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Caterino JM, Stephens JA, Wexler R, Camargo CA, Hunold KM, Wei L, Hains D, Southerland LT, Bischof JJ, Schwaderer A. Establishment of Baseline Urinary Antimicrobial Peptide Levels by Age: A Prospective Observational Study. J Gerontol A Biol Sci Med Sci 2024; 79:glad223. [PMID: 37708314 PMCID: PMC11083632 DOI: 10.1093/gerona/glad223] [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: 03/16/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND Antimicrobial peptides (AMPs) are key effectors of urinary tract innate immunity. Identifying differences in urinary AMP levels between younger and older adults is important in understanding older adults' susceptibility and response to urinary tract infections (UTI) and AMP use as diagnostic biomarkers. We hypothesized that uninfected older adults have higher urinary human neutrophil peptides 1-3 (HNP 1-3), human alpha-defensin-5 (HD-5), and human beta-defensin-2 (hBD-2), but lower urinary cathelicidin (LL-37) than younger adults. METHODS We conducted a cross-sectional study of patients aged ≥18 years completing a family medicine clinic nonacute visit. Enzyme-linked immunosorbent assays were performed for AMPs. We identified associations between age and AMPs using unadjusted and multivariable linear regression models. RESULTS Of the 308 subjects, 144 (46.8%) were ≥65 years of age. Comparing age ≥65 versus < 65 years, there were no significant differences in HNP 1-3 (p = .371), HD5 (p = .834), or LL-37 (p = .348) levels. Values for hBD-2 were lower in older adults versus younger (p < .001). In multivariable analyses, older males and females had significantly lower hBD-2 levels (p < .001 and p = .004). Models also showed urine leukocyte esterase was associated with increased levels of HNP 1-3 and HD5; hematuria with increased hBD-2; and urine cultures with contamination with increased HNP 1-3 and hBD-2. CONCLUSIONS Baseline urinary HNP 1-3, HD-5, and LL-37 did not vary with age. Older adults had lower baseline hBD-2. This finding has implications for the potential use of urinary AMPs as diagnostic markers and will facilitate further investigation into the role of innate immunity in UTI susceptibility in older adults.
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Affiliation(s)
- Jeffrey M Caterino
- Department of Emergency Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Julie A Stephens
- Department of Biomedical Informatics, Center for Biostatistics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Randell Wexler
- Department of Family and Community Medicine, The Ohio State University College of Medicine, Gahanna, Ohio, USA
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Katherine M Hunold
- Department of Emergency Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Lai Wei
- Department of Biomedical Informatics, Center for Biostatistics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - David Hains
- Division of Nephrology, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Lauren T Southerland
- Department of Emergency Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Jason J Bischof
- Department of Emergency Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Andrew Schwaderer
- Division of Nephrology, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Yeung SCJ, Qdaisat A, Bischof JJ, Caterino JM, Kyriacou DN, Coyne Md C. A case series of adrenal insufficiency (likely due to hypophysitis) in cancer patients treated with immune checkpoint inhibitors. Am J Emerg Med 2024:S0735-6757(24)00204-3. [PMID: 38705758 DOI: 10.1016/j.ajem.2024.04.046] [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: 12/05/2023] [Revised: 03/24/2024] [Accepted: 04/26/2024] [Indexed: 05/07/2024] Open
Abstract
The number of approved immune checkpoint inhibitors (ICIs) and their indications have significantly increased over the past decade. Immune-related adverse effects (irAEs) of ICIs vary widely in presentation and symptoms and can present diagnostic challenges to emergency department (ED) physicians. Moreover, when ICIs are combined with radiotherapy, cytotoxic chemotherapy, or targeted therapy, the attribution of signs and symptoms to an immune-related cause is even more difficult. Here, we report a series of 5 ED cases of adrenal insufficiency in ICI-treated cancer patients. All 5 patients presented with severe fatigue and nausea. Four patients definitely had and one patient possibly had central adrenal insufficiency, and 4 patients had undetectable serum cortisol levels. The majority of the patients had nonspecific symptoms that were not recognized at their first ED presentation. These cases illustrate the need for a heightened level of suspicion for adrenal insufficiency in ICI-treated cancer patients with hypotension, nausea and/or vomiting, abdominal pain, fatigue, or hypoglycemia. As ICI use increases, irAE-associated oncologic emergencies will become more prevalent. Thus, ED physicians must update their knowledge regarding the diagnosis and management of irAEs and routinely inquire about the specific antineoplastic therapies that their ED patients with cancer are receiving. A random cortisol level (results readily available in most EDs) with interpretation taking the circadian rhythm and the current level of physiological stress into consideration can inform the differential diagnosis and whether further investigation of this potential irAE is warranted.
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Affiliation(s)
- Sai-Ching Jim Yeung
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States.
| | - Aiham Qdaisat
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Jason J Bischof
- Department of Emergency Medicine, Ohio State University, Columbus, OH, United States
| | - Jeffrey M Caterino
- Department of Emergency Medicine, Ohio State University, Columbus, OH, United States
| | - Demetrios N Kyriacou
- Department of Emergency Medicine, Northwestern University, Chicago, IL, United States
| | - Christopher Coyne Md
- Department of Emergency Medicine, University of California San Diego, San Diego, CA, United States
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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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Punches BE, Freiermuth CE, Sprague JE, Brown JL, Hutzel-Dunham E, Lambert J, Braun R, Littlefield A, Frey JA, Bachmann DJ, Bischof JJ, Pantalon MV, Ancona RM, Kisor DF, Lyons MS. Screening for problematic opioid use in the emergency department: Comparison of two screening measures. J Am Coll Emerg Physicians Open 2024; 5:e13106. [PMID: 38250198 PMCID: PMC10798174 DOI: 10.1002/emp2.13106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 11/30/2023] [Accepted: 12/29/2023] [Indexed: 01/23/2024] Open
Abstract
Study objective Earlier intervention for opioid use disorder (OUD) may reduce long-term health implications. Emergency departments (EDs) in the United States treat millions with OUD annually who may not seek care elsewhere. Our objectives were (1) to compare two screening measures for OUD characterization in the ED and (2) to determine the proportion of ED patients screening positive for OUD and those who endorse other substance use to guide future screening programs. Methods A cross-sectional study of randomly selected adult patients presenting to three Midwestern US EDs were enrolled, with duplicate patients excluded. Surveys were administered via research assistant and documented on tablet devices. Demographics were self-reported, and OUD positivity was assessed by the DSM 5 checklist and the WHO ASSIST 3.1. The primary outcome was the concordance between two screening measures for OUD. Our secondary outcome was the proportion of ED patients meeting OUD criteria and endorsed co-occurring substance use disorder (SUD) criteria. Results We enrolled 1305 participants; median age of participants was 46 years (range 18-84), with 639 (49.0%) Non-Hispanic, White, and 693 (53.1%) female. Current OUD positivity was identified in 17% (222 out of 1305) of the participants via either DSM-5 (two or more criteria) or ASSIST (score of 4 or greater). We found moderate agreement between the measures (kappa = 0.56; Phi coefficient = 0.57). Of individuals screening positive for OUD, 182 (82%) endorsed criteria for co-occurring SUD. Conclusions OUD is remarkably prevalent in ED populations, with one in six ED patients screening positive. We found a high prevalence of persons identified with OUD and co-occurring SUD, with moderate agreement between measures. Developing and implementing clinically feasible OUD screening in the ED is essential to enable intervention.
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Affiliation(s)
- Brittany E Punches
- College of Nursing The Ohio State University Columbus Ohio USA
- Department of Emergency Medicine The Ohio State University College of Medicine Columbus Ohio USA
| | - Caroline E Freiermuth
- Department of Emergency Medicine University of Cincinnati College of Medicine Cincinnati Ohio USA
| | - Jon E Sprague
- The Ohio Attorney General's Center for the Future of Forensic Science Bowling Green State University Bowling Green Ohio USA
| | - Jennifer L Brown
- Department of Psychological Sciences Purdue University West Lafayette Indiana USA
| | | | - Joshua Lambert
- College of Nursing University of Cincinnati Cincinnati Ohio USA
| | - Robert Braun
- Department of Emergency Medicine University of Cincinnati College of Medicine Cincinnati Ohio USA
| | - Andrew Littlefield
- Department of Psychological Sciences Texas Tech University Lubbock Texas USA
| | - Jennifer A Frey
- Department of Emergency Medicine The Ohio State University College of Medicine Columbus Ohio USA
| | - Daniel J Bachmann
- Department of Emergency Medicine The Ohio State University College of Medicine Columbus Ohio USA
| | - Jason J Bischof
- Department of Emergency Medicine The Ohio State University College of Medicine Columbus Ohio USA
| | - Michael V Pantalon
- Department of Emergency Medicine Yale University School of Medicine New Haven Connecticut USA
| | - Rachel M Ancona
- Department of Emergency Medicine Washington University School of Medicine St. Louis Missouri USA
| | - David F Kisor
- Department of Pharmaceutical Sciences and Pharmacogenomics College of Pharmacy Natural and Health Sciences Manchester University Fort Wayne Indiana USA
| | - Michael S Lyons
- Department of Emergency Medicine The Ohio State University College of Medicine Columbus Ohio USA
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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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Pang PS, Berger DA, Mahler SA, Li X, Pressler SJ, Lane KA, Bischof JJ, Char D, Diercks D, Jones AE, Hess EP, Levy P, Miller JB, Venkat A, Harrison NE, Collins SP. Short-Stay Units vs Routine Admission From the Emergency Department in Patients With Acute Heart Failure: The SSU-AHF Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2350511. [PMID: 38198141 PMCID: PMC10782263 DOI: 10.1001/jamanetworkopen.2023.50511] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 11/15/2023] [Indexed: 01/11/2024] Open
Abstract
Importance More than 80% of patients who present to the emergency department (ED) with acute heart failure (AHF) are hospitalized. With more than 1 million annual hospitalizations for AHF in the US, safe and effective alternatives are needed. Care for AHF in short-stay units (SSUs) may be safe and more efficient than hospitalization, especially for lower-risk patients, but randomized clinical trial data are lacking. Objective To compare the effectiveness of SSU care vs hospitalization in lower-risk patients with AHF. Design, Setting, and Participants This multicenter randomized clinical trial randomly assigned low-risk patients with AHF 1:1 to SSU or hospital admission from the ED. Patients received follow-up at 30 and 90 days post discharge. The study began December 6, 2017, and was completed on July 22, 2021. The data were analyzed between March 27, 2020, and November 11, 2023. Intervention Randomized post-ED disposition to less than 24 hours of SSU care vs hospitalization. Main Outcomes and Measures The study was designed to detect at least 1-day superiority for a primary outcome of days alive and out of hospital (DAOOH) at 30-day follow-up for 534 participants, with an allowance of 10% participant attrition. Due to the COVID-19 pandemic, enrollment was truncated at 194 participants. Before unmasking, the primary outcome was changed from DAOOH to an outcome with adequate statistical power: quality of life as measured by the 12-item Kansas City Cardiomyopathy Questionnaire (KCCQ-12). The KCCQ-12 scores range from 0 to 100, with higher scores indicating better quality of life. Results Of the 193 patients enrolled (1 was found ineligible after randomization), the mean (SD) age was 64.8 (14.8) years, 79 (40.9%) were women, and 114 (59.1%) were men. Baseline characteristics were balanced between arms. The mean (SD) KCCQ-12 summary score between the SSU and hospitalization arms at 30 days was 51.3 (25.7) vs 45.8 (23.8) points, respectively (P = .19). Participants in the SSU arm had 1.6 more DAOOH at 30-day follow-up than those in the hospitalization arm (median [IQR], 26.9 [24.4-28.8] vs 25.4 [22.0-27.7] days; P = .02). Adverse events were uncommon and similar in both arms. Conclusions and Relevance The findings show that the SSU strategy was no different than hospitalization with regard to KCCQ-12 score, superior for more DAOOH, and safe for lower-risk patients with AHF. These findings of lower health care utilization with the SSU strategy need to be definitively tested in an adequately powered study. Trial Registration ClinicalTrials.gov Identifier: NCT03302910.
