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Wang RC, Carlos C Montoy J, Rodriguez RM, Menegazzi JJ, Lacocque J, Dillon DG. Trends in Presumed Drug Overdose Out-Of-Hospital Cardiac Arrests in San Francisco, 2015-2023. Resuscitation 2024:110159. [PMID: 38458415 DOI: 10.1016/j.resuscitation.2024.110159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 02/21/2024] [Accepted: 02/24/2024] [Indexed: 03/10/2024]
Abstract
INTRODUCTION Estimates of the prevalence of drug-related out of hospital cardiac arrest (OHCA) vary, ranging from 1.8 - 10.0% of medical OHCA. However, studies conducted prior to the recent wave of fentanyl deaths likely underestimate the current prevalence of drug-related OHCA. We evaluated recent trends in drug-related OHCA, hypothesizing that the proportion of presumed drug-related OHCA treated by emergency medical services (EMS) has increased since 2015. METHODS We conducted a retrospective analysis of OHCA patients treated by EMS providers in San Francisco, California between 2015 - 2023. Participants included OHCA cases in which resuscitation was attempted by EMS. The study exposure was the year of arrest. Our primary outcome was the occurrence of drug-related OHCA, defined as the EMS impression of OHCA caused by a presumed or known overdose of medication(s) or drug(s). RESULTS From 2015 to 2023, 5044 OHCA resuscitations attended by EMS (average 561 per year) met inclusion criteria. The median age was 65 (IQR 50-79); 3508 (69.6%) were male. The EMS impression of arrest etiology was drug-related in 446/5044 (8.8%) of OHCA. The prevalence of presumed drug-related OHCA increased significantly each year from 1% in 2015 to 17.6% in 2023 (p-value for trend = 0.0001). After adjustment, presumed drug-related OHCA increased by 30% each year from 2015-2023. CONCLUSION Drug-related OHCA is an increasingly common etiology of OHCA. In 2023, one in six OHCA was presumed to be drug related. Among participants less than 60 years old, one in three OHCA was presumed to be drug related.
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Affiliation(s)
- Ralph C Wang
- Department of Emergency Medicine, University of California, San Francisco.
| | | | - Robert M Rodriguez
- Department of Emergency Medicine, University of California, San Francisco
| | - James J Menegazzi
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh
| | - Jeremy Lacocque
- Department of Emergency Medicine, University of California, San Francisco
| | - David G Dillon
- Department of Emergency Medicine, University of California, Davis
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Huebinger R, Ketterer AR, Hill MJ, Mann NC, Wang RC, Montoy JCC, Osborn L, Ugalde IT. National community disparities in prehospital penetrating trauma adjusted for income, 2020-2021. Am J Emerg Med 2024; 77:183-186. [PMID: 38163413 DOI: 10.1016/j.ajem.2023.12.015] [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: 12/05/2023] [Accepted: 12/07/2023] [Indexed: 01/03/2024] Open
Abstract
INTRODUCTION While Black individuals experienced disproportionately increased firearm violence and deaths during the COVID-19 pandemic, less is known about community level disparities. We sought to evaluate national community race and ethnicity differences in 2020 and 2021 rates of penetrating trauma. METHODS We linked the 2018-2021 National Emergency Medical Services Information System databases to ZIP Code demographics. We stratified encounters into majority race/ethnicity communities (>50% White, Black, or Hispanic/Latino). We used logistic regression to compare penetrating trauma for each community in 2020 and 2021 to a combined 2018-2019 historical baseline. Majority Black and majority Hispanic/Latino communities were compared to majority White communities for each year. Analyses were adjusted for household income. RESULTS We included 87,504,097 encounters (259,449 penetrating traumas). All communities had increased odds of trauma in 2020 when compared to 2018-2019, but this increase was largest for Black communities (aOR 1.4, [1.3-1.4]; White communities - aOR 1.2, [1.2-1.3]; Hispanic/Latino communities - aOR 1.1. [1.1-1.2]). There was a similar trend of increased penetrating trauma in 2021 for Black (aOR 1.2, [1.2-1.3]); White (aOR 1.2, [1.1-1.2]); Hispanic/Latino (aOR 1.1, [1.1-1.1]). Comparing penetrating trauma in each year to White communities, Black communities had higher odds of trauma in all years (2018/2019 - aOR 3.0, [3.0-3.1]; 2020 - aOR 3.3, [3.3-3.4]; 2021 - aOR 3.3, [3.2-3.2]). Hispanic/Latino also had more trauma each year but to a lesser degree (2018/2019 - aOR 2.0, [2.0-2.0]; 2020 - aOR 1.8, [1.8-1.9]; 2021 - aOR 1.9, [1.8-1.9]). CONCLUSION Black communities were most impacted by increased penetrating trauma rates in 2020 and 2021 even after adjusting for income.
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Affiliation(s)
- Ryan Huebinger
- Department of Emergency Medicine, University of New Mexico, Albuquerque, NM, United States of America.
| | - Andrew R Ketterer
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School, Boston, MA, United States of America.
| | - Mandy J Hill
- Department of Emergency Medicine, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth), Houston, TX, United States of America.
| | - N Clay Mann
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, United States of America.
| | - Ralph C Wang
- Department of Emergency Medicine, University of California San Francisco, San Francisco, CA, United States of America.
| | - Juan Carlos C Montoy
- Department of Emergency Medicine, University of California San Francisco, San Francisco, CA, United States of America.
| | - Lesley Osborn
- Department of Emergency Medicine, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO, United States of America.
| | - Irma T Ugalde
- Department of Emergency Medicine, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth), Houston, TX, United States of America.
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O’Laughlin KN, Klabbers RE, Ebna Mannan I, Gentile NL, Geyer RE, Zheng Z, Yu H, Li SX, Chan KCG, Spatz ES, Wang RC, L’Hommedieu M, Weinstein RA, Plumb ID, Gottlieb M, Huebinger RM, Hagen M, Elmore JG, Hill MJ, Kelly M, McDonald S, Rising KL, Rodriguez RM, Venkatesh A, Idris AH, Santangelo M, Koo K, Saydah S, Nichol G, Stephens KA. Ethnic and racial differences in self-reported symptoms, health status, activity level, and missed work at 3 and 6 months following SARS-CoV-2 infection. Front Public Health 2024; 11:1324636. [PMID: 38352132 PMCID: PMC10861779 DOI: 10.3389/fpubh.2023.1324636] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 12/12/2023] [Indexed: 02/16/2024] Open
Abstract
Introduction Data on ethnic and racial differences in symptoms and health-related impacts following SARS-CoV-2 infection are limited. We aimed to estimate the ethnic and racial differences in symptoms and health-related impacts 3 and 6 months after the first SARS-CoV-2 infection. Methods Participants included adults with SARS-CoV-2 infection enrolled in a prospective multicenter US study between 12/11/2020 and 7/4/2022 as the primary cohort of interest, as well as a SARS-CoV-2-negative cohort to account for non-SARS-CoV-2-infection impacts, who completed enrollment and 3-month surveys (N = 3,161; 2,402 SARS-CoV-2-positive, 759 SARS-CoV-2-negative). Marginal odds ratios were estimated using GEE logistic regression for individual symptoms, health status, activity level, and missed work 3 and 6 months after COVID-19 illness, comparing each ethnicity or race to the referent group (non-Hispanic or white), adjusting for demographic factors, social determinants of health, substance use, pre-existing health conditions, SARS-CoV-2 infection status, COVID-19 vaccination status, and survey time point, with interactions between ethnicity or race and time point, ethnicity or race and SARS-CoV-2 infection status, and SARS-CoV-2 infection status and time point. Results Following SARS-CoV-2 infection, the majority of symptoms were similar over time between ethnic and racial groups. At 3 months, Hispanic participants were more likely than non-Hispanic participants to report fair/poor health (OR: 1.94; 95%CI: 1.36-2.78) and reduced activity (somewhat less, OR: 1.47; 95%CI: 1.06-2.02; much less, OR: 2.23; 95%CI: 1.38-3.61). At 6 months, differences by ethnicity were not present. At 3 months, Other/Multiple race participants were more likely than white participants to report fair/poor health (OR: 1.90; 95% CI: 1.25-2.88), reduced activity (somewhat less, OR: 1.72; 95%CI: 1.21-2.46; much less, OR: 2.08; 95%CI: 1.18-3.65). At 6 months, Asian participants were more likely than white participants to report fair/poor health (OR: 1.88; 95%CI: 1.13-3.12); Black participants reported more missed work (OR, 2.83; 95%CI: 1.60-5.00); and Other/Multiple race participants reported more fair/poor health (OR: 1.83; 95%CI: 1.10-3.05), reduced activity (somewhat less, OR: 1.60; 95%CI: 1.02-2.51; much less, OR: 2.49; 95%CI: 1.40-4.44), and more missed work (OR: 2.25; 95%CI: 1.27-3.98). Discussion Awareness of ethnic and racial differences in outcomes following SARS-CoV-2 infection may inform clinical and public health efforts to advance health equity in long-term outcomes.
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Affiliation(s)
- Kelli N. O’Laughlin
- Department of Emergency Medicine, University of Washington, Seattle, WA, United States
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Robin E. Klabbers
- Department of Emergency Medicine, University of Washington, Seattle, WA, United States
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Imtiaz Ebna Mannan
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, CT, United States
| | - Nicole L. Gentile
- Department of Family Medicine, University of Washington, Seattle, WA, United States
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, United States
- Post-COVID Rehabilitation and Recovery Clinic, University of Washington, Seattle, WA, United States
| | - Rachel E. Geyer
- Department of Family Medicine, University of Washington, Seattle, WA, United States
| | - Zihan Zheng
- Department of Family Medicine, University of Washington, Seattle, WA, United States
| | - Huihui Yu
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, CT, United States
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, United States
| | - Shu-Xia Li
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, CT, United States
| | - Kwun C. G. Chan
- Department of Biostatistics, University of Washington, Seattle, WA, United States
- Department of Health Systems and Population Health, University of Washington, Seattle, WA, United States
| | - Erica S. Spatz
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, United States
- Department of Epidemiology, Yale School of Public Health, New Haven, CT, United States
- Yale Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, CT, United States
| | - Ralph C. Wang
- Department of Emergency Medicine, University of California San Francisco, San Francisco, CA, United States
| | - Michelle L’Hommedieu
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Robert A. Weinstein
- Divisions of Infectious Diseases, Department of Internal Medicine, Rush University Medical Center, Chicago, IL, United States
- Department of Medicine, Cook County Hospital, Chicago, IL, United States
| | - Ian D. Plumb
- National Center for Immunizations and Respiratory Diseases, U.S. Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, United States
| | - Ryan M. Huebinger
- UTHealth Houston McGovern Medical School Department of Emergency Medicine, Houston, TX, United States
| | - Melissa Hagen
- National Center for Immunizations and Respiratory Diseases, U.S. Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Joann G. Elmore
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Mandy J. Hill
- UTHealth Houston McGovern Medical School Department of Emergency Medicine, Houston, TX, United States
| | - Morgan Kelly
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States
| | - Samuel McDonald
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
- Clinical Informatics Center, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Kristin L. Rising
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States
- Center for Connected Care, Thomas Jefferson University, Philadelphia, PA, United States
| | - Robert M. Rodriguez
- Department of Emergency Medicine, University of California San Francisco, San Francisco, CA, United States
| | - Arjun Venkatesh
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, CT, United States
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, United States
| | - Ahamed H. Idris
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Michelle Santangelo
- Divisions of Infectious Diseases, Department of Internal Medicine, Rush University Medical Center, Chicago, IL, United States
| | - Katherine Koo
- Divisions of Infectious Diseases, Department of Internal Medicine, Rush University Medical Center, Chicago, IL, United States
| | - Sharon Saydah
- National Center for Immunizations and Respiratory Diseases, U.S. Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Graham Nichol
- Department of Emergency Medicine, University of Washington, Seattle, WA, United States
| | - Kari A. Stephens
- Department of Family Medicine, University of Washington, Seattle, WA, United States
- Biomedical Informatics and Medical Education, University of Washington, Seattle, WA, United States
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Akhetuamhen A, Bibbins-Domingo K, Fahimi J, Fontil V, Rodriguez R, Wang RC. Missed Opportunities to Diagnose and Treat Asymptomatic Hypertension in Emergency Departments in the United States, 2016-2019. J Emerg Med 2024:S0736-4679(24)00002-7. [PMID: 38679548 DOI: 10.1016/j.jemermed.2024.01.006] [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: 12/14/2022] [Revised: 12/21/2023] [Accepted: 01/06/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND Fewer than one-half of U.S. adults with hypertension (HTN) have it controlled and one-third are unaware of their condition. The emergency department (ED) represents a setting to improve HTN control by increasing awareness of asymptomatic hypertension (aHTN) according to the 2013 American College of Emergency Physicians asymptomatic elevated blood pressure clinical policy. OBJECTIVE The aim of the study was to estimate the prevalence and management of aHTN in U.S. EDs. METHODS We examined the 2016-2019 National Hospital Ambulatory Medical Care Surveys to provide a more valid estimate of aHTN visits in U.S. EDs. aHTN is defined as adult patients with blood pressure ≥ 160/100 mm Hg at triage and discharge without trauma or signs of end organ damage. We then stratified aHTN into a 160-179/100-109 mm Hg subgroup and > 180/110 mm Hg subgroup and examined diagnosis and treatment outcomes. RESULTS Approximately 5.9% of total visits between 2016 and 2019 met the definition for aHTN and 74% of patients were discharged home, representing an estimated 26.5 million visits. Among those discharged home, emergency physicians diagnosed 13% (95% CI 10.6-15.8%) and treated aHTN in 3.9% (95% CI 2.8-5.5%) of patients in the higher aHTN subgroup. In the lower aHTN subgroup, diagnosis and treatment decreased to 3.1% (95% CI 2.4-4.1%) and 1.2% (95% CI 0.7-2.0%), respectively. CONCLUSIONS Millions of ED patients found to have aHTN are discharged home without diagnosis or treatment. Although management practices follow clinical policy to delay treatment of aHTN, there are missed opportunities to diagnosis aHTN.
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Affiliation(s)
- Adesuwa Akhetuamhen
- Department of Emergency Medicine, Emory School of Medicine, Atlanta, Georgia.
| | - Kristin Bibbins-Domingo
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California; Department of Medicine, University of California, San Francisco, California
| | - Jahan Fahimi
- Department of Emergency Medicine, Emory School of Medicine, Atlanta, Georgia
| | - Valy Fontil
- Department of Population Health at New York University Grossman School of Medicine, New York, New York
| | - Robert Rodriguez
- Department of Emergency Medicine, Emory School of Medicine, Atlanta, Georgia
| | - Ralph C Wang
- Department of Emergency Medicine, Emory School of Medicine, Atlanta, Georgia
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Wang RC, Degesys NF, Fahimi J, Jin C, Rosenthal E, Lazar AA, Yaffee AQ, Peterson S, Rothmann RE, Jones CMC, Tolia V, Shah MN, Raven MC. Incidence of Fit Test Failure During N95 Respirator Reuse and Extended Use. JAMA Netw Open 2024; 7:e2353631. [PMID: 38277142 DOI: 10.1001/jamanetworkopen.2023.53631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2024] Open
Abstract
Importance The COVID-19 pandemic resulted in a widespread acute shortage of N95 respirators, prompting the Centers for Disease Control and Prevention to develop guidelines for extended use and limited reuse of N95s for health care workers (HCWs). While HCWs followed these guidelines to conserve N95s, evidence from clinical settings regarding the safety of reuse and extended use is limited. Objective To measure the incidence of fit test failure during N95 reuse and compare the incidence between N95 types. Design, Setting, and Participants This prospective cohort study, conducted from April 2, 2021, to July 15, 2022, at 6 US emergency departments (EDs), included HCWs who practiced N95 reuse for more than half of their clinical shift. Those who were unwilling to wear an N95 for most of their shift, repeatedly failed baseline fit testing, were pregnant, or had facial hair or jewelry that interfered with the N95 face seal were excluded. Exposures Wearing the same N95 for more than half of each clinical shift and for up to 5 consecutive shifts. Participants chose an N95 model available at their institution; models were categorized into 3 types: dome (3M 1860R, 1860S, and 8210), trifold (3M 1870+ and 9205+), and duckbill (Halyard 46727, 46767, and 46827). Participants underwent 2 rounds of testing using a different mask of the same type for each round. Main Outcomes and Measures The primary outcome was Occupational Safety and Health Administration-approved qualitative fit test failure. Trained coordinators conducted fit tests after clinical shifts and recorded pass or fail based on participants tasting a bitter solution. Results A total of 412 HCWs and 824 N95s were fit tested at baseline; 21 N95s (2.5%) were withdrawn. Participants' median age was 34.5 years (IQR, 29.5-41.8 years); 252 (61.2%) were female, and 205 (49.8%) were physicians. The overall cumulative incidence of fit failure after 1 shift was 38.7% (95% CI, 35.4%-42.1%), which differed by N95 type: dome, 25.8% (95% CI, 21.2%-30.6%); duckbill, 28.3% (95% CI, 22.2%-34.7%); and trifold, 61.3% (95% CI, 55.3%-67.3%). The risk of fit failure was significantly higher for trifold than dome N95s (adjusted hazard ratio, 1.75; 95% CI, 1.46-2.10). Conclusions and Relevance In this cohort study of ED HCWs practicing N95 reuse, fit failure occurred in 38.7% of masks after 1 shift. Trifold N95s had higher incidence of fit failure compared with dome N95s. These results may inform pandemic preparedness, specifically policies related to N95 selection and reuse practices.
