Emergency Department Management of Patients on Warfarin Therapy.
Ann Emerg Med. 2011 Apr 7;
Authors: Meeker E, Dennehy CE, Weber EJ, Kayser SR
STUDY OBJECTIVE: To characterize warfarin management in the emergency depar…

[Read more →]

Two Days of Dexamethasone Versus 5 Days of Prednisone in the Treatment of Acute Asthma: A Randomized Controlled Trial.

Ann Emerg Med. 2011 Feb 17;

Authors: Kravitz J, Dominici P, Ufberg J, Fisher J, Giraldo P

STUDY OBJECTIVE: Dexamethasone has a longer half-life than prednisone and is well tolerated orally. We compare the time needed to return to normal activity and the frequency of relapse after acute exacerbation in adults receiving either 5 days of prednisone or 2 days of dexamethasone. METHODS: We randomized adult emergency department patients (aged 18 to 45 years) with acute exacerbations of asthma (peak expiratory flow rate less than 80% of ideal) to receive either 50 mg of daily oral prednisone for 5 days or 16 mg of daily oral dexamethasone for 2 days. Outcomes were assessed by telephone follow-up. RESULTS: Ninety-six prednisone and 104 dexamethasone subjects completed the study regimen and follow-up. More patients in the dexamethasone group reported a return to normal activities within 3 days compared with the prednisone group (90% versus 80%; difference 10%; 95% confidence interval 0% to 20%; P=.049). Relapse was similar between groups (13% versus 11%; difference 2%; 95% confidence interval -7% to 11%, P=.67). CONCLUSION: In acute exacerbations of asthma in adults, 2 days of oral dexamethasone is at least as effective as 5 days of oral prednisone in returning patients to their normal level of activity and preventing relapse.

PMID: 21334098 [PubMed - as supplied by publisher]

[Read more →]

Hospital Determinants of Emergency Department Left Without Being Seen Rates.

Ann Emerg Med. 2011 Feb 18;

Authors: Hsia RY, Asch SM, Weiss RE, Zingmond D, Liang LJ, Han W, McCreath H, Sun BC

STUDY OBJECTIVE: The proportion of patients who leave without being seen in the emergency department (ED) is an outcome-oriented measure of impaired access to emergency care and represents the failure of an emergency care delivery system to meet its goals of providing care to those most in need. Little is known about variation in the amount of left without being seen or about hospital-level determinants. Such knowledge is necessary to target hospital-level interventions to improve access to emergency care. We seek to determine whether hospital-level socioeconomic status case mix or hospital structural characteristics are predictive of ED left without being seen rates. METHODS: We performed a cross-sectional study of all acute-care, nonfederal hospitals in California that operated an ED in 2007, using data from the California Office of Statewide Health Planning and Development database and the US census. Our outcome of interest was whether a visit to a given hospital ED resulted in left without being seen. The proportion of left without being seen was measured by the number of left without being seen cases out of the total number of visits. RESULTS: We studied 9.2 million ED visits to 262 hospitals in California. The percentage of left without being seen varied greatly over hospitals, ranging from 0% to 20.3%, with a median percentage of 2.6%. In multivariable analyses adjusting for hospital-level socioeconomic status case mix, visitors to EDs with a higher proportion of low-income and poorly insured patients experienced a higher risk of left without being seen. We found that the odds of an ED visit resulting in left without being seen increased by a factor of 1.15 for each 10-percentage-point increase in poorly insured patients, and odds of left without being seen decreased by a factor of 0.86 for each $10,000 increase in household income. When hospital structural characteristics were added to the model, county ownership, trauma center designation, and teaching program affiliation were positively associated with increased probability of left without being seen (odds ratio 2.09; 1.62, and 2.14, respectively), and these factors attenuated the association with insurance status. CONCLUSION: Visitors to different EDs experience a large variation in their probability of left without being seen, and visitors to hospitals serving a high proportion of low-income and poorly insured patients are at disproportionately higher risk of leaving without being seen. Our findings suggest that there is room for substantial improvement in this outcome, and regional interventions can be targeted toward certain at-risk hospitals to improve access to emergency care.

