Department of Emergency Medicine

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    1-year mortality following contrast-induced nephropathy
    (2013) Mitchell, Alice M; Jones, Alan E; Tumlin, James A; Kline, Jeffrey A.
    Objective: The aim of this study was to determine the 1-year mortality risk subsequent to Contrast-Induced Nephropathy (CIN) following CECT imaging, relative to other well-recognized predictors of mortality. Methods: We followed a prospective, consecutive cohort of ambulatory patients who received intravenous contrast for CECT for the outcome of death from any cause within 1 year. In a multivariate analysis, we compared CIN with other predictors of mortality: active malignancy, coronary artery disease (CAD), congestive heart failure (CHF) and age ≥70 years. Anticipating that terminal cancers would account for the majority of deaths in this population, we also analyzed the subset of patients without an active malignancy at the time of enrollment. Results: We followed 633 patients and 46 died (7%, 95%CI: 5-9%) within 1 year. The incidence of CIN was 11% (95%CI: 8-14%). Active malignancy (HR 9.2, 95%CI: 5.1-16.8), CIN (HR 2.4, 95%CI: 1.3-4.6), CHF (HR 2.1, 95%CI: 1.0-4.2), CAD (HR 2.2, 95%CI: 1.0-5.5) and age ≥70 years (HR 1.8, 95%CI: 1.0-3.8) were significant predictors of all-cause mortality. Among patients without active malignancies, the mortality rate was 4% (25/580, 95%CI: 3-6%) and CIN (HR 4.0, 95%CI: 1.7-9.6) and age ≥70 years (HR 3.7, 95%CI: 1.4-9.7) were significantly associated with death, whereas CAD (HR 2.5, 95%CI: 0.8-7.7) and CHF (HR 1.8, 95%CI: 0.6-5.3) were not. Conclusions: The development of CIN following CECT is associated with an increased likelihood of death at 1 year among patients with and without active malignancies, comparable to CAD, CHF and advanced age.
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    2-Hour Accelerated Diagnostic Protocol to Assess Patients With Chest Pain Symptoms Using Contemporary Troponins as the Only Biomarker
    (2012-06) Than, Martin; Cullen, Louise; Aldous, Sally; Parsonage, William A; Reid, Christopher M; Greenslade, Jaimi; Flaws, Dylan; Hammett, Christopher J; Beam, Daren M; Ardagh, Michael W; Troughton, Richard; Brown, Anthony FT; George, Peter; Florkowski, Christopher M; Kline, Jeffrey A.; Peacock, W Frank; Maisel, Alan S; Lim, Swee Han; Lamanna, Arvin; Richards, A Mark
    Objectives The purpose of this study was to determine whether a new accelerated diagnostic protocol (ADP) for possible cardiac chest pain could identify low-risk patients suitable for early discharge (with follow-up shortly after discharge). Background Patients presenting with possible acute coronary syndrome (ACS), who have a low short-term risk of adverse cardiac events may be suitable for early discharge and shorter hospital stays. Methods This prospective observational study tested an ADP that included pre-test probability scoring by the Thrombolysis In Myocardial Infarction (TIMI) score, electrocardiography, and 0 + 2 h values of laboratory troponin I as the sole biomarker. Patients presenting with chest pain due to suspected ACS were included. The primary endpoint was major adverse cardiac event (MACE) within 30 days. Results Of 1,975 patients, 302 (15.3%) had a MACE. The ADP classified 392 patients (20%) as low risk. One (0.25%) of these patients had a MACE, giving the ADP a sensitivity of 99.7% (95% confidence interval [CI]: 98.1% to 99.9%), negative predictive value of 99.7% (95% CI: 98.6% to 100.0%), specificity of 23.4% (95% CI: 21.4% to 25.4%), and positive predictive value of 19.0% (95% CI: 17.2% to 21.0%). Many ADP negative patients had further investigations (74.1%), and therapeutic (18.3%) or procedural (2.0%) interventions during the initial hospital attendance and/or 30-day follow-up. Conclusions Using the ADP, a large group of patients was successfully identified as at low short-term risk of a MACE and therefore suitable for rapid discharge from the emergency department with early follow-up. This approach could decrease the observation period required for some patients with chest pain. (An observational study of the diagnostic utility of an accelerated diagnostic protocol using contemporary central laboratory cardiac troponin in the assessment of patients presenting to two Australasian hospitals with chest pain of possible cardiac origin; ACTRN12611001069943)
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    The 2016 Model of the Clinical Practice of Emergency Medicine
    (Elsevier, 2017-06) Counselman, Francis L.; Babu, Kavita; Edens, Mary Ann; Gorgas, Diane L.; Hobgood, Cherri; Marco, Catherine A.; Katz, Eric; Rodgers, Kevin; Stallings, Leonard A.; Wadman, Michael C.; Beeson, Michael S.; Keehbauch, Julia N.; Emergency Medicine, School of Medicine
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    2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department: A Report of the American College of Cardiology Solution Set Oversight Committee
    (Elsevier, 2022) Kontos, Michael C.; de Lemos, James A.; Deitelzweig, Steven B.; Diercks, Deborah B.; Gore, M. Odette; Hess, Erik P.; McCarthy, Cian P.; McCord, James K.; Musey, Paul I., Jr.; Villines, Todd C.; Wright, Leesa J.; Emergency Medicine, School of Medicine
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    24-year Old Medical Student with Raynaud's Phenomenon
    (Elsevier, 2016-10) Leech, Lindsay S.; Welch, Julie L.; Department of Emergency Medicine, IU School of Medicine