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Affiliation(s)
- Ralph C Wang
- Department of Emergency Medicine, University of California, San Francisco
| | - Nida F Degesys
- Department of Emergency Medicine, University of California, San Francisco
| | - Jahan Fahimi
- Department of Emergency Medicine, University of California, San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
| | - Chengshi Jin
- Department of Epidemiology & Biostatistics, University of California, San Francisco
| | - Efrat Rosenthal
- Department of Emergency Medicine, University of California, San Francisco
| | - Ann A Lazar
- Department of Epidemiology & Biostatistics, University of California, San Francisco
| | - Anna Q Yaffee
- Department of Emergency Medicine, Emory University, Atlanta, Georgia
| | - Susan Peterson
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Richard E Rothmann
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Courtney M C Jones
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York
| | - Vaishal Tolia
- Department of Emergency Medicine, University of California, San Diego
| | - Manish N Shah
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin, Madison
| | - Maria C Raven
- Department of Emergency Medicine, University of California, San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
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Eswaran V, Molina MF, Hwong AR, Dillon DG, Alvarez L, Allen IE, Wang RC. Racial Disparities in Emergency Department Physical Restraint Use: A Systematic Review and Meta-Analysis. JAMA Intern Med 2023; 183:1229-1237. [PMID: 37747721 PMCID: PMC10520842 DOI: 10.1001/jamainternmed.2023.4832] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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: 12/07/2022] [Accepted: 07/28/2023] [Indexed: 09/26/2023]
Abstract
Importance Recent studies have demonstrated that people of color are more likely to be restrained in emergency department (ED) settings compared with other patients, but many of these studies are based at a single site or health care system, limiting their generalizability. Objective To synthesize existing literature on risk of physical restraint use in adult EDs, specifically in reference to patients of different racial and ethnic backgrounds. Data Sources A systematic search of PubMed, Embase, Web of Science, and CINAHL was performed from database inception to February 8, 2022. Study Selection Included peer-reviewed studies met 3 criteria: (1) published in English, (2) original human participants research performed in an adult ED, and (3) reported an outcome of physical restraint use by patient race or ethnicity. Studies were excluded if they were conducted outside of the US, or if full text was unavailable. Data Extraction and Synthesis Four independent reviewers (V.E., M.M., D.D., and A.H.) abstracted data from selected articles following Meta-Analysis of Observational Studies in Epidemiology guidelines. A modified Newcastle-Ottawa scale was used to assess quality. A meta-analysis of restraint outcomes among minoritized racial and ethnic groups was performed using a random-effects model in 2022. Main Outcome(s) and Measure(s) Risk of physical restraint use in adult ED patients by racial and ethnic background. Results The search yielded 1597 articles, of which 10 met inclusion criteria (0.63%). These studies represented 2 557 983 patient encounters and 24 030 events of physical restraint (0.94%). In the meta-analysis, Black patients were more likely to be restrained compared with White patients (RR, 1.31; 95% CI, 1.19-1.43) and to all non-Black patients (RR, 1.27; 95% CI, 1.23-1.31). With respect to ethnicity, Hispanic patients were less likely to be restrained compared with non-Hispanic patients (RR, 0.85; 95% CI, 0.81-0.89). Conclusions and Relevance Physical restraint was uncommon, occurring in less than 1% of encounters, but adult Black patients experienced a significantly higher risk of physical restraint in ED settings compared with other racial groups. Hispanic patients were less likely to be restrained compared with non-Hispanic patients, though this observation may have occurred if Black patients, with a higher risk of restraint, were included in the non-Hispanic group. Further work, including qualitative studies, to explore and address mechanisms of racism at the interpersonal, institutional, and structural levels are needed.
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Affiliation(s)
- Vidya Eswaran
- Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas
- Section of Health Services Research, Department of Medicine, Center for Innovations in Quality, Effectiveness and Safety, DeBakey VA Medical Center; Houston, Texas
- Department of Emergency Medicine, University of California, San Francisco
| | - Melanie F. Molina
- Department of Emergency Medicine, University of California, San Francisco
- National Clinician Scholars Program, Philip R Lee Institute of Health Policy Studies, University of California, San Francisco
- Philip R Lee Institute of Health Policy Studies, University of California, San Francisco
| | - Alison R. Hwong
- National Clinician Scholars Program, Philip R Lee Institute of Health Policy Studies, University of California, San Francisco
- Department of Psychiatry and Behavioral Sciences, University of California; San Francisco
- San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - David G. Dillon
- Department of Emergency Medicine, University of California, Davis, Sacramento
| | - Lizbeth Alvarez
- School of Medicine, University of California, Davis, Sacramento
| | - Isabel E. Allen
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Ralph C. Wang
- Department of Emergency Medicine, University of California, San Francisco
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Dillon DG, Wang RC, Shetty P, Douchee J, Rodriguez RM, Montoy JCC. Efficacy of emergency department calcium administration in cardiac arrest: A 9-year retrospective evaluation. Resuscitation 2023; 191:109933. [PMID: 37562663 PMCID: PMC10529187 DOI: 10.1016/j.resuscitation.2023.109933] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 06/07/2023] [Revised: 07/15/2023] [Accepted: 08/03/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND The efficacy of empiric calcium for patients with undifferentiated cardiac arrest has come under increased scrutiny, including a randomized controlled trial that was stopped early due to a trend towards harm with calcium administration. However, small sample sizes and non-significant findings have hindered precise effect estimates. In this analysis we evaluate the association of calcium administration with survival in a large retrospective cohort of patients with cardiac arrest treated in the emergency department (ED). METHODS We conducted a retrospective review of medical records from two academic hospitals (one quaternary care center, one county trauma center) in San Francisco between 2011 and 2019. Inclusion criteria were patients aged greater than or equal to 18 years old who received treatment for cardiac arrest during their ED course. Our primary exposure was the administration of calcium while in the ED and the main outcome was survival to hospital admission. The association between calcium and survival to admission was estimated using a multivariable log-binomial regression, and also with two propensity score models. RESULTS We examined 781 patients with cardiac arrest treated in San Francisco EDs between 2011 and 2019 and found that calcium administration was associated with decreased survival to hospital admission (RR 0.74; 95% CI 0.66-0.82). These findings remained significant after adjustment for patient age, sex, whether the cardiac arrest was witnessed, and including an interaction term for shockable cardiac rhythms (RR 0.60; 95% CI 0.50-0.72) and non-shockable cardiac rhythms (RR 0.87; 95% CI 0.76-0.99). Risk ratios for the association between calcium and survival to hospital admission were also similar between two propensity score-based models: nearest neighbor propensity matching model (RR 0.79; 95% CI 0.68-0.89) and inverse propensity weighted regression adjustment model (RR 0.75; 95% CI 0.67-0.84). CONCLUSIONS Calcium administration as part of ED-directed treatment for cardiac arrest was associated with lower survival to hospital admission. Given the lack of statistically significant outcomes from smaller, more methodologically robust evaluations on this topic, we believe these findings have an important role to serve in confirming previous results and allowing for more precise effect estimates. Our data adds to the growing body evidence against the empiric use of calcium in cardiac arrest.
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Affiliation(s)
- David G Dillon
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento, CA, USA.
| | - Ralph C Wang
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Pranav Shetty
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento, CA, USA
| | - Jeremiah Douchee
- Columbia University Vagelos College of Physicians and Surgeons, New York-Presbyterian Columbia University Medical Center, New York, NY, USA
| | - Robert M Rodriguez
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Juan Carlos C Montoy
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, CA, USA
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8
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Montoy JCC, Ford J, Yu H, Gottlieb M, Morse D, Santangelo M, O’Laughlin KN, Schaeffer K, Logan P, Rising K, Hill MJ, Wisk LE, Salah W, Idris AH, Huebinger RM, Spatz ES, Rodriguez RM, Klabbers RE, Gatling K, Wang RC, Elmore JG, McDonald SA, Stephens KA, Weinstein RA, Venkatesh AK, Saydah S. Prevalence of Symptoms ≤12 Months After Acute Illness, by COVID-19 Testing Status Among Adults - United States, December 2020-March 2023. MMWR Morb Mortal Wkly Rep 2023; 72:859-865. [PMID: 37561663 PMCID: PMC10415002 DOI: 10.15585/mmwr.mm7232a2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
To further the understanding of post-COVID conditions, and provide a more nuanced description of symptom progression, resolution, emergence, and reemergence after SARS-CoV-2 infection or COVID-like illness, analysts examined data from the Innovative Support for Patients with SARS-CoV-2 Infections Registry (INSPIRE), a prospective multicenter cohort study. This report includes analysis of data on self-reported symptoms collected from 1,296 adults with COVID-like illness who were tested for SARS-CoV-2 using a Food and Drug Administration-approved polymerase chain reaction or antigen test at the time of enrollment and reported symptoms at 3-month intervals for 12 months. Prevalence of any symptom decreased substantially between baseline and the 3-month follow-up, from 98.4% to 48.2% for persons who received a positive SARS-CoV-2 test results (COVID test-positive participants) and from 88.2% to 36.6% for persons who received negative SARS-CoV-2 test results (COVID test-negative participants). Persistent symptoms decreased through 12 months; no difference between the groups was observed at 12 months (prevalence among COVID test-positive and COVID test-negative participants = 18.3% and 16.1%, respectively; p>0.05). Both groups reported symptoms that emerged or reemerged at 6, 9, and 12 months. Thus, these symptoms are not unique to COVID-19 or to post-COVID conditions. Awareness that symptoms might persist for up to 12 months, and that many symptoms might emerge or reemerge in the year after COVID-like illness, can assist health care providers in understanding the clinical signs and symptoms associated with post-COVID-like conditions.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Innovative Support for Patients with SARS-CoV-2 Infections Registry (INSPIRE) Group
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California; Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, New Haven, Connecticut; Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut; Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois; Department of Emergency Medicine, University of Washington, Seattle, Washington; Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois; Department of Emergency Medicine, University of Washington, Seattle, Washington; Department of Global Health, University of Washington, Seattle, Washington; Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania; National Center for Immunizations and Respiratory Diseases, CDC; Center for Connected Care, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania; Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania; UTHealth Houston, Houston, Texas; University of California, Los Angeles, Los Angeles, California; Department of Emergency Medicine, Yale University, New Haven, Connecticut; University of Texas Southwestern Medical Center, Dallas, Texas; Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California; Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California; Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Clinical Informatics Center, University of Texas Southwestern Medical Center, Dallas, Texas; Department of Family Medicine, University of Washington, Seattle, Washington; Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, Washington; Department of Medicine, Division of Infectious Diseases, Rush University Medical Center, Chicago, Illinois; Department of Medicine, Division of Infectious Diseases, Cook County Hospital, Chicago, Illinois; Department of Internal Medicine, Yale University, New Haven, Connecticut
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9
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Gottlieb M, Spatz ES, Yu H, Wisk LE, Elmore JG, Gentile NL, Hill M, Huebinger RM, Idris AH, Kean ER, Koo K, Li SX, McDonald S, Montoy JCC, Nichol G, O’Laughlin KN, Plumb ID, Rising KL, Santangelo M, Saydah S, Wang RC, Venkatesh A, Stephens KA, Weinstein RA. Long COVID Clinical Phenotypes up to 6 Months After Infection Identified by Latent Class Analysis of Self-Reported Symptoms. Open Forum Infect Dis 2023; 10:ofad277. [PMID: 37426952 PMCID: PMC10327879 DOI: 10.1093/ofid/ofad277] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 05/15/2023] [Indexed: 07/11/2023] Open
Abstract
Background The prevalence, incidence, and interrelationships of persistent symptoms after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection vary. There are limited data on specific phenotypes of persistent symptoms. Using latent class analysis (LCA) modeling, we sought to identify whether specific phenotypes of COVID-19 were present 3 months and 6 months post-infection. Methods This was a multicenter study of symptomatic adults tested for SARS-CoV-2 with prospectively collected data on general symptoms and fatigue-related symptoms up to 6 months postdiagnosis. Using LCA, we identified symptomatically homogenous groups among COVID-positive and COVID-negative participants at each time period for both general and fatigue-related symptoms. Results Among 5963 baseline participants (4504 COVID-positive and 1459 COVID-negative), 4056 had 3-month and 2856 had 6-month data at the time of analysis. We identified 4 distinct phenotypes of post-COVID conditions (PCCs) at 3 and 6 months for both general and fatigue-related symptoms; minimal-symptom groups represented 70% of participants at 3 and 6 months. When compared with the COVID-negative cohort, COVID-positive participants had higher occurrence of loss of taste/smell and cognition problems. There was substantial class-switching over time; those in 1 symptom class at 3 months were equally likely to remain or enter a new phenotype at 6 months. Conclusions We identified distinct classes of PCC phenotypes for general and fatigue-related symptoms. Most participants had minimal or no symptoms at 3 and 6 months of follow-up. Significant proportions of participants changed symptom groups over time, suggesting that symptoms present during the acute illness may differ from prolonged symptoms and that PCCs may have a more dynamic nature than previously recognized. Clinical Trials Registration. NCT04610515.