PMID: 21334761 [PubMed - as supplied by publisher]

[Read more →]

One-Year Prognosis After Syncope and the Failure of the ROSE Decision Instrument to Predict One-Year Adverse Events.

Ann Emerg Med. 2011 Feb 1;

Authors: Reed MJ, Henderson SS, Newby BS, Gray AJ

STUDY OBJECTIVE: We investigate the incidence of adverse events at 1 year in the cohort of emergency department (ED) syncope patients enrolled in the original Risk Stratification of Syncope in the Emergency Department (ROSE) study, the time to adverse event, and the test performance of the ROSE decision instrument to detect events at 1 year. METHODS: This report details the 1-year follow-up of adult syncope patients presenting to the ED who were enrolled into the ROSE study, a single-center, prospective, observational cohort study. The primary endpoint was the combination of serious outcome and all-cause death at 1 year. Serious outcome encompassed acute myocardial infarction, life-threatening arrhythmia, need for pacemaker/implantable defibrillator, pulmonary embolus, cerebrovascular accident, intracranial or subarachnoid hemorrhage, and interventional procedure or hemorrhage requiring blood transfusion. Secondary endpoints were all-cause death and cardiovascular serious outcome at 1 year. RESULTS: One thousand forty-three patients were available for analysis; 162 patients (15.5%) had a primary outcome. Twenty-eight (17%) of these were within 24 hours, 56 (35%) were within 1 week, and 78 (48%) were within 1 month. The remaining 84 (52%) outcomes occurred between months 2 and 12. At 1 year, 71 (6.8%) patients had died and 76 (7.3%) had a cardiovascular serious outcome. The sensitivity and specificity of the ROSE decision instrument for 1-year serious outcome and all-cause death were, respectively, 71.6% (95% confidence interval [CI] 63.9% to 78.3%) and 71.1% (95% CI 67.9% to 74.0%); for 1-year all-cause death, 76.1% (95% CI 64.2% to 85.1%) and 67.4% (95% CI 64.3% to 70.3%); and for 1-year cardiovascular serious outcome, 75.0% (95% CI 63.5% to 83.9%) and 67.5% (95% CI 64.5% to 70.5%). CONCLUSION: The proportion of patients with serious outcome and all-cause death 1 year after syncope is similar to that reported in recent international syncope studies. We have defined the proportion of patients with cardiovascular serious outcome at 1 year and have shown that most events occurred in the first month, with decreased frequency of events observed after that time especially marked for cardiovascular serious outcome. More than 50% of the outcomes observed, however, occurred after the first month. The ROSE decision instrument does not perform well at predicting 1-year outcome of ED syncope patients.

PMID: 21288597 [PubMed - as supplied by publisher]

[Read more →]

To treat or not to treat: adjunctive antibiotics for uncomplicated abscesses.

Ann Emerg Med. 2011 Feb;57(2):183-5

Authors: Spellberg B, Boucher H, Bradley J, Das A, Talbot G

PMID: 21251530 [PubMed - in process]

[Read more →]

Metoclopramide for Acute Migraine: A Dose-Finding Randomized Clinical Trial.

Ann Emerg Med. 2011 Jan 10;

Authors: Friedman BW, Mulvey L, Esses D, Solorzano C, Paternoster J, Lipton RB, Gallagher EJ

