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Ashburn NP, Snavely AC, Allen BR, Christenson RH, Madsen T, McCord JK, Mumma BE, Hashemian T, Stopyra JP, Wilkerson RG, Mahler SA. Performance of the European Society of Cardiology 0/1-hour algorithm with high-sensitivity cardiac troponin T at 90 days among patients with known coronary artery disease. Am J Emerg Med 2024; 79:111-115. [PMID: 38417221 DOI: 10.1016/j.ajem.2024.02.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 02/07/2024] [Accepted: 02/19/2024] [Indexed: 03/01/2024] Open
Abstract
BACKGROUND The European Society of Cardiology (ESC) 0/1-h high sensitivity troponin T (hs-cTnT) algorithm does not differentiate risk based on known coronary artery disease (CAD: prior myocardial infarction [MI], coronary revascularization, or ≥ 70% coronary stenosis). We recently evaluated its performance among patients with known CAD at 30-days, but little is known about its longer-term risk prediction. The objective of this study is to determine and compare the performance of the algorithm at 90-days among patients with and without known CAD. METHODS We performed a pre-planned subgroup analysis of the STOP-CP cohort, which prospectively enrolled ED patients ≥21 years old with symptoms suggestive of ACS without ST-elevation on initial ECG across 8 US sites (1/25/2017-9/6/2018). Participants with 0- and 1-h hs-cTnT measures (Roche, Basel, Switzerland) were stratified into rule-out, observe, and rule-in groups using the ESC 0/1-h algorithm. Algorithm performance was tested among patients with or without known CAD, as determined by the treating provider. The primary outcome was cardiac death or MI at 90-days. Fisher's exact tests were used to compare 90-day event and rule-out rates between patients with and without known CAD. Negative predictive values (NPVs) for 90-day cardiac death or MI with exact 95% confidence intervals were calculated and compared using Fisher's exact test. RESULTS The STOP-CP study accrued 1430 patients, of which 31.4% (449/1430) had known CAD. Cardiac death or MI at 90 days was more common in patients with known CAD than in those without [21.2% (95/449) vs. 10.0% (98/981); p < 0.001]. Using the ESC 0/1-h algorithm, 39.6% (178/449) of patients with known CAD and 66.1% (648/981) of patients without known CAD were ruled-out (p < 0.001). Among rule-out patients, 90-day cardiac death or MI occurred in 3.4% (6/178) of patients with known CAD and 1.2% (8/648) without known CAD (p = 0.09). NPV for 90-day cardiac death or MI was 96.6% (95%CI 92.8-98.8) among patients with known CAD and 98.8% (95%CI 97.6-99.5) in patients without known CAD (p = 0.09). CONCLUSION Patients with known CAD who were ruled-out using the ESC 0/1-h hs-cTnT algorithm had a high rate of missed 90-day cardiac events, suggesting that the ESC 0/1-h hs-cTnT algorithm may not be safe for use among patients with known CAD. TRIAL REGISTRATION High-Sensitivity Cardiac Troponin T to Optimize Chest Pain Risk Stratification (STOP-CP; ClinicalTrials.gov: NCT02984436; https://clinicaltrials.gov/ct2/show/NCT02984436).
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Affiliation(s)
- Nicklaus P Ashburn
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
| | - Anna C Snavely
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Brandon R Allen
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Robert H Christenson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Troy Madsen
- Department of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - James K McCord
- Department of Cardiology, Henry Ford Health System, Detroit, MI, USA
| | - Bryn E Mumma
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, CA, USA
| | - Tara Hashemian
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Jason P Stopyra
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Simon A Mahler
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Department of Epidemiology and Prevention, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, NC, USA
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Supples MW, Snavely AC, Ashburn NP, Allen BR, Christenson RH, Nowak R, Wilkerson RG, Mumma BE, Madsen T, Stopyra JP, Mahler SA. Performance of the 0/2-hour high-sensitivity cardiac troponin T diagnostic protocol in a multisite United States cohort. Acad Emerg Med 2024; 31:239-248. [PMID: 37925594 DOI: 10.1111/acem.14827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/04/2023] [Accepted: 10/13/2023] [Indexed: 11/06/2023]
Abstract
BACKGROUND The diagnostic performance of the high-sensitivity troponin T (hs-cTnT) 0/2-h algorithm is unclear among U.S. emergency department (ED) patients with acute chest pain. METHODS A preplanned subgroup analysis of the STOP-CP cohort study was conducted. Participants with 0- and 2-h hs-cTnT measures prospectively enrolled at eight U.S. EDs from January 2017 to September 2018 were stratified into rule-out, observation, and rule-in zones using the hs-cTnT 0/2-h algorithm alone and combined with the history, electrocardiogram, age, and risk factor (HEAR) score. The primary outcome was adjudicated 30-day cardiac death or myocardial infarction (CDMI). The sensitivity and negative predictive value (NPV) of the 0/2-h rule-out zone and specificity and positive predictive value (PPV) of the rule-in zone for 30-day CDMI were calculated. RESULTS Of the 1307 patients accrued, 53.6% (700/1307) were male and 58.6% (762/1307) were White, with a mean ± SD age of 57.5 ± 12.7 years. At 30 days, CDMI occurred in 12.9% (168/1307) of participants. The 0/2-h algorithm ruled out 61.4% (802/1307) of patients. Among rule-out patients, 1.9% (15/802) experienced 30-day CDMI, resulting in a sensitivity of 91.1% (95% confidence interval [CI] 85.7%-94.9%) and NPV of 98.1% (95% CI 96.9%-98.9%). The 0/2-h algorithm ruled in 12.4% (162/1307) patients of whom 61.7% (100/162) experienced 30-day CDMI. The rule-in zone specificity was 94.6% (95% CI 93.1%-95.8%) and PPV was 61.7% (95% CI 53.8%-69.2%) for 30-day CDMI. The 0/2-h algorithm combined with HEAR score ruled out 30.7% (401/1307) of patients with a sensitivity and NPV for 30-day CDMI of 98.2% (95% CI 94.9%-99.6%) and 99.3% (95% CI 97.8%-99.8%), respectively. CONCLUSIONS The hs-cTnT 0/2-h algorithm ruled out most patients. With NPV of <99% for 30-day CDMI, the hs-cTnT 0/2-h algorithm, many emergency physicians may not consider it safe to use for U.S. ED patients. When combined with a low-risk HEAR score, NPV was >99% for 30-day CDMI at the cost of reduced efficacy.
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Affiliation(s)
- Michael W Supples
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Anna C Snavely
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Nicklaus P Ashburn
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Section on Cardiovascular Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Brandon R Allen
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Robert H Christenson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Massachusetts, USA
| | - Richard Nowak
- Department of Emergency Medicine, Henry Ford Health System, Detroit, Michigan, USA
| | - R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Massachusetts, USA
| | - Bryn E Mumma
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, California, USA
| | - Troy Madsen
- Department of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Jason P Stopyra
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Simon A Mahler
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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Supples MW, Snavely AC, O'Neill JC, Ashburn NP, Allen BR, Christenson RH, Nowak R, Wilkerson RG, Mumma BE, Madsen T, Stopyra JP, Mahler SA. Sex and race differences in the performance of the European Society of Cardiology 0/1-h algorithm with high-sensitivity troponin T. Clin Cardiol 2024; 47:e24199. [PMID: 38088463 PMCID: PMC10823440 DOI: 10.1002/clc.24199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 11/09/2023] [Accepted: 11/15/2023] [Indexed: 02/01/2024] Open
Abstract
The diagnostic performance of the high-sensitivity troponin T (hs-cTnT) European Society of Cardiology (ESC) 0/1-h algorithm in sex and race subgroups of US Emergency Department (ED) patients is unclear. A pre-planned subgroup analysis of the STOP-CP cohort study was conducted. Participants with 0- and 1-h hs-cTnT measures from eight US EDs (1/2017 to 9/2018) were stratified into rule-out, observation, and rule-in zones using the hs-cTnT ESC 0/1 algorithm. The primary outcome was adjudicated 30-day cardiac death or MI. The proportion with the primary outcome in each zone was compared between subgroups with Fisher's exact tests. The negative predictive value (NPV) of the ESC 0/1 rule-out zone for 30-day CDMI was calculated and compared between subgroups using Fisher's exact tests. Of the 1422 patients enrolled, 54.2% (770/1422) were male and 58.1% (826/1422) white with a mean age of 57.6 ± 12.8 years. At 30 days, cardiac death or myocardial infarction (MI) occurred in 12.9% (183/1422) of participants. Among patients stratified to the rule-out zone, 30-day cardiac death or MI occurred in 1.1% (5/436) of women versus 2.1% (8/436) of men (p = .40) and 1.2% (4/331) of non-white patients versus 1.8% (9/490) of white patients (p = .58). The NPV for 30-day cardiac death or MI was similar among women versus men (98.9% [95% confidence interval, CI: 97.3-99.6] vs. 97.9% [95% CI: 95.9-99.1]; p = .40) and among white versus non-white patients (98.8% [95% CI: 96.9-99.7] vs. 98.2% [95% CI: 96.5-99.2]; p = .39). NPVs <99% in each subgroup suggest the hs-cTnT ESC 0/1-h algorithm may not be safe for use in US EDs. Trial Registration: High-Sensitivity Cardiac Troponin T to Optimize Chest Pain Risk Stratification (STOP-CP; ClinicalTrials.gov: NCT02984436; https://clinicaltrials.gov/ct2/show/NCT02984436).