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Affiliation(s)
- Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Erica S Spatz
- Section of Cardiovascular Medicine, Yale School of Medicine,New Haven, Connecticut, USA
- Department of Epidemiology, Yale School of Public Health,New Haven, Connecticut, USA
- Yale Center for Outcomes Research and Evaluation, Yale School of Medicine,New Haven, Connecticut, USA
| | - Huihui Yu
- Section of Cardiovascular Medicine, Yale School of Medicine,New Haven, Connecticut, USA
- Yale Center for Outcomes Research and Evaluation, Yale School of Medicine,New Haven, Connecticut, USA
| | - Lauren E Wisk
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Joann G Elmore
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Nicole L Gentile
- Post-COVID Rehabilitation and Recovery Clinic, Department of Family Medicine, Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Mandy Hill
- Department of Emergency Medicine, UTHealth, Houston, Texas, USA
| | | | - Ahamed H Idris
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Efrat R Kean
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Katherine Koo
- Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Shu-Xia Li
- Yale Center for Outcomes Research and Evaluation, Yale School of Medicine,New Haven, Connecticut, USA
| | - Samuel McDonald
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Clinical Informatics Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Juan Carlos C Montoy
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Graham Nichol
- Departments of Medicine and Emergency Medicine, University of Washington, Seattle, Washington, USA
| | - Kelli N O’Laughlin
- Departments of Emergency Medicine and Global Health, University of Washington, Seattle, Washington, USA
| | - Ian D Plumb
- National Center for Immunizations and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Kristin L Rising
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
- Center for Connected Care, Sidney Kimmel Medical School, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Michelle Santangelo
- Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Sharon Saydah
- National Center for Immunizations and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Ralph C Wang
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Arjun Venkatesh
- Yale Center for Outcomes Research and Evaluation, Yale School of Medicine,New Haven, Connecticut, USA
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Kari A Stephens
- Departments of Family Medicine, Biomedical Informatics and Medical Education, University of Washington, Seattle, Washington, USA
| | - Robert A Weinstein
- Division of Infectious Diseases, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
- Department of Internal Medicine, Cook County Hospital, Chicago, Illinois, USA
- The CORE Center, Chicago, Illinois, USA
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10
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Wang RC, Gottlieb M, Montoy JCC, Rodriguez RM, Yu H, Spatz ES, Chandler CW, Elmore JG, Hannikainen PA, Chang AM, Hill M, Huebinger RM, Idris AH, Koo K, Li SX, McDonald S, Nichol G, O’Laughlin KN, Plumb ID, Santangelo M, Saydah S, Stephens KA, Venkatesh AK, Weinstein RA. Association Between SARS-CoV-2 Variants and Frequency of Acute Symptoms: Analysis of a Multi-institutional Prospective Cohort Study-December 20, 2020-June 20, 2022. Open Forum Infect Dis 2023; 10:ofad275. [PMID: 37426947 PMCID: PMC10327880 DOI: 10.1093/ofid/ofad275] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 05/22/2023] [Indexed: 07/11/2023] Open
Abstract
Background While prior work examining severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants of concern focused on hospitalization and death, less is known about differences in clinical presentation. We compared the prevalence of acute symptoms across pre-Delta, Delta, and Omicron. Methods We conducted an analysis of the Innovative Support for Patients with SARS-CoV-2 Infections Registry (INSPIRE), a cohort study enrolling symptomatic SARS-CoV-2-positive participants. We determined the association between the pre-Delta, Delta, and Omicron time periods and the prevalence of 21 coronavirus disease 2019 (COVID-19) acute symptoms. Results We enrolled 4113 participants from December 2020 to June 2022. Pre-Delta vs Delta vs Omicron participants had increasing sore throat (40.9%, 54.6%, 70.6%; P < .001), cough (50.9%, 63.3%, 66.7%; P < .001), and runny noses (48.9%, 71.3%, 72.9%; P < .001). We observed reductions during Omicron in chest pain (31.1%, 24.2%, 20.9%; P < .001), shortness of breath (42.7%, 29.5%, 27.5%; P < .001), loss of taste (47.1%, 61.8%, 19.2%; P < .001), and loss of smell (47.5%, 55.6%, 20.0%; P < .001). After adjustment, those infected during Omicron had significantly higher odds of sore throat vs pre-Delta (odds ratio [OR], 2.76; 95% CI, 2.26-3.35) and Delta (OR, 1.96; 95% CI, 1.69-2.28). Conclusions Participants infected during Omicron were more likely to report symptoms of common respiratory viruses, such as sore throat, and less likely to report loss of smell and taste. Trial registration NCT04610515.
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Affiliation(s)
- Ralph C Wang
- Department of Emergency Medicine, University of California San Francisco, San Francisco, California, USA
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Juan Carlos C Montoy
- Department of Emergency Medicine, University of California San Francisco, San Francisco, California, USA
| | - Robert M Rodriguez
- Department of Emergency Medicine, University of California San Francisco, San Francisco, California, USA
| | - Huihui Yu
- Center for Outcomes Research and Evaluation, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Erica S Spatz
- Center for Outcomes Research and Evaluation, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Christopher W Chandler
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Joann G Elmore
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
- Department of Health Policy and Management, Fielding School of Public Health, University of California Los Angeles, Los Angeles, California, USA
| | - Paavali A Hannikainen
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Anna Marie Chang
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Mandy Hill
- Department of Emergency Medicine, UTHealth Houston, Houston, Texas, USA
| | - Ryan M Huebinger
- Department of Emergency Medicine, UTHealth Houston, Houston, Texas, USA
| | - Ahamed H Idris
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Katherine Koo
- Department of Medicine, Division of Infectious Diseases, Rush University Medical Center, Chicago, Illinois, USA
| | - Shu-Xia Li
- Center for Outcomes Research and Evaluation, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Samuel McDonald
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Graham Nichol
- Departments of Medicine and Emergency Medicine, University of Washington, Seattle, Washington, USA
| | - Kelli N O’Laughlin
- Departments of Emergency Medicine and Global Health, University of Washington, Seattle, Washington, USA
| | - Ian D Plumb
- Centers for Disease Control and Prevention, National Center for Immunizations and Respiratory Diseases, Atlanta, Georgia, USA
| | - Michelle Santangelo
- Division of Infectious Diseases, Department of Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Sharon Saydah
- Centers for Disease Control and Prevention, National Center for Immunizations and Respiratory Diseases, Atlanta, Georgia, USA
| | - Kari A Stephens
- Departments of Family Medicine and Biomedical Informatics & Medical Education, University of Washington, Seattle, Washington, USA
| | - Arjun K Venkatesh
- Center for Outcomes Research and Evaluation, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Robert A Weinstein
- Department of Medicine, Division of Infectious Diseases, Rush University Medical Center, Chicago, Illinois, USA
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11
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Gottlieb M, Wang RC, Yu H, Spatz ES, Montoy JCC, Rodriguez RM, Chang AM, Elmore JG, Hannikainen PA, Hill M, Huebinger RM, Idris AH, Lin Z, Koo K, McDonald S, O’Laughlin KN, Plumb ID, Santangelo M, Saydah S, Willis M, Wisk LE, Venkatesh A, Stephens KA, Weinstein RA. Severe Fatigue and Persistent Symptoms at 3 Months Following Severe Acute Respiratory Syndrome Coronavirus 2 Infections During the Pre-Delta, Delta, and Omicron Time Periods: A Multicenter Prospective Cohort Study. Clin Infect Dis 2023; 76:1930-1941. [PMID: 36705268 PMCID: PMC10249989 DOI: 10.1093/cid/ciad045] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [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: 11/11/2022] [Revised: 01/12/2023] [Accepted: 01/25/2023] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Most research on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants focuses on initial symptomatology with limited longer-term data. We characterized prevalences of prolonged symptoms 3 months post-SARS-CoV-2 infection across 3 variant time-periods (pre-Delta, Delta, and Omicron). METHODS This multicenter prospective cohort study of adults with acute illness tested for SARS-CoV-2 compared fatigue severity, fatigue symptoms, organ system-based symptoms, and ≥3 symptoms across variants among participants with a positive ("COVID-positive") or negative SARS-CoV-2 test ("COVID-negative") at 3 months after SARS-CoV-2 testing. Variant periods were defined by dates with ≥50% dominant strain. We performed multivariable logistic regression modeling to estimate independent effects of variants adjusting for sociodemographics, baseline health, and vaccine status. RESULTS The study included 2402 COVID-positive and 821 COVID-negative participants. Among COVID-positives, 463 (19.3%) were pre-Delta, 1198 (49.9%) Delta, and 741 (30.8%) Omicron. The pre-Delta COVID-positive cohort exhibited more prolonged severe fatigue (16.7% vs 11.5% vs 12.3%; P = .017) and presence of ≥3 prolonged symptoms (28.4% vs 21.7% vs 16.0%; P < .001) compared with the Delta and Omicron cohorts. No differences were seen in the COVID-negatives across time-periods. In multivariable models adjusted for vaccination, severe fatigue and odds of having ≥3 symptoms were no longer significant across variants. CONCLUSIONS Prolonged symptoms following SARS-CoV-2 infection were more common among participants infected during pre-Delta than with Delta and Omicron; however, these differences were no longer significant after adjusting for vaccination status, suggesting a beneficial effect of vaccination on risk of long-term symptoms. Clinical Trials Registration. NCT04610515.
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Affiliation(s)
- Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Ralph C Wang
- Department of Emergency Medicine, University of California, San Francisco, California, USA
| | - Huihui Yu
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, Connecticut, USA
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Erica S Spatz
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Epidemiology, Yale School of Public Health, New Haven, Connecticut, USA
| | - Juan Carlos C Montoy
- Department of Emergency Medicine, University of California, San Francisco, California, USA
| | - Robert M Rodriguez
- Department of Emergency Medicine, University of California – San Francisco School of Medicine, San Francisco, California, USA
| | - Anna Marie Chang
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Joann G Elmore
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California – Los Angeles, Los Angeles, California, USA
| | - Paavali A Hannikainen
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Mandy Hill
- Department of Emergency Medicine, UTHealth Houston, Houston, Texas, USA
| | - Ryan M Huebinger
- Department of Emergency Medicine, UTHealth Houston, Houston, Texas, USA
| | - Ahamed H Idris
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Zhenqiu Lin
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, Connecticut, USA
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Katherine Koo
- Department of Medicine, Division of Infectious Diseases, Rush University Medical Center, Chicago, Illinois, USA
| | - Samuel McDonald
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Clinical Informatics Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Kelli N O’Laughlin
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Ian D Plumb
- National Center for Immunizations and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Michelle Santangelo
- Department of Medicine, Division of Infectious Diseases, Rush University Medical Center, Chicago, Illinois, USA
| | - Sharon Saydah
- National Center for Immunizations and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Michael Willis
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Lauren E Wisk
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California – Los Angeles, Los Angeles, California, USA
| | - Arjun Venkatesh
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Kari A Stephens
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, Washington, USA
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - Robert A Weinstein
- Department of Medicine, Division of Infectious Diseases, Rush University Medical Center, Chicago, Illinois, USA
- Department of Medicine, Division of Infectious Diseases, Cook County Hospital, Chicago, Illinois, USA
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12
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Murphy CE, Coralic Z, Wang RC, Montoy JCC, Ramirez B, Raven MC. Extended-Release Naltrexone and Case Management for Treatment of Alcohol Use Disorder in the Emergency Department. Ann Emerg Med 2023; 81:440-449. [PMID: 36328851 DOI: 10.1016/j.annemergmed.2022.08.453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 08/01/2022] [Accepted: 08/25/2022] [Indexed: 11/15/2022]
Abstract
STUDY OBJECTIVE To assess the feasibility of initiating treatment for alcohol use disorder with extended-release naltrexone and case management services in the emergency department (ED) and measure the intervention's impact on daily alcohol consumption and quality of life. METHODS This is a 12-week prospective open-label single-arm study of a multimodal treatment for alcohol use disorder consisting of monthly extended-release naltrexone injections and case management services initiated at an urban academic ED. Participants were actively drinking adult patients in ED with known or suspected alcohol use disorder and an AUDIT-C score more than 4. The main feasibility outcomes included the rates of participant enrollment, retention in the study, and continuing treatment after study completion. Efficacy outcomes were the change in daily alcohol consumption (drinks per day; 14 g ethanol per drink), measured by a 14-day timeline followback, and the change in quality of life measured with a single-item Kemp quality of life scale. RESULTS One hundred seventy-nine patients were approached, and 32 were enrolled (18%). Of the 32 enrolled patients, 25 (78%) completed all visits, and 22 (69%) continued naltrexone after the trial. The mean baseline daily alcohol consumption was 7.6 drinks per day (interquartile range, 4.5, 13.4), and the mean quality of life was 3.6 (SD 1.7) on a 7-point scale. The median daily alcohol consumption change was -7.5 drinks per day (Hodges-Lehmann 95% confidence interval -8.6, -5.9). The mean quality of life change was 1.2 points (95% confidence interval 0.5, 1.9; P<.01). CONCLUSION We found that initiation of treatment of alcohol use disorder with extended-release naltrexone and case management is feasible in an ED setting and observed significant reductions in drinking with improved quality of life in the short term. Multicenter randomized controlled trials are needed to further validate these findings.
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Affiliation(s)
- Charles E Murphy
- Department of Emergency Medicine, University of California, San Francisco, CA.
| | - Zlatan Coralic
- Department of Emergency Medicine, University of California, San Francisco, CA; Department of Pharmacy, University of California, San Francisco, CA
| | - Ralph C Wang
- Department of Emergency Medicine, University of California, San Francisco, CA
| | | | - Bianca Ramirez
- Department of Emergency Medicine, University of California, San Francisco, CA
| | - Maria C Raven
- Department of Emergency Medicine, University of California, San Francisco, CA; Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA
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13
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Ravi A, Shochat G, Wang RC, Khanna R. Improvements to emergency department length of stay and user satisfaction after implementation of an integrated consult order. J Am Coll Emerg Physicians Open 2023; 4:e12922. [PMID: 36960353 PMCID: PMC10028414 DOI: 10.1002/emp2.12922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 01/23/2023] [Accepted: 02/17/2023] [Indexed: 03/24/2023] Open
Abstract
Objective Subspecialty consultation in the emergency department (ED) is a vital, albeit time consuming, part of modern medicine. Traditional consultation requires manual paging to initiate communication. Although consult orders through the electronic health record (EHR) may help, they do not facilitate 2‐way communication. However, the impact of combining these systems within the EHR is unknown. We estimated the effect of implementing an integrated paging system on ED workflow efficiency and user attitudes. Methods We integrated a messaging system into order entry at our tertiary care academic ED, such that placing a consult order simultaneously paged the consultant. We measured ED workflow efficiency metrics (length of stay [LOS], consult initiation time) and MD/nurse practitioner (NP)/physician assistant (PA) attitudes (perceived mis‐pages, efficiency, and workflow preference) 3 months before and 6 months after the implementation. Results Six months after implementation, there was 25% use of the new workflow. During the pre‐implementation phase, the median time to consult initiation and ED LOS were 150 and 621 minutes, respectively. Implementation of the order was associated with a 15‐minute reduction in median time to consult initiation (P < 0.001), and a 52‐minute reduction in median ED LOS (P < 0.001). ED MDs/NPs/PAs perceived a reduction in the rate of mis‐pages, improved efficiency, and overall preferred the new workflow. Conclusions We consolidated steps in the ED consult workflow using an integrated consult order, which improved user satisfaction, and reduced consult initiation time and ED LOS for patients requiring a consult at an urban tertiary care ED.
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Affiliation(s)
- Akshay Ravi
- Department of MedicineUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Guy Shochat
- Department of Emergency MedicineUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Ralph C. Wang
- Department of Emergency MedicineUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Raman Khanna
- Department of MedicineUniversity of CaliforniaSan FranciscoCaliforniaUSA
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14
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Asiaban JN, Patel S, Ormseth CH, Donohue KC, Wallin D, Wang RC, Raven MC. Advance Care Planning Among Patients With Advanced Illness Presenting to the Emergency Department. J Emerg Med 2023; 64:476-480. [PMID: 36990851 DOI: 10.1016/j.jemermed.2022.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 08/13/2022] [Accepted: 12/13/2022] [Indexed: 03/30/2023]
Abstract
BACKGROUND Advance care planning (ACP) benefits emergency department (ED) patients with advanced illness. Although Medicare implemented physician reimbursement for ACP discussions in 2016, early studies found limited uptake. OBJECTIVE We conducted a pilot study to assess ACP documentation and billing to inform the development of ED-based interventions to increase ACP. METHODS We conducted a retrospective chart review to quantify the proportion of ED patients with advanced illness with Physician Orders for Life-Sustaining Treatment (POLST) or coding of ACP discussion in the medical record. We surveyed a subset of patients via phone to evaluate ACP participation. RESULTS Of 186 patients included in the chart review, 68 (37%) had a POLST and none had ACP discussions billed. Of 50 patients surveyed, 18 (36%) recalled prior ACP discussions. CONCLUSIONS Given the low uptake of ACP discussions in ED patients with advanced illness, the ED may be an underused setting for interventions to increase ACP discussions and documentation.