STUDY OBJECTIVE:: Intravenous metoclopramide is effective as primary therapy for acute migraine, but the optimal dose of this medication is not yet known. The objective of this study is to compare the efficacy and safety of 3 different doses of intravenous metoclopramide for the treatment of acute migraine. METHODS:: This was a randomized, double-blind, dose-finding study conducted on patients who presented to our emergency department (ED) meeting International Classification of Headache Disorders criteria for migraine without aura. We randomized patients to 10, 20, or 40 mg of intravenous metoclopramide. We coadministered diphenhydramine to all patients to prevent extrapyramidal adverse effects. The primary outcome was improvement in pain on an 11-point numeric rating scale at 1 hour. Secondary outcomes included sustained pain freedom at 48 hours and adverse effects. RESULTS:: In this study, 356 patients were randomized. Baseline demographics and headache features were comparable among the groups. At 1 hour, those who received 10 mg of intravenous metoclopramide improved by a mean of 4.7 numeric rating scale points (95% confidence interval [CI] 4.2 to 5.2 points); those who received 20 mg improved by 4.9 points (95% CI 4.4 to 5.4 points), and those who received 40 mg improved by 5.3 points (95% CI 4.8 to 5.9 points). Rates of 48-hour sustained pain freedom in the 10-, 20-, and 40-mg groups were 16% (95% CI 10% to 24%), 20% (95% CI 14% to 28%), and 21% (95% CI 15% to 29%), respectively. The most commonly occurring adverse event was drowsiness, which impaired function in 17% (95% CI 13% to 21%) of the overall study population. Akathisia developed in 33 patients. Both drowsiness and akathisia were evenly distributed across the 3 arms of the study. One month later, no patient had developed tardive dyskinesia. CONCLUSION:: Twenty milligrams or 40 mg of metoclopramide is no better for acute migraine than 10 mg of metoclopramide.

PMID: 21227540 [PubMed - as supplied by publisher]

[Read more →]

Prospective Trial of Real-Time Electronic Surveillance to Expedite Early Care of Severe Sepsis.

Ann Emerg Med. 2011 Jan 10;

Authors: Nelson JL, Smith BL, Jared JD, Younger JG

STUDY OBJECTIVE: An automated, real-time electronic medical record query and caregiver notification system was developed and examined for its utility in improving sepsis care. We hypothesize that the algorithm will increase the rate and timeliness of sampling of blood lactate and blood cultures, performance of chest radiography, and provision of antibiotics. METHODS: A before-and-after, prospective study with consecutive enrollment examined an algorithm that automatically identified adult patients accumulating 2 or more systemic inflammatory response syndrome (SIRS) criteria and 2 or more blood pressure measurements less than or equal to 90 mm Hg during their emergency department (ED) stay. In phase 1, the system collected information but did not alert caregivers. In phase 2, caregivers were notified by alphanumeric paging and a text entry into the electronic medical record of the patients’ potential illness and were provided with specific recommendations. RESULTS: Patients (33,460) were screened during 6 months; 398 patients activated the system, including 184 (46%) appropriately identified as severely septic. The algorithm had a 54% positive predictive value and 99% negative predictive value in detecting severe infection with acute organ dysfunction. The median time for patients to accumulate SIRS and blood pressure criteria was 152 minutes (interquartile range [IQR] 71 to 284 minutes), underscoring the dynamic nature of diagnosing critical illness in the emergency setting and the need for detection algorithms to repeatedly assess patients during their evaluation. After implementation, 2 interventions were performed more frequently, chest radiograph before admission (odds ratio 3.2; 95% confidence interval 1.1 to 9.5) and collection of blood cultures (odds ratio 2.9; 95% confidence interval 1.1 to 7.7). Only blood culture testing was performed significantly faster in the presence of decision support (median time to culture before intervention 86 minutes, IQR 31, 296 minutes; median time to culture after intervention 81 minutes, IQR 37, 245 minutes; P=.032 by Cox proportional hazards modeling). The predominant shortcoming of the strategy was failing to detect severely septic cases before caregivers. CONCLUSION: An automated algorithm for detecting potential sepsis increased the frequency and timeliness of some ED interventions for severe sepsis. Future efforts need to identify patient features present earlier in ED evaluation than SIRS and hypotension.

PMID: 21227543 [PubMed - as supplied by publisher]

[Read more →]

Patient Perceptions of Computed Tomographic Imaging and Their Understanding of Radiation Risk and Exposure.