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Affiliation(s)
- Michael W. Supples
- Department of Emergency MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Anna C. Snavely
- Department of Emergency MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
- Department of Biostatistics and Data ScienceWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - James C. O'Neill
- Department of Emergency MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Nicklaus P. Ashburn
- Department of Emergency MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
- Section on Cardiovascular Medicine, Department of Internal MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Brandon R. Allen
- Department of Emergency MedicineUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Robert H. Christenson
- Department of PathologyUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Richard Nowak
- Department of Emergency MedicineHenry Ford Health SystemDetroitMichiganUSA
| | - R. Gentry Wilkerson
- Department of Emergency MedicineUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Bryn E. Mumma
- Department of Emergency MedicineUniversity of California Davis School of MedicineSacramentoCaliforniaUSA
| | - Troy Madsen
- Division of Emergency MedicineUniversity of Utah School of MedicineSalt Lake CityUtahUSA
| | - Jason P. Stopyra
- Department of Emergency MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Simon A. Mahler
- Department of Emergency MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
- Department of Epidemiology and PreventionWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
- Department of Implementation ScienceWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
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Tanabe P, Ibemere S, Pierce AE, Freiermuth CE, Bosworth HB, Yang H, Osunkwo I, Paxton JH, Strouse JJ, Miller J, Paice JA, Veeramreddy P, Kavanagh PL, Wilkerson RG, Hughes R, Barnhart HX. A comparison of the effect of patient-specific versus weight-based protocols to treat vaso-occlusive episodes in the emergency department. Acad Emerg Med 2023; 30:1210-1222. [PMID: 37731093 PMCID: PMC10783854 DOI: 10.1111/acem.14805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 08/04/2023] [Accepted: 09/05/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Vaso-occlusive crises (VOCs) cause debilitating pain and are a common cause of emergency department (ED) visits, for people with sickle cell disease (SCD). Strategies for achieving optimal pain control vary widely despite evidence-based guidelines. We tested existing guidelines and hypothesized that a patient-specific pain protocol (PSP) written by their SCD provider may be more effective than weight-based (WB) dosing of parenteral opiate medication, in relieving pain. METHODS This study was a prospective, randomized controlled trial comparing a PSP versus WB protocol for patients presenting with VOCs to six EDs. Patients were randomized to a PSP or WB protocol prior to an ED visit. The SCD provider wrote their protocol and placed it in the electronic health record for future ED visits with VOC exclusion criteria that included preexisting PSP excluding parenteral opioid analgesia or outpatient use of buprenorphine or methadone or highly suspected for COVID-19. Pain intensity scores, side effects, and safety were obtained every 30 min for up to 6 h post-ED bed placement. The primary outcome was change in pain intensity score from placement in an ED space to disposition or 6 h. RESULTS A total of 328 subjects were randomized; 104 participants enrolled (ED visit, target n = 230) with complete data for 96 visits. The study was unable to reach the target sample size and stopped early due to the impact of COVID-19. We found no significant differences between groups in the primary outcome; patients randomized to a PSP had a shorter ED length of stay (p = 0.008), and the prevalence of side effects was low in both groups. Subjects in both groups experienced both a clinically meaningful and a statistically significant decrease in pain (27 mm on a 0- to 100-mm scale). CONCLUSIONS We found a shorter ED length of stay for patients assigned to a PSP. Patients in both groups experienced good pain relief without significant side effects.
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Affiliation(s)
- Paula Tanabe
- Duke University School of Nursing and School of Medicine, Durham, North Carolina, USA
| | - Stephanie Ibemere
- Duke University School of Nursing, Durham, North Carolina, USA
- Duke Global Health Institute, Durham, North Carolina, USA
| | - Ava E. Pierce
- University of Texas Southwestern Medical Center, Department of Emergency Medicine, Dallas, Texas, USA
| | | | - Hayden B. Bosworth
- Veterans Affairs Medical Center Durham, Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham, NC, USA, Duke University Medical Center
- Departments of Population Health Sciences, School of Medicine, Department of Psychiatry and Behavioral Sciences, School of Nursing, Durham, NC, USA
| | - Hongqui Yang
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Ifeyinwa Osunkwo
- Prior affiliation: Atrium Health, Levine Cancer Institute, Sickle Cell Disease Enterprise, Charlotte, North Carolina, USA, Current affiliation: Senior Vice President, Chief Patient Officer, Novo Nordisk
| | - James H. Paxton
- Wayne State University School of Medicine, Emergency Medicine, Detroit, Michigan, USA
| | - John J. Strouse
- Duke University School of Medicine, Department of Medicine and Pediatrics, , Durham, North Carolina, USA
| | - Joseph Miller
- Henry Ford Health System, Emergency Medicine, Detroit, Michigan, USA
| | - Judith A. Paice
- Northwestern University Feinberg School of Medicine, Division of Hematology-Oncology, , Chicago, Illinois, USA
| | | | - Patricia L. Kavanagh
- Boston University School of Medicine, Department of Pediatrics, , Boston, Massachusetts, USA
| | - R. Gentry Wilkerson
- University of Maryland School of Medicine, Emergency Medicine, Baltimore, Maryland, USA
| | - Robert Hughes
- Case Western Reserve University, School of Medicine, Emergency Medicine, Cleveland, Ohio, USA
| | - Huiman X. Barnhart
- Duke University School of Medicine, Duke Molecular Physiology, Department of Biostatistics and Bioinformatics, Durham, North Carolina, USA
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Popp LM, Ashburn NP, Snavely AC, Allen BR, Christenson RH, Madsen T, Mumma BE, Nowak R, Stopyra JP, Wilkerson RG, Mahler SA. Race differences in cardiac testing rates for patients with chest pain in a multisite cohort. Acad Emerg Med 2023; 30:1020-1028. [PMID: 37306075 DOI: 10.1111/acem.14762] [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: 04/01/2023] [Revised: 06/07/2023] [Accepted: 06/08/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND Identifying and eliminating racial health care disparities is a public health priority. However, data evaluating race differences in emergency department (ED) chest pain care are limited. METHODS We conducted a secondary analysis of the High-Sensitivity Cardiac Troponin T to Optimize Chest Pain Risk Stratification (STOP-CP) cohort, which prospectively enrolled adults with symptoms suggestive of acute coronary syndrome without ST-elevation from eight EDs in the United States from 2017 to 2018. Race was self-reported by patients and abstracted from health records. Rates of 30-day noninvasive testing (NIT), cardiac catheterization, revascularization, and adjudicated cardiac death or myocardial infarction (MI) were determined. Logistic regression was used to evaluate the association between race and 30-day outcomes with and without adjustment for potential confounders. RESULTS Among 1454 participants, 42.3% (615/1454) were non-White. At 30 days NIT occurred in 31.4% (457/1454), cardiac catheterization in 13.5% (197/1454), revascularization in 6.0% (87/1454), and cardiac death or MI in 13.1% (190/1454). Among Whites versus non-Whites, NIT occurred in 33.8% (284/839) versus 28.1% (173/615; odds ratio [OR] 0.76, 95% confidence interval [CI] 0.61-0.96) and catheterization in 15.9% (133/839) versus 10.4% (64/615; OR 0.62, 95% CI 0.45-0.84). After covariates were adjusted for, non-White race remained associated with decreased 30-day NIT (adjusted OR [aOR] 0.71, 95% CI 0.56-0.90) and cardiac catheterization (aOR 0.62, 95% CI 0.43-0.88). Revascularization occurred in 6.9% (58/839) of Whites versus 4.7% (29/615) of non-Whites (OR 0.67, 95% CI 0.42-1.04). Cardiac death or MI at 30 days occurred in 14.2% of Whites (119/839) versus 11.5% (71/615) of non-Whites (OR 0.79 95% CI 0.57-1.08). After adjustment there was still no association between race and 30-day revascularization (aOR 0.74, 95% CI 0.45-1.20) or cardiac death or MI (aOR 0.74, 95% CI 0.50-1.09). CONCLUSIONS In this U.S. cohort, non-White patients were less likely to receive NIT and cardiac catheterization compared to Whites but had similar rates of revascularization and cardiac death or MI.
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Affiliation(s)
- Lucas M Popp
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Nicklaus P Ashburn
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Section on Cardiovascular Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Anna C Snavely
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Brandon R Allen
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Robert H Christenson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Troy Madsen
- Department of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Bryn E Mumma
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, California, USA
| | - Richard Nowak
- Department of Emergency Medicine, Henry Ford Health System, Detroit, Michigan, USA
| | - Jason P Stopyra
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Simon A Mahler
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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Wilkerson RG. Drug Hypersensitivity Reactions. Immunol Allergy Clin North Am 2023; 43:473-489. [PMID: 37394254 DOI: 10.1016/j.iac.2022.10.005] [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] [Indexed: 07/04/2023]
Abstract
Drug hypersensitivity reactions are a diverse group of reactions mediated by the immune system after exposure to a drug. The Gell and Coombs classification divides immunologic DHRs into 4 major pathophysiologic categories based on immunologic mechanism. Anaphylaxis is a Type I hypersensitivity reaction that requires immediate recognition and treatment. Severe cutaneous adverse reactions (SCARs) are a group of dermatologic diseases that result from a Type IV hypersensitivity process and include drug reaction with eosinophilia and systemic symptom (DRESS) syndrome, Stevens-Johnson Syndrome (SJS), toxic epidermal necrolysis (TEN), and acute generalized exanthematous pustulosis (AGEP). Other types of reactions are slow to develop and do not always require rapid treatment. Emergency physicians should have a good understanding of these various types of drug hypersensitivity reactions and how to approach the patient regarding evaluation and treatment.
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Affiliation(s)
- R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
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Wilkerson RG, Suau S. Anaphylaxis, Angioedema, and Other Immunologic Emergencies. Immunol Allergy Clin North Am 2023; 43:xiii-xiv. [PMID: 37394264 DOI: 10.1016/j.iac.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Affiliation(s)
- R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street 6th Floor, Suite 200, Baltimore, MD 21201, USA.
| | - Salvador Suau
- Department of Emergency Medicine, Ochsner Health System, Ochsner Emergency Department, 1514 Jefferson Highway, New Orleans, LA 71021, USA.
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Wilkerson RG, Winters ME. Angiotensin-Converting Enzyme Inhibitor-Induced Angioedema. Immunol Allergy Clin North Am 2023; 43:513-532. [PMID: 37394257 DOI: 10.1016/j.iac.2022.10.013] [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] [Indexed: 07/04/2023]
Abstract
Angioedema is a well-recognized and potentially lethal complication of angiotensin-converting enzyme inhibitor (ACEi) therapy. In ACEi-induced angioedema, bradykinin accumulates due to a decrease in its metabolism by ACE, the enzyme that is primarily responsible for this function. The action of bradykinin at bradykinin type 2 receptors leads to increased vascular permeability and the accumulation of fluid in the subcutaneous and submucosal space. Patients with ACEi-induced angioedema are at risk for airway compromise because of the tendency for the face, lips, tongue, and airway structures to be affected. The emergency physician should focus on airway evaluation and management when treating patients with ACEi-induced angioedema.
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Affiliation(s)
- R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
| | - Michael E Winters
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA. https://twitter.com/critcareguys
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Abstract
Hereditary angioedema (HAE) is a rare autosomal dominant genetic disorder that usual results from a decreased level of functional C1-INH and clinically manifests with intermittent attacks of swelling of the subcutaneous tissue or submucosal layers of the respiratory or gastrointestinal tracts. Laboratory studies and radiographic imaging have limited roles in evaluation of patients with acute attacks of HAE except when the diagnosis is uncertain and other processes must be ruled out. Treatment begins with assessment of the airway to determine the need for immediate intervention. Emergency physicians should understand the pathophysiology of HAE to help guide management decisions.
