Jonathan Handler

Clinical predictors of bioterrorism-related inhalational anthrax

Limitation of a bioterrorist anthrax attack will require rapid and accurate recognition of the earliest victims. To identify clinical characteristics of inhalational anthrax, we compared 47 historical cases (including 11 cases of bioterrorism-related anthrax) with 376 controls with community-acquired pneumonia or influenza-like illness. Nausea, vomiting, pallor or cyanosis, diaphoresis, altered mental status, and raised haematocrit were more frequently recorded in the inhalational anthrax cases than in either the community-acquired pneumonia or influenza-like illness controls. The most accurate predictor of anthrax was mediastinal widening or pleural effusion on a chest radiograph. This finding was 100% sensitive (95% CI 84.6-100.0) for inhalational anthrax, 71.8% specific (64.8-78.1) compared with community-acquired pneumonia, and 95.6% specific (90.0-98.5) compared with influenza-like illness. Our findings represent preliminary efforts toward identifying clinical predictors of inhalational anthrax.

Delphi Consensus on the Feasibility of Translating the ACEP Clinical Policies Into Computerized Clinical Decision Support

Clinical practice guidelines are developed to reduce variations in clinical practice, with the goal of improving health care quality and cost. However, evidence-based practice guidelines face barriers to dissemination, implementation, usability, integration into practice, and use. The American College of Emergency Physicians (ACEP) clinical policies have been shown to be safe and effective and are even cited by other specialties. In spite of the benefits of the ACEP clinical policies, implementation of these clinical practice guidelines into physician practice continues to be a challenge. Translation of the ACEP clinical policies into real-time computerized clinical decision support systems could help address these barriers and improve clinician decision making at the point of care. The investigators convened an emergency medicine informatics expert panel and used a Delphi consensus process to assess the feasibility of translating the current ACEP clinical policies into clinical decision support content. This resulting consensus document will serve to identify limitations to implementation of the existing ACEP Clinical Policies so that future clinical practice guideline development will consider implementation into clinical decision support at all stages of guideline development.

Vision-Based Autonomous Robot Self-Docking and Recharging

This paper presents a method for autonomous recharging of a mobile robot, a necessity for achieving long-term robotic activity without human intervention. A recharging station is designed consisting of a stationary docking station and a docking mechanism mounted to an ER-1 Evolution Robotics robot. The docking station and docking mechanism serve as a dual-power source, providing a mechanical and electrical connection between the recharging system of the robot and a laptop placed on it. Docking strategy algorithms use vision based navigation. The result is a significantly low-cost, high-entrance angle tolerant system. Iterative improvements to the system, to resist environmental perturbations and implement obstacle avoidance, ultimately resulted in a docking success rate of 100 percent over 50 trials.

False-positive urine β-HCG in a woman with a tubo-ovarian abscess

Modern urine β-human chorionic gonadotropin (HCG) assays that use enzyme-linked immunosorbent assay (ELISA) technology are sensitive and specific for diagnosing pregnancy, both intrauterine and ectopic, and have become indispensable to the practice of Emergency Medicine. A urine HCG test is often relied on by the Emergency Physician as a critical component in the diagnostic regimen of a patient with a possible ectopic pregnancy. We report a case of a false-positive urine β-HCG test in a patient with a ruptured tubo-ovarian abscess. Though false-positive pregnancy tests with tubo-ovarian abscesses have previously been reported with older methods of HCG detection, we believe that this is the first case where the pregnancy test was the modern ELISA type. The mechanism for the false-positive reaction in this case is unknown, but time may show that the ELISA test kit, like its predecessors, may occasionally give a false-positive reaction in this class of patients.

Impact of Emergency Department Built Environment on Timeliness of Physician Assessment of Patients With Chest Pain

A retrospective cohort study was conducted to evaluate the effect of the built environment of an emergency department (ED) on the timeliness of physician assessment of chest pain patients. The main outcome variable was time to initial physician assessment. Potential predictor variables included presence of a solid door, distance of treatment room from work area, staffing team, day of week, and the patients age, sex, and triage level. After multi-variate adjustment, the only predictors of time to initial assessment greater than 10 minutes were being placed in a room with a door (adjusted odds ratio [OR] 1.58; 95% confidence interval [CI] 1.01-2.48) and being placed in a room 25 feet or more from the main physician work area (adjusted OR 1.38; 95% CI 1.13-1.67). These findings suggest that the ED built environment can be a barrier for providing timely care for this group of patients and may have implications for future ED architectural designs.

Case study: the Health SmartLibrary experiences in web personalization and customization at the Galter Health Sciences Library, Northwestern University

QUESTION How can the users access to health information, especially full-text articles, be improved? The solution is building and evaluating the Health SmartLibrary (HSL). SETTING The setting is the Galter Health Sciences Library, Feinberg School of Medicine, Northwestern University. METHOD The HSL was built on web-based personalization and customization tools: My E-Resources, Stay Current, Quick Search, and File Cabinet. Personalization and customization data were tracked to show user activity with these value-added, online services. MAIN RESULTS Registration data indicated that users were receptive to personalized resource selection and that the automated application of specialty-based, personalized HSLs was more frequently adopted than manual customization by users. Those who did customize customized My E-Resources and Stay Current more often than Quick Search and File Cabinet. Most of those who customized did so only once. CONCLUSION Users did not always take advantage of the services designed to aid their library research experiences. When personalization is available at registration, users readily accepted it. Customization tools were used less frequently; however, more research is needed to determine why this was the case.

In response to: Method of electronic health record documentation and quality of primary care

We read with interest the article by Linder, Schnipper, and Middleton comparing dictation, free-text typing, and structured data entry to quality outcomes.1 The authors conclude that using dictation appeared to provide a lower quality of care, but that conclusion seems unsupported by the reported results. Most importantly, the authors themselves note that most of the differences found were not actually quality of care or clinical outcome measures. The authors write that ‘even if documentation style were only associated with better documentation quality, a complete and accurate record is important to demonstrate high-quality care and inform clinical decision support and population management.’ However, the methodology states that text notes were not used for quality assessment, so the ‘missing’ data elements might have been just as completely and accurately …