In emergency departments, radiologists' access to EHRs may influence interpretations and medical management

The adoption of electronic health records (EHRs) that meet federal meaningful-use standards is a major US national policy priority. Policy makers recognize the potential of electronic communication in delivering high-quality health care, particularly in an environment of expanding remote access to medical care and the ever-increasing need to transmit health care records across institutions. To demonstrate this principle, we sought to estimate the significance of EHR access in emergent neuroradiologic interpretations. Three neuroradiologists conducted a prospective expert-rater analysis of 2,000 consecutive head computed tomography (CT) exams ordered by emergency department (ED) physicians. For each head CT exam, the neuroradiologists compared medical information generated by ED physicians to information generated by the interpreting radiologists who had access to additional EHR-derived patient data. In 6.1 percent of the head CT exams, the neuroradiologists reached consensus--meaning two out of three agreed--that the additional clinical data derived from the EHR was "very likely" to influence radiological interpretations and that the lack of that data would have adversely affected medical management in those patients. Health care providers must recognize the value of implementing EHRs and foster their widespread adoption.

A randomized clinical trial of high-dosage coenzyme Q10 in early Parkinson disease: no evidence of benefit

IMPORTANCE

Coenzyme Q10 (CoQ10), an antioxidant that supports mitochondrial function, has been shown in preclinical Parkinson disease (PD) models to reduce the loss of dopamine neurons, and was safe and well tolerated in early-phase human studies. A previous phase II study suggested possible clinical benefit.

OBJECTIVE

To examine whether CoQ10 could slow disease progression in early PD.

DESIGN, SETTING, AND PARTICIPANTS

A phase III randomized, placebo-controlled, double-blind clinical trial at 67 North American sites consisting of participants 30 years of age or older who received a diagnosis of PD within 5 years and who had the following inclusion criteria: the presence of a rest tremor, bradykinesia, and rigidity; a modified Hoehn and Yahr stage of 2.5 or less; and no anticipated need for dopaminergic therapy within 3 months. Exclusion criteria included the use of any PD medication within 60 days, the use of any symptomatic PD medication for more than 90 days, atypical or drug-induced parkinsonism, a Unified Parkinson's Disease Rating Scale (UPDRS) rest tremor score of 3 or greater for any limb, a Mini-Mental State Examination score of 25 or less, a history of stroke, the use of certain supplements, and substantial recent exposure to CoQ10. Of 696 participants screened, 78 were found to be ineligible, and 18 declined participation.

INTERVENTIONS

The remaining 600 participants were randomly assigned to receive placebo, 1200 mg/d of CoQ10, or 2400 mg/d of CoQ10; all participants received 1200 IU/d of vitamin E.

MAIN OUTCOMES AND MEASURES

Participants were observed for 16 months or until a disability requiring dopaminergic treatment. The prospectively defined primary outcome measure was the change in total UPDRS score (Parts I-III) from baseline to final visit. The study was powered to detect a 3-point difference between an active treatment and placebo.

RESULTS

The baseline characteristics of the participants were well balanced, the mean age was 62.5 years, 66% of participants were male, and the mean baseline total UPDRS score was 22.7. A total of 267 participants required treatment (94 received placebo, 87 received 1200 mg/d of CoQ10, and 86 received 2400 mg/d of CoQ10), and 65 participants (29 who received placebo, 19 who received 1200 mg/d of CoQ10, and 17 who received 2400 mg/d of CoQ10) withdrew prematurely. Treatments were well tolerated with no safety concerns. The study was terminated after a prespecified futility criterion was reached. At study termination, both active treatment groups showed slight adverse trends relative to placebo. Adjusted mean changes (worsening) in total UPDRS scores from baseline to final visit were 6.9 points (placebo), 7.5 points (1200 mg/d of CoQ10; P = .49 relative to placebo), and 8.0 points (2400 mg/d of CoQ10; P = .21 relative to placebo).

CONCLUSIONS AND RELEVANCE

Coenzyme Q10 was safe and well tolerated in this population, but showed no evidence of clinical benefit.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00740714.

Outpatient pediatric pain management practices for fractures

OBJECTIVES

Describe the pattern of utilization and effectiveness of outpatient fracture pain medication.

METHODS

A cross-sectional survey of caregivers of children with an isolated extremity fracture at a hospital-based pediatric orthopedic clinic during initial follow-up.

