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Biomedical subjects

C L Emerman

Publications and source records attributed to C L Emerman.

At least 37 records · Page 2Linked to original sources
PubMed1997

Recognition of depression in geriatric ED patients by emergency physicians.

STUDY OBJECTIVE: To prospectively evaluate identification of geriatric depression by emergency physicians and to assess the utility of a self-rated depression scale to improve case-finding in geriatric patients presenting to the ED. METHODS: We conducted an observational survey of geriatric ED patients who presented to an urban, university-affiliated public hospital. A brief self-rated depression scale was administered to 101 patients aged 65 years or older. Emergency physicians, blinded to depression scale scores, prospectively rated the likelihood of depression in these patients. Our main outcome measures were prevalence of depression (in accordance with a predetermined cutoff score for detecting depression) and the emergency physicians' clinical recognition of depression. RESULTS: Thirty patients (30%; 95% confidence interval [CI], 21% to 39%) met the predetermined criteria for depression. Age, sex, race, and education were not significantly different between depressed and nondepressed patients. Patients who categorized their health as good were less likely to be depressed than those who considered their health poor or fair (18% versus 37%; 95% CI for difference of 19%, 10% to 35%). Recognition of depression by emergency physicians was poor, with a sensitivity of 27% (95% CI; 12% to 46%), specificity of 75% (95% CI, 63% to 84%), and positive predictive value of 32% (95% CI, 27% to 41%). Only 13% (95% CI, 4% to 31%) of depressed patients were referred for further mental health evaluation. CONCLUSION: Depression is common in older ED patients but often goes unrecognized by emergency physicians. Use of a brief depression scale can improve case-finding in this age group, leading to appropriate referral for further management.

Aged↗
PubMed1997

Depression in geriatric ED patients: prevalence and recognition.

STUDY OBJECTIVE: To determine the prevalence of depression in geriatric ED patients and to assess recognition of geriatric depression by emergency physicians. METHODS: We conducted an observational survey of geriatric patients who presented to an urban, university-affiliated public hospital ED. A convenience sample of 259 patients aged 65 years or older were administered a brief, self-rated depression scale. Main outcome measures were prevalence of depression (using a predetermined cutoff score for detecting depression) and recognition of depression by the treating emergency physician, assessed by chart review. RESULTS: Seventy subjects (27%; 95% confidence interval [CI], 22% to 32%) were rated as depressed. Depressed and nondepressed patients were not significantly different with regard to age, sex, race, or education. Forty-seven percent of nursing home residents were depressed, compared with 24% of those living independently (95% CI for difference of 23%, 6% to 41%). Patients who described their health as poor were also more likely to be depressed (33 of 65, 51%) than patients who reported their health to be good or fair (37 of 194, 19%) (95% CI for difference of 32%, 18% to 45%). Emergency physicians failed to recognize depression in all the patients found to be depressed on this scale (95% CI, 0 to 5%). CONCLUSION: The prevalence of unrecognized depression in the geriatric ED patients we studied was high, especially in those who reported their health as poor. Use of a brief depression scale can aid recognition of depression in older patients, leading to appropriate referral and treatment.

Aged↗
PubMed1997

Effect of different albuterol dosing regimens in the treatment of acute exacerbation of chronic obstructive pulmonary disease.

STUDY OBJECTIVE: To compare hourly administration of albuterol with more frequent administration of a higher cumulative dose in patients with an acute exacerbation of chronic obstructive pulmonary disease (COPD). METHODS: Participants in this pilot study were patients older than 50 years who presented to the emergency department with an acute exacerbation of COPD. After initial assessment and spirometry, all patients received nebulized aerosols every 20 minutes. Patients were randomly assigned to receive either albuterol (2.5 mg) every 60 minutes for two doses, interspersed with saline aerosols every 20 minutes; or albuterol (2.5 mg) every 20 minutes for 2 hours. Patients were assessed with spirometry after 60 and 120 minutes. No other medications were administered during the course of this study. RESULTS: Eighty-six patients were enrolled in the study. No statistically significant difference was found between groups in mean 1-second forced expiratory volume (FEV1) at study initiation, 1 hour, or 2 hours or in the interval changes in mean FEV1. There was, however, almost twice as much improvement in FEV1 in the higher-dose group. Group hospitalization rates were similar. There were more side effects in the higher-dose group (45% versus 24%, P < .05). Among 32 patients with a pretreatment FEV1 less than 20% of predicted, there was a significantly greater interval improvement in FEV1 at both 1 hour and 2 hours. CONCLUSION: This study failed to demonstrate a statistically significant advantage to use of a higher cumulative dose of albuterol in patients with acute exacerbation of COPD, possibly because of type II statistical error. There may be an advantage to more frequent dosing, particularly in patients with initially severe bronchospasm, although at the expense of more frequent side effects.

