Amber Laurie

Rest-activity cycle and melatonin rhythm in blind free-runners have similar periods.

In the absence of the entraining light-dark cycle, most totally blind humans free-run, albeit with relative coordination to nonphotic zeitgebers. Such blind free-runners (BFRs) often attempt to maintain a 24-h sleep-wake schedule and consequently suffer from recurrent sleep disruption and daytime somnolence. This study was conducted to determine the periods of the free-running melatonin rhythm and of the rest-activity cycle in 16 BFRs. It was found that the non-24-h component of the rest-activity rhythm correlated with the observed period of the circadian pacemaker.

The Effect of a Dedicated Psychiatric Team to Pediatric Emergency Mental Health Care

BACKGROUND Pediatric emergency department (PED) visits among children and adolescents with acute mental health needs have increased over the past decade with long wait times in the PED awaiting disposition. OBJECTIVE The objective of this study was to evaluate the effect of a new pediatric mental health liaison program with the hypothesis that this model reduces length of stay (LOS) and hospitalization rates among pediatric mental health patients. METHODS This was a pre- and postintervention retrospective study of the year prior to (June 2012-June 2013) and the year after (October 2013-October 2014) implementation of a new PED psychiatric team. All patients aged 1-18 years with a mental health International Classification of Diseases-9(th) Revision code were included. Patients who did not receive a Psychiatry consult in the PED were excluded. RESULTS There were 83 encounters in the year prior to and 129 encounters in the year after the implementation of the liaison program. There was an increase in the suicidality of mental health patients during this time. There was a significant decrease in mean PED LOS of 27% (95% confidence interval [CI] 0-46%; p = 0.05) from pre- to postintervention period. The decrease in the proportion of patients admitted/transferred to an inpatient psychiatric facility in the postintervention year was statistically significant (odds ratio 0.35; 95% CI 0.17-0.71; p < 0.01). CONCLUSIONS The use of a dedicated child psychiatrist and mental health social worker to the PED results in significantly decreased LOS and need for admission without any change in return visit rate. Larger, multicenter studies are needed to confirm these findings.

Reliability of clinical assessments in older adults with syncope or near syncope

OBJECTIVES Clinical prediction models for risk stratification of older adults with syncope or near syncope may improve resource utilization and management. Predictors considered for inclusion into such models must be reliable. Our primary objective was to evaluate the inter-rater agreement of historical, physical examination, and electrocardiogram (ECG) findings in older adults undergoing emergency department (ED) evaluation for syncope or near syncope. Our secondary objective was to assess the level of agreement between clinicians on the patients overall risk for death or serious cardiac outcomes. METHODS We conducted a cross-sectional study at 11 EDs in adults 60 years of age or older who presented with unexplained syncope or near syncope. We excluded patients with a presumptive cause of syncope (e.g., seizure) or if they were unable or unwilling to follow-up. Evaluations of the patients past medical history and current medication use were completed by treating provider and trained research associate pairs. Evaluations of the patients physical examination and ECG interpretation were completed by attending/resident, attending/advanced practice provider, or attending/attending pairs. All evaluations were blinded to the responses from the other rater. We calculated the percent agreement and kappa statistic for binary variables. Inter-rater agreement was considered acceptable if the kappa statistic was 0.6 or higher. RESULTS We obtained paired observations from 255 patients; mean (±SD) age was 73 (±9) years, 137 (54%) were male, and 204 (80%) were admitted to the hospital. Acceptable agreement was achieved in 18 of the 21 (86%) past medical history and current medication findings, none of the 10 physical examination variables, and three of the 13 (23%) ECG interpretation variables. There was moderate agreement (Spearman correlation coefficient, r = 0.40) between clinicians on the patients probability of 30-day death or serious cardiac outcome, although as the probability increased, there was less agreement. CONCLUSIONS Acceptable agreement between raters was more commonly achieved with historical rather than physical examination or ECG interpretation variables. Clinicians had moderate agreement in assessing the patients overall risk for a serious outcome at 30 days. Future development of clinical prediction models in older adults with syncope should account for variability of assessments between raters and consider the use of objective clinical variables.

