Section of Emergency Medicine

Dartmouth, Lebanon

Section of Emergency Medicine

Dartmouth, Lebanon
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McAllister T.W.,Section of Neuropsychiatry | McDonald B.C.,Section of Neuropsychiatry | McDonald B.C.,Indiana University | Flashman L.A.,Section of Neuropsychiatry | And 5 more authors.
International Journal of Psychophysiology | Year: 2011

Alterations in working memory (WM) are common after traumatic brain injury (TBI). Frontal catecholaminergic systems, including the alpha-2 adrenergic system, modulate WM function and may be affected in TBI. We hypothesized that administration of an alpha-2 adrenergic agonist might improve WM after mild TBI (MTBI). Thirteen individuals with MTBI 1. month after injury and 14 healthy controls (HC) were challenged with guanfacine and placebo prior to administration of a verbal WM functional MRI task. Guanfacine was associated with improved WM performance in the MTBI but not the HC group. On guanfacine the MTBI group showed increased activation within a WM task-specific region of interest. Findings are consistent with the hypothesis that alterations in WM after MTBI may be improved with the alpha-2 agonist guanfacine. © 2011 Elsevier B.V.

PubMed | Section of Emergency Medicine, Medical College of Wisconsin and Mary Bridge Childrens Hospital
Type: Journal Article | Journal: Pediatrics | Year: 2016

Rapid repetitive administration of short-acting -agonists (SABA) is the most effective means of reducing acute airflow obstruction in asthma. Little evidence exists that assesses process measures (ie, timeliness) and outcomes for asthma. We used quality improvement (QI) methods to improve emergency department care in accordance with national guidelines including timely SABA administration and use of asthma severity scores.The Model for Improvement was used and interventions were targeted at 4 key drivers: knowledge, engagement, decision support, and workflow enhancement. Time series analysis was performed and outcomes assessed on statistical process control charts.Asthma severity scoring increased from 0% to >95% in triage and to >75% for repeat scores. Time to first SABA (T1) improved by 32.8 minutes (47%). T1 for low severity patients improved by 17.6 minutes (28%). T1 for high severity patients improved by 3.1 minutes to 18.1 minutes (15%). Time to third SABA (T3) improved by 30 minutes (24%). T3 for low severity patients improved by 42.5 minutes (29%) and T3 for high severity patients improved by 21 minutes (23%). Emergency department length of stay for low severity patients discharged to home improved by 29.3 minutes (15%). The number of asthma-related visits between 48-hour return hospitalizations increased from 114 to 261. The admission rate decreased 6.0%.We implemented standardized asthma severity scoring with high rates of compliance, improved timely administration of -agonist treatments, demonstrated early improvements in Emergency department length of stay, and reduced admission rates without increasing unplanned return admissions.

Medford-Davis L.N.,University of Pennsylvania | Eswaran V.,Baylor College of Medicine | Shah R.M.,Baylor College of Medicine | Dark C.,Section of Emergency Medicine | Dark C.,Harris Health System
Annals of Emergency Medicine | Year: 2015

This review synthesizes the existing literature to provide evidence-based predictions for the future of emergency care in the United States as a result of the Patient Protection and Affordable Care Act, with a focus on emergency department (ED) visit volume, acuity, and reimbursement. Patient behavior will likely be quite different for patients gaining Medicaid than for those gaining private insurance through the Marketplaces. Despite the threat of the individual mandate, not all uninsured patients will enroll, and those who choose to enroll will likely be a different population from those who remain uninsured. New Medicaid enrollees will be a sicker population and will likely increase their number of ED visits substantially. Their acuity will be higher at first but will then revert to the traditionally high number of low-acuity visits made by Medicaid patients. Most patients enrolling through the Marketplace are choosing high-deductible health plans, and they will initially avoid the ED because of high out-of-pocket costs but may present later and sicker after self-rationing their care. Most patients gaining health coverage through the Affordable Care Act will be shifting from uninsured to either Medicaid or private insurance, both of which reimburse more than self-pay, so ED collections should increase. Because of the differences between Medicaid and Marketplace plans, there will be a difference in ED volume, acuity, and financial outcomes, depending on states' current demographics, whether states expand Medicaid, and how aggressively states advertise new options for coverage in Medicaid or state health insurance Marketplaces. © 2015 American College of Emergency Physicians.

