Search this website

Recent Research Articles from JPS Health Network

The value of using the HEART score among cocaine associated chest pain patients in the emergency department - A closer look.

Fri, 11/06/2020 - 06:03
Related Articles

The value of using the HEART score among cocaine associated chest pain patients in the emergency department - A closer look.

Am J Emerg Med. 2020 Oct 29;:

Authors: Holmes KA, Posey RA, Wang H

PMID: 33148470 [PubMed - as supplied by publisher]

Dedicated homeless clinics reduce inappropriate emergency department utilization.

Thu, 11/05/2020 - 05:49
Related Articles

Dedicated homeless clinics reduce inappropriate emergency department utilization.

J Am Coll Emerg Physicians Open. 2020 Oct;1(5):829-836

Authors: Holmes CT, Holmes KA, MacDonald A, Lonergan FR, Hunt JJ, Shaikh S, Cheeti R, D'Etienne JP, Zenarosa NR, Wang H

Abstract
Background: The homeless patient population is known to have a high occurrence of inappropriate emergency department (ED) utilization. The study hospital initiated a dedicated homeless clinic targeting patients experiencing homelessness with a combination of special features. We aim to determine whether this mode of care can reduce inappropriate ED utilization among homeless patients.
Methods: We conducted a retrospective observational study from July 1, 2017 to Dec 31, 2017. The study enrolled all homeless patients who visited any hospital regular clinic, dedicated homeless clinic, and ED at least once during the study period. ED homeless patients were divided into four groups (A: no clinic visits; B: those who only visited hospital regular clinic; C: those who only visited dedicated homeless clinic; and D: those who visited both hospital regular clinic and dedicated homeless clinic). The New York University algorithm was used to determine appropriate ED utilization. We compared inappropriate ED utilization among patients from these groups. Multivariate logistic regression was used to determine the risks of different clinical visits in association with inappropriate ED utilization.
Results: A total of 16,323 clinic and 8511 ED visits occurred among 5022 unique homeless patients, in which 2450 unique patients were seen in hospital regular clinic, 784 patients in dedicated homeless clinic, 688 patients in both hospital regular clinic and dedicated homeless clinic, and 1110 patients with no clinic visits. Twenty-nine percent (230/784) of patients from dedicated homeless clinic utilized the ED, among which 21% (175/844) of their ED visits were considered inappropriate. In contrast, 40% of patients from hospital regular clinic utilized the ED, among which 29% were inappropriate (P < 0.001). The adjusted odds ratio (OR) was 0.61 (95% confidence interval [CI] = 0.50-0.74, P < 0.001) on dedicated homeless clinic predicting inappropriate ED visits in multivariate logistic regression.
Conclusion: Implementing a dedicated homeless clinic with these features can reduce ED inappropriate utilization among patients experiencing homelessness.

PMID: 33145527 [PubMed]

Tranexamic acid administration in the field does not affect admission thromboelastography after traumatic brain injury.

Tue, 10/27/2020 - 06:48

Tranexamic acid administration in the field does not affect admission thromboelastography after traumatic brain injury.

J Trauma Acute Care Surg. 2020 Nov;89(5):900-907

Authors: Dixon AL, McCully BH, Rick EA, Dewey E, Farrell DH, Morrison LJ, McMullan J, Robinson BRH, Callum J, Tibbs B, Dries DJ, Jui J, Gandhi RR, Garrett JS, Weisfeldt ML, Wade CE, Aufderheide TP, Frascone RJ, Tallon JM, Kannas D, Williams C, Rowell SE, Schreiber MA

Abstract
BACKGROUND: No Food and Drug Administration-approved medication improves outcomes following traumatic brain injury (TBI). A forthcoming clinical trial that evaluated the effects of two prehospital tranexamic acid (TXA) dosing strategies compared with placebo demonstrated no differences in thromboelastography (TEG) values. We proposed to explore the impact of TXA on markers of coagulation and fibrinolysis in patients with moderate to severe TBI.
METHODS: Data were extracted from a placebo-controlled clinical trial in which patients 15 years or older with TBI (Glasgow Coma Scale, 3-12) and systolic blood pressure of ≥90 mm Hg were randomized prehospital to receive placebo bolus/placebo infusion (placebo), 1 g of TXA bolus/1 g of TXA infusion (bolus maintenance), or 2 g of TXA bolus/placebo infusion (bolus only). Thromboelastography was performed, and coagulation measures including prothrombin time, activated partial thromboplastin time, international ratio, fibrinogen, D-dimer, plasmin-antiplasmin (PAP), thrombin antithrombin, tissue plasminogen activator, and plasminogen activator inhibitor 1 were quantified at admission and 6 hours later.
RESULTS: Of 966 patients receiving study drug, 700 had laboratory tests drawn at admission and 6 hours later. There were no statistically significant differences in TEG values, including LY30, between groups (p > 0.05). No differences between prothrombin time, activated partial thromboplastin time, international ratio, fibrinogen, thrombin antithrombin, tissue plasminogen activator, and plasminogen activator inhibitor 1 were demonstrated across treatment groups. Concentrations of D-dimer in TXA treatment groups were less than placebo at 6 hours (p < 0.001). Concentrations of PAP in TXA treatment groups were less than placebo on admission (p < 0.001) and 6 hours (p = 0.02). No differences in D-dimer and PAP were observed between bolus maintenance and bolus only.
CONCLUSION: While D-dimer and PAP levels reflect a lower degree of fibrinolysis following prehospital administration of TXA when compared with placebo in a large prehospital trial of patients with TBI, TEG obtained on admission and 6 hours later did not demonstrate any differences in fibrinolysis between the two TXA dosing regimens and placebo.
LEVEL OF EVIDENCE: Diagnostic test, level III.

