Troponin is unrelated to outcomes in heart failure patients discharged from the emergency department

Background

Prior data has demonstrated increased mortality in hospitalized patients with acute heart failure (AHF) and troponin elevation. No data has specifically examined the prognostic significance of troponin elevation in patients with AHF discharged after emergency department (ED) management.

Objective

Evaluate the relationship between troponin elevation and outcomes in patients with AHF who are treated and released from the ED.

Methods

This was a secondary analysis of the Get with the Guidelines to Reduce Disparities in AHF Patients Discharged from the ED (GUIDED‐HF) trial, a randomized, controlled trial of ED patients with AHF who were discharged. Patients with elevated conventional troponin not due to acute coronary syndrome (ACS) were included. Our primary outcome was a composite endpoint: time to 30‐day cardiovascular death and/or heart failure‐related events.

Results

Of the 491 subjects included in the GUIDED‐HF trial, 418 had troponin measured during the ED evaluation and 66 (16%) had troponin values above the 99th percentile. Median age was 63 years (interquartile range, 54‐70), 62% (n = 261) were male, 63% (n = 265) were Black, and 16% (n = 67) experienced our primary outcome. There were no differences in our primary outcome between those with and without troponin elevation (12/66, 18.1% vs 55/352, 15.6%; P = 0.60). This effect was maintained regardless of assignment to usual care or the intervention arm. In multivariable regression analysis, there was no association between our primary outcome and elevated troponin (hazard ratio, 1.00; 95% confidence interval,  0.49–2.01, P = 0.994)

Conclusion

If confirmed in a larger cohort, these findings may facilitate safe ED discharge for a group of patients with AHF without ACS when an elevated troponin is the primary reason for admission.

Utility of COVID-19 antigen testing in the emergency department

BACKGROUND

The BinaxNOW coronavirus disease 2019 (COVID-19) Ag Card test (Abbott Diagnostics Scarborough, Inc.) is a lateral flow immunochromatographic point-of-care test for the qualitative detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) nucleocapsid protein antigen. It provides results from nasal swabs in 15 minutes. Our purpose was to determine its sensitivity and specificity for a COVID-19 diagnosis.

METHODS

Eligible patients had symptoms of COVID-19 or suspected exposure. After consent, 2 nasal swabs were collected; 1 was tested using the Abbott RealTime SARS-CoV-2 (ie, the gold standard polymerase chain reaction test) and the second run on the BinaxNOW point of care platform by emergency department staff.

RESULTS

From July 20 to October 28, 2020, 767 patients were enrolled, of which 735 had evaluable samples. Their mean (SD) age was 46.8 (16.6) years, and 422 (57.4%) were women. A total of 623 (84.8%) patients had COVID-19 symptoms, most commonly shortness of breath (n = 404; 55.0%), cough (n = 314; 42.7%), and fever (n = 253; 34.4%). Although 460 (62.6%) had symptoms ≤7 days, the mean (SD) time since symptom onset was 8.1 (14.0) days. Positive tests occurred in 173 (23.5%) and 141 (19.2%) with the gold standard versus BinaxNOW test, respectively. Those with symptoms >2 weeks had a positive test rate roughly half of those with earlier presentations. In patients with symptoms ≤7 days, the sensitivity, specificity, and negative and positive predictive values for the BinaxNOW test were 84.6%, 98.5%, 94.9%, and 95.2%, respectively.

CONCLUSIONS

The BinaxNOW point-of-care test has good sensitivity and excellent specificity for the detection of COVID-19. We recommend using the BinasNOW for patients with symptoms up to 2 weeks.

Improvement in Kansas City Cardiomyopathy Questionnaire Scores After a Self-Care Intervention in Patients With Acute Heart Failure Discharged From the Emergency Department

BACKGROUND

We conducted a secondary analysis of changes in the Kansas City Cardiomyopathy Questionnaire (KCCQ)-12 over 30 days in a randomized trial of self-care coaching versus structured usual care in patients with acute heart failure who were discharged from the emergency department.

METHODS

Patients in 15 emergency departments completed the KCCQ-12 at emergency department discharge and at 30 days. We compared change in KCCQ-12 scores between the intervention and usual care arms, adjusted for enrollment KCCQ-12 and demographic characteristics. We used linear regression to describe changes in KCCQ-12 summary scores and logistic regression to characterize clinically meaningful KCCQ-12 subdomain changes at 30 days.

RESULTS

There were 350 patients with both enrollment and 30-day KCCQ summary scores available; 166 allocated to usual care and 184 to the intervention arm. Median age was 64 years (interquartile range, 55-70), 37% were female participants, 63% were Black, median KCCQ-12 summary score at enrollment was 47 (interquartile range, 33-64). Self-care coaching resulted in significantly greater improvement in health status compared with structured usual care (5.4-point greater improvement, 95% CI, 1.12-9.68; P=0.01). Improvements in health status in the intervention arm were driven by improvements within the symptom frequency (adjusted odds ratio, 1.62 [95% CI, 1.01-2.59]) and quality of life (adjusted odds ratio, 2.39 [95% CI, 1.46-3.90]) subdomains.

CONCLUSIONS

In this secondary analysis, patients with acute heart failure who received a tailored, self-care intervention after emergency department discharge had clinically significant improvements in health status at 30 days compared with structured usual care largely due to improvements within the symptom frequency and quality of life subdomains of the KCCQ-12. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02519283.

