis of proportions was performed; the pooled proportion of abnormal CTs was estimated using a random effects model. Heterogeneity was determined via the I2 statistic. Factors associated with an abnormal CT head were summarized qualitatively. RESULTS Forty-six studies were included for analysis. The overall yield of CT head in the inpatient/ED was 13% (95% CI: 10.2%-15.9%) and in ICU was 17.4% (95% CI: 10%-26.3%), with considerable heterogeneity (I2 96% and 98% respectively). Heterogeneity was partly explained after accounting for study region, publication year, and representativeness of the target population. Yield of CT head diminished after year 2000 (19.8% vs. 11.1%) and varied widely depending on geographical region (8.4%-25.9%). The presence of focal neurological deficits was a consistent factor that increased yield. CONCLUSION Use of CT head to diagnose the etiology of delirium and AMS varied widely and yield has declined. Guidelines and clinical decision support tools could increase the appropriate use of CT head in the diagnostic etiology of delirium/AMS.
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Affiliation(s)
- Haris Akhtar
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Canada
| | - Shazia H Chaudhry
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Émilie Bortolussi-Courval
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Canada
| | - Ryan Hanula
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Canada
| | - Anas Akhtar
- Department of General Surgery, Letterkenny University Hospital, Letterkenny, Ireland
| | - Bénédicte Nauche
- McGill University Health Centre Medical Libraries, Montreal, Canada
| | - Emily G McDonald
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Canada
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Canada
- Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montreal, Canada
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Marchese AL, Fine AM, Levy JA, Monuteaux MC, Michelson KA. Physician Risk Perception and Testing Behaviors for Children With Fever. Pediatr Emerg Care 2022; 38:e805-e810. [PMID: 35100780 PMCID: PMC9340816 DOI: 10.1097/pec.0000000000002413] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Risk tolerance and risk perceptions may impact clinicians' decisions to obtain diagnostic tests. We sought to determine whether physician risk perception was associated with the decision to obtain blood or imaging tests among children who present to the emergency department with fever. METHODS We conducted a retrospective, cross-sectional study in the Boston Children's Hospital emergency department. We included children aged 6 months to 18 years from May 1, 2014 to April 30, 2019, with fever. Our primary outcome was diagnostic testing: obtaining a blood and/or imaging test. We assessed risk perception using 3 scales: the Risk Tolerance Scale (RTS), Stress From Uncertainty Scale (SUS), and Malpractice Fear Scale (MFS). A z score was assigned to each physician for each scale. Mixed-effects logistic regression assessed the association between physician risk perception and blood or imaging testing. We also examined the relationship between each risk perception scale and several secondary outcomes: blood testing, urine testing, diagnostic imaging, specialist consultation, hospitalization, and revisit within 72 hours. RESULTS The response rate was 55/56 (98%). We analyzed 12,527 encounters. Blood/imaging testing varied between physicians (median, 48%; interquartile range, 41%-53%; range, 30%-71%). Risk Tolerance Scale responses were not associated with blood/imaging testing (odds ratio [OR], 1.03 per SD of increased risk perception; 95% confidence interval [CI], 0.95-1.13). Stress From Uncertainty Scale responses were not associated with blood/imaging testing (OR, 1.04 per SD; 95% CI, 0.95-1.14). Malpractice Fear Scale responses were not associated with blood/imaging testing (OR, 1.00 per SD; 95% CI, 0.91-1.09). There was no significant association between RTS, MFS, or SUS and any secondary outcome, except that there was a weak association between SUS and specialist consultation (OR, 1.12; 95% CI, 1.00-1.24). CONCLUSIONS Across 55 pediatric emergency physicians with variable testing practices, there was no association between risk perception and blood/imaging testing in febrile children.
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Affiliation(s)
- Ashley L Marchese
- From the Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
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Mansoori JN, Clark BJ, Havranek EP, Douglas IS. The Impact of Choice Architecture on Sepsis Fluid Resuscitation Decisions: An Exploratory Survey-Based Study. MDM Policy Pract 2022; 7:23814683221099454. [PMID: 35592271 PMCID: PMC9112319 DOI: 10.1177/23814683221099454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 04/21/2022] [Indexed: 11/16/2022] Open
Abstract
Background Discordance with well-known sepsis resuscitation guidelines is often
attributed to rational assessments of patients at the point of care.
