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Hinson JS, Zhao X, Klein E, Badaki‐Makun O, Rothman R, Copenhaver M, Smith A, Fenstermacher K, Toerper M, Pekosz A, Levin S. Multisite development and validation of machine learning models to predict severe outcomes and guide decision-making for emergency department patients with influenza. J Am Coll Emerg Physicians Open 2024; 5:e13117. [PMID: 38500599 PMCID: PMC10945311 DOI: 10.1002/emp2.13117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 01/10/2024] [Accepted: 01/25/2024] [Indexed: 03/20/2024] Open
Abstract
Objective Millions of Americans are infected by influenza annually. A minority seek care in the emergency department (ED) and, of those, only a limited number experience severe disease or death. ED clinicians must distinguish those at risk for deterioration from those who can be safely discharged. Methods We developed random forest machine learning (ML) models to estimate needs for critical care within 24 h and inpatient care within 72 h in ED patients with influenza. Predictor data were limited to those recorded prior to ED disposition decision: demographics, ED complaint, medical problems, vital signs, supplemental oxygen use, and laboratory results. Our study population was comprised of adults diagnosed with influenza at one of five EDs in our university health system between January 1, 2017 and May 18, 2022; visits were divided into two cohorts to facilitate model development and validation. Prediction performance was assessed by the area under the receiver operating characteristic curve (AUC) and the Brier score. Results Among 8032 patients with laboratory-confirmed influenza, incidence of critical care needs was 6.3% and incidence of inpatient care needs was 19.6%. The most common reasons for ED visit were symptoms of respiratory tract infection, fever, and shortness of breath. Model AUCs were 0.89 (95% CI 0.86-0.93) for prediction of critical care and 0.90 (95% CI 0.88-0.93) for inpatient care needs; Brier scores were 0.026 and 0.042, respectively. Importantpredictors included shortness of breath, increasing respiratory rate, and a high number of comorbid diseases. Conclusions ML methods can be used to accurately predict clinical deterioration in ED patients with influenza and have potential to support ED disposition decision-making.
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Affiliation(s)
- Jeremiah S. Hinson
- Department of Emergency MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
- Malone Center for Engineering in HealthcareJohns Hopkins University Whiting School of EngineeringBaltimoreMarylandUSA
| | - Xihan Zhao
- Department of Emergency MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Eili Klein
- Department of Emergency MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
- One Health TrustWashingtonDistrict of ColumbiaUSA
| | - Oluwakemi Badaki‐Makun
- Department of Emergency MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
- Department of PediatricsJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Richard Rothman
- Department of Emergency MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Martin Copenhaver
- Department of Emergency MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Aria Smith
- Department of Emergency MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
- Malone Center for Engineering in HealthcareJohns Hopkins University Whiting School of EngineeringBaltimoreMarylandUSA
| | - Katherine Fenstermacher
- Department of Emergency MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Matthew Toerper
- Department of Emergency MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Andrew Pekosz
- Department of Microbiology and ImmunologyJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Scott Levin
- Department of Emergency MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
- Malone Center for Engineering in HealthcareJohns Hopkins University Whiting School of EngineeringBaltimoreMarylandUSA
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Busse LW, Schaich CL, Chappell MC, McCurdy MT, Staples EM, Ten Lohuis CC, Hinson JS, Sevransky JE, Rothman RE, Wright DW, Martin GS, Khanna AK. Association of Active Renin Content With Mortality in Critically Ill Patients: A Post hoc Analysis of the Vitamin C, Thiamine, and Steroids in Sepsis (VICTAS) Trial. Crit Care Med 2024; 52:441-451. [PMID: 37947484 PMCID: PMC10876175 DOI: 10.1097/ccm.0000000000006095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
OBJECTIVE Sepsis is a leading cause of mortality. Predicting outcomes is challenging and few biomarkers perform well. Defects in the renin-angiotensin system (RAS) can predict clinical outcomes in sepsis and may outperform traditional biomarkers. We postulated that RAS dysfunction (elevated active renin, angiotensin 1-7 [Ang-(1-7)], and angiotensin-converting enzyme 2 (ACE2) activity with depressed Ang-II and ACE activity) would be associated with mortality in a cohort of septic patients. DESIGN Post hoc analysis of patients enrolled in the Vitamin C, Thiamine, and Steroids in Sepsis (VICTAS) randomized controlled trial. SETTING Forty-three hospitals across the United States. PATIENTS Biorepository samples of 103 patients. INTERVENTIONS We analyzed day 0 (within 24 hr of respiratory failure, septic shock, or both) and day 3 samples ( n = 103 and 95, respectively) for assessment of the RAS. The association of RAS values with 30-day mortality was determined using Cox proportional hazards regression with multivariable adjustments for age, sex, VICTAS treatment arm, systolic blood pressure, Sequential Organ Failure Assessment Score, and vasopressor use. MEASUREMENTS AND MAIN RESULTS High baseline active renin values were associated with higher 30-day mortality when dichotomized to the median of 188.7 pg/mL (hazard ratio [HR] = 2.84 [95% CI, 1.10-7.33], p = 0.031) or stratified into quartiles (Q1 = ref, HR Q2 = 2.01 [0.37-11.04], HR Q3 = 3.22 [0.64-16.28], HR Q4 = 5.58 [1.18-26.32], p for linear trend = 0.023). A 1- sd (593.6 pg/mL) increase in renin from day 0 to day 3 was associated with increased mortality (HR = 3.75 [95% CI, 1.94-7.22], p < 0.001), and patients whose renin decreased had improved survival compared with those whose renin increased (HR 0.22 [95% CI, 0.08-0.60], p = 0.003). Ang-(1-7), ACE2 activity, Ang-II and ACE activity did not show this association. Mortality was attenuated in patients with renin over the median on day 0 who received the VICTAS intervention, but not on day 3 ( p interaction 0.020 and 0.137, respectively). There were no additional consistent patterns of mortality on the RAS from the VICTAS intervention. CONCLUSIONS Baseline serum active renin levels were strongly associated with mortality in critically ill patients with sepsis. Furthermore, a greater relative activation in circulating renin from day 0 to day 3 was associated with a higher risk of death.
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Affiliation(s)
- Laurence W Busse
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA
- Emory Critical Care Center, Emory Healthcare, Atlanta, GA
| | - Christopher L Schaich
- Hypertension and Vascular Research Center, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Mark C Chappell
- Hypertension and Vascular Research Center, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Michael T McCurdy
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Erin M Staples
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
| | | | - Jeremiah S Hinson
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Jonathan E Sevransky
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA
- Emory Critical Care Center, Emory Healthcare, Atlanta, GA
| | - Richard E Rothman
- Department of Emergency Medicine, Johns Hopkins University, The Johns Hopkins Hospital, Baltimore, MD
| | - David W Wright
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA
- Grady Marcus Trauma and Emergency Care Center, Atlanta, GA
| | - Greg S Martin
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA
- Emory Critical Care Center, Emory Healthcare, Atlanta, GA
| | - Ashish K Khanna
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA
- Emory Critical Care Center, Emory Healthcare, Atlanta, GA
- Hypertension and Vascular Research Center, Wake Forest University School of Medicine, Winston-Salem, NC
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, MD
- Department of Emergency Medicine, Johns Hopkins University, The Johns Hopkins Hospital, Baltimore, MD
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA
- Grady Marcus Trauma and Emergency Care Center, Atlanta, GA
- Department of Anesthesiology, Section of Critical Care Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
- Outcomes Research Consortium, Cleveland, OH
- Perioperative Outcomes and Informatics Collaborative, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC
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Chambliss AB, Devaraj S, Hinson JS, Katz SE, Kerbel RB, Ledeboer NA. New Sepsis Diagnostics and Their Impacts on Clinical Decision-Making and Treatment Protocols. Clin Chem 2024; 70:361-367. [PMID: 38170198 DOI: 10.1093/clinchem/hvad211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 11/16/2023] [Indexed: 01/05/2024]
Affiliation(s)
- Allison B Chambliss
- Associate Professor, Department of Pathology and Laboratory Medicine, University of California Los Angeles, Los Angeles, CA, United States
| | - Sridevi Devaraj
- Professor, Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, United States
| | - Jeremiah S Hinson
- Associate Professor, Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Sophie E Katz
- Assistant Professor, Department of Pediatric Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Russell B Kerbel
- Associate Professor, Department of Medicine, University of California Los Angeles, Los Angeles, CA, United States
| | - Nathan A Ledeboer
- Professor, Department of Pathology and Laboratory Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
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Ehmann MR, Klein EY, Zhao X, Mitchell J, Menez S, Smith A, Levin S, Hinson JS. Epidemiology and Clinical Outcomes of Community-Acquired Acute Kidney Injury in the Emergency Department: A Multisite Retrospective Cohort Study. Am J Kidney Dis 2023:S0272-6386(23)00945-9. [PMID: 38072210 DOI: 10.1053/j.ajkd.2023.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 09/26/2023] [Accepted: 10/07/2023] [Indexed: 02/02/2024]
Abstract
RATIONALE & OBJECTIVE The prevalence of community-acquired acute kidney injury (CA-AKI) in the United States and its clinical consequences are not well described. Our objective was to describe the epidemiology of CA-AKI and the associated clinical outcomes. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS 178,927 encounters by 139,632 adults at 5 US emergency departments (EDs) between July 1, 2017, and December 31, 2022. PREDICTORS CA-AKI identified using KDIGO (Kidney Disease: Improving Global Outcomes) serum creatinine (Scr)-based criteria. OUTCOMES For encounters resulting in hospitalization, the in-hospital trajectory of AKI severity, dialysis initiation, intensive care unit (ICU) admission, and death. For all encounters, occurrence over 180 days of hospitalization, ICU admission, new or progressive chronic kidney disease, dialysis initiation, and death. ANALYTICAL APPROACH Multivariable logistic regression analysis to test the association between CA-AKI and measured outcomes. RESULTS For all encounters, 10.4% of patients met the criteria for any stage of AKI on arrival to the ED. 16.6% of patients admitted to the hospital from the ED had CA-AKI on arrival to the ED. The likelihood of AKI recovery was inversely related to CA-AKI stage on arrival to the ED. Among encounters for hospitalized patients, CA-AKI was associated with in-hospital dialysis initiation (OR, 6.2; 95% CI, 5.1-7.5), ICU admission (OR, 1.9; 95% CI, 1.7-2.0), and death (OR, 2.2; 95% CI, 2.0-2.5) compared with patients without CA-AKI. Among all encounters, CA-AKI was associated with new or progressive chronic kidney disease (OR, 6.0; 95% CI, 5.6-6.4), dialysis initiation (OR, 5.1; 95% CI, 4.5-5.7), subsequent hospitalization (OR, 1.1; 95% CI, 1.1-1.2) including ICU admission (OR, 1.2; 95% CI, 1.1-1.4), and death (OR, 1.6; 95% CI, 1.5-1.7) during the subsequent 180 days. LIMITATIONS Residual confounding. Study implemented at a single university-based health system. Potential selection bias related to exclusion of patients without an available baseline Scr measurement. Potential ascertainment bias related to limited repeat Scr data during follow-up after an ED visit. CONCLUSIONS CA-AKI is a common and important entity that is associated with serious adverse clinical consequences during the 6-month period after diagnosis. PLAIN-LANGUAGE SUMMARY Acute kidney injury (AKI) is a condition characterized by a rapid decline in kidney function. There are many causes of AKI, but few studies have examined how often AKI is already present when patients first arrive to an emergency department seeking medical attention for any reason. We analyzed approximately 175,000 visits to Johns Hopkins emergency departments and found that AKI is common on presentation to the emergency department and that patients with AKI have increased risks of hospitalization, intensive care unit admission, development of chronic kidney disease, requirement of dialysis, and death in the first 6 months after diagnosis. AKI is an important condition for health care professionals to recognize and is associated with serious adverse outcomes.
