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Browsing by Author "Department of Emergency Medicine, School of Medicine"
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Item 72-year-old with abdominal wall abscess(Elsevier, 2017-01) Leech, Lindsay; Welch, Julie; Department of Emergency Medicine, School of MedicineItem Affinity purification of bacterial outer membrane vesicles (OMVs) utilizing a His-tag mutant(Elsevier, 2017-02) Alves, Nathan J.; Turner, Kendrick B.; DiVito, Kyle A.; Daniele, Michael A.; Walper, Scott A.; Department of Emergency Medicine, School of MedicineTo facilitate the rapid purification of bacterial outer membrane vesicles (OMVs), we developed two plasmid constructs that utilize a truncated, transmembrane protein to present an exterior histidine repeat sequence. We chose OmpA, a highly abundant porin protein, as the protein scaffold and utilized the lac promoter to allow for inducible control of the epitope-presenting construct. OMVs containing mutant OmpA-His6 were purified directly from Escherichia coli culture media on an immobilized metal affinity chromatography (IMAC) Ni-NTA resin. This enabling technology can be combined with other molecular tools directed at OMV packaging to facilitate the separation of modified/cargo-loaded OMV from their wt counterparts. In addition to numerous applications in the pharmaceutical and environmental remediation industries, this technology can be utilized to enhance basic research capabilities in the area of elucidating endogenous OMV function.Item Approach to Acute Heart Failure in the Emergency Department(Elsevier, 2017-09) Hunter, Benton R.; Martindale, Jennifer; Abdel-Hafez, Osama; Pang, Peter S.; Department of Emergency Medicine, School of MedicineAcute heart failure (AHF) patients rarely present complaining of ‘acute heart failure.’ Rather, they initially present to the emergency department (ED) with a myriad of chief complaints, symptoms, and physical exam findings. Such heterogeneity prompts an initially broad differential diagnosis; securing the correct diagnosis can be challenging. Although AHF may be the ultimate diagnosis, the precipitant of decompensation must also be sought and addressed. For those AHF patients who present in respiratory or circulatory failure requiring immediate stabilization, treatment begins even while the diagnosis is uncertain. The initial diagnostic workup consists of a thorough history and exam (with a particular focus on the cause of decompensation), an EKG, chest X-ray, laboratory testing, and point-of-care ultrasonography performed by a qualified clinician or technologist. We recommend initial treatment be guided by presenting phenotype. Hypertensive patients, particularly those in severe distress and markedly elevated blood pressure, should be treated aggressively with vasodilators, most commonly nitroglycerin. Normotensive patients generally require significant diuresis with intravenous loop diuretics. A small minority of patients present with hypotension or circulatory collapse. These patients are the most difficult to manage and require careful assessment of intra- and extra-vascular volume status. After stabilization, diagnosis, and management, most ED patients with AHF in the United States (US) are admitted. While this is understandable, it may be unnecessary. Ongoing research to improve diagnosis, initial treatment, risk stratification, and disposition may help ease the tremendous public health burden of AHF.Item Changing Systems Through Effective Teams: A Role for Simulation(Wiley, 2017) Rosenman, Elizabeth D.; Fernandez, Rosemarie; Wong, Ambrose H.; Cassara, Michael; Cooper, Dylan D.; Kou, Maybelle; Laack, Torrey A.; Motola, Ivette; Parsons, Jessica R.; Levine, Benjamin R.; Grand, James A.; Department of Emergency Medicine, School of MedicineTeams are the building blocks of the healthcare system, with growing evidence linking the quality of health care to team effectiveness, and team effectiveness to team training. Simulation has been identified as an effective modality for team training and assessment. Despite this, there are gaps in methodology, measurement, and implementation that prevent maximizing the impact of simulation modalities on team performance. As part of the 2017 Academic Emergency Medicine Consensus Conference “Catalyzing System Change through Health Care Simulation: Systems, Competency, and Outcomes,” we explored the impact of simulation on various aspects of team effectiveness. The consensus process included an extensive literature review, group discussions, and the