Biomedical subjects

Charles V Pollack

Publications and source records attributed to Charles V Pollack.

70 records · Page 4Linked to original sources

PubMed2003

Status report: Development of emergency medicine research since the Macy Report.

In Williamsburg, VA, April 17 to 20, 1994, the Josiah Macy, Jr. Foundation sponsored a conference entitled "The Role of Emergency Medicine in the Future of American Medical Care," a report on which was published in Annals in 1995. This report promulgated recommendations for the development and enhancement of academic departments of emergency medicine and a conference to develop an agenda for research in emergency medicine. The American College of Emergency Physicians' Research Committee, along with several ad hoc members, presents updates in several of the areas addressed by the Macy Report and subsequent conferences, as a status report for the development of emergency medicine research as a whole, as of late 2002.

Congresses as Topic↗

PubMed2003

2002 update to the ACC/AHA guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction: implications for emergency department practice.

The publication of comprehensive evidence-based guidelines for the management of non-ST-segment elevation acute coronary syndrome by the American College of Cardiology and the American Heart Association in September 2000 marked a sentinel event in the evolution of managing this challenging patient population. Many of the recommendations included in the guidelines have relevance to the emergency department care of patients with non-ST-segment elevation acute coronary syndrome and were summarized in Annals of Emergency Medicine in September 2001. New clinical data in this area continue to accumulate at a remarkably rapid rate, prompting the American College of Cardiology and the American Heart Association to publish an update of the 2000 guidelines in October 2002. Several of the modified and new recommendations again potentially affect ED management. These are presented and discussed here.

American Heart Association↗

PubMed2003

The impact of race on the acute management of chest pain.

OBJECTIVES: African Americans with acute coronary syndromes receive cardiac catheterization less frequently than whites. The objective was to determine if such disparities extend to acute evaluation and non interventional treatment. METHODS: Data on adults with chest pain (N = 7,935) presenting to eight emergency departments (EDs) were evaluated from the Internet Tracking Registry of Acute Coronary Syndromes. Groups were selected from final ED diagnosis: 1) acute myocardial infarction (AMI), n = 400; 2) unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI), n = 1,153; and 3) nonacute coronary syndrome chest pain (non-ACS CP), n = 6,382. American College of Cardiology/American Heart Association guidelines for AMI and UA/NSTEMI were used to evaluate racial disparities with logistic regression models. Odds ratios (ORs) were adjusted for age, gender, guideline publication, and insurance status. Non-ACS CP patients were assessed by comparing electrocardiographic (ECG)/laboratory evaluation, medical treatment, admission rates, and invasive and noninvasive testing for coronary artery disease (CAD). RESULTS: African Americans with UA/NSTEMI received glycoprotein IIb/IIIa receptor inhibitors less often than whites (OR, 0.41; 95% CI = 0.19 to 0.91). African Americans with non-ACS CP underwent ECG/laboratory evaluation, medical treatment, and invasive and noninvasive testing for CAD less often than whites (p < 0.05). Other nonwhites with non-ACS CP were admitted and received invasive testing for CAD less often than whites (p < 0.01). African Americans and other nonwhites with AMI underwent catheterization less frequently than whites (OR, 0.45; 95% CI = 0.29 to 0.71 and OR, 0.40; 95% CI = 0.17 to 0.92, respectively). A similar disparity in catheterization was noted in UA/NSTEMI therapy (OR, 0.53; 95% CI = 0.40 to 0.68 and OR, 0.68; 95% CI = 0.47 to 0.99). CONCLUSIONS: Racial disparities in acute chest pain management extend beyond cardiac catheterization. Poor compliance with recommended treatments for ACS may be an explanation.

Black or African American↗

PubMed2003

Interrater reliability of criteria used in assessing blunt head injury patients for intracranial injuries.

