Michael Menchine

Trial to Examine Text Message–Based mHealth in Emergency Department Patients With Diabetes (TExT-MED): A Randomized Controlled Trial

STUDY OBJECTIVE Increasingly, low-income inner-city patients with diabetes utilize emergency departments (EDs) for acute and chronic care. We seek to determine whether a scalable, low-cost, unidirectional, text message-based mobile health intervention (TExT-MED) improves clinical outcomes, increases healthy behaviors, and decreases ED utilization in a safety net population. METHODS We conducted an randomized controlled trial of 128 adult patients with poorly controlled diabetes (glycosylated hemoglobin [Hb A1C] level ≥8%) in an urban, public ED. The TExT-MED group received 2 daily text messages for 6 months in English or Spanish. The primary outcome was change in Hb A1C level. Secondary outcomes included changes in medication adherence, self-efficacy, performance of self-care tasks, quality of life, diabetes-specific knowledge, ED utilization, and patient satisfaction. RESULTS Hb A1C level decreased by 1.05% in the TExT-MED group compared with 0.60% in the controls (Δ0.45; 95% confidence interval [CI] -0.27 to 1.17) at 6 months. Secondary outcomes favored the TExT-MED group, with the most sizable change observed in self-reported medication adherence (as measured by the Morisky Medication Adherence Scale, an 8-point validated scale with higher scores representing better adherence), which improved from 4.5 to 5.4 in the TExT-MED group compared with a net decrease of -0.1 in the controls (Δ1.1 [95% CI 0.1 to 2.1]). Effects were larger among Spanish speakers for both medication adherence (1.1 versus -0.3; Δ1.4; 95% CI 0.2 to 2.7) and Hb A1C (-1.2% versus -0.4%) in the TExT-MED group. The proportion of patients who used emergency services trended lower in the TExT-MED group (35.9% versus 51.6%; Δ15.7%; 95% CI 9.4% to 22%). Overall, 93.6% of respondents enjoyed TExT-MED and 100% would recommend it to family/friends. CONCLUSION The TExT-MED program did not result in a statistically significant improvement in Hb A1C. However, trends toward improvement in the primary outcome of Hb A1C and other secondary outcomes, including quality of life, were observed, the most pronounced being improved medication adherence. TExT-MED also decreased ED utilization. These findings were magnified in the Spanish-speaking subgroup. Technologies such as TExT-MED represent highly scalable, low-cost, and widely accessible solutions for safety-net ED populations.

A Mobile Health Intervention for Inner City Patients with Poorly Controlled Diabetes: Proof-of-Concept of the TExT-MED Program

OBJECTIVE Numerous mobile health (mHealth) interventions are being developed to aid in management of complex chronic medical conditions. However, the acceptance of mHealth programs by low-income, bilingual populations has not yet been evaluated. The Trial to Examine Text-based mHealth for Emergency department patients with Diabetes (TExT-MED) program is a text message-based mHealth program designed specifically for resource-poor patients with diabetes. We conducted a prospective proof-of-concept trial to assess satisfaction and preliminary effectiveness of the TExT-MED program. RESEARCH DESIGN AND METHODS A consecutive sample of adult patients in the emergency department with diabetes and a text message-capable mobile phone was enrolled in the TExT-MED program. Participants received three text messages daily for 3 weeks in English or Spanish in the following domains: educational/motivational, medication reminders, healthy living challenges, diabetes trivia, and links to free diabetes management tools. RESULTS Twenty-three patients with diabetes (median hemoglobin A1c, 8.9%) were enrolled in TExT-MED. In the week before TExT-MED, 56.5% of subjects reported eating fruits/vegetables daily versus 83% after, 43.5% reported exercising before versus 74% after, and 74% reported performing foot checks before versus 85% after. Self-efficacy, measured by the Diabetes Empowerment Scale-Short Form, improved from 3.9 to 4.2. Scores on the Morisky Medication Adherence Scale improved more dramatically from 3.5 to 4.75. Ninety percent of participants indicated they would like to continue the program, and 100% would recommend the program to family or friends. CONCLUSIONS This pilot trial of the TExT-MED program demonstrated increased healthy behaviors, improved diabetes self-efficacy and medication adherence, and received excellent satisfaction scores in resource-poor, inner city patients with diabetes.