Ann Emerg Med. 2010 Dec 10;

Authors: Baumann BM, Chen EH, Mills AM, Glaspey L, Thompson NM, Jones MK, Farner MC

STUDY OBJECTIVE:: We describe patient perceptions of computed tomography (CT) and their understanding of radiation exposure and risk. METHODS:: This was a cross-sectional study of acute abdominal pain patients aged 18 years or older. Confidence in medical evaluations with increasing levels of laboratory testing and imaging was rated on a 100-point visual analog scale. Knowledge of radiation exposure was ascertained when participants compared the radiation dose of one abdomen-pelvis CT with 2-view chest radiography. To assess cancer risk knowledge, participants rated their agreement with these factual statements: “Approximately 2 to 3 abdominal CTs give the same radiation exposure as experienced by Hiroshima survivors” and “2 to 3 abdominal CTs over a person’s lifetime can increase cancer risk.” Previous CT was also assessed. RESULTS:: There were 1,168 participants, 67% women and mean age 40.7 years (SD 15.9 years). Median confidence in a medical evaluation without ancillary testing was 20 (95% confidence interval [CI] 16 to 25) compared with 90 (95% CI 88 to 91) when laboratory testing and CT were included. More than 70% of participants underestimated the radiation dose of CT relative to chest radiography, and cancer risk comprehension was poor. Median agreement with the Hiroshima statement was 13 (95% CI 10 to 16) and 45 (95% CI 40 to 45) with the increased lifetime cancer risk statement. Seven hundred ninety-five patients reported receiving a previous CT. Of 365 patients who reported no previous CT, 142 (39%) had one documented in our electronic medical record. CONCLUSION:: Patients are more confident when CT imaging is part of their medical evaluation but have a poor understanding of the concomitant radiation exposure and risk and underestimate their previous imaging experience.

PMID: 21146900 [PubMed - as supplied by publisher]

[Read more →]

Serum Lactate Is a Better Predictor of Short-Term Mortality When Stratified by C-reactive Protein in Adult Emergency Department Patients Hospitalized for a Suspected Infection.

Ann Emerg Med. 2010 Nov 24;

Authors: Green JP, Berger T, Garg N, Shapiro NI

STUDY OBJECTIVE:: We determine whether C-reactive protein (CRP) adds prognostic value to serum lactate levels when assessing mortality risk in emergency department (ED) patients admitted for a suspected infection. METHODS:: This was an observational cohort of unique adult patients (?21 years of age) who had lactate and CRP testing in the ED and were admitted for a suspected infection during a 1-year period. All data were collected through retrospective chart review. The study site is an urban teaching hospital with an approximate annual census of 95,000 patients. The endpoint was 28-day inpatient mortality. RESULTS:: One thousand one hundred forty-three patients had lactate and CRP testing in the ED, an admitting diagnosis of infection, and complete records. Twenty-eight-day inpatient mortality for patients with both a lactate level greater than or equal to 4.0 mmol/L and CRP level greater than 10.0 mg/dL was 44.0% (95% confidence interval [CI] 32.5% to 55.5%), for lactate greater than or equal to 4.0 mmol/L and CRP less than or equal to 10.0 mg/dL, it was 9.7% (95% CI 2.7% to 16.7%), and for lactate level less than 4.0 mmol/L, it was 9.1% (95% CI 7.3% to 10.9%). In a logistic regression model that included patient demographics and Charlson score, as well as 4 separate dichotomous variables that were positive only in subjects with (1) serum lactate greater than or equal to 4.0 mmol/L and CRP level greater than 10.0 mg/dL, (2) lactate level greater than or equal to 4.0 mmol/L and CRP level less than or equal to 10.0 mg/dL, (3) lactate level less than 4.0 mmol/L and CRP level greater than 10.0 mg/dL, and (4) lactate level less than 4.0 mmol/L and CRP level less than or equal to 10.0 mg/dL (as reference), patients with both a lactate level greater than or equal to 4.0 mmol/L and CRP greater than 10 mg/dL had an increased risk of 28-day inpatient mortality (odds ratio 12.3; 95% CI 6.8 to 22.3). CONCLUSION:: In this cohort, patients with both an increased CRP level and hyperlactatemia had a higher mortality rate than patients with abnormalities of either laboratory test in isolation.

PMID: 21111512 [PubMed - as supplied by publisher]

[Read more →]

Effectiveness and Acceptability of a Computerized Decision Support System Using Modified Wells Criteria for Evaluation of Suspected Pulmonary Embolism.

