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Weekes AJ, Davison J, Lupez K, Raper JD, Thomas AM, Cox CA, Esener D, Boyd JS, Nomura JT, Murphy K, Ockerse PM, Leech S, Johnson J, Abrams E, Kelly C, O'Connell NS. Quality of life 1 month after acute pulmonary embolism in emergency department patients. Acad Emerg Med 2023; 30:819-831. [PMID: 36786661 DOI: 10.1111/acem.14692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 01/30/2023] [Accepted: 02/07/2023] [Indexed: 02/15/2023]
Abstract
OBJECTIVE The Pulmonary Embolism Quality-of-Life (PEmb-QoL) questionnaire assesses quality of life (QoL) after pulmonary embolism (PE). We aimed to determine whether any clinical or pathophysiologic features of PE were associated with worse PEmb-QoL scores 1 month after PE. METHODS In this prospective multicenter registry, we conducted PEmb-QoL questionnaires. We determined differences in QoL domain scores for four primary variables: clinical deterioration (death, cardiac arrest, respiratory failure, hypotension requiring fluid bolus, catecholamine support, or new dysrhythmia), right ventricular dysfunction (RVD), PE risk stratification, and subsequent rehospitalization. For overall QoL score, we fit a multivariable regression model that included these four primary variables as independent variables. RESULTS Of 788 PE patients participating in QoL assessments, 156 (19.8%) had a clinical deterioration event, 236 (30.7%) had RVD of which 38 (16.1%) had escalated interventions. For those without and with clinical deterioration, social limitations had mean (±SD) scores of 2.07 (±1.27) and 2.36 (±1.47), respectively (p = 0.027). For intensity of complaints, mean (±SD) scores for patients without RVD (4.32 ± 2.69) were significantly higher than for those with RVD with or without reperfusion interventions (3.82 ± 1.81 and 3.83 ± 2.11, respectively; p = 0.043). There were no domain score differences between PE risk stratification groups. All domain scores were worse for patients with rehospitalization versus without. By multivariable analysis, worse total PEmb-QoL scores with effect sizes were subsequent rehospitalization 11.29 (6.68-15.89), chronic obstructive pulmonary disease (COPD) 8.17 (3.91-12.43), and longer index hospital length of stay 0.06 (0.03-0.08). CONCLUSIONS Acute clinical deterioration, RVD, and PE severity were not predictors of QoL at 1 month post-PE. Independent predictors of worsened QoL were rehospitalization, COPD, and index hospital length of stay.
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Affiliation(s)
- Anthony J Weekes
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Jillian Davison
- Department of Emergency Medicine, Orlando Health, Orlando, Florida, USA
| | - Kathryn Lupez
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, North Carolina, USA
- Department of Emergency Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Jaron D Raper
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, North Carolina, USA
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Alyssa M Thomas
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, North Carolina, USA
- Emergency Department, Houston Methodist Baytown Hospital, Houston, Texas, USA
| | - Carly A Cox
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, North Carolina, USA
- Emergency Medicine of Idaho, Meridian, Idaho, USA
| | - Dasia Esener
- Department of Emergency Medicine, Kaiser Permanente, San Diego, California, USA
| | - Jeremy S Boyd
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jason T Nomura
- Department of Emergency Medicine, Christiana Care, Newark, Delaware, USA
| | - Kathleen Murphy
- Department of Emergency Medicine, Christiana Care, Newark, Delaware, USA
| | - Patrick M Ockerse
- Department of Emergency Medicine, University of Utah Health, Salt Lake City, Utah, USA
| | - Stephen Leech
- Department of Emergency Medicine, Orlando Health, Orlando, Florida, USA
| | - Jakea Johnson
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Eric Abrams
- Department of Emergency Medicine, Kaiser Permanente, San Diego, California, USA
| | - Christopher Kelly
- Department of Emergency Medicine, University of Utah Health, Salt Lake City, Utah, USA
| | - Nathaniel S O'Connell
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
