Harrison J. Alter

Does the addition of dexamethasone to standard therapy for acute migraine headache decrease the incidence of recurrent headache for patients treated in the emergency department: a meta-analysis and systematic review of the literature

OBJECTIVESnNeurogenic inflammation is thought to play a role in the development and perpetuation of migraine headache. The emergency department (ED) administration of dexamethasone in addition to standard antimigraine therapy has been used to decrease the incidence of recurrent headaches at 24 to 72 hours following evaluation. This systematic review details the completed trials that have evaluated the use of dexamethasone in this role.nnnMETHODSnThe authors searched MEDLINE, EMBASE, CINAHL, LILACS, recent emergency medicine scientific abstracts, and several prepublication trial registries for potential investigations related to the research question. The authors included studies that incorporated randomized, double-blind, placebo-controlled methodology and that were performed in the ED. A fixed-effects and random-effects model was used to obtain summary risk ratios (RRs) and 95% confidence intervals (CIs) for the self-reported outcome of moderate or severe headache on follow-up evaluation.nnnRESULTSnA pooled analysis of seven trials involving 742 patients suggests a modest but significant benefit when dexamethasone is added to standard antimigraine therapy to reduce the rate of patients with moderate or severe headache on 24- to 72-hour follow-up evaluation (RR = 0.87, 95% CI = 0.80 to 0.95; absolute risk reduction = 9.7%). The treatment of 1,000 patients with acute migraine headache using dexamethasone in addition to standard antimigraine therapy would be expected to prevent 97 patients from experiencing the outcome of moderate or severe headache at 24 to 72 hours after ED evaluation. The sensitivity analysis yielded similar results with sequential trial elimination, indicating that no single trial was responsible for the overall result. Adverse effects related to the administration of a single dose of dexamethasone were infrequent, mild, and transient.nnnCONCLUSIONSnThese results suggest that dexamethasone is efficacious in preventing headache recurrence and safe when added to standard treatment for the management of acute migraine headache in the ED.

Results of a Rapid Hepatitis C Virus Screening and Diagnostic Testing Program in an Urban Emergency Department.

STUDY OBJECTIVEnWe describe the results of an emergency department (ED) hepatitis C virus testing program that integrated birth cohort screening and screening of patients with a history of injection drug use, as well as physician diagnostic testing, according to national guidelines.nnnMETHODSnWe conducted a retrospective cohort study using data collected as part of clinical care. The primary outcome was the hepatitis C virus prevalence among tested patients. We evaluated factors associated with testing positive with logistic regression.nnnRESULTSnOf the 26,639 unique adults aged 18 years or older and presenting to the ED during the 6-month study, 2,581 (9.7%) completed hepatitis C virus screening (2,028) or diagnostic testing (553), of whom 267 were antibody positive (10.3% prevalence). Factors associated with testing positive for hepatitis C virus included injection drug use (38.4% prevalence; odds ratio [OR] 10.8; 95% confidence interval [CI] 7.5 to 15.5), homeless (25.5% prevalence; OR 3.1; 95% CI 1.5 to 6.8), diagnostic testing (14.8% prevalence; OR 2.6; 95% CI 1.7 to 3.9), birth cohort (13.7% prevalence; OR 3.6; 95% CI 2.4 to 5.3), and male sex (12.4% prevalence; OR 1.4; 95% CI 1.0 to 2.0). Of the 267 patients testing positive for hepatitis C virus antibody, 137 (51%) had documentation of result disclosure and 180 (67%) had confirmatory ribonucleic acid testing performed, of whom 126 (70%) had a positive result. Follow-up appointments at the hepatitis C virus clinic were arranged for 57 of the 126 (45%) patients with confirmed positive results, of which 30 attended.nnnCONCLUSIONnThis ED screening and diagnostic testing program found a high prevalence of hepatitis C virus antibody positivity across all groups. Challenges encountered with hepatitis C virus screening included result disclosure, confirmatory testing, and linkage to care. Our results warrant continued efforts to develop and evaluate policies for ED-based hepatitis C virus screening.

