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1.  Impact of a Physician-in-Triage Process on Resident Education 
Emergency department (ED) crowding negatively impacts patient care quality and efficiency. To reduce crowding many EDs use a physician-in-triage (PIT) process. However, few studies have evaluated the effect of a PIT processes on resident education. Our objective was to determine the impact of a PIT process implementation on resident education within the ED of an academic medical center.
We performed a prospective cross-sectional study for a 10-week period from March to June 2011, during operationally historic trended peak patient volume and arrival periods. Emergency medicine residents (three-year program) and faculty, blinded to the research objectives, were asked to evaluate the educational quality of each shift using a 5-point Likert scale. Residents and faculty also completed a questionnaire at the end of the study period assessing the perceived impact of the PIT process on resident education, patient care, satisfaction, and throughput. We compared resident and attending data using Mann-Whitney U tests.
During the study period, 54 residents and attendings worked clinically during the PIT process with 78% completing questionnaires related to the study. Attendings and residents indicated “no impact” of the PIT process on resident education [median Likert score of 3.0, inter-quartile range (IQR): 2–4]. There was no difference in attending and resident perceptions (p-value =0.18). Both groups perceived patient satisfaction to be “positively impacted” [4.0, IQR:2–4 for attendings vs 4.0, IQR:1–5 for residents, p-value =0.75]. Residents perceived more improvement in patient throughput to than attendings [3.5, IQR:3–4 for attendings vs 4.0, IQR:3–5 for residents, p-value =0.006]. Perceived impact on differential diagnosis generation was negative in both groups [2.0, IQR:1–3 vs 2.5, IQR:1–5, p-value = 0.42]. The impact of PIT on selection of diagnostic studies and medical decision making was negative for attendings and neutral for residents: [(2.0, IQR:1–3 vs 3.0, IQR:1–4, p-value =0.10) and (2.0, IQR:1–4 vs 3.0, IQR:1–5, p-value =0.14 respectively].
Implementation of a PIT process at an academic medical center was not associated with a negative (or positive) perceived impact on resident education. However, attendings and residents felt that differential diagnosis development was negatively impacted. Attendings also felt diagnostic test selection and medical decision-making learning were negatively impacted by the PIT process.
PMCID: PMC4251252  PMID: 25493151
2.  Identifying Patients for Early Discharge: Performance of Decision Rules Among Patients with Acute Chest Pain 
International journal of cardiology  2012;168(2):795-802.
The HEART score and North American Chest Pain Rule (NACPR) are decision rules designed to identify acute chest pain patients for early discharge without stress testing or cardiac imaging. This study compares the clinical utility of these decision rules combined with serial troponin determinations.
Methods and Results
A secondary analysis was conducted of 1005 participants in the Myeloperoxidase In the Diagnosis of Acute coronary syndromes Study (MIDAS). MIDAS is a prospective observational cohort of Emergency Department (ED) patients enrolled from 18 US sites with symptoms suggestive of acute coronary syndrome (ACS). The ability to identify participants for early discharge and the sensitivity for ACS at 30 days were compared among an unstructured assessment, NACPR, and HEART score, each combined with troponin measures at 0 and 3 hours. ACS, defined as cardiac death, acute myocardial infarction, or unstable angina, occurred in 22% of the cohort. The unstructured assessment identified 13.5% (95% CI 11.5-16%) of participants for early discharge with 98% (95% CI 95-99%) sensitivity for ACS. The NACPR identified 4.4% (95% CI 3-6%) for early discharge with 100% (95% CI 98-100%) sensitivity for ACS. The HEART score identified 20% (95% CI 18-23%) for early discharge with 99% (95% CI 97-100%) sensitivity for ACS. The HEART score had a net reclassification improvement of 10% (95% CI 8-12%) versus unstructured assessment and 19% (95% CI 17-21%) versus NACPR.
The HEART score with 0 and 3 hour serial troponin measures identifies a substantial number of patients for early discharge while maintaining high sensitivity for ACS.
PMCID: PMC3565031  PMID: 23117012
chest pain; risk stratification; clinical decision rules; acute coronary syndrome
3.  Stress Cardiac Magnetic Resonance Imaging Reduces Revascularization, Hospital Readmission, and Recurrent Cardiac Testing in Intermediate Risk Patients with Acute Chest Pain: A Randomized Trial 
JACC. Cardiovascular imaging  2013;6(7):785-794.
