Reasons For Emergency Room Visits Research Articles

Urgences oncologiques

Around 40 % of patients with lung cancer are required to consult the emergency room during their follow-up. These are often patients at an advanced stage of their disease. These consultations lead in about 2/3 of cases to hospitalization, some of which in intensive care. Respiratory problems, fever, pain and digestive complaints are the classic reasons for emergency room visits. The advent of targeted therapies and immunotherapy has greatly diversified the reasons for presenting to emergency departments. If cancer or its treatment can be the cause of the emergency room consultation, around 30 % of these consultations have no link with the cancer.1877-1203/© 2024 SPLF. Published by Elsevier Masson SAS. All rights reserved.

Eficacia de la técnica autoasistida de Boss-Holzach- Matter para la reducción de luxaciones glenohumerales anteriores: revisión sistemática

Background: Anterior shoulder dislocation represents a common reason for emergency room visits. Despite the wide range of motion provided by this joint in three-dimensional space, it is prone to dislocation, with a significant incidence rate. The choice of reduction technique lacks consensus, with over 25 possible maneuvers, largely dependent on the physician's preference and experience. Additionally, potential neurovascular injuries resulting from the maneuver or its poor execution add complexity to this issue, challenging emergency physicians and orthopedic surgeons. The self-assisted technique Boss-Holzach-Matter (BHM) shows promising benefits in reducing patient anxiety and medical costs. Materials and Methods: A manual bibliographic search was conducted in PubMed, Scielo, and Central databases for studies from the last 10 years analyzing reduction techniques using the keywords "techniques for shoulder dislocation". Titles, abstracts, and full articles were reviewed, extracting pertinent data. Out of the 17 articles found, including systematic reviews, clinical trials, and other publications, 10 were selected without language restrictions. Results: Reduction methods varied significantly among studies. Comparison between self-assisted techniques like BHM and Spaso revealed differences in success rate and pain tolerance. The Davos technique demonstrated high effectiveness, although it was associated with potential complications. Comparative studies supported the efficacy of BHM and Milch in unassisted reduction. Conclusions: The need for further research to validate these findings, identify limitations, and evaluate clinical applicability is acknowledged. Additional studies are required to confirm the effectiveness of self-assisted techniques such as BHM, Milch, and Davos, as well as to address the potential limitations and considerations associated with each technique

Presentation Rates for Acute Pharyngitis in the Emergency Room Are Influenced by Extreme Weather Events.

Extreme weather events are becoming more prevalent with the increasing pace of climate change. These events negatively impact human health and put considerable strain on health care resources, including emergency departments. Within otolaryngology, acute pharyngitis is a common reason for emergency room visits (ERV). Therefore, we aimed to investigate the impact of extreme meteorological conditions on ERV rates related to acute pharyngitis. Retrospective time-series study. ERVs related to acute pharyngitis (n = 1511) were identified at a tertiary care hospital in Vienna, Austria, between 2015 and 2018. The effects of single-day and prolonged (3-day) extreme weather events on ERVs were analyzed using a distributed lag nonlinear model. Relative risk (RR) and cumulative relative risk (cRR) were calculated over a lag period of 14 days. RR refers to the risk for pharyngitis-related ERV at extreme conditions (1st, 5th, 95th, or 99th percentile) compared to the risk at median conditions. Same-day RR (lag0) was elevated more than 3-fold after prolonged extremely low mean temperatures (P = .028). Furthermore, same-day RR after single-day and prolonged extremely high relative humidity was elevated by 51% (P = .024) and 46% (P = .036), respectively. Significant delayed effects on cRR were observed for extreme mean temperatures, relative humidity, and mean wind speeds within 8 days and for extreme atmospheric pressure within 14 days. Extreme weather events impact ERV rates for acute pharyngitis. Extremely low temperatures, high relative humidity, high atmospheric pressure, and low and high wind speeds were risk-promoting factors.

Intra-Rectal Foreign Bodies: About 8 Cases

The introduction of foreign bodies through the anus has become a fairly frequent reason for emergency room visits (Most often voluntary, related to sexual practices). Male gender is the most concerned. The reasons for consultation are rectal discharge, abdominal pain and occlusive syndrome. ASP confirms the diagnosis if the foreign body is radio- opaque, and searches for perforation (pneumoperitoneum): emergency laparotomy. Extraction may be performed under sedation (anal extraction), or by laparotomy in the case of failure or complication.