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Affiliation(s)
- R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
| | - Joseph J Moellman
- Department of Emergency Medicine, University of Cincinnati College of Medicine, 231 Albert Sabin Way, MSB 1654, Cincinnati, OH 45267-0769, USA. https://twitter.com/edmojo
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Wilkerson RG, Annous Y, Farhy E, Hurst J, Smedley AD. Home Pulse Oximetry Monitoring during the COVID-19 Pandemic: An Assessment of Patient Engagement and Compliance. Health Policy Technol 2023; 12:100776. [PMID: 38620095 PMCID: PMC10291857 DOI: 10.1016/j.hlpt.2023.100776] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
Objectives Patients with suspected COVID-19 remain at risk for clinical deterioration after discharge and may benefit from home oxygen saturation (SpO2) monitoring using portable pulse oximeter devices. Our study aims to evaluate patient engagement and compliance with a home SpO2 monitoring program. Methods This is a single center, prospective pilot study of patients being discharged from the ED or urgent care after evaluation of symptoms consistent with COVID-19. Subjects were given a portable pulse oximeter and instructed to obtain measurements at rest and with exertion twice daily for 14 days. Patients were contacted daily to collect recorded data. If attempts to contact the patient were unsuccessful for 3 consecutive days, patients were considered lost to follow up. The primary outcome of interest was patient engagement in the program which was defined as the percentage of patients that completed the 14-day study period, meaning they were not lost to follow up. Secondary outcomes included compliance with performing the SpO2 readings. Patient compliance was calculated as a percentage of completed readings out of the total expected readings. Results Fifty patients were enrolled - 2 withdrew and 1 was a screen failure. Overall, engagement in the program was 46.8% with no significant difference between those who tested positive for SARS-CoV-2 versus those who tested negative (48.2% vs 45%, p = 0.831). Median compliance overall was 42.9% (IQR 22.22-78.57). Median compliance for the positive group was 50.0% (IQR 20-85.71) and 42.86% (IQR 22.92-76.44) for the negative group (p= 0.838). Conclusion Our study demonstrated that there was acceptable engagement and compliance in a 14-day home SpO2 monitoring program. These results support the use of home pulse oximetry monitoring in a select group of mildly ill patients with suspected COVID-19.
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Affiliation(s)
- R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 S. Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201
| | - Youssef Annous
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 S. Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201
| | - Eli Farhy
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 S. Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201
| | - Jonathan Hurst
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 S. Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201
| | - Angela D Smedley
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 S. Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201
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Wilkerson RG, Dakessian A, Moellman JJ, Bernstein JA. Clinical trial of C1-INH for treatment of ACEi-induced angioedema. Am J Emerg Med 2023; 68:196-197. [PMID: 37061431 DOI: 10.1016/j.ajem.2023.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 04/08/2023] [Indexed: 04/17/2023] Open
Affiliation(s)
- R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States of America.
| | - Alik Dakessian
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - Joseph J Moellman
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, United States of America
| | - Jonathan A Bernstein
- Department of Medicine, Division of Rheumatology, Allergy and Immunology, University of Cincinnati College of Medicine, Cincinnati, OH, United States of America
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Ashburn NP, Snavely AC, O’Neill JC, Allen BR, Christenson RH, Madsen T, Massoomi MR, McCord JK, Mumma BE, Nowak R, Stopyra JP, in’t Veld MH, Wilkerson RG, Mahler SA. Performance of the European Society of Cardiology 0/1-Hour Algorithm With High-Sensitivity Cardiac Troponin T Among Patients With Known Coronary Artery Disease. JAMA Cardiol 2023; 8:347-356. [PMID: 36857071 PMCID: PMC9979014 DOI: 10.1001/jamacardio.2023.0031] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [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: 07/26/2022] [Accepted: 12/29/2022] [Indexed: 03/02/2023]
Abstract
Importance The European Society of Cardiology (ESC) 0/1-hour algorithm is a validated high-sensitivity cardiac troponin (hs-cTn) protocol for emergency department patients with possible acute coronary syndrome. However, limited data exist regarding its performance in patients with known coronary artery disease (CAD; prior myocardial infarction [MI], coronary revascularization, or ≥70% coronary stenosis). Objective To evaluate and compare the diagnostic performance of the ESC 0/1-hour algorithm for 30-day cardiac death or MI among patients with and without known CAD and determine if the algorithm could achieve the negative predictive value rule-out threshold of 99% or higher. Design, Setting, and Participants This was a preplanned subgroup analysis of the STOP-CP prospective multisite cohort study, which was conducted from January 25, 2017, through September 6, 2018, at 8 emergency departments in the US. Patients 21 years or older with symptoms suggestive of acute coronary syndrome without ST-segment elevation on initial electrocardiogram were included. Analysis took place between February and December 2022. Interventions/Exposures Participants with 0- and 1-hour high-sensitivity cardiac troponin T (hs-cTnT) measures were stratified into rule-out, observation, and rule-in zones using the ESC 0/1-hour hs-cTnT algorithm. Main Outcomes and Measures Cardiac death or MI at 30 days determined by expert adjudicators. Results During the study period, 1430 patients were accrued. In the cohort, 775 individuals (54.2%) were male, 826 (57.8%) were White, and the mean (SD) age was 57.6 (12.8) years. At 30 days, cardiac death or MI occurred in 183 participants (12.8%). Known CAD was present in 449 (31.4%). Among patients with known CAD, the ESC 0/1-hour algorithm classified 178 of 449 (39.6%) into the rule-out zone compared with 648 of 981 (66.1%) without CAD (P < .001). Among rule-out zone patients, 30-day cardiac death or MI occurred in 6 of 178 patients (3.4%) with known CAD and 7 of 648 (1.1%) without CAD (P < .001). The negative predictive value for 30-day cardiac death or MI was 96.6% (95% CI, 92.8-98.8) among patients with known CAD and 98.9% (95% CI, 97.8-99.6) in patients without known CAD (P = .04). Conclusions and Relevance Among patients with known CAD, the ESC 0/1-hour hs-cTnT algorithm was unable to safely exclude 30-day cardiac death or MI. This suggests that clinicians should be cautious if using the algorithm in patients with known CAD. The negative predictive value was significantly higher in patients without a history of CAD but remained less than 99%.
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Affiliation(s)
- Nicklaus P. Ashburn
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Section on Cardiovascular Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Anna C. Snavely
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - James C. O’Neill
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Brandon R. Allen
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville
| | | | - Troy Madsen
- Department of Emergency Medicine, University of Utah School of Medicine, Salt Lake City
| | - Michael R. Massoomi
- Department of Cardiology, University of Florida College of Medicine, Gainesville
| | - James K. McCord
- Department of Cardiology, Henry Ford Health System, Detroit, Michigan
| | - Bryn E. Mumma
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento
| | - Richard Nowak
- Department of Emergency Medicine, Henry Ford Health System, Detroit, Michigan
| | - Jason P. Stopyra
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Maite Huis in’t Veld
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore
| | - R. Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore
| | - Simon A. Mahler
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
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13
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Snavely AC, Paradee BE, Ashburn NP, Allen BR, Christenson R, O'Neill JC, Nowak R, Wilkerson RG, Mumma BE, Madsen T, Stopyra JP, Mahler SA. Derivation and validation of a high sensitivity troponin-T HEART pathway. Am Heart J 2023; 256:148-157. [PMID: 36400184 DOI: 10.1016/j.ahj.2022.11.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 11/07/2022] [Accepted: 11/08/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND The HEART Pathway is widely used for chest pain risk stratification but has yet to be optimized for high sensitivity troponin T (hs-cTnT) assays. METHODS We conducted a secondary analysis of STOP-CP, a prospective cohort study enrolling adult ED patients with symptoms suggestive of acute coronary syndrome at 8 sites in the United States (US). Patients had a 0- and 1-hour hs-cTnT measured and a HEAR score completed. A derivation set consisting of 729 randomly selected participants was used to derive a hs-cTnT HEART Pathway with rule-out, observation, and rule-in groups for 30-day cardiac death or myocardial infarction (MI). Optimal baseline and 1-hour troponin cutoffs were selected using generalized cross validation to achieve a negative predictive value (NPV) >99% for rule out and positive predictive value (PPV) >60% or maximum Youden index for rule-in. Optimal 0-1-hour delta values were derived using generalized cross validation to maximize the NPV for the rule-out group and PPV for the rule-in group. The hs-cTnT HEART Pathway performance was validated in the remaining cohort (n = 723). RESULTS Among the 1452 patients, 30-day cardiac death or MI occurred in 12.7% (184/1452). Within the derivation cohort the optimal hs-cTnT HEART Pathway classified 36.5% (266/729) into the rule-out group, yielding a NPV of 99.2% (95% CI: 98.2-100) for 30-day cardiac death or MI. The rule-in group included 15.4% (112/729) with a PPV of 55.4% (95% CI: 46.2-64.6). In the validation cohort, the hs-cTnT HEART Pathway ruled-out 37.6% (272/723), of which 2 had 30-day cardiac death or MI, yielding a NPV of 99.3% (95% CI: 98.3-100). The rule-in group included 14.5% (105/723), yielding a PPV of 57.1% (95% CI: 47.7-66.6). CONCLUSIONS A novel hs-cTnT HEART Pathway with serial 0- and 1-hour hs-cTnT measures has high NPV and moderate PPV for 30-day cardiac death or MI.
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Affiliation(s)
- Anna C Snavely
- Department of Biostatistics and Data Science, Wake Forest School of Medicine (WFSOM), Winston-Salem, NC; Department of Emergency Medicine, WFSOM, Winston Salem, NC.
| | | | | | - Brandon R Allen
- Department of Emergency Medicine, College of Medicine, University of Florida, Gainesville, FL
| | - Robert Christenson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD
| | | | - Richard Nowak
- Department of Emergency Medicine, Henry Ford Health, Detroit, MI
| | - R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Bryn E Mumma
- Department of Emergency Medicine, School of Medicine, University of California Davis, Sacramento, CA
| | - Troy Madsen
- Department of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | | | - Simon A Mahler
- Department of Emergency Medicine, WFSOM, Winston Salem, NC; Department of Implementation Science, WFSOM, Winston-Salem, NC; Department of Epidemiology and Prevention, WFSOM, Winston-Salem, NC
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14
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Marshall JD, Heavner JJ, Olivieri PP, Van Ryzin HK, Thomas J, Annous Y, Wilkerson RG. Length of Stay and Hospital Cost Reductions After Implementing Bedside Percutaneous Ultrasound Gastrostomy (PUG) in a Critical Care Unit. J Intensive Care Med 2022; 37:1667-1672. [PMID: 35473419 PMCID: PMC9647312 DOI: 10.1177/08850666221097018] [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] [Indexed: 01/27/2023]
Abstract
Background: Critical care patients receive 50% of gastrostomy tubes placed in the United States. Several gastrostomy placement methods exist, however care processes remain variable and often lack health system cost effectiveness. No data exists on efficiency or cost impact of performing bedside percutaneous ultrasound gastrostomy (PUG) on patients with ventilator-dependent respiratory failure. This study's objective was to determine if implementing bedside PUG would positively impact efficiency and cost outcomes in intensive care unit (ICU) patients compared to usual care gastrostomy. Design and Methods: This is a retrospective cohort study of patients with ventilator-dependent respiratory failure who received a gastrostomy consult or procedure in the ICU. Patients received PUG or usual care gastrostomy, determined by the presiding attending's skillset, and both groups were compared across patients' demographics, clinical characteristics and outcomes. Primary outcomes were length of stay (LOS) and total hospital costs. Results: A total of 88 patients were included in the analysis, 45 patients in the PUG group and 43 in the usual care gastrostomy group. No differences were observed in demographic and clinical characteristics. Patients who received PUG had a significantly shorter mean ICULOS and hospital LOS, with reductions of 5.0 and 8.7 days, respectively. Total hospital costs were significantly reduced in the PUG group, with a cost savings of US $26,621 per patient. No differences in mortality or discharge disposition were observed. PUG patients received concomitant percutaneous dilatation tracheostomy (PDT) and PUG ("TPUG") 70% of the time, whereas no usual care patients received concomitant procedures. Off-hour procedures occurred in 53.3% of PUG and 4.6% of usual care gastrostomy. Conclusions: This study demonstrates bedside PUG leads to decreased LOS and total hospital costs in patients with ventilator-dependent respiratory failure. Hospital costs were significantly reduced with a per patient savings of $26,621 compared to usual care gastrostomy.