Ann Emerg Med. 2010 Nov 1;

Authors: Drescher FS, Chandrika S, Weir ID, Weintraub JT, Berman L, Lee R, Buskirk PD, Wang Y, Adewunmi A, Fine JM

STUDY OBJECTIVE:: Ready availability of computed tomography (CT) angiography for evaluation of pulmonary embolism in emergency departments (EDs) is associated with a dramatic increase in the number of CT angiography tests. The aims of this study are to determine whether a validated prediction algorithm embedded in a computerized decision support system improves the positive yield rate of CT angiography for pulmonary embolism and is acceptable to emergency physicians. METHODS:: This study was conducted as a prospective interventional study with a retrospective preinterventional comparison group. RESULTS:: The implementation of the computerized physician order entry-based computerized decision support system was associated with an overall increase in the positivity rate of from 8.3% (95% confidence interval [CI] 4.9% to 12.9%) preintervention to 12.7% (95% CI 8.6% to 17.7%) postintervention, with a difference of 4.4% (95% CI -1.4% to 10.1%). A total of 404 patients were eligible for inclusion. Physician nonadherence to the computerized decision support system occurred in 105 (26.7%) cases. Fifteen patients underwent CT angiography despite low Wells score and negative D-dimer result, all of whose results were negative for pulmonary embolism. Emergency physicians did not order CT angiography for 44 patients despite high pretest probability, with one receiving a diagnosis of pulmonary embolism on a subsequent visit and another, of DVT. When emergency physicians adhered to the computerized decision support system for the evaluation of suspected pulmonary embolism, a higher yield of CT angiography for pulmonary embolism occurred, with 28 positive results of 168 CT angiography tests (16.7%; 95% CI 11.4% to 23.2%) and a difference compared with preintervention of 8.4% (95% CI 1.7% to 15.4%). Physicians cited the time required to apply the computerized decision support system and a preference for intuitive judgment as reasons for not adhering to the computerized decision support system. CONCLUSION:: Use of an evidence-based computerized physician order entry-based computerized decision support system for the evaluation of suspected pulmonary embolism was associated with a higher yield of CT angiography for pulmonary embolism. The computerized decision support system, however, was poorly accepted by emergency physicians (partly because of increased computer time), leading to possibly selective use, reducing the effect on overall yield, and leading to removal of the computerized decision support system from the computer order entry. These findings emphasize the importance of facilitation of rule-based decisionmaking in the ED and attentiveness to the complex demands placed on emergency physicians.

PMID: 21050624 [PubMed - as supplied by publisher]

[Read more →]

Compression Ultrasonography of the Lower Extremity With Portable Vascular Ultrasonography Can Accurately Detect Deep Venous Thrombosis in the Emergency Department.

Ann Emerg Med. 2010 Sep 21;

Authors: Crisp JG, Lovato LM, Jang TB

STUDY OBJECTIVE:: Compression ultrasonography of the lower extremity is an established method of detecting proximal lower extremity deep venous thrombosis when performed by a certified operator in a vascular laboratory. Our objective is to determine the sensitivity and specificity of bedside 2-point compression ultrasonography performed in the emergency department (ED) with portable vascular ultrasonography for the detection of proximal lower extremity deep venous thrombosis. We did this by directly comparing emergency physician-performed ultrasonography to lower extremity duplex ultrasonography performed by the Department of Radiology. METHODS:: This was a prospective, cross-sectional study and diagnostic test assessment of a convenience sample of ED patients with a suspected lower extremity deep venous thrombosis, conducted at a single-center, urban, academic ED. All physicians had a 10-minute training session before enrolling patients. ED compression ultrasonography occurred before Department of Radiology ultrasonography and involved identification of 2 specific points: the common femoral and popliteal vessels, with subsequent compression of the common femoral and popliteal veins. The study result was considered positive for proximal lower extremity deep venous thrombosis if either vein was incompressible or a thrombus was visualized. Sensitivity and specificity were calculated with the final radiologist interpretation of the Department of Radiology ultrasonography as the criterion standard. RESULTS:: A total of 47 physicians performed 199 2-point compression ultrasonographic examinations in the ED. Median number of examinations per physician was 2 (range 1 to 29 examinations; interquartile range 1 to 5 examinations). There were 45 proximal lower extremity deep venous thromboses observed on Department of Radiology evaluation, all correctly identified by ED 2-point compression ultrasonography. The 153 patients without proximal lower extremity deep venous thrombosis all had a negative ED compression ultrasonographic result. One patient with a negative Department of Radiology ultrasonographic result was found to have decreased compression of the popliteal vein on ED compression ultrasonography, giving a single false-positive result, yet repeated ultrasonography by the Department of Radiology 1 week later showed a popliteal deep venous thrombosis. The sensitivity and specificity of ED 2-point compression ultrasonography for deep venous thrombosis were 100% (95% confidence interval 92% to 100%) and 99% (95% confidence interval 96% to 100%), respectively. CONCLUSION:: Emergency physician-performed 2-point compression ultrasonography of the lower extremity with a portable vascular ultrasonographic machine, conducted in the ED by this physician group and in this patient sample, accurately identified the presence and absence of proximal lower extremity deep venous thrombosis.