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Affiliation(s)
- Michael R Ehmann
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland; Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland.
| | - Eili Y Klein
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland; Center for Disease Dynamics, Economics & Policy, Washington, District of Columbia
| | - Xihan Zhao
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jonathon Mitchell
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Steven Menez
- Division of Nephrology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | | | - Scott Levin
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland; Malone Center for Engineering in Healthcare, Johns Hopkins Whiting School of Engineering, Baltimore, Maryland; Beckman Coulter, Brea, California
| | - Jeremiah S Hinson
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland; Malone Center for Engineering in Healthcare, Johns Hopkins Whiting School of Engineering, Baltimore, Maryland; Beckman Coulter, Brea, California
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Strauss AT, Sidoti CN, Sung HC, Jain VS, Lehmann H, Purnell TS, Jackson JW, Malinsky D, Hamilton JP, Garonzik-Wang J, Gray SH, Levan ML, Hinson JS, Gurses AP, Gurakar A, Segev DL, Levin S. Artificial intelligence-based clinical decision support for liver transplant evaluation and considerations about fairness: A qualitative study. Hepatol Commun 2023; 7:e0239. [PMID: 37695082 PMCID: PMC10497243 DOI: 10.1097/hc9.0000000000000239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 06/28/2023] [Indexed: 09/12/2023] Open
Abstract
BACKGROUND The use of large-scale data and artificial intelligence (AI) to support complex transplantation decisions is in its infancy. Transplant candidate decision-making, which relies heavily on subjective assessment (ie, high variability), provides a ripe opportunity for AI-based clinical decision support (CDS). However, AI-CDS for transplant applications must consider important concerns regarding fairness (ie, health equity). The objective of this study was to use human-centered design methods to elicit providers' perceptions of AI-CDS for liver transplant listing decisions. METHODS In this multicenter qualitative study conducted from December 2020 to July 2021, we performed semistructured interviews with 53 multidisciplinary liver transplant providers from 2 transplant centers. We used inductive coding and constant comparison analysis of interview data. RESULTS Analysis yielded 6 themes important for the design of fair AI-CDS for liver transplant listing decisions: (1) transparency in the creators behind the AI-CDS and their motivations; (2) understanding how the AI-CDS uses data to support recommendations (ie, interpretability); (3) acknowledgment that AI-CDS could mitigate emotions and biases; (4) AI-CDS as a member of the transplant team, not a replacement; (5) identifying patient resource needs; and (6) including the patient's role in the AI-CDS. CONCLUSIONS Overall, providers interviewed were cautiously optimistic about the potential for AI-CDS to improve clinical and equitable outcomes for patients. These findings can guide multidisciplinary developers in the design and implementation of AI-CDS that deliberately considers health equity.
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Affiliation(s)
- Alexandra T. Strauss
- Department of Medicine, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Carolyn N. Sidoti
- Department of Surgery, New York University, Grossman School of Medicine, New York, New York, USA
| | - Hannah C. Sung
- Department of Surgery, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Vedant S. Jain
- Department of Surgery, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Harold Lehmann
- Department of Medicine, Division of Biomedical Informatics & Data Science, School of Medicine, Baltimore, Maryland, USA
| | - Tanjala S. Purnell
- Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - John W. Jackson
- Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Daniel Malinsky
- Department of Biostatistics, Columbia University Mailman School of Public Health, New York, New York, USA
| | - James P. Hamilton
- Department of Medicine, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Jacqueline Garonzik-Wang
- Department of Surgery, University of Wisconsin, School of Medicine and Public Health, Madison, Wisconsin
| | - Stephen H. Gray
- Department of Surgery, University of Maryland, School of Medicine, Baltimore, Maryland, USA
| | - Macey L. Levan
- Department of Surgery, New York University, Grossman School of Medicine, New York, New York, USA
| | - Jeremiah S. Hinson
- Department of Emergency Medicine, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Ayse P. Gurses
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ahmet Gurakar
- Department of Medicine, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Dorry L. Segev
- Department of Surgery, New York University, Grossman School of Medicine, New York, New York, USA
| | - Scott Levin
- Department of Emergency Medicine, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
- Beckman Coulter, Brea, California, USA
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Troncoso R, Garfinkel EM, Hinson JS, Smith A, Margolis AM, Levy MJ. Do prehospital sepsis alerts decrease time to complete CMS sepsis measures? Am J Emerg Med 2023; 71:81-85. [PMID: 37354893 DOI: 10.1016/j.ajem.2023.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 06/09/2023] [Accepted: 06/11/2023] [Indexed: 06/26/2023] Open
Abstract
INTRODUCTION In an effort to improve sepsis outcomes the Centers for Medicare and Medicaid Services (CMS) established a time sensitive sepsis management bundle as a core quality measure that includes blood culture collection, serum lactate collection, initiation of intravenous fluid administration, and initiation of broad-spectrum antibiotics. Few studies examine the effects of a prehospital sepsis alert protocol on decreasing time to complete CMS sepsis core measures. METHODS This study was a retrospective cohort study of patients transported via EMS from December 1, 2018 to December 1, 2019 who met the criteria of the Maryland Statewide EMS sepsis protocol and compared outcomes between patients who activated a prehospital sepsis alert and patients who did not activate a prehospital sepsis alert. The Maryland Institute for Emergency Medical Services Systems developed a sepsis protocol that instructs EMS providers to notify the nearest appropriate facility with a sepsis alert if a patient 18 years of age and older is suspected of having an infection and also presents with at least two of the following: temperature >38 °C or <35.5 °C, a heart rate >100 beats per minute, a respiratory rate >25 breaths per minute or end-tidal carbon dioxide less than or equal to 32 mmHg, a systolic blood pressure <90 mmHg, or a point of care lactate reading greater than or equal to 4 mmol/L. RESULTS Median time to achieve all four studied CMS sepsis core measures was 103 min [IQR 61-153] for patients who received a prehospital sepsis alert and 106.5 min [IQR 75-189] for patients who did not receive a prehospital sepsis alert (p-value 0.105). Median time to completion was shorter for serum lactate collection (28 min. vs 35 min., p-value 0.019), blood culture collection (28 min. vs 38 min., p-value <0.01), and intravenous fluid administration (54 min. vs 61 min., p-value 0.025) but was not significantly different for antibiotic administration (94 min. vs 103 min., p-value 0.12) among patients who triggered a sepsis alert. CONCLUSION This study questions the effectiveness of prehospital sepsis alert protocols on decreasing time to complete CMS sepsis core measures. Future studies should address if these times can be impacted by having EMS providers independently administer antibiotics.
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Affiliation(s)
- Ruben Troncoso
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, United States of America.
| | - Eric M Garfinkel
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, United States of America
| | - Jeremiah S Hinson
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, United States of America
| | - Aria Smith
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, United States of America
| | - Asa M Margolis
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, United States of America
| | - Matthew J Levy
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, United States of America
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Ehmann MR, Mitchell J, Levin S, Smith A, Menez S, Hinson JS, Klein EY. Renal outcomes following intravenous contrast administration in patients with acute kidney injury: a multi-site retrospective propensity-adjusted analysis. Intensive Care Med 2023; 49:205-215. [PMID: 36715705 DOI: 10.1007/s00134-022-06966-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 12/21/2022] [Indexed: 01/31/2023]
Abstract
PURPOSE Evidence of an association between intravenous contrast media (CM) and persistent renal dysfunction is lacking for patients with pre-existing acute kidney injury (AKI). This study was designed to determine the association between intravenous CM administration and persistent AKI in patients with pre-existing AKI. METHODS A retrospective propensity-weighted and entropy-balanced observational cohort analysis of consecutive hospitalized patients ≥ 18 years old meeting Kidney Disease Improving Global Outcomes (KDIGO) creatinine-based criteria for AKI at time of arrival to one of three emergency departments between 7/1/2017 and 6/30/2021 who did or did not receive intravenous CM. Outcomes included persistent AKI at hospital discharge and initiation of dialysis within 180 days of index encounter. RESULTS Our analysis included 14,449 patient encounters, with 12.8% admitted to the intensive care unit (ICU). CM was administered in 18.4% of all encounters. AKI resolved prior to hospital discharge for 69.1%. No association between intravenous CM administration and persistent AKI was observed after unadjusted multivariable logistic regression modeling (OR 1; 95% CI 0.89-1.11), propensity weighting (OR 0.93; 95% CI 0.83-1.05), and entropy balancing (OR 0.94; 95% CI 0.83-1.05). Sub-group analysis in those admitted to the ICU yielded similar results. Initiation of dialysis within 180 days was observed in 5.4% of the cohort. An association between CM administration and increased risk of dialysis within 180 days was not observed. CONCLUSION Among patients with pre-existing AKI, contrast administration was not associated with either persistent AKI at hospital discharge or initiation of dialysis within 180 days. Current consensus recommendations for use of intravenous CM in patients with stable renal disease may also be applied to patients with pre-existing AKI.