A Randomized Controlled Noninferiority Trial of Single Dose of Oral Dexamethasone Versus 5 Days of Oral Prednisone in Acute Adult Asthma

STUDY OBJECTIVEnOral dexamethasone demonstrates bioavailability similar to that of oral prednisone but has a longer half-life. We evaluate whether a single dose of oral dexamethasone plus 4 days of placebo is not inferior to 5 days of oral prednisone in treatment of adults with mild to moderate asthma exacerbations to prevent relapse defined as an unscheduled return visit for additional treatment for persistent or worsening asthma within 14 days.nnnMETHODSnAdult emergency department patients (aged 18 to 55 years) were randomized to receive either a single dose of 12 mg of oral dexamethasone with 4 days of placebo or a 5-day course of oral prednisone 60 mg a day. Outcomes including relapse were assessed by a follow-up telephone interview at 2 weeks.nnnRESULTSnOne hundred seventy-three dexamethasone and 203 prednisone subjects completed the study regimen and telephone follow-up. The dexamethasone group by a small margin surpassed the preset 8% difference between groups for noninferiority in relapse rates within 14 days (12.1% versus 9.8%; difference 2.3%; 95% confidence interval -4.1% to 8.6%). Subjects in the 2 groups had similar rates of hospitalization for their relapse visit (dexamethasone 3.4% versus prednisone 2.9%; difference 0.5%; 95% confidence interval -4.1% to 3.1%). Adverse effect rates were generally the same in the 2 groups.nnnCONCLUSIONnA single dose of oral dexamethasone did not demonstrate noninferiority to prednisone for 5 days by a very small margin for treatment of adults with mild to moderate asthma exacerbations. Enhanced compliance and convenience may support the use of dexamethasone regardless.

Social Emergency Medicine: Embracing the Dual Role of the Emergency Department in Acute Care and Population Health

INTRODUCTION Mr. Henry (a pseudonym) has visited our emergency department (ED) an average of 3 times a week for the past 5 years. He has a medical history of AIDS and end-stage renal disease, is addicted to cocaine and prescription opioids, and is intermittently homeless. His dialysis access is a frequent issue because, without stable housing, he is prone to frequent skin and soft tissue infections, complicating both fistulas and indwelling catheters. Despite receiving regular dialysis, he often visits the ED for urgent dialysis at least in part because he has access only to fast food in his neighborhood, which wreaks havoc on his fluid status and electrolyte levels. On a slow Thanksgiving Day shift this past year, he reflected on the role the ED plays in his life beyond addressing his medical needs: refuge from the cold, a social support system, a food kitchen, and even a place to get a jacket without holes. Mr. Henry’s experience is not unique; it represents a reality in EDs all across the country. In 1999, Gordon wrote that vulnerable and disadvantaged patients “define us as a specialty—as much, or more so, than the medical procedures we perform” and that “given the importance of social factors to health, emergency physicians who work daily at the interface of medicine and society have a special obligation to broaden their scope of practice.” In the modern ED, homelessness, substance abuse, and violence are as pervasive as coronary artery disease, diabetes, and hypertension, each with a clinical significance. In this environment, where does the responsibility of an ED begin and end? This question is as relevant to our daily practice as any clinical decision that we make. Social emergency medicine is an approach to our specialty that emphasizes, enriches, and creates a framework for emergency medicine as society’s medical and social safety net. This view of emergency medicine considers the

Long-term mortality of patients surviving firearm violence

Objective We aim to calculate the 5-year mortality after surviving to hospital discharge after a firearm injury and estimate the association of firearm injury with later mortality. Methods We performed a retrospective cohort study of patients from an urban emergency department (ED) and trauma centre in Oakland, California, USA, in 2007. We created three cohorts of patients presenting for (1) gunshot wound (GSW), (2) MVC and (3) assault without a firearm. Demographic and clinical information was obtained from the clinical chart, and the California Department of Public Health Vital Statistics and Social Security Death Master File (2007–2012) were queried to identify patients who died. Results We analysed 516 GSW patients, 992 MVC patients and 695 non-GSW assault patients. Of the GSW patients, 86.4% were alive at 5u2005years. All-cause 5-year mortality among GSW victims surviving to discharge after injury was 5.1%. Compared with MVC patients, both GSW and non-GSW assault patients have higher risk of death at 5u2005years (HR 2.54 (95% CI 1.41 to 4.59) and HR 1.64 (95% CI 1.01 to 2.68), respectively), adjusting for age, sex and race. Risk of death was higher in the first year for the GSW cohort (HR 6.14 (95% CI 2.35 to 16.08) and HR 5.06 (95% CI 1.88 to 13.63) as compared with MVC and non-GSW assault cohorts, respectively). Homicide was the cause of death in 79.2% of GSW patients who died after surviving the index injury. Conclusion Among individuals presenting to the ED after injury or assault and surviving to discharge, firearm injury exposure is an important predictor of death within 5u2005years and most pronounced in the first year after injury.