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Affiliation(s)
- Jeffrey D. Marshall
- Department of Pulmonary & Critical Care Medicine, University of Maryland Baltimore
Washington Medical Center, Glen Burnie, USA,Jeffrey D. Marshall, Department of
Pulmonary & Critical Care Medicine, University of Maryland Baltimore
Washington Medical Center, 301 Hospital Drive, 2nd Floor, Glen Burnie, MD,
21061, USA.
| | - Jason J. Heavner
- Department of Pulmonary & Critical Care Medicine, University of Maryland Baltimore
Washington Medical Center, Glen Burnie, USA
| | - Peter P. Olivieri
- Department of Pulmonary & Critical Care Medicine, University of Maryland Baltimore
Washington Medical Center, Glen Burnie, USA
| | - Hannah K. Van Ryzin
- Department of Pulmonary & Critical Care Medicine, University of Maryland Baltimore
Washington Medical Center, Glen Burnie, USA
| | - Janelle Thomas
- Department of Pulmonary & Critical Care Medicine, University of Maryland Baltimore
Washington Medical Center, Glen Burnie, USA
| | - Youssef Annous
- Department of Emergency Medicine, University of Maryland School of
Medicine, Baltimore, USA
| | - R. Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of
Medicine, Baltimore, USA
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15
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Lurie T, Bonnin N, Rea J, Tuteja G, Dezman Z, Wilkerson RG, Buganu A, Chasm R, Haase DJ, Tran QK. Patterns of opioid prescribing in emergency departments during the early phase of the COVID-19 pandemic. Am J Emerg Med 2022; 56:63-70. [PMID: 35367681 PMCID: PMC8956353 DOI: 10.1016/j.ajem.2022.03.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 03/09/2022] [Accepted: 03/20/2022] [Indexed: 02/06/2023] Open
Abstract
Introduction The COVID-19 pandemic was superimposed upon an ongoing epidemic of opioid use disorder and overdose deaths. Although the trend of opioid prescription patterns (OPP) had decreased in response to public health efforts before the pandemic, little is known about the OPP from emergency department (ED) clinicians during the COVID-19 pandemic. Methods We conducted a pre-post study of adult patients who were discharged from 13 EDs and one urgent care within our academic medical system between 01/01/2019 and 09/30/2020 using an interrupted time series (ITS) approach. Patient characteristics and prescription data were extracted from the single unified electronic medical record across all study sites. Prescriptions of opioids were converted into morphine equivalent dose (MED). We compared the “Covid-19 Pandemic” period (C19, 03/29/2020–9/30/2020) and the “Pre-Pandemic” period (PP, 1/19/2020–03/28/2020). We used a multivariate logistic regression to assess clinical factors associated with opioid prescriptions. Results We analyzed 361,794 ED visits by adult patients, including 259,242 (72%) PP and 102,552 (28%) C19 visits. Demographic information and percentages of patients receiving opioid prescriptions were similar in both groups. The median [IQR] MED per prescription was higher for C19 patients (70 [56–90]) than for PP patients (60 [60–90], P < 0.001). ITS demonstrated a significant trend toward higher MED prescription per ED visit during the pandemic (coefficient 0.11, 95% CI 0.05–0.16, P = 0.002). A few factors, that were associated with lower likelihood of opioid prescriptions before the pandemic, became non-significant during the pandemic. Conclusion Our study demonstrated that emergency clinicians increased the prescribed amount of opioids per prescription during the COVID-19 pandemic compared to the pre-pandemic period. Etiologies for this finding could include lack of access to primary care and other specialties during the pandemic, or lower volumes allowing for emergency clinicians to identify who is safe to be prescribed opioids.
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16
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Eswaran V, Chang AM, Wilkerson RG, O’Laughlin KN, Chinnock B, Eucker SA, Baumann BM, Anaya N, Miller DG, Haggins AN, Torres JR, Anderson ES, Lim SC, Caldwell MT, Raja AS, Rodriguez RM. Facemasks: Perceptions and use in an ED population during COVID-19. PLoS One 2022; 17:e0266148. [PMID: 35417505 PMCID: PMC9007380 DOI: 10.1371/journal.pone.0266148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 03/15/2022] [Indexed: 12/02/2022] Open
Abstract
Study objective Facemask use is associated with reduced transmission of SARS-CoV-2. Most surveys assessing perceptions and practices of mask use miss the most vulnerable racial, ethnic, and socio-economic populations. These same populations have suffered disproportionate impacts from the pandemic. The purpose of this study was to assess beliefs, access, and practices of mask wearing across 15 urban emergency department (ED) populations. Methods This was a secondary analysis of a cross-sectional study of ED patients from December 2020 to March 2021 at 15 geographically diverse, safety net EDs across the US. The primary outcome was frequency of mask use outside the home and around others. Other outcome measures included having enough masks and difficulty obtaining them. Results Of 2,575 patients approached, 2,301 (89%) agreed to participate; nine had missing data pertaining to the primary outcome, leaving 2,292 included in the final analysis. A total of 79% of respondents reported wearing masks “all of the time” and 96% reported wearing masks over half the time. Subjects with PCPs were more likely to report wearing masks over half the time compared to those without PCPs (97% vs 92%). Individuals experiencing homelessness were less likely to wear a mask over half the time compared to those who were housed (81% vs 96%). Conclusions Study participants reported high rates of facemask use. Respondents who did not have PCPs and those who were homeless were less likely to report wearing a mask over half the time and more likely to report barriers in obtaining masks. The ED may serve a critical role in education regarding, and provision of, masks for vulnerable populations.
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Affiliation(s)
- Vidya Eswaran
- Department of Emergency Medicine, University of California, San Francisco, CA, United States of America
- National Clinician Scholars Program, Philip R Lee Institute of Health Policy Studies, University of California, San Francisco, CA, United States of America
- * E-mail:
| | - Anna Marie Chang
- Department of Emergency Medicine, Thomas Jefferson University, Sidney Kimmel Medical College, Philadelphia, PA, United States of America
| | - R. Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - Kelli N. O’Laughlin
- Department of Emergency Medicine and Global Health, University of Washington, Seattle, WA, United States of America
| | - Brian Chinnock
- Department of Emergency Medicine, University of California, San Francisco, CA, United States of America
| | - Stephanie A. Eucker
- Division of Emergency Medicine, Department of Surgery, Duke University School of Medicine, Durham, NC, United States of America
| | - Brigitte M. Baumann
- Department of Emergency Medicine, Cooper Medical School of Rowan University, Cooper University Hospital, Camden, NJ, United States of America
| | - Nancy Anaya
- Department of Emergency Medicine, University of California, San Francisco, CA, United States of America
| | - Daniel G. Miller
- Departments of Emergency and Internal Medicine, University of Iowa Hospitals and Clinics, Iowa, IA, United States of America
| | - Adrianne N. Haggins
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan
| | - Jesus R. Torres
- Department of Emergency Medicine, Olive View UCLA Medical Center, University of California Los Angeles Schools of Medicine, Los Angeles, CA, United States of America
- National Clinician Scholars Program, University of California, Los Angeles, CA, United States of America
| | - Erik S. Anderson
- Department of Emergency Medicine, Alameda Health System, Oakland, CA, United States of America
| | - Stephen C. Lim
- Section of Emergency Medicine, University Medical Center New Orleans, Louisiana State University Health Sciences Center, New Orleans, LA, United States of America
| | - Martina T. Caldwell
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States of America
| | - Ali S. Raja
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Robert M. Rodriguez
- Department of Emergency Medicine, University of California, San Francisco, CA, United States of America
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17
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Rosenblatt LS, King SA, Callahan ME, Wilkerson RG. Which Way Would You Slice It? Evaluation of 3 Educational Models for the Loop Drainage Technique. Med Sci Educ 2022; 32:481-494. [PMID: 35528288 PMCID: PMC9054987 DOI: 10.1007/s40670-022-01530-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/03/2022] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Emergency department visits for cutaneous abscesses are increasing. It is important for healthcare professionals to be proficient in identifying and treating abscesses. Loop drainage technique (LDT) is a newer technique which has been described in several articles but limited resources for teaching have been studied. The objective of this study was to compare 3 models for learning and teaching the LDT. METHODS This was a prospective survey study of a convenience sample of emergency medicine residents at a large urban academic center. Residents volunteered to participate during a scheduled cadaver and simulation session. After a self-directed review of the LDT, each participant performed ultrasound visualization and then the LDT on 3 simulated abscesses: a cadaveric model, a commercial abscess pad, and a homemade phantom. Participants completed pre- and post-simulation surveys. RESULTS Of 57 residents, 28 participated in the 1-day simulation. The majority (57.1%, p < 0.009) preferred the cadaver model for learning the LDT, and 78.6% reported it to have the most realistic physical examination for an abscess (p = 0.001). Prior to participation, 0% of residents felt proficient performing LDT. After participation, 46.4% of residents felt proficient and 78.6% reported intent to use in clinical practice (p < 0.001). CONCLUSIONS Simulation is an effective educational tool for both learning new skills and improving procedural competency. Residents found cadavers provided the most realistic physical examination, and the majority preferred it for learning the LDT. However, cadavers are not always accessible, an important factor when considering various educational settings.