Hashikawa A.N.,University of Michigan | Stevens M.W.,Section of Emergency Medicine | Juhn Y.J.,Mayo Medical School | Nimmer M.,Section of Emergency Medicine | And 3 more authors.
Pediatrics | Year: 2012

BACKGROUND: The American Academy of Pediatrics (AAP) introduced revised return-to-care recommendations for mildly ill children in 2009 that were added to national standards in 2011. Child care directors'practices in a state without clear emphasis on return-to-care guidelines are unknown. We investigated director return-to-care practices just before the release of recently revised AAP guidelines. METHODS: A telephone survey with 5 vignettes of mild illness (cold symptoms, conjunctivitis, vomiting/diarrhea, fever, and ringworm) was administered to randomly sampled directors in metropolitan Milwaukee, Wisconsin. Directors were asked about return-to-care criteria for each illness. Questions for return-to-care criteria were open-ended; multiple responses were allowed. Answers were compared with AAP return-to-care recommendations. RESULTS: A total of 305 directors participated. Based on director responses to vignettes, the percentage of correct responses regarding return-to-child care management compared with AAP return-to-care recommendations was low: fever (0%); conjunctivitis (0%); diarrhea (1.6%); cold symptoms (12%); ringworm (21%); and vomiting (80%). Two illnesses (conjunctivitis and cold symptoms) would require the child to have an urgent medical evaluation or treatment not recommended by the AAP, as follows: Conjunctivitis - antibiotics for 24 hours (62%), physician visit (49%), any antibiotic treatment (6%), and symptom resolution (4%); and Cold Symptoms - physician visit (45.6%), antibiotics (10%), and symptom resolution (25%). CONCLUSIONS: Directors' self-reported return-to-child care practices differed substantially before the release of revised AAP return-to-care recommendations. Active adoption of AAP return-to-child care guidelines would decrease the need for unnecessary urgent medical evaluation and treatment as well as unnecessary exclusion of a child from child care. Copyright © 2012 by the American Academy of Pediatrics.

Lindstrom V.,Karolinska Institutet | Karlsten R.,Uppsala University Hospital | Falk A.-C.,Karolinska Institutet | Castren M.,Section of Emergency Medicine
European Journal of Emergency Medicine | Year: 2011

OBJECTIVE: The aim of the study was to evaluate the feasibility of a newly developed computer-assisted feedback system between dispatch centre and ambulances in Stockholm, Sweden. METHODS: A computer-assisted feedback system based on a Finnish model was designed to fit the Swedish emergency medical system. Feedback codes were identified and divided into three categories; assessment of patients' primary condition when ambulance arrives at scene, no transport by the ambulance and level of priority. Two ambulances and one emergency medical communication centre (EMCC) in Stockholm participated in the study. A sample of 530 feedback codes sent through the computer-assisted feedback system was reviewed. The information on the ambulance medical records was compared with the feedback codes used and 240 assignments were further analyzed. RESULTS: The used feedback codes sent from ambulance to EMCC were correct in 92% of the assignments. The most commonly used feedback code sent to the emergency medical dispatchers was 'agree with the dispatchers' assessment'. In addition, in 160 assignments there was a mismatch between emergency medical dispatchers and ambulance nurse assessments. CONCLUSION: Our results have shown a high agreement between medical dispatchers and ambulance nurse assessment. The feasibility of the feedback codes seems to be acceptable based on the small margin of error. The computer-assisted feedback system may, when used on a daily basis, make it possible for the medical dispatchers to receive feedback in a structural way. The EMCC organization can directly evaluate any changes in the assessment protocol by structured feedback sent from the ambulance. © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins.

Vicente V.,Section of Emergency Medicine | Sjostrand F.,Section of Emergency Medicine | Sundstrom B.W.,University of Borås | Svensson L.,Karolinska Institutet | Castren M.,Section of Emergency Medicine
European Journal of Emergency Medicine | Year: 2013

OBJECTIVES: To develop a feasible and safe prehospital decision support system (DSS) for the emergency medical services (EMS), facilitating safe steering of geriatric patients to an optimal level of healthcare. METHODS: The development process involves four consecutive steps. The first step was gathering data from patients transported by EMS, with the electronic patient care record, to retrospectively identify appropriate patient categories for steering. The second step was to allow a group of medical experts to give advice and suggestions for further development of the DSS. The third step was validation of the decision support tool and the fourth step was validation of the entire prehospital DSS in a pilot study. RESULTS: The patient categories relevant to steering were those medical conditions that the geriatric clinicians felt confident in receiving from the EMS. A prehospital DSS was then developed for these 11 medical conditions. The evaluation and validation of the DSS showed a high degree of compliance with the patients' final level of healthcare. The pilot study included 110 randomized patients; 33.9% were triaged to an alternative level of healthcare, that is geriatric care or primary care. No medical inaccuracies or secondary transports from alternative care to the hospital emergency department were identified. CONCLUSION: Using this prehospital DSS - developed for 11 medical conditions - the Swedish prehospital nurse can safely decide on the level of healthcare to which an elderly patient can be steered. © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins.