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15
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Spatz ES, Gottlieb M, Wisk LE, Anderson J, Chang AM, Gentile NL, Hill MJ, Huebinger RM, Idris AH, Kinsman J, Koo K, Li SX, McDonald S, Plumb ID, Rodriguez R, Saydah S, Slovis B, Stephens KA, Unger ER, Wang RC, Yu H, Hota B, Elmore JG, Weinstein RA, Venkatesh A. Three-month symptom profiles among symptomatic adults with positive and negative SARS-CoV-2 tests: a prospective cohort study from the INSPIRE group. Clin Infect Dis 2022; 76:1559-1566. [PMID: 36573005 DOI: 10.1093/cid/ciac966] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [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: 08/10/2022] [Revised: 11/22/2022] [Accepted: 12/19/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Long-term symptoms following SARS-CoV-2 infection are a major concern, yet their prevalence is poorly understood. METHODS We conducted a prospective cohort study comparing adults with SARS-CoV-2 infection (COVID+) with adults who tested negative (COVID-), enrolled within 28 days of an FDA-approved SARS-CoV2 test result for active symptoms. Sociodemographic characteristics, symptoms of SARS-CoV-2 infection (assessed with the CDC Person Under Investigation Symptom List), and symptoms of post-infectious syndromes (i.e., fatigue, sleep quality, muscle/joint pains, unrefreshing sleep, and dizziness/fainting, assessed with CDC Short Symptom Screener for myalgic encephalomyelitis/chronic fatigue syndrome) were assessed at baseline and 3 months via electronic surveys sent via text or email. RESULTS Among the first 1,000 participants, 722 were COVID + and 278 were COVID-. Mean age was 41.5 (SD 15.2); 66.3% were female, 13.4% were Black, and 15.3% were Hispanic. At baseline, SARS-CoV-2 symptoms were more common in the COVID + group than the COVID - group. At 3-months, SARS-CoV-2 symptoms declined in both groups although were more prevalent in the COVID + group: upper respiratory symptoms/head/eyes/ears/nose/throat (HEENT; 37.3% vs 20.9%), constitutional (28.8% vs 19.4%), musculoskeletal (19.5% vs 14.7%), pulmonary (17.6% vs 12.2%), cardiovascular (10.0% vs 7.2%), and gastrointestinal (8.7% vs 8.3%); only 50.2% and 73.3% reported no symptoms at all. Symptoms of post-infectious syndromes were similarly prevalent among the COVID + and COVID - groups at 3 months. CONCLUSIONS Approximately half of COVID + participants, as compared with one-quarter of COVID - participants, had at least one SARS-CoV-2 symptom at 3 months, highlighting the need for future work to distinguish Long COVID.
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Affiliation(s)
- Erica S Spatz
- Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine; Department of Epidemiology, Yale School of Public Health, New Haven, CT, USA
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Lauren E Wisk
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at the University of California, Los Angeles (UCLA), Los Angeles, CA; Department of Health Policy and Management, Fielding School of Public Health at UCLA, Los Angeles, CA, USA
| | - Jill Anderson
- Harborview Center for Prehospital Emergency Care, University of Washington, Seattle, WA, USA
| | - Anna Marie Chang
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Nicole L Gentile
- Departments of Family Medicine and Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
| | - Mandy J Hill
- Department of Emergency Medicine, UTHealth Houston, McGovern Medical School, Houston, TX, USA
| | - Ryan M Huebinger
- Department of Emergency Medicine, UTHealth Houston, McGovern Medical School, Houston, TX, USA
| | - Ahamed H Idris
- Dept. of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jeremiah Kinsman
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Katherine Koo
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Shu-Xia Li
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT; Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT, USA
| | - Samuel McDonald
- Department of Emergency Medicine, University of Texas Southwestern, Dallas, TX, USA
| | - Ian D Plumb
- National Center for Immunizations and Respiratory Diseases, Centers for Disease Control & Prevention, Atlanta, GA, USA
| | - Robert Rodriguez
- Department of Emergency Medicine, University of California, San Francisco, CA, USA
| | - Sharon Saydah
- National Center for Immunizations and Respiratory Diseases, Centers for Disease Control & Prevention, Atlanta, GA, USA
| | - Benjamin Slovis
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Kari A Stephens
- Departments of Family Medicine, Harborview Center for Prehospital Emergency Care, University of Washington, Seattle, WA, USA
| | - Elizabeth R Unger
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control & Prevention, Atlanta, GA, USA
| | - Ralph C Wang
- Department of Emergency Medicine, University of California, San Francisco, CA, USA
| | - Huihui Yu
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT; Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT, USA
| | - Bala Hota
- Chief Informatics Officer, Tendo Systems, Inc., San Francisco, CA, USA
| | - Joann G Elmore
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at the University of California, Los Angeles (UCLA), Los Angeles, CA; Department of Health Policy and Management, Fielding School of Public Health at UCLA, Los Angeles, CA, USA
| | - Robert A Weinstein
- Division of Infectious Diseases, Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Arjun Venkatesh
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT, USA
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Smith-Bindman R, Nielsen ME, Wang RC. Unchanged Diagnostic Imaging for Urinary Stone Disease-Where Do We Go From Here? JAMA Intern Med 2022; 182:1246-1247. [PMID: 36315160 DOI: 10.1001/jamainternmed.2022.4917] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Rebecca Smith-Bindman
- Department of Epidemiology and Biostatistics, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco.,Departments of Urology, Epidemiology, and Health Policy & Management, University of North Carolina, Chapel Hill
| | - Matthew E Nielsen
- Department of Emergency Medicine, University of California, San Francisco
| | - Ralph C Wang
- Department of Emergency Medicine, University of California, San Francisco
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17
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Wisk LE, Gottlieb MA, Spatz ES, Yu H, Wang RC, Slovis BH, Saydah S, Plumb ID, O’Laughlin KN, Montoy JCC, McDonald SA, Lin Z, Lin JMS, Koo K, Idris AH, Huebinger RM, Hill MJ, Gentile NL, Chang AM, Anderson J, Hota B, Venkatesh AK, Weinstein RA, Elmore JG, Nichol G. Association of Initial SARS-CoV-2 Test Positivity With Patient-Reported Well-being 3 Months After a Symptomatic Illness. JAMA Netw Open 2022; 5:e2244486. [PMID: 36454572 PMCID: PMC9716377 DOI: 10.1001/jamanetworkopen.2022.44486] [Citation(s) in RCA: 22] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
IMPORTANCE Long-term sequelae after symptomatic SARS-CoV-2 infection may impact well-being, yet existing data primarily focus on discrete symptoms and/or health care use. OBJECTIVE To compare patient-reported outcomes of physical, mental, and social well-being among adults with symptomatic illness who received a positive vs negative test result for SARS-CoV-2 infection. DESIGN, SETTING, AND PARTICIPANTS This cohort study was a planned interim analysis of an ongoing multicenter prospective longitudinal registry study (the Innovative Support for Patients With SARS-CoV-2 Infections Registry [INSPIRE]). Participants were enrolled from December 11, 2020, to September 10, 2021, and comprised adults (aged ≥18 years) with acute symptoms suggestive of SARS-CoV-2 infection at the time of receipt of a SARS-CoV-2 test approved by the US Food and Drug Administration. The analysis included the first 1000 participants who completed baseline and 3-month follow-up surveys consisting of questions from the 29-item Patient-Reported Outcomes Measurement Information System (PROMIS-29; 7 subscales, including physical function, anxiety, depression, fatigue, social participation, sleep disturbance, and pain interference) and the PROMIS Short Form-Cognitive Function 8a scale, for which population-normed T scores were reported. EXPOSURES SARS-CoV-2 status (positive or negative test result) at enrollment. MAIN OUTCOMES AND MEASURES Mean PROMIS scores for participants with positive COVID-19 tests vs negative COVID-19 tests were compared descriptively and using multivariable regression analysis. RESULTS Among 1000 participants, 722 (72.2%) received a positive COVID-19 result and 278 (27.8%) received a negative result; 406 of 998 participants (40.7%) were aged 18 to 34 years, 644 of 972 (66.3%) were female, 833 of 984 (84.7%) were non-Hispanic, and 685 of 974 (70.3%) were White. A total of 282 of 712 participants (39.6%) in the COVID-19-positive group and 147 of 275 participants (53.5%) in the COVID-19-negative group reported persistently poor physical, mental, or social well-being at 3-month follow-up. After adjustment, improvements in well-being were statistically and clinically greater for participants in the COVID-19-positive group vs the COVID-19-negative group only for social participation (β = 3.32; 95% CI, 1.84-4.80; P < .001); changes in other well-being domains were not clinically different between groups. Improvements in well-being in the COVID-19-positive group were concentrated among participants aged 18 to 34 years (eg, social participation: β = 3.90; 95% CI, 1.75-6.05; P < .001) and those who presented for COVID-19 testing in an ambulatory setting (eg, social participation: β = 4.16; 95% CI, 2.12-6.20; P < .001). CONCLUSIONS AND RELEVANCE In this study, participants in both the COVID-19-positive and COVID-19-negative groups reported persistently poor physical, mental, or social well-being at 3-month follow-up. Although some individuals had clinically meaningful improvements over time, many reported moderate to severe impairments in well-being 3 months later. These results highlight the importance of including a control group of participants with negative COVID-19 results for comparison when examining the sequelae of COVID-19.
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Affiliation(s)
- Lauren E. Wisk
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles
- Department of Health Policy and Management, Fielding School of Public Health at the University of California, Los Angeles, Los Angeles
| | - Michael A. Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois
| | - Erica S. Spatz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
| | - Huihui Yu
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
| | - Ralph C. Wang
- Department of Emergency Medicine, University of California, San Francisco, San Francisco
| | - Benjamin H. Slovis
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Sharon Saydah
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ian D. Plumb
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kelli N. O’Laughlin
- Department of Emergency Medicine, University of Washington, Seattle
- Department of Global Health, University of Washington, Seattle
| | - Juan Carlos C. Montoy
- Department of Emergency Medicine, University of California, San Francisco, San Francisco
| | - Samuel A. McDonald
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas
- Clinical Informatics Center, University of Texas Southwestern Medical Center, Dallas
| | - Zhenqiu Lin
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
| | - Jin-Mann S. Lin
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Katherine Koo
- Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Ahamed H. Idris
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Ryan M. Huebinger
- Department of Emergency Medicine, McGovern Medical School, UTHealth Houston, Houston, Texas
| | - Mandy J. Hill
- Department of Emergency Medicine, McGovern Medical School, UTHealth Houston, Houston, Texas
| | - Nicole L. Gentile
- Department of Family Medicine, University of Washington, Seattle
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle
| | - Anna Marie Chang
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jill Anderson
- Department of Medicine, Harborview Center for Prehospital Emergency Care, University of Washington, Seattle
| | | | - Arjun K. Venkatesh
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Robert A. Weinstein
- Department of Medicine, Rush University Medical Center, Chicago, Illinois
- Division of Infectious Diseases, Cook County Health, Chicago, Illinois
| | - Joann G. Elmore
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles
- Department of Health Policy and Management, Fielding School of Public Health at the University of California, Los Angeles, Los Angeles
| | - Graham Nichol
- Department of Emergency Medicine, University of Washington, Seattle
- Department of Medicine, Harborview Center for Prehospital Emergency Care, University of Washington, Seattle
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18
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Wang RC, Fahimi J, Dillon D, Shyy W, Mongan J, McCulloch C, Smith-Bindman R. Effect of an ultrasound-first clinical decision tool in emergency department patients with suspected nephrolithiasis: A randomized trial. Am J Emerg Med 2022; 60:164-170. [PMID: 35986979 DOI: 10.1016/j.ajem.2022.08.015] [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: 01/12/2022] [Revised: 08/04/2022] [Accepted: 08/05/2022] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Previously, we found that the use of ultrasonography for patients with suspected nephrolithiasis resulted in similar outcomes and less radiation exposure vs. CT scan. In this study, we evaluated the implementation of an ultrasound-first clinical decision support (CDS) tool in patients with suspected nephrolithiasis. METHODS This randomized trial was conducted at an academic emergency department (ED). We implemented the ultrasound-first CDS tool, deployed when an ED provider placed a CT order for suspected nephrolithiasis. Providers were randomized to receiving the CDS tool vs. usual care. The primary outcome was receipt of CT during the index ED visit. Secondary outcomes included radiation dose and ED revisit. RESULTS 64 ED Providers and 254 patients with suspected nephrolithiasis were enrolled from January 2019 through Dec 2020. The US-First CDS tool was deployed for 128 patients and was not deployed for 126 patients. 86.7% of patients in the CDS arm received a CT vs. 94.4% in the usual care arm, resulting in an absolute risk difference of -7.7% (-14.8 to -0.6%). Mean radiation dose in the CDS arm was 6.8 mSv (95% CI 5.7-7.9 mSv) vs. 6.1 mSv (95% CI 5.1-7.1 mSv) in the usual care arm. The CDS arm did not result in increased ED revisits, CT scans, or hospitalizations at 7 or 30 days. CONCLUSIONS AND RELEVANCE Implementation of the US-first CDS tool resulted in lower CT use for ED patients with suspected nephrolithiasis. The use of this decision support may improve the evaluation of a common problem in the ED. TRIAL REGISTRATION ClinicalTrials.gov#NCT03461536.
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Affiliation(s)
- Ralph C Wang
- Department of Emergency Medicine, University of California, San Francisco, United States of America.
| | - Jahan Fahimi
- Department of Emergency Medicine, University of California, San Francisco, United States of America; Philip R Lee Institute for Health Policy Studies, University of California, San Francisco
| | - David Dillon
- Department of Emergency Medicine, University of California, San Francisco, United States of America
| | - William Shyy
- Department of Emergency Medicine, University of California, San Francisco, United States of America
| | - John Mongan
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, United States of America
| | - Charles McCulloch
- Department of Epidemiology and Biostatistics, University of California, San Francisco, United States of America
| | - Rebecca Smith-Bindman
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, United States of America; Department of Epidemiology and Biostatistics, University of California, San Francisco, United States of America; Philip R Lee Institute for Health Policy Studies, University of California, San Francisco
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19
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Eswaran V, Raven MC, Wang RC, Cawley C, Izenberg JM, Kanzaria HK. Understanding the association between frequent emergency department use and jail incarceration: A cross-sectional analysis. Acad Emerg Med 2022; 29:606-614. [PMID: 35064709 DOI: 10.1111/acem.14437] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 01/06/2022] [Accepted: 01/08/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Frequent emergency department (ED) use and incarceration can be driven by underlying structural factors and social needs. If frequent ED users are at increased risk for incarceration, ED-based interventions could be developed to mitigate this risk. The objective of this study was to determine whether frequent ED use is associated with incarceration. METHODS We conducted a retrospective cross-sectional study of 46,752 individuals in San Francisco Department of Public Health's interagency, integrated Coordinated Care Management System (CCMS) during fiscal year 2018-2019. The primary exposure was frequency of ED visits, and the primary outcome was presence of any county jail incarceration during the study period. We performed descriptive and multivariable analysis to determine the association between the frequency of ED use and jail encounters. RESULTS The percentage of those with at least one episode of incarceration during the study period increased with increasing ED visit frequency. Unadjusted odds of incarceration increased with ED use frequency: odds ratio (OR) = 2.14 (95% confidence interval [CI] = 1.94-2.35) for infrequent use, OR = 4.98 (95% CI = 4.43-5.60) for those with frequent ED use, and OR = 12.33 (95% CI = 9.59-15.86) for those with super-frequent ED use. After adjustment for observable confounders, the odds of incarceration for those with super-frequent ED use remained elevated at 2.57 (95% CI = 1.94-3.41). Of those with super-frequent ED use and at least one jail encounter, 18% were seen in an ED within 30 days after release from jail and 25% were seen in an ED within 30 days prior to arrest. CONCLUSIONS Frequent ED use is independently associated with incarceration. The ED may be a site for intervention to prevent incarceration among frequent ED users by addressing unmet social needs.
