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Takakuwa KM, Schears RM. Emergency Medicine Physicians Would Prefer Using Cannabis Over Opioids for First-Line Treatment of a Medical Condition if Provided With Medical Evidence: A National Survey. Cureus 2021; 13:e19641. [PMID: 34926086 PMCID: PMC8673685 DOI: 10.7759/cureus.19641] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2021] [Indexed: 11/21/2022] Open
Abstract
Objective: To determine emergency medicine (EM) physicians’ preferences for using medical cannabis versus opioids if medical cannabis was legalized. Methods: We surveyed US physicians at the largest national EM conference (American College of Emergency Physicians’ Annual Conference) held in San Diego, CA from October 1 to 4, 2018. Of the thousands of conference participants approached, 539 US physicians completed the anonymous written survey, which represented 15.2% of the US physicians attending the conference. Results: The mean age of the participants was 39.6 ± 10.9 years, men composed 57.5% of the participants, and whites made up 72.8% of the respondents. Participants practicing in medically legal (54.8%) and medically plus adult-use legal cannabis states (23.1%) totaled 77.9%. A majority (70.7%) of the participants believed that cannabis has medical value. EM physicians preferred cannabis over opioids as a first-line treatment addressing a medical condition provided that medical studies found that cannabis was equally effective (p < 0.001, X2 = 36.8 [95% CI 2, 415]), and overwhelmingly preferred cannabis over opioids if it were more effective (p < 0.001, X2 = 90.8 [95% CI 2, 415]). Physicians appeared to prefer opioids over cannabis if medical studies found that cannabis was less effective though it was not significant (p > 0.05). Subgroup analyses showed that belief in the medical value of cannabis significantly increased the odds ratio of choosing cannabis over opioids if cannabis was equally or more effective than opioids. Conclusion: Our study shows that EM physicians believe cannabis has medical value and would prefer using cannabis over opioids if provided with equivalent findings. We believe our findings reflect EM physicians’ experience of the opioid epidemic and suggest the need for further study of this potential therapeutic.
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Affiliation(s)
- Kevin M Takakuwa
- Emergency Medicine, Society of Cannabis Clinicians, Sebastopol, USA
| | - Raquel M Schears
- College of Medicine, University of Central Florida, Orlando, USA
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Takakuwa KM, Mistretta A, Pazdernik VK, Sulak D. Education, Knowledge, and Practice Characteristics of Cannabis Physicians: A Survey of the Society of Cannabis Clinicians. Cannabis Cannabinoid Res 2021; 6:58-65. [PMID: 33614953 DOI: 10.1089/can.2019.0025] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Context: Medical cannabis use has increased in recent years despite being a federally illegal drug in the United States. States with medical cannabis use laws require patients to be certified by physicians. However, little is known about the education, knowledge, and practice characteristics of physicians who recommend and supervise patients' use of medical cannabis. Objective: This study assessed how U.S. physicians who practice cannabis medicine are educated, self-assess their knowledge, and describe their practice. Methods: In fall 2017, a 57-item, electronic survey was sent to all members of the Society of Cannabis Clinicians. Because California has had legalized medical cannabis for longer than any other state, we analyzed responses for 14 items between California and non-California physicians. Results: Of 282 surveyed, 133 were eligible and 45 completed the survey. Of those, multiple medical specialties were represented. Only one physician received education during medical school about cannabis medicine, but physicians gained knowledge through conferences (71%, 32/45), the medical literature (64%, 29/45), and websites (62%, 28/45). Just over half (56%, 20/45) felt that there was sufficient information available to practice cannabis medicine. Of the 37 who answered the knowledge question, most felt knowledgable about cannabinoids (78%, 29/37) and the endocannabinoid system (76%, 28/37). There was a wide variation in the number of cannabis recommendations provided by physicians over the course of their practice career (median 1200; interquartile range, 100-5000), and most provided condition-specific treatment (69%, 31/45) and dosing recommendations (62%, 28/45). The majority (81%, 30/37) of physicians received referrals from mainstream medical providers. No differences were found between California and non-California physicians, except more women were from California (p=0.02). Conclusions: The use of medical cannabis continues to increase in the United States and globally. All states that allow medical cannabis require a physician's recommendation, yet few states require specific clinical training. Findings of this study suggest the need for more formal education and training of physicians in medical school and residency, more opportunities for cannabis-related continuing medical education for practicing physicians, and clinical and basic science research that will inform best practices in cannabis medicine.
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Affiliation(s)
| | - Anthony Mistretta
- School of Osteopathic Medicine in Arizona, A.T. Still University, Mesa, Arizona, USA
| | - Vanessa K Pazdernik
- Department of Research Support, A.T. Still University, Kirksville, Missouri, USA
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Takakuwa KM, Schears RM. The emergency department care of the cannabis and synthetic cannabinoid patient: a narrative review. Int J Emerg Med 2021; 14:10. [PMID: 33568074 PMCID: PMC7874647 DOI: 10.1186/s12245-021-00330-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 10/10/2020] [Accepted: 01/05/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Cannabis is the most prevalent illegal drug used and the second most common cause of ED drug-related complaints in the USA. Recently, newer more potent strains, concentrated THC products, and consumption methods have become available. OBJECTIVE Our first objective was to define cannabis use in the USA and provide a summary background on its current preparations, pharmacokinetics, vital sign and physical exam findings, adverse effects, and laboratory testing. Our second objective, using the aforementioned summary as relevant background information, was to present and summarize the care and treatment of the most commonly reported cannabis-related topics relevant to ED physicians. METHODS We first performed an extensive literature search of peer-reviewed publications using New PubMed and Cochrane Central Register of Controlled Trials to identify the most commonly reported cannabis-related topics in emergency care. Once the six topic areas were identified, we undertook an extensive narrative literature review for each section of this paper using New PubMed and Cochrane Central Register of Controlled Trials from the inception of the databases to September 30, 2020. RESULTS The six subject areas that were most frequently reported in the medical literature relevant to cannabis-related ED care were acute intoxication/overdose, pediatric exposure, cannabinoid hyperemesis syndrome, cannabis withdrawal, e-cigarette or vaping product use-associated lung injury (EVALI), and synthetic cannabinoids. CONCLUSION As cannabis becomes more widely available with the adoption of state medical cannabis laws, ED-related cannabis visits will likely rise. While cannabis has historically been considered a relatively safe drug, increased legal and illegal access to newer formulations of higher potency products and consumption methods have altered the management and approach to ED patient care and forced physicians to become more vigilant about recognizing and treating some new cannabis-related life-threatening conditions.