Conversely, we sought to explore the impact of choice architecture (i.e.,
the environment, manner, and behavioral psychology within which options are
presented and decisions are made) on decisions to prescribe
guideline-discordant fluid volumes. Design We conducted an electronic, survey-based study using a septic shock clinical
vignette. Physicians from multiple specialties and training levels at an
academic tertiary-care hospital and academic safety-net hospital were
randomized to distinct answer sets: control (6 fluid options), time
constraint (6 fluid options with a 10-s limit to answer), or choice overload
(25 fluid options). The primary outcome was discordance with Surviving
Sepsis Campaign fluid resuscitation guidelines. We also measured response
times and examined the relationship between each choice architecture
intervention group, response time, and guideline discordance. Results A total of 189 of 624 (30.3%) physicians completed the survey. Time spent
answering the vignette was reduced in time constraint (9.5 s, interquartile
range [IQR] 7.3 s to 10.0 s, P < 0.001) and increased in
choice overload (56.8 s, IQR 35.9 s to 86.7 s, P <
0.001) groups compared with control (28.3 s, IQR 20.0 s to 44.6 s). In
contrast, the relative risk of guideline discordance was higher in time
constraint (2.07, 1.33 to 3.23, P = 0.001) and lower in
choice overload (0.75, 0.60, to 0.95, P =0.02) groups.
After controlling for time spent reading the vignette, the overall odds of
choosing guideline-discordant fluid volumes were reduced for every
additional second spent answering the vignette (OR 0.98, 0.97, to 0.99,
P < 0.001). Conclusions Choice architecture may affect fluid resuscitation decisions in sepsis
regardless of patient conditions, warranting further investigation in
real-world contexts. These effects should be considered when implementing
practice guidelines. Highlights
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Affiliation(s)
- Jason N. Mansoori
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver, CO, USA
| | - Brendan J. Clark
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Edward P. Havranek
- Division of Cardiology, Department of Medicine, Denver, CO, USA
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ivor S. Douglas
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver, CO, USA
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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Smulowitz PB, Burke RC, Ostrovsky D, Novack V, Isbell L, Landon BE. Attitudes toward risk among emergency physicians and advanced practice clinicians in Massachusetts. J Am Coll Emerg Physicians Open 2021; 2:e12573. [PMID: 34693400 PMCID: PMC8514146 DOI: 10.1002/emp2.12573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 09/01/2021] [Accepted: 09/15/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Risk aversion is a personality trait influential to decision making in medicine. Little is known about how emergency department (ED) clinicians differ in their attitudes toward risk taking. METHODS We conducted a cross-sectional survey of practicing ED clinicians (physicians and advanced practice clinicians [APCs]) in Massachusetts using the following 4 existing validated scales: the Risk-Taking Scale (RTS), Stress from Uncertainty Scale (SUS), the Fear of Malpractice Scale (FMS), and the Need for (Cognitive) Closure Scale (NCC). We used Cronbach's α to assess the reliability of each scale and performed multivariable linear regressions to analyze the association between the score for each scale and clinician characteristics. RESULTS Of 1458 ED clinicians recruited for participation, 1116 (76.5%) responded from 93% of acute care hospitals in Massachusetts. Each of the 4 scales demonstrated high internal consistency reliability with Cronbach's αs ranging from 0.76 to 0.92. The 4 scales also were moderately correlated with one another (0.08 to 0.54; all P < 0.05). The multivariable results demonstrated differences between physicians and APCs, with physicians showing a greater tolerance for risk or uncertainty (NCC difference, -3.58 [95% confidence interval, CI, -5.26 to -1.90]; SUS difference, -3.14 [95% CI: -4.99 to -1.29]) and a higher concern about malpractice (FMS difference, 1.14 [95% CI, 0.11-2.17]). Differences were also observed based on clinician age (a proxy for years of experience), with greater age associated with greater tolerance of risk or uncertainty (age older than 50 years compared with age 35 years and younger; NCC difference, -2.84 [95% CI, -4.69 to -1.00]; SUS difference, -4.71 [95% CI, -6,74 to -2.68]) and less concern about malpractice (FMS difference, -3.19 [95% CI, -4.31 to -2.06]). There were no appreciable differences based on sex, and there were no consistent associations between scale scores and the practice and payment characteristics assessed. CONCLUSION We found that risk attitudes of ED clinicians were associated with type of training (physician vs APC) and age (experience). These differences suggest one possible explanation for the observed differences in decision making.
