Patients Requiring Emergency Department Research Articles

Outcomes of Transplant-Eligible and Transplant-Ineligible Patients with Mantle Cell Lymphoma in Ontario, Canada

Background The frontline treatment of patients with symptomatic mantle cell lymphoma (MCL) requiring treatment varies in practice. In Ontario, Canada, transplant-eligible (TE) patients have been treated with chemoimmunotherapy followed by autologous stem cell transplant (ASCT). In 2013, R-CHOP alternating with R-DHAP prior to ASCT replaced R-CHOP alone as standard of care based on the European MCL Younger trial (Hermine JCO 2022). Although this regimen improves progression-free survival, there remains concern about its toxicity. For transplant-ineligible (TI) patients, the standard of care has evolved over time. Evidence in support of bendamustine-rituximab (BR) efficacy in indolent lymphoma resulted in its increased use in TI patients with MCL over the last decade. However, real-world data are lacking on toxicities of this regimen compared to other chemoimmunotherapy. We aimed to characterize survival and healthcare utilization outcomes of patients with MCL using current treatment approaches. Methods We conducted a retrospective population-based study of patients with MCL using healthcare administrative databases from Ontario, Canada, from 2005 to 2020. Patients were defined as TE if they were less than 70 years old at the time of treatment initiation, and received either R-CHOP or R-CHOP/R-DHAP. Patients were defined as TI if they were 70 years or greater at the time of treatment initiation, and treated with BR or other forms of chemoimmunotherapy. The primary outcome was 5-year overall survival (OS), from the time of first treatment to death or end of the study period. Secondary outcomes were toxicities of treatment and healthcare utilization. Cox regression analyses were used to assess the impact of demographic and treatment variables on OS. Results A total of 918 patients with MCL were included in this study; 426 were TE and 492 TI. For TE patients, 254 were treated with R-CHOP, and 172 with R-CHOP/R-DHAP. The median age of patients in both groups was 60 years (range 36-70 years, p=0.37). Patients treated with R-CHOP alone were followed for a mean of 6.01 years, and patients treated with R-CHOP/R-DHAP for a mean of 3.38 years. Maintenance rituximab (MR) was used in 70.5% of patients treated with R-CHOP and 77.3% of patients treated with R-CHOP/R-DHAP (p=0.12). ASCT was received by 53.5% of patients treated with R-CHOP and 83.7% of patients treated with R-CHOP/R-DHAP (p<0.01). 5-year OS of patients treated with R-CHOP/R-DHAP was 70.5% vs 62.0% for patients treated with R-CHOP regardless of transplant status ( Figure 1A hazard ratio [HR] 0.75, 95% CI 0.51-1.10). Of the 270 patients who received ASCT within 1 year of treatment initiation, survival was not impacted by prior receipt of R-CHOP alone or R-CHOP/R-DHAP (HR for R-CHOP/R-DHAP vs. R-CHOP 0.76, 95% CI 0.42-1.39). A higher proportion of patients treated with R-CHOP/R-DHAP required hospital admissions for fever, infection, neutropenia, and renal toxicity, compared to R-CHOP alone ( Table 1). There was no difference between regimens in the number of patients requiring emergency department (ED) visits between regimens (p=0.39). 492 TI patients were included; 303 treated with BR and 189 treated with other regimens, most commonly R-CHOP (n=62) or R-CVP (n=108). The median age of patients in both groups was 77 years (range 71-94 years, p=0.17), and there was no significant difference in comorbidities (p=0.23). MR was more commonly used after BR compared to historical regimens (72.6% vs. 54.5%, p<0.01). 5-year unadjusted OS of patients treated with BR was 40.3% and 27.5% for patients treated with R-CHOP/R-CVP ( Figure 1B), with significantly lower mortality with the use of BR (HR 0.68, 95% CI 0.51-0.89). After adjusting for age, sex, comorbidities, and MR, this was no longer significant (HR 0.86, 95% CI 0.65-1.14). MR use was associated with significantly lower mortality (HR 0.33, 95% CI 0.24-0.44). More patients treated with BR had hospital admissions for neutropenia and febrile neutropenia ( Table 1). Conclusion In this large population-based study of patients with MCL, R-CHOP/R-DHAP prior to ASCT showed a trend toward improved 5-year OS, though not significant. For TI patients, BR resulted in superior OS compared to other regimens with similar rates of toxicities, however this was not significant after adjusting for use of MR, suggesting other regimens followed by MR may be a reasonable alternatives.