The Highland Health Advocates: a preliminary evaluation of a novel programme addressing the social needs of emergency department patients

Objectives Patients commonly come to the emergency department (ED) with social needs. To address this, we created the Highland Health Advocates (HHA), an ED-based help desk and medical-legal partnership using undergraduate volunteers to help patients navigate public resources and provide onsite legal and social work referrals. We were able to provide these services in English and Spanish. We aimed to determine the social needs of the patients who presented to our ED and the potential impact of the programme in resolving those needs and connecting them to a ‘medical home’ (defined as a consistent, primary source of medical care such as a primary care doctor or clinic). Methods ED patients at a US safety net hospital were enrolled in a 1:2 ratio in a quasi-experiment comparing those who received intervention from the HHA during a limited access rollout with controls who received usual care on days with no help desk. We collected a baseline social needs evaluation, with follow-up assessments at 1 and 6 months. Primary outcomes were linkages for the primary identified need and to a medical home within 1u2009month. Other outcomes at 6 months included whether a patient (1) felt helped; 2) had a decreased number of ED visits; (3) had the primary identified need met; (4) had a primary doctor; and (5) had a change in self-reported health status. Results We enrolled 459 subjects (intervention=154, control=305). Housing (41%), employment (23%) and inability to pay bills (22%) were participants’ top identified needs. At baseline, 32% reported the ED as their medical home, with the intervention cohort having higher ED utilisation (>1 ED visit in the prior month: 49% vs 24%). At 1u2009month, 185 (40%) subjects were reached for follow-up, with more HHA subjects linked to a resource (59% vs 37%) and a medical home (92% vs 76%). At 6 months, 75% of subjects felt HHA was helpful and more subjects in the HHA group had a doctor (93% v 69%). No difference was found in ED utilisation, primary need resolution or self-reported health status. Conclusions Health-related social needs are common in this US safety net ED. Our help desk is one possible model for addressing social needs.

Accuracy and Discomfort of Different Types of Intranasal Specimen Collection Methods for Molecular Influenza Testing in Emergency Department Patients

Study objective: While development is under way of accurate, point‐of‐care molecular tests for influenza infection, the optimal specimen type for molecular tests remains unclear. Compared with standard nasopharyngeal swab specimens, less invasive nasal swab and midturbinate swab specimens may cause less patient discomfort and be more suitable for routine emergency department (ED) testing, although possibly at the expense of diagnostic accuracy. We compare both the accuracy of a polymerase chain reaction molecular influenza test and discomfort between these 3 intranasal specimen types. Methods: A convenience sample of adult and pediatric patients with influenza‐like illness and presenting to 2 Northern California EDs and 2 EDs in Santiago, Chile, was prospectively enrolled during the 2015 to 2016 influenza season. Research nurses collected nasopharyngeal swab, midturbinate swab, and nasal swab specimens from each subject and assessed discomfort on a validated 6‐point scale. Specimens were tested for influenza A and B by real‐time polymerase chain reaction at reference laboratories. Outcome measures were comparison of test performance between nasal swab and midturbinate swab, when compared with a reference standard nasopharyngeal swab; and comparison of discomfort between all 3 specimen types. Results: Four hundred eighty‐four subjects were enrolled, and all 3 swabs were obtained for each subject; 14% were children. The prevalence of influenza (A or B) was 30.0% (95% confidence interval [CI] 26.0% to 34.8%). The sensitivity for detecting influenza was 98% (95% CI 94.25% to 99.65%) with the midturbinate swab versus 84.4% (95% CI 77.5% to 89.8%) with the nasal swab, difference 13.6% (95% CI 8.2% to 19.3%). Specificity was 98.5% (95% CI 96.6% to 99.5%) with the midturbinate swab versus 99.1% (95% CI 97.4% to 99.8%) with the nasal swab, difference −0.6% (95% CI −1.8% to 0.6%). Swab discomfort levels correlated with the depth of the swab type. Median discomfort scores for the nasal swab, midturbinate swab, and nasopharyngeal swab were 0, 1, and 3, respectively; the median differences were nasopharyngeal swab–midturbinate swab 2 (95% CI 1 to 2), nasopharyngeal swab–nasal swab 3 (95% CI 2 to 3), and midturbinate swab–nasal swab 1 (95% CI 1 to 2). Conclusion: Compared with the reference standard nasopharyngeal swab specimen, midturbinate swab specimens provided a significantly more comfortable sampling experience, with only a small sacrifice in sensitivity for influenza detection. Nasal swab specimens were significantly less sensitive than midturbinate swab. Our results suggest the midturbinate swab is the sampling method of choice for molecular influenza testing in ED patients.

