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Early Career Outcomes of Family Medicine Residency Graduates Exposed to Innovative Flexible Longitudinal Tracks.

Daniel Casey, MD - Wed, 01/30/2019 - 08:17
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Early Career Outcomes of Family Medicine Residency Graduates Exposed to Innovative Flexible Longitudinal Tracks.

Fam Med. 2017 May;49(5):353-360

Authors: Young RA, Casey D, Singer D, Waller E, Carney PA

Abstract
BACKGROUND AND OBJECTIVES: The Preparing the Personal Physician for Practice (P4) project used a case series design to study innovations in the content, length, structure, and location of residency training in 14 geographically diverse family medicine programs between 2007 and 2012. We aimed to explore how offering flexible longitudinal tracks (FLT) affected graduates' scope of practice, particularly in maternal child health (MCH), which included at least 17 months of focused training that increased each year over 4 years.
METHODS: We administered a cross-sectional survey to graduates of P4 residencies approximately 18 months after they completed training (2011-2014) and compared graduates of the John Peter Smith (JPS) Family Medicine Residency MCH FLT to all other P4 graduates.
RESULTS: The overall response rate was 81.8% (365/446). JPS graduates who completed the flexible MCH track (n=15) compared to all other P4 graduates (n=332) were more likely to deliver babies (13/15, 86.7% versus 48/324, 14.6%) and perform C-sections as the primary surgeon (12/15, 80.0% versus 15/322, 4.7%). Additional areas of expanded scope associated with the MCH track included endoscopy (4/15, 26.7% versus 10/323, 3.1%), the care of hospitalized adults and associated procedures (central lines, eg: 8/15, 53.3% versus 47/322, 14.6%), and the care of hospitalized children (13/15, 86.7% versus 111/323, 34.4%).
CONCLUSIONS: Graduating from the JPS MCH FLT was associated with a higher provision of maternal, child, and ill adult patient care services, including associated procedures.

PMID: 28535315 [PubMed - indexed for MEDLINE]

Predictors of early versus late mortality in pelvic trauma patients.

Dahlia Hassani, MD - Wed, 01/30/2019 - 08:17
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Predictors of early versus late mortality in pelvic trauma patients.

Scand J Trauma Resusc Emerg Med. 2016 Mar 10;24:27

Authors: Wang H, Robinson RD, Moore B, Kirk AJ, Phillips JL, Umejiego J, Chukwuma J, Miller T, Hassani D, Zenarosa NR

Abstract
BACKGROUND: Risks of predicting time-related in-hospital mortality varies in pelvic trauma patients. We aim to identify potential independent risks predictive of time-related (early versus late) mortality among pelvic trauma patients.
METHODS: Local trauma registry data from 2004 through 2013 were reviewed. Mortality causes and timing of death were investigated. Multivariate logistic regression identified independent risks predictive of early versus late mortality in pelvic trauma patients while adjusting for patient demographics (age, sex, race), clinical variables (initial vital signs, mental status, injury severity, associated injuries, comorbidities), and hospital outcomes (surgical interventions, crystalloid resuscitations, blood transfusions).
RESULTS: We retrospectively collected data on 1566 pelvic trauma patients with a mortality rate of 9.96% (156/1566). Approximately 74% of patients died from massive hemorrhage within the first 24 h of hospitalization (early mortality). Revised trauma score (RTS), injury severity score (ISS), initial hemoglobin, direct transfer to operating room, and blood transfusion administration in the Emergency Department were considered independent risk factors predictive of early mortality. Age, ISS, and Glasgow Coma Scale (GCS) were deemed risk factors predictive of death after 24 h (late mortality).
DISCUSSION: Given the fact of a substantial number of patients died within the first 24 h of hospital arrival, it is reasonable to consider the first 24 h of hospitalization as the appropriate window within which early mortality may be expected to occur in pelvic trauma patients. The risk factors associated with massive hemorrhage were strong predictors of early mortality, whereas late mortality predictors were more closely linked with comorbidities or in-hospital complications.
CONCLUSIONS: While risk factors predictive of early versus late mortality vary, ISS seems to predict both early and late mortality accurately in pelvic trauma patients.

PMID: 26964737 [PubMed - indexed for MEDLINE]

Modeling the Cost-Effectiveness of Interventions to Reduce Suicide Risk Among Hospital Emergency Department Patients.

Cynthia Claassen, PhD - Wed, 01/30/2019 - 08:16
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Modeling the Cost-Effectiveness of Interventions to Reduce Suicide Risk Among Hospital Emergency Department Patients.