PMID: 33105308 [PubMed - as supplied by publisher]

Association between depression and hypertension using classic and revised blood pressure thresholds.

Wed, 10/21/2020 - 03:02

Association between depression and hypertension using classic and revised blood pressure thresholds.

Fam Pract. 2020 Oct 19;37(5):616-622

Authors: DeMoss DS, Teigen KJ, Claassen CA, Fisk MJ, Blair SE, Bakre SA, Hurd CL, Rush AJ

Abstract
BACKGROUND: In a primary care population, the relationship between treatment of depression and hypertension (HTN) under the recently revised American College of Cardiology and American Heart Association HTN thresholds for diagnosing HTN is unknown.
OBJECTIVE: To compare the association between changes in severity of co-occurring depression and HTN over time using the newly revised versus previous HTN guidelines.
METHODS: In this retrospective cohort study, outpatients ≥18 years (n = 3018) with clinically significant depressive symptoms and elevated blood pressure at baseline were divided into a 'revised' guideline group (baseline blood pressure ≥130/80 mmHg), a 'classic' guideline group (≥140/90 mmHg) and a 'revised-minus-classic' group (≥130/80 and <140/90 mmHg). Depressive symptom change was assessed using the Patient Health Questionnaire-9 (PHQ-9). Correlations between changes in PHQ-9 scores and HTN levels by group over a 6- to 18-month observation period were assessed using robust regression analysis.
RESULTS: There were demographic and clinical differences between groups. A total of 41% of study subjects (1252/3018) had a visit during the follow-up period where additional PHQ-9 and HTN results were available. Depressive symptom change was unrelated to change in blood pressure in the revised and revised-minus-classic groups. The classic HTN group demonstrated a clinically insignificant change in systolic blood pressure for each unit change in PHQ-9 score (β = 0.23, P-value =0.02).
CONCLUSIONS: Although a statistically significant association between reduced HTN levels and improvement in depressive symptoms was demonstrated under classic HTN guidelines, there was no clinically meaningful association between treatment of depression and improved HTN levels under either guideline.

PMID: 33075127 [PubMed - in process]

Chemiluminescent Measurement of Hydrogen Peroxide in the Exhaled Breath Condensate of Healthy and Asthmatic Adults.

Mon, 10/19/2020 - 21:16

Chemiluminescent Measurement of Hydrogen Peroxide in the Exhaled Breath Condensate of Healthy and Asthmatic Adults.

Anal Chem. 2020 Oct 16;:

Authors: Quimbar ME, Davis SQ, Al-Farra ST, Hayes A, Jovic V, Masuda M, Lippert AR

Abstract
Reactive oxygen species are centrally involved in the pathophysiology of airway diseases such as asthma and chronic obstructive pulmonary disease. This study reports the development of a chemiluminescence assay and a device for measuring hydrogen peroxide in the exhaled breath condensate of asthma patients and healthy participants. A stand-alone photon detection device was constructed for use with an optimized chemiluminescence assay. Calibrations using a catalase control to scavenge residual hydrogen peroxide in calibrant solutions provided analytically sensitive and specific measurements. We evaluated exhaled breath condensate hydrogen peroxide in 60 patients (ages 20-83; 30 healthy patients and 30 asthma patients) recruited from the John Peter Smith Hospital Network. The exhaled breath condensate hydrogen peroxide concentrations trended toward higher values in asthma patients compared to healthy participants (mean 142.5 vs 115.5 nM; p = 0.32). Asthma patients who had not used an albuterol rescue inhaler in the past week were compared to those who had and showed a trend toward higher hydrogen peroxide levels (mean 172.8 vs 115.9 nM; p = 0.25), and these patients also trended toward higher hydrogen peroxide than healthy participants (mean 172.8 vs 115.5 nM; p = 0.14). This pilot study demonstrates the ability of the newly developed assay and device to measure exhaled breath condensate hydrogen peroxide in asthma patients and healthy participants. The trends observed in this study are in agreement with previous literature and warrant further investigation of using this system to measure exhaled breath condensate hydrogen peroxide for monitoring oxidative stress in asthma.