Auscultation of Bowel Sounds and Ultrasound of Peristalsis Are Neither Compartmentalized Nor Correlated

Objective  Auscultation of bowel sounds has been taught as a component of the physical examination since the beginning of the 20th century. However, there has been little research or consensus on the significance of listening in different quadrants. Some textbooks indicate that bowel sounds are the result of peristalsis in that region, while others state that bowel sounds can be generalized over the entire abdominal wall. With ultrasonography, peristalsis can be visualized in a dynamic and non-invasive manner. The purpose of this study was to determine the relationship between auscultation of bowel sounds and visualization of peristalsis with ultrasound, to understand whether or not bowel sounds and peristalsis are compartmentalized. Methods  Study participants quietly lay supine, while one investigator positioned an ultrasound probe on the abdomen visualizing the small intestine, and a second investigator placed an EKO Digital Stethoscope (Eko Devices, Inc., Oakland, CA) directly adjacent to the probe auscultate for bowel sounds. During a two-minute interval, a third investigator noted every time a bowel sound was heard (A+), peristalsis was seen (U+), or a combined event (C+) occurred, recording the total number of events. Measurements were recorded from four quadrants (right upper quadrant {RUQ}, left upper quadrant {LUQ}, right lower quadrant {RLQ}, left lower quadrant {LLQ}) and the periumbilical region (PUR). Fisher Exact test was used to determine whether there were significant differences between the number of bowel sounds heard but not seen (A+) and those seen but not heard (U+) with sounds that were both seen and heard (C+). Significance was determined with p < 0.05. Results  A total of 16 participants were included, with a combined 973 discrete bowel events, both auscultated and visualized. No quadrant showed a significant correlation between an isolated sound (A+) or peristalsis (U+) and a combined event (C+), indicating there were many events where an auscultated sound failed to correlate with observed peristalsis, and vice versa. The average p-value was 0.544, with a range of 0.052-1.00. Conclusion  This study showed that there is no significant correlation between auscultated bowel sounds and peristalsis within a given region. This study calls into question whether auscultation of all four quadrants provides more meaningful information than auscultation of one central point of the abdomen.

Ultrasound-guided peripheral intravenous access in chronic kidney disease patients

OBJECTIVE

Ultrasound-guided peripheral intravenous (USPIV) catheters are being placed in emergency department (ED) patients with increasing frequency. USPIV catheters have been shown to improve the success rates of cannulation. It is unknown what the long-term effect of USPIV placement will be on fistula creation in chronic kidney disease (CKD) patients considering these ultrasound-guided peripheral lines often target the same deeper vessels used for fistulas. This study aimed to survey whether emergency medicine programs place restrictions on USPIV placement in patients with CKD stages 3-5.

METHODS

This was a survey study encompassing all 110 emergency ultrasound fellowship directors in the United States at the time the survey was conducted. Data was collected on an anonymous and voluntary basis. The primary outcome was the number of programs with restrictions on USPIV placement in patients with CKD stage 3 or greater.

RESULTS

Of the 56 programs that responded, 21% reported having policies limiting which patients were appropriate for USPIV. Despite this, only one program reported placing restrictions on USPIV in CKD stage 3 or greater (p < 0.0001).

CONCLUSIONS

Emergency departments do not have or follow restrictions placed on USPIV placement in patients with CKD stage 3 or greater. The use of these veins in the ED may result in thrombosis as well as inflammation and permanent scarring which could negatively impact the ability to utilize those vessels for fistula creation. Future studies are needed to further characterize the impact of USPIV on fistula creation.

Prevention of posterior wall puncture with a self-made needle block

Vascular access is one of the most commonly performed invasive procedures in medicine. Ultrasound-guided vascular access has been shown to improve patient safety, decrease associated complications and increase first attempt success rates, however, the risk for a posterior venous wall puncture (PVWP) still exists. To reduce this complication, needle guides have been used, though, current methods have limited accessibility and generalizability. Thus, the aim of this article is to describe how a self-made needle block constructed with materials present in a central line kit can reduce the incidence of PVWP and its associated complications in novice POCUS users.

Innovations with tele-ultrasound in education sonography: the use of tele-ultrasound to train novice scanners

Objectives

Point-of-care ultrasound (POCUS) has become increasingly integrated into medical education given the growing role of evaluative and procedural techniques in practice today. Tele-ultrasound is a new and promising venture that aims to expand medical knowledge and education to previously unreached or underserved areas. This study aimed to determine the non-inferiority of teaching ultrasound remotely using tele-ultrasound via the Philips Lumify (Philips Medical Systems, Bothell, WA) system, which utilizes video conferencing technology and real-time imaging that can be viewed by the operator and educator simultaneously.

Methods

Three commonly used ultrasound exams were taught and evaluated in 56 ultrasound-naive medical participants: Focused Assessment with Sonography in Trauma (FAST), Lower Extremity Deep Venous Thrombosis (LEDVT) screening, and ultrasound-guided vascular access. The participants were randomized into either in-person traditional learning or tele-ultrasound learning with the Philips Lumify (Philips Medical Systems, Bothell, WA) units. The primary outcome of interest was the ability to perform certain tasks for each exam

Results

Competency on each exam was tested across all exams and no inferiority was found between in-person and remote learning (p < 0.05).

Conclusions

Our findings support the use of tele-ultrasound in beginner ultrasound education.

Myocardial Infarction Can Be Safely Excluded by High-sensitivity Troponin I Testing 3 Hours After Emergency Department Presentation

BACKGROUND

The accuracy and speed by which acute myocardial infarction (AMI) is excluded are an important determinant of emergency department (ED) length of stay and resource utilization. While high-sensitivity troponin I (hsTnI) >99th percentile (upper reference level [URL]) represents a "rule-in" cutpoint, our purpose was to evaluate the ability of the Beckman Coulter hsTnI assay, using various level-of-quantification (LoQ) cutpoints, to rule out AMI within 3 hours of ED presentation in suspected acute coronary syndrome (ACS) patients.

