Impact of MRI to clear the cervical spine after a negative CT for suspected spine trauma

PURPOSE

To describe the clinical presentation of trauma patients receiving a negative cervical spine MRI (CSMRI) after cervical spine CT (CSCT) without acute findings and calculate the associated costs.

METHODS

Our cohort consisted of 55 retrospectively reviewed consecutive trauma patients with CSMRI performed between October 2016 and March 2020, who had negative CSCT within 7 days of CSMRI and no other clinically significant injuries. Our outcome was the cost related to CSMRI, estimated by CSMRI charges and the charges related to additional hours of prolonged hospital stay from CT until MRI.

RESULTS

The most common presenting mechanisms of injury were fall from standing (20/55, 36%), followed by motor vehicle accident (18, 33%). Indications for CSMRI included persistent neck pain (32/55, 58%), followed by recommendation from the radiologist (12, 22%), and neurological symptoms concerning for spine injury (9, 16%). An average of 11.2 h (median: 8.5, range: 0.2-25.4 h) passed from CSCT to CSMRI. Fifty-four (98%) of the CSMRI exams were completed within 24 h of the CSCT. The Medicare reimbursement for non-contrast CSMRI is $309 with the average cost for waiting in ED observation of $907. The total cost of CSMRI and associated wait time ranged from $325 to $2366 with an average of $1216 per patient.

CONCLUSIONS

The cost of negative CSMRI following a negative CSCT for cervical spine clearance in trauma patients without other significant injury is substantial. The length of time that trauma patients remain in observation in the cervical collar prior to the finalized MRI exam is not only distressing to the patient but also adds costs to health care systems in both time and resources.

Multicenter Implementation of a Novel Management Protocol Increases the Outpatient Treatment of Pulmonary Embolism and Deep Vein Thrombosis

OBJECTIVE

The objective was to determine whether a protocol combining risk stratification, treatment with the direct-acting oral anticoagulant rivaroxaban, and defined follow-up is associated with a greater proportion of patients with venous thromboembolism (VTE) treated as outpatients, without hospital admission.

METHODS

We performed a multicenter study of patients diagnosed with VTE (pulmonary embolism [PE] or deep vein thrombosis [DVT]) in two urban EDs, 18 months before and 18 months after implementation of an outpatient VTE treatment protocol. Patients with radiographically confirmed acute VTE were eligible. Our primary outcome was the proportion of VTE patients discharged from the ED or observation unit (i.e., without hospital admission). We performed subgroup analyses according to hospital, DVT and PE, and low-risk PE. We also assessed 7- and 30-day mortality, major bleeding, and returns to the ED. We compared proportions using chi-square and Fisher's exact tests.

RESULTS

We enrolled 2,212 patients, 1,081 (49%) before protocol and 1,131 (51%) after protocol. Mean age (59 years vs. 60 years), female sex (49% vs. 49%), other demographics, comorbid illness, and PE risk stratification were similar before and after. After protocol, more VTE (35% from 26%, p < 0.001), PE (18% from 12%, p = 0.002), low-risk PE (28% from 18%, p < 0.001), and DVT (60% from 49%, p = 0.002) patients were treated as outpatients. Mortality, bleeding, and returns to ED were rare and did not increase after protocol.

CONCLUSIONS

A treatment protocol combining risk-stratification, rivaroxaban treatment and defined follow-up is associated with an increase in PE and DVT patients treated as outpatients, with no increase in adverse outcomes.

Comparison of 30-Day Serious Adverse Clinical Events for Elderly Patients Presenting to the Emergency Department With Near-Syncope Versus Syncope

STUDY OBJECTIVE

Controversy remains in regard to the risk of adverse events for patients presenting with syncope compared with near-syncope. The purpose of our study is to describe the difference in outcomes between these groups in a large multicenter cohort of older emergency department (ED) patients.

METHODS

From April 28, 2013, to September 21, 2016, we conducted a prospective, observational study across 11 EDs in adults (≥60 years) with syncope or near-syncope. A standardized data extraction tool was used to collect information during their index visit and at 30-day follow-up. Our primary outcome was the incidence of 30-day death or serious clinical events. Data were analyzed with descriptive statistics and multivariate logistic regression analysis adjusting for relevant demographic or historical variables.

RESULTS

A total of 3,581 patients (mean age 72.8 years; 51.6% men) were enrolled in the study. There were 1,380 patients (39%) presenting with near-syncope and 2,201 (61%) presenting with syncope. Baseline characteristics revealed a greater incidence of congestive heart failure, coronary artery disease, previous arrhythmia, nonwhite race, and presenting dyspnea in the near-syncope compared with syncope cohort. There were no differences in the primary outcome between the groups (near-syncope 18.7% versus syncope 18.2%). A multivariate logistic regression analysis identified no difference in 30-day serious outcomes for patients with near-syncope (odds ratio 0.94; 95% confidence interval 0.78 to 1.14) compared with syncope.