Évaluation quantitative de l’effet sur le passage aux urgences et les hospitalisations d’un dispositif départemental innovant de prise en charge des situations de crise durant l’adolescence en Haute-Garonne, France

ObjectivesCrisis situations are common during adolescence. Current data show that adolescents in crisis are either directly referred to hospital psychiatric emergency rooms, or they make an appointment for a specialized consultation, in a medical-psychological center (CMP), in a medical-psychological-pedagogical center (CMPP), or with a private practitioner. The Departmental Reactive System for Adolescents was implemented in 2017 in the French department of Haute-Garonne to provide adolescents in crisis an immediate specialized psychiatric consultation including on-going support for three months. Our objective was to measure the effect of the implementation of this health system organization (HSO) on the evolution of the annual incidence of emergency room visits and hospitalizations of adolescents for psychiatric reasons at the Toulouse University Hospital, the sole facility for such care in Haute-Garonne. MethodsWe conducted a quasi-experimental study comparing the evolution, before and after the implementation of the DDRA31, the annual incidence rates of emergency room visits (pediatric and adult) and hospitalizations related to mental health at the Toulouse University Hospital for adolescents aged 12 to 17 years of age, residing in Haute-Garonne, from 2014 to 2019. Factors associated with the risk of hospitalization were analyzed using mixed-effects logistic regression to measure the effect of the system, over time, with the specific year as the primary explanatory variable, adjusted for sex and age. ResultsFrom 2014 to 2019, 6 686 emergency room visits by 4 245 adolescents took placefor psychiatric motives or diagnostics. The annual incidence rate of emergency department visits related to mental health was stable from 14.0 (95 % CI: 13.2–14.9), per 100 adolescents in 2014 to 13.9 (95 % CI: 13.2–14.7) in 2019, with a higher incidence rate for girls and adolescents aged from 15 to 17 years old. The main reasons for emergency room visits were behavioral problems or agitation, drug intoxications or suicide attempts, and drug or alcohol use or abuse. The annual incidence of hospitalizations decreased significantly since 2017, from 38.3 (95 % CI: 34.1–42.8) per 100 adolescents in 2014 to 24.2 (95 % CI: 21.2–27.4) per 100 adolescents in 2019. This decrease was shown for both males and females but only for adolescents aged from 15 to 17 years old, from 21.8 (CI 95 %: 17.9–26.1) in 2014 to 2.6 (CI 95 %: 1.5–4.1) in 2019. Modeling of the hospitalization risk showed a significant reduction from 2017 onward inclusive with an odds ratio ranging from 0.63 (95 % CI: 0.49–0.80) in 2017 to 0.52 (95 % CI: 0.41–0.67) in 2019. DiscussionThe fact that an impact of the HSO was found only for adolescents aged 15 to 17 years of age could indicate a selective effectiveness depending on age possibly caused by differences in physician attitudes depending on the age of the patient. The chronology of changes in hospitalization rates after a visit to the emergency room corresponded to the period when the HSO was implemented, whereas hospitalization rates were stable over the three years prior to its implementation. The main limitations of our study were the absence of data regarding emergency department diagnoses and discharge modes for the year 2019 and the lack of a temporal perspective. ConclusionOur study did not show any significant effect of the HSO on the annual incidence of emergency room visits related to mental health, but there was a possible effect on reducing the yearly incidence rate and the risk of hospitalization of adolescents in psychiatric services following an emergency room visit. The implementation of reactive ambulatory structures could therefore reduce the demand on hospitalization services that are under pressure.