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Affiliation(s)
- Peter B. Smulowitz
- Department of Emergency MedicineUniversity of Massachusetts Medical SchoolWorcesterMassachusettsUSA
| | - Ryan C. Burke
- Department of Emergency MedicineBeth Israel Deaconess Medical CenterBostonMassachusettsUSA
| | - Daniel Ostrovsky
- Clinical Research Center, Soroka University Medical CenterBen‐Gurion University of the NegevIsrael
| | - Victor Novack
- Clinical Research Center, Soroka University Medical CenterBen‐Gurion University of the NegevIsrael
| | - Linda Isbell
- Department of Psychological and Brain SciencesUniversity of MassachusettsAmherstMassachusetts
| | - Bruce E. Landon
- Department of Health Care PolicyHarvard Medical School and Division of General InternalMedicineBeth Israel Deaconess Medical CenterBostonMassachusettsUSA
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Cheng CY, Pan HY, Li CJ, Chen YC, Chen CC, Huang YS, Cheng FJ. Physicians' Risk Tolerance and Head Computed Tomography Use for Pediatric Patients With Minor Head Injury. Pediatr Emerg Care 2021; 37:e129-e135. [PMID: 29847541 PMCID: PMC7938907 DOI: 10.1097/pec.0000000000001540] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVES Traumatic brain injury is the leading cause of death and disability in children worldwide. The objective of this study was to determine the association between physician risk tolerance and head computed tomography (CT) use in patients with minor head injury (MHI) in the emergency department (ED). METHODS We retrospectively analyzed pediatric patients (<17 years old) with MHI in the ED and then administered 2 questionnaires (a risk-taking subscale [RTS] of the Jackson Personality Inventory and a malpractice fear scale [MFS]) to attending physicians who had evaluated these patients and made decisions regarding head CT use. The primary outcome was head CT use during ED evaluation; the secondary outcome was ED length of stay and final diagnosis of intracranial injury (ICI). RESULTS Of 523 patients with MHI, 233 (44.6%) underwent brain CT, and 16 (3.1%) received a final diagnosis of ICI. Among the 16 emergency physicians (EPs), the median scores of the MFS and RTS were 22 (interquartile range, 17-26) and 23 (interquartile range, 19-25), respectively. Emergency physicians who were most risk averse tended to order more head CT scans compared with the more risk-tolerant EPs (56.96% vs 37.37%; odds ratio, 8.463; confidence interval, 2.783-25.736). The ED length of stay (P = 0.442 and P = 0.889) and final diagnosis (P = 0.155 and P = 0.835) of ICI were not significantly associated with the RTS and MFS scores. CONCLUSIONS Individual EP risk tolerance, as measured by RTS, was predictive of CT use in pediatric patients with MHI.
