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Yore M, Sharp A, Wu YL, Kawatkar A, Lee MS, Ferencik M, Redberg R, Shen E, Zheng C, Sun B. Emergency Department Cardiac Risk Stratification With High-Sensitivity vs Conventional Troponin HEART Pathway. JAMA Netw Open 2023; 6:e2348351. [PMID: 38113042 PMCID: PMC10731477 DOI: 10.1001/jamanetworkopen.2023.48351] [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] [Received: 04/30/2023] [Accepted: 10/26/2023] [Indexed: 12/21/2023] Open
Abstract
Importance Patients presenting to the emergency department with chest pain are routinely risk stratified for major adverse cardiac events using the HEART (History, Electrocardiogram, Age, Risk factors, and Troponin) score pathway, which incorporates clinical features, risk factors, electrocardiography findings, and initial serum troponin testing. A new HEART pathway incorporating high-sensitivity troponin level may improve risk stratification among patients with possible acute myocardial infarction (AMI). Objective To compare health outcomes and resource use among emergency department patients undergoing cardiac risk stratification with a HEART pathway using conventional vs high-sensitivity serum troponin. Design, Setting, and Participants This multicenter pre-post cohort study was conducted between January 1 and September 6, 2021, at 16 Kaiser Permanente Southern California hospitals during uptake of a high-sensitivity serum troponin assay and included 17 384 adult patients who presented to an emergency department with chest pain and were risk stratified with a HEART pathway based on conventional troponin or high-sensitivity troponin. Exposures A HEART pathway incorporating either conventional or high-sensitivity serum troponin was used to stratify study groups for risk of major adverse cardiac events within 30 days. Main Outcomes and Measures The primary outcome was detection of AMI in the emergency department and within 30 days. Results Of the 17 384 patients (median age, 58 years [IQR, 45-69 years]; 9767 women [56.2%]), 12 440 (71.6%) were risk stratified with a HEART pathway based on conventional troponin, and 4944 (28.4%) were risk stratified with a HEART pathway based on high-sensitivity troponin. Detection of AMI within 30 days was higher for the high-sensitivity troponin group than the conventional troponin group (288 [5.8%] vs 545 [4.4%]; P < .001), while the 30-day all-cause mortality rate was unchanged (16 [0.3%] vs 50 [0.4%]; P = .50). In the emergency department, 228 of 4944 patients (4.6%) in the high-sensitivity troponin group received a diagnosis of AMI compared with 251 of 12 440 patients (2.0%) in the conventional troponin group (P < .001). Among those who did not receive a diagnosis of AMI in the emergency department, an additional 60 patients (1.2%) in the high-sensitivity troponin group and 294 (2.4%) in the conventional troponin group (P < .001) received a diagnosis within 30 days. Patients in the high-sensitivity troponin group had lower rates of health care use compared with the conventional troponin group, including admission (605 [12.2%] vs 1862 [15.0%]; P < .001), stress testing within 7 days (506 [10.2%] vs 1591 [12.8%]; P < .001), and coronary revascularization within 30 days (51 [1.0%] vs 244 [2.0%]; P < .001). Conclusions and Relevance This multicenter pre-post cohort study suggests that a new HEART pathway incorporating high-sensitivity troponin may improve detection of AMI and decrease resource use among emergency department patients with chest pain.