METHODS

This multicenter evaluation enrolled adults with >5 minutes of ACS symptoms and an electrocardiogram obtained per standard care. Exclusions were ST-segment elevation or chronic hemodialysis. After informed consent was obtained, blood samples were collected in heparin at ED admission (baseline), ≥1 to 3, ≥3 to 6, and ≥6 to 9 hours postadmission. Samples were processed and stored at -20°C within 1 hour and were tested at three independent clinical laboratories on an immunoassay system (DxI 800, Beckman Coulter). Analytic cutpoints were the URL of 17.9 ng/L and two LoQ cutpoints, defined as the 10 and 20% coefficient of variation (5.6 and 2.3 ng/L, respectively). A criterion standard MI diagnosis was adjudicated by an independent endpoint committee, blinded to hsTnI, and using the universal definition of MI.

RESULTS

Of 1,049 patients meeting the entry criteria, and with baseline and 1- to 3-hour hsTnI results, 117 (11.2%) had an adjudicated final diagnosis of AMI. AMI patients were typically older, with more cardiovascular risk factors. Median (IQR) presentation time was 4 (1.6-16.0) hours after symptom onset, although AMI patients presented ~0.5 hour earlier than non-AMI. Enrollment and first blood draw occurred at a mean of ~1 hour after arrival. To evaluate the assay's rule-out performance, patients with any hsTnI > URL were considered high risk and were excluded. The remaining population (n = 829) was divided into four LoQ relative categories: both hsTnI < LoQ (Lo-Lo cohort); first hsTnI < LoQ and 2nd > LoQ (Lo-Hi cohort); first > LoQ and second < LoQ (Hi-Lo cohort); or both > LoQ (Hi-Hi cohort). In patients with any hsTnI result <20% CV LoQ (Groups 1-3), n = 231 (23.9% ruled out), AMI negative predictive value (NPV) was 100% (95% confidence interval [CI] = 98.9% to 100%). In patients with any hsTnI below the 10% LoQ, n = 611 (58% rule out), AMI NPV was 100% (95% CI = 99.5% to 100%). Of the Hi-Hi cohort (i.e., no hsTnI below the 10% LoQ, but both < URL), there were four AMI patients, NPV was 98.2% (95% CI = 95.4% to 99.3%), and sensitivity was 96.6.

CONCLUSIONS

Patients presenting >3 hours after the onset of suspected ACS symptoms, with at least two Beckman Coulter Access hsTnI < URL and at least one of which is below either the 10 or the 20% LoQ, had a 100% NPV for AMI. Two hsTnI values 1 to 3 hours apart with both < URL, but also >LoQ had inadequate sensitivity and NPV.

Take -home naloxone rescue kits following heroin overdose in the emergency department to prevent opioid overdose related repeat emergency department visits, hospitalization and death- a pilot study

Background

Opioid overdoses are at an epidemic in the United States causing the deaths of thousands each year. Project DAWN (Deaths Avoided with Naloxone) is an opioid overdose education and naloxone distribution program in Ohio that distributes naloxone rescue kits at clinics and in the emergency departments of a single hospital system.

Methods

We performed a retrospective analytic cohort study comparing heroin overdose survivors who presented to the emergency department and were subsequently discharged. We compared those who received a naloxone rescue kit at discharge with those who did not. Our composite outcome was repeat opioid overdose related emergency department visit(s), hospitalization and death at 0–3 months and at 3–6 months following emergency department overdose. Heroin overdose encounters were identified by ICD- 9 or 10 codes and data was abstracted from the electronic medical record for emergency department patients who presented for heroin overdose and were discharged over a 31- month period between 2013 and 2016. Patients were excluded for previous naloxone access, incarceration, suicidal ideation, admission to the hospital or death from acute overdose on initial emergency department presentation. Data was analyzed with the Chi- square statistical test.

Results

We identified 291emergency department heroin overdose encounters by ICD-9 or 10 codes and were analyzed. A total of 71% of heroin overdose survivors received a naloxone rescue kit at emergency department discharge. Between the patients who did not receive a naloxone rescue kit at discharge, no overdose deaths occurred and 10.8% reached the composite outcome. Of the patients who received a naloxone rescue kit, 14.4% reached the composite endpoint and 7 opioid overdose deaths occurred in this cohort. No difference in mortality at 3 or 6 months was detected, p = 0.15 and 0.36 respectively. No difference in the composite outcome was detected at 3 or 6 months either, p = 0.9 and 0.99 respectively.

Conclusions

Of our emergency department patients receiving a naloxone rescue kit we did not find a benefit in the reduction of repeat emergency department visits hospitalizations, or deaths following a non-fatal heroin overdose.

The Extended Treatment Window's Impact on Emergency Systems of Care for Acute Stroke

The window for acute ischemic stroke treatment was previously limited to 4.5 hours for intravenous tissue plasminogen activator and to 6 hours for thrombectomy. Recent studies using advanced imaging selection expand this window for select patients up to 24 hours from last known well. These studies directly affect emergency stroke management, including prehospital triage and emergency department (ED) management of suspected stroke patients. This narrative review summarizes the data expanding the treatment window for ischemic stroke to 24 hours and discusses these implications on stroke systems of care. It analyzes the implications on prehospital protocols to identify and transfer large-vessel occlusion stroke patients, on issues of distributive justice, and on ED management to provide advanced imaging and access to thrombectomy centers. The creation of high-performing systems of care to manage acute ischemic stroke patients requires academic emergency physician leadership attentive to the rapidly changing science of stroke care.