E006 An audit showing the successful operation of a nurse-led gout clinic during the COVID-19 pandemic

Abstract Background/Aims Research has shown nurse-led gout clinics provide better outcomes compared to usual care. This District General Hospital set up a pilot nurse-led gout clinic in autumn 2019. This aimed to improve patients’ understanding of their condition, achieve better control of serum uric acid levels (SUA), reduce flares and prevent Emergency Department attendances. Methods A modified clinic protocol, closely modelled on BSR guidance was agreed within the department. With consultant supervision, one nurse specialist provided a mix of in-person and telephone appointments. Targets were set aiming for SUA <360µmol/L for most patients and <300µmol/L for those with erosive change or tophi. All patients were offered prophylaxis. Patients required a rheumatologist’s diagnosis of gout or crystal confirmation for enrolment. Exclusion criteria were significant renal or hepatic derangement. Within 3 months of the service starting SARS-CoV-2 impacted the operation of healthcare worldwide and led to the closure of routine outpatient clinics in Northern Ireland. A decision was made to switch the gout clinic to run entirely by telephone. Blood testing was facilitated through primary care and phlebotomy hubs. Results Over a 19-month period, 78 patients were treated and audited through this clinic: 69 men and 9 women. Average age was 57, mean SUA 509 µmol/L at referral and 322 µmol/L on discharge. 69 patients received allopurinol and 9 received febuxostat. No patients required uricosuric drugs. All patients were offered and agreed to take prophylaxis with a majority (85.8%) remaining on it for 3-6 months. Patients required a mean of 3.38 appointments prior to discharge from the clinic. The mean dose of urate lowering therapy on discharge was 315.9mg allopurinol and 93.3mg febuxostat. 95% experienced ≤2 flares during their enrolment in the clinic with no patients requiring Emergency Department attendance due to gout flare. Conclusion The nurse-led gout clinic was well received by patients and was effective as a telephone service during the pandemic when so many services were stood down. The clinic was able to continue to provide education, deliver effective reductions in uric acid as well as reduce incidence of flares and Emergency Department attendances. Lower doses of urate lowering therapy than expected were needed to achieve target. A small number of patients were discharged prior to enrolment for initial non-engagement which may have been exacerbated by the lack of face-to-face appointments. Our COVID-19 model did struggle with those patients needing an interpreter. In-person initial appointments have since been restarted; however, a greater proportion of reviews will continue to be offered by telephone given the unexpected success of the model. This audit showed that a nurse-led gout clinic can run successfully, even during a pandemic with a significant reliance on telephone consultations. Disclosure L. McWilliams: None. R.G.A. Stewart: None.

Clinical outcomes of children and adolescents with sickle cell disease and COVID-19 infection: A year in review at a metropolitan tertiary pediatric hospital.

COVID-19 was declared a global pandemic in March 2020. Early reports were primarily in adults, and sickle cell disease (SCD) was classified as a risk factor for severe COVID-19 disease. However, there are a limited number of primarily multi-center studies reporting on the clinical course of pediatric patients with SCD and COVID-19. We conducted an observational study of all patients with SCD diagnosed with COVID-19 at our institution between March 31, 2020, and February 12, 2021. Demographic and clinical characteristics of this group were collected by retrospective chart review. A total of 55 patients were studied, including 38 children and 17 adolescents. Demographics, acute COVID-19 clinical presentation, respiratory support, laboratory findings, healthcare utilization, and SCD modifying therapies were comparable between the children and adolescents. Seventy-three percent (N = 40) of all patients required emergency department care or hospitalization. While 47% (N = 26) were hospitalized, only 5% (N = 3) of all patients required intensive care unit admission. Patients frequently had concurrent vaso-occlusive pain crisis (VOC) (N = 17, 43%) and acute chest syndrome (ACS) (N = 14, 35%). Those with ACS or an oxygen requirement had significantly higher white blood cell count, lower nadir hemoglobin, and higher D-dimers, supporting a pro-inflammatory and coagulopathic picture. Non-hospitalized patients were more likely to be on hydroxyurea than hospitalized patients (79 vs. 50%, p = 0.023). Children and adolescent patients with SCD and acute COVID-19 often present with ACS and VOC pain requiring hospital-level care. Hydroxyurea treatment appears to be protective. We observed no mortality despite variable morbidity.

