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Uccella L, Riboni C, Polinelli F, Biondi C, Uccheddu G, Petrino R, Majno-Hurst P. Use of the Canadian CT head rule for patients on anticoagulant/anti-platelet therapy presenting with mild traumatic brain injury: prospective observational study. Front Neurol 2024; 15:1327871. [PMID: 38699056 PMCID: PMC11063395 DOI: 10.3389/fneur.2024.1327871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 04/02/2024] [Indexed: 05/05/2024] Open
Abstract
Background and importanceMild traumatic brain injury (mTBI) is a frequent presentation in Emergency Department (ED). There are standardised guidelines, the Canadian CT Head Rule (CCHR), for CT scan in mTBI that rule out patients on either anticoagulant or anti-platelet therapy. All patients with these therapies undergo a CT scan irrespectively of other consideration.ObjectiveTo determine whether standard guidelines could be applied to patients on anticoagulants or anti-platelet drugs.Design, settings, and participants1,015 patients with mTBI and Glasgow Coma Score (GCS) of 15 were prospectively recruited, 509 either on anticoagulant or anti-platelet therapy and 506 on neither. All patients on neither therapy underwent CT scan following guidelines. All patients with mTBI on either therapy underwent CT scan irrespective of the guidelines.Outcome measure and analysisPrimary endpoint was the incidence of post-traumatic intracranial bleeding in patients either on anticoagulants or anti-platelet drugs and in patients who were not on these therapies. Bayesian statistical analysis with calculation of Confidence Intervals (CI) was then performed.Main resultsSixty scans were positive for bleeding: 59 patients fulfilled the criteria and 1 did not. Amongst patients with haemorrhage, 24 were on either therapy and only one did not meet the guidelines but in this patient the CT scan was performed before 2 h from the mTBI. Patients on either therapy did not have higher bleeding rates than patients on neither. There were higher bleeding rates in patients on anti-platelet therapy who met the guidelines vs. patients who did not. These rates overlapped with patients on neither therapy, meeting CCHR.ConclusionThe CCHR might be used for mTBI patients on either therapy. Anticoagulants and anti-platelet drugs should not be considered a risk factor for patients with mTBI and a GCS of 15. Multicentric studies are needed to confirm this result.
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Affiliation(s)
- Laura Uccella
- Emergency Department—EOC—Ospedale Regionale di Lugano, Lugano, Switzerland
| | - Cristiana Riboni
- Emergency Department—EOC—Ospedale Regionale di Lugano, Lugano, Switzerland
| | | | - Carola Biondi
- Emergency Department—EOC—Ospedale Regionale di Lugano, Lugano, Switzerland
| | - Graziano Uccheddu
- Emergency Department—EOC—Ospedale Regionale di Lugano, Lugano, Switzerland
| | - Roberta Petrino
- Emergency Department—EOC—Ospedale Regionale di Lugano, Lugano, Switzerland
| | - Pietro Majno-Hurst
- Surgery Department—EOC—Ospedale Regionale di Lugano, Lugano, Switzerland
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Wilson S, Chen KCJ, Chartier LB, Campbell SG, Dowling S, Upadhye S, Thiruganasambandamoorthy V. Revisiting Choosing Wisely recommendation #1: "Don't order CT head scan in adults and children who have suffered minor head injuries (unless positive for a validated clinical decision rule)". CAN J EMERG MED 2023:10.1007/s43678-023-00515-0. [PMID: 37253996 DOI: 10.1007/s43678-023-00515-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 04/22/2023] [Indexed: 06/01/2023]
Affiliation(s)
- Samuel Wilson
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | - Lucas B Chartier
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Emergency Medicine, University Health Network, Toronto, ON, Canada
| | - Samuel G Campbell
- Department of Emergency Medicine, Dalhousie University, Halifax, NS, Canada
| | - Shawn Dowling
- Department of Emergency Medicine, University of Calgary, Calgary, AB, Canada
| | - Suneel Upadhye
- Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada
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Hanaki N, Miyata J, Yamada Y, Shiga T. Choosing Wisely® in Japanese Emergency Medicine: Nine Recommendations to Improve The Value of Health Care. J Emerg Med 2023; 64:371-379. [PMID: 37019499 DOI: 10.1016/j.jemermed.2023.01.005] [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: 08/12/2022] [Revised: 12/09/2022] [Accepted: 01/06/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND The overuse of diagnostic and therapeutic modalities has become an issue in the field of emergency medicine. The health care system of Japan aims to provide the most appropriate quality and quantity of care at the right price, while focusing on patient value. The Choosing Wisely® campaign was launched in Japan and other countries. OBJECTIVE In this article, recommendations were discussed to improve the field of emergency medicine based on the state of the Japanese health care system. METHODS The modified Delphi method, a consensus-building method, was used in this study. The final recommendations were developed by a working group of 20 medical professionals, students, and patients, consisting of members of the emergency physician electronic mailing list. RESULTS From the 80 candidates recommended and excessive actions gathered, nine recommendations were formulated after two Delphi rounds. The recommendations included the suppression of excessive behavior and the implementation of appropriate medical treatment, like rapid pain relief and the application of ultrasonography during central venous catheter placement. CONCLUSIONS This study formulated recommendations to improve the field of Japanese emergency medicine, based on the feedback of patients and health care professionals. The nine recommendations will be helpful for all people involved in emergency care in Japan because they have the potential to prevent the overuse of diagnostic and therapeutic modalities, while maintaining the appropriate quality of patient care.