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Affiliation(s)
- Mackensie Yore
- Department of Emergency Medicine, Veterans Affairs/University of California Los Angeles National Clinician Scholars Program, Los Angeles
| | - Adam Sharp
- Clinical Science Department, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Yi-Lin Wu
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Aniket Kawatkar
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Ming-Sum Lee
- Department of Cardiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
| | - Maros Ferencik
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland
| | - Rita Redberg
- Division of Cardiology, University of California, San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California, San Franciscio
| | - Ernest Shen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Chengyi Zheng
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Benjamin Sun
- Department of Emergency Medicine, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
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Hitchner L, Yore M, Burk C, Mason J, Sawtelle Vohra S. The resident experience with psychological safety during interprofessional critical event debriefings. AEM Educ Train 2023; 7:e10864. [PMID: 37013133 PMCID: PMC10066498 DOI: 10.1002/aet2.10864] [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] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 01/27/2023] [Accepted: 02/27/2023] [Indexed: 06/19/2023]
Abstract
OBJECTIVES Interprofessional feedback and teamwork skills training are important in graduate medical education. Critical event debriefing is a unique interprofessional team training opportunity in the emergency department. While potentially educational, these varied, high-stakes events can threaten psychological safety for learners. This is a qualitative study of emergency medicine resident physicians' experience of interprofessional feedback during critical event debriefing to characterize factors that impact their psychological safety. METHODS The authors conduced semistructured interviews with resident physicians who were the physician team leader during a critical event debriefing. Interviews were coded and themes were generated using a general inductive approach and concepts from social ecological theory. RESULTS Eight residents were interviewed. The findings suggest that cultivating a safe learning environment for residents during debriefings involves the following: (1) allowing space for validating statements, (2) supporting strong interprofessional relationships, (3) providing structured opportunities for interprofessional learning, (4) encouraging attendings to model vulnerability, (5) standardizing the process of debriefing, (6) rejecting unprofessional behavior, and (7) creating the time and space for the process in the workplace. CONCLUSIONS Given the numerous intrapersonal, interpersonal, and institutional factors at play, educators should be sensitive to times when a resident cannot engage due to unaddressed threats to their psychological safety. Educators can address these threats in real time and over the course of a resident's training to enhance psychological safety and the potential educational impact of critical event debriefing.
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Affiliation(s)
- Lily Hitchner
- Department of Emergency MedicineUCSF Fresno Medical Education ProgramFresnoCaliforniaUSA
| | - Mackensie Yore
- UCLA National Clinician Scholars Program, Department of Emergency MedicineGreater Los Angeles VA Medical CenterCaliforniaLos AngelesUSA
| | - Charney Burk
- Department of Emergency MedicineUCSF Fresno Medical Education ProgramFresnoCaliforniaUSA
| | - Jessica Mason
- Department of Emergency MedicineJohn Peter Smith HospitalFort WorthTexasUSA
| | - Stacy Sawtelle Vohra
- Department of Emergency MedicineUCSF Fresno Medical Education ProgramFresnoCaliforniaUSA
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Yore M, Fockele CE, Duber HC, Doran KM, Cooper RJ, Lin MP, Campbell S, Eswaran V, Chang B, Hong H, Gbenedio K, Stanford KA, Gavin N. 2021 SAEM Consensus Conference Proceedings: Research Priorities for Implementing Emergency Department Screening for Social Risks and Needs. West J Emerg Med 2023; 24:302-311. [PMID: 36976611 PMCID: PMC10047739 DOI: 10.5811/westjem.2022.10.57368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 10/06/2022] [Indexed: 03/29/2023] Open
Abstract
INTRODUCTION Despite literature on a variety of social risks and needs screening interventions in emergency department (ED) settings, there is no universally accepted or evidence-based process for conducting such interventions. Many factors hamper or promote implementation of social risks and needs screening in the ED, but the relative impact of these factors and how best to mitigate/leverage them is unknown. METHODS Drawing on an extensive literature review, expert assessment, and feedback from participants in the 2021 Society for Academic Emergency Medicine Consensus Conference through moderated discussions and follow-up surveys, we identified research gaps and rated research priorities for implementing screening for social risks and needs in the ED. We identified three main knowledge gaps: 1) screening implementation mechanics; 2) outreach and engagement with communities; and 3) addressing barriers and leveraging facilitators to screening. Within these gaps, we identified 12 high-priority research questions as well as research methods for future studies. RESULTS Consensus Conference participants broadly agreed that social risks and needs screening is generally acceptable to patients and clinicians and feasible in an ED setting. Our literature review and conference discussion identified several research gaps in the specific mechanics of screening implementation, including screening and referral team composition, workflow, and use of technology. Discussions also highlighted a need for more collaboration with stakeholders in screening design and implementation. Additionally, discussions identified the need for studies using adaptive designs or hybrid effectiveness-implementation models to test multiple strategies for implementation and sustainability. CONCLUSION Through a robust consensus process we developed an actionable research agenda for implementing social risks and needs screening in EDs. Future work in this area should use implementation science frameworks and research best practices to further develop and refine ED screening for social risks and needs and to address barriers as well as leverage facilitators to such screening.