conference “work-shop” involving emergency medicine physicians, medical educators, and team science experts. The objectives of this work are to: (1) explore the antecedents and processes that support team effectiveness, (2) summarize the current role of simulation in developing and understanding team effectiveness, and (3) identify research targets to further improve team-based training and assessment, with the ultimate goal of improving health care systems.Item Contribution of fibrinolysis to the physical component summary of the SF-36 after acute submassive pulmonary embolism(Springer US, 2015-08) Stewart, Lauren K.; Peitz, Geoffrey W.; Nordenholz, Kristen E.; Courtney, D. Mark; Kabrhel, Christopher; Jones, Alan E.; Rondina, Matthew T.; Diercks, Deborah B.; Klinger, James R.; Kline, Jeffrey A.; Department of Emergency Medicine, School of MedicineAcute pulmonary embolism (PE) can diminish patient quality of life (QoL). The objective was to test whether treatment with tenecteplase has an independent effect on a measurement that reflects QoL in patients with submassive PE. This was a secondary analysis of an 8-center, prospective randomized controlled trial, utilizing multivariate regression to control for predefined predictors of worsened QoL including: age, active malignancy, history of PE or deep venous thrombosis (DVT), recurrent PE or DVT, chronic obstructive pulmonary disease and heart failure. QoL was measured with the physical component summary (PCS) of the SF-36. Analysis included 76 patients (37 randomized to tenecteplase, 39 to placebo). Multivariate regression yielded an equation f(8, 67), P<0.001, with R2 = 0.303. Obesity had the largest effect on PCS (β = −8.6, P<0.001), with tenecteplase second (β = 4.73, P = 0.056). After controlling for all interactions, tenecteplase increased the PCS by +5.37 points (P = 0.027). In patients without any of the defined comorbidities, the coefficient on the tenecteplase variable was not significant (−0.835, P = 0.777). In patients with submassive PE, obesity had the greatest influence on QoL, followed by use of fibrinolysis. Fibrinolysis had a marginal independent effect on patient QoL after controlling for comorbidities, but was not significant in patients without comorbid conditions.Item Directed Protein Packaging within Outer Membrane Vesicles from Escherichia coli: Design, Production and Purification(2016) Alves, Nathan J.; Turner, Kendrick B.; Walper, Scott A.; Department of Emergency Medicine, School of MedicineA protocol for the production, purification, and use of enzyme packaged outer membrane vesicles (OMV) providing for enhanced enzyme stability for implementation across diverse applications is presented.Item Emergency Department Cardiopulmonary Evaluation of Low-Risk Chest Pain Patients with Self-Reported Stress and Anxiety(Elsevier, 2017-03) Musey, Paul I., Jr.; Kline, Jeffrey A.; Department of Emergency Medicine, School of MedicineBackground Chest pain is a high-risk emergency department (ED) chief complaint; the majority of clinical resources are directed toward detecting and treating cardiopulmonary emergencies. However, at follow-up, 80%–95% of these patients have only a symptom-based diagnosis; a large number have undiagnosed anxiety disorders. Objective Our aim was to measure the frequency of self-identified stress or anxiety among chest pain patients, and compare their pretest probabilities, care processes, and outcomes. Methods Patients were divided into two groups: explicitly self-reported anxiety and stress or not at 90-day follow-up, then compared on several variables: ultralow (<2.5%) pretest probability, outcome rates for acute coronary syndrome (ACS) and pulmonary embolism (PE), radiation exposure, total costs at 30 days, and 90-day recidivism. Results Eight hundred and forty-five patients were studied. Sixty-seven (8%) explicitly attributed their chest pain to “stress” or “anxiety”; their mean ACS pretest probability was 4% (95% confidence interval 2.9%–5.7%) and 49% (33/67) had ultralow pretest probability (0/33 with ACS or PE). None (0/67) were diagnosed with anxiety. Seven hundred and seventy-eight did not report stress or anxiety and, of these, 52% (403/778) had ultralow ACS pretest probability. Only one patient (0.2%; 1/403) was diagnosed with ACS and one patient (0.4%; 1/268) was diagnosed with PE. Patients with self-reported anxiety had similar radiation exposure, associated costs, and nearly identical (25.4% vs. 25.7%) ED recidivism to patients without reported anxiety. Conclusions Without prompting, 8% of patients self-identified “stress” or “anxiety” as the etiology for their chest pain. Most had low pretest probability, were over-investigated for ACS and PE, and not investigated for anxiety syndromes.Item Rationale and Design of the ICON-RELOADED Study: International Collaborative of Nterminal pro-B-type Natriuretic Peptide Re-evaluation of Acute Diagnostic Cut-Offs in the Emergency Department(Elsevier, 2017-10) Gaggin, Hanna Kim; Chen-Tournoux, Annabel Angela; Christenson, Robert H.; Doros, Gheorghe; Hollander, Judd Eric; Levy, Phillip David; Nagurney, John Tobias; Nowak, Richard Michael; Pang, Peter S.; Patel, Darshita; Peacock, Willam Frank; Walters, Elizabeth Lea; Januzzi, James Louis; Department of Emergency Medicine, School of MedicineObjectives The objectives were to reassess use of amino-terminal pro B-type natriuretic peptide (NT-proBNP) concentrations for diagnosis and prognosis of acute heart failure (HF) in patients with acute dyspnea. Background NT-proBNP facilitates diagnosis, prognosis, and treatment in patients with suspected or proven acute HF. As demographics of such patients are changing, previous diagnostic NT-proBNP thresholds may need updating. Additionally, value of in-hospital NT-proBNP prognostic monitoring for HF is less understood. Methods In a prospective, multicenter study in the United States and Canada, patients presenting to emergency departments with acute dyspnea were enrolled, with demographic, medication, imaging, and clinical course information collected. NT-proBNP analysis will be performed using the Roche Diagnostics Elecsys proBNPII immunoassay in blood samples obtained at baseline and at discharge (if hospitalized). Primary end points include positive predictive value of previously established age-stratified NT-proBNP thresholds for the adjudicated diagnosis of acute HF and its negative predictive value to exclude acute HF. Secondary end points include sensitivity, specificity, and positive and negative likelihood ratios for acute HF and, among those with HF, the prognostic value of baseline and predischarge NT-proBNP for adjudicated clinical end points (including all-cause death and hospitalization) at 30 and 180 days. Results A total of 1,461 dyspneic subjects have been enrolled and are eligible for analysis. Follow-up for clinical outcome is ongoing. Conclusions The International Collaborative of N-terminal pro–B-type Natriuretic Peptide Re-evaluation of Acute Diagnostic Cut-Offs in the Emergency Department study offers a contemporary opportunity to understand best diagnostic cutoff points for NT-proBNP in acute HF and validate in-hospital monitoring of HF using NT-proBNP.Item Superficial Temporal Artery Pseudoaneurysm Presenting as A Suspected Sebaceous Cyst(Elsevier, 2016-12) Rood, Loren K.; Department of Emergency Medicine, School of MedicineA 20-year-old man presented to the emergency department (ED) requesting to have a “cyst” on his scalp drained. The patient stated that he had first noticed the cyst about 1.5 years ago, which seemed to develop after he was hit on the head during an altercation. He reported that it was drained in this ED 6 to 8 months earlier but that it did not resolve. On examination, the left temporal scalp had a 2-cm indurated cystic subcutaneous lesion that was minimally tender, without any drainage or overlying erythema. The patient was advised that it appeared to be sebaceous cyst, which would likely recur until formally excised. Because of his mild discomfort, he opted for incision and drainage pending his clinic referral. After alcohol preparation and local anesthesia, the incision yielded only brisk bleeding that was easily controlled with fingertip pressure but required suture placement for complete hemostasis. The lesion was felt to be faintly pulsatile while holding pressure. Point of care (POC) ultrasound evaluation performed with a high frequency linear array probe revealed the cyst (Figure 1) to be a superficial temporal artery (STA) pseudoaneurysm. Standard B mode imaging clearly showed turbulent blood flow (Video 1). Color Doppler ultrasound imaging (Video 2) showed the typical swirling of blood within the aneurysm (the “yin-yang” sign). Vascular surgery was consulted and arrangements were made for outpatient excision of the lesion. At surgery approximately 1 month later, the lesion was confirmed to be a pseudoaneurysm.Item Update: Does Rocuronium Create Better Intubating Conditions Than Succinylcholine for Rapid Sequence Intubation?(Elsevier, 2017-05) Welch, Julie L.; Seupaul, Rawle A.; Department of Emergency Medicine, School of Medicine