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Affiliation(s)
- Peter S. Pang
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis
| | - David A. Berger
- Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, Michigan
| | - Simon A. Mahler
- Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Xiaochun Li
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis
| | | | - Kathleen A. Lane
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis
| | - Jason J. Bischof
- Department of Emergency Medicine, The Ohio State University, Columbus
| | - Douglas Char
- Department of Emergency Medicine, Washington University in St Louis, St Louis, Missouri
| | - Deborah Diercks
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Alan E. Jones
- Department of Emergency Medicine, University of Mississippi Medical Center, Jackson
| | - Erik P. Hess
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Phillip Levy
- Wayne State University School of Medicine and Integrative Biosciences Center, Detroit, Michigan
| | - Joseph B. Miller
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Arvind Venkat
- Department of Emergency Medicine, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Nicholas E. Harrison
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis
| | - Sean P. Collins
- Department of Emergency Medicine, Vanderbilt University School of Medicine and Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center, Nashville, Tennessee
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Pettit NR, Bischof JJ. The emergency department: A key pillar in the cancer care continuum. Acad Emerg Med 2023; 30:1288-1289. [PMID: 37684050 DOI: 10.1111/acem.14802] [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: 08/11/2023] [Revised: 09/01/2023] [Accepted: 09/02/2023] [Indexed: 09/10/2023]
Affiliation(s)
- Nicholas R Pettit
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jason J Bischof
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
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Punches BE, Osuji E, Bischof JJ, Li-Sauerwine S, Young H, Lyons MS, Southerland LT. Patient perceptions of microaggressions and discrimination toward patients during emergency department care. Acad Emerg Med 2023; 30:1192-1200. [PMID: 37335980 PMCID: PMC11075179 DOI: 10.1111/acem.14767] [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: 02/10/2023] [Revised: 06/13/2023] [Accepted: 06/13/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND Disparities in emergency department (ED) care based on race and ethnicity have been demonstrated. Patient perceptions of emergency care can have broad impacts, including poor health outcomes. Our objective was to measure and explore patient experiences of microaggressions and discrimination during ED care. METHODS This mixed-methods study of adult patients from two urban academic EDs integrates quantitative discrimination measures and semistructured interviews of discrimination experiences during ED care. Participants completed demographic questionnaires and the Discrimination in Medical Settings (DMS) scale and were invited for a follow-up interview. Transcripts of recorded interviews were analyzed leveraging conventional content analysis with line-by-line coding for thematic descriptions. RESULTS The cohort included 52 participants, with 30 completing the interview. Nearly half the participants were Black (n = 24, 46.1%) and half were male (n = 26, 50%). "No" or "rare" experiences of discrimination during the ED visit were reported by 22/48 (46%), some/moderate discrimination by 19/48 (39%), and significant discrimination in 7/48 (15%). Five main themes were found: (1) clinician behaviors-communication and empathy, (2) emotional response to health care team actions, (3) perceived reasons for discrimination, (4) environmental pressures in the ED, and (5) patients are hesitant to complain. We found an emergent concept where persons with moderate/high DMS scores, in discussing instances of discrimination, frequently reflected on previous health care experiences rather than on their current ED visit. CONCLUSIONS Patients attributed microaggressions to many factors beyond race and gender, including age, socioeconomic status, and environmental pressures in the ED. Of those who endorsed moderate to significant discrimination via survey response during their recent ED visit, most described historical experiences of discrimination during their interview. Previous experiences of discrimination may have lasting effects on patient perceptions of current health care. System and clinician investment in patient rapport and satisfaction is important to prevent negative expectations for future encounters and counteract those already in place.
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Affiliation(s)
- Brittany E. Punches
- The Ohio State University College of Nursing, Columbus, Ohio, USA
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Evans Osuji
- The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Jason J. Bischof
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Simiao Li-Sauerwine
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Henry Young
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Michael S. Lyons
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Lauren T. Southerland
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Rafique Z, Budden J, Quinn CM, Duanmu Y, Safdar B, Bischof JJ, Driver BE, Herzog CA, Weir MR, Singer AJ, Boone S, Soto-Ruiz KM, Peacock WF. Patiromer utility as an adjunct treatment in patients needing urgent hyperkalaemia management (PLATINUM): design of a multicentre, randomised, double-blind, placebo-controlled, parallel-group study. BMJ Open 2023; 13:e071311. [PMID: 37308268 PMCID: PMC10277034 DOI: 10.1136/bmjopen-2022-071311] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 05/11/2023] [Indexed: 06/14/2023] Open
Abstract
INTRODUCTION Hyperkalaemia is common, life-threatening and often requires emergency department (ED) management; however, no standardised ED treatment protocol exists. Common treatments transiently reducing serum potassium (K+) (including albuterol, glucose and insulin) may cause hypoglycaemia. We outline the design and rationale of the Patiromer Utility as an Adjunct Treatment in Patients Needing Urgent Hyperkalaemia Management (PLATINUM) study, which will be the largest ED randomised controlled hyperkalaemia trial ever performed, enabling assessment of a standardised approach to hyperkalaemia management, as well as establishing a new evaluation parameter (net clinical benefit) for acute hyperkalaemia treatment investigations. METHODS AND ANALYSIS PLATINUM is a Phase 4, multicentre, randomised, double-blind, placebo-controlled study in participants who present to the ED at approximately 30 US sites. Approximately 300 adult participants with hyperkalaemia (K+ ≥5.8 mEq/L) will be enrolled. Participants will be randomised 1:1 to receive glucose (25 g intravenously <15 min before insulin), insulin (5 units intravenous bolus) and aerosolised albuterol (10 mg over 30 min), followed by a single oral dose of either 25.2 g patiromer or placebo, with a second dose of patiromer (8.4 g) or placebo after 24 hours. The primary endpoint is net clinical benefit, defined as the mean change in the number of additional interventions less the mean change in serum K+, at hour 6. Secondary endpoints are net clinical benefit at hour 4, proportion of participants without additional K+-related medical interventions, number of additional K+-related interventions and proportion of participants with sustained K+ reduction (K+ ≤5.5 mEq/L). Safety endpoints are the incidence of adverse events, and severity of changes in serum K+ and magnesium. ETHICS AND DISSEMINATION A central Institutional Review Board (IRB) and Ethics Committee provided protocol approval (#20201569), with subsequent approval by local IRBs at each site, and participants will provide written consent. Primary results will be published in peer-reviewed manuscripts promptly following study completion. TRIAL REGISTRATION NUMBER NCT04443608.
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Affiliation(s)
- Zubaid Rafique
- Henry JN Taub Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
| | | | | | - Youyou Duanmu
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Basmah Safdar
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jason J Bischof
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Charles A Herzog
- Division of Cardiology, Department of Internal Medicine, Hennepin Healthcare/University of Minnesota, Minneapolis, Minnesota, USA
| | - Matthew R Weir
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Adam J Singer
- Department of Emergency Medicine, SUNY Stony Brook, Stony Brook, New York, USA
| | - Stephen Boone
- Henry JN Taub Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
| | | | - W Frank Peacock
- Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
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10
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Freiermuth CE, Kisor DF, Lambert J, Braun R, Frey JA, Bachmann DJ, Bischof JJ, Lyons MS, Pantalon MV, Punches BE, Ancona R, Sprague JE. Genetic Variants Associated with Opioid Use Disorder. Clin Pharmacol Ther 2023; 113:1089-1095. [PMID: 36744646 DOI: 10.1002/cpt.2864] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 01/29/2023] [Indexed: 02/07/2023]
Abstract
Genetics are presumed to contribute 30-40% to opioid use disorder (OUD), allowing for the possibility that genetic markers could be used to identify personal risk for developing OUD. We aimed to test the potential association among 180 candidate single nucleotide polymorphisms (SNPs), 120 of which were related to the dopamine reward pathway and 60 related to pharmacokinetics. Participants were randomly recruited in 2020-2021 in a cross-sectional genetic association study. Self-reported health history including Diagnostic and Statistical Manual of Mental Disorders (DSM-5) OUD criteria and buccal swabs were collected. A total of 1,301 participants were included in the analyses for this study. Of included participants, 250 met the DSM-5 criteria for ever having OUD. Logistic regression, adjusting for age and biologic sex, was used to characterize the association between each SNP and DSM-5 criteria consistent with OUD. Six SNPs found in 4 genes were associated with OUD: increased odds with CYP3A5 (rs15524 and rs776746) and DRD3 (rs324029 and rs2654754), and decreased odds with CYP3A4 (rs2740574) and CYP1A2 (rs2069514). Homozygotic CYP3A5 (rs15524 and rs776746) had the highest adjusted odds ratio of 2.812 (95% confidence interval (CI) 1.737, 4.798) and 2.495 (95% CI 1.670, 3.835), respectively. Variants within the dopamine reward and opioid metabolism pathways have significant positive (DRD3 and CYP3A5) and negative (CYP3A4 and CYP1A2) associations with OUD. Identification of these variants provides promising possibilities for genetic prognostic and therapeutic targets for future investigation.