PMID: 33064450 [PubMed - as supplied by publisher]

Age of First Use of Prescription Opioids and Prescription Opioid Non-Medical Use among Older Adolescents.

Mon, 10/19/2020 - 21:16

Age of First Use of Prescription Opioids and Prescription Opioid Non-Medical Use among Older Adolescents.

Subst Use Misuse. 2020 Oct 15;:1-8

Authors: Osborne V, Serdarevic M, Striley CW, Nixon SJ, Winterstein AG, Cottler LB

Abstract
BACKGROUND: Non-medical use (NMU) of prescription opioids is of concern due to the opioid epidemic in the United States. Objective: We examined sex differences in the effect of age of first use of prescription opioids on prescription opioid NMU among 17- and 18-year olds. Methods: The National Monitoring of Adolescent Prescription Stimulants Study (N-MAPSS) recruited youth 10-18 years from 10 United States cities between 2008 and 2011 (n = 11,048). The cross-sectional survey included questions on past 30 day prescription opioid use (10,965 provided responses; 278 age 17 to 18 years who used opioids in past 30 days), with NMU defined as non-oral use and/or use of someone else's opioids. Nonparametric survival analysis with lifetable estimates was used to examine age at first use. Binomial logistic regression was conducted predicting any NMU, adjusted for covariates. Results: Among 278 youth 17 to 18 years, a significant difference in age of first use between those with MU only and any NMU (p < .0001) was observed. Each one year increase in age resulted in a 33% decrease in the odds of any prescription opioid NMU compared to MU only, after controlling for covariates (Odds Ratio = 0.67, 95% Confidence Interval: 0.47,0.96). Sex differences in age at first use were not observed. Conclusions: Risk of past 30 day prescription opioid NMU decreased by a third for each one year increase in age of first use, after adjustment for other covariates. Use of prescription opioids in young adolescents may need to be limited where possible and researched further.

PMID: 33059498 [PubMed - as supplied by publisher]

Lung Ultrasound for COVID-19 Evaluation in the Emergency Department: Is It Feasible?

Tue, 10/06/2020 - 06:17

Lung Ultrasound for COVID-19 Evaluation in the Emergency Department: Is It Feasible?

Ann Emerg Med. 2020 Oct;76(4):552-553

Authors: Wolfshohl J, Shedd A, Chou EH, d'Etienne JP

PMID: 33012385 [PubMed - in process]

Study protocol for a multicentre implementation trial of monotherapy anticoagulation to expedite home treatment of patients diagnosed with venous thromboembolism in the emergency department.

Sat, 10/03/2020 - 07:48

Study protocol for a multicentre implementation trial of monotherapy anticoagulation to expedite home treatment of patients diagnosed with venous thromboembolism in the emergency department.

BMJ Open. 2020 Oct 01;10(10):e038078

Authors: Kline J, Adler D, Alanis N, Bledsoe J, Courtney D, D'Etienne J, B Diercks D, Garrett J, Jones AE, MacKenzie D, Madsen T, Matuskowitz A, Mumma B, Nordenholz K, Pagenhardt J, Runyon M, Stubblefield W, Willoughby C

Abstract
INTRODUCTION: In the USA, many emergency departments (EDs) have established protocols to treat patients with newly diagnosed deep vein thrombosis (DVT) as outpatients. Similar treatment of patients with pulmonary embolism (PE) has been proposed, but no large-scale study has been published to evaluate a comprehensive, integrated protocol that employs monotherapy anticoagulation to treat patients diagnosed with DVT and PE in the ED.
METHODS AND ANALYSIS: This protocol describes the implementation of the Monotherapy Anticoagulation To expedite Home treatment of Venous ThromboEmbolism (MATH-VTE) study at 33 hospitals in the USA. The study was designed and executed to meet the requirements for the Standards for Reporting Implementation Studies guideline. The study was funded by investigator-initiated awards from industry, with Indiana University as the sponsor. The study principal investigator and study associates travelled to each site to provide on-site training. The protocol identically screens patients with both DVT or PE to determine low risk of death using either the modified Hestia criteria or physician judgement plus a negative result from the simplified PE severity index. Patients must be discharged from the ED within 24 hours of triage and treated with either apixaban or rivaroxaban. Overall effectiveness is based upon the primary efficacy and safety outcomes of recurrent VTE and bleeding requiring hospitalisation respectively. Target enrolment of 1300 patients was estimated with efficacy success defined as the upper limit of the 95% CI for the 30-day frequency of VTE recurrence below 2.0%. Thirty-three hospitals in 17 states were initiated in 2016-2017.
ETHICS AND DISSEMINATION: All sites had Institutional Review Board approval. We anticipate completion of enrolment in June 2020; study data will be available after peer-reviewed publication. MATH-VTE will provide information from a large multicentre sample of US patients about the efficacy and safety of home treatment of VTE with monotherapy anticoagulation.