Abstract 11578: A Case of Spontaneous Coronary Artery Dissection Masking as Acute Myopericarditis

Introduction: Chest pain is a common reason for emergency room visits. Acute coronary syndrome (ACS) remains a high mortality etiology of chest pain. Spontaneous coronary artery dissection (SCAD) is a rare cause of ACS in the general population, but a relatively common cause of ACS in young women. Case: Patient is a 29-year-old female with history of anxiety and fibroids that presented with chest pain. She described the chest pain as sharp, substernal, non-radiating that lasted for 10 minutes after eating dinner. The pain improved with leaning forward and resolved when lying on her stomach. She had a second episode of chest pain after 2 hours with similar characteristics which lasted 10 minutes. She was 4 months post-partum. She reported having a sore throat 4 days prior to the presentation. Troponin peaked at 0.173. ECG showed diffuse ST-elevation and PR depression in V3-V6 I II III aVF. TTE showed LVEF 65% and no wall motion abnormalities. CTA coronary showed 50-60% narrowing of mid LAD. Cardiac MR showed mild hypokinesis of mid-anteroseptal wall with associated subendocardial to midmyocardial delayed enhancement with focal elevations in myocardial native T1 and T2, and LVEF 53%. Coronary catheterization showed 50-60% stenosis in the mid-LAD distal to the first diagonal artery, there was no improvement in the stenosis after administration of intra-coronary nitroglycerin, there were no septals noted to arise from this area, consistent with diagnosis of SCAD (figure 1). Diagnosis: On initial evaluation, the etiology of her chest pain appeared to be myopericarditis. However, using CTA coronary, cardiac MR and coronary catheterization findings, the pain was more consistent with type 1 NSTEMI in the setting of SCAD. Patient was started on IV heparin, metoprolol tartrate, and aspirin. Conclusions: SCAD is a life-threating and often missed etiology of ACS. It requires a high index of suspicion and should be in the differential diagnosis in young women presenting with chest pain.

FACIAL WOUND ASSESSMENT KIT

Facial wounds are a frequent reason for emergency room visits. The goals of laceration repair are to achieve hemostasis, avoid infection, restore function to the involved tissues, and achieve optimal cosmetic results with minimal scarring. Therefore, these cases are most appropriately managed by plastic surgeons who have a thorough knowledge of anatomy, aesthetic sense, and meticulous expertise in atraumatic tissue manipulation, combined with the surgical skill to repair any structure. You need to know what to do and what not to do : whether to suture or leave open. What local anesthesia to use and how. What equipment to use (and have it available beforehand). Whether to give antibiotic therapy and what kind. How to avoid aesthetic or functional after-effects. Which dressing to use depending on the state of the wound. This article will serve as an aid to wound management and review repair techniques for high-risk areas of the face.

The determinants of emergency room visits and missed school days in children with asthma in a tertiary hospital in north central Nigeria

Background: Asthma is a major cause of emergency room visits and missed school days. However, the magnitude of this problem in Nigeria is yet to be evaluated. This study assessed the number of emergency room visits, missed school days as well as identified their determinants. Methods: This was a cross-sectional study carried out in the Paediatric Respiratory Clinic and the Emergency Paediatrics Unit of a tertiary hospital. The number of missed school days and emergency room visits were calculated and extrapolated for the estimated population of children with asthma in the state. Results: A total of 60 children with a male to female ratio of 1: 0.6 were studied. There were an estimated 5.3 million missed school days and over 460,000 emergency room visits per year for children with asthma in Plateau state. The commonest reasons for emergency room visits were severe acute exacerbation, poor knowledge of self-management and non-response to inhaled bronchodilators while the duration of asthma diagnosis, family member with atopy, family history of asthma and exercise intolerance were the determinants of emergency room visits and missed school days. Conclusion: With 5.3 million missed school days and over 460,000 emergency room visits in a year, asthma is a disease of significant public health importance. Self-management at home must be well taught at the beginning to all the patients. Care givers and patients need to know when they need to seek for help and not wait till the acute exacerbations are severe before presenting to the hospital.

SOCIO-DEMOGRAPHIC AND CLINICAL PROFILE OF PEDIATRIC OCULAR TRAUMA: A HOSPITAL BASED PROSPECTIVE STUDY.