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Affiliation(s)
- Vidya Eswaran
- Department of Emergency Medicine University of California, San Francisco San Francisco California USA
- National Clinician Scholars Program, Philip R. Lee Institute for Health Policy Studies University of California, San Francisco San Francisco California USA
| | - Maria C. Raven
- Department of Emergency Medicine University of California, San Francisco San Francisco California USA
- Philip R. Lee Institute for Health Policy Studies University of California, San Francisco San Francisco California USA
- Benioff Homelessness and Housing Initiative, Center for Vulnerable Populations University of California, San Francisco San Francisco California USA
| | - Ralph C. Wang
- Department of Emergency Medicine University of California, San Francisco San Francisco California USA
| | - Caroline Cawley
- Department of Emergency Medicine University of California, San Francisco San Francisco California USA
- Benioff Homelessness and Housing Initiative, Center for Vulnerable Populations University of California, San Francisco San Francisco California USA
| | - Jacob M. Izenberg
- Department of Psychiatry and Behavioral Sciences University of California, San Francisco San Francisco California USA
| | - Hemal K. Kanzaria
- Department of Emergency Medicine University of California, San Francisco San Francisco California USA
- Philip R. Lee Institute for Health Policy Studies University of California, San Francisco San Francisco California USA
- Benioff Homelessness and Housing Initiative, Center for Vulnerable Populations University of California, San Francisco San Francisco California USA
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Chen SW, Chang ST, Ho CH, Wang JS, Wang RC, Takeuchi K, Chuang SS. Merkel cell carcinoma in Taiwan: A rare tumour with a better prognosis in those harbouring Merkel cell polyomavirus. Malays J Pathol 2022; 44:61-66. [PMID: 35484887] [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] [Indexed: 06/14/2023]
Abstract
Merkel cell carcinoma (MCC) is a rare malignant cutaneous neuroendocrine tumour affecting mainly elderly patients and is more common in the West than in Asia. It is associated with Merkel cell polyomavirus (MCPyV), immunosuppression, and ultraviolet light. In this study, we retrospectively investigated the first series of MCC from Taiwan and identified 19 cases from three tertiary centres. All patients were males with a median age of 67.5. Twelve (63%) cases occurred in the extremities, with one unique case presenting initially as nodal metastasis of unknown primary. Immunohistochemically, the great majority of tumours expressed CK20 (89%), synaptophysin (89%), and INSM1 (84%), with none positive for TTF1. Eleven (58%) cases were positive for MCPyV by immunohistochemistry (clone CM2B4). All patients were treated with excision, including four with additional radiotherapy and one with radiotherapy and chemotherapy. Nodal status and treatment modalities significantly affected survival. The median survival time of MCPyV-positive cases was much longer than the negative cases (median 40 vs. 10 months). In summary, we presented the first report on the clinicopathological features of MCC in Taiwan, with 58% cases associated with MCPyV. The prognosis of patients with MCPyV-positive tumours was better than those negative for MCPyV.
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Affiliation(s)
- S W Chen
- Lioying Chi-Mei Hospital, Department of Internal Medicine, Division of Hemato-Oncology, Tainan, Taiwan
| | - S T Chang
- Lioying Chi-Mei Hospital, Department of Pathology, Tainan, Taiwan
| | - C H Ho
- Lioying Chi-Mei Hospital, Chi-Mei Medical Center, Medical Research, Tainan, Taiwan
| | - J S Wang
- Kaohsiung Veterans General Hospital, Department of Pathology and Laboratory Medicine, Kaohsiung, Taiwan
| | - R C Wang
- China Medical University Hospital, Department of Pathology, Taichung, Taiwan and HungKuang University, College of Nursing, Department of Nursing, Taichung, Taiwan
| | - K Takeuchi
- The Cancer Institute, Pathology Project for Molecular Targets and The Cancer Institute Hospital, Division of Pathology, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - S S Chuang
- Lioying Chi-Mei Hospital, Department of Pathology, Tainan, Taiwan
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Wang RC, Murphy CE, Kornblith AE, Hohenstein NA, Carter CM, Wong AHK, Kurtz T, Kohn MA. SARS COV-2 anti-nucleocapsid and anti-spike antibodies in an emergency department healthcare worker cohort: September 2020 – April 2021. Am J Emerg Med 2022; 54:81-86. [PMID: 35144108 PMCID: PMC8808429 DOI: 10.1016/j.ajem.2022.01.055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 01/19/2022] [Accepted: 01/24/2022] [Indexed: 01/06/2023] Open
Abstract
Background Emergency department (ED) workers have an increased seroprevalence of SARS-CoV-2 antibodies. However, breakthrough infections in ED workers have led to a reduced workforce within a strained healthcare system. By measuring levels of IgG antibodies to the SARS-CoV-2 nucleocapsid and spike antigens in ED workers, we determined the incidence of infection and described the course of antibody levels. We also measured the antibody response to vaccination and examined factors associated with immunogenicity. Methods We conducted a prospective cohort study of ED workers conducted at a single ED from September 2020–April 2021. IgG antibodies to the SARS-CoV-2 nucleocapsid antigen were measured at baseline, 3, and 6 months, and IgG antibodies to the SARS-CoV-2 spike antigen were measured at 6 months. Results At baseline, we found 5 out of 139 (3.6%) participants with prior infection. At 6 months, 4 of the 5 had antibody results below the test manufacturer's positivity threshold. We identified one incident case of SARS-COV-2 infection out of 130 seronegative participants (0.8%, 95% CI 0.02–4.2%). In 131 vaccinated participants (125 BNT162b2, 6 mRNA-1273), 131 tested positive for anti-spike antibodies. We identified predictors of anti-spike antibody levels: time since vaccination, prior COVID-19 infection, age, and vaccine type. Each additional week since vaccination was associated with an 11.1% decrease in anti-spike antibody levels. (95% CI 6.2–15.8%). Conclusion ED workers experienced a low incidence of SARS-CoV-2 infection and developed antibodies in response to vaccines and prior infection. Antibody levels decreased markedly with time since infection or vaccination.
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Affiliation(s)
- Ralph C Wang
- Department of Emergency Medicine, University of California, San Francisco, CA, United States of America.
| | - Charles E Murphy
- Department of Emergency Medicine, University of California, San Francisco, CA, United States of America.
| | - Aaron E Kornblith
- Department of Emergency Medicine and Department of Pediatrics, University of California, , San Francisco, CA, United States of America.
| | - Nicole A Hohenstein
- Department of Emergency Medicine, University of California, San Francisco, CA, United States of America.
| | - Cornelius M Carter
- Department of Emergency Medicine, University of California, San Francisco, CA, United States of America.
| | - Angela H K Wong
- Department of Emergency Medicine, University of California, San Francisco, CA, United States of America.
| | - Theodore Kurtz
- Department of Laboratory Medicine, University of California, , San Francisco, CA, United States of America.
| | - Michael A Kohn
- Department of Epidemiology and Biostatistics, University of California, , San Francisco, CA, United States of America.
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22
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O’Laughlin KN, Thompson M, Hota B, Gottlieb M, Plumb ID, Chang AM, Wisk LE, Hall AJ, Wang RC, Spatz ES, Stephens KA, Huebinger RM, McDonald SA, Venkatesh A, Gentile N, Slovis BH, Hill M, Saydah S, Idris AH, Rodriguez R, Krumholz HM, Elmore JG, Weinstein RA, Nichol G. Study protocol for the Innovative Support for Patients with SARS-COV-2 Infections Registry (INSPIRE): A longitudinal study of the medium and long-term sequelae of SARS-CoV-2 infection. PLoS One 2022; 17:e0264260. [PMID: 35239680 PMCID: PMC8893622 DOI: 10.1371/journal.pone.0264260] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [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: 07/30/2021] [Accepted: 02/05/2022] [Indexed: 12/26/2022] Open
Abstract
Background Reports on medium and long-term sequelae of SARS-CoV-2 infections largely lack quantification of incidence and relative risk. We describe the rationale and methods of the Innovative Support for Patients with SARS-CoV-2 Registry (INSPIRE) that combines patient-reported outcomes with data from digital health records to understand predictors and impacts of SARS-CoV-2 infection. Methods INSPIRE is a prospective, multicenter, longitudinal study of individuals with symptoms of SARS-CoV-2 infection in eight regions across the US. Adults are eligible for enrollment if they are fluent in English or Spanish, reported symptoms suggestive of acute SARS-CoV-2 infection, and if they are within 42 days of having a SARS-CoV-2 viral test (i.e., nucleic acid amplification test or antigen test), regardless of test results. Recruitment occurs in-person, by phone or email, and through online advertisement. A secure online platform is used to facilitate the collation of consent-related materials, digital health records, and responses to self-administered surveys. Participants are followed for up to 18 months, with patient-reported outcomes collected every three months via survey and linked to concurrent digital health data; follow-up includes no in-person involvement. Our planned enrollment is 4,800 participants, including 2,400 SARS-CoV-2 positive and 2,400 SARS-CoV-2 negative participants (as a concurrent comparison group). These data will allow assessment of longitudinal outcomes from SARS-CoV-2 infection and comparison of the relative risk of outcomes in individuals with and without infection. Patient-reported outcomes include self-reported health function and status, as well as clinical outcomes including health system encounters and new diagnoses. Results Participating sites obtained institutional review board approval. Enrollment and follow-up are ongoing. Conclusions This study will characterize medium and long-term sequelae of SARS-CoV-2 infection among a diverse population, predictors of sequelae, and their relative risk compared to persons with similar symptomatology but without SARS-CoV-2 infection. These data may inform clinical interventions for individuals with sequelae of SARS-CoV-2 infection.
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Affiliation(s)
- Kelli N. O’Laughlin
- Department of Emergency Medicine, University of Washington, Seattle, WA, United States of America
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- * E-mail:
| | - Matthew Thompson
- Department of Family Medicine, University of Washington, Seattle, WA, United States of America
| | - Bala Hota
- Division of Infectious Diseases, Department of Internal Medicine, Rush University Medical Center, Chicago, IL, United States of America
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, United States of America
| | - Ian D. Plumb
- Division of Viral Diseases, Centers for Disease Control and Prevention, Respiratory Viruses Branch, Atlanta, GA, United States of America
| | - Anna Marie Chang
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia PA, United States of America
| | - Lauren E. Wisk
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Aron J. Hall
- Division of Viral Diseases, Centers for Disease Control and Prevention, Respiratory Viruses Branch, Atlanta, GA, United States of America
| | - Ralph C. Wang
- Department of Emergency Medicine, University of California, San Francisco, CA, United States of America
| | - Erica S. Spatz
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - Kari A. Stephens
- Department of Family Medicine, University of Washington, Seattle, WA, United States of America
| | - Ryan M. Huebinger
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, United States of America
| | - Samuel A. McDonald
- Department of Emergency Medicine and Clinical Informatics Center, UT Southwestern, Dallas, TX, United States of America
| | - Arjun Venkatesh
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - Nikki Gentile
- Department of Family Medicine, University of Washington, Seattle, WA, United States of America
| | - Benjamin H. Slovis
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia PA, United States of America
| | - Mandy Hill
- Department of Emergency Medicine, UTHealth McGovern Medical School, Houston, TX, United States of America
| | - Sharon Saydah
- Division of Viral Diseases, Centers for Disease Control and Prevention, Respiratory Viruses Branch, Atlanta, GA, United States of America
| | - Ahamed H. Idris
- Department of Emergency Medicine and Clinical Informatics Center, UT Southwestern, Dallas, TX, United States of America
| | - Robert Rodriguez
- Department of Emergency Medicine, University of California, San Francisco, CA, United States of America
| | - Harlan M. Krumholz
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - Joann G. Elmore
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Robert A. Weinstein
- Division of Infectious Diseases, Department of Internal Medicine, Rush University Medical Center, Chicago, IL, United States of America
- Department of Medicine, Cook County Health, Chicago, IL, United States of America
| | - Graham Nichol
- Department of Emergency Medicine, University of Washington, Seattle, WA, United States of America
- Departments of Medicine, University of Washington, Seattle, WA, United States of America
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Murphy CE, Wang RC, Montoy JC, Whittaker E, Raven M. Effect of extended-release naltrexone on alcohol consumption: a systematic review and meta-analysis. Addiction 2022; 117:271-281. [PMID: 34033183 DOI: 10.1111/add.15572] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 12/07/2020] [Accepted: 05/05/2021] [Indexed: 12/29/2022]
Abstract
AIMS The aims of this study were to (1) estimate the effect of extended-release naltrexone compared with placebo on alcohol consumption in patients with alcohol use disorder (AUD) and (2) conduct pre-planned subgroup analyses to test whether being abstinent when initiating treatment (lead-in abstinence) or the duration of treatment improves treatment efficacy. DESIGN Systematic review and random-effects meta-analysis of blinded randomized placebo-controlled trials reporting the effect extended-release naltrexone on alcohol consumption. SETTING Outpatient clinics. PARTICIPANTS Seven trials evaluating a total of 1500 adults with AUD receiving monthly injections of either placebo or extended-release naltrexone at doses of 150-400 mg for 2-6 months and some form of behavioral therapy. MEASUREMENTS Pooled weighted mean difference (WMD) in drinking days per month and heavy drinking days per month. FINDINGS The WMD was -2.0 [95% confidence interval (CI) = -3.4, -0.6; P = 0.03] in favor of extended-release naltrexone for drinking days per month and -1.2 (95% CI = -0.2, -2.1; P = 0.02) for heavy drinking days per month, indicating that treatment resulted in two fewer drinking days per month and 1.2 fewer heavy drinking days per month compared with placebo. Trials not requiring lead-in abstinence and those lasting longer than 3 months reported larger reductions in heavy drinking days per month; WMD -2.0 (95% CI = -3.52, -0.48; P = 0.01) and -1.9 (95% CI = -3.2, -0.5; P = 0.01), respectively. In all cases, the I2 statistics (0-7.2%) did not suggest substantial heterogeneity. CONCLUSIONS Extended-release naltrexone reduces drinking days and heavy drinking days per month compared with placebo. Reductions are larger with a longer duration of treatment.
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Affiliation(s)
- Charles E Murphy
- Department of Emergency Medicine, University of California, San Francisco, CA, USA
| | - Ralph C Wang
- Department of Emergency Medicine, University of California, San Francisco, CA, USA
| | - Juan Carlos Montoy
- Department of Emergency Medicine, University of California, San Francisco, CA, USA
| | - Evans Whittaker
- UCSF Health Sciences Library, University of California, San Francisco, CA, USA
| | - Maria Raven
- Department of Emergency Medicine, University of California, San Francisco, CA, USA.,Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA, USA
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Ramachandran A, Noble J, Deucher A, Miller S, Tang PW, Wang RC. Performance of Abbott ID-Now rapid nucleic amplification test for laboratory identification of COVID-19 in asymptomatic emergency department patients. J Am Coll Emerg Physicians Open 2021; 2:e12592. [PMID: 35005704 PMCID: PMC8716572 DOI: 10.1002/emp2.12592] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 08/25/2021] [Accepted: 09/29/2021] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE We sought to evaluate the test characteristics of Abbott ID-Now as a screening tool compared to polymerase chain reaction (PCR) testing for identification of COVID in an asymptomatic emergency department population. METHODS We performed a prospective study enrolling a convenience sample of asymptomatic patients presenting to a single academic emergency department (ED) who received simultaneous testing with ID-Now and PCR per standardized ED protocols. Sensitivity, specificity, and positive and negative predictive value (PPV, NPV) of ID-Now were calculated compared to PCR. Stratified analysis by cycle threshold (Ct) values was also performed, defined as high viral load (Ct < 33) and low viral load (Ct ≥ 33). RESULTS A total of 3121 patients were enrolled, of whom 2895 had valid results for ID-Now and PCR. COVID prevalence was 2.6%. ID-Now had a sensitivity of 85.1% (95% CI 75.9% to 92.7%) and a specificity of 99.7% (99.5% to 99.9%). PPV and NPV were high at 87.5% (83.1% to 96.1%) and 99.6% (99.3% to 99.8%). Stratified analysis by low and high Ct values demonstrated reduction in sensitivity in patients with low viral loads: 91.7% (81.6% to 97.2%) in low Ct value patients versus 58.3% (27.7% to 84.8%) in high Ct value patients. CONCLUSIONS ID-Now had excellent performance in asymptomatic ED patients with a low rate of false positives. Cycle threshold analysis suggests a relationship between viral load and ID-Now sensitivity. Given its speed and performance in this population, ID-Now should be considered an excellent tool to support clinical decision-making in ED populations.