PubMed | Section of Emergency Medicine, McMaster University and Southwestern University
Type: Journal Article | Journal: Burns : journal of the International Society for Burn Injuries | Year: 2015

In an otherwise healthy patient with severe facial disfigurement secondary to burns, composite tissue allotransplantation (CTA) results in life-long immunosuppressive therapy and its associated risk. In this study, we assess the net gain of CTA of face (in terms of utilities) from the perspectives of patient, general public and medical expert, in comparison to the risks.Using the standard gamble (SG) and time-trade off (TTO) techniques, utilities were obtained from members of general public, patients with facial burns, and medical experts (n=25 for each group). The gain (or loss) in utility and quality adjusted life years (QALY) were estimated using face-to-face interviews. A sensitivity analysis using variable life expectancy was conducted.From the patient perspective, severe facial burn was associated with a health utility value of 0.53, and 27.1 QALYs as calculated by SG, and a health utility value of 0.57, and 28.9 QALYs as calculated by TTO. In comparison, CTA of the face was associated with a health utility value of 0.64, and 32.3 QALYs (or 18.2 QALYs years per sensitivity analysis) as calculated by SG, and a health utility value of 0.67, and 34.1 QALYs (or 19.2QALYs per sensitivity analysis) as calculated by TTO. However, a loss of 8.9 QALYs (by SG method) to 9.5 QALYs (by TTO method) was observed when the life expectancy was decreased in the sensitivity analysis. Similar results were obtained from the general population and medical experts perspectives.We found that severe facial disfigurement is associated with a significant reduction in the health-related quality of life, and CTA has the potential to improve this. Further, we found that a trade-off exists between the life expectancy and gain in the QALYs, i.e. if life expectancy following CTA of face is reduced, the gain in QALY is also diminished. This trade-off needs to be validated in future studies.

Sharp W.W.,Section of Emergency Medicine | Fang Y.H.,Section of Emergency Medicine | Han M.,Section of Emergency Medicine | Zhang H.J.,Section of Emergency Medicine | And 6 more authors.
FASEB Journal | Year: 2014

Mitochondrial fission, regulated by dynamin- related protein-1 (Drp1), is a newly recognized determinant of mitochondrial function, but its contribution to left ventricular (LV) impairment following ischemia-reperfusion (IR) injury is unknown. We report that Drp1 activation during IR results in LV dysfunction and that Drp1 inhibition is beneficial. In both isolated neonatal murine cardiomyocytes and adult rat hearts (Langendorff preparation) mitochondrial fragmentation and swelling occurred within 30 min of IR. Drp1- S637 (serine 637) dephosphorylation resulted in Drp1 mitochondrial translocation and increased mitochondrial fission. The Drp1 inhibitor Mdivi-1 preserved mitochondrial morphology, reduced cytosolic calcium, and prevented cell death. Drp1 siRNA similarly preserved mitochondrial morphology. In Langendorff hearts, Mdivi-1 reduced mitochondrial reactive oxygen species, improved LV developed pressure (92±5 vs. 28±10 mmHg, P<0.001), and lowered LV end diastolic pressure (10±1 vs. 86±13 mmHg, P<0.001) following IR. Mdivi-1 was protective if administered prior to or following ischemia. Because Drp1-S637 dephosphorylation is calcineurin sensitive, we assessed the effects of a calcineurin inhibitor, FK506. FK506 treatment prior to IR prevented Drp1-S637 dephosphorylation and preserved cardiac function. Likewise, therapeutic hypothermia (30°C) inhibited Drp1-S637 dephosphorylation and preserved mitochondrial morphology and myocardial function. Drp1 inhibition is a novel strategy to improve myocardial function following IR.

Beiser D.,Section of Emergency Medicine | Vu M.,Section of Emergency Medicine | Gibbons R.,University of Chicago
Psychiatric Services | Year: 2016

Objective: Computerized adaptive testing (CAT) provides improved precision and decreased test burden compared with traditional, fixed-length tests. Concerns have been raised regarding reliability of CAT-based measurements because the items administered vary both between and within individuals over time. The study measured test-retest reliability of the CAT Depression Inventory (CAT-DI) for assessment of depression in a screening setting where most scores fall in the normal range. Methods: A random sample of adults (N=101) at an academic emergency department (ED) was screened twice with the CAT-DI during their visit. Test-retest scores, bias, and reliability were assessed. Results: Fourteen percent of patients scored in the mild range for depression, 4% in the moderate range, and 3% in the severe range. Test-retest scores were without significant bias and had excellent reliability (r=.92). Conclusions: The CAT-DI provided reliable screening results among ED patients. Concerns about whether changes in item presentation during repeat testing would affect testretest reliability were not supported.

Macias C.G.,Section of Emergency Medicine
Pediatric radiology | Year: 2011

During the past decades, the use of CT to diagnose conditions and monitor treatment in the pediatric setting has increased. Infants and children often require procedural sedation to maintain a motionless state to ensure high-quality imaging. Various medication regimens have been recommended to achieve satisfactory sedation for this painless procedure. While the incidence of adverse events remains low, procedural sedation carries the risk of serious morbidity and mortality. The use of evidence-based, structured approaches to procedural sedation should be used to reduce variation in clinical practice and improve outcomes.

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