Psychiatr Serv. 2018 Jan 01;69(1):23-31

Authors: Denchev P, Pearson JL, Allen MH, Claassen CA, Currier GW, Zatzick DF, Schoenbaum M

Abstract
OBJECTIVE: This study estimated the expected cost-effectiveness and population impact of outpatient interventions to reduce suicide risk among patients presenting to general hospital emergency departments (EDs), compared with usual care. Several such interventions have been found efficacious, but none is yet widespread, and the cost-effectiveness of population-based implementation is unknown.
METHODS: Modeled cost-effectiveness analysis compared three ED-initiated suicide prevention interventions previously found to be efficacious-follow-up via postcards or caring letters, follow-up via telephone outreach, and suicide-focused cognitive-behavioral therapy (CBT)-with usual care. Primary outcomes were treatment costs, suicides, and life-years saved, evaluated over the year after the index ED visit.
RESULTS: Compared with usual care, adding postcards improved outcomes and reduced costs. Adding telephone outreach and suicide-focused CBT, respectively, improved outcomes at a mean incremental cost of $4,300 and $18,800 per life-year saved, respectively. Monte Carlo simulation (1,000 repetitions) revealed the chance of incremental cost-effectiveness to be a certainty for all three interventions, assuming societal willingness to pay ≥$50,000 per life-year. These main findings were robust to various sensitivity analyses, including conservative assumptions about effect size and incremental costs. Population impact was limited by low sensitivity of detecting ED patients' suicide risk, and health care delivery inefficiencies.
CONCLUSIONS: The highly favorable cost-effectiveness found for each outpatient intervention provides a strong basis for widespread implementation of any or all of the interventions. The estimated population benefits of doing so would be enhanced by increasing the sensitivity of suicide risk detection among individuals presenting to general hospital EDs.

PMID: 28945181 [PubMed - in process]

Temporal Association Between Nonfatal Self-Directed Violence and Tree and Grass Pollen Counts.

Cynthia Claassen, PhD - Wed, 01/30/2019 - 08:16
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Temporal Association Between Nonfatal Self-Directed Violence and Tree and Grass Pollen Counts.

J Clin Psychiatry. 2016 Sep;77(9):1160-1167

Authors: Jeon-Slaughter H, Claassen CA, Khan DA, Mihalakos P, Lee KB, Brown ES

Abstract
OBJECTIVES: Prior research suggests a possible association between pollen and suicide. No studies have examined the relationship between pollen and attempted suicide. This study examines the temporal association between airborne pollen counts and nonfatal suicidal and nonsuicidal self-directed violence (SDV) requiring an emergency department visit.
METHODS: Data on daily emergency department visits due to nonfatal SDV as identified by ICD-9 diagnosis criteria were extracted from emergency department medical records of Parkland Memorial Hospital in Dallas, Texas, between January 2000 and December 2003. Concurrent daily airborne tree, grass, and ragweed pollen data from the city of Dallas were extracted from the National Allergy Bureau online database. The data were analyzed using the time series method of generalized autoregressive conditional heteroskedasticity.
RESULTS: There were statistically significant and positive temporal associations between tree pollen counts and the number of nonfatal SDV events among women (P = .04) and between grass pollen counts and number of nonfatal SDV events among both men (P = .03) and women (P < .0001). There was no significant temporal association found between ragweed pollen counts and number of nonfatal SDV events.
CONCLUSIONS: The study findings suggest that an increase in nonfatal SDV is associated with changes in tree and grass pollen counts. This is the first study that has examined an association between seasonal variation in tree and grass pollen levels and nonfatal SDV event data. The study also used a narrowly defined geographic area and temporal window. The findings suggest that pollen count may be a factor influencing seasonal patterns in suicidal behavior.

PMID: 27314288 [PubMed - indexed for MEDLINE]

Prognostic models to detect and monitor the near-term risk of suicide: state of the science.

Cynthia Claassen, PhD - Wed, 01/30/2019 - 08:16
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Prognostic models to detect and monitor the near-term risk of suicide: state of the science.

Am J Prev Med. 2014 Sep;47(3 Suppl 2):S181-5

Authors: Claassen CA, Harvilchuck-Laurenson JD, Fawcett J

Abstract
Aspirational Goal 3 of the National Action Alliance for Suicide Prevention's Research Prioritization Task Force research agenda is to "find ways to assess who is at risk for attempting suicide in the immediate future." Suicide risk assessment is the practice of detecting patient-level conditions that may rapidly progress toward suicidal acts. With hundreds of thousands of risk assessments occurring every year, this single activity arguably represents the most broadly implemented, sustained suicide prevention activity practiced in the U.S. Given this scope of practice, accurate and reliable risk assessment capabilities hold a central and irreplaceable position among interventions mounted as part of any public health approach to suicide prevention. Development of more reliable methods to detect and measure the likelihood of impending suicidal behaviors, therefore, represents one of the more substantial advancements possible in suicide prevention science today. Although past "second-generation" risk models using largely static risk factors failed to show predictive capabilities, the current "third-generation" dynamic risk prognostic models have shown initial promise. Methodologic improvements to these models include the advent of real-time, in vivo data collection processes, common data elements across studies and data sharing to build knowledge around key factors, and analytic methods designed to address rare event outcomes. Given the critical need for improved risk detection, these promising recent developments may well foreshadow advancement toward eventual achievement of this Aspirational Goal.

