Andrew C. Meltzer

Poor Sensitivity of a Modified Alvarado Score in Adults With Suspected Appendicitis

STUDY OBJECTIVE A clinical decision rule that identifies patients at low risk for appendicitis may reduce the reliance on computed tomography (CT) for diagnosis. We seek to prospectively evaluate the accuracy of a low modified Alvarado score in emergency department (ED) patients with suspected appendicitis and compare the score to clinical judgment. We hypothesize that a low modified Alvarado score will have a sufficiently high sensitivity to rule out acute appendicitis. METHODS We performed a prospective observational study of adult patients with suspected appendicitis at 2 academic urban EDs. A low modified Alvarado score was defined as less than 4. The sensitivity and specificity were calculated with 95% confidence interval (CI) for a low modified Alvarado score, and a final diagnosis of appendicitis was confirmed by CT, laparotomy, or 7-day follow-up. RESULTS Two hundred sixty-one patients were included for analysis (mean age 35 years [range 18 to 89 years], 68% female patients, 52% white). Fifty-three patients (20%) had acute appendicitis. The modified Alvarado score test characteristics demonstrated a sensitivity and specificity of 72% (95% CI 58% to 84%) and 54% (95% CI 47% to 61%), respectively. Unstructured clinical judgment that appendicitis was either the most likely or second most likely diagnosis demonstrated a sensitivity and specificity of 93% (95% CI 82% to 98%) and 33% (95% CI 27% to 40%), respectively. CONCLUSION With a sensitivity of 72%, a low modified Alvarado score is less sensitive than clinical judgment in excluding acute appendicitis.

Video capsule endoscopy in the emergency department: A prospective study of acute upper gastrointestinal hemorrhage

STUDY OBJECTIVE Video capsule endoscopy has been used to diagnose gastrointestinal hemorrhage and other small bowel diseases but has not been tested in an emergency department (ED) setting. The objectives in this pilot study are to demonstrate the ability of emergency physicians to detect blood in the upper gastrointestinal tract with capsule endoscopy after a short training period, measure ED patient acceptance of capsule endoscopy, and estimate the test characteristics of capsule endoscopy to detect acute upper gastrointestinal hemorrhage. METHODS During a 6-month period at a single academic hospital, eligible patients underwent video capsule endoscopy (Pillcam Eso2; Given Imaging) in the ED. Video images were reviewed by 4 blinded physicians (2 emergency physicians with brief training in capsule endoscopy interpretation and 2 gastroenterologists with capsule endoscopy experience). RESULTS A total of 25 subjects with acute upper gastrointestinal hemorrhage were enrolled. There was excellent agreement between gastroenterologists and emergency physicians for the presence of fresh or coffee-ground blood (0.96 overall agreement; κ=0.90). Capsule endoscopy was well tolerated by 96% of patients and showed an 88% sensitivity (95% confidence interval 65% to 100%) and 64% specificity (95% confidence interval 35% to 92%) for the detection of fresh blood. Capsule endoscopy missed 1 bleeding lesion located in the postpyloric region, which was not imaged because of expired battery life. CONCLUSION Video capsule endoscopy is a sensitive way to identify upper gastrointestinal hemorrhage in the ED. It is well tolerated and there is excellent agreement in interpretation between gastroenterologists and emergency physicians.

Pre-Endoscopic Rockall and Blatchford Scores to Identify Which Emergency Department Patients with Suspected Gastrointestinal Bleed Do Not Need Endoscopic Hemostasis

BACKGROUND The pre-endoscopic Rockall Score (RS) and the Glasgow-Blatchford Scores (GBS) can help risk stratify patients with upper gastrointestinal bleed who are seen in the Emergency Department (ED). The RS and GBS have yet to be validated in a United States patient population for their ability to discriminate which ED patients with upper gastrointestinal bleed do not need endoscopic hemostasis. OBJECTIVE We sought to determine whether patients who received a score of zero on either score (the lowest risk) in the ED still required upper endoscopic hemostasis during hospitalization. METHODS Retrospective electronic medical record chart review was performed during a 3-year period (2007-2009) to identify patients with suspected upper gastrointestinal bleed by ED final diagnosis of gastrointestinal hemorrhage and related terms at a single urban academic ED. The RS and GBS were calculated from ED chart abstraction and the hospital records of admitted patients were queried for subsequent endoscopic hemostasis. RESULTS Six hundred and ninety patients with gastrointestinal bleed were identified and 86% were admitted to the hospital. One hundred and twenty-two patients had an RS equal to zero; 67 (55%; 95% confidence interval [CI] 46-63%) of these patients were admitted to the hospital and 11 (16%; 95% CI 9-27%) received endoscopic hemostasis. Sixty-three patients had a GBS equal to zero; 15 (24%; 95% CI 15-36%) were admitted to the hospital and 2 (13%; 95% CI 4-38%) received endoscopic hemostasis. CONCLUSIONS Some patients who were identified as lowest risk by the GBS or RS still received endoscopic hemostasis during hospital admission. These clinical decision rules may be insufficiently sensitive to predict which patients do not require endoscopic hemostasis.