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Affiliation(s)
- Lauren S. Rosenblatt
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 S. Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201 USA
| | - Samantha A. King
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 S. Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201 USA
| | - Michele E. Callahan
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 S. Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201 USA
| | - R. Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 S. Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201 USA
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18
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Wilkerson RG, Suau S. Allergy, Inflammatory, and Autoimmune Disorders in Emergency Medicine. Emerg Med Clin North Am 2022. [DOI: 10.1016/s0733-8627(21)00109-7] [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: 11/27/2022]
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19
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Ford E, Wilkerson RG. Bilateral Hyphema - An Unexpected Complication of Exercise Resistance Band Use: A Case Report. J Emerg Med 2021; 62:e20-e22. [PMID: 34955319 DOI: 10.1016/j.jemermed.2021.10.023] [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: 05/23/2021] [Revised: 09/29/2021] [Accepted: 10/12/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Resistance bands commonly used for strength training exercise come with an unexpected risk for ocular trauma. CASE REPORT In this report, we describe an unintended consequence of a 28-year-old man sustaining an unusual injury-bilateral hyphema-as a result of the use of elastic resistance bands. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Resistance bands are commonly used for strength training exercise and, in this case, a potentially severe, vision-threatening injury-traumatic hyphema-occurred. Traumatic hyphema occurs when blood pools in the anterior chamber of the eye, usually as the result of blunt force trauma or penetrating injury. Early recognition of this condition is imperative, as complications of traumatic hyphema, such as intraocular hypertension or rebleeding, can lead to permanent vision loss.
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Affiliation(s)
- Elizabeth Ford
- Department of Emergency Medicine, University of Maryland Medical Center, Baltimore, Maryland
| | - R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland Medical Center, Baltimore, Maryland
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20
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Abstract
Drug hypersensitivity reactions are a diverse group of reactions mediated by the immune system after exposure to a drug. The Gell and Coombs classification divides immunologic DHRs into 4 major pathophysiologic categories based on immunologic mechanism. Anaphylaxis is a Type I hypersensitivity reaction that requires immediate recognition and treatment. Severe cutaneous adverse reactions (SCARs) are a group of dermatologic diseases that result from a Type IV hypersensitivity process and include drug reaction with eosinophilia and systemic symptom (DRESS) syndrome, Stevens-Johnson Syndrome (SJS), toxic epidermal necrolysis (TEN), and acute generalized exanthematous pustulosis (AGEP). Other types of reactions are slow to develop and do not always require rapid treatment. Emergency physicians should have a good understanding of these various types of drug hypersensitivity reactions and how to approach the patient regarding evaluation and treatment.
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Affiliation(s)
- R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
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21
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Abstract
Hereditary angioedema (HAE) is a rare autosomal dominant genetic disorder that usual results from a decreased level of functional C1-INH and clinically manifests with intermittent attacks of swelling of the subcutaneous tissue or submucosal layers of the respiratory or gastrointestinal tracts. Laboratory studies and radiographic imaging have limited roles in evaluation of patients with acute attacks of HAE except when the diagnosis is uncertain and other processes must be ruled out. Treatment begins with assessment of the airway to determine the need for immediate intervention. Emergency physicians should understand the pathophysiology of HAE to help guide management decisions.
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Affiliation(s)
- R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
| | - Joseph J Moellman
- Department of Emergency Medicine, University of Cincinnati College of Medicine, 231 Albert Sabin Way, MSB 1654, Cincinnati, OH 45267-0769, USA. https://twitter.com/edmojo
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Pickering A, Kuhn D, Sutherland M, Hollis G, Gentry Wilkerson R. 184 Understanding Emergency Medicine Residency Programs’ Scholarly Activity Requirement Implementation: A Mixed Methods Approach. Ann Emerg Med 2021. [DOI: 10.1016/j.annemergmed.2021.09.195] [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: 11/27/2022]
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23
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Rodriguez RM, Torres JR, Chang AM, Haggins AN, Eucker SA, O'Laughlin KN, Anderson E, Miller DG, Wilkerson RG, Caldwell M, Lim SC, Raja AS, Baumann BM, Graterol J, Eswaran V, Chinnock B. The Rapid Evaluation of COVID-19 Vaccination in Emergency Departments for Underserved Patients Study. Ann Emerg Med 2021; 78:502-510. [PMID: 34272104 PMCID: PMC8165082 DOI: 10.1016/j.annemergmed.2021.05.026] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 05/09/2021] [Accepted: 05/24/2021] [Indexed: 12/20/2022]
Abstract
Study objective Emergency departments (EDs) often serve vulnerable populations who may lack primary care and have suffered disproportionate COVID-19 pandemic effects. Comparing patients having and lacking a regular source of medical care and other ED patient characteristics, we assessed COVID-19 vaccine hesitancy, reasons for not wanting the vaccine, perceived access to vaccine sites, and willingness to get the vaccine as part of ED care. Methods This was a cross-sectional survey conducted from December 10, 2020, to March 7, 2021, at 15 safety net US EDs. Primary outcomes were COVID-19 vaccine hesitancy, reasons for vaccine hesitancy, and sites (including EDs) for potential COVID-19 vaccine receipt. Results Of 2,575 patients approached, 2,301 (89.4%) participated. Of the 18.4% of respondents who lacked a regular source of medical care, 65% used the ED as their usual source of health care. The overall rate of vaccine hesitancy was 39%; the range among the 15 sites was 28% to 58%. Respondents who lacked a regular source of medical care were more commonly vaccine hesitant than those who had a regular source of medical care (47% versus 38%, 9% difference, 95% confidence interval 4% to 14%). Other characteristics associated with greater vaccine hesitancy were younger age, female sex, Black race, Latinx ethnicity, and not having received an influenza vaccine in the past 5 years. Of the 61% who would accept a COVID-19 vaccine, 21% stated that they lacked a primary physician or clinic at which to receive it; the vast majority (95%) of these respondents would accept the COVID-19 vaccine as part of their care in the ED. Conclusion ED patients who lack a regular source of medical care are particularly hesitant regarding COVID-19 vaccination. Most COVID-19 vaccine acceptors would accept it as part of their care in the ED. EDs may play pivotal roles in COVID-19 vaccine messaging and delivery to highly vulnerable populations.
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Affiliation(s)
- Robert M Rodriguez
- Department of Emergency Medicine, University of California San Francisco, San Francisco, CA.
| | - Jesus R Torres
- Department of Emergency Medicine, Olive View UCLA Medical Center-University of California Los Angeles School of Medicine, Los Angeles, CA
| | - Anna Marie Chang
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA
| | | | - Stephanie A Eucker
- Division of Emergency Medicine, Department of Surgery, Duke University, Durham, NC
| | - Kelli N O'Laughlin
- Departments of Emergency Medicine and Global Health, University of Washington, Seattle, WA
| | - Erik Anderson
- Department of Emergency Medicine, Highland Hospital-Alameda Health System, Oakland, CA
| | - Daniel G Miller
- Department of Emergency Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, College Park, MD
| | - Martina Caldwell
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI
| | - Stephen C Lim
- Section of Emergency Medicine, University Medical Center New Orleans, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Ali S Raja
- Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Brigitte M Baumann
- Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, NJ
| | - Joseph Graterol
- Department of Emergency Medicine, University of California San Francisco, San Francisco, CA
| | - Vidya Eswaran
- Department of Emergency Medicine, University of California San Francisco, San Francisco, CA
| | - Brian Chinnock
- Department of Emergency Medicine, University of California San Francisco Fresno, Fresno, CA
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24
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Rosenbaum S, Wilkerson RG, Winters ME, Vilke GM, Wu MYC. Clinical Practice Statement: What is the Emergency Department Management of Patients with Angioedema Secondary to an ACE-Inhibitor? J Emerg Med 2021; 61:105-112. [PMID: 34006418 DOI: 10.1016/j.jemermed.2021.02.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 02/07/2021] [Accepted: 02/21/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND Angioedema is a complication that has been reported in up to 1.0% of individuals taking angiotensin-converting enzyme inhibitors (ACE-Is). Importantly, the onset of angioedema can occur anywhere from hours to several years after initiation of therapy with ACE-Is. Although most cases of ACE-I-induced angioedema (ACE-I-AE) are self-limiting, a major clinical concern is development of airway compromise, which can potentially require emergent airway management. The underlying pathophysiology of ACE-I-AE is incompletely understood, but is considered to be due in large part to excess bradykinin. Numerous medications have been proposed for the treatment of ACE-I-AE. This article is an update to the 2011 Clinical Practice Committee (CPC) statement from the American Academy of Emergency Medicine. METHODS A literature search in PubMed was performed with search terms angioedema and ACE inhibitors from August 1, 2012 to May 13, 2019. Following CPC guidelines, articles written in English were identified and then underwent a structured review for evaluation. RESULTS The search parameters resulted in 323 articles. The abstracts of these articles were assessed independently by the reviewers, who determined there were 63 articles that were specific to ACE-I-AE, of which 46 were deemed appropriate for grading in the final focused review. CONCLUSIONS The primary focus for the treatment of ACE-I-AE is airway management. In the absence of high-quality evidence, no specific medication therapy is recommended for its treatment. If, however, the treating physician feels the patient's presentation is more typical of an acute allergic reaction or anaphylaxis, it may be appropriate to treat for those conditions. Any patient with suspected ACE-I-AE should immediately discontinue that medication.
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Affiliation(s)
| | | | | | - Gary M Vilke
- University of California at San Diego Medical Center, San Diego, California
| | - Marie Yung Chen Wu
- University of California at San Diego Medical Center, San Diego, California
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25
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Gatz JD, Gingold DB, Lemkin DL, Wilkerson RG. Association of Resident Shift Length with Procedural Complications. J Emerg Med 2021; 61:189-197. [PMID: 34006422 DOI: 10.1016/j.jemermed.2021.02.029] [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: 12/03/2020] [Revised: 02/02/2021] [Accepted: 02/19/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Training programs for resident physicians struggle to balance the need for clinical experience with the impact of fatigue on patient safety. The length of shifts worked by emergency medicine (EM) residents is likely an important determinant of resident fatigue. OBJECTIVE Assess the impact of a longer clinical shift on procedural competency. METHODS We conducted a retrospective chart review of arterial line placements, central venous catheterizations, tube thoracostomies, endotracheal intubations, and lumbar punctures performed by EM residents working 12-h shifts in the emergency department of an academic medical center over an academic year. We compared complication rates between procedures performed in the first 8 vs. the last 4 h of a 12-h shift. Procedures without complication were defined as successful on first-pass attempt and without a downstream mechanical or medical complication. Multivariable modified Poisson regression was used to simultaneously control for possible confounders affecting procedure success. RESULTS We identified 548 eligible procedures: 307 performed in the first 8 h of a 12-h shift and 241 in the last 4 h. The complication rate across all procedures was higher in the last 4 h of the shift (pooled risk ratio 1.41, 95% confidence interval 1.18-1.67). This effect persisted when adjusting for potential confounders (adjusted risk ratio 1.42, 95% confidence interval 1.19-1.69). CONCLUSION Overall, complication rates of included procedures performed by EM residents were higher during the last 4 vs. first 8 h of a 12-h shift. Training programs should consider the impact of resident fatigue on patient safety when making work schedules.