Coronavirus disease 2019 rebounds following nirmatrelvir/ritonavir treatment.

Nirmatrelvir/ritonavir (NMV-r) is an effective anti-SARS-CoV-2 agent and has been recommended in the treatment of non-hospitalized patients with COVID-19. In rare occasions, some patients experience virologic and symptomatic rebound after initial resolution, which we call COVID-19 rebound after NMV-r. Although COVID rebound can also occur after molnupiravir treatment or even no antiviral treatment, we have more serious concern about the rebound after NMV-r, which remains the most effective antiviral. Due to a lack of information about its frequency, mechanism, outcomes, and management, we conducted this review to provide comprehensive and updated information to address these questions. Based on the limited evidence, the incidence of COVID-19 rebound after NMV-r was less than 2%, and most cases developed 5-15 days after initiating NMV-r treatment. Almost all reported cases had mild symptoms, and the clinical condition gradually subsided without additional treatment. Overall, the clinical outcome was favourable, and only a small number of patients required emergency department visits or hospitalization. Regarding virologic rebound, culturable SARS-CoV-2 with possible transmission was observed, so re-isolation may be needed. This article is protected by copyright. All rights reserved.

Enteral tube feeding selection at NICU discharge and resource utilization.

To evaluate resource utilization in infants discharged with different forms of feeding access. Retrospective chart review of neonates discharged from 2012 to 2018. Data were collected from the medical record and relevant outcomes were compared. 300 patients were sampled. 196 (65%) were discharged on NG feeds, 95 (32%) via GT, and 9 gastrojejunal (GJ 3%). NG-fed infants discharged sooner (mean DOL: NG = 85.4 vs GT = 122.8, p < 0.001). More GT/GJ patients required emergency department (ED) visits for tube complications (GT = 61 vs GJ = 7 vs NG = 42, p < 0.001) and more frequently (mean visits: GT = 1.63 ± 2.33 vs GJ = 4.22 ± 4.44 vs NG = 0.48 ± 1.40, p < 0.001). However, 44 (24%) of the patients discharged on NG later had a GT placed. Many patients discharged from the NICU can be supported with NG feeds. This may shorten hospital stays and decrease ED visits but select patients will later merit surgical tube placement.

Patterns of azithromycin use in obstructive airway diseases: a real-world observational study.

Low-dose long-term azithromycin is recommended in clinical practice guidelines for obstructive airway diseases (OAD); however, an optimal therapeutic regimen is not yet established. To understand the patterns of azithromycin use in OAD, characterise the patients who received it and evaluate its safety and efficacy using real-world data. We audited 91 patients who had received azithromycin for at least 4 weeks for the management of asthma, chronic obstructive pulmonary disease (COPD) or non-cystic fibrosis bronchiectasis. The mean age was 65 ± 18 years, 60% were female and 48% were ex-smokers. The majority had asthma (75%), either alone (50%) or in combination with COPD (12%) or bronchiectasis (13%). Most (64%) reported cough or sputum at baseline. The most common treatment regimen was azithromycin 250 mg daily (73%) for more than 1 year (57%), with only seven adverse events. There was a significant reduction in the proportions of patients requiring emergency department visits (48% vs 32%; P < 0.001) and hospital admissions (35% vs 31%; P < 0.001) after starting azithromycin. In 88% of cases, physicians favoured the use of azithromycin. Physicians are currently using low-dose azithromycin for a long duration of more than 1 year for the management of OAD. The typical case definition is an older non-smoking adult with persistent asthma, often in combination with another OAD and presenting with bothersome cough or sputum. Azithromycin was well tolerated and led to reduced healthcare utilisation. Further research is required to establish an optimal dosage regimen of azithromycin in OAD.

Rapid Adoption of Telemedicine Along with Emergent Use of Continuous Glucose Monitors in the Ambulatory Care of Young Persons with New-Onset Type 1 Diabetes in the Time of COVID-19: A Case Series.