To determine the effect of stress cardiac magnetic resonance (CMR) imaging in an observation unit (OU) on revascularization, hospital readmission, and recurrent cardiac testing in intermediate risk patients with possible acute coronary syndrome (ACS).
Intermediate risk patients commonly undergo hospital admission with high rates of coronary revascularization. It is unknown whether OU-based care with CMR is a more efficient alternative.
We randomized 105 intermediate risk participants with symptoms of ACS but without definite ACS based on the first electrocardiogram and troponin to usual care provided by Cardiologists and Internists (n=53) versus OU care with stress CMR (n=52). We determined the primary composite endpoint of coronary artery revascularization, hospital readmission, and recurrent cardiac testing at 90 days. The secondary endpoint was length of stay from randomization to index visit discharge; safety was measured as ACS after discharge.
The median age of participants was 56 (range 35 to 91) years, 54% were men, and 20% had pre-existing coronary disease. Index hospital admission was avoided in 85% of the OU-CMR participants. The primary outcome occurred in 20 (38%) usual care versus 7 (13%) OU-CMR participants (hazard ratio 3.4, 95% CI 1.4 – 8.0, p = .006). The OU-CMR group experienced significant reductions in all components: revascularizations [15% vs 2%, p=0.03], hospital readmissions [23% vs 8%, p = .03], and recurrent cardiac testing [17% vs 4%, p = .03]. Median length of stay was 26 hours (IQR: 23 – 45) in the usual care group and 21 hours (IQR: 15 – 25) in the OU-CMR group (p < .001). ACS after discharge occurred in 3 (6%) usual care and no OU-CMR participants.
In this single center trial, management of intermediate risk patients with possible ACS in an OU with stress CMR reduced coronary artery revascularization, hospital readmissions, and recurrent cardiac testing without an increase in post-discharge ACS at 90 days.
PMCID: PMC3710522  PMID: 23664718
chest pain; acute coronary syndrome; angioplasty; balloon; coronary; magnetic resonance imaging
4.  Reduction in Observation Unit Length of Stay with Coronary Computed Tomography Angiography Depends on Time of Emergency Department Presentation 
Prior studies demonstrating shorter length of stay (LOS) from coronary computed tomography angiography (CCTA) relative to stress testing in emergency department (ED) patients have not considered time of patient presentation. The objectives of this study were to determine whether low-risk chest pain patients receiving stress testing or CCTA have differences in ED plus observation unit (OU) LOS, and if there are disparities in testing modality use, based upon the time of patient presentation to the ED.
The authors examined a cohort of low-risk chest pain patients evaluated in an ED-based OU using prospective and retrospective OU registry data. During the study period, stress testing and CCTA were both available from 08:00 to 17:00 hrs. CCTA was not available on weekends, and therefore only subjects presenting on weekdays were included. Cox regression analysis was used to model the effect of testing modality (stress testing vs. CCTA) on OU LOS. Separate models were fit based on time of patient presentation to the ED using four hour blocks beginning at midnight. The primary independent variable was testing modality: stress testing or CCTA. Age, sex, and race were included as covariates. Logistic regression was used to model testing modality choice by time period adjusted for age, sex, and race.
Over the study period, 841 subjects presented Monday through Friday. Median LOS was 18.0 hours (IQR 11.7 to 22.9 hours). Objective cardiac testing was completed in 788 of 841 (94%) patients, with 496 (63%) receiving stress testing and 292 (37%) receiving CCTA. After adjusting for age, race, and sex, patients presenting between 08:00 and 11:59 hrs not only had a shorter LOS associated with CCTA (p < 0.0001), but also had a greater likelihood of being tested by CCTA (p = 0.001). None of the other time periods had significant differences in LOS or testing modality choice for CCTA relative to stress testing.
In an OU setting with weekday and standard business hours CCTA availability, CCTA testing was associated with shorter LOS among low-risk chest pain patients only in patients presenting to the ED between 08:00 and 11:59 hrs. That time period was also associated with a greater likelihood of being tested by CCTA, suggesting that ED providers may have intuited the inability of CCTA to shorten LOS during other times.
PMCID: PMC3607957  PMID: 23517254
5.  Incremental Value of Objective Cardiac Testing in Addition to Physician Impression and Serial Contemporary Troponin Measurements in Women 
Guidelines recommend that patients presenting to the emergency department (ED) with chest pain who are at low risk for acute coronary syndrome (ACS) receive an objective cardiac evaluation with a stress test or coronary imaging. It is uncertain whether all women derive benefit from this process. The study aim was to determine the incremental value of objective cardiac testing after serial cardiac markers and physician risk assessment.