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Affiliation(s)
- Mackensie Yore
- VA Los Angeles and UCLA National Clinician Scholars Program, VA Greater Los Angeles Healthcare System HSR&D Center of Innovation, Los Angeles, California
| | | | - Herbert C Duber
- University of Washington, Department of Emergency Medicine, Seattle, Washington
| | - Kelly M Doran
- NYU Grossman School of Medicine, Departments of Emergency Medicine and Population Health, New York, New York
| | - Richelle J Cooper
- UCLA David Geffen School of Medicine, UCLA Department of Emergency Medicine, Los Angeles, California
| | - Michelle P Lin
- Stanford University, Department of Emergency Medicine, Stanford, California
| | | | - Vidya Eswaran
- Baylor College of Medicine, Department of Emergency Medicine and Section of Health Services Research, Department of Medicine, Houston, Texas
| | - Betty Chang
- Columbia University, Department of Emergency Medicine, New York, New York
| | - Haeyeon Hong
- Boston Medical Center, Department of Emergency Medicine, Boston, Massachusetts
| | - Kessiena Gbenedio
- Columbia University, Department of Emergency Medicine, New York, New York
| | | | - Nicholas Gavin
- Mount Sinai Icahn School of Medicine, Department of Emergency Medicine, New York, New York
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Saito M, McGready R, Tinto H, Rouamba T, Mosha D, Rulisa S, Kariuki S, Desai M, Manyando C, Njunju EM, Sevene E, Vala A, Augusto O, Clerk C, Were E, Mrema S, Kisinza W, Byamugisha J, Kagawa M, Singlovic J, Yore M, van Eijk AM, Mehta U, Stergachis A, Hill J, Stepniewska K, Gomes M, Guérin PJ, Nosten F, Ter Kuile FO, Dellicour S. Pregnancy outcomes after first-trimester treatment with artemisinin derivatives versus non-artemisinin antimalarials: a systematic review and individual patient data meta-analysis. Lancet 2023; 401:118-130. [PMID: 36442488 PMCID: PMC9874756 DOI: 10.1016/s0140-6736(22)01881-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 09/15/2022] [Accepted: 09/22/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Malaria in the first trimester of pregnancy is associated with adverse pregnancy outcomes. Artemisinin-based combination therapies (ACTs) are a highly effective, first-line treatment for uncomplicated Plasmodium falciparum malaria, except in the first trimester of pregnancy, when quinine with clindamycin is recommended due to concerns about the potential embryotoxicity of artemisinins. We compared adverse pregnancy outcomes after artemisinin-based treatment (ABT) versus non-ABTs in the first trimester of pregnancy. METHODS For this systematic review and individual patient data (IPD) meta-analysis, we searched MEDLINE, Embase, and the Malaria in Pregnancy Library for prospective cohort studies published between Nov 1, 2015, and Dec 21, 2021, containing data on outcomes of pregnancies exposed to ABT and non-ABT in the first trimester. The results of this search were added to those of a previous systematic review that included publications published up until November, 2015. We included pregnancies enrolled before the pregnancy outcome was known. We excluded pregnancies with missing estimated gestational age or exposure information, multiple gestation pregnancies, and if the fetus was confirmed to be unviable before antimalarial treatment. The primary endpoint was adverse pregnancy outcome, defined as a composite of either miscarriage, stillbirth, or major congenital anomalies. A one-stage IPD meta-analysis was done by use of shared-frailty Cox models. This study is registered with PROSPERO, number CRD42015032371. FINDINGS We identified seven eligible studies that included 12 cohorts. All 12 cohorts contributed IPD, including 34 178 pregnancies, 737 with confirmed first-trimester exposure to ABTs and 1076 with confirmed first-trimester exposure to non-ABTs. Adverse pregnancy outcomes occurred in 42 (5·7%) of 736 ABT-exposed pregnancies compared with 96 (8·9%) of 1074 non-ABT-exposed pregnancies in the first trimester (adjusted hazard ratio [aHR] 0·71, 95% CI 0·49-1·03). Similar results were seen for the individual components of miscarriage (aHR=0·74, 0·47-1·17), stillbirth (aHR=0·71, 0·32-1·57), and major congenital anomalies (aHR=0·60, 0·13-2·87). The risk of adverse pregnancy outcomes was lower with artemether-lumefantrine than with oral