Aims: The COVID-19 pandemic has caused strain on hospital systems and potential delay in diagnosis of type 1 diabetes (T1D). Outpatient diagnosis and treatment of metabolically stable young persons with new-onset T1D have been shown to be equivalent to inpatient. We describe an approach to outpatient management of newly diagnosed T1D during the COVID-19 pandemic using an interdisciplinary team, telemedicine, and diabetes technologies including rapid implementation of continuous glucose monitoring (CGM). Methods: Following the onset of the COVID-19 pandemic, new-onset cases of T1D were tracked. After laboratory confirmation of diagnosis and metabolic stability, patients and families were referred for ambulatory initiation of insulin therapy and diabetes education. These cases were reviewed using data extracted from the electronic health record, comments from multidisciplinary team members, and cloud-based glucose data. Results: We report on seven young people with new-onset T1D without diabetic ketoacidosis from April to June 2020, during the COVID-19 pandemic. Ages ranged 9-23 years with presenting hemoglobin A1c (HbA1c) values 10-14.5%. Initial evaluation was generally face-to-face, followed by frequent telemedicine visits. Five patients had a family history of T1D. Two patients had access to at-home HbA1c kits prompting evaluation in the absence of symptoms. Four patients required emergency department evaluation. Five patients presented with ketosis. All patients were prescribed CGM at the first visit, most starting within 1 month. Conclusions: Technology is extraordinarily useful for the care of young persons with new-onset T1D in the ambulatory setting during the COVID-19 pandemic. Large observational studies are needed to better understand outcomes of an outpatient, technology-focused approach.

Novel treatment of dihydrogen sulfide inhalation using hyperbaric oxygen during mass casualty

Hydrogen sulfide (H2S) is a toxic gas produced via breakdown of organic matter. Hydrogen sulfide exposure can cause symptoms ranging in severity from mild effects (dizziness, headache, nausea) to severe lactic acidosis, respiratory failure, pulmonary edema, cardiac arrhythmias and death. Treatment modalities include oral countermeasures and 100% FiO2 with supportive therapy. However, case studies utilizing hyperbaric oxygen (HBO2) therapy have been reported with general benefit seen in severe cases of toxicity. In this report, cases of mild to moderate H2S toxicity occurred aboard a U.S. Navy ship, resulting in a mass casualty incident of more than 30 patients. Patient symptoms included dizziness, headaches, nausea, vomiting, and one patient with altered mental status. Most patients’ symptoms resolved after several hours of supportive therapy, but six patients had symptoms refractory to 100% FiO2 at 1 atm. These six patients received HBO2 therapy with a USN Treatment Table 9 after consultation with the local emergency room and hyperbaric assets. Four separate chambers were utilized, including two chambers onboard USN ships and the local explosive ordnance disposal (EOD) chamber. Complete resolution of symptoms in all six patients was achieved within the first breathing period. Patients were monitored after treatment aboard the USN ship medical department. No patients required emergency department care. These cases demonstrate an expanded use of HBO2 to include moderate cases of H2S toxicity refractory to first-line therapy.

Cryptococcal meningitis: a review for emergency clinicians.

Cryptococcal Meningitis (CM) remains a high-risk clinical condition, and many patients require emergency department (ED) management for complications and stabilization. This narrative review provides an evidence-based summary of the current data for the emergency medicine evaluation and management of CM. This review evaluates the diagnosis, management, and empiric treatment of suspected CM in the ED. CM can easily evade diagnosis with a subacute presentation, and should be considered in any patient with a headache, neurological deficit, or who is immunocompromised. As a definitive diagnosis of CM will not be made in the ED, management of a patient with suspected CM includes prompt diagnostic testing and initiation of empiric treatment. Multiple types of newer Cryptococcal antigen tests provide high sensitivity and specificity both in serum and cerebrospinal fluid (CSF). Patients should be treated empirically for bacterial, fungal, and viral meningitis, specifically with amphotericin B and flucytosine for presumed CM. Additionally, appropriate resuscitation and supportive care, including advanced airway management, management of increased intracranial pressure (ICP), antipyretics, intravenous fluids, and isolation, should be initiated. Antiretroviral therapy (ART) should not be initiated in the ED for those found or known to be HIV-positive for risk of immune reconstitution inflammatory syndrome (IRIS). CM remains a rare clinical presentation, but carries significant morbidity and mortality. Physicians must rapidly diagnose these patients while evaluating for other diseases and complications. Early consultation with an infectious disease specialist is imperative, as is initiating symptomatic care.