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Affiliation(s)
- Chi-Yung Cheng
- From the Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung
| | - Hsiu-Yung Pan
- From the Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung
| | - Chao-Jui Li
- From the Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung
| | - Yi-Chuan Chen
- Department of Emergency Medicine, Chang Gung Memorial Hospital
- Department of Nursing, Chang Gung University of Science and Technology, Chiayi, Taiwan
| | - Chien-Chih Chen
- From the Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung
| | - Yi-Syun Huang
- From the Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung
| | - Fu-Jen Cheng
- From the Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung
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Tsai MT, Chang KP, Huang JB, Cheng SY, Chiang CY, Cheng FJ. Influence of physicians’ seniority on head computed tomography use for patients with isolated vertigo/dizziness. J Int Med Res 2020; 48:300060520955033. [PMID: 32993400 PMCID: PMC7536495 DOI: 10.1177/0300060520955033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective Vertigo/dizziness is a common reason for emergency department (ED) visits. Emergency physicians (EPs) must distinguish patients with dizziness/vertigo owing to serious central nervous system (CNS) disorders. We aimed to evaluate the association between physician seniority and use of head computed tomography (CT) and ED length of stay (LOS) in patients presenting to the ED with isolated dizziness/vertigo. Methods This retrospective cohort study included adult patients with non-traumatic dizziness/vertigo in the ED. EPs were categorized according to seniority: junior (less than 6 years’ clinical experience), intermediate (7–12 years), and senior (≥12 years). Results Among 2589 patients with isolated dizziness/vertigo, 460 (17.8%) received brain CT; 46 (1.78%) had CNS disorder as a final diagnosis. Junior and intermediate EPs ordered more CT examinations than senior EPs: (odds ratio [OR] = 1.329, 95% confidence interval [CI]: 1.002–1.769 and OR = 1.531, 95% CI: 1.178–2.001, respectively). Patients treated by junior and intermediate EPs had lower patient ED LOS (OR = −0.432, 95% CI: −0.887 to 0.024 and OR = −0.436, 95% CI: −0.862 to −0.011). Conclusions We revealed different judgment strategies among senior, intermediate, and junior EPs. Senior EPs ordered fewer CT examinations for patients with isolated vertigo/dizziness but had longer patient LOS.
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Affiliation(s)
- Ming-Ta Tsai
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Dapi Rd., Niaosong Township, Kaohsiung County 833
| | - Kung-Pin Chang
- Department of Emergency Medicine, Kaohsiung Municipal Ta-Tung Hospital, No. 68, Zhonghua 3rd Rd., Qianjin Dist., Kaohsiung City 801
| | - Jyun-Bin Huang
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Dapi Rd., Niaosong Township, Kaohsiung County 833
| | - Shih-Yu Cheng
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Dapi Rd., Niaosong Township, Kaohsiung County 833
| | - Charng-Yen Chiang
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Dapi Rd., Niaosong Township, Kaohsiung County 833
| | - Fu-Jen Cheng
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Dapi Rd., Niaosong Township, Kaohsiung County 833
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Nontraumatic Headache in Adult Emergency Patients: Prevalence, Etiologies, and Radiological Findings. J Clin Med 2020; 9:jcm9082621. [PMID: 32806717 PMCID: PMC7464980 DOI: 10.3390/jcm9082621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/04/2020] [Accepted: 08/07/2020] [Indexed: 02/03/2023] Open
Abstract
The aim of this study was to measure prevalence, to describe underlying etiologies, and to assess radiological findings, focusing on significant intracranial abnormality (sICA). This was a prospective study of unselected adult patients admitted to the emergency department (ED) in a tertiary care hospital where all presenters were systematically interviewed about their symptoms. We attributed nontraumatic headache with neuroimaging to four groups: Normal or no new finding, extracranial abnormality, insignificant intracranial abnormality, or significant intracranial abnormality. sICA was defined as “needing acute therapy”, “needing follow-up neuroimaging”, or “clinically important neurological disorder”. Among 11,269 screened ED presentations, the prevalence of nontraumatic headache was 10.1% (1132 patients). Neuroimaging (cCT and/or cMRI) was performed in 303 patients. Seventy (23.1% of scanned; 6.2% of all headache patients) patients had sICA. Etiologies were cerebrovascular disease (56%), intracranial bleeding (17%), tumors (14%), infection (9%), and others (6%). Short-term outcome was excellent, with 99.3% in-hospital survival in patients with and 99.4% in patients without neuroimaging, and 97.1% in sICA; 1-year survival in outpatients with neuroimaging was 99.2%, 99.0% in outpatients without, and 88.6% in patients with sICA. Factors associated with sICA were age, emergency severity index (ESI) of 1 or 2, Glasgow coma score (GCS) under 14, focal neurological signs, and a history of malignancy. Prevalence of headache and incidence of sICA were high, but survival after work-up for nontraumatic headache was excellent in the 94% patients without sICA. Due to the incidence of sICA, extensive indication for neuroimaging in headache patients is further warranted, particularly in patients with risk factors.