PMID: 33004396 [PubMed - in process]

Building RAFT: Trafficking Screening Tool Derivation and Validation Methods.

Thu, 10/01/2020 - 10:58
Related Articles

Building RAFT: Trafficking Screening Tool Derivation and Validation Methods.

Acad Emerg Med. 2020 04;27(4):297-304

Authors: Chisolm-Straker M, Singer E, Rothman EF, Clesca C, Strong D, Loo GT, Sze JJ, d'Etienne JP, Alanis N, Richardson LD

Abstract
BACKGROUND: Labor and sex trafficking have long impacted the patients who seek care in emergency departments (ED) across the United States. Increasing social and legislative pressures have led to multiple calls for screening for trafficking in the clinical care setting, but adoption of unvalidated screening tools for trafficking recognition is unwise for individual patient care and population-level data. Development of a valid screening tool for a social malady that is largely "invisible" to most clinicians requires significant investments. Valid screening tool development is largely a poorly understood process in the antitrafficking field and among clinicians who would use the tools.
METHODS: The authors describe the study design and procedures for reliable data collection and analysis in the development of RAFT (Rapid Appraisal for Trafficking). In a five-ED, randomized, prospective study, RAFT will be derived and validated as a labor and sex trafficking screening tool for use among adult ED patients. Using a novel method of ED patient-participant randomization, intensively trained data collectors use qualitative data to assess subjects for a lifetime experience of human trafficking.
CONCLUSION: Study methodology transparency encourages investigative rigor and integrity and will allow other sites to reproduce and externally validate this study's findings.

PMID: 31725176 [PubMed - indexed for MEDLINE]

Biomechanical Study of Patellar Component Fixation with Varying Degrees of Bone Loss.

Mon, 09/28/2020 - 06:56
Related Articles

Biomechanical Study of Patellar Component Fixation with Varying Degrees of Bone Loss.

J Arthroplasty. 2020 Aug 25;:

Authors: Beck CM, Nwannunu BI, Teigen KJ, Wagner RA

Abstract
BACKGROUND: The decision as to whether or not to resurface the patella in revision total knee arthroplasty (TKA) is affected by the amount of patellar bone stock remaining; however, the impact of the cancellous bone status on patellar component fixation has not been studied. Therefore, we conducted a biomechanical study of patellar component fixation with varying degrees of cancellous bone loss.
METHODS: Sixty pairs of cadaveric patellae were randomly assigned between 3 groups and prepared in similar manner to a TKA with the standard 3-hole configuration. A control patella and an experimental patella were designated in each pair. To simulate bone loss in the experimental patellae, 1, 2, and 3 of the standard drill holes were uniformly enlarged to 12 mm in group 1, group 2, and group 3, respectively. Afterward, an all-polyethylene patellar component was cemented to each patella, as done intraoperatively. Patellar components were then sheared off using a materials testing system. The resulting mean offset yield force was analyzed within each group using paired t-tests.
RESULTS: The mean offset yield force for the control patellae was greater than the experimental patellae in group 1. In groups 2 and 3, the experimental patellae produced a greater mean offset yield force than the control patellae. Comparison within each group did not demonstrate a statistically significant difference.
CONCLUSION: Bone loss with enlargement of the patellar fixation holes, as is frequently seen in revision TKA, with holes up to 12 mm, does not significantly decrease patellar component fixation shear strength in this biomechanical cadaveric study.

PMID: 32978021 [PubMed - as supplied by publisher]

Is it time to incorporate physics into the Dental Admissions Test?

Wed, 09/23/2020 - 07:36
Related Articles

Is it time to incorporate physics into the Dental Admissions Test?

J Dent Educ. 2020 Sep 21;:

Authors: Tandon R

Abstract
Although physics is a pre-requisite for dental students prior to matriculation it is not tested on the Dental Admissions Test (DAT). The concepts of physics are found throughout the dental profession, and by testing it on the DAT dental students will be better equipped to relate physics to their field and help advance it. The purpose of this paper is to make the argument for why it should be tested, as well as eliminating some of the superfluous topics on the DAT (ecology, environmental sciences, and plant physiology). This paper will focus on a few of concepts already taught in dentistry, and explore how physics principles apply to several of them. We want to emphasize the importance of physics and how testing even the most basic concepts will help prepare students to "think outside the box". Classical physics, specifically Newtonian Mechanics, has several applications in nearly all areas of dentistry: restorative, orthodontics, prosthodontics, and surgery. The testing of basic formulas studied in the pre-requisite physics classes will help ease the transition from college to dental school. Modern physics, namely Quantum Mechanics, also plays a significant role in current dental diagnostics and therapeutics. Additionally, with the development of the Integrated National Board Dental Examination (INBDE) as a replacement for the old NBDE part 1 and 2, there are topics tested that specifically focus on physics: Foundational Knowledge Areas 2 and 3. Thus, it is critical that the student dentist be familiar with these concepts. It is important to note that scientific changes occurring in the health sciences almost mandates students be familiar with concepts rooted in physics. It is then proposed that physics be incorporated into the exam, either with the natural sciences or within the quantitative reasoning section, in addition to eliminating topics not relevant to the dental field.

