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Riviere P, Morgan KM, Deshler LN, Huang X, Marienfeld C, Coyne CJ, Rose BS, Murphy JD. Opioid tapering in older cancer survivors does not increase psychiatric or drug hospitalization rates. J Natl Cancer Inst 2024; 116:606-612. [PMID: 37971959 PMCID: PMC10995846 DOI: 10.1093/jnci/djad241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 11/06/2023] [Accepted: 11/13/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Opioid tapering in the general population is linked to increases in hospitalizations or emergency department visits related to psychiatric or drug-related diagnoses. Cancer survivors represent a unique population with different opioid indications, prescription patterns, and more frequent follow-up care. This study sought to describe patterns of opioid tapering among older cancer survivors and to test the hypothesis of whether older cancer survivors face increased risks of adverse events with opioid tapering. METHODS Using the Surveillance, Epidemiology and End Results Medicare-linked database, we identified 15 002 Medicare-beneficiary cancer survivors diagnosed between 2010 and 2017 prescribed opioids consistently for at least 6 months after their cancer diagnosis. Tapering was defined as a binary time-varying event occurring with any monthly oral morphine equivalent reduction of 15% or more from the previous month. Primary diagnostic billing codes associated with emergency room or hospital admissions were used for the composite endpoint of psychiatric- or drug-related event(s). RESULTS There were 3.86 events per 100 patient-months, with 97.8% events being mental health emergencies, 1.91% events being overdose emergencies, and 0.25% involving both. Using a generalized estimating equation for repeated measure time-based analysis, opioid tapering was not statistically associated with acute events in the 3-month posttaper period (odds ratio [OR] = 1.02; P = .62) or at any point in the future (OR = 0.96; P = .46). CONCLUSIONS Opioid tapering in older cancer survivors does not appear to be linked to a higher risk of acute psychiatric- or drug-related events, in contrast to prior research in the general population.
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Affiliation(s)
- Paul Riviere
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, USA
- Center for Health Equity and Education Research, University of California San Diego, La Jolla, CA, USA
| | - Kylie M Morgan
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, USA
- Center for Health Equity and Education Research, University of California San Diego, La Jolla, CA, USA
| | - Leah N Deshler
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, USA
- Center for Health Equity and Education Research, University of California San Diego, La Jolla, CA, USA
| | - Xinyi Huang
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, USA
- Division of Biostatistics and Bioinformatics, Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, CA, USA
| | - Carla Marienfeld
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
| | - Christopher J Coyne
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, USA
- Department of Emergency Medicine, University of California San Diego, La Jolla, CA, USA
| | - Brent S Rose
- Center for Health Equity and Education Research, University of California San Diego, La Jolla, CA, USA
| | - James D Murphy
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, USA
- Center for Health Equity and Education Research, University of California San Diego, La Jolla, CA, USA
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Reyes-Gibby CC, Qdaisat A, Ferrarotto R, Fadol A, Bischof JJ, Coyne CJ, Lipe DN, Hanna EY, Shete S, Abe JI, Yeung SCJ. Cardiovascular events after cancer immunotherapy as oncologic emergencies: Analyses of 610 head and neck cancer patients treated with immune checkpoint inhibitors. Head Neck 2024; 46:627-635. [PMID: 38151809 PMCID: PMC10922978 DOI: 10.1002/hed.27604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 11/24/2023] [Accepted: 12/06/2023] [Indexed: 12/29/2023] Open
Abstract
BACKGROUND Cardio-oncology and emergency medicine are closely collaborative, as many cardiac events in cancer patients require evaluation and treatment in the emergency department (ED). Immune checkpoint inhibitors (ICIs) have become a common treatment for patients with head and neck cancer (HNC). However, the immune-related adverse events (irAEs) from ICIs can be clinically significant. METHODS We reviewed and analyzed cardiovascular diagnoses among HNC patients who received ICI during the period April 1, 2016-December 31, 2020 in a large tertiary cancer center. Demographics, clinical and cancer-related data were abstracted, and billing databases were queried for cardiovascular disease (CVD)-related diagnosis using International Classification of Disease-version10 (ICD-10) codes. We recorded receipt of care at the ED as one of the outcome variables. RESULTS A total of 610 HNC patients with a median follow-up time of 12.3 months (median, interquartile range = 5-30 months) comprised our study cohort. Overall, 25.7% of patients had pre-existing CVD prior to ICI treatment. Of the remaining 453 patients without pre-existing CVD, 31.5% (n = 143) had at least one CVD-related diagnosis after ICI initiation. Tachyarrhythmias (91 new events) was the most frequent CVD-related diagnosis after ICI. The time to diagnosis of myocarditis from initiation of ICI occurred the earliest (median 2.5 months, 1.5-6.8 months), followed by myocardial infarction (3.7, 0.5-9), cardiomyopathy (4.5, 1.6-7.3), and tachyarrhythmias (4.9, 1.2-11.4). Patients with myocarditis and tachyarrhythmias mainly presented to the ED for care. CONCLUSION The use of ICI in HNC is still expanding and the spectrum of delayed manifestation of ICI-induced cardiovascular toxicities is yet to be fully defined in HNC survivors.
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Affiliation(s)
- Cielito C. Reyes-Gibby
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Aiham Qdaisat
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Renata Ferrarotto
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anecita Fadol
- Department of Nursing, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jason J. Bischof
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Christopher J. Coyne
- Department of Emergency Medicine, University of California San Diego, San Diego, California, USA
| | - Demis N. Lipe
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ehab Y Hanna
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sanjay Shete
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jun-ichi Abe
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sai-Ching J. Yeung
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Guerra-García A, Trněný O, Brus J, Renzi JP, Kumar S, Bariotakis M, Coyne CJ, Chitikineni A, Bett KE, Varshney R, Pirintsos S, Berger J, von Wettberg EJB, Smýkal P. Genetic structure and ecological niche space of lentil's closest wild relative, Lens orientalis (Boiss.) Schmalh. Plant Biol (Stuttg) 2024; 26:232-244. [PMID: 38230798 DOI: 10.1111/plb.13615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 11/27/2023] [Indexed: 01/18/2024]
Abstract
Crops arose from wild ancestors and to understand their domestication it is essential to compare the cultivated species with their crop wild relatives. These represent an important source of further crop improvement, in particular in relation to climate change. Although there are about 58,000 Lens accessions held in genebanks, only 1% are wild. We examined the geographic distribution and genetic diversity of the lentil's immediate progenitor L. orientalis. We used Genotyping by Sequencing (GBS) to identify and characterize differentiation among accessions held at germplasm collections. We then determined whether genetically distinct clusters of accessions had been collected from climatically distinct locations. Of the 195 genotyped accessions, 124 were genuine L. orientalis with four identified genetic groups. Although an environmental distance matrix was significantly correlated with geographic distance in a Mantel test, the four identified genetic clusters were not found to occupy significantly different environmental space. Maxent modelling gave a distinct predicted distribution pattern centred in the Fertile Crescent, with intermediate probabilities of occurrence in parts of Turkey, Greece, Cyprus, Morocco, and the south of the Iberian Peninsula with NW Africa. Future projections did not show any dramatic alterations in the distribution according to the climate change scenarios tested. We have found considerable diversity in L. orientalis, some of which track climatic variability. The results of the study showed the genetic diversity of wild lentil and indicate the importance of ongoing collections and in situ conservation for our future capacity to harness the genetic variation of the lentil progenitor.
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Affiliation(s)
- A Guerra-García
- Department of Plant Sciences, University of Saskatchewan, Saskatoon, Canada
- Departamento de Biotecnología y Bioquímica, Centro de Investigación y de Estudios Avanzados del Instituto Politécnico Nacional (CINVESTAV-IPN), Irapuato, Guanajuato, Mexico
| | - O Trněný
- Agriculture Research Ltd, Troubsko, Czech Republic
| | - J Brus
- Department of Geoinformatics, Palacký University, Olomouc, Czech Republic
| | - J P Renzi
- Instituto Nacional de Tecnología Agropecuaria, Buenos Aires, Argentina
| | - S Kumar
- International Center for Agricultural Research in the Dry Areas (ICARDA), Rabat, Morocco
| | - M Bariotakis
- Department of Biology, University of Crete, Heraklion, Greece
- Botanical Garden, Rethymnon, Greece
| | - C J Coyne
- Western Regional Plant Introduction Station, USDA-ARS, Pullman, WA, USA
| | - A Chitikineni
- International Crop Research Institute for the semi-Arid Tropics (ICRISAT), Patancheru, Hyderabad, India
| | - K E Bett
- Department of Plant Sciences, University of Saskatchewan, Saskatoon, Canada
| | - R Varshney
- International Crop Research Institute for the semi-Arid Tropics (ICRISAT), Patancheru, Hyderabad, India
- Murdoch University, Murdoch, WA, Australia
| | - S Pirintsos
- Department of Biology, University of Crete, Heraklion, Greece
| | - J Berger
- CSIRO Plant Industry, Wembley, WA, Australia
| | - E J B von Wettberg
- Department of Plant and Soil Sciences, Gund Institute for the Environment, University of Vermont, Burlington, VT, USA
| | - P Smýkal
- Department of Botany, Palacký University, Olomouc, Czech Republic
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Reyes-Gibby CC, Caterino JM, Coyne CJ, Kyriacou DN, Qdaisat A, McQuade J, Owen DH, Bischof JJ, Shete S, Yeung SCJ. Immune-related adverse event in the emergency department: methodology of the immune-related emergency disposition index (IrEDi). Emerg Cancer Care 2024; 3:1. [PMID: 38725994 PMCID: PMC11081141 DOI: 10.1186/s44201-023-00023-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 12/13/2023] [Indexed: 05/12/2024]
Abstract
For many cancer patients, immune checkpoint inhibitors (ICIs) can be life-saving. However, the immune-related adverse events (irAEs) from ICIs can be debilitating and can quickly become severe or even be fatal. Often, irAEs will precipitate visits to the emergency department (ED). Therefore, early recognition and the decision to admit, observe, or discharge these patients from the ED can be key to a cancer patient's morbidity and mortality. ED clinicians typically make their decision for disposition (admit, observe, or discharge) within 2-6 h from their patient's ED presentation. However, irAEs are particularly challenging in the ED because of atypical presentations, the absence of classic symptoms, the delayed availability of diagnostic tests during the ED encounter, and the fast pace in the ED setting. At present, there is no single sufficiently large ED data source with clinical, biological, laboratory, and imaging data that will allow for the development of a tool that will guide early recognition and appropriate ED disposition of patients with potential irAEs. We describe an ongoing federally funded project that aims to develop an immune-related emergency disposition index (IrEDi). The project capitalizes on a multi-site collaboration among 4 members of the Comprehensive Oncologic Emergency Research Network (CONCERN): MD Anderson Cancer Center, Ohio State University, Northwestern University, and University of California San Diego. If the aims are achieved, the IrEDi will be the first risk stratification tool derived from a large racial/ethnically and geographically diverse population of cancer patients. The future goal is to validate irEDi in general EDs to improve emergency care of cancer patients on ICIs.
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Affiliation(s)
- Cielito C. Reyes-Gibby
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey M. Caterino
- Departments of Emergency Medicine and Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Christopher J. Coyne
- Department of Emergency Medicine, University of California San Diego, San Diego, CA, USA
| | - Demetrios N. Kyriacou
- Department of Emergency Medicine and Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Aiham Qdaisat
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jennifer McQuade
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Dwight H. Owen
- Departments of Emergency Medicine and Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jason J. Bischof
- Departments of Emergency Medicine and Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Sanjay Shete
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sai-Ching Jim Yeung
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Quenzer FC, Coyne CJ, Ferran K, Williams A, Lafree AT, Kajitani S, Mathen G, Villegas V, Kajitani KM, Tomaszewski C, Brodine S. ICU Admission Risk Factors for Latinx COVID-19 Patients at a U.S.-Mexico Border Hospital. J Racial Ethn Health Disparities 2023; 10:3039-3050. [PMID: 36478268 PMCID: PMC9735002 DOI: 10.1007/s40615-022-01478-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 11/22/2022] [Accepted: 11/23/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Few studies have examined the impact of coronavirus disease 2019 (COVID-19) on the primarily Latinx community along the U.S.-Mexico border. This study explores the socioeconomic impacts which contribute to strong predictors of severe COVID-19 complications such as intensive care unit (ICU) hospitalization in a primarily Latinx/Hispanic U.S.-Mexico border hospital. METHODS A retrospective, observational study of 156 patients (≥ 18 years) Latinx/Hispanic patients who were admitted for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection at a U.S.-Mexico border hospital from April 10, 2020, to May 30, 2020. Descriptive statistics of sex, age, body mass index (BMI), and comorbidities (coronary artery disease, hypertension, diabetes, cancer/lymphoma, current use of immunosuppressive drug therapy, chronic kidney disease/dialysis, or chronic respiratory disease). Multivariate regression models were produced from the most significant variables and factors for ICU admission. RESULTS Of the 156 hospitalized Latinx patients, 63.5% were male, 84.6% had respiratory failure, and 45% were admitted to the ICU. The average age was 67.2 (± 12.2). Those with body mass index (BMI) ≥ 25 had a higher frequency of ICU admission. Males had a 4.4 (95% CI 1.58, 12.308) odds of ICU admission (p = 0.0047). Those who developed acute kidney injury (AKI) and BMI 25-29.9 were strong predictors of ICU admission (p < 0.001 and p = 0.0020, respectively). Those with at least one reported comorbidity had 1.98 increased odds (95% CI 1.313, 2.99) of an ICU admission. CONCLUSION Findings show that age, AKI, and male sex were the strongest predictors of COVID-19 ICU admissions in the primarily Latinx population at the U.S.-Mexico border. These predictors are also likely driven by socioeconomic inequalities which are most apparent in border hospitals.
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Affiliation(s)
- Faith C Quenzer
- Division of Epidemiology and Biostatistics, School of Public Health, San Diego State University, San Diego, CA, USA.