Abstract WP486: Do Social Determinants of Health Predict Recovery in the First 90 Days After Stroke?

Background: Understanding the factors impacting recovery after stroke is a critical step in developing interventions to optimize stroke outcomes. Previous work from Ohio Coverdell Program suggested that race may be independently associated with reduced odds of improvement in the first 30 days after stroke.

Purpose: To determine if race, household income, and insurance status are independently associated with improvement in disability in the first 90 days after hospital discharge in patients admitted to comprehensive stroke centers (CSC) who received acute intervention.

Methods: Retrospective cohort study of patients entered into the GWTG-Stroke from 7 Ohio Coverdell CSCs from 1/1/2015 to 7/16/2018 who received IV tPA and/or acute catheter-based intervention and had a mRS score at discharge and 90 days. Multivariable linear regression was performed to examine the association of race, household income estimated by ZIP code, and insurance on improvement in mRS between discharge and 90 days after adjusting for discharge mRS, clinical characteristics and hospital management.

Results: There were 1,140 patients in the cohort who had mean age 66.7 yrs (SD 15.0). Estimated median income was $51,190 (SD $18,050); 18.3% were nonwhite. Of the socioeconomic variables assessed, only Medicaid insurance was associated with less recovery in the first 90 days post-discharge (β = -0.40; 95% CI -0.67, -0.14).Other variables associated with recovery were discharge mRS, hospital, premorbid ambulatory status, admission NIHSS, discharge destination, and length of stay. (see Table)

Conclusion: Race and household income were not associated with recovery in the first 90 days post-discharge in stroke patients admitted to CSCs receiving acute interventions. Patients with Medicaid insurance had reduced probability of improvement. Further evaluation is indicated to determine if the worse recovery in Medicaid patients is due to socioeconomic status or premorbid health status.

Abstract TP358: Prehospital Diagnosis of Intracerebral Hemorrhage in a Mobile Stroke Treatment Unit

Introduction: The mobile stroke unit (MSTU) is an on-site pre-hospital treatment team that incorporates laboratory and CT scanner and reduces times to treatment for ischemic stroke thrombolysis. The impact of MSTU on treatment and outcomes of intracerebral hemorrhage (ICH) remains unknown. We report our initial experience with ICH encountered on MSTU.

Hypothesis: ICH can be quickly identified using MSTU. Hypertension and coagulopathy are common in ICH evaluated on MSTU.

Methods: We identified ICH cases from the prospectively collected database encounters. Demographics, clinical features, MSTU imaging and repeat imaging characteristics were reviewed. Initial and follow-up hematoma volume was calculated by the ABC/2 method.

Results: Of 295 encounters on MSTU from July 2014 to July 2015, 20 (6.7%) had intracranial hemorrhage, which comprised of 17 intracerebral, 1 subarachnoid and 2 subdural hemorrhages. Median time to CT diagnosis of ICH from emergency medical dispatch was 31 minutes (interquartile range (IQR) 28-36) and that from last known well was 118 minutes (IQR 39-301). Of the 17 ICH patients, 15 (88%) were hypertensive, with a mean systolic blood pressure of 178.1 and diastolic 91.0 mm Hg. Five (29.4%) individuals were found with INR>1.4, 1 of whom received 4-factor prothrombin complex concentrate. Median NIH Stroke Scale was 11 (IQR 7.5-14.5), and median hematoma volume was 10.7 cc (IQR 4.3-30.8). One patient had significant hematoma expansion as defined by >6 cc or 33% relative volume increase.

Conclusions: Over 5% of the cases evaluated in the unit presented with ICH, most of whom were hypertensive and had small hematoma volume. MSTU enables early diagnosis of ICH after activation of emergency system, can provide early treatment, and appropriate triage.

Abstract TP255: The Emergency Department Dysphagia Screen is Associated With Lower Rates of Pneumonia in Acute Ischemic Stroke Patients

Introduction: Dysphagia is a common problem in acute ischemic stroke (AIS) patients predisposing them to pneumonia and leading to worse outcomes. The Joint Commission mandated that dysphagia screening be performed at hospital presentation which for most patients with AIS, is the Emergency Department (ED). No evidence exists to demonstrate if the use of an ED dysphagia screen is associated with lower rates of pneumonia.

Hypothesis: We assessed the hypothesis that the use of our ED dysphagia screen would not be associated with lower rates of pneumonia in AIS patients.

Methods: We performed a pre-post cohort study evaluating the rates of pneumonia in AIS patients presenting to our ED. Our pre group were AIS patients presenting from 2005-2009 and our post group from 2011-2015. The presence of pneumonia was pre-defined as new pulmonary infiltrate treated with antibiotics. We collected demographic and clinical data including rates of dysphagia and stroke severity. Data are presented as frequencies and medians with interquartile ranges (IQR) where appropriate. Rates of pneumonia were compared using the t-test.

Results: We evaluated 419 pre screen and 1022 post screen AIS patients. Both groups were 50% female. The use of thombolytics in the pre group was 10% and post group was 11%. The median ages and ED NIHSS scores for the pre and post population were 63 years (IQR 53-73), 6 (IQR 3-10) and 64 years (IQR 56-76), 4 (IQR 2-8). Rates of dysphagia during hospitalization were 20% and 31% for the pre-post groups respectively. Rates of pneumonia for the pre-post groups were 13.8% and 8.0% respectively which was significantly different P=0.0007.