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Affiliation(s)
- Kevin M Takakuwa
- Society of Cannabis Clinicians, PO Box 27574, San Francisco, CA, 94127, USA.
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Takakuwa KM, Shofer FS, Schears RM. Letter to the Editor: A National Survey of U.S. Emergency Medicine Physicians on Their Knowledge Regarding State and Federal Cannabis Laws. Cannabis Cannabinoid Res 2021; 5:337-339. [PMID: 33381647 DOI: 10.1089/can.2019.0073] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Frances S Shofer
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Raquel M Schears
- Department of Emergency Medicine, University of Central Florida, Orlando, Florida, USA
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Takakuwa KM, Sulak D. A Survey on the Effect That Medical Cannabis Has on Prescription Opioid Medication Usage for the Treatment of Chronic Pain at Three Medical Cannabis Practice Sites. Cureus 2020; 12:e11848. [PMID: 33409086 PMCID: PMC7781576 DOI: 10.7759/cureus.11848] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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] [Indexed: 11/05/2022] Open
Abstract
Objective: The opioid epidemic continues to claim thousands of lives every year without an effective strategy useful in mitigating mortality. The use of medical cannabis has been proposed as a potential strategy to decrease opioid usage. The objective of this study was to determine how the use of medical cannabis affects prescribed opioid usage in chronic pain patients. Methods: We conducted an online convenience sample survey of patients from three medical cannabis practice sites who had reported using opioids. A total of 1181 patients responded, 656 were excluded for not using medical cannabis in combination with opioid use or not meeting the definition of chronic pain, leaving 525 patients who had used prescription opioid medications continuously for at least three months to treat chronic pain and were using medical cannabis in combination with their prescribed opioid use. Results: Overall, 40.4% (n=204) reported that they stopped all opioids, 45.2% (n=228) reported some decrease in their opioid usage, 13.3% (n=67) reported no change in opioid usage, and 1.1% (n=6) reported an increase in opioid usage. The majority (65.3%, n=299) reported that they sustained the opioid change for over a year. Almost half (48.2%, n=241) reported a 40-100% decrease in pain while 8.6% (n=43) had no change in pain and 2.6% (n=13) had worsening pain. The majority reported improved ability to function (80.0%, n=420) and improved quality of life (87.0%, n=457) with medical cannabis. The majority (62.8%, n=323) did not want to take opioids in the future. While the change in pain level was not affected by age and gender, the younger age group had improved ability to function compared with the middle and older age groups. Conclusions: Patients in this study reported that cannabis was a useful adjunct and substitute for prescription opioids in treating their chronic pain and had the added benefit of improving the ability to function and quality of life.
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Affiliation(s)
- Kevin M Takakuwa
- Emergency Medicine, Society of Cannabis Clinicians, Sebastopol, USA
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Takakuwa KM, Hergenrather JY, Shofer FS, Schears RM. The Impact of Medical Cannabis on Intermittent and Chronic Opioid Users with Back Pain: How Cannabis Diminished Prescription Opioid Usage. Cannabis Cannabinoid Res 2020; 5:263-270. [PMID: 32923663 DOI: 10.1089/can.2019.0039] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Objective: To determine if cannabis may be used as an alternative or adjunct treatment for intermittent and chronic prescription opioid users. Design: Retrospective cohort study. Setting: A single-center cannabis medical practice site in California. Patients: A total of 180 patients who had a chief complaint of low back pain were identified (International Classification of Diseases, 10th Revision, code M54.5). Sixty-one patients who used prescription opioids were analyzed. Interventions: Cannabis recommendations were provided to patients as a way to mitigate their low back pain. Outcome Measures: Number of patients who stopped opioids and change in morphine equivalents. Results: There were no between-group differences based on demographic, experiential, or attitudinal variables. We found that 50.8% were able to stop all opioid usage, which took a median of 6.4 years (IQR=1.75-11 years) after excluding two patients who transitioned off opioids by utilizing opioid agonists. For those 29 patients (47.5%) who did not stop opioids, 9 (31%) were able to reduce opioid use, 3 (10%) held the same baseline, and 17 (59%) increased their usage. Forty-eight percent of patients subjectively felt like cannabis helped them mitigate their opioid intake but this sentiment did not predict who actually stopped opioid usage. There were no variables that predicted who stopped opioids, except that those who used higher doses of cannabis were more likely to stop, which suggests that some patients might be able to stop opioids by using cannabis, particularly those who are dosed at higher levels. Conclusions: In this long-term observational study, cannabis use worked as an alternative to prescription opioids in just over half of patients with low back pain and as an adjunct to diminish use in some chronic opioid users.
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Affiliation(s)
| | | | - Frances S Shofer
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Raquel M Schears
- Department of Emergency Medicine, University of Central Florida, Orlando, Florida
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Takakuwa KM, Schears RM. Indications and preference considerations for using medical Cannabis in an emergency department: A National Survey. Am J Emerg Med 2020; 45:513-515. [PMID: 32682602 DOI: 10.1016/j.ajem.2020.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 07/01/2020] [Indexed: 11/29/2022] Open
Affiliation(s)
- Kevin M Takakuwa
- Society of Cannabis Clinicians, Sebastopol, California (Dr Takakuwa); University of Central Florida, Orlando, FL (Dr Schears), United States of America.
| | - Raquel M Schears
- Society of Cannabis Clinicians, Sebastopol, California (Dr Takakuwa); University of Central Florida, Orlando, FL (Dr Schears), United States of America
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Takakuwa KM. A history of the Society of Cannabis Clinicians and its contributions and impact on the US medical cannabis movement. Int J Drug Policy 2020; 79:102749. [PMID: 32289591 DOI: 10.1016/j.drugpo.2020.102749] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 12/06/2019] [Revised: 03/22/2020] [Accepted: 03/25/2020] [Indexed: 11/18/2022]
Abstract
The US medical marijuana movement has come about in a relatively short period of time. Despite millennia in which cannabis was used medically, it was taxed and then banned in the US during the 20th century. It would take a number of factors working concurrently-increasing social use, scientific developments, the AIDS epidemic, and political activism-before its use became accepted again. Some of the groundwork for the medical marijuana movement to take hold was laid out by cannabis clinicians, practitioners who recognized the medical potential of the plant and its constituent compounds, kept abreast of the relevant scientific discoveries, and risked their medical licenses, professional reputations and even arrest to approve and guide medical use to their patients as it became legal in their states. Once the tide started moving, it did so relatively quickly. In this article, a history detailing the first and oldest U.S. medical organization promoting the use of medical cannabis and its founder is reviewed, shedding light on an aspect of history within the medical cannabis movement that is largely unrecognized.