Adolescent intentional abuse ingestions: overall 10-year trends and regional variation

Objective Adolescent intentional ingestions remain a significant public health problem in the United States with little research to date on the over-the-counter or prescription medicines that adolescents abuse. These data are important for anticipatory guidance by primary care providers, preventive health, and poison center outreach. Methods This was an observational study using the American Association of Poison Control Centers National Poison Data System. The study population consisted of all cases of patients aged 13 to 19 years from 2004 to 2013 with a coding of “intentional abuse.” Results There were 95,695 patient calls that were coded for intentional abuse between 2004 and 2013 for adolescents aged 13 to 19 years. The most common agent reportedly ingested in intentional-abuse cases was antihistamine and/or decongestant with dextromethorphan, and this agent remained the most common throughout the 10-year study period. The next 4 most common agents remained similar across the study period as well and included ethanol, benzodiazepines, dextromethorphan alone, and marijuana. These 5 agents remained the most commonly reported across the study period for all US regions (West, Midwest, South Northeast, and US territories). Conclusions Over a recent 10-year period, common cough preparations remain the most commonly reported intentional abuse ingestion among all years and regions for adolescents.

Association of Early Stress Testing with Outcomes for Emergency Department Evaluation of Suspected Acute Coronary Syndrome.

BACKGROUND Professional society guidelines suggest early stress testing (within 72 hours) after an emergency department (ED) evaluation for suspected acute coronary syndrome (ACS). However, there is increasing concern that current practice results in over-testing without evidence of benefit. We test the hypothesis that early stress testing improves outcomes. METHODS We analyzed prospectively collected data from 9 EDs on patients with suspected ACS, 1999-2001. We excluded patients with an ED diagnosis of ACS. The primary outcome was 30-day major adverse cardiac events (MACEs), including all-cause death, acute myocardial infarction, and revascularization. We used the HEART score to determine pretest ACS risk (low, intermediate, and high). To mitigate potential confounding, patients with and without early stress testing were matched within pretest risk strata in a 1:2 ratio using propensity scores. RESULTS Of 7127 potentially eligible patients, 895 (13%) received early stress testing. The analytic cohort included 895 patients with early stress testing matched to 1790 without early stress testing. The overall 30-day MACE rate in both the source and analytic population was 3%. There were no baseline imbalances after propensity score matching (P > 0.1 for more than 30 variables). There was no association between early stress testing and 30-day MACE [odds ratio, 1.0; 95% confidence interval (CI), 0.6-1.7]. There was no effect modification by pretest risk (low: odds ratio, 1.0; 95% CI, 0.2-3.7; intermediate: 1.2; 95% CI, 0.6-2.6; high: 0.4; 95% CI, 0.1-1.6). CONCLUSIONS Early stress testing is not associated with reduced MACE in patients evaluated for suspected ACS. Early stress testing may have limited value in populations with low MACE rate.

Estimating the cost of care for emergency department syncope patients: Comparison of three models

Introduction We sought to compare three hospital cost-estimation models for patients undergoing evaluation for unexplained syncope using hospital cost data. Developing such a model would allow researchers to assess the value of novel clinical algorithms for syncope management. Methods We collected complete health services data, including disposition, testing, and length of stay (LOS), on 67 adult patients (age 60 years and older) who presented to the emergency department (ED) with syncope at a single hospital. Patients were excluded if a serious medical condition was identified. We created three hospital cost-estimation models to estimate facility costs: V1, unadjusted Medicare payments for observation and/or hospital admission; V2: modified Medicare payment, prorated by LOS in calendar days; and V3: modified Medicare payment, prorated by LOS in hours. Total hospital costs included unadjusted Medicare payments for diagnostic testing and estimated facility costs. We plotted these estimates against actual cost data from the hospital finance department, and performed correlation and regression analyses. Results Of the three models, V3 consistently outperformed the others with regard to correlation and goodness of fit. The Pearson correlation coefficient for V3 was 0.88 (95% confidence interval [CI] 0.81, 0.92) with an R-square value of 0.77 and a linear regression coefficient of 0.87 (95% CI 0.76, 0.99). Conclusion Using basic health services data, it is possible to accurately estimate hospital costs for older adults undergoing a hospital-based evaluation for unexplained syncope. This methodology could help assess the potential economic impact of implementing novel clinical algorithms for ED syncope.