PMID: 32959369 [PubMed - as supplied by publisher]

Military experience in the management of pelvic fractures from OIF/OEF.

Fri, 09/18/2020 - 05:39
Related Articles

Military experience in the management of pelvic fractures from OIF/OEF.

BMJ Mil Health. 2020 Sep 16;:

Authors: Parker W, Despain RW, Bailey J, Elster E, Rodriguez CJ, Bradley M

Abstract
INTRODUCTION: Pelvic fractures are a common occurrence in combat trauma. However, the fracture pattern and management within the most recent conflicts, i.e. Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), have yet to be described, especially in the context of dismounted complex blast injury. Our goal was to identify the incidence, patterns of injury and management of pelvic fractures.
METHODS: We conducted a retrospective review on all combat-injured patients who arrived at our military treatment hospital between November 2010 and November 2012. Basic demographics, Young-Burgess fracture pattern classification and treatment strategies were examined.
RESULTS: Of 562 patients identified within the study time period, 14% (81 of 562) were found to have a pelvic fracture. The vast majority (85%) were secondary to an improvised explosive device. The average Injury Severity Score for patients with pelvic fracture was 31±12 and 70% were classified as open. Of the 228 patients with any traumatic lower extremity amputation, 23% had pelvic fractures, while 30% of patients with bilateral above-knee amputations also sustained a pelvic fracture. The most common Young-Burgess injury pattern was anteroposterior compression (APC) (57%), followed by lateral compression (LC) (36%) and vertical shear (VS) (7%). Only 2% (nine of 562) of all patients were recorded as having pelvic binders placed in the prehospital setting. 49% of patients with pelvic fracture required procedural therapy, the most common of which was placement of a pelvic external fixator (34 of 40; 85%), followed by preperitoneal packing (16 of 40; 40%) and angioembolisation (three of 40; 0.75%). 17 (42.5%) patients required combinations of these three treatment modalities, the majority of which were a combination of external fixator and preperitoneal packing. The likelihood to need procedural therapy was impacted by injury pattern, as 72% of patients with an APC injury, 100% of patients with a VS injury and 25% of patients with an LC injury required procedural therapy.
CONCLUSIONS: Pelvic fractures were common concomitant injuries following blast-induced traumatic lower extremity amputations. APC was the most common pelvic fracture pattern identified. While procedural therapy was frequent, the majority of patients underwent conservative therapy. However, placement of an external fixator was the most frequently used modality. Considering angioembolisation was used in less than 1% of cases, in the forward deployed military environment, management should focus on pelvic external fixation±preperitoneal packing. Finally, prehospital pelvic binder application may be an area for further process improvement.

PMID: 32938710 [PubMed - as supplied by publisher]

45-year-old man • fever • generalized rash • recent history of calcaneal osteomyelitis • Dx?

Thu, 09/17/2020 - 07:50
Related Articles

45-year-old man • fever • generalized rash • recent history of calcaneal osteomyelitis • Dx?

J Fam Pract. 2020 Sep;69(7):353-356

Authors: Cobb WJ

Abstract
► Fever ► Generalized rash ► Recent history of calcaneal osteomyelitis.

PMID: 32936844 [PubMed - as supplied by publisher]

Good Trouble.

Wed, 09/16/2020 - 19:09
Related Articles

Good Trouble.

Fam Med. 2020 Sep;52(8):607-608

Authors: Elliott TC

PMID: 32931015 [PubMed - as supplied by publisher]

The North Karelia Project: Prevention of Cardiovascular Disease in Finland Through Population-Based Lifestyle Interventions.

Tue, 09/15/2020 - 05:41

The North Karelia Project: Prevention of Cardiovascular Disease in Finland Through Population-Based Lifestyle Interventions.

Am J Lifestyle Med. 2020 Sep-Oct;14(5):495-499

Authors: Puska P, Jaini P

Abstract
The North Karelia Project was started in 1972 as a response to the high cardiovascular mortality among men in North Karelia, Finland's easternmost province. Prevalent cardiovascular disease risk factors in the province included elevated serum cholesterol, hypertension, and smoking. Through a sociobehavioral framework utilizing community-based interventions and national-level policy changes and legislation, the project targeted lifestyle changes as a means to alleviate cardiovascular disease risk factors. Diet recommendations included minimizing the use of saturated fats and decreasing salt intake. Another target of the project was to reduce the prevalence of smoking. As a result of the lifestyle interventions that continued beyond the initial 5 years of the project and then expanded to all of Finland, there were significant reductions in serum cholesterol levels, hypertension, smoking prevalence, and cardiovascular disease mortality. The North Karelia Project demonstrates that successful population-based lifestyle interventions serve as a sustainable public health solution to the growing chronic disease burden.