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Weekes AJ, Raper JD, Esener D, Davison J, Boyd JS, Kelly C, Nomura JT, Thomas AM, Lupez K, Cox CA, Ockerse PM, Leech S, Johnson J, Abrams E, Murphy K, O'Connell NS. Comparing predictive performance of pulmonary embolism risk stratification tools for acute clinical deterioration. J Am Coll Emerg Physicians Open 2023; 4:e12983. [PMID: 37251351 PMCID: PMC10214857 DOI: 10.1002/emp2.12983] [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: 01/06/2023] [Revised: 05/04/2023] [Accepted: 05/11/2023] [Indexed: 05/31/2023] Open
Abstract
Objectives Existing pulmonary embolism (PE) risk scores were developed to predict death within weeks, but not more proximate adverse events. We determined the ability of 3 PE risk stratification tools (simplified pulmonary embolism severity index [sPESI], 2019 European Society of Cardiology guidelines [ESC], and PE short-term clinical outcomes risk estimation [PE-SCORE]) to predict 5-day clinical deterioration after emergency department (ED) diagnosis of PE. Methods We analyzed data from six EDs on ED patients with confirmed PE. Clinical deterioration was defined as death, respiratory failure, cardiac arrest, new dysrhythmia, sustained hypotension requiring vasopressors or volume resuscitation, or escalated intervention within 5 days of PE diagnosis. We determined sensitivity and specificity of sPESI, ESC, and PE-SCORE for predicting clinical deterioration. Results Of 1569 patients, 24.5% had clinical deterioration within 5 days. sPESI, ESC, and PE-SCORE classifications were low-risk in 558 (35.6%), 167 (10.6%), and 309 (19.6%), respectively. Sensitivities of sPESI, ESC, and PE-SCORE for clinical deterioration were 81.8 (78, 85.7), 98.7 (97.6, 99.8), and 96.1 (94.2, 98), respectively. Specificities of sPESI, ESC, and PE-SCORE for clinical deterioration were 41.2 (38.4, 44), 13.7 (11.7, 15.6), and 24.8 (22.4, 27.3). Areas under the curve were 61.5 (59.1, 63.9), 56.2 (55.1, 57.3), and 60.5 (58.9, 62.0). Negative predictive values were 87.5 (84.7, 90.2), 97 (94.4, 99.6), and 95.1 (92.7, 97.5). Conclusions ESC and PE-SCORE were better than sPESI for detecting clinical deterioration within 5 days after PE diagnosis.
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Affiliation(s)
- Anthony J. Weekes
- Department of Emergency MedicineAtrium Health's Carolinas Medical CenterCharlotteNorth CarolinaUSA
| | - Jaron D. Raper
- Department of Emergency MedicineAtrium Health's Carolinas Medical CenterCharlotteNorth CarolinaUSA
- Present address:
Department of Emergency MedicineUniversity of Alabama at BirminghamBirminghamAlabama
| | - Dasia Esener
- Department of Emergency MedicineKaiser PermanenteSan DiegoCaliforniaUSA
| | - Jillian Davison
- Department of Emergency MedicineOrlando HealthOrlandoFloridaUSA
| | - Jeremy S. Boyd
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Christopher Kelly
- Department of Emergency MedicineUniversity of Utah HealthSalt Lake CityUtahUSA
| | - Jason T. Nomura
- Department of Emergency MedicineChristiana CareNewarkDelawareUSA
| | - Alyssa M. Thomas
- Department of Emergency MedicineAtrium Health's Carolinas Medical CenterCharlotteNorth CarolinaUSA
- Present address:
Emergency DepartmentHouston Methodist Baytown HospitalHoustonTexas
| | - Kathryn Lupez
- Department of Emergency MedicineAtrium Health's Carolinas Medical CenterCharlotteNorth CarolinaUSA
- Present address:
Department of Emergency MedicineTufts Medical CenterBostonMassachusetts
| | - Carly A. Cox
- Department of Emergency MedicineAtrium Health's Carolinas Medical CenterCharlotteNorth CarolinaUSA
- Present address:
Emergency Medicine of IdahoMeridianIdaho
| | - Patrick M. Ockerse
- Department of Emergency MedicineUniversity of Utah HealthSalt Lake CityUtahUSA
| | - Stephen Leech
- Department of Emergency MedicineOrlando HealthOrlandoFloridaUSA
| | - Jakea Johnson
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Eric Abrams
- Department of Emergency MedicineKaiser PermanenteSan DiegoCaliforniaUSA
| | - Kathleen Murphy
- Department of Emergency MedicineChristiana CareNewarkDelawareUSA
| | - Nathaniel S. O'Connell
- Department of Biostatistics and Data ScienceWake Forest University School of MedicineWinston‐SalemNorth CarolinaUSA
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Krenz JR, Medeiros K, Lupez K. Retrospective evaluation of ketamine versus droperidol on time to restraint removal in agitated emergency department patients. Am J Emerg Med 2023; 69:23-27. [PMID: 37031618 DOI: 10.1016/j.ajem.2023.03.058] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 03/27/2023] [Accepted: 03/29/2023] [Indexed: 04/05/2023] Open