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Affiliation(s)
- Nao Hanaki
- Department of Social Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Jun Miyata
- Department of Island and Community Medicine, Nagasaki University Graduate School of Biomedical Sciences, Goto-shi, Nagasaki, Japan
| | - Yoshie Yamada
- Department of Healthcare Epidemiology, School of Public Health, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takashi Shiga
- Department of Emergency Medicine, International University of Health and Welfare, Tokyo, Otawara, Japan
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Ibrahim T, Thompson C, Borgundvaag B, McLeod SL. Antibiotic prescribing and outcomes for patients with uncomplicated purulent skin and soft tissue infections in the emergency department. CAN J EMERG MED 2022; 24:719-724. [PMID: 36166156 DOI: 10.1007/s43678-022-00366-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 07/20/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Current guidelines suggest adjuvant antibiotics after incision and drainage (I&D) of small, uncomplicated abscesses may improve patient outcomes, minimize pain, and prevent recurrence. The objective was to explore antibiotic prescribing at ED discharge and describe patient outcomes. METHODS This was a health records review of adult patients (≥ 18 years) discharged from an academic hospital ED (annual census 65,000) over a 2-year period with diagnosis of an uncomplicated skin abscess. Outcomes included any unplanned return ED visits within 30 days, repeat I&D, and escalation to intravenous (IV) antibiotics. RESULTS Of 389 ED visits, 85.6% patients underwent I&D, of which 62.2% were prescribed antibiotics at discharge. Of these patients, 36.7% received guideline recommended antibiotics (TMP-SMX or clindamycin). Of all patients who underwent I&D, 13.2% had an unplanned return ED visit within 30 days, 6.9% required repeat I&D, and 0.6% patients were escalated to IV antibiotics. Patients treated with cefalexin were more likely to have an unplanned return ED visit within 30 days (20.0 vs 5.3%; Δ14.7, 95% CI 4.6-24.4), and were more likely to have a repeat I&D within 30 days (13.7 vs 0%; Δ13.7, 95% CI 6.4-22.0), compared to patients prescribed guideline recommended antibiotics. Treatment with guideline recommended antibiotics reduced treatment failure significantly in MRSA positive patients (0.0 vs 44.4%; Δ44.4, 95% CI 13.4-73.3). CONCLUSIONS Antibiotics were prescribed for most abscesses that underwent I&D. Less than half of the patients received antibiotics that were guideline recommended. Compared to those who received cefalexin, patients prescribed TMP-SMX or clindamycin had fewer return ED visits and were less likely to have a repeat I&D within 30 days. However, adjuvant antibiotic use did not significantly improve outcomes overall, with most patients not requiring a change in management irrespective of antibiotic use.
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Affiliation(s)
- Tarek Ibrahim
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Cameron Thompson
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health, Toronto, ON, Canada
| | - Bjug Borgundvaag
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Shelley L McLeod
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health, Toronto, ON, Canada. .,Department of Medicine, University of Toronto, Toronto, ON, Canada. .,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.
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Chen KCJ, Thiruganasambandamoorthy V, Campbell SG, Upadhye S, Dowling S, Chartier LB. Choosing Wisely Canada: scratching the 7-year itch. CAN J EMERG MED 2022; 24:569-573. [PMID: 35819640 PMCID: PMC9273920 DOI: 10.1007/s43678-022-00349-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 06/15/2022] [Indexed: 02/08/2023]
Affiliation(s)
| | | | - Samuel G Campbell
- Department of Emergency Medicine, Dalhousie University, Halifax, NS, Canada
| | - Suneel Upadhye
- Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada
| | - Shawn Dowling
- Department of Emergency Medicine, University of Calgary, Calgary, AB, Canada
| | - Lucas B Chartier
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Emergency Medicine, University Health Network, Toronto, ON, Canada
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Response to Letter: "Do systemic antibiotics for skin and soft tissue abscesses after incision and drainage improve cure rates compared with placebo? - A critical appraisal". CAN J EMERG MED 2020; 22:E6. [PMID: 32697183 DOI: 10.1017/cem.2020.351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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