- Department of Emergency Medicine, Temecula Valley Hospital, Temecula, CA, USA.
| | - Christopher J Coyne
- Department of Emergency Medicine, University of California San Diego Health, San Diego, CA, USA
| | - Karen Ferran
- Division of Epidemiology and Biostatistics, School of Public Health, San Diego State University, San Diego, CA, USA
| | - Ashley Williams
- Division of Epidemiology and Biostatistics, School of Public Health, San Diego State University, San Diego, CA, USA
| | - Andrew T Lafree
- Department of Emergency Medicine, University of California San Diego Health, San Diego, CA, USA
- Department of Emergency Medicine, El Centro Regional Medical Center, El Centro, CA, USA
| | - Sten Kajitani
- Department of Emergency Medicine, University of California San Diego Health, San Diego, CA, USA
- Department of Emergency Medicine, El Centro Regional Medical Center, El Centro, CA, USA
| | - George Mathen
- Department of Emergency Medicine, University of California San Diego Health, San Diego, CA, USA
- Department of Emergency Medicine, El Centro Regional Medical Center, El Centro, CA, USA
| | - Vanessa Villegas
- Department of Emergency Medicine, El Centro Regional Medical Center, El Centro, CA, USA
| | - Kari M Kajitani
- Department of Emergency Medicine, University of California San Diego Health, San Diego, CA, USA
- Department of Emergency Medicine, El Centro Regional Medical Center, El Centro, CA, USA
| | - Christian Tomaszewski
- Department of Emergency Medicine, University of California San Diego Health, San Diego, CA, USA
- Department of Emergency Medicine, El Centro Regional Medical Center, El Centro, CA, USA
| | - Stephanie Brodine
- Division of Epidemiology and Biostatistics, School of Public Health, San Diego State University, San Diego, CA, USA
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Hoenigl M, Lo M, Coyne CJ, Wagner GA, Blumenthal J, Mathur K, Horton LE, Martin TC, Vilke GM, Little SJ. 4th Generation HIV screening in the emergency department: net profit or loss for hospitals? AIDS Care 2023; 35:714-718. [PMID: 34839750 PMCID: PMC9135954 DOI: 10.1080/09540121.2021.1995838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 10/13/2021] [Indexed: 10/19/2022]
Abstract
ABSTRACTThe objective of this study was to determine hospital costs and revenue of universal opt-out HIV ED screening. An electronic medical record (EMR)-directed, automated ED screening program was instituted at an academic medical center in San Diego, California. A base model calculated net income in US dollars for the hospital by comparing annual testing costs with reimbursements using payor mixes and cost variables. To account for differences in payor mixes, testing costs, and reimbursement rates across hospitals in the US, we performed a probabilistic sensitivity analysis. The base model included a total of 12,513 annual 4th generation HIV tests with the following payor mix: 18% Medicare, 9% MediCal, 28% commercial and 8% self-payers, with the remainder being capitated contracts. The base model resulted in a net profit for the hospital. In the probabilistic sensitivity analysis, universal 4th generation HIV screening resulted in a net profit for the hospital in 81.9% of simulations. Universal 4th generation opt-out HIV screening in EDs resulted in a net profit to an academic hospital. Sensitivity analysis indicated that ED HIV screening results in a net-profit for the majority of simulations, with higher proportions of self-payers being the major predictor of a net loss.
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Affiliation(s)
- Martin Hoenigl
- Department of Medicine, Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California, United States
- Department of Pathology, University of California San Diego, San Diego, California, United States
- Division of Infectious Diseases, Medical University of Graz, Graz, Austria
| | - Megan Lo
- School of Medicine, University of San Diego, San Diego, California, United States
| | - Christopher J. Coyne
- Department of Emergency Medicine, University of California San Diego, San Diego, California, United States
| | - Gabriel A. Wagner
- Department of Medicine, Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California, United States
| | - Jill Blumenthal
- Department of Medicine, Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California, United States
| | - Kushagra Mathur
- School of Medicine, University of San Diego, San Diego, California, United States
| | - Lucy E. Horton
- Department of Medicine, Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California, United States
| | - Thomas C.S. Martin
- Department of Medicine, Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California, United States
| | - Gary M. Vilke
- Department of Emergency Medicine, University of California San Diego, San Diego, California, United States
| | - Susan J. Little
- Department of Medicine, Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California, United States
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Nunez J, Corroon J, Vilke G, Castillo E, Alfaraj DN, Coyne CJ. Perceptions and Practices of Cannabis Use Among Emergency Department Patients. J Emerg Med 2023; 64:543-554. [PMID: 37032203 DOI: 10.1016/j.jemermed.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 02/06/2023] [Accepted: 02/17/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND Nationally, in states where cannabis has been legalized, increases in cannabis-related hospitalizations and emergency department (ED) visits have also been observed. OBJECTIVES This study aims to: 1) Describe the sociodemographic characteristics of cannabis users presenting to two academic EDs in California; 2) Assess cannabis-related behaviors; 3) Assess perceptions of cannabis; 4) Identify and describe reasons for cannabis-related ED utilization. METHODS This is a cross-sectional study of patients visiting one of two academic EDs between February 16, 2018 and November 21, 2020. Eligible participants completed a novel questionnaire developed by the authors. Basic descriptive statistics, Pearson correlation coefficients, and logistic regression were used for statistical analysis of responses. RESULTS The questionnaire was completed by 2577 patients. A quarter were categorized as Current Users (n = 628, 24.4%). Current, Regular Users were evenly divided across gender, were relatively younger (18-34 years, 48.1%), and were largely non-Hispanic Caucasian. Over half of all respondents believed that the use of cannabis was less harmful than tobacco or alcohol use (n = 1537, 59.6%). One in five Current Users (n = 123, 19.8%) reported driving while using cannabis in the past month. A small proportion (n = 24, 3.9%) of Current Users reported ever visiting the ED for a cannabis-related chief complaint. CONCLUSIONS Overall, many ED patients are currently using cannabis; few report utilizing the ED due to cannabis-related problems. Current, Irregular Users may represent the ideal target group for ED-based educational efforts aimed at improving knowledge of safe cannabis use.
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Affiliation(s)
- Jason Nunez
- Department of Emergency Medicine, University of California San Diego, San Diego, California
| | - Jamie Corroon
- Department of Family Medicine, University of California San Diego, San Diego, California; Helfgott Research Institute, National University of Natural Medicine, Portland, Oregon
| | - Gary Vilke
- Department of Emergency Medicine, University of California San Diego, San Diego, California
| | - Edward Castillo
- Department of Emergency Medicine, University of California San Diego, San Diego, California
| | - Dunya N Alfaraj
- King Fahd Hospital, Imam Abdulrahman Bin Faisal University, Al Khobar, Eastern, Saudi Arabia
| | - Christopher J Coyne
- Department of Emergency Medicine, University of California San Diego, San Diego, California
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Zewe JA, Castillo EM, Cronin AO, Kreshak AA, Sloane CM, Coyne CJ, Vilke GM. Physiological Effects of a Spit Restraint Device Saturated With Artificial Saliva. J Emerg Med 2023; 64:464-470. [PMID: 36990853 DOI: 10.1016/j.jemermed.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 12/06/2022] [Accepted: 12/12/2022] [Indexed: 03/29/2023]
Abstract
BACKGROUND Spit restraint devices, also referred to as spit hoods, spit masks, or spit socks, are used by law enforcement and medical personnel to minimize transmission of communicable disease from bodily fluids from agitated individuals. Several lawsuits have implicated spit restraint devices as contributing to the death of individuals who are physically restrained by means of asphyxiation due to saturation of the mesh restraint device with saliva. OBJECTIVES This study aims to evaluate whether a saturated spit restraint device has any clinically significant effects on the ventilatory or circulatory parameters of healthy adult subjects. METHODS Subjects wore a spit restraint device dampened with 0.5% carboxymethylcellulose, an artificial saliva. Baseline vitals were taken, and a wet spit restraint device was then placed over the subject's head, and repeat measurements were taken at 10, 20, 30, and 45 min. A second spit restraint device was placed 15 min after the first. Measurements at 10, 20, 30, and 45 min were compared with baseline using paired t-tests. RESULTS The mean age of 10 subjects was 33.8 years, and 50% were female. There was no significant difference between baseline and while wearing the spit sock for 10, 20, 30, and 45 min for the measured parameters including heart rate, oxygen saturation, end-tidal CO2, respiratory rate, or blood pressure. No subject indicated respiratory distress or had to terminate the study. CONCLUSIONS In healthy adult subjects, there were no statistically or clinically significant differences in ventilatory or circulatory parameters while wearing the saturated spit restraint.
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Affiliation(s)
- Jacqueline A Zewe
- Department of Emergency Medicine, University of California, San Diego, San Diego, California
| | - Edward M Castillo
- Department of Emergency Medicine, University of California, San Diego, San Diego, California
| | - Alexandrea O Cronin
- Department of Emergency Medicine, University of California, San Diego, San Diego, California
| | - Allyson A Kreshak
- Department of Emergency Medicine, University of California, San Diego, San Diego, California
| | - Christian M Sloane
- Department of Emergency Medicine, University of California, San Diego, San Diego, California
| | - Christopher J Coyne
- Department of Emergency Medicine, University of California, San Diego, San Diego, California
| | - Gary M Vilke
- Department of Emergency Medicine, University of California, San Diego, San Diego, California
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Quenzer FC, Coyne CJ, Grey L, Fernandez J, Witucki P, Ly B, Oyama LC, Hayden SR. Impacts of USMLE Step 1 Scoring Change on EM Applicant Screening. J Emerg Med 2023. [DOI: 10.1016/j.jemermed.2023.03.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
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10
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Bischof JJ, Elsaid MI, Bridges JFP, Rosko AE, Presley CJ, Abar B, Adler D, Bastani A, Baugh CW, Bernstein SL, Coyne CJ, Durham DD, Grudzen CR, Henning DJ, Hudson MF, Klotz A, Lyman GH, Madsen TE, Reyes-Gibby CC, Rico JF, Ryan RJ, Shapiro NI, Swor R, Thomas CR, Venkat A, Wilson J, Yeung SCJ, Yilmaz S, Caterino JM. Characterization of older adults with cancer seeking acute emergency department care: A prospective observational study. J Geriatr Oncol 2022; 13:943-951. [PMID: 35718667 DOI: 10.1016/j.jgo.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 04/05/2022] [Accepted: 06/10/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Disparities in care of older adults in cancer treatment trials and emergency department (ED) use exist. This report provides a baseline description of older adults ≥65 years old who present to the ED with active cancer. MATERIALS AND METHODS Planned secondary analysis of the Comprehensive Oncologic Emergencies Research Network observational ED cohort study sponsored by the National Cancer Institute. Of 1564 eligible adults with active cancer, 1075 patients were prospectively enrolled, of which 505 were ≥ 65 years old. We recruited this convenience sample from eighteen participating sites across the United States between February 1, 2016 and January 30, 2017. RESULTS Compared to cancer patients younger than 65 years of age, older adults were more likely to be transported to the ED by emergency medical services, have a higher Charlson Comorbidity Index score, and be admitted despite no significant difference in acuity as measured by the Emergency Severity Index. Despite the higher admission rate, no significant difference was noted in hospitalization length of stay, 30-day mortality, ED revisit or hospital admission within 30 days after the index visit. Three of the top five ED diagnoses for older adults were symptom-related (fever of other and unknown origin, abdominal and pelvic pain, and pain in throat and chest). Despite this, older adults were less likely to report symptoms and less likely to receive symptomatic treatment for pain and nausea than the younger comparison group. Both younger and older adults reported a higher symptom burden on the patient reported Condensed Memorial Symptom Assessment Scale than to ED providers. When treating suspected infection, no differences were noted in regard to administration of antibiotics in the ED, admissions, or length of stay ≤2 days for those receiving ED antibiotics. DISCUSSION We identified several differences between older (≥65 years old) and younger adults with active cancer seeking emergency care. Older adults frequently presented for symptom-related diagnoses but received fewer symptomatic interventions in the ED suggesting that important opportunities to improve the care of older adults with cancer in the ED exist.
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Affiliation(s)
- Jason J Bischof
- Departments of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
| | - Mohamed I Elsaid
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, OH, USA.
| | - John F P Bridges
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, OH, USA.
| | - Ashley E Rosko
- Department of Internal Medicine, Division of Hematology, Ohio State University Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA.
| | - Carolyn J Presley
- Department of Internal Medicine, Division of Medical Oncology, Ohio State University Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA.
| | - Beau Abar
- Department of Emergency Medicine, University of Rochester, Rochester, NY, USA.
| | - David Adler
- Department of Emergency Medicine, University of Rochester, Rochester, NY, USA.
| | - Aveh Bastani
- Department of Emergency Medicine, William Beaumont Hospital - Troy Campus, Troy, MI, USA.
| | - Christopher W Baugh
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA.
| | - Steven L Bernstein
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA.
| | - Christopher J Coyne
- Department of Emergency Medicine, University of California San Diego, San Diego, CA, USA.
| | - Danielle D Durham
- Department of Radiology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA.
| | - Corita R Grudzen
- Ronald O. Perelman Department of Emergency Medicine and Population Health, New York University Grossman School of Medicine, New York, NY, USA.
| | - Daniel J Henning
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA.
| | | | - Adam Klotz
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Gary H Lyman
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center and the Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA.
| | - Troy E Madsen
- Division of Emergency Medicine, University of Utah, Salt Lake City, UT, USA.
| | - Cielito C Reyes-Gibby
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Juan Felipe Rico
- Department of Pediatrics, University of South Florida Morsani College of Medicine, Tampa, FL, USA.
| | - Richard J Ryan
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH, USA.
| | - Nathan I Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | - Robert Swor
- Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, MI, USA.
| | - Charles R Thomas
- Department of Radiation Oncology, Geisel School of Medicine @ Dartmouth, Lebanon, NH, USA.
| | - Arvind Venkat
- Department of Emergency Medicine, Allegheny Health Network, Pittsburgh, PA, USA.
| | - Jason Wilson
- Department of Emergency Medicine, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Sai-Ching Jim Yeung
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Sule Yilmaz
- Department of Surgery, Division of Supportive Care in Cancer, University of Rochester Medical Center, Rochester, NY, USA.
| | - Jeffrey M Caterino
- Departments of Emergency Medicine and Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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11
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Gupta R, Lin L, Resley V, Khan A, Li DR, Shatsky RA, Coyne CJ. Evaluating Cancer Pain Characteristics and Treatment Factors in the Emergency Department: A Retrospective Cohort Study. J Palliat Care 2022; 37:486-493. [PMID: 35979605 PMCID: PMC9465546 DOI: 10.1177/08258597221121316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Objectives: To identify patient characteristics and treatment
factors of patients presenting to the emergency department (ED) with
cancer-related pain that may affect patient outcomes. Methods: We
conducted a retrospective cohort study to evaluate adult patients with active
cancer, who presented to the ED with a chief complaint of pain between June
first, 2012 and January first, 2016. We utilized multivariable logistic
regression to evaluate the association of several exposure variables, including
disease and demographic characteristics, primary pain site, and treatment
methods, on ED disposition and revisit rate. Results: We included
483 patients with active cancer with a chief complaint of pain. Patients with
severe pain on arrival tended to be younger than those who did not present with
severe pain (median: 58 vs 62 respectively, OR 8.0 p < 0.01). Patients with
high ECOG scores (3-4) with severe pain on arrival (≥7 out of 10) had less
improvement in their pain than the rest of our cohort (OR 8.4, p < 0.01).
Also, those with musculoskeletal pain had significantly less improvement in
reported pain than all other pain types (delta pain −2.1 vs −3.4, OR 2.3,
p = 0.025) Long delays in initial analgesic administration were associated with
increased rates of subsequent admission (OR 3.4) [p = 0.014]. Although opioid
analgesics led to greater decreases in pain than non-opioid analgesics, patients
treated with opioids were more likely to be admitted (43% vs 34.5% AOR 1.51,
p = 0.048). Conclusion: Our study showed that delays in analgesic
administration, poor functional status, and the presence of musculoskeletal
(MSK) pain significantly influenced outcomes for this patient cohort. These
findings suggest the development of specific protocols and tools to address
cancer-related pain in the ED may be necessary.