Conclusion: The use of an ED dysphagia screen is associated with a lower rate of pneumonia in AIS patients. This study was not designed to prove causation so other factors also may have influenced the lower rate of pneumonia including possibly slightly less severe strokes. The rates of diagnosed dysphagia were higher in the post group suggesting ED screening may heighten awareness resulting in increased diagnoses of dysphagia. Given the rates of dysphagia and pneumonia early screening of AIS patients in the ED seems prudent.

The management of acute hypertension in patients with renal dysfunction: labetalol or nicardipine?

STUDY OBJECTIVES

To compare the safety and efficacy of U.S. Food and Drug Administration (FDA)-recommended doses of labetalol and nicardipine for hypertension (HTN) management in a subset of patients with renal dysfunction (RD).

DESIGN

Randomized, open label, multicenter prospective clinical trial.

SETTING

Thirteen United States tertiary care emergency departments.

PATIENTS OR PARTICIPANTS

Subgroup analysis of the Evaluation of IV Cardene (Nicardipine) and Labetalol Use in the Emergency Department (CLUE) clinical trial. The subjects were 104 patients with RD (i.e., creatinine clearance < 75 mL/min) who presented to the emergency department with a systolic blood pressure (SBP) ≥ 180 mmHg on 2 consecutive readings and for whom the emergency physician felt intravenous antihypertensive therapy was desirable.

INTERVENTIONS

The FDA recommended doses of either labetalol or nicardipine for HTN management.

MEASUREMENTS

The number of patients achieving the physician's predefined target SBP range within 30 minutes of treatment.

RESULTS

Patients treated with nicardipine were within target range more often than those receiving labetalol (92% vs. 78%, P = 0.046). On 6 SBP measures, patients treated with nicardipine were more likely to achieve the target range on either 5 or all 6 readings than were patients treated with labetalol (46% vs. 25%, P = 0.024). Labetalol patients were more likely to require rescue medication (27% vs. 17%, P = 0.020). Adverse events thought to be related to either treatment group were not reported in the 30-minute active study period, and patients had slower heart rates at all time points after 5 minutes (P < 0.01).

CONCLUSIONS

In severe HTN with RD, nicardipine-treated patients are more likely to reach a target blood pressure range within 30 minutes than are patients receiving labetalol.

CLINICAL IMPLICATIONS

Within 30 minutes of administration, nicardipine is more efficacious than labetalol for acute blood pressure control in patients with RD.

Intravenous nicardipine and labetalol use in hypertensive patients with signs or symptoms suggestive of end-organ damage in the emergency department: a subgroup analysis of the CLUE trial

OBJECTIVE

To compare the efficacy of Food and Drug Administration recommended dosing of nicardipine versus labetalol for the management of hypertensive patients with signs and/or symptoms (S/S) suggestive of end-organ damage (EOD).

DESIGN

Secondary analysis of the multicentre prospective, randomised CLUE trial.

SETTING

13 academic emergency departments in the USA.

PARTICIPANTS

Eligible patients had two systolic blood pressure (SBP) measures ≥180 mm Hg at least 10 min apart, no contraindications to nicardipine or labetalol and predefined S/S suggestive of EOD on arrival.

INTERVENTIONS

Medications were administered by continuous infusion (nicardipine) or repeat intravenous bolus (labetalol) for a study period of 30 min or until a specified target SBP ±20 mm Hg was achieved.

PRIMARY OUTCOME MEASURE

Percentage of participants achieving a predefined target SBP range (TR) defined as an SBP within ±20 mm Hg as established by the treating physician.

RESULTS

Of the 141 eligible patients, 49.6% received nicardipine, 51.7% were women and 81.6% were black. Mean age was 52.2±13.9 years. Median initial SBP did not differ in the nicardipine (210.5 (IQR 197-226) mm Hg) and labetalol (210 (200-226) mm Hg) groups (p=0.862). Nicardipine patients were more likely to have a history of diabetes (41.4% vs 25.7%, p=0.05) but there were no other historical, demographic or laboratory differences between groups. Within 30 min, nicardipine patients more often reached the target SBP range than those receiving labetalol (91.4% vs 76.1%, difference=15.3% (95% CI 3.5% to 27.3%); p=0.01). On multivariable modelling with adjustment for gender and clinical site, nicardipine patients were more likely to be in TR by 30 min than patients receiving labetalol (OR 3.65, 95% CI 1.31 to 10.18, C statistic=0.72).

CONCLUSIONS

In the setting of hypertension with suspected EOD, patients treated with nicardipine are more likely to reach prespecified SBP targets within 30 min than patients receiving labetalol.

CLINICAL TRIAL REGISTRATION

NCT00765648, clinicaltrials.gov.

Central versus local adjudication of myocardial infarction in a cardiac biomarker trial

OBJECTIVES

The impact of regulatory requirements, which require central adjudication for the diagnosis of acute myocardial infarction (AMI) in cardiac biomarker studies, is unclear. We determined the impact of local (at the site of subject enrollment) versus central adjudication of AMI on final diagnosis.