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Affiliation(s)
- Michael R Ehmann
- Department of Emergency Medicine, Johns Hopkins School of Medicine, 1830 E. Monument Street, Suite 6-100, Baltimore, MD, 21287, USA.
| | - Jonathon Mitchell
- Department of Emergency Medicine, Johns Hopkins School of Medicine, 1830 E. Monument Street, Suite 6-100, Baltimore, MD, 21287, USA
| | - Scott Levin
- Department of Emergency Medicine, Johns Hopkins School of Medicine, 1830 E. Monument Street, Suite 6-100, Baltimore, MD, 21287, USA
| | - Aria Smith
- Department of Emergency Medicine, Johns Hopkins School of Medicine, 1830 E. Monument Street, Suite 6-100, Baltimore, MD, 21287, USA
| | - Steven Menez
- Division of Nephrology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Jeremiah S Hinson
- Department of Emergency Medicine, Johns Hopkins School of Medicine, 1830 E. Monument Street, Suite 6-100, Baltimore, MD, 21287, USA
| | - Eili Y Klein
- Department of Emergency Medicine, Johns Hopkins School of Medicine, 1830 E. Monument Street, Suite 6-100, Baltimore, MD, 21287, USA
- Center for Disease Dynamics, Economics & Policy, Washington, DC, USA
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Niforatos JD, Ehmann MR, Balhara KS, Hinson JS, Ramcharran L, Lobner K, Weygandt PL. Management of atrial flutter and atrial fibrillation with rapid ventricular response in patients with acute decompensated heart failure: A systematic review. Acad Emerg Med 2023; 30:124-132. [PMID: 36326565 DOI: 10.1111/acem.14618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 10/15/2022] [Accepted: 10/24/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective was to evaluate the comparative effectiveness and safety of pharmacological and nonpharmacological management options for atrial fibrillation/atrial flutter with rapid ventricular response (AFRVR) in patients with acute decompensated heart failure (ADHF) in the acute care setting. METHODS This study was a systematic review of observational studies or randomized clinical trials (RCT) of adult patients with AFRVR and concomitant ADHF in the emergency department (ED), intensive care unit, or step-down unit. The primary effectiveness outcome was successful rate or rhythm control. Safety outcomes were adverse events, such as symptomatic hypotension and venous thromboembolism. RESULTS A total of 6577 unique articles were identified. Five studies met inclusion criteria: one RCT in the inpatient setting and four retrospective studies, two in the ED and the other three in the inpatient setting. In the RCT of diltiazem versus placebo, 22 patients (100%) in the treatment group had a therapeutic response compared to 0/15 (0%) in the placebo group, with no significant safety differences between the two groups. For three of the observational studies, data were limited. One observation study showed no difference between metoprolol and diltiazem for successful rate control, but worsening heart failure symptoms occurred more frequently in those receiving diltiazem compared to metoprolol (19 patients [33%] vs. 10 patients [15%], p = 0.019). A single study included electrical cardioversion (one patient exposed with failure to convert to sinus rhythm) as nonpharmacological management. The overall risk of bias for included studies ranged from serious to critical. Missing data and heterogeneity of definitions for effectiveness and safety outcomes precluded the combination of results for quantitative meta-analysis. CONCLUSIONS High-level evidence to inform clinical decision making regarding effective and safe management of AFRVR in patients with ADHF in the acute care setting is lacking.
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Affiliation(s)
- Joshua D Niforatos
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michael R Ehmann
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kamna S Balhara
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jeremiah S Hinson
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lukas Ramcharran
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Katie Lobner
- Welch Medical Library, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - P Logan Weygandt
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Ehmann MR, Hinson JS, Menez S, Smith A, Klein EY, Levin S. Optimal Acute Kidney Injury Algorithm for Detecting Acute Kidney Injury at Emergency Department Presentation. Kidney Med 2023; 5:100588. [PMID: 36860291 PMCID: PMC9969165 DOI: 10.1016/j.xkme.2022.100588] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
- Michael R. Ehmann
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jeremiah S. Hinson
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Steven Menez
- Department of Medicine, Division of Nephrology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Aria Smith
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Eili Y. Klein
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
- Center for Disease Dynamics, Economics and Policy, Washington, District of Columbia
| | - Scott Levin
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
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10
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Malinovska A, Hernried B, Lin A, Badaki-Makun O, Fenstermacher K, Ervin AM, Ehrhardt S, Levin S, Hinson JS. Monocyte Distribution Width as a Diagnostic Marker for Infection: A Systematic Review and Meta-analysis. Chest 2023:S0012-3692(23)00122-8. [PMID: 36681146 DOI: 10.1016/j.chest.2022.12.049] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 11/16/2022] [Accepted: 12/22/2022] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Monocyte distribution width (MDW) is an emerging biomarker for infection. It is available easily and quickly as part of the CBC count, which is performed routinely on hospital admission. The increasing availability and promising results of MDW as a biomarker in sepsis has prompted an expansion of its use to other infectious diseases. RESEARCH QUESTION What is the diagnostic performance of MDW across multiple infectious disease outcomes and care settings? STUDY DESIGN AND METHODS A systematic review of the diagnostic performance of MDW across multiple infectious disease outcomes was conducted by searching PubMed, Embase, Scopus, and Web of Science through February 4, 2022. Meta-analysis was performed for outcomes with three or more reports identified (sepsis and COVID-19). Diagnostic performance measures were calculated for individual studies with pooled estimates created by linear mixed-effects models. RESULTS We identified 29 studies meeting inclusion criteria. Most examined sepsis (19 studies) and COVID-19 (six studies). Pooled estimates of diagnostic performance for sepsis differed by reference standard (Second vs Third International Consensus Definitions for Sepsis and Septic Shock criteria) and tube anticoagulant used and ranged from an area under the receiver operating characteristic curve (AUC) of 0.74 to 0.94, with mean sensitivity of 0.69 to 0.79 and mean specificity of 0.57 to 0.86. For COVID-19, the pooled AUC of MDW was 0.76, mean sensitivity was 0.79, and mean specificity was 0.59. INTERPRETATION MDW exhibited good diagnostic performance for sepsis and COVID-19. Diagnostic thresholds for sepsis should be chosen with consideration of reference standard and tube type used. TRIAL REGISTRY Prospero; No.: CRD42020210074; URL: https://www.crd.york.ac.uk/prospero/.
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Affiliation(s)
- Alexandra Malinovska
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Center for Clinical Trials and Evidence Synthesis, Department of Epidemiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Benjamin Hernried
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Andrew Lin
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Oluwakemi Badaki-Makun
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Katherine Fenstermacher
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ann Margret Ervin
- Center for Clinical Trials and Evidence Synthesis, Department of Epidemiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Stephan Ehrhardt
- Center for Clinical Trials and Evidence Synthesis, Department of Epidemiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Scott Levin
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jeremiah S Hinson
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
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11
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Hinson JS, Klein E, Smith A, Toerper M, Dungarani T, Hager D, Hill P, Kelen G, Niforatos JD, Stephens RS, Strauss AT, Levin S. Multisite implementation of a workflow-integrated machine learning system to optimize COVID-19 hospital admission decisions. NPJ Digit Med 2022; 5:94. [PMID: 35842519 PMCID: PMC9287691 DOI: 10.1038/s41746-022-00646-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 06/24/2022] [Indexed: 11/09/2022] Open
Abstract
Demand has outstripped healthcare supply during the coronavirus disease 2019 (COVID-19) pandemic. Emergency departments (EDs) are tasked with distinguishing patients who require hospital resources from those who may be safely discharged to the community. The novelty and high variability of COVID-19 have made these determinations challenging. In this study, we developed, implemented and evaluated an electronic health record (EHR) embedded clinical decision support (CDS) system that leverages machine learning (ML) to estimate short-term risk for clinical deterioration in patients with or under investigation for COVID-19. The system translates model-generated risk for critical care needs within 24 h and inpatient care needs within 72 h into rapidly interpretable COVID-19 Deterioration Risk Levels made viewable within ED clinician workflow. ML models were derived in a retrospective cohort of 21,452 ED patients who visited one of five ED study sites and were prospectively validated in 15,670 ED visits that occurred before (n = 4322) or after (n = 11,348) CDS implementation; model performance and numerous patient-oriented outcomes including in-hospital mortality were measured across study periods. Incidence of critical care needs within 24 h and inpatient care needs within 72 h were 10.7% and 22.5%, respectively and were similar across study periods. ML model performance was excellent under all conditions, with AUC ranging from 0.85 to 0.91 for prediction of critical care needs and 0.80–0.90 for inpatient care needs. Total mortality was unchanged across study periods but was reduced among high-risk patients after CDS implementation.