PMID: 20864215 [PubMed - as supplied by publisher]

[Read more →]

Significant Reduction of Laboratory Specimen Labeling Errors by Implementation of an Electronic Ordering System Paired With a Bar-Code Specimen Labeling Process.

Ann Emerg Med. 2010 Sep 3;

Authors: Hill PM, Mareiniss D, Murphy P, Gardner H, Hsieh YH, Levy F, Kelen GD

STUDY OBJECTIVE: We measure the rate of emergency department (ED) specimen processing error reduction after implementation of an electronic physician order entry system paired with a bar-coded specimen labeling process. METHODS: A cohort pre- and postintervention study was conducted in the ED during a 61-month period ending September 2008 in a large urban teaching hospital. Historically, laboratory order and requisition processing was done by hand. Interventions included implementing an ED-specific electronic documentation and information system, which included physician order entry with patient verification through bar-coded wristbands and bar-coded specimen labels. The main outcome measure was processing error rate, defined as unlabeled/mislabeled/wrong patient specimen or requisition. Pre- and postimplementation data were tabulated monthly and compared in aggregate by chi(2) test. The contribution of ED error to total institution specimen error was also calculated. RESULTS: Of the 724,465 specimens collected preintervention, 3,007 (0.42%) were recorded as errors versus 379 errors (0.11%) of 334,039 specimens collected postintervention, which represents a 74% relative and 0.31% absolute decrease (95% confidence interval 0.28% to 0.32%). The proportion of institutional errors contributed by the ED was reduced from 20.4% to 11.4%, a 44% relative and 9.0% absolute reduction (95% confidence interval 7.7% to 10.3%). Subanalysis revealed that the majority of continued errors occur when the physician order entry/bar-code system could not be used (eg, blood bank or surgical pathology specimens). CONCLUSION: Combining an electronic physician order entry with bar-coded patient verification and electronic documentation and information system-generated specimen labels can significantly reduce ED specimen-related errors, with sizable influence on institutional specimen-related errors. Continued use of hand labeling and processing for special specimens appears inadvisable, though the cost-effectiveness of this intervention has not been established.

PMID: 20822830 [PubMed - as supplied by publisher]

[Read more →]

Systemic Loxoscelism in the Age of Community-Acquired Methicillin-Resistant Staphylococcus aureus.

Ann Emerg Med. 2010 Sep 1;

Authors: Rogers KM, Klotz CR, Jack M, Seger D

The increase in cases of community-acquired methicillin-resistant Staphylococcus aureus (MRSA), as well as its isolation from the majority of skin and soft tissue abscesses in the emergency department, requires the emergency physician to consider this diagnosis in all skin or soft tissue infections. However, making the diagnosis of MRSA when the wound is actually a cutaneous lesion of a brown recluse spider bite may have untoward consequences. Furthermore, the clinical manifestations of systemic loxoscelism may be misdiagnosed as a systemic staphylococcal infection. We present a patient with systemic loxoscelism who was diagnosed with a systemic infection and received an unnecessary surgical procedure.

PMID: 20817348 [PubMed - as supplied by publisher]

[Read more →]

A Clinical Prediction Model to Estimate Risk for 30-Day Adverse Events in Emergency Department Patients With Symptomatic Atrial Fibrillation.