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Affiliation(s)
- Kevin M Takakuwa
- Independent Researcher, P.O. Box 27574, San Francisco, CA 94127, United States.
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Takakuwa KM, Shofer FS, Schears RM. The practical knowledge, experience and beliefs of US emergency medicine physicians regarding medical Cannabis: A national survey. Am J Emerg Med 2020; 38:1952-1954. [PMID: 32067838 DOI: 10.1016/j.ajem.2020.01.059] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 01/28/2020] [Accepted: 01/29/2020] [Indexed: 10/25/2022] Open
Affiliation(s)
- Kevin M Takakuwa
- Society of Cannabis Clinicians, Sebastopol, CA, United States of America.
| | - Frances S Shofer
- University of Pennsylvania, Philadelphia, PA, United States of America
| | - Raquel M Schears
- University of Central Florida, Orlando, FL, United States of America
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Takakuwa KM, Schears RM. A History of the US Medical Cannabis Movement and Its Importance to Pediatricians: Science Versus Politics in Medicine's Greatest Catch-22. Clin Pediatr (Phila) 2019; 58:1473-1477. [PMID: 31538822 DOI: 10.1177/0009922819875550] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Takakuwa KM. A physician's (and private citizen's) right to privacy against internet data brokers: Maintaining safety in an unsafe profession. Am J Emerg Med 2019; 37:1967-1968. [DOI: 10.1016/j.ajem.2019.03.042] [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] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Revised: 03/25/2019] [Accepted: 03/27/2019] [Indexed: 11/30/2022] Open
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Affiliation(s)
| | - Raquel M Schears
- Emergency Medicine, College of Medicine, University of Central Florida, Orlando
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13
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Takakuwa KM. Stop the Attack on Minnesota's Courageous Stance to Allow Its Residents to Sleep Safely. J Clin Sleep Med 2018; 14:1813. [PMID: 30353823 DOI: 10.5664/jcsm.7410] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 06/26/2018] [Indexed: 11/13/2022]
Affiliation(s)
- Kevin M Takakuwa
- American Medical Center for Cannabis Research, Zephyr Cove, Nevada
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Takakuwa KM, Biros MH, Ruddy RM, FitzGerald M, Shofer FS. A national survey of academic emergency medicine leaders on the physician workforce and institutional workforce and aging policies. Acad Med 2013; 88:269-275. [PMID: 23269295 DOI: 10.1097/acm.0b013e31827c026e] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
PURPOSE To describe the policies, practices, and attitudes of academic emergency medicine (EM) leaders regarding workforce issues, shift work, and accommodating the academic and personal needs of aging physicians. METHOD In 2009, the authors and the Society for Academic Emergency Medicine's Aging and Generational Issues taskforce developed, pilot tested, and deployed a survey of academic leaders at EM residency programs in the United States. They used descriptive statistics to analyze the results and chi-square or Fisher exact test for additional comparisons. RESULTS Seventy-eight of 146 (53%) invited EM leaders completed the survey. Forty-four of those 78 (56%) respondents reported formal or informal policies at their institutions for accommodating aging faculty, and 55 (71%) reported policies for accommodating faculty for reasons not related to age. Fifty-six (73%) reported employing physicians who work primarily overnight shifts, whereas only 23 (30%) reported employing physicians who work primarily weekend shifts. Fifty-five (71%) supported considering age in assigning shift type (overnight, weekend, etc.), but only 26 (33%) supported considering age in determining number of shifts. Sixty-six (86%) supported considering a faculty member's academic role in determining number of shifts. Only 26 (34%) supported considering a faculty member's academic rank in determining number of shifts, and 15 (20%) supported considering rank in assigning shift type. CONCLUSIONS EM leaders have considered the implications of issues related to clinical shift work and aging physicians. The findings of this report indicate some of the ways that leaders have begun to adapt their programs to ensure the field's future success.
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Affiliation(s)
- Kevin M Takakuwa
- Department of Emergency Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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Takakuwa KM, Keith SW, Estepa AT, Shofer FS. A meta-analysis of 64-section coronary CT angiography findings for predicting 30-day major adverse cardiac events in patients presenting with symptoms suggestive of acute coronary syndrome. Acad Radiol 2011; 18:1522-8. [PMID: 22055795 DOI: 10.1016/j.acra.2011.08.013] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2011] [Revised: 08/15/2011] [Accepted: 09/11/2011] [Indexed: 11/19/2022]
Abstract
RATIONALE AND OBJECTIVES To determine the accuracy of 64-section coronary computed tomography angiography (CCTA) in predicting 30 day major adverse cardiac events (MACE) for patients presenting with symptoms concerning for acute coronary syndrome (ACS). MATERIALS AND METHODS Electronic databases between January 1, 2005, and May, 1, 2011, and reference lists from relevant published research articles were searched. We included studies on adult patients who presented with active symptoms suggestive of ACS, had immediate 64-section CCTA performed and were assessed for MACE at a minimum of 30 days past their initial presentation. Studies had to report or provide sufficient detail to determine sensitivity, specificity, positive predictive value, and negative predictive value in relation to MACE using a 50% diameter stenosis as cutoff criterion for coronary artery disease. RESULTS Nine studies were included for a total of 1559 patients studied (42.3% women, mean age 51.9 ± 10.6). Patients ranged from low to intermediate risk for ACS. All had initial inconclusive electrocardiograms and negative cardiac biomarker results. A total of 14.8% of patients had a positive CCTA result. The pooled sensitivity was 93.3% (95% CI 88.3%-96.6%), specificity was 89.9% (95% CI 88.3%-91.3%), positive predictive value was 48.1% (95% CI 42.5%-53.8%), and negative predictive value was 99.3% (95% CI 98.7%-99.6%). CONCLUSION Sixty-four section CCTA had a 99.3% negative predictive value in excluding MACE for 30 days after initial symptom presentation in 85.2% of our study population. Although the value of 64-section CCTA is best for identifying patients who can safely be discharged home, it is less useful for patients who have positive results.
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Affiliation(s)
- Kevin M Takakuwa
- Thomas Jefferson University Hospital, 111 S. 11th Street, Philadelphia, PA 19107, USA.