Rising rates of proton pump inhibitor prescribing in US emergency departments

OBJECTIVE There have been mounting safety concerns over increasing prescription rates for proton pump inhibitors (PPIs). Trends in PPI use have not been studied in emergency departments (EDs). We characterize trends in PPI use in US EDs. METHODS We used data from the National Hospital Ambulatory Care Survey, from 2001 to 2010, focusing on encounters with a reason for visit with a potential indication for a PPI, histamine receptor (H2) blocker, or antacid. Patient, provider, visit, and hospital-level factors associated with increases in PPI use were evaluated. RESULTS Among included visits, ED PPI prescribing more than doubled from 3.0 (95% confidence interval [CI]: 2.4-3.8) to 7.2% (95% CI: 6.3-8.3) from 2001 to 2010. Histamine receptor blocker use decreased from 6.8% (95% CI: 6.0-7.7) to 5.7% (95% CI: 4.9-6.7) and antacids from 7.2% (95% CI: 6.3-8.2) to 5.5% (95% CI: 4.8-6.3). Proton pump inhibitor prescribing was higher in males and whites yet increased across all demographics, including in adults aged 65 years and older. Proton pump inhibitor prescribing increased significantly in all US regions and across all hospital and payer types. Pantoprazole was the agent with the largest increase in use. CONCLUSIONS Over the past decade, there have been considerable increases in PPI prescribing in US EDs. This trend occurred despite rising safety concerns, even in populations at higher risk for adverse events such as older adults. More education may be needed to ensure that ED providers are familiar with indications for PPIs.

The cost-effectiveness analysis of video capsule endoscopy compared to other strategies to manage acute upper gastrointestinal hemorrhage in the ED

STUDY OBJECTIVE Acute upper gastrointestinal (GI) hemorrhage is a common presentation in hospital-based emergency departments (EDs). A novel diagnostic approach is to use video capsule endoscopy to directly visualize the upper GI tract and identify bleeding. Our objective was to evaluate and compare the relative costs and benefits of video capsule endoscopy compared to other strategies in low- to moderate-risk ED patients with acute upper GI hemorrhage. METHODS We constructed a model using standard decision analysis software to examine the cost-effectiveness of 4 available strategies for a base-case patient who presents to the ED with either mild- or moderate-risk scenarios (by Glasgow-Blatchford Score) for requiring invasive hemostatic intervention (ie, endoscopic, surgical, etc) The 4 available diagnostic strategies were (1) direct imaging with video capsule endoscopy performed in the ED; (2) risk stratification using the Glasgow-Blatchford score; (3) nasogastric tube placement; and, finally, (4) an admit-all strategy. RESULTS In the low-risk scenario, video capsule endoscopy was the preferred strategy (cost

Levosimendan does not improve survival time in a rat model of verapamil toxicity

5691, 14.69 quality-adjusted life years [QALYs]) and was more cost-effective than the remaining strategies including nasogastric tube strategy (cost

Emergency Physicians Accurately Interpret Video Capsule Endoscopy Findings in Suspected Upper Gastrointestinal Hemorrhage: A Video Survey

8159, 14.69 QALYs), risk stratification strategy (cost

Upper gastrointestinal bleeding: patient presentation, risk stratification, and early management.

10,695, 14.69 QALYs), and admit-all strategy (cost

PNFLBA-04 RANDOMIZED CLINICAL TRIAL OF TREATMENT WITH TAMSULOSIN BEGUN IN THE EMERGENCY DEPARTMENT TO PROMOTE PASSAGE OF URINARY STONES

22,766, 14.68 QALYs). In the moderate-risk scenario, video capsule endoscopy continued to be the preferred strategy (cost

Research Priorities in the Utilization and Interpretation of Diagnostic Imaging: Education, Assessment, and Competency.

9190, 14.56 QALYs) compared to nasogastric tube (cost