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Affiliation(s)
- Rishi Gupta
- Department of Emergency Medicine, 8784University of California San Diego, San Diego, CA, USA
| | - Lucia Lin
- Department of Emergency Medicine, 8784University of California San Diego, San Diego, CA, USA
| | - Vanessa Resley
- Department of Emergency Medicine, 8784University of California San Diego, San Diego, CA, USA
| | - Ayesha Khan
- Department of Emergency Medicine, 8784University of California San Diego, San Diego, CA, USA
| | - David R Li
- Department of Emergency Medicine, 8784University of California San Diego, San Diego, CA, USA
| | - Rebecca A Shatsky
- Department of Internal Medicine, Division of Hematology/Oncology, 8784University of California San Diego, La Jolla, CA, USA
| | - Christopher J Coyne
- Department of Emergency Medicine, 8784University of California San Diego, San Diego, CA, USA
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12
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Coyne CJ, Castillo EM, Shatsky RA, Chan TC. Procalcitonin as a Predictive Tool for Death and ICU Admission among Febrile Neutropenic Patients Visiting the Emergency Department. Medicina (Kaunas) 2022; 58:985. [PMID: 35893100 PMCID: PMC9329824 DOI: 10.3390/medicina58080985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 07/15/2022] [Accepted: 07/20/2022] [Indexed: 11/17/2022]
Abstract
Background and Objectives: Risk stratification tools for febrile neutropenia exist but are infrequently utilized by emergency physicians. Procalcitonin may provide emergency physicians with a more objective tool to identify patients at risk of decompensation. Materials and Methods: We conducted a retrospective cohort study evaluating the use of procalcitonin in cases of febrile neutropenia among adult patients presenting to the Emergency Department compared to a non-neutropenic, febrile control group. Our primary outcome measure was in-hospital mortality with a secondary outcome of ICU admission. Results: Among febrile neutropenic patients, a positive initial procalcitonin value was associated with significantly increased odds of inpatient mortality after adjusting for age, sex, race, and ethnicity (AOR 9.912, p < 0.001), which was similar, though greater than, our non-neutropenic cohort (AOR 2.18, p < 0.001). All febrile neutropenic patients with a positive procalcitonin were admitted to the ICU. Procalcitonin had a higher sensitivity and negative predictive value (NPV) in regard to mortality and ICU admission for our neutropenic group versus our non-neutropenic control. Conclusions: Procalcitonin appears to be a valuable tool when attempting to risk stratify patients with febrile neutropenia presenting to the emergency department. Procalcitonin performed better in the prediction of death and ICU admission among patients with febrile neutropenia than a similar febrile, non-neutropenic control group.
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Affiliation(s)
- Christopher J. Coyne
- Department of Emergency Medicine, University of California San Diego, San Diego, CA 92103, USA; (E.M.C.); (T.C.C.)
| | - Edward M. Castillo
- Department of Emergency Medicine, University of California San Diego, San Diego, CA 92103, USA; (E.M.C.); (T.C.C.)
| | - Rebecca A. Shatsky
- Department of Medicine, Division of Hematology/Oncology, University of California San Diego, San Diego, CA 92037, USA;
| | - Theodore C. Chan
- Department of Emergency Medicine, University of California San Diego, San Diego, CA 92103, USA; (E.M.C.); (T.C.C.)
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13
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Yilmaz S, Grudzen CR, Durham DD, McNaughton C, Marcelin I, Abar B, Adler D, Bastani A, Baugh CW, Bernstein SL, Bischof JJ, Coyne CJ, Henning DJ, Hudson MF, Klotz A, Lyman GH, Madsen TE, Pallin DJ, Reyes-Gibby C, Rico JF, Ryan RJ, Shapiro NI, Swor R, Thomas CR, Venkat A, Wilson J, Yeung SCJ, Caterino JM. Palliative Care Needs and Clinical Outcomes of Patients with Advanced Cancer in the Emergency Department. J Palliat Med 2022; 25:1115-1121. [PMID: 35559758 PMCID: PMC9467631 DOI: 10.1089/jpm.2021.0567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Older adults with cancer use the emergency department (ED) for acute concerns. Objectives: Characterize the palliative care needs and clinical outcomes of advanced cancer patients in the ED. Design: A planned secondary data analysis of the Comprehensive Oncologic Emergencies Research Network (CONCERN) data. Settings/Subjects: Cancer patients who presented to the 18 CONCERN affiliated EDs in the United States. Measurements: Survey included demographics, cancer type, functional status, symptom burden, palliative and hospice care enrollment, and advance directive code status. Results: Of the total (674/1075, 62.3%) patients had advanced cancer and most were White (78.6%) and female (50.3%); median age was 64 (interquartile range 54-71) years. A small proportion of them were receiving palliative (6.5% [95% confidence interval; CI 3.0-7.6]; p = 0.005) and hospice (1.3% [95% CI 1.0-3.2]; p = 0.52) care and had a higher 30-day mortality rate (8.3%, [95% CI 6.2-10.4]). Conclusions: Patients with advanced cancer continue to present to the ED despite recommendations for early delivery of palliative care.
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Affiliation(s)
- Sule Yilmaz
- Division of Supportive Care in Cancer, Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
- Address correspondence to: Sule Yilmaz, PhD, Division of Supportive Care in Cancer, Department of Surgery, University of Rochester Medical Center, 265 Crittenden Boulevard, Rochester, NY 14642, USA
| | - Corita R. Grudzen
- Ronald O. Perelman Department of Emergency Medicine and Population Health, New York University School of Medicine, New York, New York, USA
| | - Danielle D. Durham
- Department of Radiology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | | | - Isabelle Marcelin
- Ronald O. Perelman Department of Emergency Medicine and Population Health, New York University School of Medicine, New York, New York, USA
| | - Beau Abar
- Department of Emergency Medicine, University of Rochester, Rochester, New York, USA
| | - David Adler
- Department of Emergency Medicine, University of Rochester, Rochester, New York, USA
| | - Aveh Bastani
- Department of Emergency Medicine, William Beaumont Hospital—Troy Campus, Troy, Michigan, USA
| | - Christopher W. Baugh
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Steven L. Bernstein
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jason J. Bischof
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Christopher J. Coyne
- Department of Emergency Medicine, University of California San Diego, San Diego, California, USA
| | - Daniel J. Henning
- Department of Emergency Medicine, University of Washington, Seattle, Washington, USA
| | | | - Adam Klotz
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Gary H. Lyman
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center and the Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Troy E. Madsen
- Division of Emergency Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Daniel J. Pallin
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Cielito Reyes-Gibby
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Juan Felipe Rico
- Department of Pediatrics, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Richard J. Ryan
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Nathan I. Shapiro
- Department of Emergency Medicine, Beth Israel Deaconness Medical Center, Boston, Massachusetts, USA
| | - Robert Swor
- Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, Michigan, USA
| | - Charles R. Thomas
- Department of Radiation Medicine, Knight Cancer Institute, Oregon Health and Sciences University, Portland, Oregon, USA
| | - Arvind Venkat
- Department of Emergency Medicine, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Jason Wilson
- Department of Emergency Medicine, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Sai-Ching Jim Yeung
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jeffrey M. Caterino
- Department of Emergency Medicine and Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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14
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Dusek JA, Kallenberg GA, Hughes RM, Storrow AB, Coyne CJ, Vago DR, Nielsen A, Karasz A, Kim RS, Surdam J, Segall T, McKee MD. Acupuncture in the emergency department for pain management: A BraveNet multi-center feasibility study. Medicine (Baltimore) 2022; 101:e28961. [PMID: 35244059 PMCID: PMC8896475 DOI: 10.1097/md.0000000000028961] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 02/11/2022] [Indexed: 12/22/2022] Open
Abstract
PURPOSE Pain accounts for up to 78% of emergency department (ED) patient visits and opioids remain a primary method of treatment despite risks of addiction and adverse effects. While prior acupuncture studies are promising as an alternative opioid-sparing approach to pain reduction, successful conduct of a multi-center pilot study is needed to prepare for a future definitive randomized control trial (RCT). METHODS Acupuncture in the Emergency Department for Pain Management (ACUITY) is funded by the National Center for Complementary and Integrative Health. The objectives are to: conduct a multi-center feasibility RCT, examine feasibility of data collection, develop/deploy a manualized acupuncture intervention and assess feasibility/implementation (barrier/facilitators) in 3 EDs affiliated with the BraveNet Practice Based Research Network.Adults presenting to a recruiting ED with acute non-emergent pain (e.g., musculoskeletal, back, pelvic, noncardiac chest, abdominal, flank or head) of ≥4 on a 0-10-point Numeric Rating Scale will be eligible. ED participants (n = 165) will be equally randomized to Acupuncture or Usual Care.At pre-, post-, and discharge time-points, patients will self-assess pain and anxiety using the Numeric Rating Scale. Pain, anxiety, post-ED opioid use and adverse events will be assessed at 1 and 4 weeks. Opioid utilization in the ED and discharge prescriptions will be extracted from patients' electronic medical records.Acupuncture recipients will asked to participate in a brief qualitative interview about 3 weeks after their discharge. ED providers and staff will also be interviewed about their general perspectives/experiences related to acupuncture in the ED and implementation of acupuncture in ACUITY. RESULTS Recruitment began on 5/3/21. As of 12/7/21: 84 patients have enrolled, the responsive acupuncture intervention has been developed and deployed, and 26 qualitative interviews have been conducted. CONCLUSION Successful conduct of ACUITY will provide the necessary framework for conducting a future, multi-center, definitive RCT of acupuncture in the ED. CLINICAL TRIALSGOV NCT04880733 https://clinicaltrials.gov/ct2/show/NCT04880733.
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Affiliation(s)
- Jeffery A. Dusek
- UH Connor Whole Health, University Hospitals, Cleveland, OH
- Department of Family Medicine and Community Health, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Gene A. Kallenberg
- Department of Family Medicine, University of California San Diego, La Jolla, CA
| | - Robert M. Hughes
- Department of Emergency Medicine, Case Western Reserve University School of Medicine, Cleveland OH
- Clinical Decision Unit, University Hospitals, Cleveland Medical Center, Cleveland, OH
| | - Alan B. Storrow
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Christopher J. Coyne
- Department of Emergency Medicine and Department of Radiation Medicine and Applied Sciences University of California San Diego La Jolla, CA
| | - David R. Vago
- Department of Physical Medicine and Rehabilitation and Department of Psychiatry, Vanderbilt University Medical Center, Nashville, TN
| | - Arya Nielsen
- Department of Family Medicine and Community Health Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alison Karasz
- Department of Family Medicine and Social Medicine, Albert Einstein College of Medicine/Montefiore, New York, NY
| | - Ryung S. Kim
- Department of Epidemiology and Population Health and Institute of Clinical and Translational Research, Albert Einstein College of Medicine/Montefiore, New York, NY
| | - Jessica Surdam
- UH Connor Whole Health, University Hospitals, Cleveland, OH
| | - Tracy Segall
- UH Connor Whole Health, University Hospitals, Cleveland, OH
| | - M. Diane McKee
- Department of Family Medicine and Community Health, University of Massachusetts School of Medicine, Worcester, MA
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15
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Hudson MF, Strassels SA, Durham DD, Siddique S, Adler D, Yeung SJ, Bernstein SL, Baugh CW, Coyne CJ, Grudzen CR, Henning DJ, Klotz A, Madsen TE, Pallin DJ, Rico JF, Ryan RJ, Shapiro NI, Swor R, Venkat A, Wilson J, Thomas CR, Bischof JJ, Lyman GH, Caterino JM. Examining pain among non-Hispanic Black and non-Hispanic White patients with cancer visiting emergency departments: CONCERN (Comprehensive Oncologic Emergencies Research Network). Acad Emerg Med 2022; 29:364-368. [PMID: 34606137 DOI: 10.1111/acem.14395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 09/28/2021] [Accepted: 09/30/2021] [Indexed: 11/28/2022]
Affiliation(s)
| | - Scott A. Strassels
- Division of Pharmacy Atrium Health Charlotte North Carolina USA
- Department of Surgery The Ohio State University Columbus Ohio USA
| | - Danielle D. Durham
- Department of Radiology School of Medicine University of North Carolina Chapel Hill North Carolina USA
| | - Sunny Siddique
- Healthcare Delivery Research Program Division of Cancer Control and Population Sciences National Cancer Institute Rockville Maryland USA
| | - David Adler
- Department of Emergency Medicine University of Rochester Rochester New York USA
| | - Sai‐Ching J. Yeung
- Department of Emergency Medicine The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Steven L. Bernstein
- Department of Emergency Medicine Dartmouth Hitchcock Medical Center Hanover New Hampshire USA
| | - Christopher W. Baugh
- Department of Emergency Medicine Brigham and Women’s Hospital Boston Massachusetts USA
| | - Christopher J. Coyne
- Department of Emergency Medicine University of California San Diego San Diego California USA
| | - Corita R. Grudzen
- Ronald O. Perelman Department of Emergency Medicine and Population Health New York University School of Medicine New York New York USA
| | - Daniel J. Henning
- Department of Emergency Medicine University of Washington Seattle Washington USA
| | - Adam Klotz
- Department of Medicine Memorial Sloan Kettering Cancer Center New York New York USA
| | - Troy E. Madsen
- Division of Emergency Medicine University of Utah Salt Lake City, Utah USA
| | - Daniel J. Pallin
- Department of Emergency Medicine Brigham and Women’s Hospital Boston Massachusetts USA
| | - Juan F. Rico
- Department of Pediatrics University of South Florida Morsani College of Medicine Tampa Florida USA
| | - Richard J. Ryan
- Department of Emergency Medicine University of Cincinnati Cincinnati Ohio USA
| | - Nathan I. Shapiro
- Department of Emergency Medicine Beth Israel Deaconess Medical Center Boston Massachusetts USA
| | - Robert Swor
- Department of Emergency Medicine William Beaumont Hospital Royal Oak Michigan USA
| | - Arvind Venkat
- Department of Emergency Medicine Allegheny Health Network Pittsburgh Pennsylvania USA
| | - Jason Wilson
- Department of Emergency Medicine University of South Florida Morsani College of Medicine Tampa Florida USA
| | - Charles R. Thomas
- Department of Radiation Medicine Knight Cancer Institute Oregon Health & Sciences University Portland Oregon USA
| | - Jason J. Bischof
- Department of Emergency Medicine The Ohio State University, Wexner Medical Center Columbus Ohio USA
| | - Gary H. Lyman
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center and the Department of Medicine University of Washington School of Medicine Seattle Washington USA
| | - Jeffrey M. Caterino
- Department of Emergency Medicine The Ohio State University, Wexner Medical Center Columbus Ohio USA
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16
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Qian AS, Qiao EM, Nalawade V, Voora RS, Kotha NV, Dameff C, Coyne CJ, Murphy JD. Impact of underlying malignancy on emergency department utilization and outcomes. Cancer Med 2021; 10:9129-9138. [PMID: 34821051 PMCID: PMC8683529 DOI: 10.1002/cam4.4414] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 10/14/2021] [Accepted: 10/24/2021] [Indexed: 11/11/2022] Open
Abstract
PURPOSE Cancer patients frequently utilize the emergency department (ED) for a variety of diagnoses both related to and unrelated to their cancer, yet ED outcomes for cancer patients are not well documented. This study sought to define risks and identify predictors for inpatient admission and hospital mortality among cancer patients presenting to the ED. PATIENTS AND METHODS We utilized the National Emergency Department Sample to identify patients with and without a diagnosis of cancer presenting to the ED between January 2016 and December 2018. We used multivariable mixed-effects logistic regression models to assess the influence of cancer on outcomes of hospital admission after the ED visit and hospital mortality for the whole patient cohort and individual presenting diagnoses. RESULTS There were 340 million weighted ED visits, of which 8.3 million (2.3%) were associated with a cancer diagnosis. Compared to non-cancer patients, patients with cancer had an increased risk of inpatient admission (64.7% vs. 14.8%; p < 0.0001) and hospital mortality (4.6% vs. 0.5%; p < 0.0001). For each of the top 15 presenting diagnoses, cancer patients had increased risks of hospitalization (odds ratio [OR] range 2.0-13.2) or death (OR range 2.1-14.4). Although our dataset does not contain reliable estimation of stage, cancer site was the most robust individual predictor associated with the risk of hospitalization or death compared to other clinical or system-related factors. CONCLUSIONS Cancer patients in the ED have high risks for hospital admission and death when compared to patients without cancer. Cancer patients represent a distinct population and may benefit from cancer-specific risk stratification or focused interventions to improve outcomes.