Abstract
PURPOSE Acute agitation and violent behavior in the emergency department (ED) can lead to significant patient morbidity and contribute to the growing problem of workplace violence against health care providers. To our knowledge, there is no available literature directly comparing intramuscular ketamine to intramuscular droperidol in ED patients presenting with undifferentiated agitation. The purpose of this investigation was to compare the effectiveness and safety of these agents for acute agitation in the ED. METHODS This was a retrospective observational study conducted at an urban, academic ED. The primary endpoint was time from the first dose of study medication to restraint removal. Safety endpoints included incidence of bradycardia (heart rate < 60 bpm), hypotension (systolic blood pressure < 90 mmHg), hypoxia (oxygen saturation < 90% or need for respiratory support), and incidence of intubation for ongoing agitation or respiratory failure. RESULTS An initial 189 patients were screened, of which, 92 met inclusion criteria. The median time from initial drug administration to restraint removal was 49 min (IQR 30, 168) in the ketamine group and 43 min (IQR 30, 80) in the droperidol group (Median difference 6 min; 95% CI [-7, 26]). There was no significant difference in rates of bradycardia (3% vs 3%, 95% CI [-7%, 8%]), hypotension (0% vs 2%, 95% CI [-5%, 2%]), or hypoxia (7% vs 10%, 95% CI [-15%, 9%]) in the ketamine versus droperidol groups respectively. One patient in the ketamine group was intubated for ongoing agitation, and one patient in the droperidol group was intubated for respiratory failure. CONCLUSIONS Intramuscular droperidol and intramuscular ketamine were associated with similar times from drug administration to restraint removal in patients presenting to the ED with undifferentiated agitation. Prospective studies are warranted to evaluate IM droperidol and IM ketamine head-to-head as first line agents for acute agitation in the ED.
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Weekes AJ, Raper JD, Thomas AM, Lupez K, Cox CA, Esener D, Boyd JS, Nomura JT, Davison J, Ockerse PM, Leech S, Abrams E, Kelly C, O'Connell NS. Electrocardiographic findings associated with early clinical deterioration in acute pulmonary embolism. Acad Emerg Med 2022; 29:1185-1196. [PMID: 35748352 PMCID: PMC9796434 DOI: 10.1111/acem.14554] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 06/21/2022] [Accepted: 06/21/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVES We sought to determine associations of early electrocardiogram (ECG) patterns with clinical deterioration (CD) within 5 days and with RV abnormality (abnlRV) by echocardiography in pulmonary embolism (PE). METHODS In this prospective, multicenter study of newly confirmed PE patients, early echocardiography and initial ECG were examined. Initial ECG patterns included lead-specific ST-segment elevation (STE) or depression (STD), T-wave inversion (TWI), supraventricular tachycardia (SVT), sinus tachycardia, and right bundle branch block as complete (cRBBB) or incomplete (iRBBB). We defined CD as respiratory failure, hypotension, dysrhythmia, cardiac arrest, escalated PE intervention, or death within 5 days. We calculated odds ratios (ORs) for CD and abnlRV with univariate and full multivariate models in the presence of other variables. RESULTS Of 1676 patients, 1629 (97.2%) had both ECG and GDE; 415/1676 (24.7%) had CD, and 529/1629 (32.4%) had abnlRV. AbnlRV had an OR for CD of 4.25 (3.35, 5.38). By univariable analysis, the absence of abnormal ECG patterns had OR for CD and abnlRV of 0.34 (0.26, 0.44; p < 0.001) and 0.24 (0.18, 0.31; p < 0.001), respectively. By multivariable analyses, one ECG pattern had a significant OR for CD: SVT 2.87 (1.66, 5.00). Significant ORS for abnlRV were: TWI V2-4 4.0 (2.64, 6.12), iRBBB 2.63 (1.59, 4.38), STE aVR 2.42 (1.58, 3.74), S1-Q3-T3 2.42 (1.70, 3.47), and sinus tachycardia 1.68 (1.14, 2.49). CONCLUSIONS SVT was an independent predictor of CD. TWI V2-4 , iRBBB, STE aVR, sinus tachycardia, and S1-Q3-T3 were independent predictors of abnlRV. Finding one or more of these ECG patterns may increase considerations for performance of echocardiography to look for RV abnormalities and, if present, inform concerns for early clinical deterioration.