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Affiliation(s)
| | - David F Kisor
- Department of Pharmaceutical Sciences and Pharmacogenomics, College of Pharmacy, Natural and Health Sciences, Manchester University, Fort Wayne, Indiana, USA
| | - Joshua Lambert
- College of Nursing, University of Cincinnati, Cincinnati, Ohio, USA
| | - Robert Braun
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Jennifer A Frey
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Daniel J Bachmann
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Jason J Bischof
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Michael S Lyons
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Michael V Pantalon
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Brittany E Punches
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA.,College of Nursing, The Ohio State University, Columbus, Ohio, USA
| | - Rachel Ancona
- Washington University School of Medicine, St. Louis, Missouri, USA
| | - Jon E Sprague
- The Ohio Attorney General's Center for the Future of Forensic Science, Bowling Green State University, Bowling Green, Ohio, USA
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11
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Bischof JJ, Chai P, Mohamed Y, Padappayil R, Merchant RC, Boyer EW, Rosen R, Reyes-Gibby CC, Viamonte M, W Carrico A. MyTPill: study protocol for a cross-over randomised controlled trial comparing novel strategies to monitor antiretroviral adherence among HIV+ prescription opioid users. BMJ Open 2023; 13:e062805. [PMID: 36627157 PMCID: PMC9835860 DOI: 10.1136/bmjopen-2022-062805] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION Adherence to HIV antiretroviral therapy (ART) remains the cornerstone of HIV treatment. For individuals with suboptimal adherence, electronic adherence monitoring (EAM) technologies have become an important component of multimodal adherence support strategies. Most EAM technologies detect pillbox opening, and therefore, assume but cannot verify actual ingestion of oral medication. In contrast, a digital pill system (ID-capsule manufactured by etectRX, here named My/Treatment/Pill) measures directly ingestion of medications. Identifying the superior method to measure ART adherence would improve virological suppression by enabling the delivery of real-time interventions to support ART adherence, particularly in high-risk populations. METHODS AND ANALYSIS Cross-over, randomised trial with 1:1 variable block size randomisation comparing two EAM systems in prescription opioid-using HIV+patient on once daily oral bictegravir, emtricitabine and tenofovir alafenamide regimens and detectable viral load >200 copies/mL within 30 days of screening (n=80). The primary outcome is once daily ART adherence measurement efficacy as assessed by comparing the accuracy of each EAM system as measured by concordance of the respective EAM systems to dried blood spot ART concentrations. Secondary outcomes are the identification of multilevel factors that are prevalent in the target population most closely linked to ART non-adherence and EAM non-adherence. ETHICS AND DISSEMINATION This protocol was approved by the institutional review boards of participating sites (The Ohio State University, The Fenway Institute and the University of Miami). Data will be presented at scientific conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT03978793.
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Affiliation(s)
- Jason J Bischof
- Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Peter Chai
- Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Rana Padappayil
- Internal Medicine, Monmouth Medical Center, Long Branch, New Jersey, USA
| | - Roland C Merchant
- Emergency Medicine, Mount Sinai School of Medicine, New York, New York, USA
| | - Edward W Boyer
- Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Emergency Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Rochelle Rosen
- Center for Behavioral and Preventive Medicine, Miriam Hospital, Providence, Rhode Island, USA
| | - Cielito C Reyes-Gibby
- Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Michael Viamonte
- Public Health Sciences, University of Miami, Coral Gables, Florida, USA
| | - Adam W Carrico
- Public Health Sciences, University of Miami, Coral Gables, Florida, USA
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12
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Delamare Fauvel A, Bischof JJ, Reinbolt RE, Weihing VK, Boyer EW, Caterino JM, Wang HE. Diagnosis of cancer in the Emergency Department: A scoping review. Cancer Med 2023; 12:8710-8728. [PMID: 36622062 PMCID: PMC10134283 DOI: 10.1002/cam4.5600] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 12/12/2022] [Accepted: 12/19/2022] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND The Emergency Department (ED) plays a key role in the identification and care of acute medical conditions, including cancer. In this scoping review, we aimed to determine the role of the ED in the acute diagnosis of cancer. METHODS We conducted a scoping review of articles according to Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) using PubMed and Google Scholar. We screened studies of adults with a new diagnosis of cancer in the ED. We included randomized control trials, prospective, retrospective, and cross-sectional observational studies, and case reports published in English since 2000. We grouped the articles into categories based on their objectives and findings. RESULTS Of the 4459 articles, we included 47 in the review. The identified studies fell into three major categories: (1) studies describing the incidental diagnosis of cancer in the ED (n = 11, 23%), (2) studies characterizing the acute initial presentation of cancer in the ED (n = 19, 41%), and (3) studies describing the ED as a pathway to cancer diagnosis in the healthcare system (n = 17, 36%). Across the studies, cancer diagnoses in the ED were more likely in patients with higher comorbidities, occurred at later stages, and resulted in worse survival rates. CONCLUSIONS The ED plays a prominent role in the initial diagnosis of cancer. Efforts must be made to integrate the ED within the cancer care continuum.
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Affiliation(s)
- Alix Delamare Fauvel
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA.,Emergency Department, Rouen University Hospital, Rouen, France
| | - Jason J Bischof
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Raquel E Reinbolt
- Department of Internal Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Veronica K Weihing
- McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Edward W Boyer
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Jeffrey M Caterino
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Henry E Wang
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
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13
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Schoeffler A, Bashian EJ, Callender N, Geyer ED, More A, Webb T, Butsch JL, Kman NE, Bischof JJ. Implementation of a COVID-19 Vaccine Emergency Department Education Program for Underserved Communities. Cureus 2022; 14:e30972. [PMID: 36465205 PMCID: PMC9711925 DOI: 10.7759/cureus.30972] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2022] [Indexed: 06/17/2023] Open
Abstract
Background The COVID-19 pandemic has provided an opportunity for significant reflection on our public health response as providers. Throughout the past two years, we learned that administration of COVID-19 vaccines, rapidly and widely across all communities, has been key to halting the spread of the virus. One significant challenge in promoting a large-scale immunization program is the threat of vaccine hesitancy. A general mistrust in healthcare providers exists across the country, especially in underrepresented minority (URM) communities. Objective This study aims to determine reasons for vaccine hesitancy in an urban emergency department and to provide targeted education on the safety and efficacy of the COVID-19 vaccines to patients. Methods An interprofessional quality improvement team was assembled to develop an educational intervention addressing COVID-19 vaccine safety for vaccine-eligible patients receiving treatment in the emergency department at an urban community hospital where over 70% of patients identify as URM. A survey was conducted to elucidate patients' concerns surrounding the COVID-19 vaccine. Upon completion of the survey, up-to-date safety information and education targeting their surveyed concerns were provided by trained medical students. A follow-up survey was conducted to assess the impact of education on patients' attitudes toward the vaccine. Surveys were developed using standardized scoring systems from the Oxford coronavirus explanations, attitudes, and narratives survey (OCEANS) II study and the Kaiser Foundation. Hesitancy scores before and after education were tabulated to assess the effectiveness of targeted education in improving vaccine hesitancy. Results Patients cited a variety of concerns surrounding the COVID-19 vaccine. The three most common reasons for declining vaccines were potential side effects (67.3% were concerned or extremely concerned), the belief that COVID-19 vaccines are neither effective nor safe (64.5% were concerned to extremely concerned), and the risk of developing COVID-19 infection from the vaccine itself (38.8% were concerned to extremely concerned). This information was used to address these concerns directly with patients, answer questions, clarify information, and encourage patients to get vaccinated. Through this education program, vaccine hesitancy scores improved by an average of 29% indicating an increased likelihood of patients who would get vaccinated in the future. Of patients receiving education, 38% agreed to sign up for a vaccine appointment during the intervention. Conclusion The emergency department often serves vulnerable patient populations. As such, its role in public health in these communities cannot be underestimated. This quality improvement project is a novel method that can be used to develop and implement public health education programs to address specific community needs in the emergency department. These results show that a multidisciplinary healthcare team can provide a measurable change in attitudes about vaccine safety with directed education in the emergency department that can help address vaccine hesitancy in the future.
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Affiliation(s)
- Austin Schoeffler
- Emergency Medicine, The Ohio State University College of Medicine, Columbus, USA
| | - Elizabeth J Bashian
- Emergency Medicine, The Ohio State University College of Medicine, Columbus, USA
| | - Nathan Callender
- Emergency Medicine, The Ohio State University College of Medicine, Columbus, USA
| | - Emily D Geyer
- Emergency Medicine, The Ohio State University College of Medicine, Columbus, USA
| | - Aditya More
- Emergency Medicine, The Ohio State University College of Medicine, Columbus, USA
| | - Tyler Webb
- Emergency Medicine, The Ohio State University College of Medicine, Columbus, USA
| | - Jackiethia L Butsch
- Community and Civic Engagement, The Ohio State University Wexner Medical Center, Columbus, USA
| | - Nicholas E Kman
- Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, USA
| | - Jason J Bischof
- Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, USA
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14
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Gould Rothberg BE, Quest TE, Yeung SCJ, Pelosof LC, Gerber DE, Seltzer JA, Bischof JJ, Thomas CR, Akhter N, Mamtani M, Stutman RE, Baugh CW, Anantharaman V, Pettit NR, Klotz AD, Gibbs MA, Kyriacou DN. Oncologic emergencies and urgencies: A comprehensive review. CA Cancer J Clin 2022; 72:570-593. [PMID: 35653456 DOI: 10.3322/caac.21727] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 02/15/2022] [Accepted: 02/23/2022] [Indexed: 12/12/2022] Open
Abstract
Patients with advanced cancer generate 4 million visits annually to emergency departments (EDs) and other dedicated, high-acuity oncology urgent care centers. Because of both the increasing complexity of systemic treatments overall and the higher rates of active therapy in the geriatric population, many patients experiencing acute decompensations are frail and acutely ill. This article comprehensively reviews the spectrum of oncologic emergencies and urgencies typically encountered in acute care settings. Presentation, underlying etiology, and up-to-date clinical pathways are discussed. Criteria for either a safe discharge to home or a transition of care to the inpatient oncology hospitalist team are emphasized. This review extends beyond familiar conditions such as febrile neutropenia, hypercalcemia, tumor lysis syndrome, malignant spinal cord compression, mechanical bowel obstruction, and breakthrough pain crises to include a broader spectrum of topics encompassing the syndrome of inappropriate antidiuretic hormone secretion, venous thromboembolism and malignant effusions, as well as chemotherapy-induced mucositis, cardiomyopathy, nausea, vomiting, and diarrhea. Emergent and urgent complications associated with targeted therapeutics, including small molecules, naked and drug-conjugated monoclonal antibodies, as well as immune checkpoint inhibitors and chimeric antigen receptor T-cells, are summarized. Finally, strategies for facilitating same-day direct admission to hospice from the ED are discussed. This article not only can serve as a point-of-care reference for the ED physician but also can assist outpatient oncologists as well as inpatient hospitalists in coordinating care around the ED visit.