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Wu WT, Pan HY, Wu KH, Huang YS, Wu CH, Cheng FJ. The Ottawa subarachnoid hemorrhage clinical decision rule for classifying emergency department headache patients. Am J Emerg Med 2019; 38:198-202. [PMID: 30765279 DOI: 10.1016/j.ajem.2019.02.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 01/31/2019] [Accepted: 02/04/2019] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND Subarachnoid hemorrhage (SAH) is a serious cause of headaches. The Ottawa subarachnoid hemorrhage (OSAH) rule helps identify SAH in patients with acute nontraumatic headache with high sensitivity, but provides limited information for identifying other intracranial pathology (ICP). OBJECTIVES To assess the performance of the OSAH rule in emergency department (ED) headache patients and evaluate its impact on the diagnosis of intracranial hemorrhage (ICH) and other ICP. METHOD We conducted a retrospective cohort study from January 2016 to March 2017. Patients with acute headache with onset within 14 days of the ED visit, were included. We excluded patients with head trauma that occurred in the previous 7 days, new onset of abnormal neurologic findings, or consciousness disturbance. According to the OSAH rule, patients with any included predictors required further investigation. RESULTS Of 913 patients were included, 15 of them were diagnosed with SAH. The OSAH rule had 100% (95% CI, 78.2%-100%) sensitivity and 37.0% (95% CI, 33.8-40.2%) specificity for identifying SAH. Twenty-two cases were identified as SAH or ICH with 100% sensitivity (95% CI, 84.6%-100%) and 37.3% (95% CI, 34.1%-40.5%) specificity. As for non-hemorrhagic ICP, both the sensitivity and negative predictive values (NPV) decreased to 75.0% (95% CI, 53.3%-90.2%) and 98.2% (95% CI, 96.1%-99.3%), respectively. CONCLUSIONS The OSAH rule had 100% sensitivity and NPV for diagnosing SAH and ICH with acute headache. The sensitivity and specificity were lower for non-hemorrhagic ICP. The OSAH rule may be an effective tool to exclude acute ICH and SAH in our setting.
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Affiliation(s)
- Wei-Ting Wu
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Dapi Rd., Niaosong Township, Kaohsiung County 833, Taiwan
| | - Hsiu-Yung Pan
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Dapi Rd., Niaosong Township, Kaohsiung County 833, Taiwan
| | - Kuan-Han Wu
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Dapi Rd., Niaosong Township, Kaohsiung County 833, Taiwan
| | - Yi-Syun Huang
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Dapi Rd., Niaosong Township, Kaohsiung County 833, Taiwan
| | - Chien-Hung Wu
- Department of Emergency Medicine, Yunlin Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 1500, Gongye Rd., Mailiao Township, Yunlin County 638, Taiwan
| | - Fu-Jen Cheng
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Dapi Rd., Niaosong Township, Kaohsiung County 833, Taiwan.
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Covino M, Gilardi E, Manno A, Simeoni B, Ojetti V, Cordischi C, Forte E, Carbone L, Gaudino S, Franceschi F. A new clinical score for cranial CT in ED non-trauma patients: Definition and first validation. Am J Emerg Med 2018; 37:1279-1284. [PMID: 30337090 DOI: 10.1016/j.ajem.2018.09.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 08/15/2018] [Accepted: 09/19/2018] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Well recognized guidelines are available for the use of cranial computed tomography (CCT) in traumatic patients, while no definitely accepted standards exists to for CCT in patients without history of head injury. The aim of this study is to propose an easy clinical score to stratify the need of CCT in emergency department (ED) patients with suspect non-traumatic intracranial pathology. METHODS We retrospectively evaluated patients presenting to the ED for neurological deficit, postural instability, acute headache, altered mental status, seizures, confusion, dizziness, vertigo, syncope, and pre-syncope. We build a score for positive CCT prediction by using a logistic regression model on clinical factors significant at univariate analysis. The score was validated on a population of prospectively observed patients. RESULTS We reviewed clinical data of 1156 patients; positivity of CCT was 15.2%. Persistent neurological deficit, new onset acute headache, seizures and/or altered state of consciousness, and transient neurological disorders were independent predictors of positive CCT. We observed 508 patients in a validation prospective cohort; CCT was positive in 11.3%. Our score performed well in validation population with a ROC AUC of 0.787 (CI 95% 0.748-0.822). Avoiding CT in score 0 patients would have saved 82 (16.2%) exams. No patients with score 0 had a positive CCT findings; score sensitivity was 100.0 (CI 95% 93.7-100.0). CONCLUSIONS A score for risk stratification of patients with suspect of intra-cranial pathology could reduce CT request in ED, avoiding a significant number of CCT while minimizing the risk of missing positive results.