Aerosols↗
PubMed1997

Patterns of hospitalization in elderly patients with asthma and chronic obstructive pulmonary disease.

The purpose of this study was to describe the impact of asthma and chronic obstructive pulmonary disease (COPD) in the elderly on health care utilization. The Health Care Financing Administration (HCFA) file for the year 1984 through 1991 involving beneficiaries < or = 65 yr were searched for the diagnoses of asthma and COPD by ICD-9 codes. The study groups were created by determining the first admission for an exacerbation of either disease during each year from 1984 through 1991. Patients were identified by their social security number. The 1984 cohort consisted of 56,692 patients with asthma exacerbation and 162,899 with COPD exacerbation. The 1991 cohort consisted of 67,758 patients with asthma exacerbation and 131,974 patients with COPD exacerbation. In addition, the 1984 cohort was tracked by social security number for evidence of rehospitalization for either asthma or COPD through 1991. Length of hospitalization increased as patients grew older. The discharge rate to an independent living facility diminished as age increased. The use of convalescent and nursing homes or home health care after discharge more than doubled from 1984 through 1991. The utilization of health care resources by elderly patients with asthma and COPD is immense, both during hospitalization and after discharge.

Age Factors↗
PubMed1996

Use of peak expiratory flow rate in emergency department evaluation of acute exacerbation of chronic obstructive pulmonary disease.

STUDY OBJECTIVE: The purpose of the study was to compare peak expiratory flow rate (PEFR) against 1-second forced expiratory volume (FEV1) as a measure of airway obstruction in patients with acute exacerbation of chronic obstructive pulmonary disease (COPD). METHODS: The participants were patients older than 50 years of age who presented with an acute exacerbation of COPD to the emergency department of a large, urban medical center. Pulmonary function was measured with a computerized Fleisch pneumotachygraphic spirometer before, during, and after treatment. PEFR and FEV1 were compared both as absolute values and after conversion to percent of predicted normal values (PPVs). RESULTS: Five hundred fifty-six paired sets of measurements of FEV1 and PEFR were obtained from 199 patients and compared. There was good correlation between PEFR and FEV1, both in terms of absolute value (r=84; P<.001) and in terms of PPV (r=81; P<.001). Despite good correlation, further analysis revealed that there was not uniformly good agreement between the PPVs for FEV1 and PEFR. Although the mean difference between the PPVs obtained from the two measurements was only 4.3%, the 95% limits of agreement ranged widely, from -15% to 24%. CONCLUSION: Although PEFR can be used as an alternative measure of airway obstruction in instances in which FEV1 is not available, there may be clinically significant discrepancies between the two tests. Measurement of the FEV1 is preferable because it allows comparison with baseline studies and previously published guidelines.

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PubMed1996

Evaluation of resident performance and intensive bedside teaching during direct observation.

OBJECTIVE: To describe the experience of a residency program in emergency medicine with an intensive observational evaluation of resident performance in the ED. METHODS: Each resident was directly observed and evaluated during a clinical shift four times each academic year: once by each residency codirector and twice by the resident's faculty advisor. The faculty members performed this evaluation outside of "clinical staffing time," shadowing the resident for several hours in the ED during the resident's assigned shift. The resident and assigned faculty member discussed the patients' histories and physical examination findings and developed treatment plans together. Prior to initiation of the observation, the faculty were provided with guidelines for the evaluation of specific skills. Immediate feedback of strengths and deficiencies was provided to the resident. RESULTS: Subjective evaluations by faculty suggest that new insights into resident clinical strengths and weaknesses were determined using this approach. Objective scoring of resident performance demonstrated heterogeneity of skills between residents as well as inconsistency of skills for specific residents. CONCLUSIONS: The program provided the faculty with protected teaching time, an opportunity to share clinical pearls, and unique insights into resident performance that are not obvious during standard clinical interactions.

Education, Medical, Graduate↗
PubMed1996

Is handwashing teachable?: failure to improve handwashing behavior in an urban emergency department.