METHODS

This is a retrospective analysis of data from the Myeloperoxidase in the Diagnosis of Acute Coronary Syndromes Study, an 18-center prospective study of patients with suspected acute coronary syndromes, with enrollment from December 19, 2006, to September 20, 2007. Local adjudication of AMI was performed by a single site investigator at each center following the protocol-specified definition and according to the year 2000 definition of AMI, which based cardiac troponin (cTn) elevation on local cut points for each of the 13 different assays. After completion of the Myeloperoxidase in the Diagnosis of Acute Coronary Syndromes Study primary analysis and to evaluate a new troponin assay, a Food and Drug Administration-mandated central adjudication was performed by 3 investigators at different institutions. This adjudication used the 2007 Universal Definition of AMI, which differs by use of the manufacturer's 99th percentile cTn cut point. We describe the outcome of this process and compare it with the local adjudication. Central adjudicators were not blinded to local adjudications. For central adjudication, discrepant diagnoses were resolved by consensus. Local versus central cTn cut points differed for 6 assays. Both definitions required a rise and/or fall of cTn. Discrepant cases were reviewed by the lead author. Difficult cases were defined as having a difference between local and central adjudication, an elevated cTn with a temporal rise and fall, and a negative or absent risk stratification test. Statistics were by χ(2), κ, and logistic regression.

RESULTS

Of 1,107 patients enrolled, 11 had indeterminate central adjudication, leaving 1,096 for analysis. In spite of high agreement across central versus local adjudicators, κ = 0.79 (95% CI [0.73, 0.85]), AMI was diagnosed more often by central adjudication, 134 (12.2%) versus 104 (9.5%), with 44 local diagnoses (4%) changed from non-AMI to AMI (n = 37) or AMI to non-AMI (n = 7) (P < .001). These 44 represented 34% (95% CI 26%-42%) of 141 cases in which either central or local adjudication was AMI. Of diagnoses changed to AMI, 3 reasons contributed approximately one-third each: the local use of a non-99th percentile cTn cutoff (32%), the possibility of human error (34%), and difficult cases (34%).

CONCLUSION

Despite an acceptable κ, over a third of patients with a diagnosis of AMI were not assigned that diagnosis by both sets of adjudicators. This supports the importance of 1 standard method for diagnosis of AMI.

Identifying patients for early discharge: performance of decision rules among patients with acute chest pain

BACKGROUND

The HEART score and North American Chest Pain Rule (NACPR) are decision rules designed to identify acute chest pain patients for early discharge without stress testing or cardiac imaging. This study compares the clinical utility of these decision rules combined with serial troponin determinations.

METHODS AND RESULTS

A secondary analysis was conducted of 1005 participants in the Myeloperoxidase In the Diagnosis of Acute coronary syndromes Study (MIDAS). MIDAS is a prospective observational cohort of Emergency Department (ED) patients enrolled from 18 US sites with symptoms suggestive of acute coronary syndrome (ACS). The ability to identify participants for early discharge and the sensitivity for ACS at 30 days were compared among an unstructured assessment, NACPR, and HEART score, each combined with troponin measures at 0 and 3h. ACS, defined as cardiac death, acute myocardial infarction, or unstable angina, occurred in 22% of the cohort. The unstructured assessment identified 13.5% (95% CI 11.5-16%) of participants for early discharge with 98% (95% CI 95-99%) sensitivity for ACS. The NACPR identified 4.4% (95% CI 3-6%) for early discharge with 100% (95% CI 98-100%) sensitivity for ACS. The HEART score identified 20% (95% CI 18-23%) for early discharge with 99% (95% CI 97-100%) sensitivity for ACS. The HEART score had a net reclassification improvement of 10% (95% CI 8-12%) versus unstructured assessment and 19% (95% CI 17-21%) versus NACPR.

CONCLUSIONS

The HEART score with 0 and 3 hour serial troponin measures identifies a substantial number of patients for early discharge while maintaining high sensitivity for ACS.

Abstract 2539: Evaluation of Emergency Department Acute Ischemic Stroke Patients With and Without Blockage on Computed Tomography Angiography

Background: CT angiography (CTA) provides early assessment of cerebral vasculature in ED patients presenting with Acute Ischemic Stroke (AIS). Prior studies using 4 row detector CT scanners have suggested that results may be used to determine who receives thrombolytics (tPA). We sought to evaluate the rate of normal CTA and the use of tPA in AIS patients with and without blockages using modern CT technology.

Methods: We conducted a retrospective cohort study of all code stroke patients presenting to our ED over a 3 year period ending in February 2011. Inclusion criteria included an ED and neurology diagnosis of AIS with a CTA performed at presentation. All patients had a NIHSS score recorded at presentation and underwent imaging using a 64 row detector scanner (Phillips) with 50cc of non-ionic contrast. Demographic, imaging, and clinical data were collected. Modified Rankin Scores (mRS) were assigned at presentation and hospital discharge. Good clinical outcome was defined as a mRS of 0-2. Data are reported as frequencies and medians with interquartile ranges (IQR) as appropriate. Rates of tPA use were evaluated using χ 2 testing. Changes in mRS were evaluated with the paired t-test.

Results: A total of 209 subjects met inclusion for analysis of which 104 (50%) were male and 116 (55%) had no blockage on CTA. The median NIHSS score and mortality rates were 14 (IQR 8-19), 14 (15%) with CTA blockage, and 4 (IQR 2-7), 3 (3%) for those without. The use of tPA occurred in 46(50%) with 29 patients receiving intra-arterial therapy, and 14 (12%) patients with and without blockage respectively. Post tPA bleeding occurred in 12 (13%) patients with blockage on CTA and in 0 patients without blockage. Use of tPA was significantly more frequent in patients with a blockage on CTA, P <0.001. As a group, patients without a blockage had a significant decrease in mRS at discharge, however the overall difference was greater in the tPA group, difference = 0.4 (0.2-0.7) P<0.0002 and 1.9 (1.2-2.6) P<0.0001 respectively. Only AIS patients with a blockage and given tPA had a significant reduction of mRS, difference = 0.6 (0.2-1.0) P<0.005 compared with no tPA, difference = -0.1 (-0.4-0.3) P<0.7.