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Affiliation(s)
- Jeremiah S Hinson
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA. .,Malone Center for Engineering in Healthcare, Johns Hopkins University Whiting School of Engineering, Baltimore, MD, USA.
| | - Eili Klein
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Center for Disease Dynamics, Economics & Policy, Washington, DC, USA
| | - Aria Smith
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Malone Center for Engineering in Healthcare, Johns Hopkins University Whiting School of Engineering, Baltimore, MD, USA
| | - Matthew Toerper
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Trushar Dungarani
- Department of Medicine, Howard County General Hospital, Columbia, MD, USA
| | - David Hager
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Peter Hill
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gabor Kelen
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joshua D Niforatos
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - R Scott Stephens
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alexandra T Strauss
- Malone Center for Engineering in Healthcare, Johns Hopkins University Whiting School of Engineering, Baltimore, MD, USA.,Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Scott Levin
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Malone Center for Engineering in Healthcare, Johns Hopkins University Whiting School of Engineering, Baltimore, MD, USA
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12
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Malinovska A, Hinson JS, Badaki‐Makun O, Hernried B, Smith A, Debraine A, Toerper M, Rothman RE, Kickler T, Levin S. Monocyte distribution width as part of a broad pragmatic sepsis screen in the emergency department. J Am Coll Emerg Physicians Open 2022; 3:e12679. [PMID: 35252973 PMCID: PMC8886187 DOI: 10.1002/emp2.12679] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 01/24/2022] [Accepted: 01/27/2022] [Indexed: 12/12/2022] Open
Abstract
Study Objective Methods Results Conclusion
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Affiliation(s)
- Alexandra Malinovska
- Department of Emergency Medicine Johns Hopkins University School of Medicine Baltimore Maryland USA
- Department of Epidemiology Johns Hopkins University Bloomberg School of Public Health Baltimore Maryland USA
| | - Jeremiah S. Hinson
- Department of Emergency Medicine Johns Hopkins University School of Medicine Baltimore Maryland USA
- Malone Center for Engineering in Healthcare Johns Hopkins Whiting School of Engineering Baltimore Maryland USA
- StoCastic Baltimore Maryland USA
| | - Oluwakemi Badaki‐Makun
- Malone Center for Engineering in Healthcare Johns Hopkins Whiting School of Engineering Baltimore Maryland USA
- Division of Pediatric Emergency Medicine, Department of Pediatrics Johns Hopkins University School of Medicine Baltimore Maryland USA
| | - Benjamin Hernried
- Department of Emergency Medicine Johns Hopkins University School of Medicine Baltimore Maryland USA
| | - Aria Smith
- Department of Emergency Medicine Johns Hopkins University School of Medicine Baltimore Maryland USA
- Malone Center for Engineering in Healthcare Johns Hopkins Whiting School of Engineering Baltimore Maryland USA
| | | | - Matthew Toerper
- Department of Emergency Medicine Johns Hopkins University School of Medicine Baltimore Maryland USA
- Malone Center for Engineering in Healthcare Johns Hopkins Whiting School of Engineering Baltimore Maryland USA
- StoCastic Baltimore Maryland USA
| | - Richard E. Rothman
- Department of Emergency Medicine Johns Hopkins University School of Medicine Baltimore Maryland USA
| | - Thomas Kickler
- Department of Pathology Johns Hopkins University School of Medicine Baltimore Maryland USA
| | - Scott Levin
- Department of Emergency Medicine Johns Hopkins University School of Medicine Baltimore Maryland USA
- Malone Center for Engineering in Healthcare Johns Hopkins Whiting School of Engineering Baltimore Maryland USA
- StoCastic Baltimore Maryland USA
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13
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Sevransky JE, Rothman RE, Hager DN, Bernard GR, Brown SM, Buchman TG, Busse LW, Coopersmith CM, DeWilde C, Ely EW, Eyzaguirre LM, Fowler AA, Gaieski DF, Gong MN, Hall A, Hinson JS, Hooper MH, Kelen GD, Khan A, Levine MA, Lewis RJ, Lindsell CJ, Marlin JS, McGlothlin A, Moore BL, Nugent KL, Nwosu S, Polito CC, Rice TW, Ricketts EP, Rudolph CC, Sanfilippo F, Viele K, Martin GS, Wright DW. Effect of Vitamin C, Thiamine, and Hydrocortisone on Ventilator- and Vasopressor-Free Days in Patients With Sepsis: The VICTAS Randomized Clinical Trial. JAMA 2021; 325:742-750. [PMID: 33620405 PMCID: PMC7903252 DOI: 10.1001/jama.2020.24505] [Citation(s) in RCA: 144] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
IMPORTANCE Sepsis is a common syndrome with substantial morbidity and mortality. A combination of vitamin C, thiamine, and corticosteroids has been proposed as a potential treatment for patients with sepsis. OBJECTIVE To determine whether a combination of vitamin C, thiamine, and hydrocortisone every 6 hours increases ventilator- and vasopressor-free days compared with placebo in patients with sepsis. DESIGN, SETTING, AND PARTICIPANTS Multicenter, randomized, double-blind, adaptive-sample-size, placebo-controlled trial conducted in adult patients with sepsis-induced respiratory and/or cardiovascular dysfunction. Participants were enrolled in the emergency departments or intensive care units at 43 hospitals in the United States between August 2018 and July 2019. After enrollment of 501 participants, funding was withheld, leading to an administrative termination of the trial. All study-related follow-up was completed by January 2020. INTERVENTIONS Participants were randomized to receive intravenous vitamin C (1.5 g), thiamine (100 mg), and hydrocortisone (50 mg) every 6 hours (n = 252) or matching placebo (n = 249) for 96 hours or until discharge from the intensive care unit or death. Participants could be treated with open-label corticosteroids by the clinical team, with study hydrocortisone or matching placebo withheld if the total daily dose was greater or equal to the equivalent of 200 mg of hydrocortisone. MAIN OUTCOMES AND MEASURES The primary outcome was the number of consecutive ventilator- and vasopressor-free days in the first 30 days following the day of randomization. The key secondary outcome was 30-day mortality. RESULTS Among 501 participants randomized (median age, 62 [interquartile range {IQR}, 50-70] years; 46% female; 30% Black; median Acute Physiology and Chronic Health Evaluation II score, 27 [IQR, 20.8-33.0]; median Sequential Organ Failure Assessment score, 9 [IQR, 7-12]), all completed the trial. Open-label corticosteroids were prescribed to 33% and 32% of the intervention and control groups, respectively. Ventilator- and vasopressor-free days were a median of 25 days (IQR, 0-29 days) in the intervention group and 26 days (IQR, 0-28 days) in the placebo group, with a median difference of -1 day (95% CI, -4 to 2 days; P = .85). Thirty-day mortality was 22% in the intervention group and 24% in the placebo group. CONCLUSIONS AND RELEVANCE Among critically ill patients with sepsis, treatment with vitamin C, thiamine, and hydrocortisone, compared with placebo, did not significantly increase ventilator- and vasopressor-free days within 30 days. However, the trial was terminated early for administrative reasons and may have been underpowered to detect a clinically important difference. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03509350.
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Affiliation(s)
- Jonathan E. Sevransky
- Division of Pulmonary, Allergy, Critical Care, and Sleep, Emory University School of Medicine, Atlanta, Georgia
- Emory Critical Care Center, Emory Healthcare, Atlanta, Georgia
| | - Richard E. Rothman
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, Maryland
| | - David N. Hager
- Division of Pulmonary Critical Care, Johns Hopkins University, Baltimore, Maryland
| | - Gordon R. Bernard
- Division of Pulmonary Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Samuel M. Brown
- Division of Pulmonary Critical Care, Intermountain Medical Center and University of Utah, Salt Lake City
| | - Timothy G. Buchman
- Emory Critical Care Center, Emory Healthcare, Atlanta, Georgia
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Laurence W. Busse
- Division of Pulmonary, Allergy, Critical Care, and Sleep, Emory University School of Medicine, Atlanta, Georgia
- Emory Critical Care Center, Emory Healthcare, Atlanta, Georgia
| | - Craig M. Coopersmith
- Emory Critical Care Center, Emory Healthcare, Atlanta, Georgia
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Christine DeWilde
- Division of Pulmonary Critical Care, Virginia Commonwealth University, Richmond
| | - E. Wesley Ely
- Division of Pulmonary Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee
- Johns Hopkins Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Baltimore, Maryland
- Veteran’s Affairs Tennessee Valley Geriatric Research Education Clinical Center (GRECC), Nashville
| | | | - Alpha A. Fowler
- Division of Pulmonary Critical Care, Virginia Commonwealth University, Richmond
| | - David F. Gaieski
- Department of Emergency Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Michelle N. Gong
- Department of Critical Care, Montefiore Medical Center, Bronx, New York
| | - Alex Hall
- Department of Emergency Medicine, Emory University, Atlanta, Georgia
| | - Jeremiah S. Hinson
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Michael H. Hooper
- Division of Pulmonary Critical Care, Sentara Healthcare, Norfolk, Virginia
| | - Gabor D. Kelen
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Akram Khan
- Division of Pulmonary Critical Care, Oregon Health & Science University, Portland
| | - Mark A. Levine
- Molecular and Clinical Nutrition Section, National Institutes of Health, Bethesda, Maryland
| | - Roger J. Lewis
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
- Berry Consultants LLC, Austin, Texas
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
- Lundquist Institute for Biomedical Innovation, Torrance, California
| | - Chris J. Lindsell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jessica S. Marlin
- Vanderbilt Coordinating Center, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Brooks L. Moore
- Department of Emergency Medicine, Emory University, Atlanta, Georgia
| | | | - Samuel Nwosu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Carmen C. Polito
- Division of Pulmonary, Allergy, Critical Care, and Sleep, Emory University School of Medicine, Atlanta, Georgia
- Emory Critical Care Center, Emory Healthcare, Atlanta, Georgia
| | - Todd W. Rice
- Division of Pulmonary Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Erin P. Ricketts
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, Maryland
| | | | - Fred Sanfilippo
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Kert Viele
- Berry Consultants LLC, Austin, Texas
- Department of Biostatistics, University of Kentucky, Lexington
| | - Greg S. Martin
- Division of Pulmonary, Allergy, Critical Care, and Sleep, Emory University School of Medicine, Atlanta, Georgia
- Emory Critical Care Center, Emory Healthcare, Atlanta, Georgia
| | - David W. Wright
- Department of Emergency Medicine, Emory University, Atlanta, Georgia
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14
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Hinson JS, Rothman RE, Carroll K, Mostafa HH, Ghobadi K, Smith A, Martinez D, Shaw-Saliba K, Klein E, Levin S. Targeted rapid testing for SARS-CoV-2 in the emergency department is associated with large reductions in uninfected patient exposure time. J Hosp Infect 2020; 107:35-39. [PMID: 33038435 PMCID: PMC7538869 DOI: 10.1016/j.jhin.2020.09.035] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 09/30/2020] [Accepted: 09/30/2020] [Indexed: 12/05/2022]
Abstract
Opportunity exists to decrease healthcare-related exposure to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), preserve infection control resources, and increase care capacity by reducing the time to diagnosis of coronavirus disease 2019 (COVID-19). A retrospective cohort analysis was undertaken to measure the effect of targeted rapid molecular testing for SARS-CoV-2 on these outcomes. In comparison with standard platform testing, rapid testing was associated with a 65.6% reduction (12.6 h) in the median time to removal from the isolation cohort for patients with negative diagnostic results. This translated to an increase in COVID-19 treatment capacity of 3028 bed-hours and 7500 fewer patient interactions that required the use of personal protective equipment per week.