Objectives: This present study was to evaluate the clinical and socio-demographical study in cases of paediatrics ocular injuries.
 Methods: A detail assessment and relevant investigations were performed to all paediatrics OCT. And globe injuries were recorded according to the BETT. Occular injury was examined by using equipment model OCT 2000 by TOPCON at IGIMS, Patna. Treatment was given depending on type and severity of injuries. Patients were followed up on day 1, day 7, 1 month, and at 6 months. Initial best corrected visual acuity was evaluated on first day of follow up. And final best corrected visual acuity (BCVA) was evaluated on last day of follow up after 6 months.
 Results: Data was analysed by using simple statistical methods with the help of MS-office software. All data was tabulated and percentage was calculated.
 Conclusions: Age group 0-10 years and males were more prone to ocular trauma. Stick, stone RTA and fall were more causative risk for OCT. School, home, Road traffic accident were the common places for ocular trauma. Open globe injury and close globe injury were commonly seen in ocular trauma cases. Close globe injury patients were shows the better BCVA with respect to OGI, lids and lacrimal apparatus injury and non-mechanical injury. Hence, we should aware the parents and family members about the common modes of trauma, the need of supervision of the objects of play. Self-protection should be taught to children to prevent possible ocular injuries. Houses, playgrounds and schools must be made safe and common items of trauma such as sharp objects, household lime, acids must be kept out of reach of children. Intensive campaign may be done before festival seasons about safety measures to increase public awareness. Ocular trauma is a frequent reason for emergency room visits. Evaluation of eye injuries should start with visual acuity and continue with prompt referral to an ophthalmologist as indicated.
 Key words: Ocular trauma, clinical profile, open globe injury, close globe injury, BCVA

Clinical Model for Predicting Warfarin Sensitivity

Warfarin is a widely used anticoagulant with a narrow therapeutic index and large interpatient variability in the therapeutic dose. Complications from inappropriate warfarin dosing are one of the most common reasons for emergency room visits. Approximately one third of warfarin dose variability results from common genetic variants. Therefore, it is very necessary to recognize warfarin sensitivity in individuals caused by genetic variants. Based on combined polymorphisms in CYP2C9 and VKORC1, we established a clinical classification for warfarin sensitivity. In the International Warfarin Pharmacogenetic Consortium (IWPC) with 5542 patients, we found that 95.1% of the Black in the IWPC cohort were normal warfarin responders, while 74.8% of the Asian were warfarin sensitive (P < 0.001). Moreover, we created a clinical algorithm to predict warfarin sensitivity in individual patients using logistic regression. Compared to a fixed-dose approach, the clinical algorithm provided significantly better performance. In addition, we validated the derived clinical algorithm using the external Easton cohort with 106 chronic warfarin users. The AUC was 0.836 vs. 0.867 for the Easton cohort and the IWPC cohort, respectively. With the use of this algorithm, it is very likely to facilitate patient care regarding warfarin therapy, thereby improving clinical outcomes.

Sickle cell disease complications: Prevalence and resource utilization

ObjectivesThis study evaluated the prevalence rate of vaso-occlusive crisis (VOC) episodes, rates of uncomplicated and complicated VOC episodes, and the primary reasons for emergency room (ER) visits and inpatient admissions for sickle cell disease (SCD) patients.MethodsThe Medicaid Analytic extracts database was used to identify adult SCD patients using claims from 01JUL2009-31DEC2012. The date of the first observed SCD claim was designated as the index date. Patients were required to have continuous medical and pharmacy benefits for ≥6 months baseline and ≥12 months follow-up period. Patient demographics, baseline clinical characteristics, the rate of uncomplicated and complicated VOC (VOC with concomitant SCD complications) episodes, and reasons for ER visits and inpatient stays were analyzed descriptively.ResultsA total of 8,521 patients were included in the analysis, with a median age of 30 years. The average follow-up period was 2.7 years. The rate of VOC episodes anytime in the follow-up was 3.31 in person-years. During the first-year follow-up period, an average of 2.79 VOC episodes were identified per SCD patients, with 1.06 VOC episodes treated in inpatient setting and 0.90 VOC episodes in ER without admission. A total of 76,154 VOC episodes were identified during the entire follow-up period for the overall SCD patients. Most of the VOC episodes (70.3% [n = 53,523]) were uncomplicated episodes, and 29.7% were complicated episodes. Using primary diagnosis claims only, the most frequent complications during the VOC episode were infectious diseases (25.9%), fever (21.8%), and pulmonary disorders (16.2%). Among ER and hospitalizations related to VOC or SCD complication, ~85.0% had VOCs as the primary reason for admission; 15.0% had SCD complications as the primary reason.ConclusionIn summary, SCD and its related comorbidities and complications result in high acute health care utilization. In addition, VOC remains the primary reason for SCD patients’ ER visits and inpatient admissions.