Conclusion: More than half of our AIS patients presenting through our ED have no blockage on CTA. Patients with AIS and no blockage on CTA have less severe strokes and are less likely to receive tPA. Both AIS patients with and without a blockage on CTA appear to derive benefit from tPA.

Diagnostic characteristics of S100A8/A9 in a multicenter study of patients with acute right lower quadrant abdominal pain

OBJECTIVES

Over the past decade, clinicians have become increasingly reliant on computed tomography (CT) for the evaluation of patients with suspected acute appendicitis. To limit the radiation risks and costs of CT, investigators have searched for biomarkers to aid in diagnostic decision-making. We evaluated one such biomarker, calprotectin or S100A8/A9, and determined the diagnostic performance characteristics of a developmental biomarker assay in a multicenter investigation of patients presenting with acute right lower quadrant abdominal pain.

METHODS

This was a prospective, double-blinded, single-arm, multicenter investigation performed in 13 emergency departments (EDs) from August 2009 to April 2010 of patients presenting with acute right lower quadrant abdominal pain. Plasma samples were tested using the investigational S100A8/A9 assay. The primary outcome of acute appendicitis was determined by histopathology for patients undergoing appendectomy or 2-week telephone follow-up for patients discharged without surgery. The sensitivity, specificity, negative likelihood ratio (LR-), and positive likelihood ratio (LR+) of the biomarker assay were calculated using the prespecified cutoff value of 14 units. A post hoc stability study was performed to investigate the potential effect of time and courier transport on the measured value of the S100A8/A9 assay test results.

RESULTS

Of 1,052 enrolled patients, 848 met criteria for analysis. The median age was 24.5 years (interquartile range [IQR] = 16-38 years), 57% were female, and 50% were white. There was a 27.5% prevalence of acute appendicitis. The sensitivity and specificity for the investigational S100A8/A9 assay in diagnosing acute appendicitis were estimated to be 96% (95% confidence interval [CI] = 93% to 98%) and 16% (95% CI = 13% to 19%), respectively. The LR- ratio was 0.24 (95% CI = 0.12 to 0.47), and the LR+ was 1.14 (95% CI = 1.10 to 1.19). The post hoc stability study demonstrated that in the samples that were shipped, the estimated time coefficient was 7.6 × 10(-3) ± 2.0 × 10(-3) log units/hour, representing an average increase of 43% in the measured value over 48 hours; in the samples that were not shipped, the estimated time coefficient was 2.5 × 10(-3) ± 0.4 × 10(-3) log units/hour, representing a 13% increase on average in the measured value over 48 hours, which was the maximum delay allowed by the study protocol. Thus, adjusting the cutoff value of 14 units by the magnitude of systematic inflation observed in the stability study at 48 hours would result in a new cutoff value of 20 units and a "corrected" sensitivity and specificity of 91 and 28%, respectively.

CONCLUSIONS

In patients presenting with acute right lower quadrant abdominal pain, we found the investigational enzyme-linked immunosorbent assay (ELISA) test for S100A8/A9 to perform with high sensitivity but very limited specificity. We found that shipping effect and delay in analysis resulted in a subsequent rise in test values, thereby increasing the sensitivity and decreasing the specificity of the test. Further investigation with hospital-based laboratory analyzers is the next critical step for determining the ultimate clinical utility of the ELISA test for S100A8/A9 in ED patients presenting with acute right lower quadrant abdominal pain.

CLUE: a randomized comparative effectiveness trial of IV nicardipine versus labetalol use in the emergency department

Introduction

Our purpose was to compare the safety and efficacy of food and drug administration (FDA) recommended dosing of IV nicardipine versus IV labetalol for the management of acute hypertension.

Methods

Multicenter randomized clinical trial. Eligible patients had 2 systolic blood pressure (SBP) measures ≥180 mmHg and no contraindications to nicardipine or labetalol. Before randomization, the physician specified a target SBP ± 20 mmHg (the target range: TR). The primary endpoint was the percent of subjects meeting TR during the initial 30 minutes of treatment.

Results

Of 226 randomized patients, 110 received nicardipine and 116 labetalol. End organ damage preceded treatment in 143 (63.3%); 71 nicardipine and 72 labetalol patients. Median initial SBP was 212.5 (IQR 197, 230) and 212 mmHg (IQR 200,225) for nicardipine and labetalol patients (P = 0.68), respectively. Within 30 minutes, nicardipine patients more often reached TR than labetalol (91.7 vs. 82.5%, P = 0.039). Of 6 BP measures (taken every 5 minutes) during the study period, nicardipine patients had higher rates of five and six instances within TR than labetalol (47.3% vs. 32.8%, P = 0.026). Rescue medication need did not differ between nicardipine and labetalol (15.5 vs. 22.4%, P = 0.183). Labetalol patients had slower heart rates at all time points (P < 0.01). Multivariable modeling showed nicardipine patients were more likely in TR than labetalol patients at 30 minutes (OR 2.73, P = 0.028; C stat for model = 0.72)

Conclusions

Patients treated with nicardipine are more likely to reach the physician-specified SBP target range within 30 minutes than those treated with labetalol.

Trial registration

ClinicalTrials.gov: NCT00765648

A novel emergency department dysphagia screen for patients presenting with acute stroke

OBJECTIVES

Dysphagia is a common complication for emergency department (ED) patients presenting with acute stroke (AS). Recent stroke recommendations have suggested that EDs screen patients with AS for dysphagia prior to administering anything by mouth. This study sought to develop and test a novel ED dysphagia screen to be used in this population.