quinine in the first trimester of pregnancy (25 [4·8%] of 524 vs 84 [9·2%] of 915; aHR 0·58, 0·36-0·92). INTERPRETATION We found no evidence of embryotoxicity or teratogenicity based on the risk of miscarriage, stillbirth, or major congenital anomalies associated with ABT during the first trimester of pregnancy. Given that treatment with artemether-lumefantrine was associated with fewer adverse pregnancy outcomes than quinine, and because of the known superior tolerability and antimalarial effectiveness of ACTs, artemether-lumefantrine should be considered the preferred treatment for uncomplicated P falciparum malaria in the first trimester. If artemether-lumefantrine is unavailable, other ACTs (except artesunate-sulfadoxine-pyrimethamine) should be preferred to quinine. Continued active pharmacovigilance is warranted. FUNDING Medicines for Malaria Venture, WHO, and the Worldwide Antimalarial Resistance Network funded by the Bill & Melinda Gates Foundation.
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Affiliation(s)
- Makoto Saito
- WorldWide Antimalarial Resistance Network, Oxford, UK; Infectious Diseases Data Observatory, Oxford, UK; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK; Division of Infectious Diseases, Advanced Clinical Research Center, Institute of Medical Science, University of Tokyo, Tokyo, Japan
| | - Rose McGready
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK; Shoklo Malaria Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Halidou Tinto
- Clinical Research Unit of Nanoro, Institut de Recherche en Sciences de la Santé, Nanoro, Burkina Faso
| | - Toussaint Rouamba
- Clinical Research Unit of Nanoro, Institut de Recherche en Sciences de la Santé, Nanoro, Burkina Faso
| | | | - Stephen Rulisa
- School of Medicine and Pharmacy, University Teaching Hospital of Kigali, University of Rwanda, Kigali, Rwanda
| | - Simon Kariuki
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - Meghna Desai
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Eric M Njunju
- Department of Basic Sciences, Copperbelt University, Ndola, Zambia
| | - Esperanca Sevene
- Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique; Centro de Investigação em Saúde de Manhiça, Manhiça, Mozambique
| | - Anifa Vala
- Centro de Investigação em Saúde de Manhiça, Manhiça, Mozambique
| | - Orvalho Augusto
- Centro de Investigação em Saúde de Manhiça, Manhiça, Mozambique
| | | | - Edwin Were
- Department of Reproductive Health, Moi University, Eldoret, Kenya
| | | | - William Kisinza
- National Institute of Medical Research, Amani Medical Research Centre, Muheza, Tanzania
| | - Josaphat Byamugisha
- Department of Obstetrics and Gynaecology, Makerere University, Kampala, Uganda
| | - Mike Kagawa
- Department of Obstetrics and Gynaecology, Makerere University, Kampala, Uganda
| | | | - Mackensie Yore
- VA Los Angeles and University of California, Los Angeles National Clinician Scholars Program, VA Greater Los Angeles Healthcare System Health Services Research and Development Service Center of Innovation, Los Angeles, CA, USA
| | - Anna Maria van Eijk
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Ushma Mehta
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - Andy Stergachis
- Department of Pharmacy, School of Pharmacy, and Department of Global Health, School of Public Health, University of Washington, Seattle, WA, USA
| | - Jenny Hill
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Kasia Stepniewska
- WorldWide Antimalarial Resistance Network, Oxford, UK; Infectious Diseases Data Observatory, Oxford, UK; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Melba Gomes
- UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases, Geneva, Switzerland; School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Philippe J Guérin
- WorldWide Antimalarial Resistance Network, Oxford, UK; Infectious Diseases Data Observatory, Oxford, UK; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Francois Nosten
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK; Shoklo Malaria Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Feiko O Ter Kuile
- WorldWide Antimalarial Resistance Network, Oxford, UK; Infectious Diseases Data Observatory, Oxford, UK; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Stephanie Dellicour
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.