OBJECTIVE: To determine the interrater reliability of potential predictor variables that may be used to construct a clinical decision rule for emergency computed tomography of the head in blunt head injury victims. METHODS: As a substudy of the NEXUS II study of blunt head trauma, physicians from 21 different emergency departments performed paired evaluations of patients undergoing computed tomography of the head after blunt head injury. Each physician independently determined, for each subject, the presence or absence of each of 19 separate clinical characteristics. The physicians were either residents or attending physicians in the participating emergency departments. Paired responses on a sample of 3,951 patients were compared for raw level of agreement and for interrater concordance using the kappa statistic. If the lower margin of the 95% confidence interval for raw agreement was at least 85% and was equal to or greater than 0.50 for kappa, this was predetermined to represent substantial interrater agreement. RESULTS: There was substantial interobserver agreement by both measures for 17 of the 19 candidate variables in patients with blunt head trauma. Interobserver agreement was substantial for all candidate variables except presence of seizure (kappa = 0.57 [95% CI = 0.47 to 0.67]; raw agreement = 96.5%) and abnormal cerebellar function (kappa = 0.54 [95% CI = 0.41 to 0.67]; raw agreement = 96.5%). CONCLUSIONS: The clinicians in our study had a substantial level of agreement regarding most clinical criteria assessed in this large sample of patients with blunt head injury.

Analysis of Variance↗

PubMed2003

Can electrocardiographic criteria predict adverse cardiac events and positive cardiac markers?

OBJECTIVES: To determine electrocardiogram (ECG) predictors of positive cardiac markers and short-term adverse cardiac events in an undifferentiated chest pain population presenting to emergency departments (EDs). The authors hypothesized that specific ECG findings, other than those previously identified in higher-risk populations, would be predictive of cardiac outcomes and positive cardiac markers. METHODS: This study used data from a prospectively collected, retrospectively analyzed Internet-based data registry of undifferentiated chest pain patients (i*trACS). Logistic regression modeling was performed to determine the ECG findings that were predictive of 1) positive cardiac markers and 2) short-term adverse cardiac events. RESULTS: ST-segment elevation (STE), ST-segment depression (STD), pathological Q-waves (PQW), and T-wave inversion were associated with increased odds of percutaneous coronary intervention or catheterization, myocardial infarction, or coronary artery bypass grafting. The odds of creatine kinase-MB (CK-MB) measuring positive were increased if STE, STD, or PQW were present [odds ratio (OR) 2.495, 2.582, and 1.295, respectively]. A right bundle branch block tended to decrease the odds of CK-MB measuring positive (OR 0.658). A similar pattern of results was observed for troponin I (OR 3.608 for STE, 3.72 for STD, 1.538 for PQW). Troponin T showed an increased odds of measuring positive if any of STE, STD, left bundle branch block, or T-wave inversion were evident (OR 2.313, 2.816, 1.80, and 1.449, respectively). CONCLUSIONS: Initial ECG criteria can be used to predict short-term cardiac outcomes and positive cardiac markers. These findings can be important aids in the risk-stratification and aggressive treatment regimens of chest pain patients presenting to EDs.

Adult↗

PubMed2003

Use of helium-oxygen mixtures in the treatment of acute asthma: a systematic review.

STUDY OBJECTIVE: To determine the effect of the addition of heliox to standard medical care on the course of acute asthma. DESIGN: Systematic review of randomized and nonrandomized prospective, controlled trials of children and adults that compared heliox to placebo when used in conjunction with other standard acute treatments. MAIN OUTCOME MEASURES: Pulmonary function tests, hospital admissions, physiologic measures, side effects, and clinical outcomes. RESULTS: Seven trials were selected for inclusion, with a total of 392 patients with acute asthma. Six studies involved adults, and one study dealt solely with children. The main outcome variable was spirometric measurements (peak expiratory flow or FEV(1)) in six trials. Two studies evaluated the effect of heliox on airways resistance. No significant differences were demonstrated between heliox or oxygen/air groups (standardized mean difference [SMD], - 0.20; 95% confidence interval [CI], - 0.91 to 0.51; p = 0.6). However, the four studies that used heliox to deliver nebulized therapy showed a nonsignificant increase in pulmonary function (SMD, - 0.21; 95% CI, - 0.43 to 0.01; p = 0.06). In two studies of the same subgroup, heliox mixtures produced a significantly greater increase of heart rate than oxygen/air (weighted mean difference, 9.0; 95% CI, 1.27 to 16.8; p = 0.02). However, the four studies that used heliox to deliver nebulized therapy reported a nonsignificant difference in hospital admissions (odds ratio, 1.07; 95% CI, 0.46 to 2.48; p = 0.9). Overall, heliox appears to be safe and well tolerated. CONCLUSIONS: The existing evidence does not provide support for the administration of helium-oxygen mixtures to emergency department patients with moderate-to-severe acute asthma. However, these conclusions are based on between-group comparisons and small studies, and these results should be interpreted with caution.