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Affiliation(s)
- Bonnie E Gould Rothberg
- Yale Cancer Center Innovations Laboratory, Yale Comprehensive Cancer Center, New Haven, Connecticut
| | - Tammie E Quest
- Department of Emergency Medicine, Emory University, Atlanta, Georgia
| | - Sai-Ching J Yeung
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lorraine C Pelosof
- Office of Oncologic Diseases, US Food and Drug Administration, Silver Spring, Maryland
| | - David E Gerber
- Division of Hematology-Oncology, Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical School, Dallas, Texas
| | - Justin A Seltzer
- Department of Emergency Medicine, University of California San Diego, San Diego, California
| | - Jason J Bischof
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Charles R Thomas
- Department of Radiation Oncology, Geisel School of Medicine at Dartmouth, Norris Cotton Cancer Center, Lebanon, New Hampshire
| | - Nausheen Akhter
- Department of Medicine, Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mira Mamtani
- Department of Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Robin E Stutman
- Department of Medicine, Division of Urgent Care Services, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Christopher W Baugh
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Venkataraman Anantharaman
- Department of Emergency Medicine, Singapore General Hospital, SingHealth Duke-National University of Singapore Academic Medical Center, Singapore, Singapore
| | - Nicholas R Pettit
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Adam D Klotz
- Department of Medicine, Division of Urgent Care Services, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michael A Gibbs
- Department of Emergency Medicine, Atrium Health-Carolinas Medical Center, Charlotte, North Carolina
| | - Demetrios N Kyriacou
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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15
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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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16
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Grudzen CR, Barker PC, Bischof JJ, Cuthel AM, Isaacs ED, Southerland LT, Yamarik RL. Palliative care models for patients living with advanced cancer: a narrative review for the emergency department clinician. Emerg Cancer Care 2022; 1:10. [PMID: 35966217 PMCID: PMC9362452 DOI: 10.1186/s44201-022-00010-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 07/18/2022] [Indexed: 11/19/2022]
Abstract
Eighty-one percent of persons living with cancer have an emergency department (ED) visit within the last 6 months of life. Many cancer patients in the ED are at an advanced stage with high symptom burden and complex needs, and over half is admitted to an inpatient setting. Innovative models of care have been developed to provide high quality, ambulatory, and home-based care to persons living with serious, life-limiting illness, such as advanced cancer. New care models can be divided into a number of categories based on either prognosis (e.g., greater than or less than 6 months), or level of care (e.g., lower versus higher intensity needs, such as intravenous pain/nausea medication or frequent monitoring), and goals of care (e.g., cancer-directed treatment versus symptom-focused care only). We performed a narrative review to (1) compare models of care for seriously ill cancer patients in the ED and (2) examine factors that may hasten or impede wider dissemination of these models.
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17
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Southerland LT, Benson KK, Schoeffler AJ, Lashutka MA, Borson S, Bischof JJ. Inclusion of older adults and reporting of consent processes in randomized controlled trials in the emergency department: A scoping review. J Am Coll Emerg Physicians Open 2022; 3:e12774. [PMID: 35919513 PMCID: PMC9337842 DOI: 10.1002/emp2.12774] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 06/06/2022] [Accepted: 06/07/2022] [Indexed: 01/07/2023] Open
Abstract
Objective Conducting research in the emergency department (ED) is often complicated by patients' acute and chronic illnesses, which can adversely affect cognition and subsequently capacity to consent for research, especially in older adults. Validated screening tools to assess capacity to consent for research exist, but neither the frequency of use nor which ones are used for ED research are known. Methods We conducted a scoping review using standard review techniques. Inclusion criteria included (1) randomized controlled trials (RCTs) from publication years 2014-2019 that (2) enrolled participants only in the ED, (3) included patients aged 65+ years, and (4) were fully published in English. Articles were sourced from Embase and screened using Covidence. Results From 3130 search results, 269 studies passed title/abstract and full text screening. Average of the mean or median ages was 55.7 years (SD 14.2). The mean number of study participants was 311.9 [range 8-10,807 participants]. A few (n = 13, 4.8%) waived or had exception from informed consent. Of the 256 studies requiring consent, a fourth (26.5%, n = 68) specifically excluded patients due to impaired capacity to consent. Only 11 (4.3%) documented a formal capacity screening tool and only 13 (5.1%) reported consent by legally authorized representative (LAR). Conclusions Most RCTs enrolling older adults in EDs did not report assessment of capacity to consent or use of LARs. This snapshot of informed consent procedures is potentially concerning and suggests that either research consent processes for older patients and/or reporting of consent processes require improvement.
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Affiliation(s)
- Lauren T Southerland
- Department of Emergency MedicineThe Ohio State University Wexner Medical CenterColumbusOhioUSA
| | | | | | - Margaret A. Lashutka
- Department of Emergency MedicineThe Ohio State University Wexner Medical CenterColumbusOhioUSA
| | - Soo Borson
- Department of Family MedicineKeck School of Medicine University of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Jason J. Bischof
- Department of Emergency MedicineThe Ohio State University Wexner Medical CenterColumbusOhioUSA
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18
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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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19
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Kizziah MA, Miller KN, Bischof JJ, Emerson G, Khandelwal S, Mitzman J, Southerland LT, Way DP, Hunold KM. Emergency medicine resident clinical experience vs. in-training examination content: A national database study. AEM Educ Train 2022; 6:e10729. [PMID: 35368501 PMCID: PMC8908307 DOI: 10.1002/aet2.10729] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 01/12/2022] [Accepted: 01/25/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVES Emergency medicine (EM) residents take the In-Training Examination (ITE) annually to assess medical knowledge. Question content is derived from the Model of Clinical Practice of Emergency Medicine (EM Model), but it is unknown how well clinical encounters reflect the EM Model. The objective of this study was to compare the content of resident patient encounters from 2016-2018 to the content of the EM Model represented by the ITE Blueprint. METHODS This was a retrospective cross-sectional study utilizing the National Hospital Ambulatory Medical Care Survey (NHAMCS). Reason for visit (RFV) codes were matched to the 20 categories of the American Board of Emergency Medicine (ABEM) ITE Blueprint. All analyses were done with weighted methodology. The proportion of visits in each of the 20 content categories and 5 acuity levels were compared to the proportion in the ITE Blueprint using 95% confidence intervals (CIs). RESULTS Both resident and nonresident patient visits demonstrated content differences from the ITE Blueprint. The most common EM Model category were visits with only RFV codes related to signs, symptoms, and presentations regardless of resident involvement. Musculoskeletal disorders (nontraumatic), psychobehavioral disorders, and traumatic disorders categories were overrepresented in resident encounters. Cardiovascular disorders and systemic infectious diseases were underrepresented. When residents were involved with patient care, visits had a higher proportion of RFV codes in the emergent and urgent acuity categories compared to those without a resident. CONCLUSIONS Resident physicians see higher acuity patients with varied patient presentations, but the distribution of encounters differ in content category than those represented by the ITE Blueprint.
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Affiliation(s)
- Melinda A. Kizziah
- Department of Emergency MedicineThe Ohio State UniversityColumbusOhioUSA
| | - Krystin N. Miller
- Department of Emergency MedicineThe Ohio State UniversityColumbusOhioUSA
| | - Jason J. Bischof
- Department of Emergency MedicineThe Ohio State UniversityColumbusOhioUSA
| | - Geremiha Emerson
- Department of Emergency MedicineThe Ohio State UniversityColumbusOhioUSA
| | - Sorabh Khandelwal
- Department of Emergency MedicineThe Ohio State UniversityColumbusOhioUSA
| | - Jennifer Mitzman
- Department of Emergency MedicineThe Ohio State UniversityColumbusOhioUSA
| | | | - David P. Way
- Department of Emergency MedicineThe Ohio State UniversityColumbusOhioUSA
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20
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Kauffman E, Qiu Y, Frey JA, Bischof JJ. Barriers and Facilitators to Peer Support Services for Patients With Opioid Use Disorder in the Emergency Department. Cureus 2022; 14:e23145. [PMID: 35444910 PMCID: PMC9009995 DOI: 10.7759/cureus.23145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2022] [Indexed: 12/02/2022] Open
Abstract
There is a high prevalence of opioid use disorder in the United States, and emergency departments (EDs) play multiple vital roles in providing care to help these patients with achieving sobriety, one of which is the application of peer recovery services. This technical report discusses the utilization of peer recovery supporters in the ED and associated barriers. They include but are not limited to the difficult hiring process, referral process challenges for certain populations, difficulty with follow-up data collection, retention of peer recovery supporters, and a lack of ED provider awareness. This article also discussed strategies to address these barriers. Examples include simplifying hospital onboarding processes for peer recovery supporters, obtaining grants to utilize peer recovery services, and using managed care organizations to facilitate follow-up data collection, ED provider education, and discharge planning.
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21
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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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22
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Southerland LT, Hunold KM, Van Fossen J, Caterino JM, Gulker P, Stephens JA, Bischof JJ, Farrell E, Carpenter CR, Mion LC. An implementation science approach to geriatric screening in an emergency department. J Am Geriatr Soc 2022; 70:178-187. [PMID: 34580860 PMCID: PMC8742753 DOI: 10.1111/jgs.17481] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [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: 04/12/2021] [Revised: 08/27/2021] [Accepted: 08/30/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND The Geriatric Emergency Department (ED) Guidelines recommend screening older adults during their ED visit for delirium, fall risk/safe mobility, and home safety needs. We used the Consolidated Framework for Implementation Research (CFIR) and the Expert Recommendations for Implementation Change (ERIC) tool for preimplementation planning. METHODS The cross-sectional survey was conducted among ED nurses at an academic medical center. The survey was adapted from the CFIR Interview Guide Tool and consisted of 21 Likert scale questions based on four CFIR domains. Potential barriers identified by the survey were mapped to identify recommended implementation strategies using ERIC. RESULTS Forty-six of 160 potential participants (29%) responded. Intervention Characteristics: Nurses felt geriatric screening should be standard practice for all EDs (76.1% agreed some/very much) and that there was good evidence (67.4% agreed some/very much). Outer setting: The national and regional practices such as the existence of guidelines or similar practices in other hospitals were unknown to many (20.0%). Nurses did agree some/very much (64.4%) that the intervention was good for the hospital/health system. Inner Setting: 67.4% felt more staff or infrastructure and 63.0% felt more equipment were needed for the intervention. When asked to pick from a list of potential barriers, the most commonly chosen were motivational (I often do not remember (n = 27, 58.7%) and It is not a priority (n = 14, 30.4%)). The identified barriers were mapped using the ERIC tool to rate potential implementation strategies. Strategies to target culture change were identifying champions, improve adaptability, facilitate the nurses performing the intervention, and increase demand for the intervention. CONCLUSION CFIR domains and ERIC tools are applicable to an ED intervention for older adults. This preimplementation process could be replicated in other EDs considering implementing geriatric screening.
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Affiliation(s)
| | | | - Jenifer Van Fossen
- Department of Emergency Medicine, The Ohio State University, Columbus OH
| | | | - Peg Gulker
- Department of Emergency Medicine, The Ohio State University, Columbus OH
| | - Julie A. Stephens
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State College of Medicine, Columbus, OH, USA
| | - Jason J. Bischof
- Department of Emergency Medicine, The Ohio State University, Columbus OH
| | - Erin Farrell
- Department of Emergency Medicine, The Ohio State University, Columbus OH
| | | | - Lorraine C. Mion
- College of Nursing, The Ohio State Wexner Medical Center, Columbus, OH, USA
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23
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Brathwaite D, Waller AE, Gaynes BN, Stemerman R, Deselm TM, Bischof JJ, Tintinalli J, Brice JH, Bush M. A 7 Year Summary of Emergency Department Visits by Patients With Mental Health Disorders. Front Psychiatry 2022; 13:831843. [PMID: 35222127 PMCID: PMC8863870 DOI: 10.3389/fpsyt.2022.831843] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 01/18/2022] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Emergency departments (EDs) have been increasingly utilized over time for psychiatric care. While multiple studies have assessed these trends in nationally representative data, few have evaluated these trends in state-level data. This investigation seeks to understand the mental health-related ED burden in North Carolina (NC) by describing trends in ED visits associated with a mental health diagnosis (MHD) over time. METHODS Using data from NC DETECT, this investigation describes trends in NC ED visits from January 1, 2008 through December 31, 2014 by presence of a MHD code. A visit was classified by the first listed MHD ICD-9-CM code in the surveillance record and MHD codes were grouped into related categories for analysis. Visits were summarized by MHD status and by MHD category. RESULTS Over 32 million ED visits were recorded from 2008 to 2014, of which 3,030,746 (9.4%) were MHD-related visits. The average age at presentation for MHD-related visits was 50 years (SD 23.5) and 63.9% of visits were from female patients. The proportion of ED visits with a MHD increased from 8.3 to 10.2% from 2008 to 2014. Annually and overall, the largest diagnostic category was stress/anxiety/depression. Hospital admissions resulting from MHD-related visits declined from 32.2 to 18.5% from 2008 to 2014 but remained consistently higher than the rate of admissions among non-MHD visits. CONCLUSION Similar to national trends, the proportion of ED visits associated with a MHD in NC has increased over time. This indicates a need for continued surveillance, both stateside and nationally, in order to inform future efforts to mitigate the growing ED burden.