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Mumma BE, Baumann BM, Diercks DB, Takakuwa KM, Campbell CF, Shofer FS, Chang AM, Jones MK, Hollander JE. Sex bias in cardiovascular testing: the contribution of patient preference. Ann Emerg Med 2010; 57:551-560.e4. [PMID: 21146255 DOI: 10.1016/j.annemergmed.2010.09.026] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2010] [Revised: 09/02/2010] [Accepted: 09/24/2010] [Indexed: 01/23/2023]
Abstract
STUDY OBJECTIVE Women with potential acute coronary syndromes are less likely to receive cardiac catheterization or revascularization than men. We hypothesize that this may be due to different diagnostic test preferences of female and male patients. METHODS We conducted a cohort study at 4 emergency departments enrolling patients who presented with symptoms of potential acute coronary syndromes. After hearing the potential benefits and harms of each test, subjects completed a 21-item survey assessing their preference for noninvasive testing versus cardiac catheterization. Based on hypothetical test results, similar questions about medical versus interventional management were asked. Subjects were also queried about likelihood of following physician recommendation for each test or intervention. Actual 30-day testing and interventions were recorded. The main outcome was patient preference about each procedure and the likelihood of patient saying they would accept the physician recommendation. RESULTS One thousand eighty patients enrolled; 652 (60%) were admitted to the hospital. With regard to diagnostic test preference, both women and men preferred stress test to catheterization (women 58% versus men 52%; difference 6% [95% confidence interval {CI} -0.06% to 12%]), and the proportion of women and men who would accept the physician recommendation for stress tests was similar (85% for both); however, the stated acceptance rate for cardiac catheterization was lower for women (65% versus 75%; difference -10% [95% CI -15% to -4%]). Women were 6% less likely (67% versus 73%; 95% CI for difference 12% to 0.5%) to accept percutaneous coronary intervention over medical therapy and 7% less likely (61% versus 68%; 95% CI for difference -13% to 1%) to desire coronary artery bypass grafting over medical therapy. The survey results are consistent with the patients' clinical course. During the initial hospitalization, women were less likely to receive diagnostic testing of any type (38% versus 45%; difference -7%; 95% CI for the difference -13% to -1.5%) and cardiac catheterization (10% versus 17%; difference -7% [95% CI -11% to -2%]). Revascularization was infrequent in both groups (4% versus 6%; difference -2% [95% CI -5% to 0.6%]). CONCLUSION Although women and men had similar preferences about cardiac diagnostic tests and treatment options, women were less likely than men to say they would accept the physician recommendation for any intervention. Patient preference may partially explain the disparity in cardiovascular testing between women and men.
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Affiliation(s)
- Bryn E Mumma
- Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA
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Takakuwa KM, Ku BS, Halpern EJ. Myopericarditis diagnosed by a 64-slice coronary CT angiography "triple rule out" protocol. Int J Emerg Med 2010; 3:447-9. [PMID: 21373320 PMCID: PMC3047842 DOI: 10.1007/s12245-010-0210-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2010] [Accepted: 06/15/2010] [Indexed: 11/18/2022] Open
Abstract
We report a case of myopericarditis in a 30-year-old male complaining of shortness of breath. In an emergency department (ED) setting, the symptoms of myopericarditis may overlap with many disease entities and can be a challenging diagnosis to make. However, with the use of a 64-section coronary CT angiography in a “triple rule out” (TRO) protocol, we were able to detect a large pericardial effusion surrounding the heart and moderate global hypokinesis in the setting of normal-sized heart chambers and normal coronary arteries. We were further able to exclude pulmonary embolism and thoracic dissection. This is the first reported case of diagnosing myopericarditis using a TRO protocol. It demonstrates the usefulness of TRO in making an emergent diagnosis of myopericarditis while excluding other life-threatening diseases that can lead to earlier appropriate ED disposition and care.
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Takakuwa KM, Ou FS, Peterson ED, Pollack CV, Peacock WF, Hoekstra JW, Ohman EM, Gibler WB, Blomkalns AL, Roe MT. The usage patterns of cardiac bedside markers employing point-of-care testing for troponin in non-ST-segment elevation acute coronary syndrome: results from CRUSADE. Clin Cardiol 2009; 32:498-505. [PMID: 19743496 DOI: 10.1002/clc.20626] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Point-of-care (POC) testing may expedite the care of emergency department (ED) patients suspected of having acute coronary syndromes (ACS). We evaluated the use patterns of cardiac bedside markers or POC testing for troponin in patients with non-ST-segment elevation (NSTE) ACS. METHODS NSTE ACS data were collected from the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association (ACC/AHA) Guidelines (CRUSADE) registry. We compared hospital and patient characteristics, in-hospital events, and process-of-care variables between hospitals to those that did not use POC testing in > or = 50% of enrolled patients. We examined characteristics, in-hospital events, and process-of-care differences between patients with negative vs positive troponin POC testing results. RESULTS Of 568 hospitals, 74 (16,276 patients) had high POC usage compared with 197 hospitals (50,782 patients) with no troponin POC usage. From the high POC usage hospitals, 12,604 patients had recorded troponin POC test results. Hospitals with high POC usage had a shorter ED length of stay and were less likely to administer aspirin, beta-blockers, and heparin during the first 24 hours of care. Patients with positive troponin POC results were more often older, minority, female, Medicare-insured, diabetic, and renally impaired. They had fewer electrocardiograms within 10 minutes but were more likely to get aspirin, beta-blockers, glycoprotein IIb/IIIa inhibitors, and heparin within 24 hours of arrival. They also had longer ED lengths of stay, received fewer in-hospital and interventional procedures, and had more adverse clinical events. CONCLUSION Differences existed in how hospitals used POC testing and the care given based on those results. Positive POC results are associated with expedited and higher use of anti-ischemic therapies.
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Affiliation(s)
- Kevin M Takakuwa
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania 19107, USA.