Giant cell arteritis in association with cerebral amyloid angiopathy: Immunohistochemical and molecular studies

Giant cell arteritis (GCA) usually manifests as a transmural vascular infiltrate of mononuclear and multinucleated giant cells (MNGC). We describe six patients with GCA associated with severe cerebral amyloid angiopathy (CAA), all with cerebral hemorrhage or varying degrees of cerebral infarct, and histological evidence of Alzheimers disease (cortical CAA often predominating over senile plaques and neurofibrillary tangles). One case showed mostly cortical involvement (with old microhemorrhages), and the others were primarily leptomeningeal (with involvement of the underlying cortex and extensive encephalomalacia of adjacent brain). Many vessels with CAA exhibited a pronounced adventitial and perivascular infiltrate of lymphocytes, histiocytes, and MNGC. Immunohistochemical staining showed deposition of beta/A4 peptide primarily in the thickened media of CAA vessels, and within the cytoplasm of MNGC--suggesting phagocytosis of insoluble peptide. Cystatin C antibody stained vascular amyloid and diffusely highlighted astrocytic and MNGC cytoplasm. HAM56-positive macrophages were frequently seen around amyloid-laden vessels. Anti-smooth muscle actin immunohistochemistry suggests the occurrence of medial destruction by amyloid, with relative preservation of intimal cells. Ultrastructural studies performed in one case confirmed the presence of intracytoplasmic amyloid in MNGC. The GCA seen in these cases of CAA most likely represents a foreign body response to amyloid proteins, causing secondary destruction of the vessel wall. DNA from brain tissues of five affected patients was examined to assess whether mutations were present in exon 17 of the APP gene or exon 2 of the cystatin C gene, a finding that might explain the foreign body giant cell response to amyloid proteins in these cases. However, restriction fragment mapping of amplified gene segments showed that previously described mutations were not present in these cases.

A Prospective Evaluation of Emergency Department Bedside Ultrasonography for the Detection of Acute Cholecystitis

STUDY OBJECTIVE We assess the diagnostic accuracy of emergency physician-performed bedside ultrasonography and radiology ultrasonography for the detection of cholecystitis, as determined by surgical pathology. METHODS We conducted a prospective, observational study on a convenience sample of emergency department (ED) patients presenting with suspected cholecystitis from May 2006 to February 2008. Bedside gallbladder ultrasonography was performed by emergency medicine residents and attending physicians at an academic institution. Emergency physicians assessed for gallstones, a sonographic Murphys sign, gallbladder wall thickness, and pericholecystic fluid, and the findings were recorded before formal imaging. The test characteristics of bedside and radiology ultrasonography were determined by comparing their respective results to pathology reports and clinical follow-up at 2 weeks. RESULTS Of the 193 patients enrolled, 189 were evaluated by bedside ultrasonography. Forty-three emergency physicians conducted the ultrasonography, and each physician performed a median of 2 tests. After the bedside ultrasonography, 125 patients received additional radiology ultrasonography. Twenty-six patients underwent cholecystectomy, 23 had pathology-confirmed cholecystitis, and 163 were discharged home to follow-up. Twenty-five were excluded (23 lost to follow-up and 2 unavailable pathology). The test characteristics of bedside ultrasonography were sensitivity 87% (95% confidence interval [CI] 66% to 97%), specificity 82% (95% CI 74% to 88%), positive likelihood ratio 4.7 (95% CI 3.2 to 6.9), negative likelihood ratio 0.16 (95% CI 0.06 to 0.46), positive predictive value 44% (95% CI 29% to 59%), and negative predictive value 97% (95% CI 93% to 99%). The test characteristics of radiology ultrasonography were sensitivity 83% (95% CI 61% to 95%), specificity 86% (95% CI 77% to 92%), positive likelihood ratio 5.7 (95% CI 3.3 to 9.8), negative likelihood ratio 0.20 (95% CI 0.08 to 0.50), positive predictive value 59% (95% CI 41% to 76%), and negative predictive value 95% (95% CI 88% to 99%). CONCLUSION The test characteristics of emergency physician-performed bedside ultrasonography for the detection of acute cholecystitis are similar to the test characteristics of radiology ultrasonography. Patients with a negative ED bedside ultrasonography result are unlikely to require cholecystectomy or admission for cholecystitis within 2 weeks of their initial presentation.