Early Fever As a Predictor of Paroxysmal Sympathetic Hyperactivity in Traumatic Brain Injury

Objective: Paroxysmal sympathetic hyperactivity (PSH) is characterized by episodic, hyperadrenergic alterations in vital signs after traumatic brain injury (TBI). We sought to apply an objective scale to the vital sign alterations of PSH in order to determine whether 1 element might be predictive of developing PSH. Setting/Participants/Design: We conducted an observational study of consecutive TBI patients (Glasgow Coma Scale score ⩽12) and monitored the cohort for clinical evidence of PSH. PSH was defined as a paroxysm of 3 or more of the following characteristics: (1) tachycardia, (2) tachypnea, (3) hypertension, (4) fever, (5) dystonia (rigidity or decerebrate posturing), and (6) diaphoresis, with no other obvious causation (ie, alcohol withdrawal, sepsis). Main Measures: The Modified Clinical Feature Severity Scale (mCFSS) was applied to each participant once daily for the first 5 days of hospitalization. Results: Nineteen (11%) of the 167 patients met criteria for PSH. Patients with PSH had a higher 5-day cumulative mCFSS score than those without PSH (median [interquartile range] = 36 [29-42] vs 29 [22-35], P = .01). Of the 4 components of the mCFSS, elevated temperature appeared to be most predictive of the development of PSH, especially during the first 24 hours (odds ratio = 1.95; 95% confidence interval, 1.12-3.40). Conclusion: Early fever after TBI may signal impending autonomic dysfunction.

Meta-analysis of the Impact of Patient Characteristics on Estimates of Effectiveness and Harms of Recombinant Human Bone Morphogenetic Protein-2 in Lumbar Spinal Fusion

Study Design. Meta-analysis of individual patient data from randomized controlled trials of recombinant human bone morphogenetic protein-2 (rhBMP-2) in lumbar spinal fusion. Objective. To determine how patient characteristics impact estimates of effectiveness and harms of rhBMP-2 versus iliac crest bone graft (ICBG) in lumbar spinal fusion. Summary of Background Data. Patient characteristics are thought to impact rates of fusion in spinal fusion surgery, but no analyses examining the effect of patient characteristics on efficacy and safety of rhBMP-2 as compared with ICBG have been conducted. Methods. Using individual patient data obtained from the Yale Open Data Access Project, the impact of patient characteristics on the effects of rhBMP-2 on fusion, overall success, and harms were assessed using linear and generalized linear mixed effects models. Results. Ten industry-sponsored randomized controlled trials of rhBMP-2 were included in the analysis. There is preliminary support for an association between rhBMP-2 and improved outcomes for smokers (P = 0.01), individuals under the age of 60 years (P < 0.01), and patients of normal weight (P = 0.03), but not in patients who are nonsmokers, over the age of 60 years, obese or severely obese. RhBMP-2 usage was associated with decreased harms in individuals with no previous back surgeries but this was not seen in individuals with a previous back surgery (P < 0.01). Conclusion. Effects of rhBMP-2 may vary according to patient characteristics. Future studies of rhBMP-2 should include planned subgroup analysis in patients over 60 years, smokers, patients that are obese and severely obese, and individuals with previous back surgeries to better identify those most likely to benefit. Level of Evidence: 1

Relative Effectiveness of Dopamine Antagonists for Pediatric Migraine in the Emergency Department.

Objective Migraine headaches are common in the pediatric emergency department. The mainstay of abortive treatment consists of nonsteroidal anti-inflammatories and dopamine antagonists. The objective of this study was to compare the effectiveness of 3 commonly used dopamine antagonists to abort pediatric migraine. Methods This was a retrospective cohort study of all patients who presented to the pediatric emergency department at a tertiary care pediatric hospital between January 2010 and December 2013. Patients were treated for a migraine headache with a combination of ketorolac and one of the following dopamine antagonists: prochlorperazine, metoclopramide, or promethazine. The primary outcome was treatment failure and receiving non–evidence-based treatment defined by the need for opioids. Secondary outcomes included pain score reduction and return visit within 48 hours. Results There were 57 patients during this period with 67 visits that met inclusion criteria: 27 (40.3%) visits in which patients were treated with prochlorperazine, 23 (34.3%) visits in which patients were treated with metoclopramide, and 17 (25.4%) visits in which patients were treated with promethazine. Across visits, the mean age was 14.5 years, and 63% were women. Opioids were given for treatment failure in 8.7% of visits in which patients received prochlorperazine, 25% in which patients received metoclopramide, and 42.8% in which patients received promethazine. Patients treated with promethazine had significantly higher odds of needing opioids and experiencing less than 50% reduction in pain score compared with prochlorperazine after adjusting for patient characteristics. Conclusions This study suggests variable efficacy among 3 commonly used dopamine antagonists for pediatric migraine headache. Promethazine seems least effective and results in higher use of opioids compared with other available dopamine antagonists.

Do Emergency Medicine Residents Prefer Resident-initiated or Attending-initiated Feedback?

Real‐time feedback is crucial to improving physician performance. Emerging theory suggests that learner‐initiated feedback may be more effective in changing performance than attending‐initiated feedback, but little is known about how residents perceive resident‐ versus attending‐initiated feedback.