Acute Disease↗

PubMed2002

A prospective multicenter study of factors associated with hospital admission among adults with acute asthma.

PURPOSE: We sought to determine patient characteristics associated with hospital admission after emergency treatment for asthma, and whether disposition guidelines are followed. SUBJECTS AND METHODS: We performed a prospective multicenter cohort study involving 64 emergency departments in the United States and Canada. Consecutive adult patients with asthma exacerbations were interviewed, and their charts were reviewed using standardized protocols. Telephone follow-up at 2 weeks determined relapse. RESULTS: Of 1805 patients, 363 (20%; 95% confidence interval [CI]: 18% to 22%) were hospitalized. Among patients with severe exacerbations (final peak flow <50% of predicted), 122 (49%; 95% CI: 43% to 55%) were hospitalized. Admission was associated with final peak flow, female sex, nonwhite race, severity of chronic illness, and severity of exacerbation. Admission predictors were similar regardless of hospital funding, region, or size. Among patients with mild or moderate exacerbations of asthma (peak flow >or=50% predicted), the likelihood of admission was associated significantly with the number of predefined risk factors for death from asthma. Of patients who were discharged from the emergency department, 62 (5%; 95% CI: 4% to 6%) relapsed within 72 hours. Relapse was not associated with final peak flow (P = 0.39). CONCLUSION: Associations between patient characteristics and disposition were similar across sites. Despite guidelines to the contrary, half of patients with final peak flow <50% were discharged. After emergency department treatment and discharge, short-term relapse was uncommon among patients with asthma, suggesting that strict peak flow cutoffs may be unnecessary if risk factors in patients with mild or moderate exacerbations are considered.

Acute Disease↗

PubMed2002

A prospective multicenter study of patient factors associated with hospital admission from the emergency department among children with acute asthma.

BACKGROUND: Recent studies show that objective measures such as peak flow rates are strongly associated with asthma admission among adults. OBJECTIVE: To identify factors associated with admission among children. METHODS: We performed a prospective cohort study as part of the Multicenter Airway Research Collaboration. Patients aged 2 to 17 years who presented to the emergency department (ED) with acute asthma underwent a structured interview in the ED and another by telephone 2 weeks later. The study was performed at 44 EDs in 18 US states and 4 Canadian provinces. The decision to admit was made at the discretion of the treating physician. Univariate analysis of risk factors for admission was followed by multivariate logistic regression. RESULTS: Of the 1178 eligible subjects, 275 (23%; 95% confidence interval, 21%-26%) were admitted or placed into ED observation units. A multivariate model that included 12 characteristics measured at presentation and during the ED stay was associated with an area under the receiver operating characteristic curve of 0.91. Demographic factors were not independently associated with admission. Severity of symptoms (odds ratio, 1.3) and intensity of therapy both before and during ED visit correlated with the likelihood of admission. Previous admission for asthma (P =.02) and recent use of inhaled corticosteroids (P =.04) also were associated with admission. Peak flows were associated with admission but were infrequently (23% overall) measured. CONCLUSION: Hospitalization for asthma exacerbation in children is primarily associated with clinical indicators in the ED and with historical factors such as previous asthma admission or intubation, recent use of corticosteroids, and comorbidity.

Adolescent↗

PubMed2002

Cardiac troponins.