Extracorporeal shock wave lithotripsy versus ureteroscopy for management of pediatric nephrolithiasis in upper urinary tract stones: multi-institutional outcomes of efficacy and morbidity

As the incidence of pediatric nephrolithiasis rises, understanding the efficacy and morbidity of surgical treatment options is critical. Currently, there are limited comparative data assessing shock wave lithotripsy (SWL) and ureteroscopy (URS) outcomes in children. The objective of this study was to compare stone clearance, 30-day emergency department visits, and the number of general anesthetics required per stone treatment for both modalities. A multi-institutional retrospective review of children presenting for either URS or SWL between 2000 and 2017 was performed. Stone clearance, need for retreatment, the number of anesthetics, as well as the number and reason for emergency room visit were captured and compared between groups. Multivariate statistical analysis accounting for age, stone location, stone diameter, pre-intervention stent, and provider volume was performed for adjusted analysis. A total of 84 SWL and 175 URS procedures were included. Complete stone clearance and rates of residual stone fragments <4mm after final procedure for SWL were 77.0% and 90.8% and for URS were 78.5% and 91.7%, respectively. Retreatment rates for both procedures were not significantly different (17.9% SWL vs. 18.9% URS, P=0.85). Children who underwent SWL had lower rates of emergency room visits for infections (0% vs. 5.1%, P=0.03) and flank pain (3.6% vs. 10.9%, P=0.05)and required fewer general anesthetics per treatment (1.2 vs. 2.0, P<0.01) than those who underwent URS (Figure). Stone clearance after both the initial and final treatmentsand need for repeat interventionswere similar between surgical modalities. However, SWL carries less morbidity than URS. Specifically, patients who underwent SWL experienced lower rates of ED visits for urinary tract infection and for flank pain, parallel to conclusions in current comparative literature. In addition, SWL requires less general anesthetics (2.0 vs. 1.2), secondary to lower rates of ureteral stent placement and removal. Data on the potential risk of general anesthetics to neurodevelopment supportthoughtful utilization of these medications. Limitations of this study include its retrospective natureand the prolonged 20-year time period over which data were collected. When adjusting for confounders, SWL and URS achieve similar stone clearance. In the setting of equivalent efficacy, considerations regarding necessity of repeat interventions, morbidity of anesthesia, and complications should be integrated into clinical practice.

Syncope in older adults.

Syncope, defined as a self-limited transient loss of consciousness and postural tone due to global cerebral hypoperfusion, is a common reason for emergency room visits, with a third of these visits leading to an inpatient admission.[1] Syncope carries an estimated 2-year mortality rate of over 25% and is strongly associated with falls, a potentially devastating contributor to morbidity and mortality among the elderly. Given this association, it is not surprising that up to 35% of syncopal episodes result in injury.[2] Dizziness is similarly associated with poor outcomes in the elderly,[3] overlapping substantially with syncope and falls through commonly shared pathophysiologic mechanisms.[4] To optimize care of this vulnerable patient population, it is imperative to recognize the etiologies and associated risk factors for syncope in older adults, as well as appreciate their influence on diagnosis and management.

Mixed method exploration of the medical, service-related, and emotional reasons for emergency room visits of older cancer patients

When dealing with health issues, older cancer patients are likely to visit emergency rooms (ER), which are known to expose these patients to the risk of adverse outcomes. Little is known about the profile and reasons for such visits. The aim of this study is (1) to describe the profile of elderly cancer patients aged 70years and older who visited the ER of a regional hospital in Québec, Canada, and (2) to explain the medical reasons and factors determining such visits from the patients' perspective. A concurrent mixed method design was used. Descriptive analysis of administrative databases was conducted to describe the socio-demographic, clinical, and service utilization profile of 792 cancer patients aged 70years and older. Content analysis of 11 semi-structured interviews of a sub-sample was subsequently performed to better understand the experience and meaning these patients attribute to this health behaviour. The sample of 792 older cancer patients made a total of 1572 ER visits. Most visits occurred during the daytime. More than half (53%) of the patients were discharged, and close to 40% were hospitalized. The most frequent reasons for consulting were respiratory (15.8%), digestive (13.4%), neurological (8.3%), fever or infection-related (8.3%), and cardiovascular (8.2%). Content analysis of the qualitative data suggested that patients made ER visits mostly when other cancer care services were unavailable or because of a serious life-threatening health condition. The study suggests areas of improvement to prevent ER visits when health issues can be addressed by other care services.