CONCLUSION

Near-syncope confers risk to patients similar to that of syncope for the composite outcome of 30-day death or serious clinical event.

The creation and implementation of an outpatient pulmonary embolism treatment protocol

The ability to rapidly and accurately risk-stratify patients with venous thromboembolism (VTE), and the availability of direct acting oral anticoagulants have reduced the need for intravenous anticoagulation for patients with deep vein thrombosis (DVT) and pulmonary embolism (PE). Emergency physicians are generally reluctant to discharge patients with VTE without defined and reliable follow up in place, and VTE patients treated with anticoagulants can be at risk for complications related to recurrent VTE and bleeding. In addition, screening for associated diseases (e.g. cancer, hypercoagulable states) may be indicated. Therefore, the outpatient treatment of low risk VTE requires coordinated effort and reliable follow up. By leveraging detailed outcome data and collaborative relationships, we have created a protocol for the safe outpatient treatment of patients with low risk DVT and PE. Our protocol is data driven and designed to address barriers to outpatient VTE management. We expect our protocol to result in improved patient satisfaction, more efficient emergency department (ED) throughput, and decreased cost. Applied nationally, the outpatient treatment of select patients with DVT and PE could have major public health and economic impact.

Healthcare costs associated with rivaroxaban or warfarin use for the treatment of venous thromboembolism

INTRODUCTION

Rivaroxaban has been shown to have similar efficacy but less major bleeding than warfarin in randomized trials of patients experiencing venous thromboembolism (VTE). This report sought to assess healthcare costs up to 12-months following an index VTE in patients prescribed either rivaroxaban or warfarin.

MATERIALS AND METHODS

This study analyzed claims from the MarketScan Commercial Claims and Encounters Database from November 2011-July 2015. It selected adults newly-diagnosed with VTE (deep vein thrombosis [DVT] or pulmonary embolism [PE]) if they had an outpatient prescription claim for rivaroxaban or warfarin within 7-days of the index event. Warfarin users were 2:1 propensity-score matched to rivaroxaban users and followed until the end of insurance coverage, end of data availability or 12-months of follow-up. Total per patient healthcare costs, including inpatient, outpatient, and overall pharmacy costs, were compared using a multivariable generalized linear model.

RESULTS

In total, 10,929 rivaroxaban patients were matched to 21,858 warfarin patients. Mean follow-up for rivaroxaban and warfarin patients was 317- and 321-days for those experiencing an index DVT, and 313- and 318-days for those with PE. Mean overall treatment costs per patient were lower for rivaroxaban vs warfarin users (-$1,116, p = .0016). This cost difference was driven by lower inpatient (-$622) and outpatient (-$1,156) treatment costs, and the higher pharmacy costs ($661) were, therefore, fully offset. Results were similar when analysis was restricted to DVT patients. No significant difference in total costs was observed in patients experiencing an index PE.

LIMITATIONS

Claims databases are subject to inaccuracies and missing data. Prescription claims may not fully reflect actual medication utilization. Despite propensity-score matching and regression, residual confounding cannot be excluded.

CONCLUSIONS

Rivaroxaban was associated with significantly lower total per patient VTE treatment costs, despite higher pharmacy costs. These savings are the result of decreased inpatient and outpatient healthcare utilization costs associated with rivaroxaban.

A Model Longitudinal Observation Medicine Curriculum for an Emergency Medicine Residency

The role of observation services for emergency department patients has increased in recent years. Driven by changing health care practices and evolving payer policies, many hospitals in the United States currently have or are developing an observation unit (OU) and emergency physicians are most often expected to manage patients in this setting. Yet, few residency programs dedicate a portion of their clinical curriculum to observation medicine. This knowledge set should be integrated into the core training curriculum of emergency physicians. Presented here is a model observation medicine longitudinal training curriculum, which can be integrated into an emergency medicine (EM) residency. It was developed by a consensus of content experts representing the observation medicine interest group and observation medicine section, respectively, from EM's two major specialty societies: the Society for Academic Emergency Medicine (SAEM) and the American College of Emergency Physicians (ACEP). The curriculum consists of didactic, clinical, and self-directed elements. It is longitudinal, with learning objectives for each year of training, focusing initially on the basic principles of observation medicine and appropriate observation patient selection; moving to the management of various observation appropriate conditions; and then incorporating further concepts of OU management, billing, and administration. This curriculum is flexible and designed to be used in both academic and community EM training programs within the United States. Additionally, scholarly opportunities, such as elective rotations and fellowship training, are explored.

There's Another Observation Unit?: A Case Series Survey of Second Level Observation Units

OBJECTIVES

Observation units are dedicated areas in the hospital to deliver care to patients in observation status-those too risky to be immediately discharged following an emergency department evaluation but also clearly not in need of an inpatient admission. Observation units have been commonplace for several decades but in recent years some hospitals have begun to operate an additional observation unit with a distinct care delivery model and patient population.