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Chinnock B, Yore M, Mason J, Kremer M, Farshidpour L, Lopez D, Castaneda J. Self-obtained vaginal swabs are not inferior to provider-performed endocervical sampling for emergency department diagnosis of Neisseria gonorrhoeae and Chlamydia trachomatis. Acad Emerg Med 2021; 28:612-620. [PMID: 33460481 DOI: 10.1111/acem.14213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 01/09/2021] [Accepted: 01/13/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Provider-performed endocervical sampling (PPES) in the diagnosis of Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) may be difficult to perform in a busy emergency department (ED) due to patient preference, availability of the pelvic examination room, or provider availability. Our objective was to assess if self-obtained vaginal swabs (SOVS) were noninferior to PPES in the ED diagnosis of NG/CT using a rapid nucleic acid amplification test (NAAT). METHODS We conducted a prospective observational cohort study in a single ED. Participants were adult female English- and Spanish-speaking patients in whom the ED provider felt that NG/CT testing was warranted. Each patient had SOVS and PPES performed. For SOVS, a research associate reviewed a one-page handout describing the procedure but gave no other assistance. Patients answered survey questions regarding acceptability of SOVS and symptomatology. We established a minimum sensitivity of 90% for SOVS to be considered clinically noninferior to standard PPES. RESULTS A total of 533 patients completed enrollment and answered survey questions, 515 of whom had laboratory results for both SOVS and PPES. There were 86 patients with a positive result: 29 with NG, 47 with CT, and 10 with coinfection. SOVS had a sensitivity of 95% (95% confidence interval = 88% to 99%) for the detection of NG/CT when compared to PPES. SOVS were felt to be an acceptable collection method in 93% of patients and 75% preferred SOVS to PPES. CONCLUSION SOVS are noninferior to PPES in NG/CT diagnosis using a rapid NAAT in ED patients and surveys indicate high patient acceptability.