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Affiliation(s)
- Danielle Brathwaite
- Department of Health Policy and Management, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, United States
| | - Anna E Waller
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, United States.,Carolina Center for Health Informatics, University of North Carolina, Chapel Hill, NC, United States
| | - Bradley N Gaynes
- Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill, NC, United States.,Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, United States
| | - Rachel Stemerman
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, United States
| | - Tracy M Deselm
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, United States
| | - Jason J Bischof
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, United States.,Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Judith Tintinalli
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, United States
| | - Jane H Brice
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, United States
| | - Montika Bush
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, United States
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24
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Bennett CL, Ogele E, Pettit NR, Bischof JJ, Meng T, Govindarajan P, Camargo CA, Nordenholz K, Kline JA. Multicenter Study of Outcomes Among Persons With HIV Who Presented to US Emergency Departments With Suspected SARS-CoV-2. J Acquir Immune Defic Syndr 2021; 88:406-413. [PMID: 34483295 PMCID: PMC8547584 DOI: 10.1097/qai.0000000000002795] [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] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 08/16/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND There is a need to characterize patients with HIV with suspected severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). SETTING Multicenter registry of patients from 116 emergency departments in 27 US states. METHODS Planned secondary analysis of patients with suspected SARS-CoV-2, with (n = 415) and without (n = 25,306) HIV. Descriptive statistics were used to compare patient information and clinical characteristics by SARS-CoV-2 and HIV status. Unadjusted and multivariable models were used to explore factors associated with death, intubation, and hospital length of stay. Kaplan-Meier curves were used to estimate survival by SARS-CoV-2 and HIV infection status. RESULTS Patients with both SARS-CoV-2 and HIV and patients with SARS-CoV-2 but without HIV had similar admission rates (62.7% versus 58.6%, P = 0.24), hospitalization characteristics [eg, rates of admission to the intensive care unit from the emergency department (5.0% versus 6.3%, P = 0.45) and intubation (10% versus 13.3%, P = 0.17)], and rates of death (13.9% versus 15.1%, P = 0.65). They also had a similar cumulative risk of death (log-rank P = 0.72). However, patients with both HIV and SARS-CoV-2 infections compared with patients with HIV but without SAR-CoV-2 had worsened outcomes, including increased mortality (13.9% versus 5.1%, P < 0.01, log-rank P < 0.0001) and their deaths occurred sooner (median 11.5 versus 34 days, P < 0.01). CONCLUSIONS Among emergency department patients with HIV, clinical outcomes associated with SARS-CoV-2 infection are not worse when compared with patients without HIV, but SARS-CoV-2 infection increased the risk of death in patients with HIV.
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Affiliation(s)
| | - Emmanuel Ogele
- Department of Emergency Medicine, Cook County Hospital, Chicago, IL
| | - Nicholas R. Pettit
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Jason J. Bischof
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Tong Meng
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | | | - Carlos A. Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA; and
| | - Kristen Nordenholz
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Jeffrey A. Kline
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN
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25
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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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26
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Rafique Z, Peacock F, Armstead T, Bischof JJ, Hudson J, Weir MR, Neuenschwander J. Hyperkalemia management in the emergency department: An expert panel consensus. J Am Coll Emerg Physicians Open 2021; 2:e12572. [PMID: 34632453 PMCID: PMC8485984 DOI: 10.1002/emp2.12572] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [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: 05/06/2021] [Revised: 08/18/2021] [Accepted: 09/16/2021] [Indexed: 01/11/2023] Open
Abstract
Hyperkalemia is a common electrolyte abnormality identified in the emergency department (ED) and potentially fatal. However, there is no consensus over the potassium threshold that warrants intervention or its treatment algorithm. Commonly used medications are at best temporizing measures, and the roles of binders are unclear in the emergent setting. As the prevalence of comorbid conditions altering potassium homeostasis rises, hyperkalemia becomes more common, and hence there is a need to standardize management. A panel was assembled to synthesize the available evidence and identify gaps in knowledge in hyperkalemia treatment in the ED. The panel was composed of 7 medical practitioners, including 5 physicians, a nurse, and a clinical pharmacist with collective expertise in the areas of emergency medicine, nephrology, and hospital medicine. This panel was sponsored by the American College of Emergency Physicians with a goal to create a consensus document for managing acute hyperkalemia. The panel evaluated the evidence on calcium for myocyte stabilization and potassium shifting and excretion. This article summarizes information on available therapies for hyperkalemia and proposes a hyperkalemia treatment algorithm for the ED practitioner based on the currently available literature and highlights diagnostic pitfalls and evidence gaps.
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Affiliation(s)
- Zubaid Rafique
- Baylor College of MedicineDepartment of Emergency MedicineBen Taub General HospitalHoustonTexasUSA
| | - Frank Peacock
- Baylor College of MedicineDepartment of Emergency MedicineBen Taub General HospitalHoustonTexasUSA
| | | | - Jason J. Bischof
- The Ohio State UniversityDepartment of Emergency MedicineColumbusOhioUSA
| | - Joanna Hudson
- The University of Tennessee Health Science CenterDepartments of Clinical Pharmacy and Translational Science & Medicine (Nephrology)MemphisTennesseeUSA
| | - Matthew R. Weir
- Division of NephrologyDepartment of MedicineUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - James Neuenschwander
- The Ohio State UniversityDepartment of Emergency MedicineColumbusOhioUSA
- Genesis Healthcare SystemDepartment of Emergency MedicineZanesvilleOhioUSA
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Bischof JJ, Sylvester PJ, Frey JA, Stephens JA, Hammond B, Garmatter J, Hebert C, Caterino JM. Emergency department disposition of non-neutropenic febrile patients with cancer. J Am Coll Emerg Physicians Open 2021; 2:e12576. [PMID: 34632455 PMCID: PMC8487252 DOI: 10.1002/emp2.12576] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 08/31/2021] [Accepted: 09/15/2021] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES National data reveal that 60% of the 4.5 million annual emergency department (ED) visits by patients with cancer result in admission. Many of these visits are due to a febrile illness. Current literature provides limited guidance on how to treat non-neutropenic febrile ED patients. This study characterizes clinical outcomes of non-neutropenic febrile patients with cancer presenting to an academic, Comprehensive Cancer Center affiliated ED. METHODS Retrospective chart review of 101 randomly selected adult patients with active cancer presenting with a chief complaint of fever or a documented fever in the ED and an absolute neutrophil count above 1000 between October 2015 and September 2016. Descriptive statistics were calculated. RESULTS The primary malignancies represented were hematologic (24%), gastrointestinal (13%), head and neck (13%), and genitourinary (8%). Sixty-two percent were on chemotherapy, 15% on radiation therapy, and 12% were on targeted therapy. Severe illness outcomes occurred in 39% and 83% were admitted with a median length of stay of 4 days. Among admitted patients, 24% experienced a length of stay ≤2 days. A return visit to the ED or an in-system hospitalization within 7 days of the index visit occurred in 10% and death occurred within 7 days of the index visit in 4%. CONCLUSION A majority of patients presenting to the ED with non-neutropenic fever are admitted (83%), of whom nearly a quarter experience a length of stay of ≤2 days with infrequent serious illness outcomes. Future efforts should focus on the development of risk stratification tools in this population to avoid potentially unnecessary hospitalizations.
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Affiliation(s)
- Jason J. Bischof
- Department of Emergency MedicineThe Ohio State University Wexner Medical CenterColumbusOhioUSA
| | - Patrick J. Sylvester
- Department of Emergency MedicineThe Ohio State University Wexner Medical CenterColumbusOhioUSA
| | - Jennifer A. Frey
- Department of Emergency MedicineThe Ohio State University Wexner Medical CenterColumbusOhioUSA
| | - Julie A. Stephens
- Center for Biostatistics, Department of Biomedical InformaticsThe Ohio State UniversityColumbusOhioUSA
| | - Becca Hammond
- Department of Emergency MedicineThe Ohio State University Wexner Medical CenterColumbusOhioUSA
| | - Joshua Garmatter
- Department of Emergency MedicineThe Ohio State University Wexner Medical CenterColumbusOhioUSA
| | - Courtney Hebert
- Center for Biostatistics, Department of Biomedical InformaticsThe Ohio State UniversityColumbusOhioUSA
- Department of Internal Medicine, Division of Infectious DiseasesThe Ohio State University Wexner Medical CenterColumbusOhioUSA
| | - Jeffrey M. Caterino
- Department of Emergency MedicineThe Ohio State University Wexner Medical CenterColumbusOhioUSA
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28
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Pettit N, Boadu D, Bischof JJ. Emergency department management of chemotherapy related febrile neutropenia: An opportunity to improve care. Am J Emerg Med 2021; 50:5-9. [PMID: 34265732 DOI: 10.1016/j.ajem.2021.07.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 04/27/2021] [Revised: 07/01/2021] [Accepted: 07/02/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Febrile neutropenia (FN) is an important oncological emergency seen in the emergency department (ED), and the American Society of Clinical Oncology recommends risk stratification of patients with febrile neutropenia using the Multinational Association for Supportive Care in Cancer (MASCC) Index, with ED discharge on oral antibiotics recommended for low-risk patients. OBJECTIVES To determine the prevalence of FN neutropenia and medical system wide ED treatment guideline adherence. METHODS We performed a retrospective chart review of all patients with an ICD-10 confirmed diagnosis of FN from January 2016-2019at 13 affiliated EDs within one medical system. Only cancer/chemotherapy related FN were included. Following the MASCC guidelines, we used post-hoc calculations to classify patients as low/high-risk, and compared key clinical variables (mortality, blood culture positivity, interventions). RESULTS 203 patients were found to have FN. 97.9% (184/203) received broad spectrum antibiotics, including 92% of the low-risk group (60/65). All patients were admitted, and no observed in-hospital mortality was noted in the low-risk group, meanwhile 5.1% (7/138) of the high-risk group died. 14/203 patients had positive blood cultures, none in the low-risk group. CONCLUSION The prevalence of FN is low among 13 EDs that had almost 1.7 million ED visits over a 3-year period. Guideline compliance for low-risk FN was poor. All patients were admitted, and nearly all patients received IV fluids and IV antibiotics. Improving FN management to align with national guidelines represents an opportunity to improved ED care of patients with cancer by reducing unnecessary hospitalizations.