RESULTS

Surveys were completed by 98 (79.2%) of 125 caregivers. Mean age of children was 9 years (range, 1-18 years). Fracture sites include arm (36%), wrist (24%), hand (6%), leg (14%), ankle (9%), and foot (6%). Pain was reported "worst" at the time of injury in 45.3% patients (95% confidence interval [CI], 35.0%-55.8%) and in the first 48 hours of injury in 30.5% patients (95% CI, 21.5%-40.8%). The most commonly used medications were ibuprofen 43.5% (95% CI, 34.4%-52.5%) and acetaminophen with codeine 26.1% (95% CI, 18.1%-34.1%). Mean duration of medication use was 3.2 days (95% CI, 2.8-3.6 days). The mean duration of functional limitations included 4.2 days (95% CI, 2.8-5.5 days) for playing, 2.6 days (95% CI, 1.7-3.4 days) for performing at school, 2.4 days (95% CI, 1.8-3.0 days) for sleeping, and 2.0 days (95% CI, 1.0-3.0 days) for eating. Mean days of work missed by caregivers was 1.6 (95% CI, 1.1-2.0 days), and days of school missed by children was 2.0 (95% CI, 1.6-2.3 days). Significantly more children with lower extremity fractures had functional limitation (P < 0.05).

CONCLUSION

Most children with fractures have the "worst" pain in the first 48 hours after injury and used analgesia for 3 days after injury. There are noteworthy functional limitations for both children and their caregivers. Ibuprofen and acetaminophen with codeine are the analgesics most commonly used, with no clear superiority.

The anesthetic effectiveness of lidocaine-adrenaline-tetracaine gel on finger lacerations

OBJECTIVES

To determine the effectiveness of lidocaine-adrenaline-tetracaine (LAT) in providing adequate anesthesia for the repair of finger lacerations and to monitor the risk of digital ischemia following application of LAT gel to finger lacerations.

METHODS

A prospective case series. Children aged 5 to 18 years with a simple finger laceration-requiring repair were eligible for enrollment. The primary outcome measure was LAT success/failure. Failure was defined as any sharp sensation reported by the patient either before or during suturing. Enrolled patients had LAT gel applied to their laceration for 45 minutes, followed by an examination for signs of digital ischemia and standard laceration repair. Infiltration anesthesia (local subcutaneous injection/digital block) was provided for all LAT failures. Patients were followed up by phone within 3 to 5 days from discharge.

RESULTS

Sixty-seven patients were analyzed in the study. The mean age was 11.9 years. Forty-four (65.7%) of 67 patients were male and 46 (68.7%) were white. Locations of the lacerations were equally distributed on the dorsal and ventral surfaces. The overall LAT success rate was 53.7% (95% confidence interval [CI], 41.1% to 66.0%; 36/67). The success rate for dorsal surface lacerations was 68.6% (95% CI, 50.7% to 83.1%; 24/35) versus 37.5% (95% CI, 21.1% to 56.3%; 12/32) for ventral surface lacerations. The difference in success rates between dorsal and ventral surface lacerations was significant (Delta 31.1% [95% CI, 8.3% to 53.8%]). There were no differences in success rates for age, sex, or race. No signs of digital ischemia were noted in any of the 67 cases (0% [95% CI, 0.0% to 5.4%]).

CONCLUSIONS

LAT gel appears to be a safe and effective means of providing anesthesia for the repair of simple finger lacerations in children. It was most effective on the dorsal surface of the finger.

Office preparedness for pediatric emergencies: baseline preparedness and the impact of guideline distribution

OBJECTIVE

To determine the baseline level of preparedness of Wisconsin primary care physician offices for pediatric emergencies and to assess the impact of mail distribution of guidelines on this level of preparedness.

METHOD

Preintervention surveys were mailed to all Wisconsin physicians requesting information about pediatric equipment, medications, training, and policies. Guidelines were distributed by mail to all physicians who returned completed surveys. An identical postintervention survey was mailed to these physicians, and an analysis of the paired surveys for each respondent was performed.

RESULTS

Baseline preparedness of 1051 Wisconsin physician offices ranged from 37% with intraosseous needles to 96% with albuterol solution for inhalation. Physician certification in pediatric advanced life support was required in 26% of offices. A total of 568 paired preintervention and postintervention surveys were analyzed. Improvements were identified for the availability of equipment and medications, transport policies, and reference guides.

CONCLUSIONS

Mail distribution of guidelines was minimally effective in improving the preparedness of Wisconsin offices for pediatric emergencies.

The Effect of Prior Interactions With a Primary Care Provider on Nonurgent Pediatric Emergency Department Use

OBJECTIVE

To determine the effect of parental reported difficulty getting care without long waits from a primary care provider (PCP) on nonurgent pediatric emergency department (ED) use.

DESIGN

Case-control study.

SETTING

Pediatric ED within an urban pediatric hospital.