PMID: 25145737 [PubMed - indexed for MEDLINE]

Introduction to the Suicide Prevention Research Prioritization Task Force special supplement: the topic experts.

Cynthia Claassen, PhD - Wed, 01/30/2019 - 08:16
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Introduction to the Suicide Prevention Research Prioritization Task Force special supplement: the topic experts.

Am J Prev Med. 2014 Sep;47(3 Suppl 2):S102-5

Authors: Pearson JL, Claassen CA, Booth CL, Research Prioritization Task Force of the National Action Alliance for Suicide Prevention

PMID: 25145726 [PubMed - indexed for MEDLINE]

Reducing the burden of suicide in the U.S.: the aspirational research goals of the National Action Alliance for Suicide Prevention Research Prioritization Task Force.

Cynthia Claassen, PhD - Wed, 01/30/2019 - 08:16
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Reducing the burden of suicide in the U.S.: the aspirational research goals of the National Action Alliance for Suicide Prevention Research Prioritization Task Force.

Am J Prev Med. 2014 Sep;47(3):309-14

Authors: Claassen CA, Pearson JL, Khodyakov D, Satow PM, Gebbia R, Berman AL, Reidenberg DJ, Feldman S, Molock S, Carras MC, Lento RM, Sherrill J, Pringle B, Dalal S, Insel TR

Abstract
BACKGROUND: The National Action Alliance for Suicide Prevention Research Prioritization Task Force (RPTF) has created a prioritized national research agenda with the potential to rapidly and substantially reduce the suicide burden in the U.S. if fully funded and implemented.
PURPOSE: Viable, sustainable scientific research agendas addressing challenging public health issues such as suicide often need to incorporate perspectives from multiple stakeholder groups (e.g., researchers, policymakers, and other end-users of new knowledge) during an agenda-setting process. The Stakeholder Survey was a web-based survey conducted and analyzed in 2011-2012 to inform the goal-setting step in the RPTF agenda development process. The survey process, and the final list of "aspirational" research goals it produced, are presented here.
METHODS: Using a modified Delphi process, diverse constituent groups generated and evaluated candidate research goals addressing pressing suicide prevention research needs.
RESULTS: A total of 716 respondents representing 49 U.S. states and 18 foreign countries provided input that ultimately produced 12 overarching, research-informed aspirational goals aimed at reducing the U.S. suicide burden. Highest-rated goals addressed prevention of subsequent suicidal behavior after an initial attempt, strategies to retain patients in care, improved healthcare provider training, and generating care models that would ensure accessible treatment.
CONCLUSIONS: The Stakeholder Survey yielded widely valued research targets. Findings were diverse in focus, type, and current phase of research development but tended to prioritize practical solutions over theoretical advancement. Other complex public health problems requiring input from a broad-based constituency might benefit from web-based tools that facilitate such community input.

PMID: 24750971 [PubMed - indexed for MEDLINE]

Combination of tolfenamic acid and curcumin induces colon cancer cell growth inhibition through modulating specific transcription factors and reactive oxygen species.

Christopher Jordan, DO - Wed, 01/30/2019 - 08:16
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Combination of tolfenamic acid and curcumin induces colon cancer cell growth inhibition through modulating specific transcription factors and reactive oxygen species.

Oncotarget. 2016 Jan 19;7(3):3186-200

Authors: Sankpal UT, Nagaraju GP, Gottipolu SR, Hurtado M, Jordan CG, Simecka JW, Shoji M, El-Rayes B, Basha R

Abstract
Curcumin (Cur) has been extensively studied in several types of malignancies including colorectal cancer (CRC); however its clinical application is greatly affected by low bioavailability. Several strategies to improve the therapeutic response of Cur are being pursued, including its combination with small molecules and drugs. We investigated the therapeutic efficacy of Cur in combination with the small molecule tolfenamic acid (TA) in CRC cell lines. TA has been shown to inhibit the growth of human cancer cells in vitro and in vivo, via targeting the transcription factor specificity protein1 (Sp1) and suppressing survivin expression. CRC cell lines HCT116 and HT29 were treated with TA and/or Cur and cell viability was measured 24-72 hours post-treatment. While both agents caused a steady reduction in cell viability, following a clear dose/ time-dependent response, the combination of TA+Cur showed higher growth inhibition when compared to either single agent. Effects on apoptosis were determined using flow cytometry (JC-1 staining to measure mitochondrial membrane potential), Western blot analysis (c-PARP expression) and caspase 3/7 activity. Reactive oxygen species (ROS) levels were measured by flow cytometry and the translocation of NF-kB into the nucleus was determined using immunofluorescence. Results showed that apoptotic markers and ROS activity were significantly upregulated following combination treatment, when compared to the individual agents. This was accompanied by decreased expression of Sp1, survivin and NF-kB translocation. The combination of TA+Cur was more effective in HCT116 cells than HT29 cells. These results demonstrate that TA may enhance the anti-proliferative efficacy of Cur in CRC cells.