The Psychogeriatric Patient in the Emergency Room: Focus on Management and Disposition

Background. The growing geriatric population in the United States (US) has prompted better understanding of treatment of the elderly in the hospital and emergency room (ER) settings. This study examines factors influencing the disposition of psychogeriatric patients after their initial presentation in the ER. Methods. Data was collected on patients 65 years of age or older arriving at the ER of a large urban hospital in the USA (January 2009–December 2010). Results. Of the total subjects (n = 95) included in the study, majority were females (66.3%) with an average age of 75.5 years. The chief complaint for psychogeriatric patients coming to the ER was delirium (61.6%). Caucasians were significantly more likely than African-American patients to get a psychiatric consult (33% versus 9%). Patients with delirium were less likely than patients with other psychiatric complaints to get a psychiatric consult in the ER (1.2% versus 47.2%) and less likely to be referred to a psychiatric inpatient unit compared to patients with other psychiatric complaints (2.4% versus 16.7%). Conclusion. Even though delirium is the most common reason for ER visits among psychogeriatric patients, very few delirium patients got a psychiatric consultation in the ER. A well-equipped geriatric psychiatry unit can manage delirium and associated causes.

Abstract P6-06-56: Emergency room visits and hospital admission rates after curative chemotherapy for breast cancer. A retrospective single center experience

Abstract Purpose:Patients undergoing curative (adjuvant or neoadjuvant) chemotherapy (CT) for breast cancer in the Southeast Ontario Local Heath Integration Network (LHIN) have higher rates of emergency room (ER) visits and hospital admissions (HA) compared to other LHINs in Ontario, Canada. This study is to determine factors associated with ER visits and HA after curative chemotherapy for breast cancer in a tertiary Ontario hospital. Methods:A retrospective study was conducted of all patients who completed at least one cycle of curative CT for breast cancer at the Cancer Centre for Southeastern Ontario (CCSEO) in 2011 and 2012. We recorded all ER visits and/or HA within 30 days of any cycle of CT. Data collected included demographics, co-morbidities, type and date of surgery, pathologic tumour characteristics (stage, grade and receptor status), type of CT (adjuvant or neoadjuvant) and number of cycles, use and type of granulocyte-colony stimulating factors (G-CSF). We recorded dates and reasons for ER visits, referring patterns to the ER, date of admission and length of stay. Chi-square and t-tests were calculated to determine factors associated with ER visits and HA. Results:149 patients received curative CT at the CCSEO in 2011 and 2012. Mean age was 58 (range 31-88). 97.3% of patients were female. Comorbidities included hypertension (28.4%), diabetes (10.1%), dyslipidemia (10.1%), coronary artery disease (4.7%) and COPD (2%). Stage distribution was: 4.3% stage 1, 48.6% stage 2 and 36.4% stage 3. 60.8% of patients had grade 3 tumors. 69.8% were ER positive and 61.1% were PR positive. 26.2% were Her2 positive. 62.4% had breast conserving surgery and 56.4% had sentinel lymph node biopsy. Most patients received adjuvant CT (85.2%). The most common CT regimen was FEC-D (89.9%), followed by TC (5.4%) and CMF (4%). 88.6% of patients received G-CSF (either Neupogen or Neulasta) at some point during CT. 53% (n = 79) of patients were seen in the ER at least once within 30 days of CT while 13.4% (n = 20) were admitted to hospital. 36.7% (n = 29) had multiple ER visits. There were a total of 133 ER visits. The most common causes of ER visits were fever without neutropenia (23.3%), pain (13.5%) and febrile neutropenia (9%). Most ER visits occurred on weekdays (74%). We analyzed the following factors associated with ER visits and HA rates: age, gender, comorbidities, TNM staging, grade, receptor status, type of surgery and CT (adjuvant versus neoadjuvant). The only statistically significant factor associated with a higher likelihood of ER visits was stage IIIC breast cancer (p = 0.045). Statistically significant factors associated with HA were tumor size with T2 more likely to be admitted (p = 0.019), adjuvant CT (p = 0.045) and number of CT cycles (p = 0.017). Conclusions:Over half of all patients receiving curative CT for breast cancer at the CCSEO in 2011 and 2012 visited the ER at least once and more than 1/3 required multiple visits. The only factor associated with ER visits included stage of disease. Factors associated with HA were tumour size, adjuvant CT and number of CT cycles. While most patients received G-CSF at some point during their CT, febrile neutropenia was still the third most common reason for ER visits. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-06-56.