METHODS

We conducted a survey between June 2014 and December 2014 to determine the prevalence and key operational characteristics of second level observation units in the US. We accessed the list serve of a large specialty organization to reach leaders likely to be directly operating or aware of the presence of a second level unit in their hospital.

RESULTS

We received 28 responses (response rate of approximately 10%). We found 8 second level OUs, with respondents able to provide detailed data for 6 of them. All were established within the past 5 years.

CONCLUSIONS

Second level observation units are still relatively uncommon but are emerging as an extension of hospital-based observation services as an additional resource to cohort observation patients into a dedicated unit. These units share some similarities with traditional OUs, such as the nursing ratio of approximately 4:1 and the preponderance of chest pain pathways; however, they also differ in important ways around key metrics, such as length of stay, attending staffing coverage, and rate of subsequent inpatient admission. Additional study is needed both to fully characterize these units and their potential benefits.

Characteristics of emergency department visits among non-admitted oncology patients

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Background: Use of costly emergency department (ED) resources is high amongst oncology patients. However, many oncology patients who visit the ED are discharged home without admission to an inpatient setting. A better understanding of why this group of patients presents to the ED can inform alternative interventions to shift care to less costly settings and reduce ED utilization. Methods: We conducted a review of administrative data at Brigham and Women’s Hospital (BWH) that serves as the ED for patients undergoing cancer treatment at the Dana Farber Cancer Institute. We identified oncology diagnosed patients that presented to the ED between 9/1/2011 and 9/30/2012 (n=6,035 unique visits). We focused our analysis in those patients ultimately discharged home, directly discharged (Home n=1647) or after an ED observation stay < 24 hours (ED Obs n=379) to evaluate opportunities for improvement. We then reported charges, cancer type, primary ED discharge ICD-9 code, and tests ordered per ED visit by disposition status. Results: We found that 34% of the ED encounters (n=2,026) were ultimately discharged home (directly discharged or after an ED observation stay). Among them, the average charge per visit for these patients varied from $3,304 (SD= 2,734) for Home to $10,951 (SD= 6,540) for ED Obs. 73% (n=1,473) of these patients had solid tumor diagnoses. The five most common solid tumor diagnoses associated with these patients were gastrointestinal (16%), gynecologic (12%), genitourinary (10%), breast (10%), and thoracic (9%). The most common ICD-9 codes associated with these patients’ admissions were abdominal pain (9%), fever (5%), dyspnea (5%), chest pain (3%), and nausea (3%). Of these outpatients, 53% (n=1,066) had at least one radiologic test performed, the most common tests being chest x-ray in 41% and CT scans in 16%. Conclusions: About 1 in 3 cancer patients who present to the ED are not admitted to an inpatient setting, representing potentially avoidable costly ED visits. Most of these patients are represented by five solid tumor diseases. Improved alternative outpatient access and management strategies of symptoms such as abdominal pain, dyspnea, and nausea in these patients may reduce ED utilization in this patient population.

Randomized clinical trial of an emergency department observation syncope protocol versus routine inpatient admission

STUDY OBJECTIVE

Older adults are frequently hospitalized from the emergency department (ED) after an episode of unexplained syncope. Current admission patterns are costly, with little evidence of benefit. We hypothesize that an ED observation syncope protocol will reduce resource use without adversely affecting patient-oriented outcomes.

METHODS

This randomized trial at 5 EDs compared an ED observation syncope protocol to inpatient admission for intermediate-risk adults (≥50 years) presenting with syncope or near syncope. Primary outcomes included inpatient admission rate and length of stay. Secondary outcomes included 30-day and 6-month serious outcomes after hospital discharge, index and 30-day hospital costs, 30-day quality-of-life scores, and 30-day patient satisfaction.

RESULTS

Study staff randomized 124 patients. Observation resulted in a lower inpatient admission rate (15% versus 92%; 95% confidence interval [CI] difference -88% to -66%) and shorter hospital length of stay (29 versus 47 hours; 95% CI difference -28 to -8). Serious outcome rates after hospital discharge were similar for observation versus admission at 30 days (3% versus 0%; 95% CI difference -1% to 8%) and 6 months (8% versus 10%; 95% CI difference -13% to 9%). Index hospital costs in the observation group were $629 (95% CI difference -$1,376 to -$56) lower than in the admission group. There were no differences in 30-day quality-of-life scores or in patient satisfaction.

CONCLUSION

An ED observation syncope protocol reduced the primary outcomes of admission rate and hospital length of stay. Analyses of secondary outcomes suggest reduction in index hospital costs, with no difference in safety events, quality of life, or patient satisfaction. Our findings suggest that an ED observation syncope protocol can be replicated and safely reduce resource use.