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Affiliation(s)
- Alexander S Qian
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA
| | - Edmund M Qiao
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA
| | - Vinit Nalawade
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA
| | - Rohith S Voora
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA
| | - Nikhil V Kotha
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA
| | - Christian Dameff
- Department of Emergency Medicine, University of California San Diego, La Jolla, California, USA
| | - Christopher J Coyne
- Department of Emergency Medicine, University of California San Diego, La Jolla, California, USA
| | - James D Murphy
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA
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17
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Klotz AD, Caterino JM, Durham D, Felipe Rico J, Pallin DJ, Grudzen CR, McNaughton C, Marcelin I, Abar B, Adler D, Bastani A, Bernstein SL, Bischof JJ, Coyne CJ, Henning DJ, Hudson MF, Lyman GH, Madsen TE, Reyes‐Gibby CC, Ryan RJ, Shapiro NI, Swor R, Thomas CR, Venkat A, Wilson J, Jim Yeung S, Yilmaz S, Stutman R, Baugh CW. Observation unit use among patients with cancer following emergency department visits: Results of a multicenter prospective cohort from CONCERN. Acad Emerg Med 2021; 29:174-183. [PMID: 34811858 PMCID: PMC10359998 DOI: 10.1111/acem.14392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 09/08/2021] [Accepted: 09/19/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Emergency department (ED) visits by patients with cancer frequently end in hospitalization. As concerns about ED and hospital crowding increase, observation unit care may be an important strategy to deliver safe and efficient treatment for eligible patients. In this investigation, we compared the prevalence and clinical characteristics of cancer patients who received observation unit care with those who were admitted to the hospital from the ED. METHODS We performed a multicenter prospective cohort study of patients with cancer presenting to an ED affiliated with one of 18 hospitals of the Comprehensive Oncologic Emergency Research Network (CONCERN) between March 1, 2016 and January 30, 2017. We compared patient characteristics with the prevalence of observation unit care usage, hospital admission, and length of stay. RESULTS Of 1051 enrolled patients, 596 (56.7%) were admitted as inpatients, and 72 (6.9%) were placed in an observation unit. For patients admitted as inpatients, 23.7% had a length of stay ≤2 days. The conversion rate from observation to inpatient was 17.1% (95% CI 14.6-19.4) among those receiving care in an observation unit. The average observation unit length of stay was 14.7 h. Patient factors associated ED disposition to observation unit care were female gender and low Charlson Comorbidity Index. CONCLUSION In this multicenter prospective cohort study, the discrepancy between observation unit care use and short inpatient hospitalization may represent underutilization of this resource and a target for process change.
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Affiliation(s)
- Adam D. Klotz
- Department of Medicine Memorial Sloan Kettering Cancer Center New York New York USA
| | - Jeffrey M. Caterino
- Departments of Emergency Medicine and Internal Medicine Wexner Medical Center The Ohio State University Columbus Ohio USA
| | - Danielle Durham
- Department of Radiology School of Medicine University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
| | - Juan Felipe Rico
- Department of Pediatrics Morsani College of Medicine University of South Florida Tampa Florida USA
| | - Daniel J. Pallin
- Department of Emergency Medicine Brigham and Women’s Hospital Boston Massachusetts USA
| | - Corita R. Grudzen
- Ronald O. Perelman Department of Emergency Medicine and Population Health School of Medicine New York University New York New York USA
| | | | - Isabelle Marcelin
- Ronald O. Perelman Department of Emergency Medicine and Population Health School of Medicine New York University New York New York USA
| | - Beau Abar
- Department of Emergency Medicine University of Rochester Rochester New York USA
| | - David Adler
- Department of Emergency Medicine University of Rochester Rochester New York USA
| | - Aveh Bastani
- Department of Emergency Medicine William Beaumont Hospital Troy Michigan USA
| | - Steven L. Bernstein
- Department of Emergency Medicine Yale School of Medicine New Haven Connecticut USA
| | - Jason J. Bischof
- Department of Emergency Medicine Wexner Medical Center The Ohio State University Columbus Ohio USA
| | - Christopher J. Coyne
- Department of Emergency Medicine University of California San Diego San Diego California USA
| | - Daniel J. Henning
- Department of Emergency Medicine University of Washington Seattle Washington USA
| | | | - Gary H Lyman
- Fred Hutchinson Cancer Research Center and the Department of Medicine Hutchinson Institute for Cancer Outcomes Research University of Washington School of Medicine Seattle Washington USA
| | - Troy E. Madsen
- Division of Emergency Medicine University of Utah Salt Lake City Utah USA
| | - Cielito C. Reyes‐Gibby
- Department of Emergency Medicine and Biostatistics The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Richard J. Ryan
- Department of Emergency Medicine University of Cincinnati Cincinnati Ohio USA
| | - Nathan I. Shapiro
- Department of Emergency Medicine Beth Israel Deaconess Medical Center Boston Massachusetts USA
| | - Robert Swor
- Department of Emergency Medicine William Beaumont Hospital Royal Oak Michigan USA
| | - Charles R. Thomas
- Department of Radiation Medicine Knight Cancer Institute Oregon Health & Sciences University Portland Oregon USA
| | - Arvind Venkat
- Department of Emergency Medicine Allegheny Health Network Pittsburgh Pennsylvania USA
| | - Jason Wilson
- Department of Emergency Medicine Morsani College of Medicine University of South Florida Tampa Florida USA
| | - Sai‐Ching Jim Yeung
- Department of Emergency Medicine The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Sule Yilmaz
- Department of Geriatric Oncology University of Rochester Medical center Rochester New York USA
| | - Robin Stutman
- Department of Medicine Memorial Sloan Kettering Cancer Center New York New York USA
| | - Christopher W. Baugh
- Department of Emergency Medicine Brigham and Women’s Hospital Boston Massachusetts USA
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18
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Lara-Paez G, Zuazo M, Blumenthal J, Coyne CJ, Hoenigl M. HIV and Hepatitis C Virus Screening in the Emergency Department and Linkage to Care During COVID-19: Challenges and Solutions. J Acquir Immune Defic Syndr 2021; 88:e14-e16. [PMID: 34267055 PMCID: PMC8425513 DOI: 10.1097/qai.0000000000002763] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- George Lara-Paez
- Department of Medicine, Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, CA
| | - Miriam Zuazo
- Department of Medicine, Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, CA
| | - Jill Blumenthal
- Department of Medicine, Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, CA
| | - Christopher J Coyne
- Department of Emergency Medicine, University of California San Diego, San Diego, CA
| | - Martin Hoenigl
- Department of Medicine, Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, CA
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19
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Nene RV, Brennan JJ, Castillo EM, Tran P, Hsia RY, Coyne CJ. Cancer-related Emergency Department Visits: Comparing Characteristics and Outcomes. West J Emerg Med 2021; 22:1117-1123. [PMID: 34546888 PMCID: PMC8463053 DOI: 10.5811/westjem.2021.5.51118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 05/16/2021] [Indexed: 11/27/2022] Open
Abstract
Introduction There is increasing appreciation of the challenges of providing safe and appropriate care to cancer patients in the emergency department (ED). Our goal here was to assess which patient characteristics are associated with more frequent ED revisits. Methods This was a retrospective cohort study of all ED visits in California during the 2016 calendar year using data from the California Office of Statewide Health Planning and Development. We defined revisits as a return visit to an ED within seven days of the index visit. For both index and return visits, we assessed various patient characteristics, including age, cancer type, medical comorbidities, and ED disposition. Results Among 12.9 million ED visits, we identified 73,465 adult cancer patients comprising 103,523 visits that met our inclusion criteria. Cancer patients had a 7-day revisit rate of 17.9% vs 13.2% for non-cancer patients. Cancer patients had a higher rate of admission upon 7-day revisit (36.7% vs 15.6%). Patients with cancers of the small intestine, stomach, and pancreas had the highest rate of 7-day revisits (22–24%). Cancer patients younger than 65 had a higher 7-day revisit rate than the elderly (20.0% vs 16.2%). Conclusion In a review of all cancer-related ED visits in the state of California, we found a variety of characteristics associated with a higher rate of 7-day ED revisits. Our goal in this study was to inform future research to identify interventions on the index visit that may improve patient outcomes.
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Affiliation(s)
- Rahul V Nene
- University of California, San Diego, Department of Emergency Medicine, San Diego, California
| | - Jesse J Brennan
- University of California, San Diego, Department of Emergency Medicine, San Diego, California
| | - Edward M Castillo
- University of California, San Diego, Department of Emergency Medicine, San Diego, California
| | - Peter Tran
- University of California, San Diego, Department of Emergency Medicine, San Diego, California
| | - Renee Y Hsia
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California.,University of California, San Francisco, Institute for Health Policy Studies, San Francisco, California
| | - Christopher J Coyne
- University of California, San Diego, Department of Emergency Medicine, San Diego, California
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20
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Mathur K, Blumenthal J, Horton LE, Wagner GA, Martin TCS, Lo M, Gianella S, Vilke GM, Coyne CJ, Little SJ, Hoenigl M. HIV screening in emergency departments: Linkage works but what about retention? Acad Emerg Med 2021; 28:913-917. [PMID: 33314418 PMCID: PMC8196073 DOI: 10.1111/acem.14194] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 12/07/2020] [Accepted: 12/09/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Kushagra Mathur
- University of California San Diego School of Medicine, San Diego, California, USA
| | - Jill Blumenthal
- Department of Medicine, Division of Infectious Diseases and Global Public Health, University of California at San Diego, San Diego, California, USA
| | - Lucy E. Horton
- Department of Medicine, Division of Infectious Diseases and Global Public Health, University of California at San Diego, San Diego, California, USA
| | - Gabriel A. Wagner
- Department of Medicine, Division of Infectious Diseases and Global Public Health, University of California at San Diego, San Diego, California, USA
| | - Thomas C. S. Martin
- Department of Medicine, Division of Infectious Diseases and Global Public Health, University of California at San Diego, San Diego, California, USA
| | - Megan Lo
- University of California San Diego School of Medicine, San Diego, California, USA
| | - Sara Gianella
- Department of Medicine, Division of Infectious Diseases and Global Public Health, University of California at San Diego, San Diego, California, USA
| | - Gary M. Vilke
- Department of Emergency Medicine, University of California at San Diego, San Diego, California, USA
| | - Christopher J. Coyne
- Department of Emergency Medicine, University of California at San Diego, San Diego, California, USA
| | - Susan J. Little
- Department of Medicine, Division of Infectious Diseases and Global Public Health, University of California at San Diego, San Diego, California, USA
| | - Martin Hoenigl
- Department of Medicine, Division of Infectious Diseases and Global Public Health, University of California at San Diego, San Diego, California, USA
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21
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Childers R, Cronin AO, Castillo EM, Neuman T, Chan TC, Coyne CJ, Sloane C, Vilke GM. Evaluation of the ventilatory effects on human subjects in prolonged hip-flexed/head-down restraint position. Am J Emerg Med 2021; 50:1-4. [PMID: 34265730 DOI: 10.1016/j.ajem.2021.06.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 06/25/2021] [Accepted: 06/28/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND The restraint chair is a tool used by law enforcement and correction personnel to control aggressive, agitated individuals. When initiating its use, subjects are often placed in a hip-flexed/head-down (HFHD) position to remove handcuffs. Usually, this period of time is less than two minutes but can become more prolonged in particularly agitated patients. Some have proposed this positioning limits ventilation and can result in asphyxia. The aim of this study is to evaluate if a prolonged HFHD restraint position causes significant ventilatory compromise. METHODS Subjects exercised on a stationary bicycle until they reached 85% of their predicted maximal heart rate. They were then handcuffed with their hands behind their back and placed into a HFHD seated position for five minutes. The primary outcome measurement was maximal voluntary ventilation (MVV). This was measured at baseline, after initial placement into the HFHD position, and after five minutes of being in the position while still maintaining the HFHD position. Baseline measurements were compared with final measurements for statistically significant differences. RESULTS We analyzed data for 15 subjects. Subjects had a mean MVV of 165.3 L/min at baseline, 157.8 L/min after initially being placed into the HFHD position, and a mean of 138.7 L/min after 5 min in the position. The mean baseline % predicted MVV was 115%; after 5 min in the HFHD position the mean was 96%. This 19% absolute difference was statistically significant (p = 0.001). CONCLUSIONS In healthy seated male subjects with recent exertion, up to five minutes in a HFHD position results in a small decrease in MVV compared with baseline MVV levels. Even with this decrease, mean MVV levels were still 96% of predicted after five minutes. Though a measurable decrease was found, there was no clinically significant change that would support that this positioning would lead to asphyxia over a five-minute time period.
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Affiliation(s)
- Richard Childers
- Department of Emergency Medicine, University of California, San Diego, San Diego, CA, United States of America.
| | - Alexandrea O Cronin
- Department of Emergency Medicine, University of California, San Diego, San Diego, CA, United States of America
| | - Edward M Castillo
- Department of Emergency Medicine, University of California, San Diego, San Diego, CA, United States of America
| | - Tom Neuman
- Department of Emergency Medicine, University of California, San Diego, San Diego, CA, United States of America
| | - Theodore C Chan
- Department of Emergency Medicine, University of California, San Diego, San Diego, CA, United States of America
| | - Christopher J Coyne
- Department of Emergency Medicine, University of California, San Diego, San Diego, CA, United States of America
| | - Christian Sloane
- Department of Emergency Medicine, University of California, San Diego, San Diego, CA, United States of America
| | - Gary M Vilke
- Department of Emergency Medicine, University of California, San Diego, San Diego, CA, United States of America
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22
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Wattana MK, Lipe DN, Coyne CJ, Shafer S, Brock P, Alagappan K. A Model Oncologic Emergency Medicine Curriculum for Residency Training. J Emerg Med 2021; 61:330-335. [PMID: 34011452 DOI: 10.1016/j.jemermed.2021.02.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 02/01/2021] [Accepted: 02/21/2021] [Indexed: 11/16/2022]
Abstract
Background Emergency medicine (EM) resident training in oncologic emergencies is limited, and significant gaps have been identified. Although 90% of emergency medicine residency program directors recognize the importance of residency training in oncologic emergencies, there is no standardized oncologic emergency curriculum. Objective We propose a focused oncologic EM curriculum that serves as a complement to existing EM didactics curriculums to prepare EM residents to recognize and manage the most common oncologic emergencies. It will also allow for familiarization with constantly evolving therapies, such as chimeric antigen receptor cellular therapy and immune checkpoint inhibitors.Discussion This curriculum consists of 10 hours of didactic instruction, which can be incorporated into an already existing didactic curriculum. The curriculum encompasses education on the recognition, rapid diagnosis, and management of oncologic emergencies, with the goal of improving the EM resident's understanding of cancer complications. The suggested topics can be delivered in a variety of methods, allowing for flexible integration in an already existing emergency education curriculum. The proposed curriculum should be introduced during the first postgraduate year and then in the second or third year of the residency to reinforce the learning points.Conclusions Our proposal of a focused, standardized 10 hour program curriculum aims to help to fill the gaps in knowledge of oncologic emergencies. To assist in wide dissemination and standardization of these curriculum topics, outlines for each module are given in the article and we also propose creation of open access online lectures and content to be shared for education purposes.