OBJECTIVES: To assess handwashing frequency according to CDC recommendations; and to test a simple intervention to increase handwashing compliance, designed for the unique setting of the ED. METHODS: A prospective, observational, before-and-after study design with a convenience sampling technique was used to assess handwashing compliance in the ED of a 742-bed urban, university-affiliated medical center with 65,000 visits annually. Emergency physicians (EPs), registered nurses (RNs), and nurse practitioners (NPs) were informed that their patient encounters were being monitored, but the nature of the study was kept confidential. A single observer evaluated individual EPs, RNs, and NPs in one-, two-, or three-hour blocks, recording compliance with CDC handwashing recommendations. After two weeks, brightly colored signs with CDC recommendations for handwashing were posted at all sinks and a copy of a related publication on handwashing by medical personnel was distributed to all staff. Handwashing behaviors were again observed. RESULTS: A total of 252 situations requiring handwashing were observed, 132 pre-intervention and 120 post-intervention. Total handwashing, handwashing by each staff designation, and handwashing in each CDC recommendation category--except handwashing between contacts with different patients--all showed tendencies toward improvement, though none was significant (p > 0.05). Both the NPs and RNs demonstrated significantly higher adherence to recommended handwashing between patients after the intervention than did the EPs (85% vs 71% vs 31%, p < 0.01 and p < 0.05, respectively). CONCLUSION: Despite a trend in improvement of compliance with CDC recommendations, handwashing among ED personnel remained unacceptably low.

Chi-Square Distribution↗
PubMed1996

Emergency medicine journal clubs.

OBJECTIVE: To ascertain the status of journal club within emergency medicine (EM) residency programs and to describe 3 currently used formats. METHODS: The directors of U.S. Residency Review Committee for Emergency Medicine (RRC-EM)-approved residency programs were surveyed to determine the features of their programs' journal clubs. Responses to 3 questions assessing the degree of satisfaction (5-item scales from very good to very poor) with the "current format," "resident participation," and "faculty participation" from the survey were grouped according to the program director's impressions of resident and faculty "enjoyment" (2 3-item scales) and whether the journal club is a "success" (3-item scale) to develop an overall satisfaction index. Three journal club formats currently in use at EM residencies are described in detail. RESULTS: Of the 101 directors surveyed, 91 (90%) responded. The respondents' overall satisfaction index was highest when the journal club was held in the evening (p < 0.008) or at a faculty member's home (p < 0.0004). The format of the journal club (e.g., by topic, with a statistical focus, with a research design, focus, or as a clinical practice update) was not associated with the overall satisfaction index. CONCLUSION: Journal clubs associated with EM residencies vary in format and perceived success. The 3 representative journal clubs illustrate different format options.

Cross-Sectional Studies↗
PubMed1996

Survey of asthma practice among emergency physicians.

PURPOSE: The National Asthma Education and Prevention Program (NAEPP) published guidelines for asthma management in 1991. The purpose of this study is to assess the concordance between emergency physicians' practice and the guidelines. DESIGN: Survey mailed to emergency physicians. Non-respondents were mailed a second copy of the survey. PARTICIPANTS: Eight hundred randomly selected active members of the American College of Emergency Physicians. INTERVENTIONS: None. MEASUREMENTS: Participants were asked questions regarding training, current asthma practices, and sources of information on asthma management. RESULTS: Eight hundred questionnaires were mailed, of which 416 (52%) were returned. Sixty-four percent of respondents administer beta-agonists consistent with the NAEPP guidelines. Seventy-five percent of respondents administer corticosteroids in similar accord, while 75% prescribed outpatient corticosteroids in concordance with those recommendations. Forty-seven percent report measuring pretreatment pulmonary function more than half the time and only 38% report checking pulmonary function prior to disposition more than half the time. CONCLUSIONS: Most emergency physicians surveyed use beta-agonists and steroids at least as often as recommended. A minority of emergency physicians reported utilizing pulmonary function testing in the manner recommended by the NAEPP.

Asthma↗
PubMed1995

Effect of pulmonary function testing on the management of acute asthma.

BACKGROUND: Routine pulmonary function testing has been recommended as part of the emergency department management of acute asthma despite the lack of evidence demonstrating the necessity for these measurements. The purpose of this study was to assess the physician's ability to estimate pulmonary function in patients with acute asthma and to determine the effect that pulmonary function testing has on patient management. METHODS: Emergency medicine physicians estimated pulmonary function in adult asthmatic patients prior to spirometry. The estimations and spirometry were repeated after 1 hour and again at discharge. The physicians noted their treatment plan before and after receiving the results of pulmonary function testing. RESULTS: Ninety-eight patients were enrolled in the study. There was only moderate correlation between pretreatment estimates of pulmonary function and the actual value (r = .41). On average, physicians underestimated the degree of pretreatment airway obstruction (as percentage of predicted normal value) by 8.1 +/- 16.0 percentage points. Knowledge of the pulmonary function test results changed management in 20.4% of patients. The most common change was an alteration in the decision to continue treatment after 3 hours. CONCLUSIONS: Physicians tend to underestimate the degree of airway obstruction in acute asthma, particularly on initial assessment. Since the availability of pulmonary function tests changes management in a significant number of patients, routine pulmonary function testing is recommended as part of the assessment and monitoring of acute asthma.