Fournier Gangrene: A Review for Emergency Clinicians.

Fournier gangrene (FG) is a rare, life-threatening infection that can result in significant morbidity and mortality, with many patients requiring emergency department (ED) management for complications and stabilization. This narrative review provides an evidence-based summary of the current data for the emergency medicine evaluation and management of FG. Although originally thought to be an idiopathic process, FG has been shown to have a strong association for male patients with advanced age and comorbidities affecting microvascular circulation and immune system function, most commonly those with diabetes or alcohol use disorder. However, it can also affect patients without risk factors. The initial infectious nidus is usually located in the genitourinary tract, gastrointestinal tract, or perineum. FG is a mixed infection of aerobic and anaerobic bacterial flora. The development and progression of gangrene is often fulminant and can rapidly cause multiple organ failure and death, although patients may present subacutely with findings similar to cellulitis. Laboratory studies, as well as imaging including point-of-care ultrasound, conventional radiography, and computed tomography are important diagnostic adjuncts, though negative results cannot exclude diagnosis. Treatment includes emergent surgical debridement of all necrotic tissue, broad-spectrum antibiotics, and resuscitation with intravenous fluids and vasoactive medications. FG requires a high clinical level of suspicion, combined with knowledge of anatomy, risk factors, and etiology for an accurate diagnosis. Although FG remains a clinical diagnosis, relevant laboratory and radiography investigations can serve as useful adjuncts to expedite surgical management, hemodynamic resuscitation, and antibiotic administration.

Do Patients Require Emergency Department Interventions After Prehospital Naloxone?

Patients receiving naloxone for suspected opioid overdose in the prehospital setting are typically transported to the emergency department (ED) for further evaluation, regardless of Glasgow Coma Scale (GCS). The objective of our study is to determine whether patients with GCS ≥14 after receiving prehospital naloxone received additional doses of naloxone and medical interventions in the ED compared with those with GCS <14 after prehospital naloxone. Our retrospective observational study included patients ≥18 years old treated with naloxone and transported by an inner-city hospital-based Emergency Medical Services (EMS) to its affiliated ED from January 2, 2016 to December 31, 2016. Investigators collected demographic data, prehospital interventions, GCS, ED interventions, and dispositions. Institutional Review Board approval was obtained. The main outcome measures were repeat doses of naloxone and ED interventions. In all, 473 patient encounters were reviewed. Most common route of prehospital naloxone administration was intranasal (68%). Nearly two-thirds (n = 473) of patients had GCS ≥14 upon ED arrival. Repeat naloxone was administered to 3.5% (n = 314) of patients with GCS ≥14 versus 14.6% (n = 159) of patients with GCS <14. ED interventions, such as airway maneuvers, laboratory and radiology testing, and cardiac monitoring, were less common among patients who had improved GCS of 14 or higher (n = 314). There were 8 deaths among patients with GCS <14 (n = 159) and no deaths among patients with GCS ≥14 (n = 314). Patients with GCS score ≥14 after administration of prehospital naloxone are less likely to receive additional naloxone doses and medical interventions in the ED compared with those with a GCS score <14 after prehospital naloxone and may present an invaluable opportunity for the ED to initiate an addiction treatment program for patients with nonfatal overdose.

Scleroderma renal crisis: a review for emergency physicians.

Scleroderma renal crisis (SRC) remains a high-risk clinical presentation, and many patients require emergency department (ED) management for complications and stabilization. This narrative review provides an evidence-based summary of the current data for the emergency medicine evaluation and management of SRC. While SRC remains a rare clinical presentation, surveillance data suggest an overall incidence between 4 and 6% of patients with scleroderma. The diagnostic criteria for SRC include a new onset blood pressure > 150/85mm Hg OR increase ≥ 20mm Hg from baseline systolic blood pressure, along with a decline in renal function, defined as an increase serum creatinine of ≥ 10% and supportive features. There are many risk factors for SRC, including diffuse and rapidly progressive skin thickening, palpable tendon friction rubs, and new anemia or cardiac events. Critical patients should be evaluated in the resuscitation bay, and consultation with the nephrology team for appropriate patients improves patient outcomes.