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Affiliation(s)
- Monica K Wattana
- Department of Emergency Medicine, University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Demis N Lipe
- Department of Emergency Medicine, University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Christopher J Coyne
- Department of Emergency Medicine, University of California, San Diego, San Diego, California
| | - Sarah Shafer
- Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas
| | - Patricia Brock
- Department of Emergency Medicine, University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Kumar Alagappan
- Department of Emergency Medicine, University of Texas, MD Anderson Cancer Center, Houston, Texas
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23
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Quenzer F, Givner A, Dirks R, Coyne CJ, Ercoli F, Townsend R. Self-Inflicted Gun Shot Wounds: A Retrospective, Observational Study of U.S. Trauma Centers. West J Emerg Med 2021; 22:518-524. [PMID: 34125021 PMCID: PMC8203010 DOI: 10.5811/westjem.2021.4.49315] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 04/03/2021] [Accepted: 04/03/2021] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Intentional self-harm (suicide) by firearms is a growing problem in the United States. Currently, there are no large studies that have identified risk factors for patients who die from self-inflicted gunshot wounds. Our objectives are to 1) identify risk factors for patients with the highest morbidity and mortality from self-inflicted gunshot wounds (SIGSWs) at trauma centers 2) present the outcomes of victims of SIGSW by handguns (HG) versus all other specified guns (AOG) and 3) compare the presentations and outcomes of victims with head or face (HF) injuries to other regions of the body. METHODS We performed a retrospective analysis from the National Trauma Database (NTDB) data between 2012 and 2013 of all SIGSW patients who presented to trauma centers. Categorical data included patient characteristics upon presentation and outcomes which were compared between patients with HG injury versus AOG injury using the Chi-Squared test, where AOG includes shotguns, hunting rifles, and military firearms. Additionally, analysis of head and face (HF) injuries versus other bodily injuries (OBI) were compared between the HG group versus AOG group using Chi-squared test. RESULTS There were 7,828 SIGSWs, of those, 78% (6,115) were white and 84.3% (6,600) were male. There were 5,139 HG injuries, 1,130 AOG injuries, and 1,405 unidentified gun injuries. The HG group was likely to be older (>55 years old), hypotensive (systolic blood pressure < 90), have a lower Glasgow Coma Score (GCS < 9), use illegal, or use prescription drugs. In comparing HF injuries (4,799) versus other bodily injuries (OBI) (3,028), HF group was more likely to use handguns, expire in ED, require ICU, and have a higher percent of overall mortality. Of the total OBI, the thorax, upper extremities, and abdomen were the most commonly injured. CONCLUSION In our retrospective study of SIGSWs, we were able to demonstrate that SIGSW by handguns are associated with higher rates of mortality versus all other types of firearms. SIGSWs in older white males with handguns are the most at-risk for severe complications. Future efforts should improve screening methods for handguns in suicidal patients and at developing prevention programs.
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Affiliation(s)
- Faith Quenzer
- University of California, San Diego, Department of Emergency Medicine, San Diego, California
| | - Andrew Givner
- Desert Regional Medical Center, Department of Emergency Medicine, Palm Springs, California
| | - Rachel Dirks
- University of California, San Francisco-Fresno, Department of Emergency Medicine, Fresno, California
| | - Christopher J. Coyne
- University of California, San Diego, Department of Emergency Medicine, San Diego, California
| | - Frank Ercoli
- Desert Regional Medical Center, Department of Emergency Medicine, Palm Springs, California
- Desert Regional Medical Center, Desert Trauma Surgeons, Palm Springs, California
| | - Ricard Townsend
- Desert Regional Medical Center, Department of Emergency Medicine, Palm Springs, California
- Desert Regional Medical Center, Desert Trauma Surgeons, Palm Springs, California
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24
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Abstract
How can public policy best deal with infectious disease? In answering this question, scholarship on the optimal control of infectious disease adopts the model of a benevolent social planner who maximizes social welfare. This approach, which treats the social health planner as a unitary "public health brain" standing outside of society, removes the policymaking process from economic analysis. This paper opens the black box of the social health planner by extending the tools of economics to the policymaking process itself. We explore the nature of the economic problem facing policymakers and the epistemic constraints they face in trying to solve that problem. Additionally, we analyze the incentives facing policymakers in their efforts to address infectious diseases and consider how they affect the design and implementation of public health policy. Finally, we consider how unanticipated system effects emerge due to interventions in complex systems, and how these effects can undermine well-intentioned efforts to improve human welfare. We illustrate the various dynamics of the political economy of state responses to infectious disease by drawing on a range of examples from the COVID-19 pandemic.
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Affiliation(s)
| | | | - Abigail R. Hall
- Department of Economics and FinanceBellarmine UniversityLouisvilleKentuckyUSA
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25
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Cronin AO, Coyne CJ, Castillo EM, Dameff C. COVID-19 screening, testing and vaccination: Perceptions from emergency medicine residents and medical students. Am J Emerg Med 2021; 51:418-419. [PMID: 33810920 PMCID: PMC7981269 DOI: 10.1016/j.ajem.2021.03.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/15/2021] [Accepted: 03/16/2021] [Indexed: 11/16/2022] Open
Affiliation(s)
- Alexandrea O Cronin
- Department of Emergency Medicine, University of California, San Diego, San Diego, CA, United States.
| | - Christopher J Coyne
- Department of Emergency Medicine, University of California, San Diego, San Diego, CA, United States
| | - Edward M Castillo
- Department of Emergency Medicine, University of California, San Diego, San Diego, CA, United States
| | - Christian Dameff
- Department of Emergency Medicine, University of California, San Diego, San Diego, CA, United States; Department of Computer Science and Engineering, University of California, San Francisco, San Francisco, CA, United States; Department of Biomedical Informatics, University of California, San Diego, San Diego, CA, United States
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26
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Coyne CJ, Reyes-Gibby CC, Durham DD, Abar B, Adler D, Bastani A, Bernstein SL, Baugh CW, Bischof JJ, Grudzen CR, Henning DJ, Hudson MF, Klotz A, Lyman GH, Madsen TE, Pallin DJ, Rico JF, Ryan RJ, Shapiro NI, Swor R, Thomas CR, Venkat A, Wilson J, Yeung SCJ, Caterino JM. Cancer pain management in the emergency department: a multicenter prospective observational trial of the Comprehensive Oncologic Emergencies Research Network (CONCERN). Support Care Cancer 2021; 29:4543-4553. [PMID: 33483789 DOI: 10.1007/s00520-021-05987-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 01/04/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Many patients with cancer seek care for pain in the emergency department (ED). Prospective research on cancer pain in this setting has historically been insufficient. We conducted this study to describe the reported pain among cancer patients presenting to the ED, how pain is managed, and how pain may be associated with clinical outcomes. METHODS We conducted a multicenter cohort study on adult patients with active cancer presenting to 18 EDs in the USA. We reported pain scores, response to medication, and analgesic utilization. We estimated the associations between pain severity, medication utilization, and the following outcomes: 30-day mortality, 30-day hospital readmission, and ED disposition. RESULTS The study population included 1075 participants. Those who received an opioid in the ED were more likely to be admitted to the hospital and were more likely to be readmitted within 30 days (OR 1.4 (95% CI: 1.11, 1.88) and OR 1.56 (95% CI: 1.17, 2.07)), respectively. Severe pain at ED presentation was associated with increased 30-day mortality (OR 2.30, 95% CI: 1.05, 5.02), though this risk was attenuated when adjusting for clinical factors (most notably functional status). CONCLUSIONS Patients with severe pain had a higher risk of mortality, which was attenuated when correcting for clinical characteristics. Those patients who required opioid analgesics in the ED were more likely to require admission and were more at risk of 30-day hospital readmission. Future efforts should focus on these at-risk groups, who may benefit from additional services including palliative care, hospice, or home-health services.
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Affiliation(s)
- Christopher J Coyne
- Department of Emergency Medicine, University of California San Diego, 200 W. Arbor Dr. #8676, San Diego, CA, 92103, USA.
| | - Cielito C Reyes-Gibby
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Danielle D Durham
- The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Beau Abar
- Department of Emergency Medicine, University of Rochester, Rochester, NY, USA
| | - David Adler
- Department of Emergency Medicine, University of Rochester, Rochester, NY, USA
| | - Aveh Bastani
- Department of Emergency Medicine, William Beaumont Hospital - Troy Campus, Troy, MI, USA
| | - Steven L Bernstein
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Christopher W Baugh
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Jason J Bischof
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Corita R Grudzen
- Ronald O. Perelman Department of Emergency Medicine and Population Health, New York University School of Medicine, New York, NY, USA
| | - Daniel J Henning
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA
| | | | - Adam Klotz
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Gary H Lyman
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center and the Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Troy E Madsen
- Division of Emergency Medicine, University of Utah, Salt Lake City, UT, USA
| | - Daniel J Pallin
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Juan Felipe Rico
- Department of Pediatrics, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Richard J Ryan
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Nathan I Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Robert Swor
- Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, MI, USA
| | - Charles R Thomas
- Department of Radiation Medicine, Knight Cancer Institute, Oregon Health & Sciences University, Portland, OR, USA
| | - Arvind Venkat
- Department of Emergency Medicine, Allegheny Health Network, Pittsburgh, PA, USA
| | - Jason Wilson
- Department of Emergency Medicine, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Sai-Ching Jim Yeung
- Department of Emergency Medicine and Department of Endocrine Neoplasia & Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey M Caterino
- Departments of Emergency Medicine and Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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27
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Cronin AO, Carlile MA, Dameff CJ, Coyne CJ, Castillo EM. Leveraging Remote Research Associates During a Pandemic. West J Emerg Med 2020; 21:1114-1117. [PMID: 32970563 PMCID: PMC7514379 DOI: 10.5811/westjem.2020.6.48043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 06/24/2020] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION The coronavirus disease 2019 (COVID-19) pandemic has seriously impacted clinical research operations in academic medical centers due to social distancing measures and stay-at-home orders. The purpose of this paper is to describe the implementation of a program to continue clinical research based out of an emergency department (ED) using remote research associates (RA). METHODS Remote RAs were trained and granted remote access to the electronic health record (EHR) by the health system's core information technology team. Upon gaining access, remote RAs used a dual-authentication process to gain access to a host-based, firewall-protected virtual network where the EHR could be accessed to continue screening and enrollment for ongoing studies. Study training for screening and enrollment was also provided to ensure study continuity. RESULTS With constant support and guidance available to establish this EHR access pathway, the remote RAs were able to gain access relatively independently and without major technical troubleshooting. Each remote RA was granted access and trained on studies within one week and self-reported a high degree of program satisfaction, EHR access ease, and study protocol comfort through informal evaluation surveys. CONCLUSIONS In response to the COVID-19 pandemic, we virtualized a clinical research program to continue important ED-based studies.
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Affiliation(s)
- Alexandrea O Cronin
- University of California San Diego, Department of Emergency Medicine, San Diego, California
| | - Morgan A Carlile
- University of California San Diego, Department of Emergency Medicine, San Diego, California
| | - Christian J Dameff
- University of California San Diego, Department of Emergency Medicine, San Diego, California.,University of California, San Diego, Department of Biomedical Informatics, San Diego, California.,University of California, San Diego, Department of Computer Science and Engineering, San Diego, California
| | - Christopher J Coyne
- University of California San Diego, Department of Emergency Medicine, San Diego, California
| | - Edward M Castillo
- University of California San Diego, Department of Emergency Medicine, San Diego, California
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Castillo EM, Coyne CJ, Brennan JJ, Tomaszewski CA. Rates of coinfection with other respiratory pathogens in patients positive for coronavirus disease 2019 (COVID-19). J Am Coll Emerg Physicians Open 2020; 1:592-596. [PMID: 32838387 PMCID: PMC7361860 DOI: 10.1002/emp2.12172] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 05/27/2020] [Accepted: 06/04/2020] [Indexed: 01/06/2023] Open
Abstract
Objectives The purpose of this study was to assess coinfection rates of coronavirus disease 2019 (COVID-19) with other respiratory infections on presentation. Methods This is a retrospective analysis of data from a 2 hospital academic medical centers and 2 urgent care centers during the initial 2 weeks of testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) , March 10, 2020 to March 23, 2020. Testing was targeted toward high-risk patients following US Centers for Disease Control and Prevention guidelines. Demographics include age group and sex. Laboratory test results included SARS-CoV-2, rapid influenza A/B, and upper respiratory pathogen nucleic acid detection. Patient demographics and coinfections are presented overall and by test results with descriptive statistics. Results Complete laboratory results from the first 2 weeks of testing were available for 471 emergency department patients and 117 urgent care center patients who were tested for SARS-CoV. A total of 51 (8.7%) patients tested positive for COVID-19 with only 1 of these patients also testing positive for another respiratory infection. One of the patients positive for COVID-19 also tested positive for influenza A. Among the 537 patients who were screened and tested negative for COVID-19, there were 33 (6.1%) patients who tested positive in the upper respiratory pathogen nucleic acid detection test. Conclusion In our study investigating coinfections among 51 patients testing positive for COVID-19, 1 patient also tested positive for influenza A. Although we found limited coinfections in our emergency department and urgent care center patient populations, further research is needed to assess potential coinfection in patients with COVID-19.
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Affiliation(s)
- Edward M Castillo
- Department of Emergency Medicine University of California San Diego California USA
| | - Christopher J Coyne
- Department of Emergency Medicine University of California San Diego California USA
| | - Jesse J Brennan
- Department of Emergency Medicine University of California San Diego California USA
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Gupta R, Roach C, Hryniewicki AT, Vilke GM, Shatsky RA, Coyne CJ. Management of Chimeric Antigen Receptor (CAR) T-Cell Toxicities: A Review and Guideline for Emergency Providers. J Emerg Med 2020; 59:61-74. [PMID: 32473867 DOI: 10.1016/j.jemermed.2020.04.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 03/26/2020] [Accepted: 04/08/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Chimeric antigen receptor (CAR) T-cell therapy is an adoptive cellular immunotherapy that is being utilized more frequently due to its initial success in advanced-stage cancers. Unfortunately, CAR T-cell therapy is often associated with acute systemic toxicities, including cytokine release syndrome (CRS) and CAR T-cell-associated neurotoxicity (neurotoxicity). OBJECTIVE We created a review that addresses the potential common emergency department (ED) presentations associated with CAR T-cell therapy. We reviewed the relevant research and clinical guidelines to develop a guide tailored toward addressing the needs of the emergency medicine community to manage these complications. In addition, a case is presented and the evaluation and management of CRS and neurotoxicity are reviewed in detail. DISCUSSION Despite CAR T-cell designs showing promising results, the risk of acquiring an acute toxicity is high, with CRS and neurotoxicity reported most often. The systemic toxicities associated with these adverse events can lead to end-organ damage and compromise the patient acutely or jeopardize the continuation in treatment of their underlying malignancy. Depending on the severity of the toxicity, treatment typically starts with vigilant supportive care, but may include administration of tocilizumab and possibly high-dose corticosteroids if the toxicity is deemed of high severity. CONCLUSIONS With the increasing administration of CAR T-cell therapy, emergency physicians will likely encounter more patients with associated adverse events, including CRS and neurotoxicity. It is increasingly important that emergency physicians are aware of these potential toxicities in order to rapidly diagnose and treat patients undergoing CAR T-cell therapy.