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Affiliation(s)
- J S Hinson
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - R E Rothman
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - K Carroll
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - H H Mostafa
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - K Ghobadi
- Department of Civil and Systems Engineering, Johns Hopkins University Whiting School of Engineering, Baltimore, MD, USA
| | - A Smith
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - D Martinez
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - K Shaw-Saliba
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - E Klein
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - S Levin
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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15
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Martinez DA, Levin SR, Klein EY, Parikh CR, Menez S, Taylor RA, Hinson JS. Early Prediction of Acute Kidney Injury in the Emergency Department With Machine-Learning Methods Applied to Electronic Health Record Data. Ann Emerg Med 2020; 76:501-514. [DOI: 10.1016/j.annemergmed.2020.05.026] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 05/13/2020] [Accepted: 05/18/2020] [Indexed: 12/14/2022]
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16
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Abstract
This study characterizes the trends in rates of SARS-CoV-2 positive test results among individuals in the Baltimore–Washington, DC area by self-reported race/ethnicity.
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Affiliation(s)
- Diego A. Martinez
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jeremiah S. Hinson
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Eili Y. Klein
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nathan A. Irvin
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mustapha Saheed
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kathleen R. Page
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Scott R. Levin
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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17
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Ehmann MR, Klein EY, Hinson JS. Evidence-based Consensus on Intravenous Contrast Media and Acute Kidney Injury Will Improve Patient Care in the Emergency Department. Radiology 2020; 295:E2. [DOI: 10.1148/radiol.2020200247] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Michael R. Ehmann
- Department of Emergency Medicine, The Johns Hopkins University School of Medicine, 1830 E Monument St, Suite 6-100, Baltimore, MD 21287
| | - Eili Y. Klein
- Department of Emergency Medicine, The Johns Hopkins University School of Medicine, 1830 E Monument St, Suite 6-100, Baltimore, MD 21287
| | - Jeremiah S. Hinson
- Department of Emergency Medicine, The Johns Hopkins University School of Medicine, 1830 E Monument St, Suite 6-100, Baltimore, MD 21287
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18
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Hinson JS, Ehmann MR, Klein EY. Evidence and Patient Safety Prevail Over Myth and Dogma: Consensus Guidelines on the Use of Intravenous Contrast Media. Ann Emerg Med 2020; 76:149-152. [PMID: 32362431 DOI: 10.1016/j.annemergmed.2020.03.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Jeremiah S Hinson
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Michael R Ehmann
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Eili Y Klein
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Emergency Medicine, Center for Disease Dynamics, Economics and Policy, Washington, DC
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19
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Lindsell CJ, McGlothlin A, Nwosu S, Rice TW, Hall A, Bernard GR, Busse LW, Ely EW, Fowler AA, Gaieski DF, Hinson JS, Hooper MH, Jackson JC, Kelen GD, Levine M, Martin GS, Rothman RE, Sevransky JE, Viele K, Wright DW, Hager DN. In response: Letter on update to the Vitamin C, Thiamine and Steroids in Sepsis (VICTAS) protocol. Trials 2020; 21:351. [PMID: 32317004 PMCID: PMC7175511 DOI: 10.1186/s13063-020-04290-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 03/28/2020] [Indexed: 11/10/2022] Open
Abstract
TRIAL REGISTRATION ClinicalTrials.gov: NCT03509350. Registered on 26 April 2018.
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Affiliation(s)
| | | | - Samuel Nwosu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Todd W Rice
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Alex Hall
- Department of Emergency Medicine, Emory University, Atlanta, GA, USA.,Grady Memorial Hospital, Atlanta, GA, USA
| | - Gordon R Bernard
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Laurence W Busse
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University, Atlanta, GA, USA
| | - E Wesley Ely
- Division of Pulmonary & Critical Care, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA.,Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center (GRECC), Nashville, TN, USA
| | - Alpha A Fowler
- Division of Pulmonary Disease & Critical Care Medicine, Department of Internal Medicine, The VCU Johnson Center for Critical Care and Pulmonary Research, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - David F Gaieski
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Jeremiah S Hinson
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Michael H Hooper
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Eastern Virginia Medical School and Sentara Healthcare, Norfolk, VA, USA
| | - James C Jackson
- Division of Pulmonary & Critical Care, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA.,Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center (GRECC), Nashville, TN, USA.,Department of Psychiatry, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Gabor D Kelen
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Mark Levine
- Molecular & Clinical Nutrition Section, Intramural Research Program, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, 10 Center Drive, Bethesda, MD, USA
| | - Greg S Martin
- Grady Memorial Hospital, Atlanta, GA, USA.,Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University, Emory Critical Care Center, Atlanta, GA, USA
| | - Richard E Rothman
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Jonathan E Sevransky
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University, Emory Critical Care Center, Atlanta, GA, USA
| | | | - David W Wright
- Department of Emergency Medicine, Emory University, Atlanta, GA, USA.,Grady Memorial Hospital, Atlanta, GA, USA
| | - David N Hager
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Johns Hopkins University, 1800 Orleans Street, Suite 9121, Baltimore, MD, 21287, USA
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20
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Hinson JS, Ehmann MR, Al Jalbout N, Ortmann MJ, Zschoche J, Klein EY. Risk of Acute Kidney Injury Associated With Medication Administration in the Emergency Department. J Emerg Med 2020; 58:487-496. [DOI: 10.1016/j.jemermed.2019.11.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 10/22/2019] [Accepted: 11/23/2019] [Indexed: 01/05/2023]
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21
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Affiliation(s)
- David N Hager
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Jeremiah S Hinson
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Richard E Rothman
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, Maryland
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22
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Lindsell CJ, McGlothlin A, Nwosu S, Rice TW, Hall A, Bernard GR, Busse LW, Ely EW, Fowler AA, Gaieski DF, Hinson JS, Hooper MH, Jackson JC, Kelen GD, Levine M, Martin GS, Rothman RE, Sevransky JE, Viele K, Wright DW, Hager DN. Update to the Vitamin C, Thiamine and Steroids in Sepsis (VICTAS) protocol: statistical analysis plan for a prospective, multicenter, double-blind, adaptive sample size, randomized, placebo-controlled, clinical trial. Trials 2019; 20:670. [PMID: 31801567 PMCID: PMC6894243 DOI: 10.1186/s13063-019-3775-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 10/09/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Observational research suggests that combined therapy with Vitamin C, thiamine and hydrocortisone may reduce mortality in patients with septic shock. METHODS AND DESIGN The Vitamin C, Thiamine and Steroids in Sepsis (VICTAS) trial is a multicenter, double-blind, adaptive sample size, randomized, placebo-controlled trial designed to test the efficacy of combination therapy with vitamin C (1.5 g), thiamine (100 mg), and hydrocortisone (50 mg) given every 6 h for up to 16 doses in patients with respiratory or circulatory dysfunction (or both) resulting from sepsis. The primary outcome is ventilator- and vasopressor-free days with mortality as the key secondary outcome. Recruitment began in August 2018 and is ongoing; 501 participants have been enrolled to date, with a planned maximum sample size of 2000. The Data and Safety Monitoring Board reviewed interim results at N = 200, 300, 400 and 500, and has recommended continuing recruitment. The next interim analysis will occur when N = 1000. This update presents the statistical analysis plan. Specifically, we provide definitions for key treatment and outcome variables, and for intent-to-treat, per-protocol, and safety analysis datasets. We describe the planned descriptive analyses, the main analysis of the primary end point, our approach to secondary and exploratory analyses, and handling of missing data. Our goal is to provide enough detail that our approach could be replicated by an independent study group, thereby enhancing the transparency of the study. TRIAL REGISTRATION ClinicalTrials.gov, NCT03509350. Registered on 26 April 2018.
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Affiliation(s)
| | | | - Samuel Nwosu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Todd W Rice
- Division of Pulmonary & Critical Care, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alex Hall
- Department of Emergency Medicine, Emory University, Atlanta, GA, USA.,Grady Memorial Hospital, Atlanta, GA, USA
| | - Gordon R Bernard
- Division of Pulmonary & Critical Care, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Laurence W Busse
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University, Atlanta, GA, USA
| | - E Wesley Ely
- Division of Pulmonary & Critical Care, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA.,Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center (GRECC), Nashville, TN, USA
| | - Alpha A Fowler
- Division of Pulmonary Disease & Critical Care Medicine, Department of Internal Medicine, The VCU Johnson Center for Critical Care and Pulmonary Research, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - David F Gaieski
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Jeremiah S Hinson
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Michael H Hooper
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Eastern Virginia Medical School and Sentara Healthcare, Norfolk, VA, USA
| | - James C Jackson
- Division of Pulmonary & Critical Care, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA.,Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center (GRECC), Nashville, TN, USA.,Department of Psychiatry, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gabor D Kelen
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Mark Levine
- Molecular & Clinical Nutrition Section, Intramural Research Program, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, 10 Center Drive, Bethesda, MD, USA
| | - Greg S Martin
- Grady Memorial Hospital, Atlanta, GA, USA.,Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University, Emory Critical Care Center, Atlanta, GA, USA
| | - Richard E Rothman
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Jonathan E Sevransky
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University, Emory Critical Care Center, Atlanta, GA, USA
| | | | - David W Wright
- Department of Emergency Medicine, Emory University, Atlanta, GA, USA.,Grady Memorial Hospital, Atlanta, GA, USA
| | - David N Hager
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Johns Hopkins University, 1800 Orleans Street, Suite 9121, Baltimore, MD, 21287, USA
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23
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Hager DN, Hooper MH, Bernard GR, Busse LW, Ely EW, Fowler AA, Gaieski DF, Hall A, Hinson JS, Jackson JC, Kelen GD, Levine M, Lindsell CJ, Malone RE, McGlothlin A, Rothman RE, Viele K, Wright DW, Sevransky JE, Martin GS. The Vitamin C, Thiamine and Steroids in Sepsis (VICTAS) Protocol: a prospective, multi-center, double-blind, adaptive sample size, randomized, placebo-controlled, clinical trial. Trials 2019; 20:197. [PMID: 30953543 PMCID: PMC6451231 DOI: 10.1186/s13063-019-3254-2] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 02/27/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Sepsis accounts for 30% to 50% of all in-hospital deaths in the United States. Other than antibiotics and source control, management strategies are largely supportive with fluid resuscitation and respiratory, renal, and circulatory support. Intravenous vitamin C in conjunction with thiamine and hydrocortisone has recently been suggested to improve outcomes in patients with sepsis in a single-center before-and-after study. However, before this therapeutic strategy is adopted, a rigorous assessment of its efficacy is needed. METHODS The Vitamin C, Thiamine and Steroids in Sepsis (VICTAS) trial is a prospective, multi-center, double-blind, adaptive sample size, randomized, placebo-controlled trial. It will enroll patients with sepsis causing respiratory or circulatory compromise or both. Patients will be randomly assigned (1:1) to receive intravenous vitamin C (1.5 g), thiamine (100 mg), and hydrocortisone (50 mg) every 6 h or matching placebos until a total of 16 administrations have been completed or intensive care unit discharge occurs (whichever is first). Patients randomly assigned to the comparator group are permitted to receive open-label stress-dose steroids at the discretion of the treating clinical team. The primary outcome is consecutive days free of ventilator and vasopressor support (VVFDs) in the 30 days following randomization. The key secondary outcome is mortality at 30 days. Sample size will be determined adaptively by using interim analyses with pre-stated stopping rules to allow the early recognition of a large mortality benefit if one exists and to refocus on the more sensitive outcome of VVFDs if an early large mortality benefit is not observed. DISCUSSION VICTAS is a large, multi-center, double-blind, adaptive sample size, randomized, placebo-controlled trial that will test the efficacy of vitamin C, thiamine, and hydrocortisone as a combined therapy in patients with respiratory or circulatory dysfunction (or both) resulting from sepsis. Because the components of this therapy are inexpensive and readily available and have very favorable risk profiles, demonstrated efficacy would have immediate implications for the management of sepsis worldwide. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03509350 . First registered on April 26, 2018, and last verified on December 20, 2018. Protocol version: 1.4, January 9, 2019.