Renal Scintigraphy in the Acute Care Setting

Renal scintigraphy is a powerful imaging method that provides both functional and anatomic information, which is particularly useful in the acute care setting. In our institution, for the past 2 decades, we have used a 25-minute renal diuretic protocol, technetium-99m ((99m)Tc) mercaptoacetyltriglycine with simultaneous intravenous injection of furosemide, for all ages and indications, including both native and transplant kidneys. As such, this protocol has been widely used in the workup of acutely ill patients. In this setting, there are common clinical entities which affect patients with native and transplant kidneys. In adult patients with native kidneys one of the most frequent reasons for emergency room visits is renal colic due to urolithiasis. Although unenhanced computed tomography is useful to assess the anatomy in cases of renal colic, it does not provide functional information. Time zero furosemide renal scintigraphy can do both and we have shown that it can effectively stratify patients with renal colic. To this end, 4 characteristic patterns of scintirenography have been identified, standardized, and consistently applied: no obstruction, partial obstruction (mild vs high grade), complete obstruction, and stunned (postdecompressed) kidney. With the extensive use of this protocol over the past 2 decades, a pattern of "regional parenchymal dysfunction" indicative of acute pyelonephritis has also been delineated. This information has proved to be useful for patients presenting with urinary tract infection and suspected pyelonephritis, as well as for patients who were referred for workup of renal colic but were found to have acute pyelonephritis instead. In instances of abdominal trauma, renal scintigraphy is uniquely suited to identify urine leaks. This is also true in cases of suspected leak following renal transplant or from other iatrogenic/postsurgical causes. Patients presenting with acute renal failure can be evaluated with renal scintigraphy. A scintigraphic pattern of "relative preservation of flow as compared to function" has been identified as indicative of acute tubular necrosis, which is distinct from other potential causes of acute renal failure, such as nephrotoxicity and in the case of renal transplants, rejection.

Emergency Room Visits in Children with Hemophilia

Abstract 1227▪▪This icon denotes a clinically relevant abstract Introduction:The emergency room (ER) management of bleeding and other complications of hemophilia constitutes an important component of hemophilia therapy. In this retrospective study, we examined the ER visits of children with hemophilia during a five-year period. Methods:Electronic medical records of all ER visits to our hospital were reviewed for hemophilia patients aged 0–21 years between January 1st, 2006- December 31st, 2010. ER visits were categorized as visits related to injury or bleeding; visits related to fever or a positive blood culture in a patient with central venous catheter (CVC); visits for general pediatric causes unrelated to hemophilia; and visits for clotting factor infusion. Results:There were 518 ER visits from 79 male patients (71 hemophilia A and 8 hemophilia B) over the 5-year period. Median age was 5 years (range 0–21). Five patients had other chronic conditions in addition to hemophilia: sickle cell anemia in 2 patients and Down syndrome, Crohn disease, and myelomeningocele in one patient each.The reasons for ER visits were as follows: 60.8% (n=315) were for injury and/or bleeding; 12.2% for either fever in a patient with CVC (n=53) or positive results of a blood culture drawn earlier from a CVC (n=10); 18.0% (n=93) for pediatric causes unrelated to hemophilia; and 9.1% (n=47) for clotting factor infusion. Four of the visits were because of a bleeding episode in patients not yet diagnosed with hemophilia.Computerized tomographic (CT) examination of the head was undertaken in 85 of the visits: trauma to the head (n=68), face (n=2), nose (n=1), or eyes (n=2); after falling backward (n=1) and motor vehicle accident (n=2) without a reported head injury; other symptoms such as headache (n=6), lethargy (n=1), pallor (n=1), and vomiting (n=1). In 6 patients with head injury, the cranial CT examination was deferred because of a normal neurologic examination. Only 4.7% (n=4) of the cranial CT examinations showed intracranial hemorrhage. These patients had presented with head trauma (n=2), vomiting (n=1), and headache (n=1).Of the 53 febrile visits in patients with CVC, blood cultures grew an organism in 43.4% (n=23) of the cases. As two of the visits for a positive blood culture were for cultures drawn in the ER the day before, there were a total of 31 visits with a new positive blood culture from a CVC: 14 with single gram-positive bacteria, 9 with single gram-negative bacteria, and 8 with multiple organisms, including two with Candida species. Conclusions:Children with hemophilia present to the ER mostly for bleeding or injury-related reasons. Head injury or headache may prompt a cranial CT examination in patients with hemophilia; however, only a minority of such patients has intracranial hemorrhage, and a good neurologic assessment should help determine patients who require this investigation. Fever in a hemophiliac patient with CVC is a serious symptom, as almost half of such children might have bacteremia. Although uncommon, undiagnosed hemophilia patients may present with their first hemorrhagic episode to the ER, and appropriate screening tests should be ordered in the event of a clinical suspicion Disclosures:No relevant conflicts of interest to declare.