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    25 In-hospital Change in Lung Ultrasound Congestion Score Predicts Heart Failure Rehospitalization and Death: Implications for Clinical Trials
    (Cambridge University Press, 2023-04-24) Harrison, Nicholas Eric; Desai, Ankit; Pang, Peter; Emergency Medicine, School of Medicine
    OBJECTIVES/GOALS: Lung Ultrasound Congestion Score (LUS-CS) is a proposed measure for guiding treatment in acute heart failure (AHF). An emergency department (ED) pilot trial of LUS-guided diuresis showed reduced LUS-CS at 48 hours but no difference at hospital discharge or for clinical outcomes. We hypothesized total change in LUS-CS would predict adverse outcomes. METHODS/STUDY POPULATION: This was a post-hoc secondary analysis of the BLUSHED-AHF trial. BLUSHED-AHF was a pilot trial in which AHF patients were randomized to a LUS-guided diuresis strategy vs. usual care in the ED. The intervention was stopped after the ED course (i.e. during hospitalization). BLUSHED-AHF was designed for the intervention to target absolute values of LUS-CS over time, rather than change in LUS-CS from each patient’s baseline. We fit a cox regression model for a primary outcome of death or AHF rehospitalization, with total (ED to Hospital Discharge) change in LUS-CS as the primary predictor, adjusted for the Get-With-The-Guidelines heart failure risk score (GWTG). Survival curves were plotted, and hazard ratios calculated. RESULTS/ANTICIPATED RESULTS: 128 patients in BLUSHED-AHF were analyzed. Greater reduction in LUS-CS from ED to hospital discharge predicted event-free survival (HR = 0.74 for each 20 unit reduction in LUS-CS, 95%CI 0.56-0.99). This effect did not vary by hospitalization length or ED disposition. There was a significant interaction between change in LUS-CS and GWTG score. DISCUSSION/SIGNIFICANCE: LUS-CS total change, and not absolute values, predict adverse events in LUS-guided diuresis. Post-ED cessation of the intervention in BLUSHED-AHF may have precluded opportunity for clinical benefit. Future trials should run the entire hospital course, target change from baseline, and consider patient selection by AHF severity and initial LUS-CS.
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    41: Health Insurance and Duration of Symptoms Prior to Emergency Department Visit: An Analysis of 19,850 Patients With Suspected COVID-19
    (Elsevier, 2021-08) Gunn, A.H.; Neptune, N.; Cunningham, H.M.; Conner, D.; Adkins, L.; Tait, S.D.; Pung, L.; Courtney, D.M.; Kline, Jeffrey A.; Purakal, J.D.; Emergency Medicine, School of Medicine
    Study Objectives The COVID-19 pandemic has emphasized disparities in health outcomes across social and economic strata. The mechanisms of this relationship are poorly understood, but the length of time patients exhibit symptoms prior to getting tested for COVID-19 increases the opportunity for community transmission. We hypothesized that there is a relationship between insurance coverage and the duration of COVID-19 symptoms prior to seeking care at the emergency department (ED). Methods A national, multi-institution (n=45 sites) registry collected information on ED visits in which patients were tested for suspected COVID-19. Demographics and clinical characteristics were summarized for the total cohort. Insurance was categorized into private (private or commercial), public (Medicare, Medicaid, or dual-eligible), worker’s compensation or unknown, or no health insurance. Negative binomial regression was used to analyze both the unadjusted and adjusted relationship between insurance and the time from symptom onset to ED presentation. Adjustments included age, sex, race, ethnicity, medical history, smoking status, drug use, and number of COVID symptoms. Results Baseline demographic and clinical characteristics of included patients (n=19,850) are displayed in Table 1. The average time from symptom onset to ED presentation among patients with suspected COVID-19 was 5.4 days. In unadjusted analysis, patients with private insurance had significantly longer time of symptom onset prior to ED presentation than patients with public insurance (5.6 vs. 5.3 days, p=0.007). After multivariate adjustment, increased duration of symptoms prior to ED presentation was significantly associated with private insurance [rate ratio (RR) 1.07, 95% confidence interval (CI): 1.03 – 1.10] and no health insurance (RR 1.06, 95% CI: 1.07 – 1.13) compared to public insurance (Figure 1). Patients residing in states with Medicaid expansion were not independently associated with the increased time to ED presentation (RR 1.03, 95% CI: 1.00 – 1.07). Conclusion Patients with private insurance or no insurance waited significantly longer to present to the ED. The extended duration of symptoms prior to presentation increases the opportunities for community transmission. The results from this study can be used by health systems to target the patients at increased risk for delayed ED presentation.
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    5 Year-old with behavior change after febrile illness
    (Elsevier, 2016-10) Snow, Jerry W.; Tormoehlen, L. M.; Department of Emergency Medicine, IU School of Medicine
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    72-year-old with abdominal wall abscess
    (Elsevier, 2017-01) Leech, Lindsay; Welch, Julie; Department of Emergency Medicine, School of Medicine
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    A large back mass
    (Wiley, 2021) Pettit, Nicholas; Corson-Knowles, Daniel; Emergency Medicine, School of Medicine