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Affiliation(s)
- David N. Hager
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Johns Hopkins Hospital, Johns Hopkins University, 1800 Orleans Street, Suite 9121, Baltimore, MD 21287 USA
| | - Michael H. Hooper
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Eastern Virginia Medical School and Sentara Healthcare, Norfolk, VA USA
| | - Gordon R. Bernard
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN USA
| | - Laurence W. Busse
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University, Atlanta, GA USA
| | - E. Wesley Ely
- Division of Pulmonary & Critical Care, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN USA
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN USA
- Tennessee Valley Veteran’s Affairs Geriatric Research Education Clinical Center (GRECC), Nashville, TN USA
| | - Alpha A. Fowler
- Division of Pulmonary Disease & Critical Care Medicine, Department of Internal Medicine, The VCU Johnson Center for Critical Care and Pulmonary Research, Virginia Commonwealth University School of Medicine, Richmond, VA USA
| | - David F. Gaieski
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA USA
| | - Alex Hall
- Department of Emergency Medicine, Emory University, Atlanta, GA USA
- Grady Memorial Hospital, Atlanta, GA USA
| | - Jeremiah S. Hinson
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD USA
| | - James C. Jackson
- Division of Pulmonary & Critical Care, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN USA
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN USA
- Tennessee Valley Veteran’s Affairs Geriatric Research Education Clinical Center (GRECC), Nashville, TN USA
- Department of Psychiatry, Vanderbilt University School of Medicine, Nashville, TN USA
| | - Gabor D. Kelen
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD USA
| | - Mark Levine
- Molecular & Clinical Nutrition Section, Intramural Research Program, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, 10 Center Drive, Bethesda, MD USA
| | | | - Richard E. Malone
- Investigational Drug Service, Vanderbilt University Medical Center, Nashville, TN USA
| | | | - Richard E. Rothman
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD USA
| | | | - David W. Wright
- Department of Emergency Medicine, Emory University, Atlanta, GA USA
- Grady Memorial Hospital, Atlanta, GA USA
| | - Jonathan E. Sevransky
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University, Atlanta, GA USA
| | - Greg S. Martin
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University, Atlanta, GA USA
- Grady Memorial Hospital, Atlanta, GA USA
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Hinson JS, Al Jalbout N, Ehmann MR, Klein EY. Acute kidney injury following contrast media administration in the septic patient: A retrospective propensity-matched analysis. J Crit Care 2019; 51:111-116. [PMID: 30798098 DOI: 10.1016/j.jcrc.2019.02.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 01/10/2019] [Accepted: 02/01/2019] [Indexed: 12/29/2022]
Abstract
PURPOSE To determine the risk for acute kidney injury (AKI) attributable to intravenous contrast media (CM) administration in septic patients. MATERIALS AND METHODS This was a single-center retrospective propensity matched cohort analysis performed in the emergency department (ED) of an academic medical center. All visits for patients ≥18 years who met sepsis diagnostic criteria and had serum creatinine (SCr) measured both on arrival to the ED and again 48 to 72 h later were included. Of 4171 visits, 1464 patients underwent contrast-enhanced CT (CECT), 976 underwent unenhanced CT and 1731 underwent no CT at all. RESULTS The primary outcome was incidence of AKI. Logistic regression and between-groups odds ratios with and without propensity-score matching were used to test for an independent association between CM administration and AKI. Incidence of AKI was 7.2%, 9.4% and 9.7% in those who underwent CECT, unenhanced CT and no CT. CM administration was not associated with increased incidence of AKI. CONCLUSIONS Sepsis is a medical emergency proven to benefit from early diagnosis and rapid initiation of treatment, which is often aided by CECT. Our findings argue against withholding CM for fear of precipitating AKI in potentially septic patients.
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Affiliation(s)
- Jeremiah S Hinson
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States.
| | - Nour Al Jalbout
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Michael R Ehmann
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Eili Y Klein
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States; Center for Disease Dynamics, Economics & Policy, Washington, DC, United States
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25
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Al Jalbout N, Troncoso R, Evans JD, Rothman RE, Hinson JS. Biomarkers and Molecular Diagnostics for Early Detection and Targeted Management of Sepsis and Septic Shock in the Emergency Department. J Appl Lab Med 2018; 3:724-729. [PMID: 31639740 DOI: 10.1373/jalm.2018.027425] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 10/23/2018] [Indexed: 12/14/2022]
Affiliation(s)
- Nour Al Jalbout
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ruben Troncoso
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jared D Evans
- Applied Physics Laboratory, Johns Hopkins University, Baltimore, MD
| | - Richard E Rothman
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jeremiah S Hinson
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD;
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26
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Hinson JS, Martinez DA, Cabral S, George K, Whalen M, Hansoti B, Levin S. Triage Performance in Emergency Medicine: A Systematic Review. Ann Emerg Med 2018; 74:140-152. [PMID: 30470513 DOI: 10.1016/j.annemergmed.2018.09.022] [Citation(s) in RCA: 93] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 09/11/2018] [Accepted: 09/21/2018] [Indexed: 12/12/2022]
Abstract
STUDY OBJECTIVE Rapid growth in emergency department (ED) triage literature has been accompanied by diversity in study design, methodology, and outcome assessment. We aim to synthesize existing ED triage literature by using a framework that enables performance comparisons and benchmarking across triage systems, with respect to clinical outcomes and reliability. METHODS PubMed, EMBASE, Scopus, and Web of Science were systematically searched for studies of adult ED triage systems through 2016. Studies evaluating triage systems with evidence of widespread adoption (Australian Triage Scale, Canadian Triage and Acuity Scale, Emergency Severity Index, Manchester Triage Scale, and South African Triage Scale) were cataloged and compared for performance in identifying patients at risk for mortality, critical illness and hospitalization, and interrater reliability. This study was performed and reported in adherence to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. RESULTS A total of 6,160 publications were identified, with 182 meeting eligibility criteria and 50 with sufficient data for inclusion in comparative analysis. The Canadian Triage and Acuity Scale (32 studies), Emergency Severity Index (43), and Manchester Triage Scale (38) were the most frequently studied triage scales, and all demonstrated similar performance. Most studies (6 of 8) reported high sensitivity (>90%) of triage scales for identifying patients with ED mortality as high acuity at triage. However, sensitivity was low (<80%) for identification of patients who had critical illness outcomes and those who died within days of the ED visit or during the index hospitalization. Sensitivity varied by critical illness and was lower for severe sepsis (36% to 74%), pulmonary embolism (54%), and non-ST-segment elevation myocardial infarction (44% to 85%) compared with ST-segment elevation myocardial infarction (56% to 92%) and general outcomes of ICU admission (58% to 100%) and lifesaving intervention (77% to 98%). Some proportion of hospitalized patients (3% to 45%) were triaged to low acuity (level 4 to 5) in all studies. Reliability measures (κ) were variable across evaluations, with only a minority (11 of 42) reporting κ above 0.8. CONCLUSION We found that a substantial proportion of ED patients who die postencounter or are critically ill are not designated as high acuity at triage. Opportunity to improve interrater reliability and triage performance in identifying patients at risk of adverse outcome exists.