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Takakuwa KM, Burek GA, Estepa AT, Shofer FS. A method for improving arrival-to-electrocardiogram time in emergency department chest pain patients and the effect on door-to-balloon time for ST-segment elevation myocardial infarction. Acad Emerg Med 2009; 16:921-7. [PMID: 19754862 DOI: 10.1111/j.1553-2712.2009.00493.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The objectives were to determine if an emergency department (ED) could improve the adherence to a door-to-electrocardiogram (ECG) time goal of 10 minutes or less for patients who presented to an ED with chest pain and the effect of this adherence on door-to-balloon (DTB) time for ST-segment elevation myocardial infarction (STEMI) cardiac catheterization (cath) alert patients. METHODS This was a planned 1-month before-and-after interventional study design for implementing a new process for obtaining ECGs in patients presenting to the study ED with chest pain. Prior to the change, patients were registered and triaged before an ECG was obtained. The new procedure required registration clerks to identify those with chest pain and directly overhead page or call a designated ECG technician. This technician had other ED duties, but prioritized performing ECGs and delivering them to attending physicians. A full registration process occurred after the clinical staff performed their initial assessment. The primary outcome was the total percentage of patients with chest pain who received an ECG within 10 minutes of ED arrival. The secondary outcome was DTB time for patients with STEMI who were emergently cath alerted. Data were analyzed using mean differences, 95% confidence intervals (CIs), and relative risk (RR) regression to adjust for possible confounders. RESULTS A total of 719 patients were studied: 313 before and 405 after the intervention. The mean (+/-standard deviation [SD]) age was 50 (+/-16) years, 54% were women, 57% were African American, and 36% were white. Patients walked in 89% of the time; 11% arrived by ambulance. Thirty-nine percent were triaged as emergent and 61% as nonemergent. Patients presented during daytime 68% of the time, and 32% presented during the night. Before the intervention, 16% received an ECG at 10 minutes or less. After the intervention, 64% met the time requirement, for a mean difference of 47.3% (95% CI = 40.8% to 53.3%, p < 0.0001). Results were not affected by age, sex, race, mode of arrival, triage classification, or time of arrival. For patients with STEMI cath alerts, four were seen before and seven after the intervention. No patients before the intervention had ECG time within 10 minutes, and one of four had DTB time of <90 minutes. After the intervention, all seven patients had ECG time within 10 minutes; the three arriving during weekday hours when the cath team was on site had DTB times of <90 minutes, but the four arriving at night and on weekends when the cath team was off site had DTB times of >90 minutes. CONCLUSIONS The overall percentage of patients with a door-to-ECG time within 10 minutes improved without increasing staffing. An ECG was performed within 10 minutes of arrival for all patients who were STEMI cath alerted, but DTB time under 90 minutes was achieved only when the cath team was on site.
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Affiliation(s)
- Kevin M Takakuwa
- Department of Emergency Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
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Halpern EJ, Levin DC, Zhang S, Takakuwa KM. Comparison of image quality and arterial enhancement with a dedicated coronary CTA protocol versus a triple rule-out coronary CTA protocol. Acad Radiol 2009; 16:1039-48. [PMID: 19523852 DOI: 10.1016/j.acra.2009.03.013] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2009] [Revised: 03/16/2009] [Accepted: 03/16/2009] [Indexed: 11/17/2022]
Abstract
RATIONALE AND OBJECTIVES To compare the image quality of dedicated coronary computed tomography angiography (cCTA) to that of triple rule-out (TRO) CTA designed to evaluate the coronary arteries, thoracic aorta, and pulmonary arteries. MATERIALS AND METHODS Consecutive cCTA examinations performed by a single radiologist over 1 year were reviewed. Biphasic injection protocols were employed: 70 mL of optiray-350 followed by 40 mL of saline injected at 5.5 mL/second for dedicated cCTA; 70 mL of optiray-350 followed by 25 mL of the contrast diluted with 25 mL of saline injected at 5.0 mL/second for TRO-CTA. Two independent cardiovascular radiologists reviewed the coronary vessels in each case and rated diagnostic image quality on a 5 point scale (1, suboptimal; 3, adequate; 5, excellent). Vascular enhancement was measured in the coronary arteries, aorta, and pulmonary arteries. RESULTS There was excellent interobserver agreement between the cardiovascular radiologists (kappa = 0.91). Coronary image quality score were similar among 260 dedicated cCTA studies and 168 TRO-CTA studies (mean: 3.8-3.9. P > .18). At least one coronary segment demonstrated suboptimal image quality in 8% of examinations, including 18 dedicated cCTA studies and 16 TRO studies (P = .94). Enhancement was greater in the distal thoracic aorta of TRO patients (336 vs. 311 Hounsfield units; P = .01); no other significant differences in enhancement were identified in the aorta and coronary arteries of dedicated cCTA and TRO studies. Vascular enhancement was adequate for diagnostic evaluation of the pulmonary arteries in all TRO studies. CONCLUSIONS A TRO-CTA protocol using 95 mL of contrast can provide comparable coronary image quality and coronary vascular enhancement as compared to dedicated cCTA with 70 mL of contrast.
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Affiliation(s)
- Ethan J Halpern
- Department of Radiology, Thomas Jefferson University Hospital, 132 South 10th Street, Philadelphia, PA 19107-5244, USA.
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Halpern EJ, Takakuwa KM, Gingold EL, Halpern DJ. A novel approach to reduce breast radiation exposure with coronary CTA: angled axial image acquisition. Acad Radiol 2009; 16:951-6. [PMID: 19375949 DOI: 10.1016/j.acra.2009.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2009] [Revised: 02/05/2009] [Accepted: 02/05/2009] [Indexed: 11/17/2022]
Abstract
RATIONALE AND OBJECTIVES To determine whether angled gantry acquisition might be used to image the heart with a shorter scan length and reduced breast exposure during coronary computed tomography angiography. MATERIALS AND METHODS One hundred consecutive coronary computed tomography angiography examinations of female patients were retrospectively evaluated to define the angle between the long axis of the left heart and the axial imaging plane. The scan length required to image the entire left ventricle along with the coronary arteries was measured for an axial scan plane as well as for a scan plane parallel to the long axis of the left heart. The overlap between these imaging volumes and the lower portion of the breast was measured. RESULTS The long axis of the left heart varied from 7 degrees to 54 degrees off the axial plane (mean 32 degrees +/- 7 degrees ). The required scan length to include the entire left ventricle and coronary arteries ranged from 8.2 to 12.4 cm (mean, 10.0 +/- 0.9 cm) for the axial scan plane and 5.6-10.1 cm (mean, 7.5 +/- 0.8 cm) for a scan plane parallel to the long axis of the heart (P < .001). cCTA in the axial plane required a 7.4 +/- 1.6 cm overlap with the lower breast, whereas cCTA in the long axis of the heart reduced the overlap to 4.5 +/- 1.8 cm (P < .001). CONCLUSIONS Using an angled gantry approach, the coronary arteries can be fully imaged in a plane along the long axis of the left heart with a single 10-cm acquisition and with substantial reduction in amount of breast tissue within the irradiated field.
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Affiliation(s)
- Ethan J Halpern
- Department of Radiology, Thomas Jefferson University Hospital, 132 South 10th Street, Philadelphia, PA 19107-5244, USA.