Acute Disease↗
PubMed1995

Effect of age on myocardial infarction and thrombolysis.

Thrombolytic therapy has emerged as the treatment of choice for patients presenting with an acute myocardial infarction. Myocardial infarction is a major cause of morbidity and mortality in the elderly. Advancing age has been considered a relative contraindication to thrombolytic therapy despite the potential for the elderly to derive the greatest benefit from this therapy. This trend not to treat the elderly has been based on a perceived increased risk of complications. Available data pooled from several studies clearly show that the elderly benefit from thrombolytic therapy.

Aged↗
PubMed1995

Factors associated with relapse after emergency department treatment for acute asthma.

STUDY OBJECTIVE: The rate of relapse after emergency department treatment for acute asthma is high. Most studies on this subject were performed before the recent recommendations for routine use of corticosteroids and followed the patients for 10 or fewer days. We sought to evaluate relapse following ED treatment for acute asthma over a longer period, focusing particularly on the relationship between steroid use and outpatient follow-up visits. DESIGN: A prospective study in which we followed patients for 21 days after discharge to determine their relapse rate (unscheduled return for asthma treatment) and compliance with scheduled outpatient appointments. SETTING: University-affiliated county hospital ED. PARTICIPANTS: One hundred four adult asthmatic patients discharged from our ED after treatment under a standardized protocol. RESULTS: Follow-up was performed for 91 patients (88%). There was no difference in the posttreatment forced expiratory volume at 1 second between those who relapsed (55.2%) and those who did not (57.8%; NS). Twenty-three patients (25.3%) relapsed within 3 weeks of discharge. Ninety-one percent of relapses occurred before the patients saw their primary care physician. Those who relapsed had a history of previous ED visits and hospitalizations. There was no difference in theophylline levels or history of cigarette use. Patients who relapsed within 3 days had higher eosinophil counts. CONCLUSION: Even with routine use of oral corticosteroids, a high percentage of patients relapse after ED treatment for acute asthma. Patients who relapse have a greater number of recent ED visits and so should be targeted for more aggressive management of their asthma.

Acute Disease↗
PubMed1995

Effects of combined treatment with glycopyrrolate and albuterol in acute exacerbation of chronic obstructive pulmonary disease.

STUDY OBJECTIVE: To investigate whether the addition of a single aerosolized dose of glycopyrrolate leads to a greater improvement in pulmonary function than treatment with albuterol alone for patients with acute exacerbation of chronic obstructive pulmonary disease (COPD). DESIGN: Prospective, randomized, blinded, controlled study. Fifty-seven patients with acute exacerbation of COPD were entered into the study. All patients received three aerosol treatments. Patients were randomized to receive 2 mg aerosolized glycopyrrolate (combination therapy group) or aerosolized placebo in addition to their first 2.5-mg albuterol aerosol treatment. All patients received 2.5 mg of aerosolized albuterol alone for the next two treatments. SETTING: Urban teaching hospital emergency department. RESULTS: We found no difference in pretreatment 1-second fractional expired volume (FEV1) between the control and glycopyrrolate groups. There was no significant difference in the absolute value of the FEV1 at 1 hour or at 3 hours between the two groups; however, patients who received combination therapy had a greater percent increase from the pretreatment value of FEV1 (56%) as measured in milliliters than did control patients (19%; P = .008). CONCLUSION: The combination of glycopyrrolate and albuterol produces a greater improvement in FEV1 than does albuterol alone in the treatment of patients with acute exacerbation of COPD.

Acute Disease↗
PubMed1995

A randomized comparison of 100-mg vs 500-mg dose of methylprednisolone in the treatment of acute asthma.