PMID: 32922234 [PubMed]

Effect of Out-of-Hospital Tranexamic Acid vs Placebo on 6-Month Functional Neurologic Outcomes in Patients With Moderate or Severe Traumatic Brain Injury.

Wed, 09/09/2020 - 07:06
Related Articles

Effect of Out-of-Hospital Tranexamic Acid vs Placebo on 6-Month Functional Neurologic Outcomes in Patients With Moderate or Severe Traumatic Brain Injury.

JAMA. 2020 Sep 08;324(10):961-974

Authors: Rowell SE, Meier EN, McKnight B, Kannas D, May S, Sheehan K, Bulger EM, Idris AH, Christenson J, Morrison LJ, Frascone RJ, Bosarge PL, Colella MR, Johannigman J, Cotton BA, Callum J, McMullan J, Dries DJ, Tibbs B, Richmond NJ, Weisfeldt ML, Tallon JM, Garrett JS, Zielinski MD, Aufderheide TP, Gandhi RR, Schlamp R, Robinson BRH, Jui J, Klein L, Rizoli S, Gamber M, Fleming M, Hwang J, Vincent LE, Williams C, Hendrickson A, Simonson R, Klotz P, Sopko G, Witham W, Ferrara M, Schreiber MA

Abstract
Importance: Traumatic brain injury (TBI) is the leading cause of death and disability due to trauma. Early administration of tranexamic acid may benefit patients with TBI.
Objective: To determine whether tranexamic acid treatment initiated in the out-of-hospital setting within 2 hours of injury improves neurologic outcome in patients with moderate or severe TBI.
Design, Setting, and Participants: Multicenter, double-blinded, randomized clinical trial at 20 trauma centers and 39 emergency medical services agencies in the US and Canada from May 2015 to November 2017. Eligible participants (N = 1280) included out-of-hospital patients with TBI aged 15 years or older with Glasgow Coma Scale score of 12 or less and systolic blood pressure of 90 mm Hg or higher.
Interventions: Three interventions were evaluated, with treatment initiated within 2 hours of TBI: out-of-hospital tranexamic acid (1 g) bolus and in-hospital tranexamic acid (1 g) 8-hour infusion (bolus maintenance group; n = 312), out-of-hospital tranexamic acid (2 g) bolus and in-hospital placebo 8-hour infusion (bolus only group; n = 345), and out-of-hospital placebo bolus and in-hospital placebo 8-hour infusion (placebo group; n = 309).
Main Outcomes and Measures: The primary outcome was favorable neurologic function at 6 months (Glasgow Outcome Scale-Extended score >4 [moderate disability or good recovery]) in the combined tranexamic acid group vs the placebo group. Asymmetric significance thresholds were set at 0.1 for benefit and 0.025 for harm. There were 18 secondary end points, of which 5 are reported in this article: 28-day mortality, 6-month Disability Rating Scale score (range, 0 [no disability] to 30 [death]), progression of intracranial hemorrhage, incidence of seizures, and incidence of thromboembolic events.
Results: Among 1063 participants, a study drug was not administered to 96 randomized participants and 1 participant was excluded, resulting in 966 participants in the analysis population (mean age, 42 years; 255 [74%] male participants; mean Glasgow Coma Scale score, 8). Of these participants, 819 (84.8%) were available for primary outcome analysis at 6-month follow-up. The primary outcome occurred in 65% of patients in the tranexamic acid groups vs 62% in the placebo group (difference, 3.5%; [90% 1-sided confidence limit for benefit, -0.9%]; P = .16; [97.5% 1-sided confidence limit for harm, 10.2%]; P = .84). There was no statistically significant difference in 28-day mortality between the tranexamic acid groups vs the placebo group (14% vs 17%; difference, -2.9% [95% CI, -7.9% to 2.1%]; P = .26), 6-month Disability Rating Scale score (6.8 vs 7.6; difference, -0.9 [95% CI, -2.5 to 0.7]; P = .29), or progression of intracranial hemorrhage (16% vs 20%; difference, -5.4% [95% CI, -12.8% to 2.1%]; P = .16).
Conclusions and Relevance: Among patients with moderate to severe TBI, out-of-hospital tranexamic acid administration within 2 hours of injury compared with placebo did not significantly improve 6-month neurologic outcome as measured by the Glasgow Outcome Scale-Extended.
Trial Registration: ClinicalTrials.gov Identifier: NCT01990768.