A Consensus-Driven Agenda for Emergency Medicine Firearm Injury Prevention Research

Study objective To identify critical emergency medicine–focused firearm injury research questions and develop an evidence‐based research agenda. Methods National content experts were recruited to a technical advisory group for the American College of Emergency Physicians Research Committee. Nominal group technique was used to identify research questions by consensus. The technical advisory group decided to focus on 5 widely accepted categorizations of firearm injury. Subgroups conducted literature reviews on each topic and developed preliminary lists of emergency medicine–relevant research questions. In‐person meetings and conference calls were held to iteratively refine the extensive list of research questions, following nominal group technique guidelines. Feedback from external stakeholders was reviewed and integrated. Results Fifty‐nine final emergency medicine–relevant research questions were identified, including questions that cut across all firearm injury topics and questions specific to self‐directed violence (suicide and attempted suicide), intimate partner violence, peer (nonpartner) violence, mass violence, and unintentional (“accidental”) injury. Some questions could be addressed through research conducted in emergency departments; others would require work in other settings. Conclusion The technical advisory group identified key emergency medicine–relevant firearm injury research questions. Emergency medicine–specific data are limited for most of these questions. Funders and researchers should consider increasing their attention to firearm injury prevention and control, particularly to the questions identified here and in other recently developed research agendas.

Material Needs of Emergency Department Patients: A Systematic Review

BACKGROUNDnInterest in social determinants of health (SDOH) has expanded in recent years, driven by a recognition that such factors may influence health outcomes, services use, and health care costs. One subset of SDOH is material needs such as housing and food. We conducted a systematic review of the literature on material needs among emergency department (ED) patients in the United States.nnnMETHODSnWe followed PRISMA guidelines for systematic review methodology. With the assistance of a research librarian, four databases were searched for studies examining material needs among ED patients. Two reviewers independently screened titles, abstracts, and full text to identify eligible articles. Information was abstracted systematically from eligible articles.nnnRESULTSnForty-three articles were eligible for inclusion. There was heterogeneity in study methods; single-center, cross-sectional studies were most common. Specific material needs examined included homelessness, poverty, housing insecurity, housing quality, food insecurity, unemployment, difficulty paying for health care, and difficulty affording basic expenses. Studies overwhelmingly supported the notion that ED patients have a high prevalence of a number of material needs.nnnCONCLUSIONSnDespite some limitations in the individual studies examined in this review, the plurality of prior research confirms that the ED serves a vulnerable population with high rates of material needs. Future research is needed to better understand the role these needs play for ED patients and how to best address them.

Patient Understanding of HIV and Hepatitis C Testing in an Emergency Department with an Integrated Program.

Introduction: We implemented triage nurse rapid HIV and hepatitis C virus (HCV) screening, in parallel with physician diagnostic testing, in our urban emergency department (ED). Methods: A 2-month cross-sectional survey was performed to determine the proportion of patients who correctly reported being tested for HIV and HCV. Results: A total of 492 patients were surveyed. Fifty-one (70%) of the 73 patients who reported being HIV tested and 372 (89%) of the 419 patients who reported not being HIV tested were correct. Thirty (60%) of the 50 patients who reported being HCV tested and 416 (94%) of the 442 patients who reported not being HCV tested were correct. Conclusion: Although most ED patients correctly reported whether testing was performed, there were many who did not. Although ED screening programs for HIV and HCV serve as an important venue for screening, strategies to improve communication require attention.