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Affiliation(s)
- Anthony J. Weekes
- Department of Emergency MedicineAtrium Health's Carolinas Medical Center (Carolinas Medical Center is the Central Site of the Pulmonary Embolism Short‐term Outcomes Registry (PESCOR) consortium)CharlotteNorth CarolinaUSA
| | - Jaron D. Raper
- Department of Emergency MedicineAtrium Health's Carolinas Medical Center (Carolinas Medical Center is the Central Site of the Pulmonary Embolism Short‐term Outcomes Registry (PESCOR) consortium)CharlotteNorth CarolinaUSA,Jaron D. Raper, Department of Emergency MedicineUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Alyssa M. Thomas
- Department of Emergency MedicineAtrium Health's Carolinas Medical Center (Carolinas Medical Center is the Central Site of the Pulmonary Embolism Short‐term Outcomes Registry (PESCOR) consortium)CharlotteNorth CarolinaUSA,Alyssa M. Thomas, Emergency DepartmentHouston Methodist Baytown HospitalHoustonTexasUSA
| | - Kathryn Lupez
- Department of Emergency MedicineAtrium Health's Carolinas Medical Center (Carolinas Medical Center is the Central Site of the Pulmonary Embolism Short‐term Outcomes Registry (PESCOR) consortium)CharlotteNorth CarolinaUSA,Kathryn Lupez, Department of Emergency MedicineTufts Medical CenterBostonMassachusettsUSA
| | - Carly A. Cox
- Department of Emergency MedicineAtrium Health's Carolinas Medical Center (Carolinas Medical Center is the Central Site of the Pulmonary Embolism Short‐term Outcomes Registry (PESCOR) consortium)CharlotteNorth CarolinaUSA,Carly A. Cox, Emergency Medicine of IdahoMeridianIdahoUSA
| | - Dasia Esener
- Department of Emergency Medicine Kaiser PermanenteSan DiegoCaliforniaUSA
| | - Jeremy S. Boyd
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Jason T. Nomura
- Department of Emergency MedicineChristiana CareNewarkDelawareUSA
| | - Jillian Davison
- Department of Emergency MedicineOrlando HealthOrlandoFloridaUSA
| | - Patrick M. Ockerse
- Division of Emergency MedicineUniversity of Utah HealthSalt Lake CityUtahUSA
| | - Stephen Leech
- Department of Emergency MedicineOrlando HealthOrlandoFloridaUSA
| | - Eric Abrams
- Department of Emergency Medicine Kaiser PermanenteSan DiegoCaliforniaUSA
| | - Christopher Kelly
- Division of Emergency MedicineUniversity of Utah HealthSalt Lake CityUtahUSA
| | - Nathaniel S. O'Connell
- Department of Biostatistics and Data ScienceWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
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Derr C, Shteyman A, Jackson SA, Lu Y, Campbell T, De Lucia A, Merritt R, Lupez K, Elkes J, Hansen A, Jelic T, DeRespino A, Grant A. Determination of Endovaginal Ultrasound Proficiency and Learning Curve Among Emergency Medicine Trainees. J Ultrasound Med 2022; 41:1741-1752. [PMID: 34698417 DOI: 10.1002/jum.15857] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 08/30/2021] [Accepted: 09/20/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES Performing and interpreting endovaginal ultrasound is an important skill used during the evaluation of obstetric and gynecologic emergencies. This study aims to describe the level of proficiency and confidence achieved after performing 25 endovaginal examinations. METHODS This is a prospective study at a single urban academic emergency department. Participants performed a minimum of 25 endovaginal ultrasounds under the supervision of a point-of-care ultrasound expert. Anatomical structures were identified by the expert under ultrasound prior to each session. Each examination was scored for agreement of findings between the participant and expert. The data were used to develop a performance curve identifying when proficiency was achieved, where experiential benefit diminished, and when participants felt confident. RESULTS A total of 1117 endovaginal ultrasound examinations were performed by 50 participants. Agreement after 25 examinations was highest (>95%) for probe insertion and preparation, bladder and uterus identification, and directionality. Agreement was lowest for identification of the ovaries (76%). Experiential benefit plateaus occurred earliest (10 exams) for preparation and insertion followed by bladder identification and directionality. Surprisingly, ovarian experiential benefit plateaued at 16 exams. Participant confidence improved overall and was lowest for the identification of ovaries and abnormal pelvic anatomy. CONCLUSIONS There is a significant learning curve when performing endovaginal ultrasound. Our data do not support the use of 25 examinations as a minimum standard for identification of the ovaries or abnormal ovarian pathology.