METHODS

A multidisciplinary approach was used to create a novel dysphagia screen performed by ED nurses during the initial evaluation of patients with suspected AS. The screen consists of five questions of which any single affirmative answer signified possible dysphagia. A prospective cohort study was conducted to evaluate the performance of this screen in detecting dysphagia after AS. Patients were followed for 30 days, and true dysphagia was determined if the patient had an abnormal modified barium swallow study (MBS), had placement of a feeding tube, or was placed on a dysphagia diet after assessment by a speech pathologist. The authors performed a substudy to determine agreement using a blinded kappa (κ) assessment with a convenience sample of 40 patients.

RESULTS

Over a 21-month period, 283 patients met eligibility for analysis. The rate of cerebral infarction in this cohort was 245 (87%). The rates for true dysphagia, pneumonia, and death were 91 (32%), 26 (9%), and 18 (6%), respectively. The dysphagia screen had a sensitivity of 95% (95% confidence [CI] = 88% to 98%) and a negative likelihood ratio of 0.1 (95% CI = 0.04 to 0.2). The inter-rater agreement assessed by kappa was substantial (0.69, 95% CI = 0.55 to 0.83).

CONCLUSIONS

These data suggest that this dysphagia screen may be a valuable tool for detecting dysphagia in ED patients presenting with AS. The simple screen can be performed by nursing personnel and appears to perform well with good agreement. Given the overall rate of dysphagia in one-third of AS patients, the use of an ED dysphagia screen appears warranted.

The Influence of Cardiac Risk Factor Burden on Cardiac Stress Test Outcomes

Background

Chest pain is the most common admission diagnosis for observation unit patients. These patients often undergo cardiac stress testing to further risk stratify for coronary artery disease (CAD). The decision of whom to stress is currently based on clinical judgment. We sought to determine the influence of cardiac risk factor burden on cardiac stress test outcome for patients tested from an observation unit, inpatient or outpatient setting.

Methods

We performed a retrospective observational cohort study for all patients undergoing stress testing in our institution from June 2006 through July 2007. Cardiac risk factors were collected at the time of stress testing. Risk factors were evaluated in a summative fashion using multivariate regression adjusting for age and known coronary artery disease. The model was tested for goodness of fit and collinearity and the c statistic was calculated using the receiver operating curve.

Results

A total of 4026 subjects were included for analysis of which 22% had known CAD. The rates of positive outcome were 89 (12.0%), 95 (12.6%), and 343 (16.9%) for the OU, outpatients, and hospitalized patients respectively. While the odds of a positive test outcome increased for additional cardiac risk factors, ROC curve analysis indicates that simply adding the number of risk factors does not add significant diagnostic value. Hospitalized patients were more likely to have a positive stress test, OR 1.41 (1.10 - 1.81).

Conclusions

Our study does not support basing the decision to perform a stress test on the number of cardiac risk factors.

Predicting observation unit treatment failures in patients with skin and soft tissue infections

Background

Skin and soft tissue infections are a common admission diagnosis to emergency department (ED) observation units (OU). Little is known about which patients fail OU treatment.

Aims

This study evaluates clinical factors of skin or soft tissue infections associated with further inpatient treatment after OU treatment failure.

Methods

A structured retrospective cohort study of consecutive adults treated for abscess or cellulitis in our OU from April 2005 to February 2006 was performed. Records were identified using ICD-9 codes and were abstracted by two trained abstractors using a structured data collection form. Significant variables on univariate analysis P < 0.1 were entered into a multivariate logistic regression.

Results

A total of 183 patient charts were reviewed. Four patients with a non-infectious diagnosis were excluded, leaving 179 patients. The median age was 41 (interquartile range: 20–74). Following observation treatment, 38% of patients required admission. The following variables were evaluated for association with failure to discharge home: intravenous drug use, gender, a positive community-acquired methicillin-resistant Staphylococcus aureus culture, age, presence of medical insurance, drainage of an abscess in the ED, diabetes and a white blood cell count (WBC) greater than 15,000. Following multivariate analysis only female gender odds ratio (OR) 2.33 [95% confidence interval (CI): 1.06–5.15] and WBC greater than 15,000 OR 4.06 (95% CI: 1.53–10.74) were significantly associated with failure to discharge.

Conclusions

Among OU patients treated for skin and soft tissue infections, women were twice as likely to require hospitalization and patients with a WBC > 15,000 on presentation to the ED, regardless of gender, were 4 times more likely to require hospitalization.

Lifelong Learning

Early American physician education lacked quality and consistency. Poorly funded institutions with weak curricula and little patient contact before graduation trained our earliest doctors. With the advent of the twentieth century, a reformation of medical education took place that created the foundation of our modern American medical education system. The importance of physician education increased, leading to the production of specialty boards and requirements for continuing medical education and culminating in a continuous certification process now required of all specialties including the American Board of Emergency Medicine. While the utility of continuing medical education has been questioned, technological advances, the Internet, and improved education techniques are helping physicians practice modern medicine in a time of rapidly expanding science.

Adenosine depresses transmitter release but is not the basis for 'tetanic fade' at the neuromuscular junction of the rat

It has been suggested that during repetitive neural stimulation adenosine accumulates at the neuromuscular junction and the resulting negative feedback action of adenosine is the major basis for tetanic fade (decline in action of adenosine during repetitive stimulation) This hypothesis was examined at the rat neuromuscular junction by examining the effects of blocking adenosine A1-receptors. Intracellular recording techniques were used to monitor end-plate potentials and miniature end-plate potentials. The data suggest that while adenosine serves a role in depressing transmitter release, adenosine accumulation during brief periods of stimulation is minimal and adenosine is not the cause for tetanic fade.