Cardiac troponins I and T are proteins integral to the function of cardiac muscle. They are very sensitive markers for the detection of myocardial damage, and the ability to assay their serum levels accurately and quickly have revolutionized the concepts of minor myocardial injury and infarction. They are also powerful prognostic indicators of future adverse cardiac events. Limitations, more of troponin T than I, include decreased specificity in renal failure and skeletal muscle disease. Rapid, whole blood assays are now available that can be done at the patient's bedside. This review discusses the cardiac troponins, their biochemistry, the assays for them currently available, and their roles in the evaluation of cardiac disease in the Emergency Department (ED).

Biomarkers↗

PubMed2002

Troubleshooting and managing the difficult airway.

Difficult airways are an inevitable part of the delivery of emergency and critical care. Failure to achieve or restore a patent airway can lead, in a matter of minutes, to hypoxic neurological injury and death in critically ill patients. As with many conditions, the keys to success in a moment of crisis are forethought and preparation. Clinicians should be able to recognize risk factors for difficult airways and plan accordingly. In the face of failed direct laryngoscopy, a variety of rescue techniques are available. Familiarity with many strategies, and practiced dexterity with one or two, should be part of every intensivist's plan for the management of this life-threatening problem.

Journal Article↗

PubMed2002

The effectiveness of inhaled corticosteroids in the emergency department treatment of acute asthma: a meta-analysis.

STUDY OBJECTIVE: Inhaled corticosteroids (ICSs) are of proven benefit in the treatment of chronic asthma; however, their role in the management of acute asthma is unclear. METHODS: We performed a systematic review of randomized controlled trials involving children or adults treated in the emergency department for acute asthma with or without the addition of ICSs. Outcome measures included hospital admission, pulmonary function tests, and side effects. RESULTS: Seven trials were selected for inclusion in the primary analyses. ICSs versus placebo were compared; data were not available on 1 of these trials. In the remaining 6 trials, a total of 352 patients were studied (179 ICS-treated and 173 non-ICS-treated patients). Two trials compared ICSs plus systemic corticosteroids versus placebo plus systemic corticosteroids; 4 trials compared ICSs versus placebo. Patients treated with ICSs were less likely to be admitted to the hospital (odds ratio 0.30; 95% confidence interval [CI] 0.16 to 0.57) and showed small improvements in peak expiratory flows (weighted mean difference 8%; 95% CI 3% to 13%) Overall, the treatment was well tolerated, with few reports of adverse side effects. A secondary analysis compared ICSs alone versus systemic corticosteroids alone; in the 4 included trials, significant heterogeneity between the study results for admission rates precluded meaningful pooling of admission data. CONCLUSION: There is evidence of decreased admission rates for patients with acute asthma treated with ICSs. However, there is insufficient evidence that ICS therapy results in clinically important changes in pulmonary function when used in acute asthma, and there is insufficient evidence that ICSs alone are as effective as systemic corticosteroids.

Acute Disease↗

PubMed2002

A study of the workforce in emergency medicine: 1999.

STUDY OBJECTIVE: We estimate the total number of physicians practicing clinical emergency medicine during a specified period, describe certain characteristics of those individuals to estimate the total number of full-time equivalents (FTEs) and the total number of individuals needed to staff those FTEs, and compare the data collected with those data collected in 1997. METHODS: Data were gathered from a survey of a random sample of 2,153 hospitals drawn from a population of 5,329 hospitals reported by the American Hospital Association as having, or potentially having, an emergency department. The survey instrument addressed items such as descriptive data on the institution, enumeration of physicians in the ED, and the total number of physicians working during the period from June 6 to June 9, 1999. Demographic data on the individuals were also collected. RESULTS: A total of 940 hospitals responded (a 44% return rate). These hospitals reported that a total of 6,719 physicians were working during the specified period, or an average of 7.85 persons scheduled per institution. The physicians were scheduled for a total of 347,702 hours. The average standard for FTE was 40 clinical hours per week. This equates to 4,346 FTEs or 5.29 FTEs per institution. The ratio of persons to FTEs was 1.48:1. With regard to demographics, 83% of the physicians were men, and 82% were white. Their average age was 42.6 years. As for professional credentials, 42% were emergency medicine residency trained, and 58% were board certified in emergency medicine; 50% were certified by the American Board of Emergency Medicine. CONCLUSION: Given that there are 5,064 hospitals with EDs and given that the data indicate that there are 5.35 FTEs per ED, the total number of FTEs is projected to be 27,067 (SE=500). Given further that the data indicate a physician/FTE ratio of 1.47:1, we conclude that there are 39,746 persons (SE=806) needed to staff those FTEs. When adjusted for persons working at more than one ED, that number is reduced to 31,797. When the 1999 data are compared with those collected in 1997, we note a statistically significant decline in the number of hospital EDs, from 5,126 in 1997 to 5,064 in 1999 (P =.02). The total number of emergency physicians remained the same over the 2-year period, whereas the number of FTEs per institution increased from 5.11 to 5.35. The physician/FTE ratio remained unchanged.