PMID: 26672603 [PubMed - indexed for MEDLINE]

The role of patient perception of crowding in the determination of real-time patient satisfaction at Emergency Department.

Chet Schrader, MD - Wed, 01/30/2019 - 08:15
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The role of patient perception of crowding in the determination of real-time patient satisfaction at Emergency Department.

Int J Qual Health Care. 2017 Oct 01;29(5):722-727

Authors: Wang H, Kline JA, Jackson BE, Robinson RD, Sullivan M, Holmes M, Watson KA, Cowden CD, Phillips JL, Schrader CD, Leuck J, Zenarosa NR

Abstract
Objective: To evaluate the associations between real-time overall patient satisfaction and Emergency Department (ED) crowding as determined by patient percepton and crowding estimation tool score in a high-volume ED.
Design: A prospective observational study.
Setting: A tertiary acute hospital ED and a Level 1 trauma center.
Participants: ED patients.
Intervention(s): Crowding status was measured by two crowding tools [National Emergency Department Overcrowding Scale (NEDOCS) and Severely overcrowded-Overcrowded-Not overcrowded Estimation Tool (SONET)] and patient perception of crowding surveys administered at discharge.
Main outcome measure(s): ED crowding and patient real-time satisfaction.
Results: From 29 November 2015 through 11 January 2016, we enrolled 1345 participants. We observed considerable agreement between the NEDOCS and SONET assessment of ED crowding (bias = 0.22; 95% limits of agreement (LOAs): -1.67, 2.12). However, agreement was more variable between patient perceptions of ED crowding with NEDOCS (bias = 0.62; 95% LOA: -5.85, 7.09) and SONET (bias = 0.40; 95% LOA: -5.81, 6.61). Compared to not overcrowded, there were overall inverse associations between ED overcrowding and patient satisfaction (Patient perception OR = 0.49, 95% confidence limit (CL): 0.38, 0.63; NEDOCS OR = 0.78, 95% CL: 0.65, 0.95; SONET OR = 0.82, 95% CL: 0.69, 0.98).
Conclusions: While heterogeneity exists in the degree of agreement between objective and patient perceived assessments of ED crowding, in our study we observed that higher degrees of ED crowding at admission might be associated with lower real-time patient satisfaction.

PMID: 28992161 [PubMed - indexed for MEDLINE]

Optimal Measurement Interval for Emergency Department Crowding Estimation Tools.

Chet Schrader, MD - Wed, 01/30/2019 - 08:15
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Optimal Measurement Interval for Emergency Department Crowding Estimation Tools.

Ann Emerg Med. 2017 Nov;70(5):632-639.e4

Authors: Wang H, Ojha RP, Robinson RD, Jackson BE, Shaikh SA, Cowden CD, Shyamanand R, Leuck J, Schrader CD, Zenarosa NR

Abstract
STUDY OBJECTIVE: Emergency department (ED) crowding is a barrier to timely care. Several crowding estimation tools have been developed to facilitate early identification of and intervention for crowding. Nevertheless, the ideal frequency is unclear for measuring ED crowding by using these tools. Short intervals may be resource intensive, whereas long ones may not be suitable for early identification. Therefore, we aim to assess whether outcomes vary by measurement interval for 4 crowding estimation tools.
METHODS: Our eligible population included all patients between July 1, 2015, and June 30, 2016, who were admitted to the JPS Health Network ED, which serves an urban population. We generated 1-, 2-, 3-, and 4-hour ED crowding scores for each patient, using 4 crowding estimation tools (National Emergency Department Overcrowding Scale [NEDOCS], Severely Overcrowded, Overcrowded, and Not Overcrowded Estimation Tool [SONET], Emergency Department Work Index [EDWIN], and ED Occupancy Rate). Our outcomes of interest included ED length of stay (minutes) and left without being seen or eloped within 4 hours. We used accelerated failure time models to estimate interval-specific time ratios and corresponding 95% confidence limits for length of stay, in which the 1-hour interval was the reference. In addition, we used binomial regression with a log link to estimate risk ratios (RRs) and corresponding confidence limit for left without being seen.
RESULTS: Our study population comprised 117,442 patients. The time ratios for length of stay were similar across intervals for each crowding estimation tool (time ratio=1.37 to 1.30 for NEDOCS, 1.44 to 1.37 for SONET, 1.32 to 1.27 for EDWIN, and 1.28 to 1.23 for ED Occupancy Rate). The RRs of left without being seen differences were also similar across intervals for each tool (RR=2.92 to 2.56 for NEDOCS, 3.61 to 3.36 for SONET, 2.65 to 2.40 for EDWIN, and 2.44 to 2.14 for ED Occupancy Rate).
CONCLUSION: Our findings suggest limited variation in length of stay or left without being seen between intervals (1 to 4 hours) regardless of which of the 4 crowding estimation tools were used. Consequently, 4 hours may be a reasonable interval for assessing crowding with these tools, which could substantially reduce the burden on ED personnel by requiring less frequent assessment of crowding.