PCN264 - ASSESSMENT OF TREATMENTS AND HEALTH CARE UTILISATION (HCU) IN SPAIN FOLLOWING INITIAL PLATINUM THERAPY FOR RECURRENT OR METASTATIC (R/M) HEAD AND NECK SQUAMOUS CELL CARCINOMA (HNSCC)

To assess treatment patterns and HCU among patients with R/M HNSCC in Spain who experienced progression during or after platinum-based chemotherapy. Physicians in Spain recruited by convenience sampling reviewed medical records of adult patients who experienced disease progression between 1 January 2011 and 31 March 2016. Progression must have occurred during or after palliative platinum chemotherapy for R/M HNSCC or within 6 months after platinum chemotherapy as part of a multimodality therapy with curative intent. Disease characteristics, treatment patterns, and HCU (including drug administration encounters) were described. Data for 196 patients (median age 58.6 years) were extracted by 43 physicians. Second-line systemic therapy was received by 154 (78.6 %) patients; 42 (21.4%) patients received best supportive care only. The most frequently received second-line regimens were cetuximab+paclitaxel (n=38, 24.7%), paclitaxel monotherapy (n=19, 12.3%), and single-agent cetuximab (n=18, 11.7%). Of patients receiving second-line treatment, only 38 (24.7%) received third-line treatment. During second-line treatment, hospital outpatient and community health visits were reported for 64 (41.6%) and 24 (15.6%) patients (median 0.9 and 0.7 visits/month, respectively); 33 (21.4%) patients required emergency department visits, and treatment- or procedure-related complications (n=15, 45.5%) were the most common reason for these visits. Hospitalisations during second-line treatment were reported for 35 (22.7%) patients; median length of stay was 10 days. Palliative care (n=18, 51.4%), disease progression (n=17, 48.6%), and treatment- or procedure-related complications (n=8, 22.9%) were common reasons for hospitalization. After progression on initial platinum therapy, 21.4% patients received best supportive care and, of the 154 (78.6%) receiving second-line therapy, only 24.7% received subsequent treatments. A considerable proportion of patients were hospitalised for disease- and treatment-related issues, highlighting the need for improved safety of new treatments.

System Stresses in 2 Pediatric Emergency Departments and 2 Pediatric Urgent Care Centers During the 2014 Enterovirus-D68 Outbreak.

To describe the association of an unprecedented large-scale Enterovirus-D68 outbreak in 2014 with changes in patient volume and acuity and system stress in 2 pediatric emergency departments and 2 pediatric urgent care centers of a single children's hospital. We compared measures of patient volume, acuity, and system stress during the 2014 Enterovirus-D68 outbreak and the corresponding dates of the previous year. Both settings experienced large census increases during the Enterovirus-D68 outbreak; patient census increased significantly more in the pediatric urgent care setting (20.3%) than in the pediatric emergency departments (14.3%). Both settings had significant increases in patient acuity. The proportion of pediatric emergency department patients requiring hospital admission increased; the proportion of patients who left the pediatric urgent care setting without being seen also increased. Although there was no emergency department inpatient boarding during the 2013 comparison period, 4.4% of admitted patients required emergency department boarding during the 2014 outbreak. There was no significant change in the mean length of stay or the probability that patient admission was to the pediatric intensive care unit. Both the pediatric emergency departments and the pediatric urgent care centers experienced increased patient volumes and acuity and significant system stress in association with the 2014 Enterovirus-D68 outbreak. These data will inform those planning resource allocation for future large-scale viral outbreaks.

Southcare Geriatric Flying Squad: an innovative Australian model providing acute care in residential aged care facilities.

This study reviews the outcomes of a model developed to improve the quality of care of residents living within residential aged care facilities (RACF). The Southcare Geriatric Flying Squad saw a total of 640 acutely unwell RACF residents over an 18-month period. Of these, 578 (90.3%) were managed in the RACF avoiding emergency department. Only 35 (5.5%) patients required emergency department transfer and 27 (4.2%) were directly admitted to a medical ward. The service may have reduced emergency presentations by offering rapid assessment and management, choice in place of treatment and level of interventions.