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Affiliation(s)
- Charlotte Derr
- Division of Emergency Medicine, University of South Florida Morsani College of Medicine, Tampa General Hospital, Tampa, FL, USA
| | - Alan Shteyman
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Saundra A Jackson
- Department of Emergency Medicine, Emergency Resources Group, Jacksonville, FL, USA
| | - Yuanyuan Lu
- Study Design and Data Analysis Center, University of South Florida Morsani College of Medicine, Knoxville, TN, USA
| | | | - Anthony De Lucia
- Department of Emergency Medicine, C.W. Bill Young Department of Veterans Affairs Medical Center, Bay Pines, FL, USA
| | - Raymond Merritt
- Division of Emergency Medicine, University of South Florida Morsani College of Medicine, Tampa General Hospital, Tampa, FL, USA
| | - Kathryn Lupez
- Department of Emergency Medicine, Tufts Medical Center, Boston, MA, USA
| | - Johnathon Elkes
- Division of Emergency Medicine, University of South Florida Morsani College of Medicine, Tampa General Hospital, Tampa, FL, USA
| | - Allyson Hansen
- Division of Emergency Medicine, University of South Florida Morsani College of Medicine, Tampa General Hospital, Tampa, FL, USA
| | - Tomislav Jelic
- Department of Emergency Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Allison DeRespino
- Department of Emergency Medicine, James A. Haley Veterans Hospital, Tampa, FL, USA
| | - Ashley Grant
- Department of Emergency Medicine, Florida State University College of Medicine, Sarasota Memorial Hospital, Sarasota, FL, USA
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Raper JD, Thomas AM, Lupez K, Cox CA, Esener D, Boyd JS, Nomura JT, Davison J, Ockerse PM, Leech S, Johnson J, Abrams E, Murphy K, Kelly C, O'Connell NS, Weekes AJ. Can right ventricular assessments improve triaging of low risk pulmonary embolism? Acad Emerg Med 2022; 29:835-850. [PMID: 35289978 DOI: 10.1111/acem.14484] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 01/21/2022] [Accepted: 02/21/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Identifying right ventricle (RV) abnormalities is important to stratifying pulmonary embolism (PE) severity. Disposition decisions are influenced by concerns about early deterioration. Triaging strategies, like the Simplified Pulmonary Embolism Severity Index (sPESI), do not include RV assessments as predictors or early deterioration as outcome(s). We aimed to (1) determine if RV assessment variables add prognostic accuracy for 5-day clinical deterioration in patients classified low risk by sPESI, and (2) determine the prognostic importance of RV assessments compared to other variables and to each other. METHODS We identified low risk sPESI patients (sPESI = 0) from a prospective PE registry. From a large field of candidate variables, we developed, and compared prognostic accuracy of, full and reduced random forest models (with and without RV assessment variables, respectively) on a validation database. We reported variable importance plots from full random forest and provided odds ratios for statistical inference of importance from multivariable logistic regression. Outcomes were death, cardiac arrest, hypotension, dysrhythmia, or respiratory failure within 5 days of PE. RESULTS Of 1736 patients, 610 (35.1%) were low risk by sPESI and 72 (11.8%) experienced early deterioration. Of the 610, RV abnormality was present in 157 (25.7%) by CT, 121 (19.8%) by echocardiography, 132 (21.6%) by natriuretic peptide, and 107 (17.5%) by troponin. For deterioration, the receiver operating characteristics for full and reduced random forest prognostic models were 0.80 (0.77-0.82) and 0.71 (0.68-0.73), respectively. RV assessments were the top four in the variable importance plot for the random forest model. Echocardiography and CT significantly increased predicted probability of 5-day clinical deterioration by the multivariable logistic regression. CONCLUSIONS A PE triaging strategy with RV imaging assessments had superior prognostic performance at classifying low risk for 5-day clinical deterioration versus one without.