PMID: 28688771 [PubMed - indexed for MEDLINE]

Chest Pain Risk Scores Can Reduce Emergent Cardiac Imaging Test Needs With Low Major Adverse Cardiac Events Occurrence in an Emergency Department Observation Unit.

Chet Schrader, MD - Wed, 01/30/2019 - 08:15
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Chest Pain Risk Scores Can Reduce Emergent Cardiac Imaging Test Needs With Low Major Adverse Cardiac Events Occurrence in an Emergency Department Observation Unit.

Crit Pathw Cardiol. 2016 12;15(4):145-151

Authors: Wang H, Watson K, Robinson RD, Domanski KH, Umejiego J, Hamblin L, Overstreet SE, Akin AM, Hoang S, Shrivastav M, Collyer M, Krech RN, Schrader CD, Zenarosa NR

Abstract
OBJECTIVE: To compare and evaluate the performance of the HEART, Global Registry of Acute Coronary Events (GRACE), and Thrombolysis in Myocardial Infarction (TIMI) scores to predict major adverse cardiac event (MACE) rates after index placement in an emergency department observation unit (EDOU) and to determine the need for observation unit initiation of emergent cardiac imaging tests, that is, noninvasive cardiac stress tests and invasive coronary angiography.
METHODS: A prospective observational single center study was conducted from January 2014 through June 2015. EDOU chest pain patients were included. HEART, GRACE, and TIMI scores were categorized as low (HEART ≤ 3, GRACE ≤ 108, and TIMI ≤1) versus elevated based on thresholds suggested in prior studies. Patients were followed for 6 months postdischarge. The results of emergent cardiac imaging tests, EDOU length of stay (LOS), and MACE occurrences were compared. Student t test was used to compare groups with continuous data, and χ testing was used for categorical data analysis.
RESULTS: Of 986 patients, emergent cardiac imaging tests were performed on 62%. A majority of patients were scored as low risk by all tools (85% by HEART, 81% by GRACE, and 80% by TIMI, P < 0.05). The low-risk patients had few abnormal cardiac imaging test results as compared with patients scored as intermediate to high risk (1% vs. 11% in HEART, 1% vs. 9% in TIMI, and 2% vs. 4% in GRACE, P < 0.05). The average LOS was 33 hours for patients with emergent cardiac imaging tests performed and 25 hours for patients without (P < 0.05). MACE occurrence rate demonstrated no significant difference regardless of whether tests were performed emergently (0.31% vs. 0.97% in HEART, 0.27% vs. 0.95% in TIMI, and 0% vs. 0.81% in GRACE, P > 0.05).
CONCLUSIONS: Chest pain risk stratification via clinical decision tool scores can minimize the need for emergent cardiac imaging tests with less than 1% MACE occurrence, especially when the HEART score is used.

PMID: 27846006 [PubMed - indexed for MEDLINE]

Roles of disease severity and post-discharge outpatient visits as predictors of hospital readmissions.

Chet Schrader, MD - Wed, 01/30/2019 - 08:15
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Roles of disease severity and post-discharge outpatient visits as predictors of hospital readmissions.