Emergency department use by the uninsured after health care reform in Massachusetts

The objective of this article is to determine if health care reform in Massachusetts in 2006 was associated with a change in ED utilization by the uninsured for asthma and upper respiratory tract infection (URI). We performed a retrospective pre-post study in an urban tertiary-care teaching hospital. Subjects included all patients, ages 2-54, who presented to the ED with asthma or URI from January 1 to July 31 for each of the 3 years before health care reform and for the period after the insurance mandate officially went into effect on January 1, 2008. We used chi-square analysis to compare the frequency of utilization of the ED by uninsured patients before and after the implementation of an individual health insurance mandate in Massachusetts. For the period before the implementation of health reform, an annual average of 301 ED visits for patients with either URI (average n = 131) or asthma (average n = 170) were identified. After health care reform, there were 366 visits found for URI (n = 132) and asthma (n = 234) over a similar time period. There was a statistically significant decrease in ED utilization by the uninsured for URI but not for asthma. As a secondary analysis, visits for patients covered by the uncompensated care pool (UCP) before health care reform was not different from the combined frequency of visits by the remaining uninsured covered by a health safety net pool and those who qualified for the state subsidized Commonwealth Care program after health care reform. In this study, health care reform was associated with a decrease in the number of uninsured patients who presented to the ED with URI but not asthma. This study is limited by its analysis of a single large institution and a limited set of diagnoses.

2.8 A crystal structure of the malachite green aptamer

Previous in vitro selection experiments identified an RNA aptamer that recognizes the chromophore malachite green (MG) with a high level of affinity, and which undergoes site-specific cleavage following laser irradiation. To understand the mechanism by which this RNA folds to recognize specifically its ligand and the structural basis for chromophore-assisted laser inactivation, we have determined the 2.8 A crystal structure of the aptamer bound to tetramethylrosamine (TMR), a high-affinity MG analog. The ligand-binding site is defined by an asymmetric internal loop, flanked by a pair of helices. A U-turn and several non-canonical base interactions stabilize the folding of loop nucleotides around the TMR. The aptamer utilizes several tiers of stacked nucleotides arranged in pairs, triples, and a novel base quadruple to effectively encapsulate the ligand. Even in the absence of specific stabilizing hydrogen bonds, discrimination between related fluorophores and chromophores is possible due to tight packing in the RNA binding pocket, which severely limits the size and shape of recognized ligands. The site of laser-induced cleavage lies relatively far from the bound TMR ( approximately 15 A). The unusual backbone conformation of the cleavage site nucleotide and its high level of solvent accessibility may combine to allow preferential reaction with freely diffusing hydroxyl radicals generated at the bound ligand. Several observations, however, favor alternative mechanisms for cleavage, such as conformational changes in the aptamer or long-range electron transfer between the bound ligand and the cleavage site nucleotide.

Growth factors in the regenerating pancreas of gamma-interferon transgenic mice

We examined the distribution of several relevant growth factors in gamma-interferon transgenic mice, which undergo continual growth and differentiation in the pancreas. As a result, epidermal growth factor (EGF), TGF-alpha, and the EGF receptor were identified as potentially important in mediating some of these regenerative changes. Transient up-regulation of EGF, TGF-alpha, and the EGF receptor were observed in acini undergoing differentiation into duct-like structures. These ducts have been shown to proliferate and potentiate regeneration of the pancreatic islet mass.

Protective effects of interferon-gamma in intraocular herpes simplex type 1 infection do not depend on major histocompatibility complex class I or class II expression

Intraocular infection with herpes simplex virus type I strain F (HSV-1) induces bilateral retinitis, the expression of both MHC class I and II molecules and activation of CD4 and CD8 cells. To investigate the role of MHC upregulation in IFN-gamma mediated antiviral effects in intraocular infection with HSV-1, we infected MHC deficient mice and mice with an additional ectopic site of IFN-gamma production in their retina (rho gamma) intravitreally with HSV-1 into one eye. Protective effects of IFN-gamma in intraocular HSV-1 infection were notable as sparing of the contralateral non-inoculated eye from retinitis, and were not dependent on MHC class I and class II expression, thus limiting the importance of MHC expression for the outcome of viral infection in vivo.

Obstructive jaundice secondary to pancreatic adenocarcinoma in a seven-year-old male

Pancreatic carcinoma in childhood is a rare cause of obstructive jaundice. This report deals with such a case in a seven-year-old boy, which was successfully treated with a pancreatoduodenectomy. A brief review of the literature reveals that children will tolerate radical pancreatic resections, including pancreatoduodenectomy, better than adults. The only hope of long-term survival rests with aggressive surgical treatment. Pancreatoduodenectomy in infants and children can be done with a low mortality (9%) and for a mean survival of greater than four years (median two years).