Emergency Medical Services Out-of-Hospital Scene and Transport Times and Their Association With Mortality in Trauma Patients Presenting to an Urban Level I Trauma Center

STUDY OBJECTIVE We determine the association between emergency medical services (EMS) out-of-hospital times and mortality in trauma patients presenting to an urban Level I trauma center. METHODS We conducted a secondary analysis of a prospective cohort registry of trauma patients presenting to a Level I trauma center during a 14-year period (1996 to 2009). Inclusion criteria were patients sustaining traumatic injury who presented to an urban Level I trauma center. Exclusion criteria were extrication, missing or erroneous out-of-hospital times, and intervals exceeding 5 hours. The primary outcome was inhospital mortality. EMS out-of-hospital intervals (scene time and transport time) were evaluated with multivariate logistic regression. RESULTS There were 19,167 trauma patients available for analysis, with 865 (4.5%) deaths; 16,170 (84%) injuries were blunt, with 596 (3.7%) deaths, and 2,997 (16%) were penetrating, with 269 (9%) deaths. Mean age and sex for blunt and penetrating trauma were 34.5 years (68% men) and 28.1 years (90% men), respectively. Of those with Injury Severity Score less than or equal to 15, 0.4% died, and 26.1% of those with a score greater than 15 died. We analyzed the relationship of scene time and transport time with mortality among patients with Injury Severity Score greater than 15, controlling for age, sex, Injury Severity Score, and Revised Trauma Score. On multivariate regression of patients with penetrating trauma, we observed that a scene time greater than 20 minutes was associated with higher odds of mortality than scene time less than 10 minutes (odds ratio [OR] 2.90; 95% confidence interval [CI] 1.09 to 7.74). Scene time of 10 to 19 minutes was not significantly associated with mortality (OR 1.19; 95% CI 0.66 to 2.16). Longer transport times were likewise not associated with increased odds of mortality in penetrating trauma cases; OR for transport time greater than or equal to 20 minutes was 0.40 (95% CI 0.14 to 1.19), and OR for transport time 10 to 19 minutes was 0.64 (95% CI 0.35 to 1.15). For patients with blunt trauma, we did not observe any association between scene or transport times and increased odds of mortality. CONCLUSION In this analysis of patients presenting to an urban Level I trauma center during a 14-year period, we observed increased odds of mortality among patients with penetrating trauma if scene time was greater than 20 minutes. We did not observe associations between increased odds of mortality and out-of-hospital times in blunt trauma victims. These findings should be validated in an external data set.

Diagnostic Accuracy of Point-of-Care Testing for Diabetic Ketoacidosis at Emergency-Department Triage: β-hydroxybutyrate versus the urine dipstick