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Affiliation(s)
- J David Gatz
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Daniel B Gingold
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Daniel L Lemkin
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland
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26
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Allen BR, Christenson RH, Cohen SA, Nowak R, Wilkerson RG, Mumma B, Madsen T, McCord J, Huis In't Veld M, Massoomi M, Stopyra JP, Montero C, Weaver MT, Yang K, Mahler SA. Diagnostic Performance of High-Sensitivity Cardiac Troponin T Strategies and Clinical Variables in a Multisite US Cohort. Circulation 2021; 143:1659-1672. [PMID: 33474976 DOI: 10.1161/circulationaha.120.049298] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND European data support the use of low high-sensitivity troponin (hs-cTn) measurements or a 0/1-hour (0/1-h) algorithm for myocardial infarction to exclude major adverse cardiac events (MACEs) among patients in the emergency department with possible acute coronary syndrome. However, modest US data exist to validate these strategies. This study evaluated the diagnostic performance of an initial hs-cTnT measure below the limit of quantification (LOQ: 6 ng/L), a 0/1-h algorithm, and their combination with history, ECG, age, risk factors, and initial troponin (HEART) scores for excluding MACE in a multisite US cohort. METHODS A prospective cohort study was conducted at 8 US sites, enrolling adult patients in the emergency department with symptoms suggestive of acute coronary syndrome and without ST-elevation on ECG. Baseline and 1-hour blood samples were collected, and hs-cTnT (Roche; Basel, Switzerland) was measured. Treating providers blinded to hs-cTnT results prospectively calculated HEART scores. MACE (cardiac death, myocardial infarction, and coronary revascularization) at 30 days was adjudicated. The proportion of patients with initial hs-cTnT measures below the LOQ and risk according to a 0/1-h algorithm was determined. The negative predictive value (NPV) was calculated for both strategies when used alone or with a HEART score. RESULTS Among 1462 participants with initial hs-cTnT measures, 46.4% (678 of 1462) were women and 37.1% (542 of 1462) were Black with an age of 57.6±12.9 (mean±SD) years. MACEs at 30 days occurred in 14.4% (210 of 1462) of participants. Initial hs-cTnT measures below the LOQ occurred in 32.8% (479 of 1462), yielding an NPV of 98.3% (95% CI, 96.7-99.3) for 30-day MACEs. A low-risk HEART score with an initial hs-cTnT below the LOQ occurred in 20.1% (294 of 1462), yielding an NPV of 99.0% (95% CI, 97.0-99.8) for 30-day MACEs. A 0/1-h algorithm was complete in 1430 patients, ruling out 57.8% (826 of 1430) with an NPV of 97.2% (95% CI, 95.9-98.2) for 30-day MACEs. Adding a low HEART score to the 0/1-h algorithm ruled out 30.8% (441 of 1430) with an NPV of 98.4% (95% CI, 96.8-99.4) for 30-day MACEs. CONCLUSIONS In a prospective multisite US cohort, an initial hs-cTnT below the LOQ combined with a low-risk HEART score has a 99% NPV for 30-day MACEs. The 0/1-h hs-cTnT algorithm did not achieve an NPV >99% for 30-day MACEs when used alone or with a HEART score. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02984436.
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Affiliation(s)
- Brandon R Allen
- Department of Emergency Medicine, College of Medicine (B.R.A., S.A.C., C.M.), University of Florida, Gainesville
| | - Robert H Christenson
- Departments of Pathology (R.H.C.), University of Maryland School of Medicine, Baltimore
| | - Scott A Cohen
- Department of Emergency Medicine, College of Medicine (B.R.A., S.A.C., C.M.), University of Florida, Gainesville
| | - Richard Nowak
- Department of Emergency Medicine (R.N.), Henry Ford Hospital, Detroit, MI
| | - R Gentry Wilkerson
- Emergency Medicine (R.G.W., M.H.i.V.), University of Maryland School of Medicine, Baltimore
| | - Bryn Mumma
- Department of Emergency Medicine, School of Medicine, University of California Davis, Sacramento (B.M.)
| | - Troy Madsen
- Division of Emergency Medicine, University of Utah School of Medicine, Salt Lake City (T.M.)
| | - James McCord
- Heart and Vascular Institute (J.M.), Henry Ford Hospital, Detroit, MI
- Department of Internal Medicine (J.M.), Henry Ford Hospital, Detroit, MI
| | - Maite Huis In't Veld
- Emergency Medicine (R.G.W., M.H.i.V.), University of Maryland School of Medicine, Baltimore
| | - Michael Massoomi
- Division of Cardiology, Department of Internal Medicine, College of Medicine (M.M.), University of Florida, Gainesville
| | - Jason P Stopyra
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC (J.P.S., S.A.M.)
| | - Cindy Montero
- Department of Emergency Medicine, College of Medicine (B.R.A., S.A.C., C.M.), University of Florida, Gainesville
| | - Michael T Weaver
- Department of Biobehavioral Nursing Science, College of Nursing (M.T.W.), University of Florida, Gainesville
| | - Kai Yang
- Department of Biostatistics, College of Public Health and Health Professions (K.Y.), University of Florida, Gainesville
| | - Simon A Mahler
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC (J.P.S., S.A.M.)
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27
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Ibemere SO, Dubbs SB, Barnhart HX, Brown JL, Freiermuth CE, Kavanagh P, Paice JA, Strouse JJ, Wilkerson RG, Tanabe P. Trial design of comparing patient-specific versus weight-based protocols to treat vaso-occlusive episodes in sickle cell disease (COMPARE-VOE). Contemp Clin Trials 2020; 101:106252. [PMID: 33348066 DOI: 10.1016/j.cct.2020.106252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 12/10/2020] [Accepted: 12/14/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Painful vaso-occlusive episodes (VOE) are the most common reason for emergency department (ED) visits experienced by patients with sickle cell disease (SCD). The National Heart, Lung and Blood Institute (NHLBI) evidence-based recommendations for VOE treatment are based primarily on expert opinion. In this randomized controlled trial (RCT), we will compare changes in pain scores between patients randomized to a patient-specific analgesic protocol versus those randomized to a weight-based analgesic protocol, as recommended by the NHLBI guidelines. METHODS We report the rationale and design of a multi-site, phase III, single-blinded, RCT to be conducted in six EDs in the United States. Eligible participants will be randomized after providing consent, anticipating 50% of those randomized would have an ED visit during the enrollment period. A total of 230 participants with one VOE ED visit provides sufficient power to detect a clinically significant difference in pain score reductions of 14 between groups with 0.05 type I error. Uniquely, this trial randomizes participants in a larger population than the study population, given the impossibility of consenting and randomizing participants during emergencies. The primary endpoint is the change in pain scores in the ED from time of placement in treatment area to time of disposition (hospitalization, discharged home, or assigned to observation status) or a maximum treatment duration of 6 hours. Additional outcomes include hospitalizations and ED visits seven days post enrollment, side effects, and safety assessments. CONCLUSIONS The COMPARE-VOE study design will provide high-level evidence to support the NHLBI VOE treatment guidelines.
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Affiliation(s)
- Stephanie O Ibemere
- School of Nursing, Duke University, Durham, NC 27710, United States of America.
| | - Sarah B Dubbs
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, United States of America
| | - Huiman X Barnhart
- Department of Biostatistics and Bioinformatics, Duke Clinical Research Institute, Duke University, Durham, NC, 27710, United States of America
| | - Jacqueline L Brown
- School of Nursing, Duke University, Durham, NC 27710, United States of America
| | - Caroline E Freiermuth
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH 45267, United States of America
| | - Patricia Kavanagh
- Division of General Pediatrics, Boston University School of Medicine/Boston Medical Center, Boston, MA 02118, United States of America
| | - Judith A Paice
- Division of Hematology-Oncology, Northwestern University; Feinberg School of Medicine, Chicago, IL 606011, United States of America
| | - John J Strouse
- Division of Hematology, Department of Medicine, and Division of Pediatric Hematology/Oncology, Department of Pediatrics, Duke University School of Medicine, Durham, NC 27710, United States of America
| | - R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, United States of America
| | - Paula Tanabe
- Schools of Nursing and Medicine, Duke University, Durham, NC 27710, United States of America
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Wilkerson RG, Adler JD, Shah NG, Brown R. Silent hypoxia: A harbinger of clinical deterioration in patients with COVID-19. Am J Emerg Med 2020; 38:2243.e5-2243.e6. [PMID: 32471783 PMCID: PMC7243756 DOI: 10.1016/j.ajem.2020.05.044] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 05/13/2020] [Accepted: 05/14/2020] [Indexed: 01/01/2023] Open
Abstract
Patients infected with the SARS-CoV-2 virus can present with a wide variety of symptoms including being entirely asymptomatic. Despite having no or minimal symptoms, some patients may have markedly reduced pulse oximetry readings. This has been referred to as “silent” or “apathetic” hypoxia (Ottestad et al., 2020 [1]). We present a case of a 72-year-old male with COVID-19 syndrome who presented to the emergency department with minimal symptoms but low peripheral oxygen saturation readings. The patient deteriorated over the following days and eventually died as a result of overwhelming multi-organ system failure. This case highlights the utility of peripheral oxygen measurements in the evaluation of patients with SARS-CoV-2 infection. Self-monitoring of pulse oximetry by patients discharged from the emergency department is a potential way to identify patients needing to return for further evaluation.
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Affiliation(s)
- R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States of America.
| | - Jason D Adler
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - Nirav G Shah
- Division of Pulmonary & Critical Care, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - Robert Brown
- Department of Emergency Medicine, University of Maryland Medical Center, Baltimore, MD, United States of America
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29
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Li M, Martinelli AN, Oliver WD, Wilkerson RG. Evaluation of Ketamine for Excited Delirium Syndrome in the Adult Emergency Department. J Emerg Med 2020; 58:100-105. [PMID: 31735659 DOI: 10.1016/j.jemermed.2019.09.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 08/23/2019] [Accepted: 09/13/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Excited delirium syndrome (ExDS) is characterized by delirium, agitation, and hyperadrenergic autonomic dysfunction. A guideline for ExDS management, which recommends the use of ketamine as a second-line agent, was implemented in our hospital's adult emergency department (ED). OBJECTIVE The primary objective was to determine whether ketamine, 1 mg/kg intravenous (i.v.) or 2 mg/kg intramuscular (i.m.), is being used according to the ExDS guideline. Secondary objectives included evaluating the specific agents, routes, and dosages used to manage ExDS and the safety and efficacy of ketamine. METHODS Single-center, retrospective chart review of patients who received ketamine for the management of ExDS in the ED. Efficacy was measured by documented Richmond Agitation Sedation Scale (RASS) scores. Safety was assessed through evaluation of vital signs and adverse effects. RESULTS Thirty-one patients met inclusion criteria. Eight (25.8%) of them received ketamine for ExDS in adherence with all aspects of the guideline. Administration of ketamine led to a statistically significant decrease in median RASS score of 4 (interquartile range [IQR] 3 to 4) vs. 0 (IQR 2 to -1) (p = 0.001). There were no statistically significant differences in vital signs or RASS scores in our subgroup analyses of patients treated according to protocol and of those treated with ketamine, 2 mg/kg i.m. CONCLUSIONS We found discordance between current practice and our department's ExDS guideline for patients managed with ketamine. Despite the lack of adherence to departmental guidelines and allowing for limitations of this analysis due to small sample size, the use of low-dose, 1 mg/kg i.v. or 2 mg/kg i.m., ketamine was effective and appears to be a reasonable option as second-line therapy for ExDS.