Women enrolled in the 18-site Myeloperoxidase in the Diagnosis of Acute Coronary Syndrome (MIDAS) study had serial troponin I measured at time 0 and 90 minutes, and physician risk assessment for the presence of ACS. Risk estimates obtained at the time of ED evaluation were dichotomized as high or non-high risk. The primary outcome was the composite of acute myocardial infarction (AMI) or revascularization at 30 days. Logistic regression with receiver operator characteristic (ROC) curves and net reclassification index were used to determine the diagnostic accuracy for the composite outcome of 30-day MI or revascularization for two models: 1) troponin I results and physician risk assessment alone; and 2) troponin I results, physician risk assessment, and objective cardiac testing.
Four hundred sixty women with a median age 58 years (IQR 48.5 to 68 years) were included, and 32 (6.9%) experienced AMI or revascularization by 30 days. Comparison of the area under the ROC curves (AUC) showed that the addition of objective cardiac testing to the combination of troponin I results and physician risk assessment did not significantly improve prediction of 30-day AMI or revascularization (AUC 0.85 vs. 0.89; p = 0.053). Using a threshold of 1%, net reclassification index showed that the addition of objective cardiac testing to troponin I results and physician risk assessment worsened the prediction for 30-day AMI and revascularization. All of the reclassified patients were false positives, with nine (2.1%) patients incorrectly reclassified from <1% risk to ≥1% risk of 30-day AMI or revascularization.
In the era of contemporary troponin assays, objective cardiac testing after an ED clinician risk assessment of non-high risk and negative troponin I results at 0 and 90 minutes does not improve the prediction of 30-day AMI or revascularization in women presenting with chest pain or other symptoms of cardiac ischemia.
PMCID: PMC3725334  PMID: 23517258
6.  Provider-Directed Imaging Stress Testing Reduces Health-Care Expenditures in Lower-Risk Chest Pain Patients Presenting to the Emergency Department 
Among intermediate to high-risk patients with chest pain, we have shown that a cardiac magnetic resonance (CMR) stress-test strategy implemented in an observation unit (OU) reduces 1-year healthcare costs compared to inpatient care. In this study, we compare two OU strategies to determine among lower-risk patients if a mandatory CMR stress test strategy was more effective than a physicians’ ability to select a stress test modality.
Methods and Results
Upon ED arrival and referral to the OU for management of low to intermediate-risk chest pain, 120 individuals were randomized to receive an a) CMR stress imaging test (n=60), or b) a provider selected stress test (n=60: stress echo [62%], CMR (32%), cardiac catheterization (3%), nuclear (2%), and coronary CT [2%]). No differences were detected in length of stay (median CMR = 24.2 hours vs 23.8 hours, p=0.75), catheterization without revascularization (CMR=0% vs 3%), appropriateness of admission decisions (CMR 87% vs 93%, p=0.36), or 30-day ACS (both 3%). Median cost was higher among those randomized to the CMR mandated group ($2005 vs $1686, p<0.001).
In patients with lower-risk chest pain receiving ED-directed OU care, the ability of a physician to select a cardiac stress imaging modality (including echocardiography, CMR, or radionuclide testing) was more cost effective than a pathway that mandates a CMR stress test. Contrary to prior observations in individuals with intermediate to high-risk chest pain, in those with lower risk chest pain, these results highlight the importance of physician-related choices during ACS diagnostic protocols.
Clinical Trial Registration
URL: Unique identifier: NCT00869245.
PMCID: PMC3272279  PMID: 22128195
chest pain diagnosis; magnetic resonance imaging; trials; cost-benefit analysis
7.  Can the HEART Score Safely Reduce Stress Testing and Cardiac Imaging in Patients at Low Risk for Acute Coronary Syndrome? 
Critical Pathways in Cardiology  2011;10(3):128-133.
Patients with low risk chest pain have high utilization of stress testing and cardiac imaging, but low rates of acute coronary syndrome (ACS). The objective of this study was to determine if the HEART score could safely reduce objective cardiac testing in patients with low risk chest pain.
A cohort of chest pain patients was identified from an Emergency Department-based observation unit registry. HEART scores were determined using registry data elements and blinded chart review. HEART scores were dichotomized into low (0–3) or high risk (>3). The outcome was MACE; a composite endpoint of all cause mortality, myocardial infarction, or coronary revascularization during the index visit or within 30 days. Sensitivity, specificity, and potential reduction of cardiac testing were calculated.