OBJECTIVE In the emergency department, hyperglycemic patients are screened for diabetic ketoacidosis (DKA) via a urine dipstick. In this prospective study, we compared the test characteristics of point-of-care β-hydroxybutyrate (β-OHB) analysis with the urine dipstick. RESEARCH DESIGN AND METHODS Emergency-department patients with blood glucose ≥250 mg/dL had urine dipstick, chemistry panel, venous blood gas, and capillary β-OHB measurements. DKA was diagnosed according to American Diabetes Association criteria. RESULTS Of 516 hyperglycemic subjects, 54 had DKA. The urine dipstick had a sensitivity of 98.1% (95% CI 90.1–100), a specificity of 35.1% (30.7–39.6), a positive predictive value of 15% (11.5–19.2), and a negative predictive value of 99.4% (96.6–100) for DKA. Using the manufacturer-suggested cutoff of >1.5 mmol/L, β-OHB had a sensitivity of 98.1% (90.1–100), a specificity of 78.6% (74.5–82.2), a positive predictive value of 34.9% (27.3–43), and a negative predictive value of 99.7% (98.5–100) for DKA. CONCLUSIONS Point-of-care β-OHB and the urine dipstick are equally sensitive for detecting DKA (98.1%). However, β-OHB is more specific (78.6 vs. 35.1%), offering the potential to significantly reduce unnecessary DKA work-ups among hyperglycemic patients in the emergency department.

Improving attendance at post-emergency department follow-up via automated text message appointment reminders: a randomized controlled trial.

OBJECTIVES Patients discharged from the emergency department (ED) are often referred for primary care, specialty, or other disease-specific follow-up appointments. Attendance at these scheduled follow-up appointments has been found to improve patient outcomes, decrease ED bounce-backs, and reduce malpractice risk. Reasons for missing follow-up visits are complex, but the most commonly reason cited by patients is simply forgetting. In this study the authors evaluated the ability of an automated text message reminder system to increase attendance at post-ED discharge follow-up appointments in a predominantly Hispanic safety-net population. METHODS This was a randomized controlled trial of ED patients with outpatient follow-up visits scheduled at the time of ED discharge. A total of 374 English- and Spanish-speaking patients with text-capable mobile phones were enrolled. Patients in the intervention arm received automated, personalized text message appointment reminders including date, time, and clinic location at 7, 3, and 1 day before scheduled visits. A t-test of proportions was used to compare outcomes between intervention and control groups. Both an intention-to-treat (ITT) and a per-protocol analysis of the data were performed. The ITT more accurately reflects real-world conditions where errors such as number entry errors are bound to occur. The per-protocol analysis adds value by isolating the effect of the intervention by comparing patients who actually received it compared with those who did not. RESULTS In the per-protocol analysis of the primary outcome, the overall appointment adherence rate was 72.6% in the intervention group compared with 62.1% in the control group (difference between groups = 10.5%, 95% confidence interval [CI] = 0.3% to 20.8%; p = 0.045; number needed to treat = 9.5). In the ITT analysis, the overall appointment attendance rate 70.2% in the intervention group compared with 62.1% in the control group (difference between groups = 8.2%; 95% CI = -1.6% to 17.7%; p = 0.100). In a secondary largely exploratory analysis, the intervention was found to have the most benefit in patients with the lowest baseline follow-up rate (English speakers with specialty care appointments). CONCLUSIONS Automated text message appointment reminders resulted in improvement in attendance at scheduled post-ED discharge outpatient follow-up visits and represent a low-cost and highly scalable solution to increase attendance at post-ED follow-up appointments, which should be further explored in larger sample sizes and diverse patient populations.

Perceptions of Successful Cues to Action and Opportunities to Augment Behavioral Triggers in Diabetes Self-Management: Qualitative Analysis of a Mobile Intervention for Low-Income Latinos With Diabetes

Background The increasing prevalence of diabetes and the associated cost of managing this complicated disease have a significant impact on public health outcomes and health expenditures, especially among resource-poor Latino patients. Mobile health (mHealth) may be the solution to reaching this group and improving their health. Objective In this qualitative study, we examined nuances of motivation, intention, and triggers to action effected by TExT-MED (Trial to Examine Text Messaging for Emergency Department patient with Diabetes), an mHealth intervention tailored to low-income, urban Latinos with diabetes. TExT-MED is a fully-automated, text message-based program designed to increase knowledge, self-efficacy, and subsequent disease management and glycemic control. Methods We conducted 5 focus group interviews with 24 people who participated in TExT-MED. We employed a modified grounded theory analytic approach—an iterative process of coding and immersion in the data used to recognize the patterns and links between concepts voiced by the participants. We coded data to identify themes of participant experiences, motivations, and responses to the program. We organized themes into a theory of TExT-MED’s action. Results Participants enjoyed their experience with TExT-MED and believed it improved their diabetes management. Through analysis of the transcripts, we identified that the strengths of the program were messages that cued specific behaviors such as medication reminders and challenge messages. Our analysis also revealed that increasing personalization of message delivery and content could augment these cues. Conclusions This in-depth qualitative analysis of TExT-MED shows that low-income Latino patients will accept text messages as a behavioral intervention. This mHealth intervention acts as a behavioral trigger rather than an education platform. Personalization is an opportunity to enhance these cues to action and further research should be conducted on the ideal forms of personalization.