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Affiliation(s)
- Rishi Gupta
- Department of Emergency Medicine, University of California, San Diego, San Diego, California
| | - Colin Roach
- Department of Emergency Medicine, University of California, San Diego, San Diego, California
| | - Adam T Hryniewicki
- Department of Emergency Medicine, University of California, San Diego, San Diego, California
| | - Gary M Vilke
- Department of Emergency Medicine, University of California, San Diego, San Diego, California
| | - Rebecca A Shatsky
- Department of Emergency Medicine, University of California, San Diego, San Diego, California
| | - Christopher J Coyne
- Department of Emergency Medicine, University of California, San Diego, San Diego, California
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Marigold O, Castillo EM, Sloane C, Brennan J, Coyne CJ, Swift S, Vilke GM. Further study on the physiological effects of an alternative spit mask. J Forensic Leg Med 2020; 72:101945. [DOI: 10.1016/j.jflm.2020.101945] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 03/12/2020] [Accepted: 03/24/2020] [Indexed: 10/24/2022]
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Gleber R, Vilke GM, Castillo EM, Brennan J, Oyama L, Coyne CJ. Trends in emergency physician opioid prescribing practices during the United States opioid crisis. Am J Emerg Med 2020; 38:735-740. [DOI: 10.1016/j.ajem.2019.06.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 06/04/2019] [Accepted: 06/04/2019] [Indexed: 11/30/2022] Open
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Kettler E, Brennan J, Coyne CJ. The effects of a morphine shortage on emergency department pain control. Am J Emerg Med 2020; 43:229-234. [PMID: 32192896 DOI: 10.1016/j.ajem.2020.03.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 03/05/2020] [Accepted: 03/08/2020] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVE In 2018, due to a national morphine shortage, our two study emergency departments (EDs) were unable to administer intravenous (IV) morphine for over six months. We evaluated the effects of this shortage on analgesia and patient disposition. METHODS This was a retrospective study in two academic EDs. Our control period (with morphine) was 4/1/17-6/30/17 and our study period (without morphine) was 4/1/18-6/30/18. We included all adult patients with a chief complaint of pain, initial pain score ≥4, and ≥2 recorded pain scores. The primary outcome was delta pain score. Secondary outcomes included final pain score, proportion of ED visits with opioids vs. non-opioids administered, and ED disposition. RESULTS We identified 6296 patients during our control period and 5816 during our study period. There was no significant difference in mean final pain score (study 4.45, control 4.44, p = 0.802), delta pain score (study -3.30, control -3.32, p = 0.556), nor admission rates (study 18.8%, control 17.8%, p = 0.131). We saw a decrease in opioid use (study 47.4%, control 60.0%, p < 0.01) and an increased use of non-opioid analgesics (study 27.3%, control 18.44%, p < 0.01). CONCLUSIONS Removing IV morphine in the ED, without a compensatory rise in alternative opioids, does not appear to significantly impact analgesia or disposition. These data favor a more limited opioid use strategy in the ED.
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Affiliation(s)
- Ellen Kettler
- University of California, San Diego School of Medicine, La Jolla, CA, USA; Department of Emergency Medicine, 200 W. Arbor Dr. #8676 San Diego, CA 92103, USA.
| | - Jesse Brennan
- University of California, San Diego School of Medicine, La Jolla, CA, USA; Department of Emergency Medicine, 200 W. Arbor Dr. #8676 San Diego, CA 92103, USA.
| | - Christopher J Coyne
- University of California, San Diego School of Medicine, La Jolla, CA, USA; Department of Emergency Medicine, 200 W. Arbor Dr. #8676 San Diego, CA 92103, USA.
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Hoenigl M, Mathur K, Blumenthal J, Brennan J, Zuazo M, McCauley M, Horton LE, Wagner GA, Reed SL, Vilke GM, Coyne CJ, Little SJ. Universal HIV and Birth Cohort HCV Screening in San Diego Emergency Departments. Sci Rep 2019; 9:14479. [PMID: 31597939 PMCID: PMC6785532 DOI: 10.1038/s41598-019-51128-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 09/25/2019] [Indexed: 12/11/2022] Open
Abstract
Universal HIV and HCV screening in emergency departments (ED) can reach populations who are less likely to get tested otherwise. The objective of this analysis was to evaluate universal opt-out HIV and HCV screening in two EDs in San Diego. HIV screening for persons aged 13-64 years (excluding persons known to be HIV+ or reporting HIV testing within last 12 months) was implemented using a 4th generation HIV antigen/antibody assay; HCV screening was offered to persons born between 1945 and 1965. Over a period of 16 months, 12,575 individuals were tested for HIV, resulting in 33 (0.26%) new HIV diagnoses, of whom 30 (90%) were successfully linked to care. Universal screening also identified 74 out-of-care for >12-months HIV+ individuals of whom 50 (68%) were successfully relinked to care. Over a one-month period, HCV antibody tests were conducted in 905 individuals with a seropositivity rate of 9.9% (90/905); 61 seropositives who were newly identified or never treated for HCV had HCV RNA testing, of which 31 (51%) resulted positive (3.4% of all participants, including 18 newly identified RNA positives representing 2% of all participants), and 13/31 individuals (42%) were linked to care. The rate of newly diagnosed HCV infections exceeded the rate of newly diagnosed HIV infections by >7-fold, underlining the importance of HCV screening in EDs.
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Affiliation(s)
- Martin Hoenigl
- Department of Medicine, Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California, United States.
| | - Kushagra Mathur
- University of San Diego School of Medicine, San Diego, California, United States
| | - Jill Blumenthal
- Department of Medicine, Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California, United States
| | - Jesse Brennan
- Department of Emergency Medicine, University of California San Diego, San Diego, California, United States
| | - Miriam Zuazo
- Department of Medicine, Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California, United States
| | - Melanie McCauley
- Department of Medicine, Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California, United States
| | - Lucy E Horton
- Department of Medicine, Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California, United States
| | - Gabriel A Wagner
- Department of Medicine, Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California, United States
| | - Sharon L Reed
- Department of Pathology, University of California San Diego, San Diego, California, United States
| | - Gary M Vilke
- Department of Emergency Medicine, University of California San Diego, San Diego, California, United States
| | - Christopher J Coyne
- Department of Emergency Medicine, University of California San Diego, San Diego, California, United States
| | - Susan J Little
- Department of Medicine, Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California, United States
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Adler D, Abar B, Durham DD, Bastani A, Bernstein SL, Baugh CW, Bischof JJ, Coyne CJ, Grudzen CR, Henning DJ, Hudson MF, Klotz A, Lyman GH, Madsen TE, Pallin DJ, Reyes-Gibby CC, Rico JF, Ryan RJ, Shapiro NI, Swor R, Thomas CR, Venkat A, Wilson J, Yeung SCJ, Caterino JM. Validation of the Emergency Severity Index (Version 4) for the Triage of Adult Emergency Department Patients With Active Cancer. J Emerg Med 2019; 57:354-361. [PMID: 31353265 DOI: 10.1016/j.jemermed.2019.05.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 04/25/2019] [Accepted: 05/06/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Patients with active cancer account for a growing percentage of all emergency department (ED) visits and have a unique set of risks related to their disease and its treatments. Effective triage for this population is fundamental to facilitating their emergency care. OBJECTIVES We evaluated the validity of the Emergency Severity Index (ESI; version 4) triage tool to predict ED-relevant outcomes among adult patients with active cancer. METHODS We conducted a prespecified analysis of the observational cohort established by the National Cancer Institute-supported Comprehensive Oncologic Emergencies Research Network's multicenter (18 sites) study of ED visits by patients with active cancer (N = 1075). We used a series of χ2 tests for independence to relate ESI scores with 1) disposition, 2) ED resource use, 3) hospital length of stay, and 4) 30-day mortality. RESULTS Among the 1008 subjects included in this analysis, the ESI distribution skewed heavily toward high acuity (>95% of subjects had an ESI level of 1, 2, or 3). ESI was significantly associated with patient disposition and ED resource use (p values < 0.05). No significant associations were observed between ESI and the non-ED based outcomes of hospital length of stay or 30-day mortality. CONCLUSION ESI scores among ED patients with active cancer indicate higher acuity than the general ED population and are predictive of disposition and ED resource use. These findings show that the ESI is a valid triage tool for use in this population for outcomes directly relevant to ED care.
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Affiliation(s)
- David Adler
- Department of Emergency Medicine, University of Rochester, Rochester, New York
| | - Beau Abar
- Department of Emergency Medicine, University of Rochester, Rochester, New York
| | - Danielle D Durham
- Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland
| | - Aveh Bastani
- Department of Emergency Medicine, William Beaumont Hospital, Troy Campus, Troy, Michigan
| | - Steven L Bernstein
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Christopher W Baugh
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jason J Bischof
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Christopher J Coyne
- Department of Emergency Medicine, University of California San Diego, San Diego, California
| | - Corita R Grudzen
- Ronald O. Perelman Department of Emergency Medicine and Population Health, New York University School of Medicine, New York, New York
| | - Daniel J Henning
- Department of Emergency Medicine, University of Washington, Seattle, Washington
| | - Matthew F Hudson
- Prisma Health-Upstate Cancer Institute, Greenville, South Carolina
| | - Adam Klotz
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Gary H Lyman
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center and the Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Troy E Madsen
- Division of Emergency Medicine, University of Utah, Salt Lake City, Utah
| | - Daniel J Pallin
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Cielito C Reyes-Gibby
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Juan Felipe Rico
- Department of Pediatrics, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Richard J Ryan
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Nathan I Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Robert Swor
- Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, Michigan
| | - Charles R Thomas
- Department of Radiation Medicine, Knight Cancer Institute, Oregon Health and Sciences University, Portland, Oregon
| | - Arvind Venkat
- Department of Emergency Medicine, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Jason Wilson
- Department of Emergency Medicine, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Sai-Ching Jim Yeung
- Department of Emergency Medicine, Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jeffrey M Caterino
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Vilke GM, Mash DC, Pardo M, Bozeman W, Hall C, Sloane C, Wilson MP, Coyne CJ, Xie X, Castillo EM. EXCITATION study: Unexplained in-custody deaths: Evaluating biomarkers of stress and agitation. J Forensic Leg Med 2019; 66:100-106. [PMID: 31252195 DOI: 10.1016/j.jflm.2019.06.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 06/05/2019] [Accepted: 06/16/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Law enforcement personnel often confront violent and dangerous individuals suffering from Excited Delirium Syndrome (ExDS) who need emergent medical evaluation and treatment to optimize the best outcomes for this potentially lethal medical emergency. These subjects typically require physical restraint and use of force measures to control them. We sought to determine if stress-related biomarkers can differentiate ExDS subjects when compared with agitation and stress under other circumstances, including agitation and extreme physical exhaustion and restraint coupled with emotional stressors. METHODS This was a prospective multi-center study enrolling a convenience sample of patients who presented with agitation or ExDS. Patients were enrolled from three academic emergency departments (ED), two in the United States and one in Canada. Three study groups (SG) included: SG1) patients brought to the ED with ExDS based on the use of standardized clinical criteria; SG2) ED patients with acute agitation who were not in a clinical state of ExDS but required sedation; SG3) a laboratory control group of subjects exercised to physical exhaustion, restrained, and psychologically stressed with threat of Conducted Energy Device (CED) activation. We examined a panel of stress-related biomarkers, including norepinephrine (NE), cortisol, copeptin, orexin A, and dynorphin (Dyn) from the blood of enrolled subjects. RESULTS A total of 82 subjects were enrolled: 31 in the agitation group, 21 in the ExDS group, and 30 in the laboratory control group. Data were analyzed, comparing the findings between ExDS and the two other groups to determine if specific stress-related biomarkers are associated with ExDS. Biomarker comparisons between subjects identified with ExDS, agitation, and control groups demonstrated that cortisol levels were more elevated in the ExDS group compared with the other groups. Orexin was only significant in ExDs (with Agitated tendency but lot of variability in the group). NE and Dyn increased as response to stress in Agitated and ExDS. CONCLUSIONS Cortisol levels were more elevated in subjects in the ExDS group compared with the other comparison groups and orexin was elevated in ExDS compared to controls, a trend that did not reach statistical significance in the agitated group. The clinical or diagnostic significance of these difference have yet to be defined and warrants further study.
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Affiliation(s)
- Gary M Vilke
- University of California, San Diego Medical Center, Department of Emergency Medicine, San Diego, CA, USA.
| | - Deborah C Mash
- University of Miami Miller School of Medicine, Department of Neurology and Molecular and Cellular Pharmacology, Miami, FL, USA
| | - Marta Pardo
- University of Miami Miller School of Medicine, Department of Neurology and Molecular and Cellular Pharmacology, Miami, FL, USA
| | - William Bozeman
- Wake Forest University School of Medicine, Department of Emergency Medicine, Winston Salem, NC, USA
| | - Christine Hall
- University of British Columbia, Department of Emergency Medicine, Island Health, Victoria, Canada
| | - Christian Sloane
- University of California, San Diego Medical Center, Department of Emergency Medicine, San Diego, CA, USA
| | | | - Christopher J Coyne
- University of California, San Diego Medical Center, Department of Emergency Medicine, San Diego, CA, USA
| | - Xiaobin Xie
- University of Miami Miller School of Medicine, Department of Neurology and Molecular and Cellular Pharmacology, Miami, FL, USA
| | - Edward M Castillo
- University of California, San Diego Medical Center, Department of Emergency Medicine, San Diego, CA, USA
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Caterino JM, Adler D, Durham DD, Yeung SCJ, Hudson MF, Bastani A, Bernstein SL, Baugh CW, Coyne CJ, Grudzen CR, Henning DJ, Klotz A, Madsen TE, Pallin DJ, Reyes-Gibby CC, Rico JF, Ryan RJ, Shapiro NI, Swor R, Venkat A, Wilson J, Thomas CR, Bischof JJ, Lyman GH. Analysis of Diagnoses, Symptoms, Medications, and Admissions Among Patients With Cancer Presenting to Emergency Departments. JAMA Netw Open 2019; 2:e190979. [PMID: 30901049 PMCID: PMC6583275 DOI: 10.1001/jamanetworkopen.2019.0979] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
IMPORTANCE Better understanding of the emergency care needs of patients with cancer will inform outpatient and emergency department (ED) management. OBJECTIVE To provide a benchmark description of patients who present to the ED with active cancer. DESIGN, SETTING, AND PARTICIPANTS This multicenter prospective cohort study included 18 EDs affiliated with the Comprehensive Oncologic Emergencies Research Network (CONCERN). Of 1564 eligible patients, 1075 adults with active cancer were included from February 1, 2016, through January 30, 2017. Data were analyzed from February 1 through August 1, 2018. MAIN OUTCOMES AND MEASURES The proportion of patients reporting symptoms (eg, pain, nausea) before and during the ED visit, ED and outpatient medications, most common diagnoses, and suspected infection as indicated by ED antibiotic administration. The proportions observed, admitted, and with a hospital length of stay (LOS) of no more than 2 days were identified. RESULTS Of 1075 participants, mean (SD) age was 62 (14) years, and 51.8% were female. Seven hundred ninety-four participants (73.9%; 95% CI, 71.1%-76.5%) had undergone cancer treatment in the preceding 30 days; 674 (62.7%; 95% CI, 59.7%-65.6%) had advanced or metastatic cancer; and 505 (47.0%; 95% CI, 43.9%-50.0%) were 65 years or older. The 5 most common ED diagnoses were symptom related. Of all participants, 82 (7.6%; 95% CI, 6.1%-9.4%) were placed in observation and 615 (57.2%; 95% CI, 54.2%-60.2%) were admitted; 154 of 615 admissions (25.0%; 95% CI, 21.7%-28.7%) had an LOS of 2 days or less (median, 3 days; interquartile range, 2-6 days). Pain during the ED visit was present in 668 patients (62.1%; 95% CI, 59.2%-65.0%; mean [SD] pain score, 6.4 [2.6] of 10.0) and in 776 (72.2%) during the prior week. Opioids were administered in the ED to 228 of 386 patients (59.1%; 95% CI, 18.8%-23.8%) with moderate to severe ED pain. Outpatient opioids were prescribed to 368 patients (47.4%; 95% CI, 3.14%-37.2%) of those with pre-ED pain, including 244 of 428 (57.0%; 95% CI, 52.2%-61.8%) who reported quite a bit or very much pain. Nausea in the ED was present in 336 (31.3%; 95% CI, 28.5%-34.1%); of these, 160 (47.6%; 95% CI, 12.8%-17.1%) received antiemetics in the ED. Antibiotics were administered in the ED to 285 patients (26.5%; 95% CI, 23.9%-29.2%). Of these, 209 patients (73.3%; 95% CI, 17.1%-21.9%) were admitted compared with 427 of 790 (54.1%; 95% CI, 50.5%-57.6%) not receiving antibiotics. CONCLUSIONS AND RELEVANCE This initial prospective, multicenter study profiling patients with cancer who were treated in the ED identifies common characteristics in this patient population and suggests opportunities to optimize care before, during, and after the ED visit. Improvement requires collaboration between specialists and emergency physicians optimizing ED use, improving symptom control, avoiding unnecessary hospitalizations, and appropriately stratifying risk to ensure safe ED treatment and disposition of patients with cancer.