Over 28 months, the registry included 1070 low risk chest pain patients. MACE occurred in 0.6% (5/904) of patients with low-risk HEART scores compared to 4.2% (7/166) with a high-risk HEART scores, OR=7.92, (95%CI 2.48–25.25). A HEART score >3 was 58% sensitive (95% CI 32–81%) and 85% specific (95% CI 83–87%) for MACE. The HEART score missed 5 cases of ACS among 1070 patients (0.5%) and could have reduced cardiac testing by 84.5% (904/1070). Combination of serial troponin > 0.065 ng/ml or HEART score >3 resulted in 100% sensitivity (95% CI 72–100%), specificity of 83% (95%CI 81–85%), and potential reduction in cardiac testing of 82% (879/1070).
If used to guide stress testing and cardiac imaging, the HEART score could substantially reduce cardiac testing in a population with low pre-test probability of ACS.
PMCID: PMC3289967  PMID: 21989033
HEART score; chest pain; cardiac testing; observation; risk stratification
8.  Alcohol Affects the Late Differentiation of Progenitor B Cells 
Aims: Previous studies show that alcohol exposure can affect the differentiation of progenitor B cells. Before final commitment to a B lineage, progenitor B cells usually undergo several important stages. However, it is still unclear whether alcohol alters B cell differentiation at which stages. The aim of this study was to determine which stage(s) of progenitor cell differentiation are affected by alcohol and to elucidate the mechanism(s) responsible for the effect of alcohol on B cell differentiation. Methods: Oligoclonal-neonatal-progenitor (ONP) cells from bone marrow cells of 2-week-old mice were cultured under different conditions in vitro with or without the exposure of 100 mM alcohol. Phenotype analysis was performed at different time points and expression levels of transcription factors (TFs) and cytokine receptors were measured quantitatively and kinetically. Results: After 3 days in vitro culture, ONP cells differentiated into two populations: B220−CD11b− and B220−CD11b+ cells. B220−CD11b− cells can further differentiate into B lineage cells only with the support of B220−CD11b+ cells. Cells exposed to 100 mM of alcohol during the first 3 days of culture showed no statistically significant difference in B cell formation after 12 days compared with the control group. However, cells exposed to alcohol from Day 4 till the end of culture yield very few B cells. Expression levels of TFs and cytokine receptors were down-regulated kinetically among ONP cells co-cultured with the addition of 100 mM alcohol. Conclusions: Alcohol affects the ONP cell differentiation into B lineage at a late stage. Alcohol also down-regulates the expression level of TFs and cytokine receptors resulting in the impairment of B cell differentiation.
PMCID: PMC3002845  PMID: 21098503
9.  Vascular Pedicle Width on Chest Radiograph as a Measure of Volume Overload: Meta-Analysis 
Vascular pedicle width (VPW), a measurement obtained from a chest radiograph (CR), is thought to be an indicator of circulating blood volume. To date there are only a handful of studies that demonstrate a correlation between high VPW and volume overload, each utilizing different VPW values and CR techniques. Our objective was to determine a mean VPW measurement from erect and supine CRs and to determine whether VPW correlates with volume overload.
MEDLINE database, Web of Science, and the Cochrane Central Register of Controlled Trials were searched electronically for relevant articles. References from the original and review publications selected electronically were manually searched for additional relevant articles. Two investigators independently reviewed relevant articles for inclusion criteria and data extraction. Mean VPW measurements from both supine and erect CRs and their correlation with volume overload were calculated.
Data from 8 studies with a total of 363 subjects were included, resulting in mean VPW measurements of 71 mm (95% confidence interval [CI] 64.9–77.3) and 62 mm (95% CI 49.3–75.1) for supine and erect CRs, respectively. The correlation coefficients for volume overload and VPW were 0.81 (95% CI 0.74–0.86) for both CR techniques and 0.81 (95% CI 0.72–0.87) for supine CR and 0.80 (95% CI 0.69–0.87) for erect CR, respectively.
There is a clinical and statistical correlation between VPW and volume overload. VPW may be used to evaluate the volume status of a patient regardless of the CR technique used.