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Affiliation(s)
- Nicholas Pettit
- Indiana University School of Medicine, Department of Emergency Medicine, Indianapolis, IN, United States of America.
| | - Daniel Boadu
- Indiana University School of Medicine, Department of Emergency Medicine, Indianapolis, IN, United States of America
| | - Jason J Bischof
- The Ohio State University Wexner Medical Center, Department of Emergency Medicine, Columbus, OH, United States of America
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29
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Bischof JJ, Bush M, Shams RB, Collichio FA, Platts-Mills TF. A hybrid model of acute unscheduled cancer care provided by a hospital-based acute care clinic and the emergency department: a descriptive study. Support Care Cancer 2021; 29:7479-7485. [PMID: 34089356 PMCID: PMC8178031 DOI: 10.1007/s00520-021-06327-1] [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] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 05/30/2021] [Indexed: 02/06/2023]
Abstract
PURPOSE Patients with cancer often experience medical events that require immediate evaluation. These evaluations typically occur in an emergency department (ED), but there is increasing interest in providing this care in other settings. We report on a novel care model whereby a nursing hotline is used to triage patients to the ED or to the North Carolina Cancer Hospital Infusion Center (NCCHIC). METHODS A retrospective study of adult patients with a neoplasm diagnosis seeking acute care at a large academic hospital pre- and post-initiation of the novel care model in January of 2016. Patients were identified by querying the electronic medical record and clinic administrative data during matched 6 month pre- and post-periods. RESULTS During the pre-initiation period, 1346 patients visited the ED on 1651 occasions (76.1% admission rate). In the post-initiation period, 1434 patients visited the ED on 1797 occasions (81.5% admission rate), and 246 patients visited the NCCHIC on 322 occasions (68.9% admission rate). The emergency severity index (ESI) in the pre-initiation ED group was primarily ESI 2 (30.6%) and ESI 3 (65.4%). In the post-initiation ED group, the ESI was similar (32.6% ESI 2 and 64.2% ESI 3). In contrast, the NCCHIC predominantly treated lower acuity patients (65.8% calculated ESI of 4/5). CONCLUSIONS This model demonstrates a multidisciplinary partnership to providing acute unscheduled care for patients with cancer. In the early implementation phase of this model, approximately 15% of patients, generally of lower acuity, were seen in the NCCHIC.
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Affiliation(s)
- Jason J Bischof
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA. .,Department of Emergency Medicine, The Ohio State University Wexner Medical Center, 760 Prior Hall, 376 W. 10th Avenue, Columbus, OH, 43210, USA.
| | - Montika Bush
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Rayad Bin Shams
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Frances A Collichio
- Lineberger Comprehensive Cancer Center, University of North Carolina At Chapel Hill, Chapel Hill, NC, USA
| | - Timothy F Platts-Mills
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA.,Quantworks, Inc., Carrboro, NC, USA
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30
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Hunold KM, Schwaderer AL, Exline M, Hebert C, Lampert BC, Southerland LT, Stephens JA, Bischof JJ, Caterino JM. Diagnosing Dyspneic Older Adult Emergency Department Patients: A Pilot Study. Acad Emerg Med 2021; 28:675-678. [PMID: 33249675 PMCID: PMC10561323 DOI: 10.1111/acem.14183] [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: 07/22/2020] [Revised: 10/29/2020] [Accepted: 11/23/2020] [Indexed: 11/29/2022]
Abstract
Study Objectives: Pneumonia, chronic obstructive pulmonary disease (COPD), and heart failure (HF) exacerbations can present similarly in the older adult in the Emergency Department (ED), leading to sub-optimal treatment from over- and under-diagnosis. There may be a role for antimicrobial peptides (AMPs) in improving the accurate diagnosis of pneumonia in these patients. Methods: This pilot was a prospective, observational cohort study of older adults (aged ≥65 years of age) who presented to the ED with dyspnea or elevated respiratory rate. To identify biomarkers of pneumonia, serum levels of white blood cell count, procalcitonin (PCT), and antimicrobial peptides (human beta defensin 1 and 2 [HBD-1, -2], human neutrophil peptides 1–3 [HNP1–3] and cathelididin [LL-37]) were compared between those with and without pneumonia. Criterion standard reviewers retrospectively determined the diagnoses present in the ED. Results: Three hundred ninety-one patients were screened, 140 were eligible, and 79 were enrolled. Based on criterion standard review, pneumonia was present in 10 (12.7%), COPD in 9 (11.4%) and HF in 31 (39.2%) with a co-diagnosis rate of 10.1% by criterion standard review. Comparatively, emergency medicine attending physicians diagnosed pneumonia in 16 (20.3%), COPD in 12 (15.2%), and HF in 30 (38.0%) with co-diagnosis rate of 15.2%. Emergency physicians agreed with criterion standard diagnoses in 90% of pneumonia, 75% of COPD and 65% of HF diagnoses. Differences in leukocyte count (p<0.01) and two novel AMPs (DEFA5 (p=0.08) and DEFB2 (p=0.09)) showed promise for diagnosing pneumonia. Conclusions: Emergency physicians continue to have poor diagnostic accuracy in dyspneic older adult patients. Serum AMP levels are one potential tool to improve diagnostic accuracy and outcomes for this important population and require further study.
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Affiliation(s)
| | | | - Matthew Exline
- The Ohio State University, Department of Internal Medicine
| | - Courtney Hebert
- The Ohio State University, Department of Biomedical Informatics
- The Ohio State University, Division of Infectious Disease
| | | | | | - Julie A. Stephens
- The Ohio State University, Center for Biostatistics, Department of Biomedical Informatics
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31
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Hunold KM, Caterino JM, Bischof JJ. Diagnostic Uncertainty in Dyspneic Patients with Cancer in the Emergency Department. West J Emerg Med 2021; 22:170-176. [PMID: 33856297 PMCID: PMC7972394 DOI: 10.5811/westjem.2020.10.48091] [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] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 10/26/2020] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE Dyspnea is the second most common symptom experienced by the approximately 4.5 million patients with cancer presenting to emergency departments (ED) each year. Distinguishing pneumonia, the most common reason for presentation, from other causes of dyspnea is challenging. This report characterizes the diagnostic uncertainty in patients with dyspnea and pneumonia presenting to an ED by establishing the rates of co-diagnosis, co-treatment, and misdiagnosis. METHODS Visits by individuals ≥18 years old with cancer who presented with a complaint of dyspnea were identified using the National Hospital Ambulatory Medical Care Survey between 2012-2014 and analyzed for rates of co-diagnosis, co-treatment (treatment or diagnosis for >1 of pneumonia, chronic obstructive pulmonary disease [COPD], and heart failure), and misdiagnosis of pneumonia. Additionally, we assessed rates of diagnostic uncertainty (co-diagnosis, co-treatment, or a lone diagnosis of dyspnea not otherwise specified [NOS]). RESULTS Among dyspneic cancer visits (1,593,930), 15.2% (95% confidence interval [CI], 11.1-20.5%) were diagnosed with pneumonia, 22.5% (95% CI, 16.7-29.7%) with COPD, and 7.4% (95% CI 4.7-11.4%) with heart failure. Dyspnea NOS was diagnosed in 32.3% (95% CI, 25.7-39.7%) of visits and as the only diagnosis in 23.1% (95% CI, 16.3-31.6%) of all visits. Co-diagnosis occurred in 4.0% (95% CI, 2.0-7.6%) of dyspneic adults with cancer and co-treatment in 12.1% (95% CI, 7.5-18.9%). Agreement between emergency physician and inpatient documentation for presence of pneumonia was 57.7% (95% CI, 37.0-76.1%). CONCLUSION Diagnostic uncertainty remains a significant concern in patients with cancer presenting to the ED with dyspnea. Clinical uncertainty among dyspneic patients results in both misdiagnosis and under-treatment of patients with pneumonia and cancer.
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Affiliation(s)
- Katherine M Hunold
- The Ohio State University Wexner Medical Center, Department of Emergency Medicine, Columbus, Ohio
| | - Jeffrey M Caterino
- The Ohio State University Wexner Medical Center, Department of Emergency Medicine, Columbus, Ohio
| | - Jason J Bischof
- The Ohio State University Wexner Medical Center, Department of Emergency Medicine, Columbus, Ohio
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32
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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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33
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Caterino JM, Stephens JA, Camargo CA, Wexler R, Hebert C, Southerland LT, Hunold KM, Hains DS, Bischof JJ, Wei L, Wolfe AJ, Schwaderer A. Asymptomatic Bacteriuria versus Symptom Underreporting in Older Emergency Department Patients with Suspected Urinary Tract Infection. J Am Geriatr Soc 2021; 68:2696-2699. [PMID: 33460062 DOI: 10.1111/jgs.16775] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 07/18/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Jeffrey M Caterino
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Julie A Stephens
- Department of Biomedical Informatics, Center for Biostatistics, The Ohio State University, Columbus, Ohio, USA
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Randell Wexler
- Department of Family Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Courtney Hebert
- Department of Internal Medicine, The Ohio State University, Columbus, Ohio, USA.,Division of Infectious Diseases, Department of Biomedical Informatics, The Ohio State University, Columbus, Ohio, USA
| | - Lauren T Southerland
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Katherine M Hunold
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - David S Hains
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jason J Bischof
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Lai Wei
- Department of Biomedical Informatics, Center for Biostatistics, The Ohio State University, Columbus, Ohio, USA
| | - Alan J Wolfe
- Department of Microbiology and Immunology, Loyola University Chicago, Chicago, Illinois, USA
| | - Andrew Schwaderer
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
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34
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Sylvester PJ, Stewart J, Schoeffler A, Aalberg J, Hunold KM, Caterino JM, Bischof JJ. Utility of Emergency Department Chest Imaging in Patients with Cancer: A Descriptive Study. J Emerg Med 2020; 59:396-402. [PMID: 32593580 DOI: 10.1016/j.jemermed.2020.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 02/24/2020] [Revised: 04/27/2020] [Accepted: 05/04/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND The use of computed tomography (CT) has been scrutinized in emergency medicine, particularly in patients with cancer. Previous studies have characterized the rate of CT use in this population; however, limited data are available about the yield of this modality compared with radiography and its clinical decision-making effect. OBJECTIVE To determine whether CT imaging of the chest increases identification of clinically significant results compared with chest radiography (CXR) in patients with cancer. METHODS This was a retrospective chart review of patients with a history of solid tumors presenting to an emergency department in 2017. Patients who received both CXR and CT (or CT angiography) of the chest during their assessment were identified and the rate of clinically significant findings on imaging was compared. Clinical findings were further categorized as requiring nonurgent, urgent, or emergent attention. Descriptive statistics and chi-squared testing were performed between the 2 imaging modalities. RESULTS From 839 patients meeting inclusion criteria, 287 were randomly sampled. The predominant malignancies were lung (32.4%), breast (13.9%), and head and neck cancer (13.6%). A greater number of patients had clinically significant findings identified on CT imaging (n = 222) compared with CXR (n = 108). Stratification upon urgency of these findings (nonurgent, urgent, or emergent) reveals a significant difference in all strata (p < 0.05). CONCLUSIONS Compared with CXR, CT imaging of the chest identified significantly more clinically relevant findings requiring attention and consequently affecting clinical decision making.