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Affiliation(s)
- Jaron D. Raper
- Department of Emergency Medicine Atrium Health's Carolinas Medical Center Charlotte North Carolina USA
- Jaron D. RaperDepartment of Emergency Medicine University of Alabama at Birmingham Birmingham Alabama USA
| | - Alyssa M. Thomas
- Department of Emergency Medicine Atrium Health's Carolinas Medical Center Charlotte North Carolina USA
- Alyssa M. Thomas, Emergency Department Houston Methodist Baytown Hospital Houston Texas USA
| | - Kathryn Lupez
- Department of Emergency Medicine Atrium Health's Carolinas Medical Center Charlotte North Carolina USA
- Kathryn Lupez, Department of Emergency Medicine Tufts Medical Center Boston Massachusetts USA
| | - Carly A. Cox
- Department of Emergency Medicine Atrium Health's Carolinas Medical Center Charlotte North Carolina USA
- Carly A. Cox, Emergency Medicine of Idaho Meridian Idaho USA
| | - Dasia Esener
- Department of Emergency Medicine Kaiser Permanente San Diego California USA
| | - Jeremy S. Boyd
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville Tennessee USA
| | - Jason T. Nomura
- Department of Emergency Medicine Christiana Care Newark Delaware USA
| | - Jillian Davison
- Department of Emergency Medicine Orlando Health Orlando Florida USA
| | - Patrick M. Ockerse
- Division of Emergency Medicine University of Utah Health Salt Lake City Utah USA
| | - Stephen Leech
- Department of Emergency Medicine Orlando Health Orlando Florida USA
| | - Jakea Johnson
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville Tennessee USA
| | - Eric Abrams
- Department of Emergency Medicine Kaiser Permanente San Diego California USA
| | - Kathleen Murphy
- Department of Emergency Medicine Christiana Care Newark Delaware USA
| | - Christopher Kelly
- Division of Emergency Medicine University of Utah Health Salt Lake City Utah USA
| | - Nathaniel S. O'Connell
- Department of Biostatistics and Data Science Wake Forest School of Medicine Winston‐Salem North Carolina USA
| | - Anthony J. Weekes
- Department of Emergency Medicine Atrium Health's Carolinas Medical Center Charlotte North Carolina USA
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Weekes AJ, Raper JD, Lupez K, Thomas AM, Cox CA, Esener D, Boyd JS, Nomura JT, Davison J, Ockerse PM, Leech S, Johnson J, Abrams E, Murphy K, Kelly C, Norton HJ. Development and validation of a prognostic tool: Pulmonary embolism short-term clinical outcomes risk estimation (PE-SCORE). PLoS One 2021; 16:e0260036. [PMID: 34793539 PMCID: PMC8601564 DOI: 10.1371/journal.pone.0260036] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 10/29/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Develop and validate a prognostic model for clinical deterioration or death within days of pulmonary embolism (PE) diagnosis using point-of-care criteria. METHODS We used prospective registry data from six emergency departments. The primary composite outcome was death or deterioration (respiratory failure, cardiac arrest, new dysrhythmia, sustained hypotension, and rescue reperfusion intervention) within 5 days. Candidate predictors included laboratory and imaging right ventricle (RV) assessments. The prognostic model was developed from 935 PE patients. Univariable analysis of 138 candidate variables was followed by penalized and standard logistic regression on 26 retained variables, and then tested with a validation database (N = 801). RESULTS Logistic regression yielded a nine-variable model, then simplified to a nine-point tool (PE-SCORE): one point each for abnormal RV by echocardiography, abnormal RV by computed tomography, systolic blood pressure < 100 mmHg, dysrhythmia, suspected/confirmed systemic infection, syncope, medico-social admission reason, abnormal heart rate, and two points for creatinine greater than 2.0 mg/dL. In the development database, 22.4% had the primary outcome. Prognostic accuracy of logistic regression model versus PE-SCORE model: 0.83 (0.80, 0.86) vs. 0.78 (0.75, 0.82) using area under the curve (AUC) and 0.61 (0.57, 0.64) vs. 0.50 (0.39, 0.60) using precision-recall curve (AUCpr). In the validation database, 26.6% had the primary outcome. PE-SCORE had AUC 0.77 (0.73, 0.81) and AUCpr 0.63 (0.43, 0.81). As points increased, outcome proportions increased: a score of zero had 2% outcome, whereas scores of six and above had ≥ 69.6% outcomes. In the validation dataset, PE-SCORE zero had 8% outcome [no deaths], whereas all patients with PE-SCORE of six and above had the primary outcome. CONCLUSIONS PE-SCORE model identifies PE patients at low- and high-risk for deterioration and may help guide decisions about early outpatient management versus need for hospital-based monitoring.