PMCID: PMC3236159  PMID: 22224132
10.  Can we make the basilic vein larger? maneuvers to facilitate ultrasound guided peripheral intravenous access: a prospective cross-sectional study 
Studies have shown that vein size is an important predictor of successful ultrasound-guided vascular access. The objective of this study is to evaluate maneuvers designed to increase basilic vein size, which could be used to facilitate ultrasound-guided peripheral intravenous access (USGPIV) in the Emergency Department (ED) setting.
This was a prospective non-randomized trial. Healthy volunteers aged 18-65 were enrolled. Basilic veins were identified and the cross-sectional area measured sonographically. Following baseline measurement, the following maneuvers were performed: application of a tourniquet, inflation of a blood pressure (BP) cuff, application of a tourniquet with the arm lowered, and BP cuff inflation with the arm lowered. Following each maneuver there was 30 s of recovery time, and a baseline measurement was repeated to ensure that the vein had returned to baseline. Change in basilic vein size was modeled using mixed model analysis with a Tukey correction for multiple comparisons to determine if significant differences existed between different maneuvers.
Over the 5-month study period, 96 basilic veins were assessed from 52 volunteers. All of the maneuvers resulted in a statistically significant increase in basilic vein size from baseline (p < 0.001). BP cuff inflation had the greatest increase in vein size from baseline 17%, 0.87 mm 95% CI (0.70-1.04). BP cuff inflation statistically significantly increased vein size compared to tourniquet placement by 3%, 0.16 mm 95% CI (0.02-0.30).
The largest increase in basilic vein size was due to blood pressure cuff inflation. BP cuff inflation resulted in a statistically significant increase in vein size compared to tourniquet application, but this difference may not be clinically significant.
PMCID: PMC3170581  PMID: 21867495
11.  Emergency Department Activation of Interventional Cardiology to Reduce Door-to-Balloon Time 
Despite American College of Cardiology (ACC) and American Heart Association (AHA) guidelines, many hospitals have door-to-balloon times in excess of 90 minutes. Emergency Department (ED) activation of interventional cardiology has been described as an important strategy to reduce door-to-balloon time. However, prior studies on ED activation have been in suburban hospitals with door-to-balloon times near the ACC/AHA targeted times.
To determine if ED activation of interventional cardiology could significantly improve reperfusion times and reach the ACC/AHA target of 90 minutes or less in a safety net hospital, a Level I trauma center and teaching hospital serving primarily uninsured and underinsured patient population with door-to-balloon times ranking in the lowest quartile of United States hospitals.
In this study, door-to balloon times before and after implementation of ED activation were compared by retrospective chart review.
Eighty patients were included in the study, 48 before and 32 after ED activation of interventional cardiology. Median door-to-balloon time decreased from 163.5 minutes before to 130 minutes after ED activation, a significant difference of 33.5 minutes (p=0.028). Door-to-balloon time on nights, weekends and holidays decreased from a median of 165.5 minutes to 130 minutes, a reduction of 35.5 minutes, which also reached statistical significance (p=0.029).
ED activation of interventional cardiology produced a statistically significant reduction in door-to-balloon time. However, the reduction was not enough to achieve a door-to-balloon time of less than 90 minutes. Safety net hospitals with door-to-balloon times in the lowest quartile nationally may require multiple strategies to achieve targeted myocardial reperfusion times.
PMCID: PMC2967690  PMID: 21079710
12.  Intestinal Angioedema Misdiagnosed as Recurrent Episodes of Gastroenteritis 
Emergency physicians (EP) frequently encounter angioedema involving the lips and tongue. However, angioedema from Angiotensin Converting Enzyme inhibitors or hereditary angioedema (HAE) can present with gastrointestinal symptoms due to bowel wall involvement. EPs should begin to consider this clinical entity as a potential cause for abdominal pain and associated gastrointestinal symptoms given the common use of medications that can precipitate angioedema. We report a case of a 34-year-old woman who presented with abdominal cramping, vomiting and diarrhea due to an acute exacerbation of HAE.
PMCID: PMC2967696  PMID: 21079716
13.  Diffuse ST segment depression from hypothermia 
Hypothermia is known to cause specific electrocardiographic (EKG) changes such as Osborne waves and bradycardia. We report diffuse ST segment depression, an atypical EKG change, in a patient with a core temperature of 29.4°C (85°F). This patient had no previous cardiovascular pathology, and his EKG changes resolved gradually with aggressive warming. We also discuss the pathophysiology and clinical significance of ST depression in the general population and the typical EKG changes in hypothermia patients.
PMCID: PMC3047890  PMID: 21373321
Electrocardiography; Hypothermia; ST depression

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