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Affiliation(s)
- Jeffrey M. Caterino
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus
| | - David Adler
- Department of Emergency Medicine, University of Rochester, Rochester, New York
| | - Danielle D. Durham
- Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland
| | - Sai-Ching Jim Yeung
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Matthew F. Hudson
- Greenville Health System Cancer Institute, Greenville, South Carolina
| | - Aveh Bastani
- Department of Emergency Medicine, William Beaumont Hospital–Troy Campus, Troy, Michigan
| | - Steven L. Bernstein
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Christopher W. Baugh
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Corita R. Grudzen
- Ronald O. Perelman Department of Emergency Medicine and Population Health, New York University School of Medicine, New York
| | | | - Adam Klotz
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Troy E. Madsen
- Division of Emergency Medicine, University of Utah, Salt Lake City
| | - Daniel J. Pallin
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Cielito C. Reyes-Gibby
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Juan Felipe Rico
- Department of Pediatrics, University of South Florida Morsani College of Medicine, Tampa
| | - Richard J. Ryan
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Nathan I. Shapiro
- Department of Emergency Medicine, Beth Israel Deaconness Medical Center, Boston, Massachusetts
| | - Robert Swor
- Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, Michigan
| | - Arvind Venkat
- Department of Emergency Medicine, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Jason Wilson
- Department of Emergency Medicine, University of South Florida Morsani College of Medicine, Tampa
| | - Charles R. Thomas
- Department of Radiation Medicine, Knight Cancer Institute, Oregon Health & Sciences University, Portland
| | - Jason J. Bischof
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus
| | - Gary H. Lyman
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Department of Medicine, University of Washington School of Medicine, Seattle
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Lutz M, Sloane CM, Castillo EM, Brennen JJ, Coyne CJ, Swift SL, Vilke GM. Physiological effects of a spit sock. Am J Emerg Med 2018; 37:291-293. [PMID: 30415982 DOI: 10.1016/j.ajem.2018.09.050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 09/28/2018] [Accepted: 09/29/2018] [Indexed: 10/28/2022] Open
Abstract
OBJECTIVES Healthcare providers and law enforcement utilize spit socks to prevent exposure to communicable diseases transmitted by bodily fluid projection from agitated individuals. There are cases in which death is reported due to breathing being limited by a spit sock. There are no formally published studies on their use and safety. The aim of this study was to evaluate whether wearing a spit sock causes a clinically significant impact on breathing. METHODS Subjects sat with the spit mask over their heads for 15 min and their vital signs and ventilatory parameters were recorded after 5 min, 10 min and 15 min. Data were compared to baseline using Student's t-test with 95% confidence intervals using SPSS. RESULTS The median age of the 15 subjects was 28 years and 53% were male. There was no significant difference between baseline and wearing the spit sock for 5, 10 or 15 min for heart rate (p = 0.250, p = 0.181, p = 0.546), oxygen saturation (p = 0.334, p = 1.00, p = 0.173), end-tidal pCO2 (p = 0.135, p = 0.384, p = 0.187), and diastolic blood pressure (p = 0.485, p = 0.508, p = 0.915). The respiratory rate was not significantly different after 5 and 10 min (p = 0.898, p = 0.583), but decreased at 15 min (p = 0.048). The systolic blood pressure was lower after 5 and 10 min (p = 0.028, p = 0.045), but not significantly different at 15 min (p = 0.146). No subject indicated distress nor did the study need to be terminated due to pre-determined concerning vital signs or ventilatory parameters. CONCLUSIONS In healthy subjects there were no clinically significant changes in the physiologic parameters of breathing while wearing a spit sock.
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Affiliation(s)
- Marie Lutz
- UCSD School of Medicine, 9500 Gilman Dr., La Jolla, CA 92093, United States.
| | - Christian M Sloane
- Department of Emergency Medicine, UCSD Medical Center, 200 W. Arbor Dr. #8676, San Diego, CA 92103, United States.
| | - Edward M Castillo
- Department of Emergency Medicine, UCSD Medical Center, 200 W. Arbor Dr. #8676, San Diego, CA 92103, United States.
| | - Jesse J Brennen
- Department of Emergency Medicine, UCSD Medical Center, 200 W. Arbor Dr. #8676, San Diego, CA 92103, United States.
| | - Christopher J Coyne
- Department of Emergency Medicine, UCSD Medical Center, 200 W. Arbor Dr. #8676, San Diego, CA 92103, United States.
| | - Sadie L Swift
- Department of Emergency Medicine, UCSD Medical Center, 200 W. Arbor Dr. #8676, San Diego, CA 92103, United States.
| | - Gary M Vilke
- Department of Emergency Medicine, UCSD Medical Center, 200 W. Arbor Dr. #8676, San Diego, CA 92103, United States.
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Hryniewicki AT, Wang C, Shatsky RA, Coyne CJ. Management of Immune Checkpoint Inhibitor Toxicities: A Review and Clinical Guideline for Emergency Physicians. J Emerg Med 2018; 55:489-502. [PMID: 30120013 DOI: 10.1016/j.jemermed.2018.07.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 06/21/2018] [Accepted: 07/02/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) are a novel class of drugs used in cancer immunotherapy that are becoming more commonly used among advanced-stage cancers. Unfortunately, these therapies are sometimes associated with often subtle, potentially fatal immune-related adverse events (irAEs). OBJECTIVES We conducted a review of relevant primary research and clinical guidelines in oncology, pharmacology, and other literature, and synthesized this information to address the needs of the emergency physician in the acute management of irAEs. DISCUSSION Although the antitumor effects of immunotherapies are desirable, the inhibition of immune checkpoints may also lead to loss of peripheral tolerance and a subsequent unleashing of the immune system on nontumor cells, leading to unintended tissue damage, which manifests as multisystem organ dysfunction. This tissue damage can affect nearly every organ system, with the dermatologic, gastrointestinal, endocrine, and pulmonary systems being the most commonly affected. Treatment may range drastically, depending on the severity of the irAE, starting with supportive care and moving toward high-dose steroids and additional immune modulators such as infliximab or intravenous immunoglobulin. CONCLUSION With the increasing success and popularity of ICIs, emergency physicians will inevitably encounter increasing numbers of patients on these medications as well as the associated side effects. It is important that emergency physicians become aware of these irAEs and improve the detection of these processes to prevent inappropriate discharges, emergency department revisits, and downstream complications.
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Affiliation(s)
- Adam T Hryniewicki
- Department of Emergency Medicine, University of California San Diego School of Medicine, San Diego, California
| | - Claire Wang
- Department of Emergency Medicine, University of California San Diego School of Medicine, San Diego, California
| | - Rebecca A Shatsky
- Department of Medicine, Division of Hematology-Oncology, University of California San Diego School of Medicine, La Jolla, California
| | - Christopher J Coyne
- Department of Emergency Medicine, University of California San Diego School of Medicine, San Diego, California
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Kelly RS, Lasky-Su J, Yeung SCJ, Stone RM, Caterino JM, Hagan SC, Lyman GH, Baden LR, Glotzbecker BE, Coyne CJ, Baugh CW, Pallin DJ. Integrative omics to detect bacteremia in patients with febrile neutropenia. PLoS One 2018; 13:e0197049. [PMID: 29768470 PMCID: PMC5955575 DOI: 10.1371/journal.pone.0197049] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 04/25/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Cancer chemotherapy-associated febrile neutropenia (FN) is a common condition that is deadly when bacteremia is present. Detection of bacteremia depends on culture, which takes days, and no accurate predictive tools applicable to the initial evaluation are available. We utilized metabolomics and transcriptomics to develop multivariable predictors of bacteremia among FN patients. METHODS We classified emergency department patients with FN and no apparent infection at presentation as bacteremic (cases) or not (controls), according to blood culture results. We assessed relative metabolite abundance in plasma, and relative expression of 2,560 immunology and cancer-related genes in whole blood. We used logistic regression to identify multivariable predictors of bacteremia, and report test characteristics of the derived predictors. RESULTS For metabolomics, 14 bacteremic cases and 25 non-bacteremic controls were available for analysis; for transcriptomics we had 7 and 22 respectively. A 5-predictor metabolomic model had an area under the receiver operating characteristic curve of 0.991 (95%CI: 0.972,1.000), 100% sensitivity, and 96% specificity for identifying bacteremia. Pregnenolone steroids were more abundant in cases and carnitine metabolites were more abundant in controls. A 3-predictor gene expression model had corresponding results of 0.961 (95%CI: 0.896,1.000), 100%, and 86%. Genes involved in innate immunity were differentially expressed. CONCLUSIONS Classifiers derived from metabolomic and gene expression data hold promise as objective and accurate predictors of bacteremia among FN patients without apparent infection at presentation, and can provide insights into the underlying biology. Our findings should be considered illustrative, but may lay the groundwork for future biomarker development.
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Affiliation(s)
- Rachel S. Kelly
- Channing Division of Network Medicine, Brigham and Women’s Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
| | - Jessica Lasky-Su
- Channing Division of Network Medicine, Brigham and Women’s Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
| | - Sai-Ching J. Yeung
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States of America
| | - Richard M. Stone
- Harvard Medical School, Boston, MA, United States of America
- Dana Farber Cancer Institute, Boston, MA, United States of America
| | - Jeffrey M. Caterino
- Ohio State University Medical School, Wexner Medical Center Department of Emergency Medicine, Columbus, OH, United States of America
| | - Sean C. Hagan
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA, United States of America
| | - Gary H. Lyman
- Fred Hutchinson Cancer Research Center, Seattle, WA, United States of America
- School of Medicine, University of Washington, Seattle, WA, United States of America
| | - Lindsey R. Baden
- Harvard Medical School, Boston, MA, United States of America
- Dana Farber Cancer Institute, Boston, MA, United States of America
| | - Brett E. Glotzbecker
- Harvard Medical School, Boston, MA, United States of America
- Dana Farber Cancer Institute, Boston, MA, United States of America
| | - Christopher J. Coyne
- University of California, San Diego, School of Medicine and Department of Emergency Medicine, San Diego, CA, United States of America
| | - Christopher W. Baugh
- Harvard Medical School, Boston, MA, United States of America
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA, United States of America
| | - Daniel J. Pallin
- Harvard Medical School, Boston, MA, United States of America
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA, United States of America
- * E-mail:
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Coyne CJ, Abraham MK, Perkins J, Vilke GM. Influenza in the Emergency Department: Vaccination, Diagnosis, and Treatment. J Emerg Med 2016; 51:735-736. [PMID: 27687169 DOI: 10.1016/j.jemermed.2016.07.095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Accepted: 07/19/2016] [Indexed: 06/06/2023]
Affiliation(s)
- Christopher J Coyne
- Department of Emergency Medicine, University of California San Diego School of Medicine, San Diego, California
| | - Michael K Abraham
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jack Perkins
- Department of Emergency Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Gary M Vilke
- Department of Emergency Medicine, University of California San Diego School of Medicine, San Diego, California
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Arora S, Ford K, Terp S, Abramson T, Ruiz R, Camilon M, Coyne CJ, Lam CN, Menchine M, Burner E. Describing the evolution of mobile technology usage for Latino patients and comparing findings to national mHealth estimates. J Am Med Inform Assoc 2016; 23:979-83. [PMID: 26995564 DOI: 10.1093/jamia/ocv203] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 11/30/2015] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Describe the change in mobile technology used by an urban Latino population between 2011 and 2014, and compare findings with national estimates. MATERIALS AND METHODS Patients were surveyed on medical history and mobile technology use. We analyzed specific areas of mobile health capacity stratified by chronic disease, age, language preference, and educational attainment. RESULTS Of 2144 Latino patients, the percentage that owned a cell phone and texted were in-line with Pew estimates, but app usage was not. Patients with chronic disease had reduced access to mobile devices (P < .001) and lower use of mobile phone functionalities. DISCUSSION Prior research suggests that Latinos can access mHealth; however, we observed lower rates among Latino patients actively seeking heath care. CONCLUSION Published national estimates do not accurately reflect the mobile technology use of Latino patients served by our public safety-net facility. The difference is greater for older, less educated patients with chronic disease.
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Affiliation(s)
- Sanjay Arora
- Department of Emergency Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Kelsey Ford
- Department of Emergency Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Sophie Terp
- Department of Emergency Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Tiffany Abramson
- Department of Emergency Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Ryan Ruiz
- Department of Emergency Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Marissa Camilon
- Department of Emergency Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Christopher J Coyne
- Department of Emergency Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Chun Nok Lam
- Department of Emergency Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Michael Menchine
- Department of Emergency Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Elizabeth Burner
- Department of Emergency Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
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Abraham MK, Perkins J, Vilke GM, Coyne CJ. Influenza in the Emergency Department: Vaccination, Diagnosis, and Treatment: Clinical Practice Paper Approved by American Academy of Emergency Medicine Clinical Guidelines Committee. J Emerg Med 2016; 50:536-42. [PMID: 26763858 DOI: 10.1016/j.jemermed.2015.10.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 10/10/2015] [Accepted: 10/13/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Influenza is an acute respiratory virus that results in significant worldwide morbidity and mortality each year. As emergency physicians, we are often the first to encounter patients with seasonal influenza. It is therefore critical that we draw on the most recent and relevant research when we make clinical decisions regarding the diagnosis, treatment, and prophylaxis of this disease. METHODS A MEDLINE literature search from August 2009 to August 2015 was performed using the keywords influenza vaccination efficacy AND systematic, influenza AND rapid antigen testing, and Oseltamivir AND systematic, while limiting the search to human studies written in the English language. General review articles and case reports were omitted. Each of the selected articles then underwent a structured review. RESULTS We identified 163 articles through our literature search, of which 68 were found to be relevant to our clinical questions. These studies then underwent a rigorous review from which recommendations were given. CONCLUSIONS Influenza vaccine efficacy continues to range between 40% and 80%. Vaccination has the potential to decrease disease severity and is recommended for individuals older than 6 months of age. If resources permit, vaccination can be offered to patients presenting to the emergency department. Rapid antigen detection for influenza is a simple bedside test with high specificity, but generally low sensitivity. If a patient presents with a syndrome consistent with influenza and has negative rapid antigen detection, they should either receive a confirmatory reverse transcriptase polymerase chain reaction or be treated as if they have influenza. Treatment with neuraminidase inhibitors can decrease the duration of influenza and is recommended in hospitalized patients, or in those with high risk of complications.