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Takakuwa KM, Halpern EJ. Evaluation of a "triple rule-out" coronary CT angiography protocol: use of 64-Section CT in low-to-moderate risk emergency department patients suspected of having acute coronary syndrome. Radiology 2008; 248:438-46. [PMID: 18641247 DOI: 10.1148/radiol.2482072169] [Citation(s) in RCA: 141] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE To determine whether coronary computed tomographic (CT) angiography "triple rule-out" evaluation of emergency department (ED) patients presenting with symptoms suggestive of acute coronary syndrome (ACS) can help identify a subset of patients who can be discharged without adverse clinical outcomes within 30 days. MATERIALS AND METHODS This protocol was approved by the university institutional review board. Each patient provided written informed consent prior to inclusion. Coronary CT angiography was performed in 201 consecutive low-to-moderate risk ACS patients. A triple rule-out protocol was used to evaluate for coronary disease, pulmonary embolism, aortic dissection, and other thoracic disease. Four patients were excluded because of technical problems. The remaining subjects underwent a 30-day follow-up. RESULTS A disease process other than coronary atherosclerosis that explained the presenting symptoms was diagnosed in 22 (11%) of 197 patients. Clinically important noncoronary diagnoses that did not explain patient symptoms were identified in 27 (14%) of 197 additional patients. With respect to coronary artery disease, 10 patients had severe disease (>70% stenosis), 12 had moderate disease (50%-70% stenosis), 46 had mild disease (up to 50% stenosis), and 129 had no disease. No further diagnostic testing was performed in 133 (76%) of 175 of patients with no to mild coronary disease. At 30-day follow-up, the negative predictive value of coronary CT angiography with no more than mild disease was 99.4%. There were no adverse outcomes at 30 days. CONCLUSION Triple rule-out coronary CT angiography evaluation of low-to-moderate risk ACS patients presenting to the ED provided a noncoronary diagnosis that explained the presenting complaint in 11% of patients, suggested the presence of significant moderate-to-severe coronary disease in 11% (22 of 197) of patients, and precluded additional diagnostic cardiac testing in the majority of patients with no adverse outcomes at 30-day follow-up.
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Affiliation(s)
- Kevin M Takakuwa
- Department of Emergency Medicine and Radiology, Thomas Jefferson University Hospital, 132 S 10th St, Philadelphia, PA 19107-5244, USA
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Takakuwa KM, Shofer FS, Limkakeng AT, Hollander JE. Preferences for cardiac tests and procedures may partially explain sex but not race disparities. Am J Emerg Med 2008; 26:545-50. [PMID: 18534282 DOI: 10.1016/j.ajem.2007.08.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2007] [Accepted: 08/18/2007] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVE There are known race and sex differences in emergent cardiac care. Many feel these differences reflect a bias from the physician. We hypothesized these differences may be the result of patient preferences. METHODS Emergency department (ED) patients 40 years and older with a chief complaint of chest pain were surveyed from July 11 through December 9, 2005, at 2 academic EDs. This prospective survey study included demographics and prior cardiac test experience. Preferences for hypothetical cardiac tests and procedures were compared between race and sex using chi(2) or Fisher exact tests. RESULTS Two hundred sixteen patients were enrolled. The mean age was 55 +/- 12 years (43% men and 51% black). Blacks compared with whites preferred the electrocardiogram (ECG) to the technetium-99m sestamibi (MIBI) stress test. Blacks also preferred a percutaneous coronary intervention (PCI) compared with whites who were more likely to forego PCI. These racial differences disappeared when a physician recommended a procedure. There were no race preferences between PCI vs coronary artery bypass graft, whether or not a doctor recommended the procedure. For sex, there were no preferences between ECG vs MIBI stress test or cardiac catheterization, whether or not a doctor recommended the test or procedure. With regard to a choice between PCI and coronary artery bypass graft, women were more likely to decline the procedure than men. Even with a physician-recommended procedure, women were more likely to refuse than men, whereas men were more likely to accept it. CONCLUSIONS Blacks were more likely to prefer the less invasive stress test and wanted PCIs more, but these racial differences disappeared when a physician-recommended test was offered. Women were more likely to refuse the most invasive cardiac procedure compared with men. The sex-related preferences might partially explain why women receive fewer invasive cardiac procedures than men. However, race-related cardiac preferences suggest that other factors beyond patient preference account for fewer PCIs in black patients.
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Affiliation(s)
- Kevin M Takakuwa
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA 19107-5004, USA.
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Takakuwa KM, Shofer FS, Abbuhl SB. Strategies for dealing with emergency department overcrowding: a one-year study on how bedside registration affects patient throughput times. J Emerg Med 2007; 32:337-42. [PMID: 17499684 DOI: 10.1016/j.jemermed.2006.07.031] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2004] [Revised: 11/09/2005] [Accepted: 07/05/2006] [Indexed: 11/16/2022]
Abstract
The objective of this study was to determine if the implementation of bedside registration would affect patient throughput times in an urban, academic emergency department. This was a before-and-after interventional study. An 8-month period before initiating bedside registration in November 2001 was compared to three subsequent 4-month intervals. Four times of day and three triage classifications were examined. Data were analyzed using a three-way analysis of covariance. There were 58,225 patient encounters analyzed. There was a significant difference in time from triage to room after bedside registration began (p < 0.0001). When examined by triage class, there were no differences in triage-to-room for emergent patients, a significant decrease for urgent patients initially and a significant decrease for non-urgent patients. Bedside registration by time of day initially reduced all four time-of-day periods but over the year they returned to pre-bedside registration levels, except for the morning period. Bedside registration decreased triage-to-room times for non-urgent patients and urgent patients initially, but this was not sustained at the end of 1 year. It had no effect on emergent patients who are routinely taken into the patient care area immediately. The sustainable effects of bedside registration were during the morning time when emergency department beds were available.
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Affiliation(s)
- Kevin M Takakuwa
- Thomas Jefferson University, Department of Emergency Medicine, Philadelphia, Pennsylvania 19107-5004, USA
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Limkakeng AT, Halpern E, Takakuwa KM. Sixty-four–slice multidetector computed tomography: the future of ED cardiac care. Am J Emerg Med 2007; 25:450-8. [PMID: 17499666 DOI: 10.1016/j.ajem.2006.10.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2006] [Accepted: 10/26/2006] [Indexed: 10/23/2022] Open
Abstract
Multidetector computed tomography (MDCT) imaging, a technological advance over traditional CT, is a promising possible alternative to cardiac catheterization for evaluating patients with chest pain in the emergency department (ED). In comparison with traditional CT, MDCT offers increased spatial and temporal resolution that allows reliable visualization of the coronary arteries. In addition, a "triple scan," which includes evaluation for pulmonary embolism and thoracic aortic dissection, can be incorporated into a single study. This test will enable emergency physicians to rapidly evaluate patients for life-threatening illnesses and may allow safer and earlier discharges of many patients with chest pain in comparison with a traditional rule-out protocol. In this article, we will highlight the technological advances of MDCT imaging, review the literature on coronary angiography via MDCT, and discuss the future of this technology as it relates to the ED.