There have been conflicting reports comparing the effects of various doses of corticosteroids in the treatment of acute asthma. The purpose of this study was to compare 100 mg with 500 mg of methylprednisolone in the emergency department treatment of acute asthma. We studied 150 patients presenting to the emergency department with acute asthma. After baseline pulmonary function testing, patients were treated with oxygen and hourly administration of aerosolized albuterol. Patients were randomized to receive either 100 or 500 mg of methylprednisolone intravenously. Spirometry was repeated at 3 h, and again at 5 h for those patients whose dyspnea had not resolved after 3 h. There was no difference in the FEV1 between the 500-mg and 100-mg dose groups either before treatment (38.0% vs 32.6% of predicted normal) or after treatment (55.3% vs 51.9% of predicted normal). There was no difference in the percentage improvement in FEV1 with treatment between the 500-mg and 100-mg dose groups (65.0% vs 71.2%). Twenty-five percent of the patients in the 500-mg dose group were admitted to the hospital compared with 28% of patients in the 100-mg dose group (not significant). We conclude that the administration of a 500-mg dose of methylprednisolone offers no advantages over a 100-mg dose in the emergency department treatment of acute asthma.

Acute Disease↗
PubMed1994

Effects of combined treatment with glycopyrrolate and albuterol in acute exacerbation of asthma.

STUDY OBJECTIVE: Recent reports suggest that glycopyrrolate is as effective as metaproterenol in the treatment of acute bronchospasm. The purpose of this study was to investigate whether the addition of a single aerosolized dose of glycopyrrolate to an albuterol regimen results in a greater improvement in pulmonary function than treatment with an albuterol regimen alone in patients with acute asthma. DESIGN: Prospective, randomized, double-blinded, controlled study. All patients received a total of three aerosol treatments and 60 mg solumedrol IV push. Patients were randomized to receive 2 mg aerosolized glycopyrrolate (combination therapy) or aerosolized placebo (control) in addition to their first 2.5 mg albuterol aerosol treatment. Both groups received 2.5 mg aerosolized albuterol alone for the next two treatments. SETTING: An urban teaching hospital emergency department. PARTICIPANTS: One hundred twenty-five patients with acute exacerbation of asthma were entered into the study. MAIN RESULTS: There was no difference in pretreatment forced expiratory volume (one second) (FEV1) between the control group and the glycopyrrolate group. Asthmatic patients receiving combination therapy had less of a change in FEV1 (52%) than did control patients (82%, P < .05). CONCLUSION: The combination of glycopyrrolate and albuterol does not appear to be beneficial over albuterol alone in treating patients with acute exacerbation of asthma.

Acute Disease↗
PubMed1994

Physician estimation of FEV1 in acute exacerbation of COPD.

There have been recent recommendations to include objective measurements of airway obstruction in the treatment of patients with acute asthma. These recommendations are based in part on the inaccuracy of physicians in estimating airways obstruction in asthmatic patients. The purpose of this study was to evaluate the ability of physicians to estimate the degree of airways obstruction in patients with acute exacerbation of COPD. We studied 90 patients. The physicians were able to estimate the percent of predicted normal FEV1 to within 10 points only 38 percent of the time prior to treatment and 46 percent of the time posttreatment. Forty-nine percent of the patients whom the physicians believed had an improvement in pulmonary function with treatment actually did not improve, while 31 percent of the patients who the physicians believed did not improve their pulmonary function with treatment actually did improve. We conclude that physicians' estimates of the degree of airway obstruction in acute exacerbation of COPD are inaccurate. Assessment of patients in the emergency department presenting with COPD should be based on objective measurements of pulmonary function.

Acute Disease↗
PubMed1993

Changes in serum catecholamine levels during acute bronchospasm.

STUDY OBJECTIVES: Previous studies reported that norepinephrine levels increased during acute asthma, while epinephrine levels have remained at normal levels. The purpose of this study was to determine whether the lack of rise in epinephrine levels is due to an inherent defect in catecholamine secretion in asthmatics or is a result of an insufficient stimulus for epinephrine release. DESIGN: County-owned, university-affiliated emergency department. SETTING: Prospective study. TYPE OF PARTICIPANTS: Patients more than 18 years old presenting to the ED with an acute exacerbation of asthma or chronic obstructive pulmonary disease (COPD). INTERVENTIONS: Initial phlebotomy and spirometry were followed by treatment with either albuterol or albuterol and glycopyrrolate. Asthmatic patients received steroids. Phlebotomy and spirometry were performed again after treatment. MEASUREMENTS AND MAIN RESULTS: There was no difference in epinephrine levels between patients with asthma and those with COPD either before or after treatment. Norepinephrine levels were higher in patients with COPD, both before and after treatment. There was only a weak correlation between epinephrine levels and pretreatment FEV1 for asthma but not for COPD. CONCLUSION: Moderate bronchospasm is not a major stimulus for epinephrine release in either acute asthma or COPD.

Acute Disease↗