Ann Emerg Med. 2010 Aug 20;

Authors: Barrett TW, Martin AR, Storrow AB, Jenkins CA, Harrell FE, Russ S, Roden DM, Darbar D

STUDY OBJECTIVE: Atrial fibrillation affects more than 2 million people in the United States and accounts for nearly 1% of emergency department (ED) visits. Physicians have little information to guide risk stratification of patients with symptomatic atrial fibrillation and admit more than 65%. Our aim is to assess whether data available in the ED management of symptomatic atrial fibrillation can estimate a patient’s risk of experiencing a 30-day adverse event. METHODS: We systematically reviewed the electronic medical records of all ED patients presenting with symptomatic atrial fibrillation between August 2005 and July 2008. Predefined adverse outcomes included 30-day ED return visit, unscheduled hospitalization, cardiovascular complication, or death. We performed multivariable logistic regression to identify predictors of 30-day adverse events. The model was validated with 300 bootstrap replications. RESULTS: During the 3-year study period, 914 patients accounted for 1,228 ED visits. Eighty patients were excluded for non-atrial-fibrillation-related complaints and 2 patients had no follow-up recorded. Of 832 eligible patients, 216 (25.9%) experienced at least 1 of the 30-day adverse events. Increasing age (odds ratio [OR] 1.20 per decade; 95% confidence interval [CI] 1.06 to 1.36 per decade), complaint of dyspnea (OR 1.57; 95% CI 1.12 to 2.20), smokers (OR 2.35; 95% CI 1.47 to 3.76), inadequate ventricular rate control (OR 1.58; 95% CI 1.13 to 2.21), and patients receiving beta-blockers (OR 1.44; 95% CI 1.02 to 2.04) were independently associated with higher risk for adverse events. C-index was 0.67. CONCLUSION: In ED patients with symptomatic atrial fibrillation, increased age, inadequate ED ventricular rate control, dyspnea, smoking, and beta-blocker treatment were associated with an increased risk of a 30-day adverse event.

PMID: 20728962 [PubMed - as supplied by publisher]

[Read more →]

Related Articles

A prospective, randomized trial of intravenous prochlorperazine versus subcutaneous sumatriptan in acute migraine therapy in the emergency department.

Ann Emerg Med. 2010 Jul;56(1):1-6

Authors: Kostic MA, Gutierrez FJ, Rieg TS, Moore TS, Gendron RT

STUDY OBJECTIVE: Intravenous (IV) prochlorperazine with diphenhydramine is superior to subcutaneous sumatriptan in the treatment of migraine patients presenting to the emergency department (ED). METHODS: In this randomized, double-blind, placebo-controlled trial, after providing written informed consent, patients presenting to the ED with a chief complaint of migraine received a 500-mL bolus of IV saline solution and either 10 mg prochlorperazine with 12.5 mg diphenhydramine IV plus saline solution placebo subcutaneously or saline solution placebo IV plus 6 mg sumatriptan subcutaneously. Pain intensity was assessed with 100-mm visual analog scales (visual analog scale at baseline and every 20 minutes for 80 minutes). The primary outcome was change in pain intensity from baseline to 80 minutes or time of ED discharge if subjects remained in the ED for fewer than 80 minutes after treatment. Sedation and nausea were assessed every 20 minutes with visual analog scale scales, and subjects were contacted within 72 hours to assess headache recurrence. RESULTS: Sixty-eight subjects entered the trial, with complete data for 66 subjects. Baseline pain scores were similar for the prochlorperazine/diphenhydramine and sumatriptan groups (76 versus 71 mm). Mean reductions in pain intensity at 80 minutes or time of ED discharge were 73 mm for the prochlorperazine/diphenhydramine group and 50 mm for those receiving sumatriptan (mean difference 23 mm; 95% confidence interval 11 to 36 mm). Sedation, nausea, and headache recurrence rates were similar. CONCLUSION: IV prochlorperazine with diphenhydramine is superior to subcutaneous sumatriptan in the treatment of migraine.

PMID: 20045576 [PubMed - indexed for MEDLINE]

[Read more →]