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Abstract
The 4 categories of hypertensive disorders of pregnancy are chronic hypertension, gestational hypertension, preeclampsia-eclampsia, and chronic hypertension with superimposed preeclampsia. These disorders are among the leading causes of maternal and fetal morbidity and mortality. Proper diagnosis in the emergency department is crucial in order to initiate appropriate treatment to reduce the potential harm to the mother and the fetus. Prompt management should be undertaken when the blood pressure is greater than 160/110 mm Hg or there are other severe features such as acute kidney injury, elevated liver function tests, severe abdominal pain, pulmonary edema, and central nervous system disturbances.
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Affiliation(s)
- R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, Suite 200; 6th Floor, Baltimore, MD 21201, USA.
| | - Adeolu C Ogunbodede
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, Suite 200; 6th Floor, Baltimore, MD 21201, USA; Department of Internal Medicine, University of Maryland School of Medicine, 110 South Paca Street, Suite 200; 6th Floor, Baltimore, MD 21201, USA
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31
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Gentry Wilkerson R, Pustavoitau A, Carolan H, Benner N, Fischer C, Sheets DJ, Wang PI, Tropello S. Percutaneous Ultrasound Gastrostomy: A Novel Device and Bedside Procedure for Gastrostomy Tube Insertion Using Magnetic and Ultrasound Guidance. J Med Device 2019. [DOI: 10.1115/1.4042866] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
This paper describes a novel percutaneous ultrasound gastrostomy (PUG) procedure and the CoapTech point-of-care ultrasound magnet-aligned gastrostomy (PUMA-G) device, which were developed to allow the placement of gastrostomy tubes by physicians across a variety of specialties, using ultrasound equipment found in many nonspecialized medical locations while consuming fewer resources. The current practice for the placement of gastrostomy tubes requires highly specialized equipment and trained physicians, which can delay the performance of the procedure or make it inaccessible in some locations. The PUMA-G device consists of an orogastric catheter with a balloon that encloses a magnetic bar at its distal end and an external, handheld magnet. The orogastric tube is passed through the mouth or the nose and into the stomach. The external magnet is then used to maneuver the balloon to the desired location in the stomach, with feedback and guidance from real-time ultrasound visualization. The novelty of this approach is the use of magnets to create the static compressive force needed for coaptation, in which the stomach is pushed flush against the abdominal wall, allowing ultrasound visualization of the entire gastrostomy tract (skin to stomach), safe cutaneous puncture, and guidewire-assisted placement of the gastrostomy tube. The development of the PUMA-G device has been aided by benchtop and simulation testing in addition to canine and human cadaver studies. The PUMA-G device was used successfully in 29 of 30 cadaver tests, with the one failure attributed to operator error and not the device. Further testing in live patients will assess the safety of the procedure, the speed with which it can be completed, the cost savings, and other benefits the device might offer over the existing gastrostomy procedures.
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Affiliation(s)
- R. Gentry Wilkerson
- Department of Emergency Medicine, School of Medicine, University of Maryland, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201 e-mail:
| | - Aliaksei Pustavoitau
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, 600 North Wolfe Street, Meyer 297, Baltimore, MD 21287 e-mail:
| | - Howard Carolan
- Armstrong Institute for Patient Safety and Quality, School of Medicine, Johns Hopkins University, 750 East Pratt Street, 15th Floor, Baltimore, MD 21202 e-mail:
| | - Nolan Benner
- School of Engineering, Johns Hopkins University, Baltimore, MD 21218 e-mail:
| | - Clark Fischer
- School of Engineering, Johns Hopkins University, Baltimore, MD 21218 e-mail:
| | - Daniel J. Sheets
- Department of Emergency Medicine, School of Medicine, University of Maryland, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201 e-mail:
| | - Peggy I. Wang
- CoapTech, 8 Market Place Suite 804, Baltimore, MD 21202 e-mail:
| | - Steven Tropello
- Department of Emergency Medicine, School of Medicine, University of Maryland, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201 e-mail:
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32
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Wilkerson RG, Martinelli AN, Oliver WD. Treatment of Angioedema Induced by Angiotensin-Converting Enzyme Inhibitor. J Emerg Med 2018; 55:132-133. [PMID: 29805069 DOI: 10.1016/j.jemermed.2018.01.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Accepted: 01/06/2018] [Indexed: 11/19/2022]
Affiliation(s)
- R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Ashley N Martinelli
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, Maryland
| | - Wesley D Oliver
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, Maryland
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34
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Ham JJ, Ordonez E, Wilkerson RG. Care of Acute Gastrointestinal Conditions in the Observation Unit. Emerg Med Clin North Am 2017; 35:571-587. [PMID: 28711125 DOI: 10.1016/j.emc.2017.03.005] [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] [Indexed: 02/07/2023]
Abstract
The Emergency Department Observation Unit (EDOU) provides a viable alternative to inpatient admission for the management of many acute gastrointestinal conditions with additional opportunities of reducing resource utilization and reducing radiation exposure. Using available evidence-based criteria to determine appropriate patient selection, evaluation, and treatment provides higher-quality medical care and improved patient satisfaction. Discussions of factors involved in creating an EDOU capable of caring for acute gastrointestinal conditions and clinical protocol examples of acute appendicitis, gastrointestinal hemorrhage, and acute pancreatitis provide a framework from which a successful EDOU can be built.
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Affiliation(s)
- Jason J Ham
- Department of Emergency Medicine, University of Michigan, 1500 East Medical Center Drive, Spc 5301, Ann Arbor, MI 48109, USA.
| | - Edgar Ordonez
- Department of Emergency Medicine, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030, USA
| | - R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201-1559, USA
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Adebayo O, Wilkerson RG. Response to: “Fresh-frozen plasma in ACE inhibitor induced angioedema- so close and yet so far”. Am J Emerg Med 2017; 35:346-347. [DOI: 10.1016/j.ajem.2016.10.080] [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: 10/31/2016] [Accepted: 10/31/2016] [Indexed: 10/20/2022] Open
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Crouter AJ, Abraham MK, Wilkerson RG. Emphysematous pyelonephritis in a renal allograft. Am J Emerg Med 2016; 35:520.e1-520.e2. [PMID: 27717721 DOI: 10.1016/j.ajem.2016.09.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 09/20/2016] [Indexed: 10/21/2022] Open
Affiliation(s)
- Andrew J Crouter
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Michael K Abraham
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD.
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Affiliation(s)
- R Gentry Wilkerson
- a Department of Emergency Medicine , University of Maryland School of Medicine , Baltimore , MD , USA
| | - Bryan D Hayes
- a Department of Emergency Medicine , University of Maryland School of Medicine , Baltimore , MD , USA
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Koo L, Layson-Wolf C, Brandt N, Hammersla M, Idzik S, Rocafort PT, Tran D, Wilkerson RG, Windemuth B. Qualitative evaluation of a standardized patient clinical simulation for nurse practitioner and pharmacy students. Nurse Educ Pract 2014; 14:740-6. [DOI: 10.1016/j.nepr.2014.10.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Revised: 08/18/2014] [Accepted: 10/15/2014] [Indexed: 11/25/2022]
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Wilkerson RG, Butler KH, Witting MD. Emergency cricothyroidotomies for trauma: further considerations. Am J Emerg Med 2013; 31:990-1. [PMID: 23680324 DOI: 10.1016/j.ajem.2013.02.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Accepted: 02/20/2013] [Indexed: 11/30/2022] Open
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Kashani K, Al-Khafaji A, Ardiles T, Artigas A, Bagshaw SM, Bell M, Bihorac A, Birkhahn R, Cely CM, Chawla LS, Davison DL, Feldkamp T, Forni LG, Gong MN, Gunnerson KJ, Haase M, Hackett J, Honore PM, Hoste EAJ, Joannes-Boyau O, Joannidis M, Kim P, Koyner JL, Laskowitz DT, Lissauer ME, Marx G, McCullough PA, Mullaney S, Ostermann M, Rimmelé T, Shapiro NI, Shaw AD, Shi J, Sprague AM, Vincent JL, Vinsonneau C, Wagner L, Walker MG, Wilkerson RG, Zacharowski K, Kellum JA. Discovery and validation of cell cycle arrest biomarkers in human acute kidney injury. Crit Care 2013; 17:R25. [PMID: 23388612 PMCID: PMC4057242 DOI: 10.1186/cc12503] [Citation(s) in RCA: 814] [Impact Index Per Article: 74.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Revised: 01/12/2013] [Accepted: 01/16/2013] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Acute kidney injury (AKI) can evolve quickly and clinical measures of function often fail to detect AKI at a time when interventions are likely to provide benefit. Identifying early markers of kidney damage has been difficult due to the complex nature of human AKI, in which multiple etiologies exist. The objective of this study was to identify and validate novel biomarkers of AKI. METHODS We performed two multicenter observational studies in critically ill patients at risk for AKI - discovery and validation. The top two markers from discovery were validated in a second study (Sapphire) and compared to a number of previously described biomarkers. In the discovery phase, we enrolled 522 adults in three distinct cohorts including patients with sepsis, shock, major surgery, and trauma and examined over 300 markers. In the Sapphire validation study, we enrolled 744 adult subjects with critical illness and without evidence of AKI at enrollment; the final analysis cohort was a heterogeneous sample of 728 critically ill patients. The primary endpoint was moderate to severe AKI (KDIGO stage 2 to 3) within 12 hours of sample collection. RESULTS Moderate to severe AKI occurred in 14% of Sapphire subjects. The two top biomarkers from discovery were validated. Urine insulin-like growth factor-binding protein 7 (IGFBP7) and tissue inhibitor of metalloproteinases-2 (TIMP-2), both inducers of G1 cell cycle arrest, a key mechanism implicated in AKI, together demonstrated an AUC of 0.80 (0.76 and 0.79 alone). Urine [TIMP-2]·[IGFBP7] was significantly superior to all previously described markers of AKI (P <0.002), none of which achieved an AUC >0.72. Furthermore, [TIMP-2]·[IGFBP7] significantly improved risk stratification when added to a nine-variable clinical model when analyzed using Cox proportional hazards model, generalized estimating equation, integrated discrimination improvement or net reclassification improvement. Finally, in sensitivity analyses [TIMP-2]·[IGFBP7] remained significant and superior to all other markers regardless of changes in reference creatinine method. CONCLUSIONS Two novel markers for AKI have been identified and validated in independent multicenter cohorts. Both markers are superior to existing markers, provide additional information over clinical variables and add mechanistic insight into AKI. TRIAL REGISTRATION ClinicalTrials.gov number NCT01209169.