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Affiliation(s)
- Anu Ramachandran
- Department of Emergency MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Jeanne Noble
- Department of Emergency MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Anne Deucher
- Department of Laboratory MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Steve Miller
- Department of Emergency MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Patrick Wai Tang
- Department of Laboratory MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Ralph C Wang
- Department of Emergency MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
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Lebin JA, Mudan A, Murphy CE, Wang RC, Smollin CG. Return Encounters in Emergency Department Patients Treated with Phenobarbital Versus Benzodiazepines for Alcohol Withdrawal. J Med Toxicol 2021; 18:4-10. [PMID: 34697777 PMCID: PMC8758850 DOI: 10.1007/s13181-021-00863-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 10/06/2021] [Accepted: 10/12/2021] [Indexed: 11/02/2022] Open
Abstract
INTRODUCTION Phenobarbital has been successfully used in the emergency department (ED) to manage symptoms of alcohol withdrawal, but few studies have reported outcomes for ED patients who receive phenobarbital and are discharged. We compared return encounter rates in discharged ED patients with alcohol withdrawal who were treated with benzodiazepines and phenobarbital. METHODS This is a retrospective cohort study conducted at a single academic medical center utilizing chart review of discharged ED patients with alcohol withdrawal from July 1, 2016, to June 30, 2019. Patients were stratified according to ED management with benzodiazepines, phenobarbital, or a combination of both agents. The primary outcome was return ED encounter within three days of the index ED encounter. Multivariate logistic regression identified significant covariates of an ED return encounter. RESULTS Of 470 patients who were discharged with the diagnosis of alcohol withdrawal, 235 were treated with benzodiazepines, 133 with phenobarbital, and 102 with a combination of both. Baseline characteristics were similar among the groups. However, patients who received phenobarbital were provided significantly more lorazepam equivalents compared to patients who received benzodiazepines alone. Treatment with phenobarbital, alone or in combination with benzodiazepines, was associated with significantly lower odds of a return ED visit within three days compared with benzodiazepines alone [AOR 0.45 (95% CI 0.23, 0.88) p = 0.02 and AOR 0.33 (95% CI 0.15, 0.74) p = 0.007]. CONCLUSIONS Patients who received phenobarbital for alcohol withdrawal were less likely to return to the ED within three days of the index encounter. Despite similar baseline characteristics, patients who received phenobarbital, with or without benzodiazepines, were provided greater lorazepam equivalents the ED.
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Affiliation(s)
- Jacob A Lebin
- Department of Emergency Medicine, University of California, San Francisco, 1001 Potrero Ave, Building 5, Room 2C8, Box 1369, San Francisco, CA, 94143, USA.
| | - Anita Mudan
- Department of Emergency Medicine, University of California, San Francisco, 1001 Potrero Ave, Building 5, Room 2C8, Box 1369, San Francisco, CA, 94143, USA
| | - Charles E Murphy
- Department of Emergency Medicine, University of California, San Francisco, 1001 Potrero Ave, Building 5, Room 2C8, Box 1369, San Francisco, CA, 94143, USA
| | - Ralph C Wang
- Department of Emergency Medicine, University of California, San Francisco, 1001 Potrero Ave, Building 5, Room 2C8, Box 1369, San Francisco, CA, 94143, USA
| | - Craig G Smollin
- Department of Emergency Medicine, University of California, San Francisco, 1001 Potrero Ave, Building 5, Room 2C8, Box 1369, San Francisco, CA, 94143, USA
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Eswaran V, Wang RC, Vashi AA, Kanzaria HK, Fahimi J, Raven MC. Patient reported delays in obtaining emergency care during COVID19. Am J Emerg Med 2021; 56:306-309. [PMID: 34391581 PMCID: PMC8349312 DOI: 10.1016/j.ajem.2021.08.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 08/02/2021] [Accepted: 08/02/2021] [Indexed: 02/06/2023] Open
Affiliation(s)
- Vidya Eswaran
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, CA, 521 Parnassus Avenue, San Francisco, CA 94143, United States; National Clinician Scholars Program, Philip R Lee Institute of Health Policy Studies, University of California, San Francisco, San Francisco, CA, Mission Bay Campus Valley Tower, 490 Illinois Street, Floor 7, San Francisco, CA 94158, United States.
| | - Ralph C Wang
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, CA, 521 Parnassus Avenue, San Francisco, CA 94143, United States.
| | - Anita A Vashi
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, CA, 521 Parnassus Avenue, San Francisco, CA 94143, United States; Veterans Affairs Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California, 3801 Miranda Avenue, Palo Alto, CA 94304, United States.
| | - Hemal K Kanzaria
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, CA, 521 Parnassus Avenue, San Francisco, CA 94143, United States; Philip R Lee Institute of Health Policy Studies, University of California, San Francisco, San Francisco, CA, Campus Box 0936, 490 Illinois Street, Floor 7, San Francisco, CA 94158, United States; Benioff Homelessness and Housing Initiative, Center for Vulnerable Populations, University of California, San Francisco, San Francisco, CA, Zuckerberg San Francisco General Hospital and Trauma Center, Box 1339, 2789 25(th) Street, Ste. 350, San Francisco, CA 94110, United States.
| | - Jahan Fahimi
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, CA, 521 Parnassus Avenue, San Francisco, CA 94143, United States; Philip R Lee Institute of Health Policy Studies, University of California, San Francisco, San Francisco, CA, Campus Box 0936, 490 Illinois Street, Floor 7, San Francisco, CA 94158, United States.
| | - Maria C Raven
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, CA, 521 Parnassus Avenue, San Francisco, CA 94143, United States; Philip R Lee Institute of Health Policy Studies, University of California, San Francisco, San Francisco, CA, Campus Box 0936, 490 Illinois Street, Floor 7, San Francisco, CA 94158, United States; Benioff Homelessness and Housing Initiative, Center for Vulnerable Populations, University of California, San Francisco, San Francisco, CA, Zuckerberg San Francisco General Hospital and Trauma Center, Box 1339, 2789 25(th) Street, Ste. 350, San Francisco, CA 94110, United States.
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Wang RC, Murphy CE, Kornblith AE, Kurtz T, Kohn MA. Prevalence of SARS-Cov-2 Antibodies in Emergency Medicine Healthcare Workers. Ann Emerg Med 2021; 77:556-557. [PMID: 33902837 PMCID: PMC7799153 DOI: 10.1016/j.annemergmed.2021.01.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Indexed: 10/28/2022]
Affiliation(s)
- Ralph C Wang
- Department of Emergency Medicine, University of California, San Francisco, CA
| | - Charles E Murphy
- Department of Emergency Medicine, University of California, San Francisco, CA
| | - Aaron E Kornblith
- Department of Emergency Medicine, Department of Pediatrics, University of California, San Francisco, CA
| | - Theodore Kurtz
- Department of Laboratory Medicine, University of California, San Francisco, CA
| | - Michael A Kohn
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA
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Rodriguez RM, Tseng ZH, Montoy JCC, Repplinger D, Moffatt E, Addo N, Wang RC. NAloxone CARdiac Arrest Decision Instruments (NACARDI) for targeted antidotal therapy in occult opioid overdose precipitated cardiac arrest. Resuscitation 2021; 159:69-76. [PMID: 33359417 DOI: 10.1016/j.resuscitation.2020.12.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 10/01/2020] [Revised: 11/29/2020] [Accepted: 12/03/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND We have recently demonstrated that a significant proportion of fatal out-of-hospital cardiac arrests (OHCAs) are precipitated by occult overdose, which could benefit from antidote therapy administered adjunctively with other cardiac resuscitation measures. We sought to develop simple decision instruments that EMS providers and other first responders can use to rapidly identify occult opioid overdose-associated OHCAs. METHODS We examined data from February 2011 through December 2017 in the Postmortem Systematic Investigation of Sudden Cardiac Death study, in which San Francisco (California) County EMS-attended OHCA deaths received autopsy and expert panel adjudication of cause of death. Using classification tree analyses, we derived highly sensitive and specific decision instruments that predicted our primary outcome of occult opioid OD-associated OHCA. We then calculated screening performance characteristics of these instruments. RESULTS Of 767 OHCA deaths, 80 (10.4%) were associated with occult opioid overdose. Of the eight models with 100% sensitivity for opioid overdose-associated cardiac arrest, the highest specificity model (23.4%, 95% confidence interval [CI] 20.3-26.7%) was age < 60 years OR race = black or non-Latinx white OR arrest in public place. The highest specificity instrument (96.3%, 95% CI 94.6-97.5%) consisting of age < 60 years AND race = black or non-Latinx white AND unwitnessed arrest AND female sex had 25% (95% CI 16-35.9%) sensitivity. CONCLUSIONS We have derived simple decision instruments that can identify patients whose OHCA precipitant was occult opioid overdose. These instruments may be used to guide selective administration of the antidote naloxone in OHCA resuscitations.
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Affiliation(s)
- Robert M Rodriguez
- Department of Emergency Medicine, University of California, San Francisco, United States.
| | - Zian H Tseng
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California, San Francisco, United States
| | - Juan Carlos C Montoy
- Department of Emergency Medicine, University of California, San Francisco, United States
| | - Daniel Repplinger
- Department of Emergency Medicine, University of California, San Francisco, United States
| | - Ellen Moffatt
- Office of the Chief Medical Examiner, City and County of San Francisco, CA, United States
| | - Newton Addo
- Department of Emergency Medicine, University of California, San Francisco, United States
| | - Ralph C Wang
- Department of Emergency Medicine, University of California, San Francisco, United States
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Wang RC, Miglioretti DL, Marlow EC, Kwan ML, Theis MK, Bowles EJA, Greenlee RT, Rahm AK, Stout NK, Weinmann S, Smith-Bindman R. Trends in Imaging for Suspected Pulmonary Embolism Across US Health Care Systems, 2004 to 2016. JAMA Netw Open 2020; 3:e2026930. [PMID: 33216141 PMCID: PMC7679949 DOI: 10.1001/jamanetworkopen.2020.26930] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [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] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE In response to calls to reduce unnecessary diagnostic testing with computed tomographic pulmonary angiography (CTPA) for suspected pulmonary embolism (PE), there have been growing efforts to create and implement decision rules for PE testing. It is unclear if the use of advanced imaging tests for PE has diminished over time. OBJECTIVE To assess the use of advanced imaging tests, including chest computed tomography (CT) (ie, all chest CT except for CTPA), CTPA, and ventilation-perfusion (V/Q) scan, for PE from 2004 to 2016. DESIGN, SETTING, AND PARTICIPANTS Cohort study of adults by age group (18-64 years and ≥65 years) enrolled in 7 US integrated and mixed-model health care systems. Joinpoint regression analysis was used to identify years with statistically significant changes in imaging rates and to calculate average annual percentage change (growth) from 2004 to 2007, 2008 to 2011, and 2012 to 2016. Analyses were conducted between June 11, 2019, and March 18, 2020. MAIN OUTCOMES AND MEASURES Rates of chest CT, CTPA, and V/Q scan by year and age, as well as annual change in rates over time. RESULTS Overall, 3.6 to 4.8 million enrollees were included each year of the study, for a total of 52 343 517 person-years of follow-up data. Adults aged 18 to 64 years accounted for 42 223 712 person-years (80.7%) and those 65 years or older accounted for 10 119 805 person-years (19.3%). Female enrollees accounted for 27 712 571 person-years (52.9%). From 2004 and 2016, chest CT use increased by 66.3% (average annual growth, 4.4% per year), CTPA use increased by 450.0% (average annual growth, 16.3% per year), and V/Q scan use decreased by 47.1% (decreasing by 4.9% per year). The use of CTPA increased most rapidly from 2004 to 2006 (44.6% in those aged 18-64 years and 43.9% in those ≥65 years), with ongoing rapid growth from 2006 to 2010 (annual growth, 19.8% in those aged 18-64 years and 18.3% in those ≥65 years) and persistent but slower growth in the most recent years (annual growth, 4.3% in those aged 18-64 years and 3.0% in those ≥65 years from 2010 to 2016). The use of V/Q scanning decreased steadily since 2004. CONCLUSIONS AND RELEVANCE From 2004 to 2016, rates of chest CT and CTPA for suspected PE continued to increase among adults but at a slower pace in more contemporary years. Efforts to combat overuse have not been completely successful as reflected by ongoing growth, rather than decline, of chest CT use. Whether the observed imaging use was appropriate or was associated with improved patient outcomes is unknown.
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Affiliation(s)
- Ralph C. Wang
- Department of Emergency Medicine, University of California, San Francisco
| | - Diana L. Miglioretti
- Department of Public Health Sciences, University of California, Davis
- Comprehensive Cancer Center, University of California, Davis
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle
| | - Emily C. Marlow
- Department of Public Health Sciences, University of California, Davis
| | - Marilyn L. Kwan
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - May K. Theis
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle
| | - Erin J. A. Bowles
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle
| | - Robert T. Greenlee
- Marshfield Clinic Research Institute, Marshfield Clinic Health System, Marshfield, Wisconsin
| | - Alanna K. Rahm
- Genomic Medicine Institute, Geisinger, Danville, Pennsylvania
| | - Natasha K. Stout
- Massachusetts Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston
| | - Sheila Weinmann
- now with Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
- Center for Integrated Health Research, Kaiser Permanente Hawaii, Honolulu
| | - Rebecca Smith-Bindman
- Department of Radiology and Biomedical Imaging, University of California, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
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Murphy CE, Wang RC, Coralic Z, Lai AR, Raven M. Association Between Methamphetamine Use and Psychiatric Hospitalization, Chemical Restraint, and Emergency Department Length of Stay. Acad Emerg Med 2020; 27:1116-1125. [PMID: 32713087 DOI: 10.1111/acem.14094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 07/06/2020] [Accepted: 07/20/2020] [Indexed: 01/30/2023]
Abstract
OBJECTIVES Methamphetamine intoxication is an increasing cause of emergency department (ED) visits in the United States, particularly in the west. In San Francisco, California, 47% of patients visiting psychiatric emergency services are intoxicated with methamphetamine. Such patients often visit the ED due to acute psychiatric symptoms, yet ED-based research investigating the outcomes and resource utilization of these visits is limited. METHODS We examined a retrospective cohort of ED patients requiring ED-based psychiatric consultation from June 2017 to July 2018. We evaluated the association between methamphetamine visits and need for chemical restraint, psychiatric hospitalization, and length of stay (LOS). RESULTS We identified 2,087 ED visits with psychiatric consults. Based on urine toxicology results and discharge diagnosis, 403 visits involved methamphetamine with or without other drugs, 480 involved other drugs without methamphetamine, and 1,204 had no evidence of drug use. Methamphetamine visits were associated with increased odds of chemical restraint compared to visits without drug use (adjusted odds ratio [AOR] = 3.2, 95% CI = 2.1 to 5.2, p < 0.001), but not other drug visits (AOR = 1.2, 95% CI = 0.8 to 1.9, p = 0.4). Methamphetamine visits had lower odds of psychiatric hospitalization than other drug visits (AOR = 0.62, 95% CI = 0.41 to 0.95, p = 0.03) and longer adjusted LOS than visits without drug use (+4.3 hours, 95% CI = 4.1 to 8.3 hours, p < 0.001) but not other drug visits (+1.5 hours, 95% CI = -0.6 to 3.7 hours, p = 0.2). CONCLUSIONS Methamphetamine ED visits were associated with increased odds of needing chemical restraint and of an increased ED LOS but not with psychiatric inpatient admission. These results indicate an opportunity to improve the efficiency of ED care for these patients.
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Affiliation(s)
- Charles E. Murphy
- From the Department of Emergency Medicine University of California San Francisco CA USA
| | - Ralph C. Wang
- From the Department of Emergency Medicine University of California San Francisco CA USA
| | - Zlatan Coralic
- From the Department of Emergency Medicine University of California San Francisco CA USA
- the Department of Pharmacy University of California San Francisco CA USA
| | - Andrew R. Lai
- the Division of Hospital Medicine Department of Medicine University of California San Francisco CA USA
| | - Maria Raven
- From the Department of Emergency Medicine University of California San Francisco CA USA
- and the Philip R. Lee Institute for Health Policy Studies University of California San Francisco CA USA
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Wang RC, Stoller ML, Smith-Bindman R. Diagnostic Imaging for Kidney Stones. JAMA 2020; 324:1464-1465. [PMID: 33048146 DOI: 10.1001/jama.2020.14865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Ralph C Wang
- Department of Emergency Medicine, University of California, San Francisco
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LeSaint KT, Klapthor B, Wang RC, Geier C. Buprenorphine for Opioid Use Disorder in the Emergency Department: A Retrospective Chart Review. West J Emerg Med 2020; 21:1175-1181. [PMID: 32970572 PMCID: PMC7514395 DOI: 10.5811/westjem.2020.6.46452] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 06/11/2020] [Indexed: 11/23/2022] Open
Abstract
Introduction Emergency care providers routinely treat patients with acute presentations and sequelae of opioid use disorder. An emergency physician and pharmacist implemented a protocol using buprenorphine for the treatment of patients with opioid withdrawal at an academic, Level I trauma center. We describe our experience regarding buprenorphine implementation in the emergency department (ED), characteristics of patients who received buprenorphine, and rates of outpatient follow-up. Methods We conducted a retrospective chart review of all patients in the ED for whom buprenorphine was administered to treat opioid withdrawal during an 18-month period from January 30, 2017–July 31, 2018. Data extraction of a priori-defined variables was recorded. We used descriptive statistics to characterize the cohort of patients. Results A total of 77 patients were included for analysis. Thirty-three patients (43%) who received buprenorphine did not present with the chief complaint of opioid withdrawal. Most patients (74%) who received buprenorphine last used heroin, and presented in moderate opioid withdrawal. One case of precipitated withdrawal occurred after buprenorphine administration. Twenty-three (30%) patients received outpatient follow-up. Conclusions This study underscores the safety of ED-initiated buprenorphine and that buprenorphine administration in the ED is feasible and effective.