Healthcare costs and utilization for Medicare beneficiaries with Alzheimer's

BackgroundAlzheimer's disease (AD) is a neurodegenerative disorder incurring significant social and economic costs. This study uses a US administrative claims database to evaluate the effect of AD on direct healthcare costs and utilization, and to identify the most common reasons for AD patients' emergency room (ER) visits and inpatient admissions.MethodsDemographically matched cohorts age 65 and over with comprehensive medical and pharmacy claims from the 2003–2004 MEDSTAT MarketScan® Medicare Supplemental and Coordination of Benefits (COB) Database were examined: 1) 25,109 individuals with an AD diagnosis or a filled prescription for an exclusively AD treatment; and 2) 75,327 matched controls. Illness burden for each person was measured using Diagnostic Cost Groups (DCGs), a comprehensive morbidity assessment system. Cost distributions and reasons for ER visits and inpatient admissions in 2004 were compared for both cohorts. Regression was used to quantify the marginal contribution of AD to health care costs and utilization, and the most common reasons for ER and inpatient admissions, using DCGs to control for overall illness burden.ResultsCompared with controls, the AD cohort had more co-morbid medical conditions, higher overall illness burden, and higher but less variable costs ($13,936 s. $10,369; Coefficient of variation = 181 vs. 324). Significant excess utilization was attributed to AD for inpatient services, pharmacy, ER visits, and home health care (all p < 0.05). In particular, AD patients were far more likely to be hospitalized for infections, pneumonia and falls (hip fracture, syncope, collapse).ConclusionPatients with AD have significantly more co-morbid medical conditions and higher healthcare costs and utilization than demographically-matched Medicare beneficiaries. Even after adjusting for differences in co-morbidity, AD patients incur excess ER visits and inpatient admissions.

Patterns of Inpatient and Outpatient Care for Asthma in Erie and Niagara Counties, Western New York State

The prevalence of asthma, as well as the morbidity and mortality due to asthma, has increased in the United States, especially among poor minority subpopulations. The causes of these increases are complex and not well understood. Our findings from an analysis of emergency room (ER) visits and hospitalizations for Erie and Niagara Counties in western New York State for the period 1984–1991 provides important background to this problem. Of all respiratory disorders, asthma was the most frequent reason for ER visits and was second only to pneumonia as a reason for hospital admissions. In Erie County the hospitalization rates for asthma in two inner-city communities with predominantly minority populations were 1.48 and 2.09 times higher than those in the rest of the county. Furthermore, the hospitalization rates for these communities showed an increasing trend over the study period. Gender differences were also found. Boys age 0 to 9 years were hospitalized for asthma twice as often as girls. However, over 15 years of age, females had admission rates that were twice those of males. In contrast, hospitalization rates for pneumonia were equal for males and females, which would suggest gender differences particular to asthma. Hospitalizations for asthma in the western New York region cost an estimated $6,000,000 in 1990. We conclude that asthma is a major cause of morbidity in this region with excessive and increasing impact on inner-city communities.