PARTICIPANTS

Children, aged 6 months to 12 years, who presented with a chief complaint from a predetermined list of nonurgent (cases) or emergent complaints (controls).

MAIN OUTCOME MEASURES

Caregivers assessed interactions with a PCP during the previous 12 months by completion of a Consumer Assessment of Health Plans (CAHPS) survey. Baseline demographic variables were compared. Composite CAHPS scores assessing difficulty meeting medical needs, including getting care without long waits, were compared using median tests. Multivariate logistic regression was used to assess the effect of getting care without long waits on nonurgent ED use.

RESULTS

Of 821 caregivers approached, 719 (87.6%) completed the survey, including 366 cases (50.9%) and 353 controls (49.1%). Those with emergent complaints were older, healthier, and more likely to be male; had higher caregiver education and income levels; and were more likely to have a PCP. Analysis of the CAHPS composite scores revealed increased difficulty meeting medical needs for those with nonurgent complaints, with the greatest difference noted for getting care without long waits (median score, 3.25 vs 3.67; P<.001). In multivariate regression, increased ability to get care without long waits was associated with decreased odds of nonurgent ED use (odds ratio, 0.48; 95% confidence interval, 0.32-0.72).

CONCLUSION

Parental-reported previous difficulty getting care without long waits from a PCP is a risk factor for nonurgent ED use.

Analgesia for children with acute abdominal pain: a survey of pediatric emergency physicians and pediatric surgeons

OBJECTIVE

To evaluate the current opinion and practice of pediatric emergency medicine physicians (PEM) and pediatric surgeons (PS) on the use of opioid analgesia in children with acute abdominal pain during their evaluation in the emergency department.

METHODS

All members of the American Academy of Pediatrics in the Section of Emergency Medicine and the American Pediatric Surgeons Association were mailed a copy of the survey. Inclusion criteria were board-eligible or -certified PEM, or PS certified by American Board of Surgery or Royal College of Surgeons currently in practice whose patient population includes children. Information on primary patient population, years in practice, practice setting, willingness to provide analgesia for acute nontraumatic abdominal pain in children, and the factors influencing their decision were requested. Data were analyzed with the Student t test and chi(2) analysis.

RESULTS

Of 1441 surveys sent, 54 were returned because of incorrect addresses. Of the 1387 presumed received, 702 completed surveys were returned with a response rate of 51%. However, of those who responded, 574 (82%) respondents met our inclusion criteria, and 385 (67%) were PEM and 189 (33%) were PS. Compared with PEM, more PS had >10 years of work experience and were in private practice. More PEM were willing to provide analgesia before definitive diagnosis. However, the overall willingness to provide analgesia was low in both groups. Among the physicians with <10 years of experience, there was no statistical difference between PEM and PS in willingness to provide analgesia. However, among the physicians with >10 years of experience, 61% of PS were less likely to provide analgesia compared with 38% of the PEM (Delta = 23%; 95% confidence interval 13%, 33%). Of the 74 PEM who made optional general comments, 64 (87%) cited disapproval by the PS as the main barrier in providing analgesia.

CONCLUSIONS

The practice of providing analgesia for children with acute abdominal pain is divergent between PEM and PS. More experienced surgeons are less likely to provide analgesia for children with acute abdominal pain. The perceived disapproval of providing analgesia to children with acute abdominal pain by PS is a barrier influencing PEM practice.

The short-term outcome of seizure management by prehospital personnel: a comparison of two protocols

OBJECTIVE

To evaluate the impact of an emergency medical service protocol with reduced diazepam dose on the intubation rate of children with seizure activity treated by emergency medical service personnel and to evaluate the short-term outcome comparing 2 emergency medical service treatment protocols.

METHODS

Retrospective review of the emergency medical service and hospital databases of children 0-18 years with seizure activity. Prior to January 1996, the county emergency medical service protocol recommended a diazepam dose of 0.2-0.5 mg/kg i.v. or pr for termination of seizure activity (group 1). As of January 1996, the diazepam dose was reduced to 0.05-0.1 mg/kg i.v. or pr (group 2). Demographics, emergency medical service and emergency department interventions, and disposition data were abstracted.

RESULTS

1516 subjects met the enrollment criteria: 1003 (66%) in group 1 and 513 (34%) in group 2. Emergency medical service administered diazepam to 288 subjects: 189 (19%) in group 1 and 99 (19%) in group 2. Twenty (7%) of all treated subjects required intubation: 19 in group 1 and 1 in group 2 (relative risk 9.7, 95% CI 1.30-72.5). Mean diazepam dose was 0.17 mg/kg in group 1 and 0.13 mg/kg in group 2 (mean difference 0.04, 95% CI 0.02-0.06). No significant difference in the requirement for repeated anticonvulsant dose, complications, or emergency department interventions was noted. However, hospital admission rate was lower in group 2 (rate difference 0.06, 95% CI 0.01-0.11).