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Affiliation(s)
- Kathy T LeSaint
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California
| | - Brent Klapthor
- Kaiser Permanente San Diego Medical Center, Department of Emergency Medicine, San Diego, California
| | - Ralph C Wang
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California
| | - Curtis Geier
- University of California, San Francisco, Department of Clinical Pharmacy, San Francisco, California
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Abstract
This cross-sectional study examines prevalence of fit test failure of 2 types of N95 mask (dome-shaped and duckbill) during extended use or reuse among health care workers over 2 days in April 2020 in the UCSF emergency department.
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Affiliation(s)
- Nida F. Degesys
- Department of Emergency Medicine, University of California, San Francisco
| | - Ralph C. Wang
- Department of Emergency Medicine, University of California, San Francisco
| | - Elizabeth Kwan
- Department of Emergency Medicine, University of California, San Francisco
| | - Jahan Fahimi
- Department of Emergency Medicine, University of California, San Francisco
| | - Jeanne A. Noble
- Department of Emergency Medicine, University of California, San Francisco
| | - Maria C. Raven
- Department of Emergency Medicine, University of California, San Francisco
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Kline JA, Lin MP, Hall CL, Puskarich MA, Dehon E, Kuehl DR, Wang RC, Hess EP, Runyon MS, Wang H, Courtney DM. Perception of Physician Empathy Varies With Educational Level and Gender of Patients Undergoing Low-Yield Computerized Tomographic Imaging. J Patient Exp 2020; 7:386-394. [PMID: 32821799 PMCID: PMC7410137 DOI: 10.1177/2374373519838529] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 12/27/2022] Open
Abstract
OBJECTIVE Lack of empathic communication between providers and patients may contribute to low value diagnostic testing in emergency care. Accordingly, we measured the perception of physician empathy and trust in patients undergoing low-value computed tomography (CT) in the emergency department (ED). METHODS Multicenter study of ED patients undergoing CT scanning, acknowledged by ordering physicians as unlikely to show an emergent condition. Near the end of their visit, patients completed the Jefferson Scale of Patient Perception of Physician Empathy (JSPPPE), Trust in Physicians Survey (TIPS), and the Group Based Medical Mistrust Scale (GBMMS). We stratified results by patient demographics including gender, race, and education. RESULTS We enrolled 305 participants across 9 sites with diverse geographic, racial, and ethnic representation. The median scores (interquartile ranges) for the JSPPPE, TIPS, and GBMMS for all patients were 29 (24-33.5), 55 (47-62), and 18 (12-29). Compared with white patients, nonwhite patients had similar JSPPPE and TIPS scores but had higher (worse) GBMMS scores. Females had significantly lower JSPPPE and TIPS scores than males, and scores were lower (worse) in females with college degrees. Patients in the lowest tier of educational status had the highest (better) JSPPPE and TIPS scores. Scores were invariant with physician characteristics. CONCLUSION Among patients undergoing low-value CT scanning in the ED, the degree of patient perception of physician empathy and trust varied based on the patients' level of education and gender. Given this variation, an intervention to increase patient perception of physician empathy should contain individualized strategies to address these subgroups, rather than a one-size-fits-all approach.
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Affiliation(s)
- Jeffrey A Kline
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Michelle P Lin
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Cassandra L Hall
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Erin Dehon
- Department of Emergency Medicine, University of Mississippi, Jackson, MS, USA
| | - Damon R Kuehl
- Department of Emergency Medicine, Virginia Tech-Carilion, Roanoke, VA, USA
| | - Ralph C Wang
- Department of Emergency Medicine, University of California, San Francisco, CA, USA
| | - Erik P Hess
- Department of Emergency Medicine, University of Alabama, Birmingham, AL, USA
| | - Michael S Runyon
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC, USA
| | - Hao Wang
- Department of Emergency Medicine, John Peter Smith Hospital, Ft. Worth, TX, USA
| | - D Mark Courtney
- Department of Emergency Medicine, Northwestern University School of Medicine, Chicago, IL, USA
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Vo KT, Merriman AJ, Wang RC. Seizure in venlafaxine overdose: a 10-year retrospective review of the California poison control system. Clin Toxicol (Phila) 2020; 58:984-990. [DOI: 10.1080/15563650.2020.1712414] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Kathy T. Vo
- Department of Emergency Medicine, University of California, San Francisco, CA, USA
- California Poison Control System, San Francisco Division, University of California, San Francisco, CA, USA
| | - Andrew J. Merriman
- Department of Emergency Medicine, University of California, San Francisco, CA, USA
| | - Ralph C. Wang
- Department of Emergency Medicine, University of California, San Francisco, CA, USA
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Lin MP, Probst MA, Puskarich MA, Dehon E, Kuehl DR, Wang RC, Hess EP, Butler K, Runyon MS, Wang H, Courtney DM, Muckley B, Hobgood CD, Hall CL, Kline JA. Improving perceptions of empathy in patients undergoing low-yield computerized tomographic imaging in the emergency department. Patient Educ Couns 2018; 101:717-722. [PMID: 29173841 DOI: 10.1016/j.pec.2017.11.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 11/17/2017] [Accepted: 11/19/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE We assessed emergency department (ED) patient perceptions of how physicians can improve their language to determine patient preferences for 11 phrases to enhance physician empathy toward the goal of reducing low-value advanced imaging. METHODS Multi-center survey study of low-risk ED patients undergoing computerized tomography (CT) scanning. RESULTS We enroled 305 participants across nine sites. The statement "I have carefully considered what you told me about what brought you here today" was most frequently rated as important (88%). The statement "I have thought about the cost of your medical care to you today" was least frequently rated as important (59%). Participants preferred statements indicating physicians had considered their "vital signs and physical examination" (86%), "past medical history" (84%), and "what prior research tells me about your condition" (79%). Participants also valued statements conveying risks of testing, including potential kidney injury (78%) and radiation (77%). CONCLUSION The majority of phrases were identified as important. Participants preferred statements conveying cognitive reassurance, medical knowledge and risks of testing. PRACTICE IMPLICATIONS Our findings suggest specific phrases have the potential to enhance ED patient perceptions of physician empathy. Further research is needed to determine whether statements to convey empathy affect diagnostic testing rates.
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Affiliation(s)
- Michelle P Lin
- Icahn School of Medicine at Mount Sinai, Department of Emergency Medicine, New York, NY, United States
| | - Marc A Probst
- Icahn School of Medicine at Mount Sinai, Department of Emergency Medicine, New York, NY, United States
| | - Michael A Puskarich
- University of Mississippi, Department of Emergency Medicine, Jackson, MS, United States
| | - Erin Dehon
- University of Mississippi, Department of Emergency Medicine, Jackson, MS, United States
| | - Damon R Kuehl
- Virginia Tech-Carilion, Department of Emergency Medicine, Roanoke, VA, United States
| | - Ralph C Wang
- University of California San Francisco Department of Emergency Medicine, San Francisco, CA, United States
| | - Erik P Hess
- Mayo Clinic, Department of Emergency Medicine, Rochester, MN, United States
| | - Katie Butler
- Carolinas Medical Center, Department of Emergency Medicine, Charlotte, NC, United States
| | - Michael S Runyon
- Carolinas Medical Center, Department of Emergency Medicine, Charlotte, NC, United States
| | - Hao Wang
- John Peter Smith Hospital, Department of Emergency Medicine, Ft. Worth, TX, United States
| | - D Mark Courtney
- Northwestern University School of Medicine, Department of Emergency Medicine, Chicago, IL, United States
| | - Brandon Muckley
- Indiana University School of Medicine, Department of Emergency Medicine, Indianapolis, IN, United States
| | - Cherri D Hobgood
- Indiana University School of Medicine, Department of Emergency Medicine, Indianapolis, IN, United States
| | - Cassandra L Hall
- Indiana University School of Medicine, Department of Emergency Medicine, Indianapolis, IN, United States
| | - Jeffrey A Kline
- Indiana University School of Medicine, Department of Emergency Medicine, Indianapolis, IN, United States.
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Maddy AJ, Lee EE, Maderal AD, Wang RC, Tosti A, Cho-Vega JH. A case of disseminated follicular spicules in HIV-associated follicular syndrome in the absence of the seven known human polyomaviruses, suggesting that this disorder is distinct from trichodysplasia spinulosa. Br J Dermatol 2018; 179:774-775. [PMID: 29573272 DOI: 10.1111/bjd.16562] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- A J Maddy
- Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami, Miami, FL, U.S.A
| | - E E Lee
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, TX, U.S.A
| | - A D Maderal
- Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami, Miami, FL, U.S.A
| | - R C Wang
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, TX, U.S.A
| | - A Tosti
- Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami, Miami, FL, U.S.A
| | - J H Cho-Vega
- Dermatopathology, Department of Pathology and Laboratory Medicine, Sylvester Comprehensive Cancer Center and Miller School of Medicine, University of Miami, Miami, FL, U.S.A
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Yan HW, Li L, Wang RC, Yang Y, Xie Y, Tang J, Shi ZY. Clinical efficacies of coracoclavicular ligament reconstruction using suture anchor versus hook plate in the treatment of distal clavicle fracture. Orthop Traumatol Surg Res 2017; 103:1287-1293. [PMID: 28801112 DOI: 10.1016/j.otsr.2017.07.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 06/19/2017] [Accepted: 07/10/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Comparison of clinical efficacies between coracoclavicular ligament reconstruction using autologous gracilis tendon with suture anchor and clavicular hook plate for the treatment of acute Neer type II distal clavicle fracture. HYPOTHESIS Both coracoclavicular reconstruction with autologous gracilis tendon and clavicular hook plate could achieve satisfactory results for treating acute Neer type II distal clavicle fracture. METHODS Acute Neer type II distal clavicle fracture patients enrolled in this prospective randomized study were divided into the coracoclavicular ligament reconstruction group (using autologous gracilis tendon and suture anchor) and the hook plate group. Clinical outcomes were evaluated by shoulder X-ray, forward flexion, abduction and external rotation angle, Constant-Murley shoulder score and pain Visual Analogue Scale (VAS) at each follow-up for up to 24 months. RESULTS The current study enrolled a total of 42 acute Neer type II distal clavicle fracture patients attended our hospital from March 2010 to December 2013. All patients had achieved complete healing and followed up for an average of 26 months (range, 24-38 months). At 3-month and 6-month follow-ups, Constant-Murley score in the ligament reconstruction group was significantly higher (93.8±2.6 vs. 88.7±8.7; 95.9±2.7 vs. 93.0±7.0, P<0.05), while VAS score was poorer than those in the hook plate group (1.6±0.8 vs. 2.5±1.9; 1.1±1.0 vs. 1.6±1.7, P<0.05). DISCUSSION Reconstruction with autologous gracilis tendon improved VAS pain score in early postoperation follow-up; while Constant-Murley score and VAS score were significantly improved in the hook plate group after the implant was removed. These suggested that both coracoclavicular reconstruction with autologous gracilis tendon and clavicular hook plate could achieve satisfactory results. LEVEL OF EVIDENCE Level II, low-powered prospective randomized trial.
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Affiliation(s)
- H W Yan
- The Fourth Affiliated Hospital of Guangxi Medical University, Liu Zhou Worker's Hospital, Liuzhou, Guangxi 545005, China
| | - L Li
- The Fourth Affiliated Hospital of Guangxi Medical University, Liu Zhou Worker's Hospital, Liuzhou, Guangxi 545005, China
| | - R C Wang
- The Fourth Affiliated Hospital of Guangxi Medical University, Liu Zhou Worker's Hospital, Liuzhou, Guangxi 545005, China
| | - Y Yang
- The Fourth Affiliated Hospital of Guangxi Medical University, Liu Zhou Worker's Hospital, Liuzhou, Guangxi 545005, China
| | - Y Xie
- The Fourth Affiliated Hospital of Guangxi Medical University, Liu Zhou Worker's Hospital, Liuzhou, Guangxi 545005, China
| | - J Tang
- The Fourth Affiliated Hospital of Guangxi Medical University, Liu Zhou Worker's Hospital, Liuzhou, Guangxi 545005, China
| | - Z Y Shi
- The Fourth Affiliated Hospital of Guangxi Medical University, Liu Zhou Worker's Hospital, Liuzhou, Guangxi 545005, China.
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Brian Savino P, Reichelderfer S, Mercer MP, Sporer KA, Wang RC. In Reply: Comparing Direct and Video Laryngoscopy for Prehospital Intubation: Can Meta-analysis Provide an Exact Solution? Acad Emerg Med 2017; 24:1417-1418. [PMID: 28752692 DOI: 10.1111/acem.13262] [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: 11/27/2022]
Affiliation(s)
| | - Scott Reichelderfer
- University of California; San Francisco Fresno School of Medicine; Fresno CA
| | - Mary P. Mercer
- University of California at San Francisco School of Medicine; San Francisco CA
| | - Karl A. Sporer
- University of California at San Francisco School of Medicine; Alameda County EMS Agency
| | - Ralph C. Wang
- University of California at San Francisco School of Medicine; San Francisco CA
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Savino PB, Reichelderfer S, Mercer MP, Wang RC, Sporer KA. Direct Versus Video Laryngoscopy for Prehospital Intubation: A Systematic Review and Meta-analysis. Acad Emerg Med 2017; 24:1018-1026. [PMID: 28370736 DOI: 10.1111/acem.13193] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 03/09/2017] [Accepted: 03/10/2017] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The use of video laryngoscopy (VL) for intubation has gained recent popularity. In the prehospital setting, it is unclear if VL increases intubation success rates compared to direct laryngoscopy (DL). We sought to conduct a systematic review and meta-analysis of studies comparing VL to DL in the prehospital setting to determine whether the use of VL increases overall and first-pass endotracheal intubation success rates compared to DL. METHODS A systematic search was performed of the PubMed, Embase, and SCOPUS databases through May 2016 to include studies comparing overall and first-pass success for VL versus DL in patients requiring intubation in the prehospital setting. Data were abstracted by two reviewers. A meta-analysis was performed using a random-effects model. RESULTS Of a potential 472 articles, eight eligible studies were included. Considerable heterogeneity (I2 > 90%) precluded reporting an overall pooled estimate across all studies. When stratified by provider type, the pooled estimates for overall intubation success using VL versus DL were a risk ratio (RR) of 0.05 (95% confidence interval [CI] = 0.01-0.18) in studies of physicians and RR = 2.28 (95% CI = 1.00-5.20) in nonphysicians. For first-pass intubation success the pooled RR estimates for using VL versus DL were 0.32 (95% CI = 0.23-0.44) and 1.83 (95% CI = 1.18-2.84) among studies using physicians and nonphysicians, respectively. There was moderate to significant heterogeneity between studies when stratified by provider. CONCLUSIONS Among physician intubators with significant DL experience, VL does not increase overall or first-pass success rates and may lead to worsening performance. However, among nonphysician intubators with less experience with DL, VL may provide benefit in the prehospital setting.