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Affiliation(s)
- Jeremiah S Hinson
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Diego A Martinez
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Stephanie Cabral
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - Kevin George
- Whiting School of Engineering, Johns Hopkins University, Baltimore, MD
| | - Madeleine Whalen
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Bhakti Hansoti
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Scott Levin
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Whiting School of Engineering, Johns Hopkins University, Baltimore, MD
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27
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Hinson JS, Martinez DA, Schmitz PSK, Toerper M, Radu D, Scheulen J, Stewart de Ramirez SA, Levin S. Accuracy of emergency department triage using the Emergency Severity Index and independent predictors of under-triage and over-triage in Brazil: a retrospective cohort analysis. Int J Emerg Med 2018; 11:3. [PMID: 29335793 PMCID: PMC5768578 DOI: 10.1186/s12245-017-0161-8] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 12/26/2017] [Indexed: 11/29/2022] Open
Abstract
Background Emergency department (ED) triage is performed to prioritize care for patients with critical and time-sensitive illness. Triage errors create opportunity for increased morbidity and mortality. Here, we sought to measure the frequency of under- and over-triage of patients by nurses using the Emergency Severity Index (ESI) in Brazil and to identify factors independently associated with each. Methods This was a single-center retrospective cohort study. The accuracy of initial ESI score assignment was determined by comparison with a score entered at the close of each ED encounter by treating physicians with full knowledge of actual resource utilization, disposition, and acute outcomes. Chi-square analysis was used to validate this surrogate gold standard, via comparison of associations with disposition and clinical outcomes. Independent predictors of under- and over-triage were identified by multivariate logistic regression. Results Initial ESI-determined triage score was classified as inaccurate for 16,426 of 96,071 patient encounters. Under-triage was associated with a significantly higher rate of admission and critical outcome, while over-triage was associated with a lower rate of both. A number of factors identifiable at time of presentation including advanced age, bradycardia, tachycardia, hypoxia, hyperthermia, and several specific chief complaints (i.e., neurologic complaints, chest pain, shortness of breath) were identified as independent predictors of under-triage, while other chief complaints (i.e., hypertension and allergic complaints) were independent predictors of over-triage. Conclusions Despite rigorous and ongoing training of ESI users, a large number of patients in this cohort were under- or over-triaged. Advanced age, vital sign derangements, and specific chief complaints—all subject to limited guidance by the ESI algorithm—were particularly under-appreciated.
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Affiliation(s)
- Jeremiah S Hinson
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, 801 Smith Avenue, Davis Building, Suite 3220, Baltimore, MD, 21209, USA.
| | - Diego A Martinez
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, 801 Smith Avenue, Davis Building, Suite 3220, Baltimore, MD, 21209, USA.,Department of Operations Integration, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Paulo S K Schmitz
- Emergency Department, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Matthew Toerper
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, 801 Smith Avenue, Davis Building, Suite 3220, Baltimore, MD, 21209, USA.,Department of Operations Integration, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Danieli Radu
- Emergency Department, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - James Scheulen
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, 801 Smith Avenue, Davis Building, Suite 3220, Baltimore, MD, 21209, USA
| | - Sarah A Stewart de Ramirez
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, 801 Smith Avenue, Davis Building, Suite 3220, Baltimore, MD, 21209, USA
| | - Scott Levin
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, 801 Smith Avenue, Davis Building, Suite 3220, Baltimore, MD, 21209, USA.,Department of Operations Integration, Johns Hopkins Hospital, Baltimore, MD, USA.,Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, USA.,Systems Institute, Johns Hopkins University, Baltimore, MD, USA
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28
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Mistry B, Balhara KS, Hinson JS, Anton X, Othman IY, E'nouz MAL, Avila NA, Henry S, Levin S, De Ramirez SS. Nursing Perceptions of the Emergency Severity Index as a Triage Tool in the United Arab Emirates: A Qualitative Analysis. J Emerg Nurs 2017; 44:360-367. [PMID: 29167033 DOI: 10.1016/j.jen.2017.10.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 08/23/2017] [Accepted: 10/16/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION With emergency department crowding becoming an increasing problem across the globe, nursing triage to prioritize patients receiving care is ever more important. ESI is the most common triage system used in the United States and is increasingly used worldwide. This qualitative study that explores emergency nursing perceptions of the ESI identifies strengths, weaknesses, and barriers to implementation of the ESI internationally. METHODS We conducted a cross-sectional qualitative analysis using semistructured interviews of 27 emergency triage nurses. Content analysis was performed by 2 independent coders, using NVivo software to identify and analyze important themes. RESULTS Interview coding revealed 7 core themes related to use of the ESI (frequencies indicated in parentheses): ease of use (90), speed and efficiency (135), patient safety (12), accuracy and reliability (30), challenging patient characteristics (123), subjectivity and variability (173), and effect of triage system on team dynamics (100). Intercoder agreement was excellent (Cohen's unweighted kappa = 0.84). Subjectivity and variability in ESI score assignment consistently emerged in all interviews and included variability in number and use of resources, definition of "high risk," nursing experience, and subjectivity in pain assessment. DISCUSSION Although emergency nurses perceive the ESI as easy to use, there are concerns about the subjectivity and variability inherent in the ESI that can lead to a functional lack of triage and a burden of undifferentiated ESI level 3 patients. These limitations in separating critically ill patients and in stratifying patients based on anticipated required resources points to the need for improvement in the ESI algorithm or a more objective triage system that can predict patient outcomes.
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Affiliation(s)
- Binoy Mistry
- Baltimore, MD; San Antonio, TX; Abu Dhabi, United Arab Emirates.
| | - Kamna S Balhara
- Baltimore, MD; San Antonio, TX; Abu Dhabi, United Arab Emirates
| | | | - Xavier Anton
- Baltimore, MD; San Antonio, TX; Abu Dhabi, United Arab Emirates
| | | | | | | | - Sophia Henry
- Baltimore, MD; San Antonio, TX; Abu Dhabi, United Arab Emirates
| | - Scott Levin
- Baltimore, MD; San Antonio, TX; Abu Dhabi, United Arab Emirates
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Berger ZD, Brito JP, Ospina NS, Kannan S, Hinson JS, Hess EP, Haskell H, Montori VM, Newman-Toker DE. Patient centred diagnosis: sharing diagnostic decisions with patients in clinical practice. BMJ 2017; 359:j4218. [PMID: 29092826 DOI: 10.1136/bmj.j4218] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Zackary D Berger
- Johns Hopkins University School of Medicine, Johns Hopkins Outpatient Center, 601 N Caroline St Suite 7143, Baltimore, MD 21287 US
| | | | - Naykky Singh Ospina
- Division of Endocrinology, University of Florida School of Medicine, Gainesville, FL, USA
| | - Suraj Kannan
- Johns Hopkins University School of Medicine, Johns Hopkins Outpatient Center, 601 N Caroline St Suite 7143, Baltimore, MD 21287 US
| | - Jeremiah S Hinson
- Johns Hopkins University School of Medicine, Johns Hopkins Outpatient Center, 601 N Caroline St Suite 7143, Baltimore, MD 21287 US
| | | | | | | | - David E Newman-Toker
- Johns Hopkins University School of Medicine, Johns Hopkins Outpatient Center, 601 N Caroline St Suite 7143, Baltimore, MD 21287 US
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Tung M, Sharma R, Hinson JS, Nothelle S, Pannikottu J, Segal JB. Factors associated with imaging overuse in the emergency department: A systematic review. Am J Emerg Med 2017; 36:301-309. [PMID: 29100783 DOI: 10.1016/j.ajem.2017.10.049] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 10/17/2017] [Accepted: 10/18/2017] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Emergency departments (ED) are sites of prevalent imaging overuse; however, determinants that drive imaging in this setting are not well-characterized. We systematically reviewed the literature to summarize the determinants of imaging overuse in the ED. METHODS We searched MEDLINE® and Embase® from January 1998 to March 2017. Studies were included if they were written in English, contained original data, pertained to a U.S. population, and identified a determinant associated with overuse of imaging in the ED. RESULTS Twenty relevant studies were included. Fourteen evaluated computerized tomography (CT) scanning in patents presenting to a regional ED who were then transferred to a level 1 trauma center; incomplete transfer of data and poor image quality were the most frequently described reasons for repeat scanning. Unnecessary pre-transfer scanning or repeated scanning after transfer, in multiple studies, was highest among older patients, those with higher Injury Severity Scores (ISS) and those being transferred further. Six studies explored determinants of overused imaging in the ED in varied conditions, with overuse greater in older patients and those having more comorbid diseases. Defensive imaging reportedly influenced physician behavior. Less integration of services across the health system also predisposed to overuse of imaging. CONCLUSIONS The literature is heterogeneous with surprisingly few studies of determinants of imaging in minor head injury or of spine imaging. Older patient age and higher ISS were the most consistently associated with ED imaging overuse. This review highlights the need for precise definitions of overuse of imaging in the ED.
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Affiliation(s)
- Monica Tung
- Johns Hopkins University School of Medicine, Department of Medicine, United States
| | - Ritu Sharma
- Johns Hopkins University Bloomberg School of Public Health, United States
| | - Jeremiah S Hinson
- Johns Hopkins University School of Medicine, Department of Emergency Medicine, United States
| | - Stephanie Nothelle
- Johns Hopkins University School of Medicine, Department of Medicine, United States
| | - Jean Pannikottu
- Johns Hopkins University School of Medicine, Department of Medicine, United States; Northeastern Ohio Medical University, United States(1)
| | - Jodi B Segal
- Johns Hopkins University School of Medicine, Department of Medicine, United States; Johns Hopkins University Bloomberg School of Public Health, United States; Johns Hopkins University Center for Health Services and Outcomes Research, United States.
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31
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Hinson JS, Ehmann MR, Fine DM, Fishman EK, Toerper MF, Rothman RE, Klein EY. Risk of Acute Kidney Injury After Intravenous Contrast Media Administration. Ann Emerg Med 2017; 69:577-586.e4. [PMID: 28131489 DOI: 10.1016/j.annemergmed.2016.11.021] [Citation(s) in RCA: 162] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 09/05/2016] [Accepted: 11/14/2016] [Indexed: 02/06/2023]
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Lentz BA, Jenson A, Hinson JS, Levin S, Cabral S, George K, Hsu EB, Kelen G, Hansoti B. Validity of ED: Addressing heterogeneous definitions of over-triage and under-triage. Am J Emerg Med 2017; 35:1023-1025. [PMID: 28188059 DOI: 10.1016/j.ajem.2017.02.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Revised: 02/04/2017] [Accepted: 02/04/2017] [Indexed: 10/20/2022] Open
Affiliation(s)
- Brian A Lentz
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Alexander Jenson
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jeremiah S Hinson
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Scott Levin
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Stephanie Cabral
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kevin George
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Edbert B Hsu
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gabor Kelen
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bhakti Hansoti
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Hinson JS, Mistry B, Hsieh YH, Risko N, Scordino D, Paziana K, Peterson S, Omron R. Using the Electronic Medical Record to Reduce Unnecessary Ordering of Coagulation Studies for Patients with Chest Pain. West J Emerg Med 2017; 18:267-269. [PMID: 28210363 PMCID: PMC5305136 DOI: 10.5811/westjem.2016.12.31927] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 10/26/2016] [Accepted: 12/12/2016] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Our goal was to reduce ordering of coagulation studies in the emergency department (ED) that have no added value for patients presenting with chest pain. We hypothesized this could be achieved via implementation of a stopgap measure in the electronic medical record (EMR). METHODS We used a pre and post quasi-experimental study design to evaluate the impact of an EMR-based intervention on coagulation study ordering for patients with chest pain. A simple interactive prompt was incorporated into the EMR of our ED that required clinicians to indicate whether patients were on anticoagulation therapy prior to completion of orders for coagulation studies. Coagulation order frequency was measured via detailed review of randomly sampled encounters during two-month periods before and after intervention. We classified existing orders as clinically indicated or non-value added. Order frequencies were calculated as percentages, and we assessed differences between groups by chi-square analysis. RESULTS Pre-intervention, 73.8% (76/103) of patients with chest pain had coagulation studies ordered, of which 67.1% (51/76) were non-value added. Post-intervention, 38.5% (40/104) of patients with chest pain had coagulation studies ordered, of which 60% (24/40) were non-value added. There was an absolute reduction of 35.3% (95% confidence interval [CI]: 22.7%, 48.0%) in the total ordering of coagulation studies and 26.4% (95% CI: 13.8%, 39.0%) in non-value added order placement. CONCLUSION Simple EMR-based interactive prompts can serve as effective deterrents to indiscriminate ordering of diagnostic studies.