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Affiliation(s)
- Michael K Abraham
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jack Perkins
- Department of Emergency Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Gary M Vilke
- Department of Emergency Medicine, University of California San Diego School of Medicine, San Diego, California
| | - Christopher J Coyne
- Department of Emergency Medicine, University of California San Diego School of Medicine, San Diego, California
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Lev R, Lee O, Petro S, Lucas J, Castillo EM, Vilke GM, Coyne CJ. Who is prescribing controlled medications to patients who die of prescription drug abuse? Am J Emerg Med 2016; 34:30-5. [DOI: 10.1016/j.ajem.2015.09.003] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Revised: 09/05/2015] [Accepted: 09/06/2015] [Indexed: 11/26/2022] Open
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Shi E, Vilke GM, Coyne CJ, Oyama LC, Castillo EM. Clinical outcomes of ED patients with bandemia. Am J Emerg Med 2015; 33:876-81. [PMID: 25937377 DOI: 10.1016/j.ajem.2015.03.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 03/13/2015] [Accepted: 03/15/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Although an elevated white blood cell count is a widely utilized measure for evidence of infection and an important criterion for evaluation of systemic inflammatory response syndrome, its component band count occupies a more contested position within clinical emergency medicine. Recent studies indicate that bandemia is highly predictive of a serious infection, suggesting that clinicians who do not appreciate the value of band counts may delay diagnosis or overlook severe infections. OBJECTIVES Whereas previous studies focused on determining the quantitative value of the band count (ie, determining sensitivity, threshold for bandemia, etc.), this study directs attention to patient-centered outcomes, hypothesizing that the degree of bandemia predisposes patients to subsequent negative clinical outcomes associated with underappreciated severe infections. METHODS This retrospective study of electronic medical records includes patients who initially presented to the emergency department (ED) with bandemia and were subsequently discharged from the ED. These patients were screened for repeat ED visits within 7 days and death within 30 days. RESULTS In patients with severe bandemia who were discharged from the ED, there was a 20.9% revisit rate at 7 days and a 4.9% mortality rate at 30 days, placing severely bandemic patients at 5 times significantly greater mortality compared to nonbandemic patients (P = .032). CONCLUSION Our review of patient outcomes suggests that the degree of bandemia, especially in the setting of concurrent tachycardia or fever, is associated with greater likelihood of negative clinical outcomes.
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Affiliation(s)
- Eileen Shi
- University of California San Diego Division of Biological Sciences, La Jolla, CA 92093-0935; University of California San Diego School of Medicine, La Jolla, CA 92093-0935.
| | - Gary M Vilke
- University of California San Diego School of Medicine, Department of Emergency Medicine, La Jolla, CA 92093-0935
| | - Christopher J Coyne
- University of California San Diego School of Medicine, Department of Emergency Medicine, La Jolla, CA 92093-0935
| | - Leslie C Oyama
- University of California San Diego School of Medicine, Department of Emergency Medicine, La Jolla, CA 92093-0935
| | - Edward M Castillo
- University of California San Diego School of Medicine, Department of Emergency Medicine, La Jolla, CA 92093-0935
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Coyne CJ, Testa N, Desai S, Lagrone J, Chang R, Zheng L, Kim H. Improving door-to-balloon time by decreasing door-to-ECG time for walk-in STEMI patients. West J Emerg Med 2014; 16:184-9. [PMID: 25671039 PMCID: PMC4307715 DOI: 10.5811/westjem.2014.10.23277] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Revised: 10/01/2014] [Accepted: 10/13/2014] [Indexed: 11/17/2022] Open
Abstract
Introduction The American Heart Association/American College of Cardiology guidelines recommend rapid door-to-electrocardiography (ECG) times for patients with ST-segment elevation myocardial infarction (STEMI). Previous quality improvement research at our institution revealed that we were not meeting this benchmark for walk-in STEMI patients. The objective is to investigate whether simple, directed changes in the emergency department (ED) triage process for potential cardiac patients could decrease door-to-ECG times and secondarily door-to-balloon times. Methods We conducted an interventional study at a large, urban, public teaching hospital from April 2010 to June 2012. All patients who walked into the ED with a confirmed STEMI were enrolled in the study. The primary intervention involved creating a chief complaint-based “cardiac triage” designation that streamlined the evaluation of potential cardiac patients. A secondary intervention involved moving our ECG technician and ECG station to our initial triage area. The primary outcome measure was door-to-ECG time and the secondary outcome measure was door-to-balloon time. Results We enrolled 91 walk-in STEMI patients prior to the intervention period and 141 patients after the invention. We observed statistically significant reductions in door-to-ECG time (43±93 to 30±72 minutes, median 23 to 14 minutes p<0.01), ECG-to-activation time (87±134 to 52±82 minutes, median 43 to 31 minutes p<0.01), and door-to-balloon time (134±146 to 84±40 minutes, median 85 -75 minutes p=0.03). Conclusion By creating a chief complaint-based cardiac triage protocol and by streamlining ECG completion, walk-in STEMI patients are systematically processed through the ED. This is not only associated with a decrease in door-to-balloon time, but also a decrease in the variability of the time sensitive intervals of door-to-ECG and ECG-to-balloon time.
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Affiliation(s)
- Christopher J Coyne
- Los Angeles County/University of Southern California, Department of Emergency Medicine, Los Angeles, California
| | - Nicholas Testa
- Los Angeles County/University of Southern California, Department of Emergency Medicine, Los Angeles, California
| | - Shoma Desai
- Los Angeles County/University of Southern California, Department of Emergency Medicine, Los Angeles, California
| | - Joy Lagrone
- Los Angeles County/University of Southern California, Los Angeles, California
| | - Roger Chang
- Los Angeles County/University of Southern California, Los Angeles, California
| | - Ling Zheng
- Los Angeles County/University of Southern California, Los Angeles, California
| | - Hyung Kim
- Los Angeles County/University of Southern California, Department of Emergency Medicine, Los Angeles, California
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Coyne CJ, Jain A. Pylephlebitis in a previously healthy emergency department patient with appendicitis. West J Emerg Med 2013; 14:428-30. [PMID: 24106533 PMCID: PMC3789899 DOI: 10.5811/westjem.2013.1.15353] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2012] [Revised: 12/29/2012] [Accepted: 01/22/2013] [Indexed: 11/11/2022] Open
Abstract
Pylephlebitis is a septic thrombophlebitis of the portal vein that is associated with multiple suppurative abdominal infections, such as diverticulitis, appendicitis, cholangitis, and cholecystitis. We describe a case of pylephlebitis in a patient with fever and diffuse, poorly localized abdominal pain who was eventually diagnosed with appendicitis. We aim to increase awareness of this condition among emergency physicians, as timely initiation of antibiotics and expedited surgical resection may improve outcomes in this potentially fatal disease.
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Affiliation(s)
- Christopher J Coyne
- Los Angeles County + University of Southern California Health Network, Department of Emergency Medicine, Los Angeles, California
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Robertson NL, Coyne CJ. First Report of Bean yellow mosaic virus from Diseased Lupinus luteus in Eastern Washington. Plant Dis 2009; 93:319. [PMID: 30764209 DOI: 10.1094/pdis-93-3-0319a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Lupine accessions from the Cool Season Food Legume Seed Collection are grown for seed regenerations in Pullman, WA by the Agricultural Research Service, Western Regional Plant Introduction Station. Selected seed was germinated in the greenhouse and assayed by indirect ELISA using antiserum for potyvirus group detection (Agdia, Inc., Elkhart, IN). Healthy transplants were grown for seed collection on outside plots. In July of 2005, more than 90% of 307 Lupinus luteus L. transplants developed severe yellowing, necrosis, and stunting with an estimated 5% plant death. Plants were heavily infested with aphids and leaf sap was serologically positive for potyvirus. Partially purified virus preparations from infected plants contained filamentous particles and a 35-kDa protein that reacted with universal potyvirus antiserum on western blots. Reverse transcription (RT)-PCR using potyvirus universal primers (2) and cDNA derived from virion RNA generated a ~1.7-kbp product that was cloned and sequenced. The sequenced portion of the genomic RNA contained 1,610 nucleotides (nt) on its 3'-terminus (GenBank Accession No. EU144223) that included a partial nuclear inclusion protein, NIb, (1 to 637 nt) with the conserved amino acid (aa) replicase motif GDD (131 to 139 nt), the coat protein (CP) gene of 821 nt (638 to 1,459 nt), and a 171-nt untranslated region (1,460 to 1,630 nt) attached to a poly(A)tail. The CP sequence contained a NAG motif instead of the DAG motif commonly associated with aphid transmission. Searches in the NCBI GenBank database revealed that the CP aa and nt sequences contained conserved domains with isolates of Bean yellow mosaic virus (BYMV). A pairwise alignment (ClustalX) (4) of the CP aa from 20 BYMV isolates with the BYMV-Pullman isolate revealed identities from 96% (BYMV-S, U47033) to 88% (BYMV-MI [X81124)] -MI-NAT [AF434661]). This meets the species demarcation criteria of more than ~80% identity for inclusion with BYMV (1). Virion mechanical inoculations resulted in local lesions on Chenopodium amaranticolor Coste et Reyn and C. quinoa Willd., necrotic blotches on Phaseolus vulgaris L., and yellow spots and systemic movement in L. succulentus Douglas ex. K. Koch, L. texensis 'Bluebonnet', and L. texensis 'Maroon'; BYMV was confirmed by western blots and ELISA. The experimental inoculations represent the first documented report of BYMV in the annual L. succulentus and biennial L. texensis species. Since BYMV is seedborne and transmitted by many aphid species (3), it is possible that several lupine transplants escaped potyvirus detection, and secondary transmission of BYMV to plants occurred by aphids. During the 1950s, BYMV was confirmed in several annual lupines grown as crops in the southeastern United States (3). To our knowledge, this is the first report of BYMV occurring naturally in a lupine species in Washington. BYMV is a destructive virus to lupine species worldwide and has a wide host range in Fabaceae. This research directly contributes toward the maintenance of virus-free lupine seed for distribution to scientists focusing on lupine research. References: (1) P. H. Berger et al. Family Potyviridae. Page 819 in: Virus Taxonomy: Eighth Report of the ICTV. C. M. Fauquet et al. eds., 2005. (2) J. Chen et al. Arch. Virol. 146:757, 2001. (3) R. A. C. Jones and G. D. Mclean, Ann. Appl. Biol. 114:609, 1989. (4) J. D. Thompson et al. Nucleic Acids Res. 24:4878, 1997.
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Affiliation(s)
- N L Robertson
- USDA, ARS, Subarctic Agricultural Research Unit, Palmer, AK
| | - C J Coyne
- USDA, ARS, Western Regional Plant Introduction Station, Pullman, WA
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Coyne CJ, McClendon MT, Walling JG, Timmerman-Vaughan GM, Murray S, Meksem K, Lightfoot DA, Shultz JL, Keller KE, Martin RR, Inglis DA, Rajesh PN, McPhee KE, Weeden NF, Grusak MA, Li CM, Storlie EW. Construction and characterization of two bacterial artificial chromosome libraries of pea (Pisum sativum L.) for the isolation of economically important genes. Genome 2007; 50:871-5. [PMID: 17893728 DOI: 10.1139/g07-063] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Pea (Pisum sativum L.) has a genome of about 4 Gb that appears to share conserved synteny with model legumes having genomes of 0.2-0.4 Gb despite extensive intergenic expansion. Pea plant inventory (PI) accession 269818 has been used to introgress genetic diversity into the cultivated germplasm pool. The aim here was to develop pea bacterial artificial chromosome (BAC) libraries that would enable the isolation of genes involved in plant disease resistance or control of economically important traits. The BAC libraries encompassed about 3.2 haploid genome equivalents consisting of partially HindIII-digested DNA fragments with a mean size of 105 kb that were inserted in 1 of 2 vectors. The low-copy oriT-based T-DNA vector (pCLD04541) library contained 55 680 clones. The single-copy oriS-based vector (pIndigoBAC-5) library contained 65 280 clones. Colony hybridization of a universal chloroplast probe indicated that about 1% of clones in the libraries were of chloroplast origin. The presence of about 0.1% empty vectors was inferred by white/blue colony plate counts. The usefulness of the libraries was tested by 2 replicated methods. First, high-density filters were probed with low copy number sequences. Second, BAC plate-pool DNA was used successfully to PCR amplify 7 of 9 published pea resistance gene analogs (RGAs) and several other low copy number pea sequences. Individual BAC clones encoding specific sequences were identified. Therefore, the HindIII BAC libraries of pea, based on germplasm accession PI 269818, will be useful for the isolation of genes underlying disease resistance and other economically important traits.
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Affiliation(s)
- C J Coyne
- USDA-ARS Plant Germplasm Introduction and Testing Unit, Washington State University, Pullman, WA 99164-6402, USA.
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Pilet-Nayel ML, Muehlbauer FJ, McGee RJ, Kraft JM, Baranger A, Coyne CJ. Consistent Quantitative Trait Loci in Pea for Partial Resistance to Aphanomyces euteiches Isolates from the United States and France. Phytopathology 2005; 95:1287-93. [PMID: 18943359 DOI: 10.1094/phyto-95-1287] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
ABSTRACT Development of pea cultivars resistant to Aphanomyces root rot, the most destructive root disease of pea worldwide, is a major disease management objective. In a previous study of a mapping population of 127 recombinant inbred lines (RILs) derived from the cross 'Puget' (susceptible) x '90-2079' (partially resistant), we identified seven genomic regions, including a major quantitative trait locus (QTL), Aph1, associated with partial resistance to Aphanomyces root rot in U.S. fields (21). The objective of the present study was to evaluate, in the same mapping population, the specificity versus consistency of Aphanomyces resistance QTL under two screening conditions (greenhouse and field, by comparison with the previous study) and with two isolates of Aphanomyces euteiches originating from the United States and France. The 127 RILs were evaluated in the greenhouse for resistance to pure culture isolates SP7 (United States) and Ae106 (France). Using the genetic map previously described, a total of 10 QTL were identified for resistance in greenhouse conditions to the two isolates. Among these were Aph1, Aph2, and Aph3, previously detected for partial field resistance in the United States. Aph1 and Aph3 were detected with both isolates and Aph2 with only the French isolate. Seven additional QTL were specifically detected with one of the two isolates and were not identified for partial field resistance in the United States. The consistency of the detected resistance QTL over two screening environments and isolates is discussed with regard to pathogen variability, and disease assessment and QTL detection methods. This study suggests the usefulness of three consistent QTL, Aph1, Aph2, and Aph3, for marker-assisted selection.
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