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Affiliation(s)
- P. Brian Savino
- Loma Linda University School of Medicine; Loma Linda CA
- University of California, San Francisco School of Medicine; San Francisco CA
| | - Scott Reichelderfer
- University of California, San Francisco School of Medicine; San Francisco CA
| | - Mary P. Mercer
- University of California, San Francisco School of Medicine; San Francisco CA
| | - Ralph C. Wang
- University of California, San Francisco School of Medicine; San Francisco CA
| | - Karl A. Sporer
- University of California, San Francisco School of Medicine; San Francisco CA
- Alameda County EMS Agency; San Francisco CA
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Kornblith AE, Fahimi J, Kanzaria HK, Wang RC. Predictors for under-prescribing antibiotics in children with respiratory infections requiring antibiotics. Am J Emerg Med 2017; 36:218-225. [PMID: 28774769 DOI: 10.1016/j.ajem.2017.07.081] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [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: 06/09/2017] [Revised: 07/25/2017] [Accepted: 07/26/2017] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND/OBJECTIVE Previous studies showed variability in the use of diagnostic and therapeutic resources for children with febrile acute respiratory tract infections (ARTI), including antibiotics. Unnecessary antibiotic use has important public and individual health outcomes, but missed antibiotic prescribing also has important consequences. We sought to determine factors associated with antibiotic prescribing in pediatric ARTI, specifically those with pneumonia. METHODS We assessed national trends in the evaluation and treatment of ARTI for pediatric emergency department (ED) patients by analyzing the National Hospital Ambulatory Medical Care Survey from 2002 to 2013. We identified ED patients aged ≤18 with a reason for visit of ARTI, and created 4 diagnostic categories: pneumonia, ARTI where antibiotics are typically indicated, ARTI where antibiotics are typically not indicated, and "other" diagnoses. Our primary outcome was factors associated with the administration or prescription of antibiotics. A multivariate logistic regression model was fit to identify risk factors for underuse of antibiotics when they were indicated. RESULTS We analyzed 6461 visits, of which 10.2% of the population had a final diagnosis of pneumonia and 86% received antibiotics. 41.5% of patients were diagnosed with an ARTI requiring antibiotics, of which 53.8% received antibiotics. 26.6% were diagnosed with ARTI not requiring antibiotics, of which 36.0% received antibiotics. Black race was a predictor for the underuse of antibiotics in ARTIs that require antibiotics (OR: 0.72; 95% CI: 0.58-0.90). CONCLUSIONS For pediatric patients presenting to the ED with pneumonia and ARTI requiring antibiotics, we found that black race was an independent predictor of antibiotic underuse.
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Affiliation(s)
- Aaron E Kornblith
- Department of Emergency Medicine & Pediatrics, University of California, San Francisco, 550 16th Street, San Francisco, CA 94143, United States; Department of Emergency Medicine, University of California, San Francisco, 1001 Potrero Ave, San Francisco, CA 94110, United States.
| | - Jahan Fahimi
- Department of Emergency Medicine, University of California, San Francisco, 1001 Potrero Ave, San Francisco, CA 94110, United States
| | - Hemal K Kanzaria
- Department of Emergency Medicine, University of California, San Francisco, 1001 Potrero Ave, San Francisco, CA 94110, United States
| | - Ralph C Wang
- Department of Emergency Medicine, University of California, San Francisco, 1001 Potrero Ave, San Francisco, CA 94110, United States
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Wang RC, Fahimi J. In reply:. Ann Emerg Med 2017; 69:524-525. [DOI: 10.1016/j.annemergmed.2016.11.043] [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: 11/22/2016] [Indexed: 10/19/2022]
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Wang RC, Rodriguez RM, Fahimi J, Hall MK, Shiboski S, Chi T, Smith-Bindman R. Derivation of decision rules to predict clinically important outcomes in acute flank pain patients. Am J Emerg Med 2017; 35:554-563. [PMID: 28082160 PMCID: PMC5701802 DOI: 10.1016/j.ajem.2016.12.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [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: 10/05/2016] [Revised: 11/09/2016] [Accepted: 12/08/2016] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE Routine CT for patients with acute flank pain has not been shown to improve patient outcomes, and it may unnecessarily expose patients to radiation and increased costs. As preliminary steps toward the development of a guideline for selective CT, we sought to determine the prevalence of clinically important outcomes in patients with acute flank pain and derive preliminary decision rules. METHODS We analyzed data from a randomized trial of CT vs. ultrasonography for patients with acute flank pain from 15 EDs between October 2011 and February 2013. Clinically important outcomes were defined as inpatient admission for ureteral stones and alternative diagnoses. Clinically important stones were defined as stones requiring urologic intervention. We sought to derive highly sensitive decision rules for both outcomes. RESULTS Of 2759 participants, 236 (8.6%) had a clinically important outcome and 143 (5.2%) had a clinically important stone. A CDR including anemia (hemoglobin <13.2g/dl), WBC count >11000/μl, age>42years, and the absence of CVAT had a sensitivity of 97.9% (95% CI 94.8-99.2%) and specificity of 18.7% (95% 17.2-20.2%) for clinically important outcome. A CDR including hydronephrosis, prior history of stone, and WBC count <8300/μl had a sensitivity of 98.6% (95% CI 94.5-99.7%) and specificity of 26.0% (95% 24.2-27.7%) for clinically important stone. CONCLUSIONS We determined the prevalence of clinically important outcomes in patients with acute flank pain, and derived preliminary high sensitivity CDRs that predict them. Validation of CDRs with similar test characteristics would require prospective enrollment of 2100 patients.
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Affiliation(s)
- Ralph C Wang
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, CA, USA.
| | - Robert M Rodriguez
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Jahan Fahimi
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - M Kennedy Hall
- Division of Emergency Medicine, University of Washington, Seattle, WA, USA
| | - Stephen Shiboski
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Tom Chi
- Department of Urology, University of California, San Francisco, San Francisco, CA, USA
| | - Rebecca Smith-Bindman
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA; Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
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Wang RC, Smith-Bindman R, Whitaker E, Neilson J, Allen IE, Stoller ML, Fahimi J. Effect of Tamsulosin on Stone Passage for Ureteral Stones: A Systematic Review and Meta-analysis. Ann Emerg Med 2017; 69:353-361.e3. [DOI: 10.1016/j.annemergmed.2016.06.044] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 06/23/2016] [Accepted: 06/28/2016] [Indexed: 01/02/2023]
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Wang RC, Fahimi J. In reply. Ann Emerg Med 2016; 68:644-645. [PMID: 27772684 DOI: 10.1016/j.annemergmed.2016.06.006] [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] [Received: 05/30/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Ralph C Wang
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, CA
| | - Jahan Fahimi
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, CA
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Metzler IS, Smith-Bindman R, Moghadassi M, Wang RC, Stoller ML, Chi T. Emergency Department Imaging Modality Effect on Surgical Management of Nephrolithiasis: A Multicenter, Randomized Clinical Trial. J Urol 2016; 197:710-714. [PMID: 27773846 DOI: 10.1016/j.juro.2016.09.122] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE In the emergency department ultrasonography is emerging as an alternative to computerized tomography for diagnosing patients with nephrolithiasis. In this multicenter randomized clinical trial we examined rates of urological referral and intervention to elucidate whether the initial diagnostic imaging modality affected the management of nephrolithiasis. MATERIALS AND METHODS Patients 18 to 76 years old who presented to the emergency department with renal colic across 15 diverse treatment centers were randomized to receive abdominal ultrasonography by an emergency department physician or a radiologist, or abdominal computerized tomography. We analyzed the 90-day followup for patients diagnosed with nephrolithiasis to assess subsequent urological evaluation, procedure type and time to intervention. RESULTS Of 1,666 patients diagnosed with nephrolithiasis in the emergency department 241 (14.5%) had a consultation with urology at initial presentation, 503 (30%) saw a urologist in followup and 192 (12%) underwent at least 1 urological procedure. Median time to outpatient procedure and type of procedure performed did not vary significantly among imaging groups. Most patients (78%) had computerized tomography performed before elective intervention. Patients with ultrasonography performed by an emergency department physician were 2.6 times more likely to undergo computerized tomography before intervention than those who had ultrasonography performed by a radiologist. CONCLUSIONS Patients undergoing a urological intervention who had ultrasonography as initial imaging do not experience a significant delay to intervention or different procedure types, but the majority ultimately undergoes computerized tomography before surgery. Formal ultrasonography by a radiologist may encourage less computerized tomography preoperatively.
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Affiliation(s)
- Ian S Metzler
- Department of Urology, University of California San Francisco, San Francisco, California.
| | - Rebecca Smith-Bindman
- Department of Radiology, University of California San Francisco, San Francisco, California
| | - Michelle Moghadassi
- Department of Obstetrics and Gynecology, University of California San Francisco, San Francisco, California
| | - Ralph C Wang
- Department of Emergency Medicine, University of California San Francisco, San Francisco, California
| | - Marshall L Stoller
- Department of Urology, University of California San Francisco, San Francisco, California
| | - Thomas Chi
- Department of Urology, University of California San Francisco, San Francisco, California
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Affiliation(s)
- Ralph C Wang
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, CA
| | - Robert M Rodriguez
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, CA
| | - Stephen Shiboski
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Tarina L Kang
- Department of Emergency Medicine, Los Angeles County at the University of Southern California, Los Angeles, CA
| | - John Bailitz
- Department of Emergency Medicine, John H. Stroger Jr. Hospital of Cook County, Chicago, IL
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Wang RC, Rodriguez RM, Moghadassi M, Noble V, Bailitz J, Mallin M, Corbo J, Kang TL, Chu P, Shiboski S, Smith-Bindman R. External Validation of the STONE Score, a Clinical Prediction Rule for Ureteral Stone: An Observational Multi-institutional Study. Ann Emerg Med 2015; 67:423-432.e2. [PMID: 26440490 PMCID: PMC4808407 DOI: 10.1016/j.annemergmed.2015.08.019] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 08/10/2015] [Accepted: 08/21/2015] [Indexed: 01/01/2023]
Abstract
Study objective The STONE score is a clinical decision rule that classifies patients with suspected nephrolithiasis into low-, moderate-, and high-score groups, with corresponding probabilities of ureteral stone. We evaluate the STONE score in a multi-institutional cohort compared with physician gestalt and hypothesize that it has a sufficiently high specificity to allow clinicians to defer computed tomography (CT) scan in patients with suspected nephrolithiasis. Methods We assessed the STONE score with data from a randomized trial for participants with suspected nephrolithiasis who enrolled at 9 emergency departments between October 2011 and February 2013. In accordance with STONE predictors, we categorized participants into low-, moderate-, or high-score groups. We determined the performance of the STONE score and physician gestalt for ureteral stone. Results Eight hundred forty-five participants were included for analysis; 331 (39%) had a ureteral stone. The global performance of the STONE score was superior to physician gestalt (area under the receiver operating characteristic curve=0.78 [95% confidence interval {CI} 0.74 to 0.81] versus 0.68 [95% CI 0.64 to 0.71]). The prevalence of ureteral stone on CT scan ranged from 14% (95% CI 9% to 19%) to 73% (95% CI 67% to 78%) in the low-, moderate-, and high-score groups. The sensitivity and specificity of a high score were 53% (95% CI 48% to 59%) and 87% (95% CI 84% to 90%), respectively. Conclusion The STONE score can successfully aggregate patients into low-, medium-, and high-risk groups and predicts ureteral stone with a higher specificity than physician gestalt. However, in its present form, the STONE score lacks sufficient accuracy to allow clinicians to defer CT scan for suspected ureteral stone.
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Affiliation(s)
- Ralph C Wang
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, CA.
| | - Robert M Rodriguez
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, CA
| | - Michelle Moghadassi
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA
| | - Vicki Noble
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - John Bailitz
- Department of Emergency Medicine, John H. Stroger Jr. Hospital of Cook County, Chicago, IL
| | - Mike Mallin
- Division of Emergency Medicine, University of Utah, Salt Lake City, UT
| | - Jill Corbo
- Department of Emergency Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, New York, NY
| | - Tarina L Kang
- Department of Emergency Medicine, Los Angeles County at the University of Southern California, Los Angeles, CA
| | - Phillip Chu
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA
| | - Steve Shiboski
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Rebecca Smith-Bindman
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA; Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
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Smith-Bindman R, Aubin C, Bailitz J, Bengiamin RN, Camargo CA, Corbo J, Dean AJ, Goldstein RB, Griffey RT, Jay GD, Kang TL, Kriesel DR, Ma OJ, Mallin M, Manson W, Melnikow J, Miglioretti DL, Miller SK, Mills LD, Miner JR, Moghadassi M, Noble VE, Press GM, Stoller ML, Valencia VE, Wang J, Wang RC, Cummings SR. Ultrasonography versus computed tomography for suspected nephrolithiasis. N Engl J Med 2014; 371:1100-10. [PMID: 25229916 DOI: 10.1056/nejmoa1404446] [Citation(s) in RCA: 372] [Impact Index Per Article: 37.2] [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] [Indexed: 12/28/2022]
Abstract
BACKGROUND There is a lack of consensus about whether the initial imaging method for patients with suspected nephrolithiasis should be computed tomography (CT) or ultrasonography. METHODS In this multicenter, pragmatic, comparative effectiveness trial, we randomly assigned patients 18 to 76 years of age who presented to the emergency department with suspected nephrolithiasis to undergo initial diagnostic ultrasonography performed by an emergency physician (point-of-care ultrasonography), ultrasonography performed by a radiologist (radiology ultrasonography), or abdominal CT. Subsequent management, including additional imaging, was at the discretion of the physician. We compared the three groups with respect to the 30-day incidence of high-risk diagnoses with complications that could be related to missed or delayed diagnosis and the 6-month cumulative radiation exposure. Secondary outcomes were serious adverse events, related serious adverse events (deemed attributable to study participation), pain (assessed on an 11-point visual-analogue scale, with higher scores indicating more severe pain), return emergency department visits, hospitalizations, and diagnostic accuracy. RESULTS A total of 2759 patients underwent randomization: 908 to point-of-care ultrasonography, 893 to radiology ultrasonography, and 958 to CT. The incidence of high-risk diagnoses with complications in the first 30 days was low (0.4%) and did not vary according to imaging method. The mean 6-month cumulative radiation exposure was significantly lower in the ultrasonography groups than in the CT group (P<0.001). Serious adverse events occurred in 12.4% of the patients assigned to point-of-care ultrasonography, 10.8% of those assigned to radiology ultrasonography, and 11.2% of those assigned to CT (P=0.50). Related adverse events were infrequent (incidence, 0.4%) and similar across groups. By 7 days, the average pain score was 2.0 in each group (P=0.84). Return emergency department visits, hospitalizations, and diagnostic accuracy did not differ significantly among the groups. CONCLUSIONS Initial ultrasonography was associated with lower cumulative radiation exposure than initial CT, without significant differences in high-risk diagnoses with complications, serious adverse events, pain scores, return emergency department visits, or hospitalizations. (Funded by the Agency for Healthcare Research and Quality.).
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Affiliation(s)
- Rebecca Smith-Bindman
- From the Departments of Radiology and Biomedical Imaging (R.S.-B., R.B.G., M. Moghadassi), Epidemiology and Biostatistics and the Philip R. Lee Institute for Health Policy Studies (R.S.-B.), Urology (M.L.S.), Medicine (V.E.V.), and Emergency Medicine (R.C.W.), University of California, San Francisco (UCSF), and the San Francisco Coordinating Center, California Pacific Medical Center Research Institute (D.R.K., S.R.C.), San Francisco, the Department of Emergency Medicine, UCSF, Fresno (R.N.B.), Keck School of Medicine of the University of Southern California, Los Angeles (T.L.K.), Center for Healthcare Policy and Research (J.M.) and Division of Biostatistics, Department of Public Health Sciences (D.L.M.) and the Department of Emergency Medicine (L.D.M.), University of California, Davis - all in California; the Division of Emergency Medicine, Washington University School of Medicine, St. Louis (C.A., R.T.G.); Department of Emergency Medicine, John H. Stroger, Jr. Hospital of Cook County, and the Department of Emergency Medicine, Rush University Medical Center - both in Chicago (J.B.); Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (C.A.C., V.E.N.); Department of Emergency Medicine, Jacobi Medical Center, Bronx, NY (J.C., J.W.); Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia (A.J.D.); Rhode Island Hospital and Brown University Department of Emergency Medicine, Providence (G.D.J.); Department of Emergency Medicine, Oregon Health and Science University, Portland (O.J.M.); and Group Health Research Institute, Group Health Cooperative, Seattle (D.L.M.); University of Utah, Salt Lake City (M. Mallin); Emory University School of Medicine, Atlanta (W.M.); University of Texas Health Science Center at Houston (S.K.M.) and the University of Texas at Houston Medical School (G.M.P.) - both in Houston; and the Hennepin County Medical Center, Minneapolis (J.R.M.)
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