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Affiliation(s)
- Anthony J. Weekes
- Department of Emergency Medicine, Atrium Health’s Carolinas Medical Center, Charlotte, NC, United States of America
| | - Jaron D. Raper
- Department of Emergency Medicine, Atrium Health’s Carolinas Medical Center, Charlotte, NC, United States of America
| | - Kathryn Lupez
- Department of Emergency Medicine, Atrium Health’s Carolinas Medical Center, Charlotte, NC, United States of America
| | - Alyssa M. Thomas
- Department of Emergency Medicine, Atrium Health’s Carolinas Medical Center, Charlotte, NC, United States of America
| | - Carly A. Cox
- Department of Emergency Medicine, Atrium Health’s Carolinas Medical Center, Charlotte, NC, United States of America
| | - Dasia Esener
- Department of Emergency Medicine, Kaiser Permanente, San Diego, CA, United States of America
| | - Jeremy S. Boyd
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Jason T. Nomura
- Department of Emergency Medicine, Christiana Care, Newark, DE, United States of America
| | - Jillian Davison
- Department of Emergency Medicine, Orlando Health, Orlando, FL, United States of America
| | - Patrick M. Ockerse
- Division of Emergency Medicine, University of Utah Health, Salt Lake City, UT, United States of America
| | - Stephen Leech
- Department of Emergency Medicine, Orlando Health, Orlando, FL, United States of America
| | - Jakea Johnson
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Eric Abrams
- Department of Emergency Medicine, Kaiser Permanente, San Diego, CA, United States of America
| | - Kathleen Murphy
- Department of Emergency Medicine, Christiana Care, Newark, DE, United States of America
| | - Christopher Kelly
- Division of Emergency Medicine, University of Utah Health, Salt Lake City, UT, United States of America
| | - H. James Norton
- Professor Emeritus of Biostatistics, Atrium Health’s Carolinas Medical Center, Charlotte, NC, United States of America
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PESCOR Steering Committee, Raper J, Thomas A, Lupez K, Cox C, Esener D, Boyd J, Nomura J, Davison J, Ockerse P, Leech S, Weekes A. 269 Added Prognostic Value of Right Ventricular Dysfunction Assessments. Ann Emerg Med 2021. [DOI: 10.1016/j.annemergmed.2021.09.282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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PESCOR Steering Committee, Weekes A, Raper J, Lupez K, Cox C, Thomas A, Esener D, Boyd J, Nomura J, Davison J, Ockerse P, Leech S. 267 Development and Validation of a Prognostic Tool: Pulmonary Embolism Short-Term Clinical Outcomes Risk Estimation. Ann Emerg Med 2021. [DOI: 10.1016/j.annemergmed.2021.09.280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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UNEQUAL Crisis Study Group, Manchanda E, Marshall A, Erfani P, Olufadeji A, Otugo O, Nelson E, Jacquet G, Lupez K, Vogel L, Janneck L, Samuels-Kalow M. 263 UNderstanding EQUity in Crisis Standards of Care (the UNEQUAL Crisis Study). Ann Emerg Med 2021. [PMCID: PMC8536262 DOI: 10.1016/j.annemergmed.2021.09.276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Lupez K, Allen B, Fox S, Lewis M. Beware of the Zebra: Nine-year-old with Fever. Clin Pract Cases Emerg Med 2019; 3:185-190. [PMID: 31403091 PMCID: PMC6682242 DOI: 10.5811/cpcem.2019.5.42119] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 04/29/2019] [Accepted: 05/16/2019] [Indexed: 11/24/2022] Open
Abstract
An otherwise healthy nine-year-old female who spoke only French presented with abdominal pain, vomiting, intermittent fevers, fatigue, and headache. She then quickly became febrile and altered requiring intubation. When treating a healthy child, the physician may initially develop a differential that includes common illnesses. Yet, as emergency medicine providers, we must be thinking about the “zebras” in order to not miss potentially deadly, curable diseases.