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Affiliation(s)
- Jeremiah S Hinson
- Johns Hopkins University School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
| | - Binoy Mistry
- Johns Hopkins University School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
| | - Yu-Hsiang Hsieh
- Johns Hopkins University School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
| | - Nicholas Risko
- Johns Hopkins University School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
| | - David Scordino
- Johns Hopkins University School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
| | - Karolina Paziana
- Johns Hopkins University School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
| | - Susan Peterson
- Johns Hopkins University School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
| | - Rodney Omron
- Johns Hopkins University School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
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Kane EM, Hinson JS, Jordan CD, Paziana K, Sauber NJ, Rothman RE, Stolbach AI. Bradycardia and hypotension after synthetic cannabinoid use: a case series. Am J Emerg Med 2016; 34:2055.e1-2055.e2. [DOI: 10.1016/j.ajem.2016.03.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 03/03/2016] [Accepted: 03/03/2016] [Indexed: 12/23/2022] Open
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Abstract
Extensive evidence indicates that serum response factor (SRF) regulates muscle-specific gene expression and that myocardin family SRF cofactors are critical for smooth muscle cell differentiation. In a yeast two hybrid screen for novel SRF binding partners expressed in aortic SMC, we identified four and a half LIM domain protein 2 (FHL2) and confirmed this interaction by GST pull-down and coimmunoprecipitation assays. FHL2 also interacted with all three myocardin factors and enhanced myocardin and myocardin-related transcription factor (MRTF)-A-dependent transactivation of smooth muscle alpha-actin, SM22, and cardiac atrial natriuretic factor promoters in 10T1/2 cells. The expression of FHL2 increased myocardin and MRTF-A protein levels, and, importantly, this effect was due to an increase in protein stability not due to an increase in myocardin factor mRNA expression. Treatment of cells with proteasome inhibitors MG-132 and lactacystin strongly upregulated endogenous MRTF-A protein levels and resulted in a substantial increase in ubiquitin immunoreactivity in MRTF-A immunoprecipitants. Interestingly, the expression of FHL2 attenuated the effects of RhoA and MRTF-B on promoter activity, perhaps through decreased MRTF-B nuclear localization or decreased SRF-CArG binding. Taken together, these data indicate that myocardin factors are regulated by proteasome-mediated degradation and that FHL2 regulates SRF-dependent transcription by multiple mechanisms, including stabilization of myocardin and MRTF-A.
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Affiliation(s)
- Jeremiah S Hinson
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC 27599-7525, USA
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Hinson JS, Medlin MD, Lockman K, Taylor JM, Mack CP. Smooth muscle cell-specific transcription is regulated by nuclear localization of the myocardin-related transcription factors. Am J Physiol Heart Circ Physiol 2007; 292:H1170-80. [PMID: 16997888 DOI: 10.1152/ajpheart.00864.2006] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
On the basis of our previous studies on RhoA signaling in smooth muscle cells (SMC), we hypothesized that RhoA-mediated nuclear translocalization of the myocardin-related transcription factors (MRTFs) was important for regulating SMC phenotype. MRTF-A protein and MRTF-B message were detected in aortic SMC and in many adult mouse organs that contain a large SMC component. Both MRTFs upregulated SMC-specific promoter activity as well as endogenous SM22α expression in multipotential 10T1/2 cells, although to a lesser extent than myocardin. We used enhanced green fluorescent protein (EGFP) fusion proteins to demonstrate that the myocardin factors have dramatically different localization patterns and that the stimulation of SMC-specific transcription by certain RhoA-dependent agonists was likely mediated by increased nuclear translocation of the MRTFs. Importantly, a dominant-negative form of MRTF-A (ΔB1/B2) that traps endogenous MRTFs in the cytoplasm inhibited the SM α-actin, SM22α, and SM myosin heavy chain promoters in SMC and attenuated the effects of sphingosine 1-phosphate and transforming growth factor (TGF)-β on SMC-specific transcription. Our data confirmed the importance of the NH2-terminal RPEL domains for regulating MRTF localization, but our analysis of MRTF-A/myocardin chimeras and myocardin RPEL2 mutations indicated that the myocardin B1/B2 region can override this signal. Gel shift assays demonstrated that myocardin factor activity correlated well with ternary complex formation at the SM α-actin CArGs and that MRTF-serum response factor interactions were partially dependent on CArG sequence. Taken together, our results indicate that the MRTFs regulate SMC-specific gene expression in at least some SMC subtypes and that regulation of MRTF nuclear localization may be important for the effects of selected agonists on SMC phenotype.
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MESH Headings
- Active Transport, Cell Nucleus/drug effects
- Animals
- Aorta, Thoracic/metabolism
- Cell Differentiation
- Cell Nucleus/drug effects
- Cell Nucleus/metabolism
- Cells, Cultured
- Lysophospholipids/pharmacology
- Microfilament Proteins/genetics
- Microfilament Proteins/metabolism
- Muscle Proteins/genetics
- Muscle Proteins/metabolism
- Muscle, Smooth, Vascular/drug effects
- Muscle, Smooth, Vascular/metabolism
- Mutation
- Myocytes, Smooth Muscle/cytology
- Myocytes, Smooth Muscle/drug effects
- Myocytes, Smooth Muscle/metabolism
- Nuclear Proteins/genetics
- Nuclear Proteins/metabolism
- Phenotype
- Platelet-Derived Growth Factor/pharmacology
- Promoter Regions, Genetic/drug effects
- RNA, Messenger/metabolism
- Rats
- Serum Response Factor/metabolism
- Sphingosine/analogs & derivatives
- Sphingosine/pharmacology
- Time Factors
- Trans-Activators/genetics
- Trans-Activators/metabolism
- Transcription, Genetic/drug effects
- Transfection
- Transforming Growth Factor beta/pharmacology
- rhoA GTP-Binding Protein/metabolism
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Affiliation(s)
- Jeremiah S Hinson
- Department of Pathology and Laboratory Medicine and the Carolina Cardiovascular Biology Center, University of North Carolina, Chapel Hill, North Carolina 27599, USA
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Affiliation(s)
- C P Mack
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC 27599, USA.
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Lockman K, Hinson JS, Medlin MD, Morris D, Taylor JM, Mack CP. Sphingosine 1-phosphate stimulates smooth muscle cell differentiation and proliferation by activating separate serum response factor co-factors. J Biol Chem 2004; 279:42422-30. [PMID: 15292266 DOI: 10.1074/jbc.m405432200] [Citation(s) in RCA: 129] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Sphingosine 1-phosphate (S1P) is a lipid agonist that regulates smooth muscle cell (SMC) and endothelial cell functions by activating several members of the S1P subfamily of G-protein-coupled Edg receptors. We have shown previously that SMC differentiation is regulated by RhoA-dependent activation of serum response factor (SRF). Because S1P is a strong activator of RhoA, we hypothesized that S1P would stimulate SMC differentiation. Treatment of primary rat aortic SMC cells with S1P activated RhoA as measured by precipitation with a glutathione S-transferase-rhotekin fusion protein. In SMC and 10T1/2 cells, S1P treatment up-regulated the activities of several transiently transfected SMC-specific promoters, and these effects were inhibited by the Rho-kinase inhibitor, Y-27632. S1P also increased smooth muscle alpha-actin protein levels in SMC but had no effect on SRF binding to the smooth muscle alpha-actin CArG B element. Quantitative reverse transcriptase-PCR showed that S1P treatment of SMC or 10T1/2 cells did not increase the mRNA level of either of the recently identified SRF co-factors, myocardin or myocardin-related transcription factor-A (MRTF-A). MRTF-A protein was expressed highly in SMC and 10T1/2 cultures, and importantly the effects of S1P were inhibited by a dominant negative form of MRTF-A indicating that S1P may regulate the transcriptional activity of MRTF-A. Indeed, S1P treatment increased the nuclear localization of FLAG-MRTF-A, and the effect of MRTF-A overexpression on smooth muscle alpha-actin promoter activity was inhibited by dominant negative RhoA. S1P also stimulated SMC growth by activating the early growth response gene, c-fos. This effect was not attenuated by Y-27632 but could be inhibited by the MEK inhibitor, UO126. S1P enhanced SMC growth through ERK-mediated phosphorylation of the SRF co-factor, Elk-1, as measured by gel shift and Elk-1 activation assays. Taken together these results demonstrate that S1P activates multiple signaling pathways in SMC and regulates proliferation by ERK-dependent activation of Elk-1 and differentiation by RhoA-dependent activation of MRTF-A.
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Affiliation(s)
- Kashelle Lockman
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina 27599, USA
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Hinson JS, Morris D, Lockman K, Medlin MD, Taylor JM, Mack CP. RHOA-DEPENDENT NUCLEAR TRANSLOCATION OF MYOCARDIN RELATED TRANSCRIPTION FACTOR A IS IMPORTANT FOR SMC-SPECIFIC TRANSCRIPTION. Cardiovasc Pathol 2004. [DOI: 10.1016/j.carpath.2004.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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