PGI44 - Economic and Quality-Of-Life Burden of Moderate to Severe Irritable Bowel Syndrome with Constipation (IBS-C) in Spain: Interim Analysis of the IBIS-C Study

PGI44 ECONOMIC AND QUALITY-OF-LIFE BURDEN OF MODERATE TO SEVERE IRRITABLE BOWEL SYNDROME WITH CONSTIPATION (IBS-C) IN SPAIN: INTERIM ANALYSIS OF THE IBIS-C STUDY Mearin F.1, Fortea J.2, Valveny N.3, Cortes X.2, Lindner L.2, Prior M.2 1Centro medico Teknon, Barcelona, Spain, 2Laboratorios Almirall S.A., Barcelona, Spain, 3TFS, Barcelona, Spain OBJECTIVES: The IBIS-C study, currently ongoing, is the first to assess the burden of IBS-C in 6 European countries (France, Germany, Italy, Spain, Sweden, UK) . We present an interim analysis of the retrospective data from Spain. METHODS: This is an observational, retrospective-prospective (±6-months(m)) study in patients diagnosed in the last five years of IBS-C (Rome-III criteria) of moderate-to-severe degree (IBS-Symptom Severity Score(IBS-SSS)≥ 175). Quality-of-life(QoL) was assessed with the EuroQoL-5D(EQ-5D) and IBS-QoL. RESULTS: We included 46 patients (62% severe, mean(±SD) 44.6±12.2 years, 83% women, time since diagnosis 2.8±3.6 years). According to IBS-SSS, 94% had abdominal pain in the last month (62% of time) and 85% abdominal distention. Other prevalent symptoms were: constipation (96%), abdominal discomfort (72%) and bloating (59%). Mean IBS-QoL was 46±23, on a scale 0-100 (worst QoL), and the most affected domains were “food avoidance” (mean:64) and “health worry” (60). Mean EQ-5D was 51±20, on a scale 0-100 (best QoL), and 93% and 70% of patients, respectively, reported problems in pain/discomfort and anxiety/ depression. In the previous 6m, 83% of patients consulted a primary care physician, and 89% a specialist (mostly a gastroenterologist)(mean(95%CI):2.8(1.4-4.3) and 2.0(0.9-3.1) visits, respectively). 20% of patients required emergency department visits or hospitalization (mean stay:1.3(0.6-1.9) days). 76% of patients underwent a diagnostic test (mean:2.1(1.3-2.9) tests). 89% of patients took medication (63% prescription drugs and 54% OTC medications), 26% received complementary therapies. The mean direct costs per patient for the National Health System(NHS) were € 1,025/6m(549-1627) and the mean costs for the patient were € 200/6m. 17% of patients had sick leave(mean:3.5 leaves; mean duration:58 days) and 46% had productivity losses(mean:49 hours). Mean indirect costs were € 991/6m. Total costs amounted to € 2216/6m. CONCLUSIONS: Moderate-to-severe IBS-C has a great impact on health care resource utilization and productivity of patients, and the results suggest significant costs to the NHS and society. QoL can be severely affected.

Simple method of fluid resuscitation in patients requiring emergency thoracotomy through direct cardiac cannulation

Patients who are critically injured with imminent cardiac arrest may require immediate thoracotomy as an integral component of their initial resuscitation in the emergency department. Fluid resuscitation can be difficult owing to a shutdown state. A simple method for fluid delivery in patients requiring emergency department clamshell thoracotomy entails the insertion of a large bore venous catheter directly into the right atrium at its appendage and using it for fluid resuscitation (Fig 1). This method is quick, safe and easily reproducible. Once the patient is stable, the catheter can be removed and a simple purse string suture used to close the atrium. Figure 1 Clamshell thoracotomy with a large bore venous catheter in the right atrium (arrow)

External validation of the Cardiff model of information sharing to reduce community violence: natural experiment

BackgroundCommunity violence is a substantial problem for the NHS. Information sharing of emergency department data with community safety partnerships (CSP) has been associated with substantial reductions in assault attendances in...