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Affiliation(s)
- Kathryn Lupez
- Carolinas Medical Center, Department of Emergency Medicine, Charlotte, North Carolina
| | - Bryant Allen
- Carolinas Medical Center, Department of Emergency Medicine, Charlotte, North Carolina
| | - Sean Fox
- Carolinas Medical Center, Department of Emergency Medicine, Charlotte, North Carolina
| | - Margaret Lewis
- Carolinas Medical Center, Department of Emergency Medicine, Charlotte, North Carolina
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Zaidi AA, Dixon J, Lupez K, De Vries S, Wallis LA, Ginde A, Mould-Millman NK. The burden of trauma at a district hospital in the Western Cape Province of South Africa. Afr J Emerg Med 2019; 9:S14-S20. [PMID: 31073509 PMCID: PMC6497867 DOI: 10.1016/j.afjem.2019.01.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [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: 07/29/2018] [Revised: 10/19/2018] [Accepted: 01/05/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Sub-Saharan Africa bears a disproportionate burden of mortality from trauma. District hospitals, although not trauma centres, play a critical role in the trauma care system by serving as frontline hospitals. However, the clinical characteristics of patients receiving trauma care in African district hospitals remains under-described and is a barrier to trauma care system development. We aim to describe the burden of trauma at district hospitals by analysing trauma patients at a prototypical district hospital emergency centre. METHODS An observational study was conducted in August, 2014 at Wesfleur Hospital, a district facility in the Western Cape Province of South Africa. Data were manually collected from a paper registry for all patients visiting the emergency centre. Patients with trauma were selected for further analysis. RESULTS Of 3299 total cases, 565 (17.1%) presented with trauma, of which 348 (61.6%) were male. Of the trauma patients, 256 (47.6%) were ages 18-34 and 298 (52.7%) presented on the weekend. Intentional injuries (assault, stab wounds, and gunshot wounds) represented 251 (44.4%) cases of trauma. There were 314 (55.6%) cases of injuries that were unintentional, including road traffic injuries. There were 144 (60%) intentionally injured patients that arrived overnight (7pm-7am). Patients with intentional injuries were three times more likely to be transferred (to higher levels of care) or admitted than patients with unintentional injuries. CONCLUSION This district hospital emergency centre, with a small complement of non-EM trained physicians and no trauma surgical services, cared for a high volume of trauma with over half presenting on weekends and overnight when personnel are limited. The high volume and rate of admission/ transfer of intentional injuries suggests the need for improving prehospital trauma triage and trauma referrals. The results suggest strengthening trauma care systems at and around this resource-limited district hospital in South Africa may help alleviate the high burden of post-trauma morbidity and mortality.
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Affiliation(s)
- Ali A. Zaidi
- Indiana University, School of Medicine, Department of Emergency Medicine, Indianapolis, IN, United States
| | - Julia Dixon
- University of Colorado, School of Medicine, Department of Emergency Medicine, Aurora, CO, United States
| | - Kathryn Lupez
- Carolinas Medical Center, Department of Emergency Medicine, Charlotte, NC, United States
| | - Shaheem De Vries
- Western Cape Government EMS, Bellville, Western Cape Province, South Africa
| | - Lee A. Wallis
- University of Cape Town, Division of Emergency Medicine, Cape Town, Western Cape Province, South Africa
- Western Cape Government EMS, Bellville, Western Cape Province, South Africa
| | - Adit Ginde
- University of Colorado, School of Medicine, Department of Emergency Medicine, Aurora, CO, United States
| | - Nee-Kofi Mould-Millman
- University of Colorado, School of Medicine, Department of Emergency Medicine, Aurora, CO, United States
- University of Cape Town, Division of Emergency Medicine, Cape Town, Western Cape Province, South Africa
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