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Affiliation(s)
- Kianoush Kashani
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Ali Al-Khafaji
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Pittsburgh, PA 15213, USA
| | - Thomas Ardiles
- Department of Critical Care, Maricopa Integrated Health System, 2601 E Roosevelt Street, Phoenix, AZ 85008, USA
| | - Antonio Artigas
- Critical Care Center, Sabadell Hospital, CIBER Enfermedades Respiratorias, Autonomous University of Barcelona, Parc Tauli s/n, Sabadell, Barcelona 8208, Spain
| | - Sean M Bagshaw
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 3C1.12 Walter C. Mackenzie Centre, 8440 112 Street NW, Edmonton, Alberta T6G 2B7, Canada
| | - Max Bell
- Department of Anesthesia and Intensive Care Medicine, Karolinska University Hospital, Karolinskavagen, Solna, Stockholm SE-171 76, Sweden
| | - Azra Bihorac
- Department of Anesthesiology, University of Florida, 1660 SW Archer Road, Gainesville, FL 32611, USA
| | - Robert Birkhahn
- Department of Emergency Medicine, New York Methodist Hospital, 506 6th Street, Brooklyn, NY 11215, USA
| | - Cynthia M Cely
- Bruce W. Carter Department of Veterans Affairs Medical Center, 1201 NW 16th Street, Miami, FL 33125, USA
| | - Lakhmir S Chawla
- Department of Anesthesiology and Critical Care Medicine, George Washington University Medical Center, 900 23rd Street NW, Washington, DC 20037, USA
| | - Danielle L Davison
- Department of Anesthesiology and Critical Care Medicine, George Washington University Medical Center, 900 23rd Street NW, Washington, DC 20037, USA
| | - Thorsten Feldkamp
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, Essen, 45147, Germany
| | - Lui G Forni
- Intensive Care Medicine, Western Sussex Hospitals Trust, Lyndhurst Road, Worthing, West Sussex, BN11 2DH, UK
| | - Michelle Ng Gong
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, USA
| | - Kyle J Gunnerson
- Departments of Anesthesiology and Emergency Medicine, Virginia Commonwealth University Medical Center, 1200 East Broad Street, Richmond, VA 23298, USA
| | - Michael Haase
- Department of Nephrology, Otto-von-Guericke-Universitat Magdeburg, Leipziger Strasse 44, Magdeburg, 39120, Germany
| | - James Hackett
- Hackett & Associates, Inc., 14419 Rancho Del Prado Trail, San Diego, CA 92127, USA
| | - Patrick M Honore
- ICU Department, Universitair Ziekenhuis Brussel (UZB), Vrije Universiteit Brussel (VUB), Laarbeeklaan 101, Brussels 1090, Belgium
| | - Eric AJ Hoste
- Intensive Care Unit, Ghent University Hospital, De Pintelaan 185, Ghent, 9000, Belgium
| | - Olivier Joannes-Boyau
- Anaesthesiology and Critical Care Department 2, University Hospital of Bordeaux, 1 Avenue De Magellon, Pessac, 33600, France
| | - Michael Joannidis
- Department of Internal Medicine, ICU, Medical University Innsbruck, Anichstrasse 35, Innsbruck, A-6020, Austria
| | - Patrick Kim
- Traumatology, Surgical Critical Care and Emergency Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Jay L Koyner
- Department of Medicine, University of Chicago, 6030 South Ellis Avenue, Chicago, IL 60637, USA
| | - Daniel T Laskowitz
- Department of Medicine, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, USA
| | - Matthew E Lissauer
- Department of Surgery, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD 21201, USA
| | - Gernot Marx
- Department of Intensive Care, Universitätsklinikum der RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany
| | - Peter A McCullough
- Department of Medicine, St John Providence Health System, Providence Hospitals and Medical Centers, Providence Park Heart Institute, 47601 Grand River Avenue, Novi, MI 48374, USA
| | - Scott Mullaney
- Department of Medicine, University of California San Diego, 200 West Arbor Drive, San Diego, CA 92103, USA
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's and St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | - Thomas Rimmelé
- Service D'Anesthésie Réanimation, Edouard Herriot Hospital, Hospices civils de Lyon, 5 Place d'Arsonval, Lyon, 69003, France
| | - Nathan I Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Boston, MA 2215, USA
| | - Andrew D Shaw
- Department of Anesthesia, Duke University Medical Center/Durham Veterans Affairs Medical Center, 508 Fulton Street, Durham, NC 27705, USA
| | - Jing Shi
- Walker Biosciences, 6321 Allston Street, Carlsbad, CA 92009, USA
| | - Amy M Sprague
- Department of Medicine, Joseph M. Still Research Foundation, 3675 J. Dewey Gray Circle, Augusta, GA 30909, USA
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Route De Lennik 808, Brussels, 1070, Belgium
| | - Christophe Vinsonneau
- Department of Intensive Care, Hospital Marc Jacquet, 2 Rue Freteau De Peny, Melun, 77011, France
| | - Ludwig Wagner
- Department of Internal Medicine, Medical University of Vienna, Spitalgasse 23, Vienna 1090, Austria
| | - Michael G Walker
- Walker Biosciences, 6321 Allston Street, Carlsbad, CA 92009, USA
| | - R Gentry Wilkerson
- Department of Emergency Medicine, Tampa General Hospital, 1 Davis Boulevard, Tampa, FL 33606, USA
| | - Kai Zacharowski
- Clinic of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Theodor-Stern-Kai 7, Frankfurt am Main, 60590, Germany
| | - John A Kellum
- Department of Critical Care Medicine, University of Pittsburgh, School of Medicine, 3550 Terrace Street, Pittsburgh, PA 15213, USA
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Wilkerson RG. Angioedema in the emergency department: an evidence-based review. Emerg Med Pract 2012; 14:1-21. [PMID: 23137438] [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] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Accepted: 10/10/2012] [Indexed: 06/01/2023]
Abstract
Angioedema is the end result of a variety of pathophysiological processes resulting in transient, localized, nonpitting swelling of the subcutaneous layer of the skin or submucosal layer of the respiratory or gastrointestinal tracts. It is now generally accepted that the swelling is mediated by either histamine or bradykinin. Angioedema may result in severe upper airway compromise or-less commonly recognized-compromise in the gastrointestinal tract often associated with severe abdominal pain. A variety of new therapeutic options are becoming available for use in the United States that have the potential to greatly impact the management and outcomes for those with severe clinical manifestations. This review assesses the evidence on the causes and treatments of angioedema in the emergency department and reviews the new therapeutic options available for treatment of angioedema based on their effectiveness, price, and availability.
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Affiliation(s)
- R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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Wilkerson RG, Stone MB. Sensitivity of bedside ultrasound and supine anteroposterior chest radiographs for the identification of pneumothorax after blunt trauma. Acad Emerg Med 2010; 17:11-7. [PMID: 20078434 DOI: 10.1111/j.1553-2712.2009.00628.x] [Citation(s) in RCA: 155] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Supine anteroposterior (AP) chest radiographs in patients with blunt trauma have poor sensitivity for the identification of pneumothorax. Ultrasound (US) has been proposed as an alternative screening test for pneumothorax in this population. The authors conducted an evidence-based review of the medical literature to compare sensitivity of bedside US and AP chest radiographs in identifying pneumothorax after blunt trauma. METHODS MEDLINE and EMBASE databases were searched for trials from 1965 through June 2009 using a search strategy derived from the following PICO formulation of our clinical question: patients included adult (18 + years) emergency department (ED) patients in whom pneumothorax was suspected after blunt trauma. The intervention was thoracic ultrasonography for the detection of pneumothorax. The comparator was the supine AP chest radiograph during the initial evaluation of the patient. The outcome was the diagnostic performance of US in identifying the presence of pneumothorax in the study population. The criterion standard for the presence or absence of pneumothorax was computed tomography (CT) of the chest or a rush of air during thoracostomy tube placement (in unstable patients). Prospective, observational trials of emergency physician (EP)-performed thoracic US were included. Trials in which the exams were performed by radiologists or surgeons, or trials that investigated patients suffering penetrating trauma or with spontaneous or iatrogenic pneumothoraces, were excluded. The methodologic quality of the studies was assessed. Qualitative methods were used to summarize the study results. Data analysis consisted of test performance (sensitivity and specificity, with 95% confidence intervals [CIs]) of thoracic US and supine AP chest radiography. RESULTS Four prospective observational studies were identified, with a total of 606 subjects who met the inclusion and exclusion criteria. The sensitivity and specificity of US for the detection of pneumothorax ranged from 86% to 98% and 97% to 100%, respectively. The sensitivity of supine AP chest radiographs for the detection of pneumothorax ranged from 28% to 75%. The specificity of supine AP chest radiographs was 100% in all included studies. CONCLUSIONS This evidence-based review suggests that bedside thoracic US is a more sensitive screening test than supine AP chest radiography for the detection of pneumothorax in adult patients with blunt chest trauma.
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Affiliation(s)
- R Gentry Wilkerson
- Department of Emergency Medicine, SUNY Downstate/Kings County Hospital Center, Brooklyn, NY, USA
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Wilkerson RG, Sinert R. The Use of Paracentesis in the Assessment of the Patient With Ascites. Ann Emerg Med 2009; 54:465-8. [DOI: 10.1016/j.annemergmed.2008.09.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2008] [Revised: 09/10/2008] [Accepted: 09/10/2008] [Indexed: 10/21/2022]
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Roy JB, Wilkerson RG. Fallibility of Griess (nitrite) test. Urology 1984; 23:270-1. [PMID: 6702041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
The Griess (nitrite) test is a simple, inexpensive, and rapid method for detecting bacteriuria. However, a working knowledge of its limitation should be considered during its interpretation.
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Czerwinski AW, Wilkerson RG, Merrill JA, Braden B, Colmore JP. Further evaluation of the Griess test to detect significant bacteriuria. II. Am J Obstet Gynecol 1971; 110:677-81. [PMID: 5563234 DOI: 10.1016/0002-9378(71)90253-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Czerwinski AW, Wilkerson RG, Braden B, Merrill JA, Colmore JP. Evaluation of first morning urine to detect significant bacteriuria. I. Am J Obstet Gynecol 1971; 110:42-5. [PMID: 4995590 DOI: 10.1016/0002-9378(71)90211-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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