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Affiliation(s)
- Marcello Covino
- Medicina D'Urgenza, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy.
| | - Emanuele Gilardi
- Medicina D'Urgenza, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Alberto Manno
- Medicina D'Urgenza, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Benedetta Simeoni
- Medicina D'Urgenza, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Veronica Ojetti
- Medicina D'Urgenza, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; Università Cattolica del Sacro Cuore, Roma, Italy
| | - Chiara Cordischi
- Medicina D'Urgenza, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Evelina Forte
- Medicina D'Urgenza, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Luigi Carbone
- Medicina D'Urgenza, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Simona Gaudino
- Università Cattolica del Sacro Cuore, Roma, Italy; UOC Radiodiagnostica e Neuroradiologia, Istituto di Radiologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Francesco Franceschi
- Medicina D'Urgenza, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; Università Cattolica del Sacro Cuore, Roma, Italy
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Huang YS, Tseng WT, Chiang CY, Zhang EW, Wu CH, Cheng FJ. The effect of peer influence on the use of CT by emergency physicians for patients with headaches. Am J Emerg Med 2018; 37:710-714. [PMID: 30017692 DOI: 10.1016/j.ajem.2018.07.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 07/08/2018] [Accepted: 07/12/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND It is challenging for emergency physicians (EPs) to distinguish between patients with life-threatening and benign headaches. We examined the effect of peer influence on computed tomography use by EPs for patients with headache and evaluated the peer influence effect in EPs with different levels of risk tolerance. METHODS We conducted a before- and after-retrospective case review, and administered the Risk-Taking subscale of the Jackson Personality Index to attending physicians. Each EP computed tomography (CT) use rate, patient number, and CT use, were e-mailed every two months to enhance EP team norm and establish a trend in behavior. RESULTS Of the 665 (before intervention) and 669 (after intervention) patients with headache, 206 (31%) and 171 (25.6%) underwent brain CT scans, respectively. Decreased use of CT examination was found in the post-intervention group (OR = 0.758, 95% CI: 0.593-0.967), especially for most risk-tolerant physicians (OR = 0.530, 95% CI: 0.311-0.889). There was prolonged ED length of stay (LOS) in the pre-intervention group (OR = 51.52, 95% CI: 26.998-76.050). CONCLUSIONS We observed that peer influence is an effective way to improve CT use rate and emergency department LOS for patients with isolated headache, especially for most risk-tolerant physicians. These findings could enhance the development of appropriate guidelines to assist ED physicians' CT use.
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Affiliation(s)
- Yi-Syun Huang
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Dapi Rd., Niaosong Township, Kaohsiung County 833, Taiwan.
| | - Wei-Ting Tseng
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Dapi Rd., Niaosong Township, Kaohsiung County 833, Taiwan
| | - Charng-Yen Chiang
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Dapi Rd., Niaosong Township, Kaohsiung County 833, Taiwan
| | - E-Wai Zhang
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Dapi Rd., Niaosong Township, Kaohsiung County 833, Taiwan
| | - Chien-Hung Wu
- Department of Emergency Medicine, Yunlin Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 1500, Gongye Rd., Mailiao Township, Yunlin County 638, Taiwan
| | - Fu-Jen Cheng
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Dapi Rd., Niaosong Township, Kaohsiung County 833, Taiwan.
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