BMC Health Serv Res. 2016 10 10;16(1):564

Authors: Wang H, Johnson C, Robinson RD, Nejtek VA, Schrader CD, Leuck J, Umejiego J, Trop A, Delaney KA, Zenarosa NR

Abstract
BACKGROUND: Risks prediction models of 30-day all-cause hospital readmissions are multi-factorial. Severity of illness (SOI) and risk of mortality (ROM) categorized by All Patient Refined Diagnosis Related Groups (APR-DRG) seem to predict hospital readmission but lack large sample validation. Effects of risk reduction interventions including providing post-discharge outpatient visits remain uncertain. We aim to determine the accuracy of using SOI and ROM to predict readmission and further investigate the role of outpatient visits in association with hospital readmission.
METHODS: Hospital readmission data were reviewed retrospectively from September 2012 through June 2015. Patient demographics and clinical variables including insurance type, homeless status, substance abuse, psychiatric problems, length of stay, SOI, ROM, ICD-10 diagnoses and medications prescribed at discharge, and prescription ratio at discharge (number of medications prescribed divided by number of ICD-10 diagnoses) were analyzed using logistic regression. Relationships among SOI, type of hospital visits, time between hospital visits, and readmissions were also investigated.
RESULTS: A total of 6011 readmissions occurred from 55,532 index admissions. The adjusted odds ratios of SOI and ROM predicting readmissions were 1.31 (SOI: 95 % CI 1.25-1.38) and 1.09 (ROM: 95 % CI 1.05-1.14) separately. Ninety percent (5381/6011) of patients were readmitted from the Emergency Department (ED) or Urgent Care Center (UCC). Average time interval from index discharge date to ED/UCC visit was 9 days in both the no readmission and readmission groups (p > 0.05). Similar hospital readmission rates were noted during the first 10 days from index discharge regardless of whether post-index discharge patient clinic visits occurred when time-to-event analysis was performed.
CONCLUSIONS: SOI and ROM significantly predict hospital readmission risk in general. Most readmissions occurred among patients presenting for ED/UCC visits after index discharge. Simply providing early post-discharge follow-up clinic visits does not seem to prevent hospital readmissions.

PMID: 27724889 [PubMed - indexed for MEDLINE]

A Derivation and Validation Study of an Early Blood Transfusion Needs Score for Severe Trauma Patients.

Chet Schrader, MD - Wed, 01/30/2019 - 08:15
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A Derivation and Validation Study of an Early Blood Transfusion Needs Score for Severe Trauma Patients.

J Clin Med Res. 2016 Aug;8(8):591-7

Authors: Wang H, Umejiego J, Robinson RD, Schrader CD, Leuck J, Barra M, Buca S, Shedd A, Bui A, Zenarosa NR

Abstract
BACKGROUND: There is no existing adequate blood transfusion needs determination tool that Emergency Medical Services (EMS) personnel can use for prehospital blood transfusion initiation. In this study, a simple and pragmatic prehospital blood transfusion needs scoring system was derived and validated.
METHODS: Local trauma registry data were reviewed retrospectively from 2004 through 2013. Patients were randomly assigned to derivation and validation cohorts. Multivariate logistic regression was used to identify the independent approachable risks associated with early blood transfusion needs in the derivation cohort in which a scoring system was derived. Sensitivity, specificity, and area under the receiver operational characteristic (AUC) were calculated and compared using both the derivation and validation data.
RESULTS: A total of 24,303 patients were included with 12,151 patients in the derivation and 12,152 patients in the validation cohorts. Age, penetrating injury, heart rate, systolic blood pressure, and Glasgow coma scale (GCS) were risks predictive of early blood transfusion needs. An early blood transfusion needs score was derived. A score > 5 indicated risk of early blood transfusion need with a sensitivity of 83% and a specificity of 80%. A sensitivity of 82% and a specificity of 80% were also found in the validation study and their AUC showed no statistically significant difference (AUC of the derivation = 0.87 versus AUC of the validation = 0.86, P > 0.05).
CONCLUSIONS: An early blood transfusion scoring system was derived and internally validated to predict severe trauma patients requiring blood transfusion during prehospital or initial emergency department resuscitation.

PMID: 27429680 [PubMed]

The role of charity care and primary care physician assignment on ED use in homeless patients.

Chet Schrader, MD - Wed, 01/30/2019 - 08:15
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The role of charity care and primary care physician assignment on ED use in homeless patients.

Am J Emerg Med. 2015 Aug;33(8):1006-11

Authors: Wang H, Nejtek VA, Zieger D, Robinson RD, Schrader CD, Phariss C, Ku J, Zenarosa NR

Abstract
OBJECTIVE: Homeless patients are a vulnerable population with a higher incidence of using the emergency department (ED) for noncrisis care. Multiple charity programs target their outreach toward improving the health of homeless patients, but few data are available on the effectiveness of reducing ED recidivism. The aim of this study is to determine whether inappropriate ED use for nonemergency care may be reduced by providing charity insurance and assigning homeless patients to a primary care physician (PCP) in an outpatient clinic setting.
METHODS: A retrospective medical records review of homeless patients presenting to the ED and receiving treatment between July 2013 and June 2014 was completed. Appropriate vs inappropriate use of the ED was determined using the New York University ED Algorithm. The association between patients with charity care coverage, PCP assignment status, and appropriate vs inappropriate ED use was analyzed and compared.
RESULTS: Following New York University ED Algorithm standards, 76% of all ED visits were deemed inappropriate with approximately 77% of homeless patients receiving charity care and 74% of patients with no insurance seeking noncrisis health care in the ED (P=.112). About 50% of inappropriate ED visits and 43.84% of appropriate ED visits occurred in patients with a PCP assignment (P=.019).
CONCLUSIONS: Both charity care homeless patients and those without insurance coverage tend to use the ED for noncrisis care resulting in high rates of inappropriate ED use. Simply providing charity care and/or PCP assignment does not seem to sufficiently reduce inappropriate ED use in homeless patients.