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Affiliation(s)
- Alexander T Limkakeng
- Department of Emergency Medicine, Chest Pain Center, Thomas Jefferson University, Philadelphia, PA 19107-5004, USA.
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Takakuwa KM, Shofer FS, Hollander JE. In reply. Acad Emerg Med 2007. [DOI: 10.1197/j.aem.2006.11.006] [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] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Abstract
OBJECTIVES To determine whether race or gender affected time to initial electrocardiogram (ECG) for patients who presented to an emergency department with chest pain. METHODS This was a prospective cohort study of patients with chest pain. Patients were divided into three groups based on final diagnosis of acute myocardial infarction or unstable angina and all others with noncardiac chest pain. Data were analyzed using ranks in a two-way analysis of covariance adjusted for age. RESULTS A total of 4,358 patients were studied; 58.6% were women and 41.4% men, and 70.3% were African American, 26.0% white, and 3.6% other. Overall, nonwhite patients had longer times to initial ECG compared with white patients. These effects were consistent regardless of ultimate diagnosis. Overall, women had longer times to initial ECG than men. However, ECG time differed by final diagnosis. There were no differences in time to ECG for women compared with men with acute myocardial infarction or unstable angina, but women received an ECG significantly slower than men for noncardiac chest pain. CONCLUSIONS The first screening test for acute coronary syndrome, the ECG, took longer to obtain for nonwhite patients, regardless of final diagnosis. This was unfortunately consistent with the literature that shows racial disparities in all aspects of emergent cardiac care. For women, the overall delay in ECG time can be explained by delays for those women with noncardiac chest pain.
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Affiliation(s)
- Kevin M Takakuwa
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA 19107, USA.
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Takakuwa KM, Ernst AA, Weiss SJ. Residents with disabilities: a national survey of directors of emergency medicine residency programs. South Med J 2002; 95:436-40. [PMID: 11958243] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
BACKGROUND The Americans With Disabilities Act (ADA) has been in effect since 1990. The present study shows response to this act for emergency medicine (EM) residents nationwide. METHODS A total of 121 surveys were mailed to the directors of American College of Graduate Medical Education (ACGME)-approved residency programs. A definition of disability was provided, and a second mailing was sent to those not replying. RESULTS Ninety-two program directors (76%) responded, representing 4,644 residents. Of these, 62 residents (1.3%) were reported as having a documented disability. Programs with a known disabled resident were significantly more likely to have available resources for assistance. Forty-seven (52%) of the program directors suspected a resident might have an undiagnosed disability, and 40 (85%) of these recommended testing or referral. CONCLUSIONS There is a wide array of disabilities among EM residents. Available assistance varies. This may apply to other residencies as well.
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Affiliation(s)
- Kevin M Takakuwa
- Division of Emergency Medicine, University of California, Davis, USA
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Abstract
OBJECTIVES To describe the extent of complementary and alternative medicine (CAM) use among emergency department (ED) patients, to evaluate patients' understanding of CAMs, and to determine gender differences in beliefs about CAMs. METHODS This study was a convenience sampling of patients seen in an urban ED. Patient demographics were recorded. A questionnaire was administered that assessed patients' knowledge and use of CAMs. Patients were also asked about their beliefs on safety, medication interactions, and conveying information about these substances to their physicians. RESULTS A total of 350 ED patients were included in the study; 87% had heard of at least one of the CAMs. There was no difference between genders or races concerning knowledge about CAMs. The most commonly known CAMs were ginseng (75%), ginkgo biloba (55%), eucalyptus (58%), and St. John's wort (57%). Forty-three percent of the responders had used CAMs at some time and 24% were presently using CAMs. The most commonly used CAMs were ginseng (13%), St. John's wort (6%), and ginkgo biloba (9%). All CAMs were considered to be safe by 16% of the patients. Only 67% would tell their doctors they were using CAMs. Females were more likely than males to believe that CAMs do not interact with other medications (15% vs 7%, difference 8%, 95% CI = 2% to 15%). CONCLUSIONS Complementary and alternative medicines are familiar to most patients and used by many of them. Despite this, a large percentage of patients would not tell their physicians about their use of alternative medications. Emergency medicine providers should be aware of the commonly used CAMs, and questions about their use should be routinely included in ED exams.
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Affiliation(s)
- S J Weiss
- UC Davis Medical Center, Sacramento, CA, USA.
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Abstract
OBJECTIVE To assess general knowledge and preventive behaviors regarding breast cancer among women who present to an urban emergency department. METHODS During a six-month study period, a convenience sampling of women aged 21 years and older who were in treatment and waiting areas was surveyed. The anonymous written survey asked about demographic variables, knowledge, and preventive behaviors regarding breast cancer. Knowledge was assessed with questions about the recommended frequency of breast self-examination and the recommended age for first mammography. Performance was assessed by questions about breast self-exam and mammography. Subgroup analysis was done by age (above and below 40 years old), race, income (above and below the median), insurance type, history of breast lump, and family history (FH) of breast cancer. RESULTS Four hundred women completed surveys. Two hundred twelve (53%) correctly knew the answers to the two knowledge questions. Knowledge was greater in women with private insurance. Knowledge of the frequency of breast self-exam was significantly greater among whites and Native Americans than among African Americans, Asians, or Hispanics. Stated performance of preventive behaviors was 72% (288) for breast self-exam and for mammography. Preventive behaviors were significantly more likely to be performed by higher-income and privately-insured women. Breast self-exam was more likely to be done in older women, those with a history of a breast lump, and those with a FH of breast cancer. CONCLUSIONS Women with lower income and without private insurance were less likely to be knowledgeable and practice preventive measures for detecting breast disease.