CONCLUSIONS

Our study demonstrated a reduction in intubation rate and a need for hospitalization in the reduced diazepam dose emergency medical service protocol. The reduction in the diazepam dose was effective in terminating the seizure activity and did not increase the risk of adverse events.

Risk of serious bacterial infection in children with fever without a source in the post-Haemophilus influenzae era when antibiotics are reserved for culture-proven bacteremia

OBJECTIVE

To determine the rate of serious bacterial infection in children aged 2 to 36 months with fever without a source in the post-Haemophilus influenzae era, when antibiotic therapy is reserved until blood culture results turn positive.

DESIGN AND SETTING

Retrospective review of emergency department, urgent care center, and hospital medical records from an urban children's hospital.

PARTICIPANTS

Eligible participants were identified from hospital medical record and microbiology laboratory databases. Immunocompetent individuals aged 2 to 36 months with fever without a source were eligible for enrollment. Exclusion criteria were temperature less than 39.0 degrees C, identifiable focus of infection, current or recent antibiotic use, and hospital admission.

INTERVENTIONS AND OUTCOME MEASURES

Enrolled participants were assigned to group 1 (blood culture obtained) or group 2 (no blood culture) and did not receive empiric antibiotic treatment in the emergency department, in the urgent care center, or for home use. Demographic and outcome data were collected on all enrolled patients.

RESULTS

During the study, 9241 febrile children were identified; 2641 (29%) met the enrollment criteria. Blood cultures (group 1) were performed on 1202 patients (46%), and 37 (3%) had culture-proven occult bacteremia (95% confidence interval, 2.2%-4.2%). Streptococcus pneumoniae was the most prevalent organism (84%). The mean +/- SD time for reporting a positive blood culture finding was 17.5 +/- 8.5 hours. Two patients (0.08%; 95% confidence interval, 0.009%-0.27%) developed serious bacterial infection, and both recovered completely.

CONCLUSION

Reserving antibiotic therapy for culture-proven occult bacteremia was not associated with increased risk of developing serious bacterial infection compared with previously published data.

A pilot coping improvement intervention for late middle-aged and older adults living with HIV/AIDS in the USA

As AIDS becomes more prevalent among late middle-aged and older adults, mental health support services that facilitate the coping and adjustment efforts of this group are increasingly needed. The current article: (1) outlines a coping improvement group intervention for HIV-infected older adults; and (2) examines the efficacy of the intervention utilizing a small sample (N = 16) of older adults living with HIV/AIDS in Milwaukee, Wisconsin and New York City. The intervention focused on enabling HIV-infected older adults to accurately appraise sources of stress, develop adaptive coping responses and access social support resources to facilitate coping efforts. An evaluation of this pilot intervention, conducted using a pretest-posttest, no control group design, revealed that the intervention increased participants' perceptions of social support, produced higher perceptions of social wellbeing and enabled participants to engage in more planful problem solving, confrontive coping and future optimism. Intervention participants also experienced less stressor burden associated with AIDS-related loss and health concerns. While the current intervention showed potential to facilitate the adjustment efforts of HIV-infected older adults, randomized clinical trials of this intervention with larger samples are needed before its appropriateness for this population can be determined.

Depression and thoughts of suicide among middle-aged and older persons living with HIV-AIDS

OBJECTIVE

This study examined the prevalence and characteristics of suicidal ideation among middle-aged and older persons who have HIV infection or AIDS.

METHODS

A total of 113 subjects older than age 45 who had HIV-AIDS were recruited from AIDS service organizations in Milwaukee, Wisconsin, and New York City. Participants completed confidential questionnaires covering suicidal ideation, emotional distress, quality of life, coping, and social support.

RESULTS

Twenty-seven percent of respondents reported having thought about taking their own life in the previous week. Those who had thought about suicide reported greater levels of emotional distress and poorer health-related quality of life than those who had not considered suicide. They were also significantly more likely to use escape and avoidance strategies for coping with HIV infection and less likely to use positive-reappraisal coping. Those who had thought about suicide also were more likely to have disclosed their HIV status to the people close to them, and yet they perceived receiving significantly less social support from friends and family. With the exceptions of physical functioning and coping strategies, differences between those who had contemplated suicide and those who had not remained unchanged after controlling for symptoms of depression.

CONCLUSIONS

Persons who are in midlife and older and are living with HIV-AIDS experience significant emotional distress and thoughts of suicide, suggesting a need for targeted interventions to improve mental health and prevent suicide.