PMID: 26001738 [PubMed - indexed for MEDLINE]

Use of the SONET score to evaluate Urgent Care Center overcrowding: a prospective pilot study.

Chet Schrader, MD - Wed, 01/30/2019 - 08:15
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Use of the SONET score to evaluate Urgent Care Center overcrowding: a prospective pilot study.

BMJ Open. 2015 Apr 14;5(4):e006860

Authors: Wang H, Robinson RD, Cowden CD, Gorman VA, Cook CD, Gicheru EK, Schrader CD, Jayswal RD, Zenarosa NR

Abstract
OBJECTIVES: To derive a tool to determine Urgent Care Center (UCC) crowding and investigate the association between different levels of UCC overcrowding and negative patient care outcomes.
DESIGN: Prospective pilot study.
SETTING: Single centre study in the USA.
PARTICIPANTS: 3565 patients who registered at UCC during the 21-day study period were included. Patients who had no overcrowding statuses estimated due to incomplete collection of operational variables at the time of registration were excluded in this study. 3139 patients were enrolled in the final data analysis.
PRIMARY AND SECONDARY OUTCOME MEASURES: A crowding estimation tool (SONET: Severely overcrowded, Overcrowded and Not overcrowded Estimation Tool) was derived using the linear regression analysis. The average length of stay (LOS) in UCC patients and the number of left without being seen (LWBS) patients were calculated and compared under the three different levels of UCC crowding.
RESULTS: Four independent operational variables could affect the UCC overcrowding score including the total number of patients, the number of results pending for patients, the number of patients in the waiting room and the longest time a patient was stationed in the waiting room. In addition, UCC overcrowding was associated with longer average LOS (not overcrowded: 133±76 min, overcrowded: 169±79 min, and severely overcrowded: 196±87 min, p<0.001) and an increased number of LWBS patients (not overcrowded: 0.28±0.69 patients, overcrowded: 0.64±0.98, and severely overcrowded: 1.00±0.97).
CONCLUSIONS: The overcrowding estimation tool (SONET) derived in this study might be used to determine different levels of crowding in a high volume UCC setting. It also showed that UCC overcrowding might be associated with negative patient care outcomes.

PMID: 25872940 [PubMed - indexed for MEDLINE]

Use of the SONET Score to Evaluate High Volume Emergency Department Overcrowding: A Prospective Derivation and Validation Study.

Charles Huggins, MD - Wed, 01/30/2019 - 08:15
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Use of the SONET Score to Evaluate High Volume Emergency Department Overcrowding: A Prospective Derivation and Validation Study.

Emerg Med Int. 2015;2015:401757

Authors: Wang H, Robinson RD, Garrett JS, Bunch K, Huggins CA, Watson K, Daniels J, Banks B, D'Etienne JP, Zenarosa NR

Abstract
Background. The accuracy and utility of current Emergency Department (ED) crowding estimation tools remain uncertain in EDs with high annual volumes. We aimed at deriving a more accurate tool to evaluate overcrowding in a high volume ED setting and determine the association between ED overcrowding and patient care outcomes. Methods. A novel scoring tool (SONET: Severely overcrowded-Overcrowded-Not overcrowded Estimation Tool) was developed and validated in two EDs with both annual volumes exceeding 100,000. Patient care outcomes including the number of left without being seen (LWBS) patients, average length of ED stay, ED 72-hour returns, and mortality were compared under the different crowding statuses. Results. The total number of ED patients, the number of mechanically ventilated patients, and patient acuity levels were independent risk factors affecting ED overcrowding. SONET was derived and found to better differentiate severely overcrowded, overcrowded, and not overcrowded statuses with similar results validated externally. In addition, SONET scores correlated with increased length of ED stay, number of LWBS patients, and ED 72-hour returns. Conclusions. SONET might be a better fit to determine high volume ED overcrowding. ED overcrowding negatively impacts patient care operations and often produces poor patient perceptions of standardized care delivery.

PMID: 26167302 [PubMed]

The inaccuracy of determining overcrowding status by using the national ED overcrowding study tool.

Charles Huggins, MD - Wed, 01/30/2019 - 08:15
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The inaccuracy of determining overcrowding status by using the national ED overcrowding study tool.