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Affiliation(s)
- Patrick J Sylvester
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | | | | | - Joshua Aalberg
- Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Katherine M Hunold
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Jeffrey M Caterino
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Jason J Bischof
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
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35
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Bischof JJ, Emerson G, Mitzman J, Khandelwal S, Way DP, Southerland LT. Does the Emergency Medicine In-training Examination Accurately Reflect Residents' Clinical Experiences? AEM Educ Train 2019; 3:317-322. [PMID: 31637348 PMCID: PMC6795359 DOI: 10.1002/aet2.10381] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 07/19/2019] [Accepted: 07/20/2019] [Indexed: 05/21/2023]
Abstract
OBJECTIVE The American Board of Emergency Medicine Model of the Clinical Practice of Emergency Medicine (ABEM Model) serves as a guide for resident education and the basis for the resident In-training Examination (ITE) and the Emergency Medicine Board Qualification Examinations. The purpose of this study was to determine how closely resident-patient encounters in our emergency departments (EDs) matched the ABEM Model as presented in the specifications of the content outline for the ITE. METHODS This single-site study of an academic residency program analyzed all documented resident-patient encounters in the ED during a 2.5-year period recorded in the electronic medical record. The chief complaints from these encounters were matched to the 20 categories of the ABEM Model. Chi-square goodness-of-fit tests were performed to compare the proportions of categorized encounters and proportions of patient acuity levels to the proportions of categories as outlined in the content blueprint of the ITE. RESULTS After the exclusion of encounters with missing data and those not involving EM residents, 125,405 encounters were analyzed. We found a significant difference between the clinical experience of EM residents and the ABEM Model as reflected in the ITE for both case categories (p < 0.01) and patient acuity (p < 0.01). The following categories were the most overrepresented in clinical care: signs, symptoms, and presentations; psychobehavioral disorders; and abdominal and gastrointestinal disorders. The most underrepresented were procedures and skills, systemic infectious disorders, and thoracic-respiratory disorders. CONCLUSION The clinical experience of EM residents differs significantly from the ITE Content Blueprint, which reflects the ABEM Model. This type of inquiry may help to provide custom education reports to residents about their clinical encounters to help identify clinical knowledge gaps that may require supplemental nonclinical training.
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Affiliation(s)
- Jason J. Bischof
- Department of Emergency MedicineThe Ohio State University Wexner Medical CenterColumbusOH
| | - Geremiha Emerson
- Department of Emergency MedicineThe Ohio State University Wexner Medical CenterColumbusOH
| | - Jennifer Mitzman
- Department of Emergency MedicineThe Ohio State University Wexner Medical CenterColumbusOH
| | - Sorabh Khandelwal
- Department of Emergency MedicineThe Ohio State University Wexner Medical CenterColumbusOH
| | - David P. Way
- Department of Emergency MedicineThe Ohio State University Wexner Medical CenterColumbusOH
| | - Lauren T. Southerland
- Department of Emergency MedicineThe Ohio State University Wexner Medical CenterColumbusOH
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36
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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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Bischof JJ, Sellers JB, Phillips AW, Petrongelli JJ, Stuckey AE, Platts-Mills TF. Patient navigation for complex care patients in the emergency department: a survey of oncology patient navigators. Support Care Cancer 2019; 27:4359-4362. [DOI: 10.1007/s00520-019-04766-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 03/19/2019] [Indexed: 11/29/2022]
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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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Bischof JJ, Presley CJ, Caterino JM. Addressing New Diagnostic and Treatment Challenges Associated With a New Age of Cancer Treatment. Ann Emerg Med 2018; 73:88-90. [PMID: 30243546 DOI: 10.1016/j.annemergmed.2018.08.421] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Indexed: 01/04/2023]
Affiliation(s)
- Jason J Bischof
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Carolyn J Presley
- Department of Internal Medicine, Division of Medical Oncology, Ohio State University Comprehensive Cancer Center, The Ohio State University, Columbus, OH
| | - Jeffrey M Caterino
- Department of Emergency Medicine, Ohio State University Wexner Medical Center, Columbus, OH.
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Le Parc JM, Bischof JJ, King AM, Greenberger S, Way DP, Panchal AR, Finnegan GI, Terndrup TE. A Randomized Comparison of In-hospital Rescuer Positions for Endotracheal Intubation in a Difficult Airway. West J Emerg Med 2018; 19:660-667. [PMID: 30013701 PMCID: PMC6040908 DOI: 10.5811/westjem.2018.4.37227] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 03/02/2018] [Accepted: 04/16/2018] [Indexed: 11/29/2022] Open
Abstract
Introduction Emergency endotracheal intubation (ETI) is a common and critical procedure performed in both prehospital and in-hospital settings. Studies of prehospital providers have demonstrated that rescuer position influences ETI outcomes. However, studies of in-hospital rescuer position for ETI are limited. While we adhere to strict standards for the administration of ETI, we posited that perhaps requiring in-hospital rescuers to stand for ETI is an obstacle to effectiveness. Our objective was to compare in-hospital emergency medicine (EM) trainees’ performance on ETI delivered from both the seated and standing positions. Methods EM residents performed ETI on a difficult airway mannequin from both a seated and standing position. They were randomized to the position from which they performed ETI first. All ETIs were recorded and then scored using a modified version of the Airway Management Proficiency Checklist. Residents also rated the laryngeal view and the difficulty of the procedure. We analyzed comparisons between ETI positions with paired t-tests. Results Forty-two of our 49 residents (85.7%) participated. Fifteen (35.7%) were female, and all three levels of training were represented. The average number of prior ETI experiences among our subjects was 44 (standard deviation=34). All scores related to ETI performance were statistically equivalent across the two positions (performance score, number of attempts, time to intubation success, and ratings of difficulty and laryngeal view). We also observed no differences across levels of training. Conclusion The position of the in-hospital provider, whether seated or standing, had no effect on the provider’s ETI performance. Since environmental circumstances sometimes necessitate alternative positioning for effective ETI administration, our findings suggest that there may be value in training residents to perform ETI from both positions.
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Affiliation(s)
| | - Jason J Bischof
- The Ohio State University, Department of Emergency Medicine, Columbus, Ohio
| | - Andrew M King
- The Ohio State University, Department of Emergency Medicine, Columbus, Ohio
| | - Sarah Greenberger
- University of Arkansas for Medical Sciences College of Medicine, Department of Emergency Medicine, Little Rock, Arkansas
| | - David P Way
- The Ohio State University, Department of Emergency Medicine, Columbus, Ohio
| | - Ashish R Panchal
- The Ohio State University, Department of Emergency Medicine, Columbus, Ohio
| | | | - Thomas E Terndrup
- The Ohio State University, Department of Emergency Medicine, Columbus, Ohio
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Namboodri BL, Rosen T, Dayaa JA, Bischof JJ, Ramadan N, Patel MD, Grover J, Brice JH, Platts-Mills TF. Elder Abuse Identification in the Prehospital Setting: An Examination of State Emergency Medical Services Protocols. J Am Geriatr Soc 2018; 66:962-968. [PMID: 29566428 DOI: 10.1111/jgs.15329] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To describe statewide emergency medical service (EMS) protocols relating to identification, management, and reporting of elder abuse in the prehospital setting. DESIGN Cross-sectional analysis. SETTING Statewide EMS protocols in the United States. PARTICIPANTS Publicly available statewide EMS protocols identified from published literature, http://EMSprotocols.org, and each state's public health website. MEASUREMENTS Protocols were reviewed to determine whether elder abuse was mentioned, elder abuse was defined, potential indicators of elder abuse were listed, management of older adults experiencing abuse was described, and instructions regarding reporting were provided. EMS protocols for child abuse were reviewed in the same manner for the purpose of comparison. RESULTS Of the 35 publicly available statewide EMS protocols, only 14 (40.0%) mention elder abuse. Of protocols that mention elder abuse, 6 (42.9%) define elder abuse, 10 (71.4%) describe indicators of elder abuse, 8 (57.1%) provide instruction regarding management, and 12 (85.7%) provide instruction regarding reporting. Almost twice as many states met each of these metrics for child abuse. CONCLUSION Statewide EMS protocols for elder abuse vary in regard to identification, management, and reporting, with the majority of states having no content on this subject. Expansion and standardization of protocols may increase the identification of elder abuse.
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Affiliation(s)
- Brooke L Namboodri
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Tony Rosen
- Division of Emergency Medicine, New York-Presbyterian Hospital / Weill Cornell Medical College, New York, New York
| | - Joseph A Dayaa
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Jason J Bischof
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Nadeem Ramadan
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Mehul D Patel
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Joseph Grover
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Jane H Brice
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Timothy F Platts-Mills
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Finnerty NM, Panchal AR, Boulger C, Vira A, Bischof JJ, Amick C, Way DP, Bahner DP. Inferior Vena Cava Measurement with Ultrasound: What Is the Best View and Best Mode? West J Emerg Med 2017; 18:496-501. [PMID: 28435502 PMCID: PMC5391901 DOI: 10.5811/westjem.2016.12.32489] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [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: 09/15/2016] [Revised: 11/26/2016] [Accepted: 12/12/2016] [Indexed: 11/20/2022] Open
Abstract
Introduction Intravascular volume status is an important clinical consideration in the management of the critically ill. Point-of-care ultrasonography (POCUS) has gained popularity as a non-invasive means of intravascular volume assessment via examination of the inferior vena cava (IVC). However, there are limited data comparing different acquisition techniques for IVC measurement by POCUS. The goal of this evaluation was to determine the reliability of three IVC acquisition techniques for volume assessment: sub-xiphoid transabdominal long axis (LA), transabdominal short axis (SA), and right lateral transabdominal coronal long axis (CLA) (aka “rescue view”). Methods Volunteers were evaluated by three experienced emergency physician sonographers (EP). Gray scale (B-mode) and motion-mode (M-mode) diameters were measured and IVC collapsibility index (IVCCI) calculated for three anatomic views (LA, SA, CLA). For each IVC measurement, we calculated descriptive statistics, intra-class correlation coefficients (ICC), and two-way univariate analyses of variance. Results EPs evaluated 39 volunteers, yielding 351 total US measurements. Measurements of the three views had similar means (LA 1.9 ± 0.4cm; SA 1.9 ± 0.4cm; CLA 2.0 ± 0.5cm). For B-Mode, LA had the highest ICC (0.86, 95% CI [0.76–0.92]) while CLA had the poorest ICC (0.74, 95% CI [0.56–0.85]). ICCs for all M-mode IVCCI were low. Significant interaction effects between anatomical view and EP were observed for B-mode and M-mode measurements. Post-hoc analyses revealed difficulty in consistent view acquisition between EPs. Conclusion Inter-rater reliability of the IVC by EPs was highest for B-mode LA and poorest for all M-Mode IVC collapsibility indices (IVCCI). These results suggest that B-mode LA holds the most promise to deliver reliable measures of IVC diameter. Future studies may focus on validation in a clinical setting as well as comparison to a reference standard.