Adult↗

PubMed2002

Validity of a decision rule to reduce cervical spine radiography in elderly patients with blunt trauma.

STUDY OBJECTIVES: A decision instrument based on 5 clinical criteria has been shown to be highly sensitive in selecting patients who require cervical spine imaging after blunt trauma, while simultaneously reducing overall imaging. We examine the performance of this instrument in the elderly and explore some of the common features of geriatric cervical spine injury (CSI). METHODS: The National Emergency X-radiography Utilization Study (NEXUS) was a prospective, observational, multicenter study conducted at 21 geographically diverse centers. We analyzed the performance of the NEXUS decision instrument among patients at least 65 years of age. RESULTS: The study group consisted of 2,943 (8.6%) geriatric patients, representing 8.6% of the entire NEXUS sample. The rate of CSI was twice as great in these patients as it was in nongeriatric patients (4.59% versus 2.19%). Odontoid fractures were particularly common in geriatric patients, accounting for 20% of geriatric fractures compared with 5% of nongeriatric fractures. The frequency of patients meeting NEXUS criteria was similar in the 2 groups, with 14% of geriatric patients and 12.5% of nongeriatric patient classified as low risk. CSI occurred in only 2 low-risk geriatric patients, and these patients' injuries met our preset definition of a clinically insignificant injury. The sensitivity of the NEXUS decision instrument for clinically significant injury in the geriatric group was therefore 100% (95% confidence interval 97.1% to 100%). CONCLUSION: The prevalence of CSI, and especially odontoid fracture, is relatively increased among geriatric patients with blunt trauma. The NEXUS decision instrument can be applied safely to these patients, with an expected reduction in cervical imaging comparable with that achieved in nongeriatric patients.

Adult↗

PubMed2002

Initial oxygen saturation as a predictor of admission in children presenting to the emergency department with acute asthma.

BACKGROUND: Previous studies have looked at the relationship between initial oxygen saturation (SaO (2)) and the need for admission in children presenting with an acute asthma exacerbation. If initial SaO (2) value is indeed predictive of admission, then the admission process could be initiated sooner, and time spent in the emergency department could be potentially lessened. STUDY OBJECTIVE: The objective of the current study was to examine whether initial room air SaO (2) in children presenting to the ED with acute asthma is a reliable predictor of hospital admission. METHODS: This was a prospective multicenter study during 1997 and 1998 at 44 North American EDs as part of the Multicenter Airway Research Collaboration. Inclusion criteria were physician diagnosis of acute asthma and age between 2 and 17 years. The association between hospital admission and SaO (2) was examined by using logistic regression. Likelihood ratios were used to assess the diagnostic value of SaO (2). RESULTS: Of the 1,184 children enrolled in the current study, 1,040 (88%) had a documented initial SaO (2) value on room air. The mean age of the cohort was 8+/-4 years, with a mean initial SaO (2) of 95%+/-4%. Overall, 241 (23%) children were admitted to the hospital. The mean SaO (2) value of children admitted to the hospital was 93%+/-5% versus 96%+/-3% for those not admitted (P <.001). The admission rate decreased with increasing SaO (2); 73% (30/41) of children with an SaO (2) value of 88% or less were admitted versus 8% (7/88) with an SaO (2) value of 100%. In the logistic regression model, children with an SaO (2) value of 88% or less were 32 (95% confidence interval 11 to 89) times more likely to be admitted than those with an SaO (2) value of 100%. The likelihood ratio for admission was 12 for children with an SaO (2) value of 88% or less (42/1,040) but decreased to 4.6 for children with an SaO (2) value of 91% or less (130/1,040) and 2.7 for children with an SaO (2) value of 94% or less (333/1,040). CONCLUSION: This large, clinical multicenter study does not support earlier findings that SaO (2) alone is a clinically useful predictor of hospital admission in children who present to the ED with acute asthma.