PMID: 32897344 [PubMed - as supplied by publisher]

TXA Administration in the Field Does Not Affect Admission TEG after Traumatic Brain Injury.

Wed, 09/02/2020 - 08:12
Related Articles

TXA Administration in the Field Does Not Affect Admission TEG after Traumatic Brain Injury.

J Trauma Acute Care Surg. 2020 Aug 28;:

Authors: Dixon AL, McCully BH, Rick EA, Dewey E, Farrell DH, Morrison LJ, McMullan J, Robinson BRH, Callum J, Tibbs B, Dries DJ, Jui J, Gandhi RR, Garrett JS, Weisfeldt ML, Wade CE, Aufderheide TP, Frascone RJ, Tallon JM, Kannas D, Williams C, Rowell SE, Schreiber MA, McKnight B, Meier EN, May S, Sheehan K, Bulger EM, Idris AH, Christenson J, Bosarge PL, Colella MR, Johannigman J, Cotton BA, Richmond NJ, Zielinski MD, Schlamp R, Klein L, Rizoli S, Gamber M, Fleming M, Hwang J, Vincent LE, Hendrickson A, Simonson R, Klotz P, Ferrara M, Sopko G, Witham W

Abstract
BACKGROUND: No FDA-approved medication improves outcomes following traumatic brain injury (TBI). A forthcoming clinical trial that evaluated the effects of two prehospital tranexamic acid (TXA) dosing strategies compared with placebo demonstrated no differences in thromboelastography (TEG) values. We proposed to explore the impact of TXA on markers of coagulation and fibrinolysis in patients with moderate to severe TBI.
METHODS: Data were extracted from a placebo-controlled clinical trial in which patients ≥15 years old with TBI (Glascow Coma Scale 3-12) and systolic blood pressure ≥90 mmHg were randomized prehospital to receive placebo bolus/placebo infusion (Placebo), 1 gram (g) TXA bolus/1g TXA infusion (Bolus Maintenance [BM]); or 2g TXA bolus/placebo infusion (Bolus Only [BO]). TEG was performed and coagulation measures including prothrombin time (PT), activated partial thromboplastin time (aPTT), international ratio (INR), fibrinogen, D-dimer, plasmin anti-plasmin (PAP), thrombin anti-thrombin (TAT), tissue plasminogen activator (tPA), and plasminogen activator inhibitor-1 (PAI-1) were quantified at admission and six hours later.
RESULTS: Of 966 patients receiving study drug, 700 had labs drawn at admission and six hours later. There were no statistically significant differences in TEG values, including LY30, between groups (p>0.05). No differences between PT, aPTT, INR, fibrinogen, TAT, tPA, and PAI-1 were demonstrated across treatment groups. Concentrations of D-dimer in TXA treatment groups were less than placebo at six hours (p<0.001). Concentrations of PAP were less in TXA treatment groups than placebo on admission (p<0.001) and six hours (p=0.02). No differences in D-dimer and PAP were observed between BM and BO.
CONCLUSION: While D-dimer and PAP levels reflect a lower degree of fibrinolysis following prehospital administration of TXA when compared to placebo in a large prehospital trial of patients with TBI, TEG obtained on admission and six hours later did not demonstrate any differences in fibrinolysis between the two TXA dosing regimens and placebo.
LEVEL OF EVIDENCE: III; Diagnostic.

PMID: 32868544 [PubMed - as supplied by publisher]

Perception of Physician Empathy Varies With Educational Level and Gender of Patients Undergoing Low-Yield Computerized Tomographic Imaging.

Sat, 08/22/2020 - 05:55
Related Articles

Perception of Physician Empathy Varies With Educational Level and Gender of Patients Undergoing Low-Yield Computerized Tomographic Imaging.

J Patient Exp. 2020 Jun;7(3):386-394

Authors: Kline JA, Lin MP, Hall CL, Puskarich MA, Dehon E, Kuehl DR, Wang RC, Hess EP, Runyon MS, Wang H, Courtney DM

Abstract
Objective: Lack of empathic communication between providers and patients may contribute to low value diagnostic testing in emergency care. Accordingly, we measured the perception of physician empathy and trust in patients undergoing low-value computed tomography (CT) in the emergency department (ED).
Methods: Multicenter study of ED patients undergoing CT scanning, acknowledged by ordering physicians as unlikely to show an emergent condition. Near the end of their visit, patients completed the Jefferson Scale of Patient Perception of Physician Empathy (JSPPPE), Trust in Physicians Survey (TIPS), and the Group Based Medical Mistrust Scale (GBMMS). We stratified results by patient demographics including gender, race, and education.
Results: We enrolled 305 participants across 9 sites with diverse geographic, racial, and ethnic representation. The median scores (interquartile ranges) for the JSPPPE, TIPS, and GBMMS for all patients were 29 (24-33.5), 55 (47-62), and 18 (12-29). Compared with white patients, nonwhite patients had similar JSPPPE and TIPS scores but had higher (worse) GBMMS scores. Females had significantly lower JSPPPE and TIPS scores than males, and scores were lower (worse) in females with college degrees. Patients in the lowest tier of educational status had the highest (better) JSPPPE and TIPS scores. Scores were invariant with physician characteristics.
Conclusion: Among patients undergoing low-value CT scanning in the ED, the degree of patient perception of physician empathy and trust varied based on the patients' level of education and gender. Given this variation, an intervention to increase patient perception of physician empathy should contain individualized strategies to address these subgroups, rather than a one-size-fits-all approach.