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Affiliation(s)
- Brian Chinnock
- Department of Emergency Medicine UCSF–FresnoMedical Education Program Fresno California USA
| | - Mackensie Yore
- Department of Emergency Medicine UCSF–FresnoMedical Education Program Fresno California USA
| | - Jessica Mason
- Department of Emergency Medicine UCSF–FresnoMedical Education Program Fresno California USA
| | - Mallory Kremer
- Department of Obstetrics and Gynecology University of Washington Seattle Washington USA
| | - Leyla Farshidpour
- University of California–Davis School of Medicine Sacramento California USA
| | - Diana Lopez
- University of California–Davis School of Medicine Sacramento California USA
| | - Jannet Castaneda
- Department of Emergency Medicine UCSF–FresnoMedical Education Program Fresno California USA
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Yan LD, Mahadevan SV, Yore M, Pirrotta EA, Woods J, Somontha K, Sovannra Y, Raman M, Cornell E, Grundmann C, Strehlow MC. An observational study of adults seeking emergency care in Cambodia. Bull World Health Organ 2014; 93:84-92. [PMID: 25883401 PMCID: PMC4339966 DOI: 10.2471/blt.14.143917] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 10/31/2014] [Accepted: 11/06/2014] [Indexed: 11/04/2022] Open
Abstract
Objective To describe the characteristics and chief complaints of adults seeking emergency care at two Cambodian provincial referral hospitals. Methods Adults aged 18 years or older who presented without an appointment at two public referral hospitals were enrolled in an observational study. Clinical and demographic data were collected and factors associated with hospital admission were identified. Patients were followed up 48 hours and 14 days after presentation. Findings In total, 1295 hospital presentations were documented. We were able to follow up 85% (1098) of patients at 48 hours and 77% (993) at 14 days. The patients’ mean age was 42 years and 64% (823) were females. Most arrived by motorbike (722) or taxi or tuk-tuk (312). Most common chief complaints were abdominal pain (36%; 468), respiratory problems (15%; 196) and headache (13%; 174). Of the 1050 patients with recorded vital signs, 280 had abnormal values, excluding temperature, on arrival. Performed diagnostic tests were recorded for 539 patients: 1.2% (15) of patients had electrocardiography and 14% (175) had diagnostic imaging. Subsequently, 783 (60%) patients were admitted and 166 of these underwent surgery. Significant predictors of admission included symptom onset within 3 days before presentation, abnormal vital signs and fever. By 14-day follow-up, 3.9% (39/993) of patients had died and 19% (192/993) remained functionally impaired. Conclusion In emergency admissions in two public hospitals in Cambodia, there is high admission-to-death ratio and limited application of diagnostic techniques. We identified ways to improve procedures, including better documentation of vital signs and increased use of diagnostic techniques.
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Affiliation(s)
- Lily D Yan
- Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, United States of America (USA)
| | - Swaminatha V Mahadevan
- Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, United States of America (USA)
| | - Mackensie Yore
- Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, United States of America (USA)
| | - Elizabeth A Pirrotta
- Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, United States of America (USA)
| | - Joan Woods
- University Research Co. Centre for Human Services, Phnom Penh, Cambodia
| | - Koy Somontha
- University Research Co. Centre for Human Services, Phnom Penh, Cambodia
| | - Yim Sovannra
- Deutsche Gesellschaft für Internationale Zusammenarbeit, Phnom Penh, Cambodia
| | - Maya Raman
- Feinberg School of Medicine, Northwestern University, Chicago, USA
| | - Erika Cornell
- Feinberg School of Medicine, Northwestern University, Chicago, USA
| | | | - Matthew C Strehlow
- Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, United States of America (USA)
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Mehta U, Clerk C, Allen E, Yore M, Sevene E, Singlovic J, Petzold M, Mangiaterra V, Elefant E, Sullivan FM, Holmes LB, Gomes M. Protocol for a drugs exposure pregnancy registry for implementation in resource-limited settings. BMC Pregnancy Childbirth 2012; 12:89. [PMID: 22943425 PMCID: PMC3500715 DOI: 10.1186/1471-2393-12-89] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Accepted: 08/24/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The absence of robust evidence of safety of medicines in pregnancy, particularly those for major diseases provided by public health programmes in developing countries, has resulted in cautious recommendations on their use. We describe a protocol for a Pregnancy Registry adapted to resource-limited settings aimed at providing evidence on the safety of medicines in pregnancy. METHODS/DESIGN Sentinel health facilities are chosen where women come for prenatal care and are likely to come for delivery. Staff capacity is improved to provide better care during the pregnancy, to identify visible birth defects at delivery and refer infants with major anomalies for surgical or clinical evaluation and treatment. Consenting women are enrolled at their first antenatal visit and careful medical, obstetric and drug-exposure histories taken; medical record linkage is encouraged. Enrolled women are followed up prospectively and their histories are updated at each subsequent visit. The enrolled woman is encouraged to deliver at the facility, where she and her baby can be assessed. DISCUSSION In addition to data pooling into a common WHO database, the WHO Pregnancy Registry has three important features: First is the inclusion of pregnant women coming for antenatal care, enabling comparison of birth outcomes of women who have been exposed to a medicine with those who have not. Second is its applicability to resource-poor settings regardless of drug or disease. Third is improvement of reproductive health care during pregnancies and at delivery. Facility delivery enables better health outcomes, timely evaluation and management of the newborn, and the collection of reliable clinical data. The Registry aims to improves maternal and neonatal care and also provide much needed information on the safety of medicines in pregnancy.