Prevalence of Undiagnosed and Suboptimally Controlled Diabetes by Point‐of‐care HbA1C in Unselected Emergency Department Patients

OBJECTIVES The objective was to estimate the glycemic control of patients with known diabetes and to assess the prevalence of undiagnosed diabetes in an unselected emergency department (ED) population. Secondary objectives include evaluating the prevalence of undiagnosed diabetes in high-risk groups of ED patients such as Hispanic patients, African Americans, and patients with body mass index (BMI) ≥ 30 kg/m(2) . METHODS A convenience sample of adult ED patients was screened for diabetes using a National Glycohemoglobin Standardization Program-certified point-of-care (POC) glycated hemoglobin (HbA1C) meter at a single academic medical center during eight 24-hour periods. Diabetes was defined as HbA1C ≥ 6.5%, consistent with new American Diabetes Association (ADA) guidelines. RESULTS Of the 1,611 patients evaluated in the ED during the study period, 313 were included in the study sample. Of these, 15% reported a history of diabetes, 42% of whom were suboptimally controlled. An additional 14% of the study sample was found to have previously undiagnosed diabetes. In our limited sample, the prevalence of previously undiagnosed diabetes in Hispanics, African Americans, and patients with BMI ≥ 30 kg/m(2) was 14, 27, and 22%, respectively. CONCLUSIONS   Patients in our sample had a high prevalence of suboptimally controlled and undiagnosed diabetes. New POC HbA1C devices and simplified diagnostic criteria for diabetes significantly enhance the possibility of ED-based screening programs. Future research should validate our findings in a broader array of EDs and study the acceptance of such ED-based diabetes screening programs.

Prevalence of hypokalemia in ED patients with diabetic ketoacidosis

OBJECTIVE Although patients with diabetic ketoacidosis (DKA) are expected to have total body potassium depletion, measured levels may be normal or elevated due to extracellular shifts of potassium secondary to acidosis. Because insulin therapy decreases serum potassium levels, which creates potential to precipitate a fatal cardiac arrhythmia in a patient with hypokalemia, the American Diabetes Association (ADA) recommends obtaining a serum potassium level before giving insulin. Although the ADA guidelines are clear, the evidence on which they are based is largely anecdotal. The purpose of this study was to estimate the prevalence of hypokalemia in patients with DKA before initiation of fluid resuscitation and insulin therapy. METHODS This is a prospective cross-sectional descriptive study of patients with a capillary blood glucose level of 250 mg/dL or higher (at risk for DKA) seen in an urban county emergency department over a 1-year period. Those who consented provided basic demographic information and had a venous blood gas and chemistry panel drawn. Diabetic ketoacidosis and hypokalemia were defined using ADA recommendations. RESULTS The mean age in our sample was 40.2 years, and 81% of patients were Hispanic. Of 503 analyzable patients with hyperglycemia, 54 (10.7%) met all criteria for DKA. Of patients with DKA, 3 (5.6%) of 54 (95% confidence interval, 1.2%-15.4%) had hypokalemia. Two of these patients had values of 3.0 mmol/L, and 1 had a value of 2.8 mmol/L. CONCLUSION Hypokalemia was observed in 5.6% of patients with DKA. These findings support the ADA recommendation to obtain a serum potassium before initiating intravenous insulin therapy in a patient with DKA.