PMID: 32821799 [PubMed - as supplied by publisher]

Examining Injustice Appraisals in a Racially Diverse Sample of Individuals With Chronic Low Back Pain.

Sat, 08/22/2020 - 05:55
Related Articles

Examining Injustice Appraisals in a Racially Diverse Sample of Individuals With Chronic Low Back Pain.

J Pain. 2019 01;20(1):83-96

Authors: Trost Z, Sturgeon J, Guck A, Ziadni M, Nowlin L, Goodin B, Scott W

Abstract
Injustice perception has emerged as a risk factor for problematic musculoskeletal pain outcomes. Despite the prevalence and impact of chronic low back pain (CLBP), no study has addressed injustice appraisals specifically among individuals with CLBP. In addition, despite racial/ethnic disparities in pain, existing injustice research has relied almost exclusively on white/Caucasian participant samples. The current study examined the associations between perceived injustice and pain, disability, and depression in a diverse community sample of individuals with CLBP (N = 137) -51 (37.2%) white, 43 (31.4%) Hispanic, 43 (31.4%) black or African American). Anger variables were tested as potential mediators of these relationships. Controlling for demographic and pain-related covariates, perceived injustice accounted for unique variance in self-reported depression and disability outcomes, but not pain intensity. State and trait anger, and anger inhibition mediated the association between perceived injustice and depression; no additional mediation by anger was observed. Significant racial differences were also noted. Compared with white and Hispanic participants, black participants reported higher levels of perceived injustice related to CLBP, as well as higher depression and pain-related disability. Black participants also reported higher pain intensity than white participants. Current findings provide initial evidence regarding the role of injustice perception specifically in the context of CLBP and within a racially diverse participant sample. Results highlight the need for greater diversity within injustice and CLBP research as well as research regarding socially informed antecedents of injustice appraisals. Perspective: Perceived injustice predicted worse outcomes in CLBP, with effects partially mediated by anger. Black participants reported worse pain outcomes and higher injustice perception than their white or Hispanic counterparts. Given racial inequities within broader health and pain-specific outcomes, this topic is critical for CLBP and perceived injustice research.

PMID: 30179671 [PubMed - indexed for MEDLINE]

Smoking cessation and survival among people diagnosed with non-metastatic cancer.

Sat, 08/08/2020 - 05:13
Related Articles

Smoking cessation and survival among people diagnosed with non-metastatic cancer.

BMC Cancer. 2020 Aug 05;20(1):726

Authors: Barnett TE, Lu Y, Gehr AW, Ghabach B, Ojha RP

Abstract
BACKGROUND: We aimed to estimate the effects of smoking cessation on survival among people diagnosed with cancer.
METHODS: We used data from a Comprehensive Community Cancer Program that is part of a large urban safety-net hospital system. Eligible patients were diagnosed with primary invasive solid tumors between 2013 and 2015, and were current smokers at time of diagnosis. Our exposure of interest was initiation of smoking cessation within 6 months of cancer diagnosis. We estimated inverse probability weighted restricted mean survival time (RMST) differences and risk ratio (RR) for all cause 3-year mortality.
RESULTS: Our study population comprised 369 patients, of whom 42% were aged < 55 years, 59% were male, 44% were racial/ethnic minorities, and 59% were uninsured. The 3-year RMST was 1.8 (95% CL: - 1.5, 5.1) months longer for individuals who initiated smoking cessation within 6 months of cancer diagnosis. The point estimate for risk of 3-year mortality was lower for initiation of smoking cessation within 6 months of diagnosis compared with no initiation within 6 months (RR = 0.72, 95% CL: 0.37, 1.4).
CONCLUSIONS: Our point estimates suggest longer 3-year survival, but the results are compatible with 1.5 month shorter or 5.1 longer 3-year overall survival after smoking cessation within 6 months of cancer diagnosis. Future studies with larger sample sizes that test the comparative effectiveness of different smoking cessation strategies are needed for more detailed evidence to inform decision-making about the effect of smoking cessation on survival among cancer patients.
IMPLICATIONS FOR CANCER SURVIVORS: The benefits of smoking cessation after cancer diagnosis may include longer survival, but the magnitude of benefit is unclear.

PMID: 32758159 [PubMed - in process]

Pages