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Affiliation(s)
- Ushma Mehta
- Independent Pharmacovigilance Consultant, Cape Town, Kenilworth 7708, South Africa
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Agbenorku P, Agbenorku M, Bentsir-Elegba E, Iddi A, Abude F, Sefenu R, Matondo P, Tuuli L, Yore M. Multicenter plastic surgery outreach services for underserved Ghanaian communities. Eur J Plast Surg 2011. [DOI: 10.1007/s00238-010-0482-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Meyer C, Yore M, Ferguson D, Watkins B, Fey E, Sporn M, Huff J, Sonis S. 536 POSTER RTA 402 suppresses tumor and treatment induced inflammation, sensitizing tumors to and protecting normal tissue from radiation. EJC Suppl 2006. [DOI: 10.1016/s1359-6349(06)70541-9] [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: 10/23/2022] Open
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Abstract
OBJECTIVE We present the frequencies of various types of mandibular fractures along with associated mechanisms and injuries. METHODS Retrospective analysis of 5196 mandible fractures in 4381 patients extracted from the Total Army Injury and Health Outcomes Database (TAIHOD), a comprehensive database developed by the U.S. Army Research Institute of Environmental Medicine (USARIEM) that links population data to all hospitalizations among active duty army soldiers. The database is based on the ICD-9 CM coding system. RESULTS We found the following frequencies for specific mandible fracture locations: angle 35.6%, symphysis 20.1%, subcondylar 14.2%, body 12.7%, condylar process 9.1%, ramus 4.5%, alveolar border 2.7%, and coronoid process 1%. The mechanisms of injury were separated into seven categories. Fighting accounts for 36.2%, automobile accidents for 18.6%, athletics for 13.6%, falls for 9.7%, motorcycle accidents for 3.1%, other land transport accidents for 3%, and miscellaneous causes for 15.8%. A few fracture locations appear to be associated with specific mechanisms. Of 82 alveolar border fractures with known mechanisms, 37% resulted from automobile accidents. Of 1094 angle fractures with known mechanisms, 48.6% resulted from fighting. Our data show that the majority of fractures were isolated to one location. Only one fracture was recorded for 70.6%, 29.2% have two fractures recorded, 0.2% have three or more fractures recorded. Associated injuries were common and include facial lacerations 1236 (28.2%), non-mandible facial bone fractures 733 (16.7%), intracranial injury 403(9.2%), internal injuries 229 (5.2%), fractures of the upper limb 295 (6.7%), fractures of the lower extremity 302 (6.9%), and cervical fractures 34 (0.8%). CONCLUSIONS The mechanism of injury is important in determining the most likely resultant mandible fracture in the case of angle of mandible and alveolar ridge fractures. The clinician should maintain a high level of suspicion for associated injuries that occur more than one fourth of the time and even more frequently in motor vehicle accident victims. Associated intracranial injury is particularly important to rule out. Associated facial fractures, intracranial injury, internal injuries, and extremity injuries are all more common than cervical fractures.
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Affiliation(s)
- J R Boole
- Otolaryngology--Head and Neck Surgery, Tripler Regional Medical Center, Honolulu, Hawaii 96859-5000, USA.
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