Burden of uncontrolled epilepsy in patients requiring an emergency room visit or hospitalization

To quantify the clinical and economic burden of uncontrolled epilepsy in patients requiring emergency department (ED) visit or hospitalization. Health insurance claims from a 5-state Medicaid database (1997Q1-2009Q2) and 55 self-insured US companies ("employer," 1999Q1 and 2008Q4) were analyzed. Adult patients with epilepsy receiving antiepileptic drugs (AED) were selected. Using a retrospective matched-cohort design, patients were categorized into cohorts of "uncontrolled" (≥ 2 changes in AED therapy, then ≥ 1 epilepsy-related ED visit/hospitalization within 1 year) and "well-controlled" (no AED change, no epilepsy-related ED visit/hospitalization) epilepsy. Matched cohorts were compared for health care resource utilization and costs using multivariate conditional regression models and nonparametric methods. From 110,312 (Medicaid) and 36,529 (employer) eligible patients, 3,454 and 602 with uncontrolled epilepsy were matched 1:1 to patients with well-controlled epilepsy, respectively. In both populations, uncontrolled epilepsy cohorts presented about 2 times more fractures and head injuries (all p values < 0.0001) and higher health care resource utilization (ranges of adjusted incidence rate ratios [IRRs] [all-cause utilization]: AEDs = 1.8-1.9, non-AEDs = 1.3-1.5, hospitalizations = 5.4-6.7, length of hospital stays = 7.3-7.7, ED visits = 3.7-5.0, outpatient visits = 1.4-1.7, neurologist visits = 2.3-3.1; all p values < 0.0001) than well-controlled groups. Total direct health care costs were higher in patients with uncontrolled epilepsy (adjusted cost difference [95% confidence interval (CI)] Medicaid = $12,258 [$10,482-$14,083]; employer = $14,582 [$12,019-$17,097]) vs well-controlled patients. Privately insured employees with uncontrolled epilepsy lost 2.5 times more work days, with associated indirect costs of $2,857 (95% CI $1,042-$4,581). Uncontrolled epilepsy in patients requiring ED visit or hospitalization was associated with significantly greater health care resource utilization and increased direct and indirect costs compared to well-controlled epilepsy in both publicly and privately insured settings.

The CT-STAT (Coronary Computed Tomographic Angiography for Systematic Triage of Acute Chest Pain Patients to Treatment) Trial

The purpose of this study was to compare the efficiency, cost, and safety of a diagnostic strategy employing early coronary computed tomographic angiography (CCTA) to a strategy employing rest-stress myocardial perfusion imaging (MPI) in the evaluation of acute low-risk chest pain. In the United States, >8 million patients require emergency department evaluation for acute chest pain annually at an estimated diagnostic cost of >$10 billion. This multicenter, randomized clinical trial in 16 emergency departments ran between June 2007 and November 2008. Patients were randomly allocated to CCTA (n = 361) or MPI (n = 338) as the index noninvasive test. The primary outcome was time to diagnosis; the secondary outcomes were emergency department costs of care and safety, defined as freedom from major adverse cardiac events in patients with normal index tests, including 6-month follow-up. The CCTA resulted in a 54% reduction in time to diagnosis compared with MPI (median 2.9 h [25th to 75th percentile: 2.1 to 4.0 h] vs. 6.3 h [25th to 75th percentile: 4.2 to 19.0 h], p < 0.0001). Costs of care were 38% lower compared with standard (median $2,137 [25th to 75th percentile: $1,660 to $3,077] vs. $3,458 [25th to 75th percentile: $2,900 to $4,297], p < 0.0001). The diagnostic strategies had no difference in major adverse cardiac events after normal index testing (0.8% in the CCTA arm vs. 0.4% in the MPI arm, p = 0.29). In emergency department acute, low-risk chest pain patients, the use of CCTA results in more rapid and cost-efficient safe diagnosis than rest-stress MPI. Further studies comparing CCTA to other diagnostic strategies are needed to optimize evaluation of specific patient subsets. (Coronary Computed Tomographic Angiography for Systematic Triage of Acute Chest Pain Patients to Treatment [CT-STAT]; NCT00468325).