Adolescent↗

PubMed2002

Developing a clinical decision instrument to rule out intracranial injuries in patients with minor head trauma: methodology of the NEXUS II investigation.

The fear of failing to identify brain injury has led to the liberal and potentially excessive use of computed tomographic (CT) scanning of patients with blunt head trauma who have even a remote possibility of intracranial injury. This practice exposes large numbers of patients to the expense and radiation exposure associated with CT imaging while detecting injuries in a small minority. Previous studies suggest that it might be possible to develop a decision instrument to identify patients with blunt head injury who have essentially no risk of significant intracranial injury and for whom CT scanning is therefore unnecessary. Development of such a decision instrument has been identified as a priority among practicing emergency physicians. The National Emergency X-Radiography Utilization Study II (NEXUS II) is a large, multicenter, prospective study designed to derive a decision rule for CT imaging of patients with blunt head injury. This study, conducted in 21 different emergency departments across the United States and Canada, will enroll more than 10 times as many patients with head trauma as any currently published study. NEXUS II should be able to definitively answer questions about the validity and reliability of clinical criteria as a preliminary screen for blunt head trauma.

Brain Injuries↗

PubMed2002

Improving the care of patients with non-ST-elevation acute coronary syndromes in the emergency department: the CRUSADE initiative.

Although acute coronary syndromes (ACS) represent a well-recognized source of morbidity and mortality for patients with cardiovascular disease, evidence-based therapies shown to improve outcomes for ACS are frequently underused in appropriate patients, especially in the emergency department (ED). Despite dissemination of expert recommendations from the American College of Cardiology/American Heart Association (ACC/AHA) and ED-focused recapitulation of them in the emergency medicine literature, significant barriers continue to limit the adoption of guidelines in clinical practice and appear to hinder the use of beneficial therapies and interventions in the ED. Unique and creative approaches are therefore needed to stimulate better adherence to practice guidelines and improve the quality of care for patients with non-ST-elevation myocardial infarction (NSTE) ACS. The CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation of the ACC/AHA Guidelines) quality improvement and educational initiative provides an innovative and multifaceted approach to the education of emergency physicians and cardiologists in the care of patients with NSTE ACS. The CRUSADE initiative is a multidisciplinary cooperative effort involving over 400 EDs and medical centers. It includes an ACS registry designed to characterize demographic patterns and risk stratification results in patients who meet diagnostic criteria for high-risk NSTE ACS. It also measures the use of ED treatment modalities including aspirin, heparin, beta-blockers, and platelet inhibitors as recommended in the ACC/AHA guidelines. The results of a given institution's treatment patterns will be reported back to the practitioners, with comparisons with national norms. These reports can be used as quality improvement tools to improve care at participating institutions. Beyond a static registry, these reports are coupled with educational efforts by the CRUSADE steering committee, scientific publications of risk stratification practice and success, as well as ED patterns of care, and tailored educational interventions, to reinforce compliance with the ACC/AHA guidelines. This initiative represents a truly innovative approach to improving care for ACS patients in the ED as well as on the cardiology service. This article describes the CRUSADE initiative and its implications for the practicing emergency physician. It is the intent of CRUSADE to improve patient care in the ED by tracking and encouraging compliance with evidence-based guidelines for the evaluation and management of NSTE ACS.

Angina, Unstable↗