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Affiliation(s)
- K M Takakuwa
- University of Pennsylvania, Philadelphia, PA, USA
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Ernst AA, Weiss SJ, Park S, Takakuwa KM, Diercks DB. Prochlorperazine versus promethazine for uncomplicated nausea and vomiting in the emergency department: a randomized, double-blind clinical trial. Ann Emerg Med 2000; 36:89-94. [PMID: 10918098 DOI: 10.1067/mem.2000.108652] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE Nausea and vomiting related to gastritis or gastroenteritis are common complaints in the emergency department. The most effective antiemetic agent is yet undetermined. This study was conducted to compare the efficacy of prochlorperazine versus promethazine for uncomplicated nausea and vomiting in the ED. METHODS The study was a randomized, double-blind comparison of prochlorperazine (Compazine) and promethazine (Phenergan) for acute ED treatment of gastritis or gastroenteritis. We studied patients 18 years or older with presumed uncomplicated gastritis or gastroenteritis who presented to 2 academic EDs. Patients were randomly assigned to receive either prochlorperazine, 10 mg intravenously, or promethazine, 25 mg intravenously. Visual analog scale readings of patient comfort were obtained at baseline and at 30- and 60-minute intervals. The primary endpoint was degree of relief at 30 and 60 minutes. Secondary endpoints were time to complete relief, need for further antiemetic medication (treatment failures), and side effects. Statistical analysis was performed using the Mann-Whitney U test for nonparametric analysis and repeated-measures analysis of variance (ANOVA). RESULTS Eighty-four patients were enrolled in the study; 42 received prochlorperazine and 42 received promethazine. There were no differences in demographics in the 2 groups. At baseline (time 0), there was no difference in symptoms (P =.23). At 30 and 60 minutes after receiving medication, prochlorperazine worked significantly better than promethazine (P =.004 and P <.001 using nonparametric analysis). Using repeated-measures ANOVA, there was a significant difference in symptoms over time for both groups (P <.001) and a significant difference in prochlorperazine versus promethazine (P =.002). Time to complete relief was significantly shorter with prochlorperazine (P =.021). There were significantly fewer treatment failures with prochlorperazine (P =.03, 9.5% versus 31%; difference 21%, 95% confidence interval 5 to 38). There was no difference in incidence of extrapyramidal effects. Prochlorperazine caused significantly fewer complaints of sleepiness (P =.002, 38% versus 71%; difference 33%, 95% confidence interval 13 to 53; P =.002). CONCLUSION Prochlorperazine works significantly better than promethazine for relieving symptoms of nausea and vomiting more quickly and completely in ED patients with uncomplicated nausea and vomiting.
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Affiliation(s)
- Amy A Ernst
- Division of Emergency Medicine, Department of Medicine, University of California-Davis, Sacramento, CA
| | - Steven J Weiss
- Division of Emergency Medicine, Department of Medicine, University of California-Davis, Sacramento, CA
| | - Sun Park
- Department of Emergency Medicine, Vanderbilt University, Nashville, TN
| | - Kevin M Takakuwa
- Division of Emergency Medicine, Department of Medicine, University of California-Davis, Sacramento, CA
| | - Deborah B Diercks
- Division of Emergency Medicine, Department of Medicine, University of California-Davis, Sacramento, CA
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Ernst AA, Weiss SJ, Johnson WD, Takakuwa KM. Blood pressure in acute vaso-occlusive crises of sickle cell disease. South Med J 2000; 93:590-2. [PMID: 10881775] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
OBJECTIVE We compared blood pressure (BP) in patients with sickle cell disease (SCD)-related crises and black patients without SCD. METHODS We retrospectively reviewed charts of emergency department (ED) patients with SCD crises in a 2-year period, recording BPs and demographic and SCD data. A cohort of consecutive black patients without SCD was compared. RESULTS Included were 459 SCD-related visits, 187 by men and 272 by women, representing 106 patients. Women had significantly lower BP than men, diastolic BP was significantly lower in patients with hemoglobin SS disease than in those with hemoglobin SC disease, and systolic BP was significantly lower in patients with bilateral versus unilateral pain. One SCD patient had a history of hypertension. The 125 non-SCD patients, excluding 25 with a history of hypertension, had significantly higher systolic and diastolic BP than patients in SCD crisis. CONCLUSION No patients seen in SCD crisis were hypertensive. Patients who were female, had SS disease, or had bilateral pain had lower BP. Significantly higher BP and more hypertension occurred in black patients without SCD.
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Affiliation(s)
- A A Ernst
- Department of Medicine, Louisiana State University, New Orleans, USA
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Takakuwa KM, Ernst AA, Weiss SJ. A breast knowledge survey in an urban emergency medicine department. Ann Emerg Med 1999. [DOI: 10.1016/s0196-0644(99)80208-x] [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] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
STUDY OBJECTIVE To test the hypothesis that ear irrigation with warmed normal saline solution is more comfortable and results in fewer side effects than irrigation with room temperature saline solution in normal volunteers. METHODS The study was a randomized, single-blind, crossover trial in which each subject received 30 mL warmed normal saline solution in 1 ear and 30 mL room temperature saline solution in the opposite ear. The solutions (warmed versus room temperature) and the order of irrigation (right versus left ear) were separately randomized. Investigators obtaining scores were blinded to solution temperature. Subjects rated the discomfort of irrigation, using separate visual analog scales, from 0 (no pain) to 100 mm (worst pain ever). RESULTS Forty volunteers were enrolled in the study. The mean difference in visual analog scale scores favoring warmed over room temperature saline solution was 26 mm (95% confidence interval [CI], 19 to 33 mm; P <.0001). Twenty percent more patients reported dizziness with room temperature irrigation (95% CI, 6% to 34%). There was no gender effect or order effect for the 2 solutions. CONCLUSION Warmed normal saline solution was both clinically and statistically more comfortable than room temperature saline solution as an ear irrigant in normal volunteers. Significantly less dizziness was reported with the warmed solution.
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Affiliation(s)
- A A Ernst
- University of California Davis Medical Center, Sacramento, CA, USA
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Takakuwa KM. Coping with a learning disability in medical school. JAMA 1998; 279:81. [PMID: 9424052] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- K M Takakuwa
- University of California Davis School of Medicine, USA
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Affiliation(s)
- K M Takakuwa
- Department of Psychiatry Research, San Francisco Veterans Administration Medical Center, CA 94121
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Takakuwa KM, Callaway E. Scopolamine and physostigmine do not alter visual detection of change: relationships to a model of lateral geniculate operations. Neuropsychobiology 1990; 24:185-91. [PMID: 2135709 DOI: 10.1159/000119483] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The effects of physostigmine and scopolamine were tested on 5 male subjects using a task based on a model of cross-inhibition among lateral geniculate neurons. The task consisted of detecting and locating a change (appearance or disappearance) of one point of light in an array of points. Earlier research suggested that the task was sensitive to drugs and pathology. In the present study, neither drug showed significant effects on any of three task variables used, although differences between subjects were significant. These findings show that the task is sensitive to individual differences but insensitive to changes in cholinergic activity produced by physostigmine and scopolamine, even though such changes should affect neuronal functioning at the lateral geniculate.
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