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Affiliation(s)
- Nathan M Finnerty
- The Ohio State University College of Medicine, Department of Emergency Medicine, Columbus, Ohio
| | - Ashish R Panchal
- The Ohio State University College of Medicine, Department of Emergency Medicine, Columbus, Ohio
| | - Creagh Boulger
- The Ohio State University College of Medicine, Department of Emergency Medicine, Columbus, Ohio
| | - Amar Vira
- The Ohio State University College of Medicine, Department of Emergency Medicine, Columbus, Ohio
| | - Jason J Bischof
- The Ohio State University College of Medicine, Department of Emergency Medicine, Columbus, Ohio
| | - Christopher Amick
- The Ohio State University College of Medicine, Department of Emergency Medicine, Columbus, Ohio
| | - David P Way
- The Ohio State University College of Medicine, Department of Emergency Medicine, Columbus, Ohio
| | - David P Bahner
- The Ohio State University College of Medicine, Department of Emergency Medicine, Columbus, Ohio
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McGrath JL, Bischof JJ, Greenberger S, Bachmann DJ, Way DP, Gorgas DL, Kman NE. 'Speed advising' for medical students applying to residency programs: an efficient supplement to traditional advising. Med Educ Online 2016; 21:31336. [PMID: 27056564 PMCID: PMC4824846 DOI: 10.3402/meo.v21.31336] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 03/16/2016] [Indexed: 05/14/2023]
Abstract
BACKGROUND Over time, Residency Match dynamics fluctuate with some specialties experiencing increases in medical student popularity. Academic departments with limited resources must devise methods for coping with increased demand for their specialty. Students perceive traditional programs on Match mechanics as inadequate. Subsequently, faculty are confronted with demands for more personal attention from more students. OBJECTIVES We developed a strategy for providing specialty-specific residency match advising to large numbers of students. METHODS The 'speed-advising' session (SAS) was developed to address the common questions and concerns that medical students pose during the Match process and to provide advisees with a breadth of faculty perspectives. Two SASs were offered over a 2-week period. After the sessions, students and faculty were surveyed regarding their experience. RESULTS Twenty-six students pursued our specialty in the 2015 Match (26 of 234, 11.1%). Twenty-three (89%) participated in the SAS. Seventy-four percent of students (17 of 23) and all faculty completed the post-session survey. Students found the SAS to be informative, helpful and an efficient use of time. Common discussion topics included: career goals, to which programs and how many to apply, and how academic record impacts their likelihood of matching in our specialty. Students would have preferred more time with each faculty; however, most (77%) conceded that their questions were adequately answered. Faculty-favored speed advising over traditional advising (86%), primarily due to estimated time savings of 7.3 h per faculty member. CONCLUSIONS In preparing students for the Match, specialty-specific speed advising offers an efficient supplement to traditional advising.
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Affiliation(s)
- Jillian L McGrath
- Department of Emergency Medicine, The Ohio State University College of Medicine, Columbus, OH, USA;
| | - Jason J Bischof
- Department of Emergency Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Sarah Greenberger
- Department of Emergency Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Daniel J Bachmann
- Department of Emergency Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - David P Way
- Department of Emergency Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Diane L Gorgas
- Department of Emergency Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Nicholas E Kman
- Department of Emergency Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
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Bischof JJ, Bell LL, Pierce JK, Cooper KL, Heine AD, Quinlivan EB, Gay CL. Detecting HIV among persons accompanying patients to an infectious diseases clinic. Sex Transm Dis 2015; 42:54-6. [PMID: 25504303 DOI: 10.1097/olq.0000000000000215] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Infectious diseases (ID) clinics are locations where members of at risk social networks, including sex partners of HIV-infected patients, make contact with a medical care setting when they accompany HIV-positive patients to appointments. METHODS We implemented a free point-of-care rapid HIV testing program for anyone accompanying a patient to the University of North Carolina ID clinic. Acceptability of the program among the general clinic population was assessed via an anonymous survey 1 year after program implementation. Basic frequencies of those who underwent and received results of rapid HIV testing, the proportion of positive rapid tests and confirmatory HIV tests performed, and the level of University of North Carolina ID clinic patient satisfaction with the HIV testing program were calculated. RESULTS Between October 2007 and June 2013, 450 (99.6%) of 452 individuals tested in the program received their results on the same day as testing. Twenty-two individuals (4.9%) tested HIV positive, of which 16 (72.7%) were newly positive, including 3 never previously tested. Excluding previously diagnosed individuals, HIV prevalence was 3.6% (16/446). Among those testing positive by rapid testing, 19 (86.4%) had confirmatory testing and immediately entered into HIV care at the clinic. CONCLUSIONS The high positivity and confirmatory HIV rates in our program confirm that the provision of rapid HIV testing in an ID clinic capitalizes on missed opportunities among an at-risk population and allows immediate linkage to care.
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Affiliation(s)
- Jason J Bischof
- From the Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Wang X, Pittman GS, Bandele OJ, Bischof JJ, Liu G, Brothers J, Spira A, Bell DA. Linking polymorphic p53 response elements with gene expression in airway epithelial cells of smokers and cancer risk. Hum Genet 2014; 133:1467-76. [PMID: 25179167 PMCID: PMC4225167 DOI: 10.1007/s00439-014-1483-8] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 08/25/2014] [Indexed: 01/22/2023]
Abstract
Chronic cigarette smoking exposes airway epithelial cells to thousands of carcinogens, oxidants and DNA-damaging agents, creating a field of molecular injury in the airway and altering gene expression. Studies of cytologically normal bronchial epithelial cells from smokers have identified transcription-based biomarkers that may prove useful in early diagnosis of lung cancer, including a number of p53-regulated genes. The ability of p53 to regulate transcription is critical for tumor suppression, and this suggests that single-nucleotide polymorphisms (SNPs) in functional p53 binding sites (p53 response elements, or p53REs) that affect gene expression could influence susceptibility to cancer. To connect p53RE SNP genotype with gene expression and cancer risk, we identified a set of 204 SNPs in putative p53REs, and performed cis expression quantitative trait loci (eQTL) analysis, assessing associations between SNP genotypes and mRNA levels of adjacent genes in bronchial epithelial cells obtained from 44 cigarette smokers. To further test and validate these genotype-expression associations, we searched published eQTL studies from independent populations and determined that 53% (39/74) of the bronchial epithelial eQTLs were observed in at least one of other studies. SNPs in p53REs were also evaluated for effects on p53-DNA binding using a quantitative in vitro protein-DNA binding assay. Last, based on linkage disequilibrium, we found 6 p53RE SNPs associated with gene expression were identified as cancer risk SNPs by either genome-wide association studies or candidate gene studies. We provide an approach for identifying and evaluating potentially functional SNPs that may modulate the airway gene expression response to smoking and may influence susceptibility to cancers.
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Affiliation(s)
- Xuting Wang
- Environmental Genomics Section, Laboratory of Molecular Genetics, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC 27709
| | - Gary S. Pittman
- Environmental Genomics Section, Laboratory of Molecular Genetics, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC 27709
| | - Omari J. Bandele
- Environmental Genomics Section, Laboratory of Molecular Genetics, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC 27709
| | - Jason J. Bischof
- Environmental Genomics Section, Laboratory of Molecular Genetics, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC 27709
| | - Gang Liu
- Section of Computational Biomedicine, Department of Medicine, Boston University, Boston, MA 02118
| | - John Brothers
- Section of Computational Biomedicine, Department of Medicine, Boston University, Boston, MA 02118
| | - Avrum Spira
- Section of Computational Biomedicine, Department of Medicine, Boston University, Boston, MA 02118
| | - Douglas A. Bell
- Environmental Genomics Section, Laboratory of Molecular Genetics, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC 27709
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Bischof JJ, Kuruc JD, Embry JA, Hatch JE, Ashton FA, Schmitz JL, Miller WC, Leone PA, Gay CL. Prospective study of the ARCHITECTHIV Ag/Ab Combo fourth generation assay to detect HIV infection in sexually transmitted infection clinics. AIDS 2011; 25:1927-9. [PMID: 21811138 DOI: 10.1097/qad.0b013e32834b40d1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This prospective, cross-sectional study of HIV testing at two sexually transmitted infection clinics compares testing results from the ARCHITECT HIV Ag/Ab Combo fourth generation assay against the current standard of care in North Carolina (third generation enzyme immunoassay testing with western blot confirmation and reflex nucleic acid amplification testing of pooled seronegative samples). In this setting, the assay reported a sensitivity of 100%, a specificity of 99.9%, and a median turn-around time of 26.1 h.
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Teotico DG, Bischof JJ, Peng L, Kliewer SA, Redinbo MR. Structural basis of human pregnane X receptor activation by the hops constituent colupulone. Mol Pharmacol 2008; 74:1512-20. [PMID: 18768384 PMCID: PMC2584763 DOI: 10.1124/mol.108.050732] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [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] [Indexed: 01/07/2023] Open
Abstract
Hops extracts are used to alleviate menopausal symptoms and as an alternative to hormone replacement therapy, but they can produce potentially harmful drug-drug interactions. The nuclear xenobiotic receptor pregnane X receptor (PXR) is promiscuously activated by a range of structurally distinct chemicals. It has a key role in the transcriptional regulation of genes that encode xenobiotic metabolism enzymes. In this study, hops extracts are shown to induce the expression of numerous drug metabolism and excretion proteins. The beta-bitter acid colupulone is demonstrated to be a bioactive component and direct activator of human PXR. The 2.8-A resolution crystal structure of the ligand binding domain of human PXR in complex with colupulone was elucidated, and colupulone was observed to bind in a single orientation stabilized by both van der Waals and hydrogen bonding contacts. The crystal structure also indicates that related alpha- and beta-bitter acids have the capacity to serve as PXR agonists as well. Taken together, these results reveal the structural basis for drug-drug interactions mediated by colupulone and related constituents of hops extracts.
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MESH Headings
- ATP Binding Cassette Transporter, Subfamily B
- ATP Binding Cassette Transporter, Subfamily B, Member 1/biosynthesis
- ATP Binding Cassette Transporter, Subfamily B, Member 1/genetics
- Aryl Hydrocarbon Hydroxylases/biosynthesis
- Binding Sites
- Crystallography, X-Ray
- Cyclohexanones/chemistry
- Cyclohexanones/pharmacology
- Cytochrome P-450 CYP2B6
- Cytochrome P-450 CYP3A/biosynthesis
- Hepatocytes/drug effects
- Hepatocytes/metabolism
- Humans
- Humulus
- In Vitro Techniques
- Oxidoreductases, N-Demethylating/biosynthesis
- Plant Extracts/chemistry
- Plant Extracts/pharmacology
- Pregnane X Receptor
- RNA, Messenger/biosynthesis
- Receptors, Steroid/agonists
- Receptors, Steroid/chemistry
- Up-Regulation
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Affiliation(s)
- Denise G Teotico
- Department of Chemistry, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-3290, USA.
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