Am J Emerg Med. 2014 Oct;32(10):1230-6

Authors: Wang H, Robinson RD, Bunch K, Huggins CA, Watson K, Jayswal RD, White NC, Banks B, Zenarosa NR

Abstract
BACKGROUND: Emergency department (ED) crowding has become more common, and perceptions of crowding vary among different health care providers. The National Emergency Department Overcrowding Study (NEDOCS) tool is the most commonly used tool to estimate ED crowding but still uncertain of its reliability in different ED settings.
OBJECTIVE: The objectives of this study are to determine the accuracy of using the NEDOCS tool to evaluate overcrowding in an extremely high-volume ED and assess the reliability and consistency of different providers' perceptions of ED crowding.
MATERIAL AND METHODS: This was a 2-phase study. In phase 1, ED crowding was determined by the NEDOCS tool. The ED length of stay and number of patients who left without being seen were analyzed. In phase 2, a survey of simulated ED census scenarios was completed by different providers. The interrater and intrarater agreements of ED crowding were tested.
RESULTS: In phase 1, the subject ED was determined to be overcrowded more than 75% of the time in which nearly 50% was rated as severely overcrowded by the NEDOCS tool. No statistically significant difference was found in terms of the average length of stay and the number of left without being seen patients under different crowding categories. In phase 2, 88 surveys were completed. A moderate level of agreement between health care providers was reached (κ = 0.5402, P < .0001). Test-retest reliability among providers was high (r = 0.8833, P = .0007). The strength of agreement between study groups and the NEDOCS was weak (κ = 0.3695, P < .001).
CONCLUSION: Using the NEDOCS tool to determine ED crowding might be inaccurate in an extremely high-volume ED setting.

PMID: 25176566 [PubMed - indexed for MEDLINE]

Midcarpal Instability: A Comprehensive Review and Update.

Bryan Ming, MD - Wed, 01/30/2019 - 08:14
Related Articles

Midcarpal Instability: A Comprehensive Review and Update.

Hand Clin. 2015 Aug;31(3):487-93

Authors: Niacaris T, Ming BW, Lichtman DM

Abstract
Midcarpal instability has been well described as a clinical entity but the pathokinematics and pathologic anatomy continue to be poorly understood. This article presents a comprehensive review of the existing knowledge and literature-based evidence for the diagnosis and management of the various entities comprising midcarpal instability. It discusses the limitations of the current understanding of midcarpal instability and proposes new directions for furthering knowledge of the causes and treatment of midcarpal instability and wrist pathomechanics in general.

PMID: 26205710 [PubMed - indexed for MEDLINE]

Surgical Techniques for the Management of Midcarpal Instability.

Bryan Ming, MD - Wed, 01/30/2019 - 08:14
Related Articles

Surgical Techniques for the Management of Midcarpal Instability.

J Wrist Surg. 2014 Aug;3(3):171-4

Authors: Ming BW, Niacaris T, Lichtman DM

Abstract
Palmar midcarpal instability (PMCI) is an uncommon and poorly understood disorder. Its etiology is believed to be due to traumatic or congenital laxity of the ligaments (volar and dorsal) that stabilize the proximal row. This laxity results in hypermobility of the proximal carpal row and unphysiologic coupling of the midcarpal joint. Clinically, the condition is manifested by a painful clunk with ulnar and radial wrist deviation. The purpose of this article is to chronicle our personal experience with this condition and to review our current treatment recommendations and outcomes.

PMID: 27054049 [PubMed]

Asymptomatic Migration of a Kirschner Wire from the Proximal Aspect of the Humerus to the Thoracic Cavity: A Case Report.

Brian Webb, MD - Wed, 01/30/2019 - 08:14
Related Articles

Asymptomatic Migration of a Kirschner Wire from the Proximal Aspect of the Humerus to the Thoracic Cavity: A Case Report.

JBJS Case Connect. 2016 Jul-Sep;6(3):e77

Authors: Pientka WF, Bates CM, Webb BG

Abstract
CASE: A 78-year-old man presented with an open fracture of the proximal aspect of the humerus and an axillary artery laceration; the fracture was treated provisionally with Kirschner wires (K-wires). Forty-five days postoperatively, he presented with pin prominence at the lateral aspect of the arm, and was incidentally noted to have migration of a separate K-wire to the left lung. He underwent successful thoracotomy and lung wedge resection for wire removal.
CONCLUSION: K-wires used in the fixation of fractures of the proximal aspect of the humerus may migrate into the thoracic cavity. No modification of this technique, including the use of threaded, terminally bent, or external pins that are visibly secured, eliminates the potential for devastating complications.

PMID: 29252654 [PubMed - indexed for MEDLINE]

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