Objective: To retrospectively analyse the use of imaging studies in the Emergency Department of community hospitals using evidence based guidelines and clinical judgement. Methods: Medical records of 661 patients who ...Objective: To retrospectively analyse the use of imaging studies in the Emergency Department of community hospitals using evidence based guidelines and clinical judgement. Methods: Medical records of 661 patients who visited the Emergency Department (ED) in 2015 and underwent imaging studies were reviewed. The Canadian Association of Radiologists, American College of Radiologists and Choosing Wisely Canada guidelines were used to determine the appropriateness of imaging studies. The use of prior patient imaging, the rate at which studies were repeated and the respective impacts on patient management of the imaging studies were also examined. Results: Of the 1056 imaging studies reviewed, 228 (22%) were found to be clinical situations where no imaging study was indicated while 168 (16%) were considered a suboptimal choice of imaging study or modality. When no study was recommended, a positive impact on the diagnosis was noted in 105 (46%) cases and on patient management 83 (36%) times. Notably, 219 (21%) patients had a relevant examination performed in the last 30 days, and 147 (14%) reports noted that the results of the prior study also concurred with the imaging study evaluated. Conclusion: In this study, 228 (22%) radiographs and CT studies, excluding MVC related imaging and extremity imaging, were not indicated based on appropriateness criteria and consequently had a limited impact on patient management. This supports the need for increased clinical decision support for ED physicians, regional health information exchanges and consideration of Computerized Physician Order Entry in the ED with embedded appropriateness criteria at the point of ordering.展开更多
Purpose: Catheter drainage of intra-abdominal abscesses has shown to be effective in reducing sepsis and mortality. We sought to determine whether or not tissue plasminogen activator (tPA), a fibrinolytic, is safe and...Purpose: Catheter drainage of intra-abdominal abscesses has shown to be effective in reducing sepsis and mortality. We sought to determine whether or not tissue plasminogen activator (tPA), a fibrinolytic, is safe and facilitates resolution when used as an adjunct during drainage of intra-abdo-minal abscesses. Methods: A single-blinded, prospective, multi-center, randomized control trial was performed on patients presenting with image confirmed abscesses;the first group (n = 24) received catheter-directed tPA of their abscess and the second group (n = 23) had their abscess drained without tPA instillation. Variables examined included patient age, gender, location of the abscess, pre-drainage volumes and size of catheters inserted. Baseline variables were compared between tPA and non-tPA groups using a chi-square test for discrete variables and a Wilcoxon rank sum test for continuous variables and for the outcome of drainage volume. Results: Technical success of the drainage procedures was 100% for both groups. The tPA group had higher volume of drainage over the first three days (median for total after 3 days: without tPA: 300 mL vs. with tPA: 322 mL, p = 0.42). At days 4 to 7 the tPA group had significant greater drainage volume than did the non-tPA patient group, 150 mL vs. 110 mL (p = 0.046). The number of days to resume diet was also assessed in the 20 patients where this datum was available, 11 tPA and 9 non-tPA with no difference between groups. No adverse events, such as localized or systemic bleeding were encountered. Conclusion: Instillation of tPA into catheter directed intra-abdominal abscesses was safe, easy to perform and was associated with significantly improved drainage of abscesses from days 4 -7.展开更多
Background: The prevalence of acute myocardial infarction(AMI) has increased due to the recent definitions,but the magnitude of this effect using contemporary highly sensitive troponin assays is unclear. The objective...Background: The prevalence of acute myocardial infarction(AMI) has increased due to the recent definitions,but the magnitude of this effect using contemporary highly sensitive troponin assays is unclear. The objective of this study is to compare the diagnosis of AMI using a contemporary troponin I(cTnI) biomarker and the 2003 American Heart Association(AHA) case definition with diagnoses made using the 1994 World Health Organization MONICA definition. Methods: Contemporary troponin I measurements were performed with the Beckman Coulter AccuTnI assay(Chaska, MN) on plasma specimens originally assayed in 1996 for creatine kinase(CK)-MB mass from 486 emergency department patients presenting within 24 hours of onset of symptoms suggestive of cardiac ischemia. Results: In a subgroup of 258 patients with 2 specimens drawn at least 6 hours apart(the AHA “adequate set of biomarkers”), AMI prevalence using CK-MB was 19.4%(95%CI 15.0-24.7)based on MONICA and 19.8%(15.4-25.1) based on the AHA case definition using the criterion for change of ≥20%between specimens. Using cTnI as the biomarker of choice, under the AHA definition, the prevalence increased to as high as 35.7%(30.1-41.7, a relative increase of 84%, P< .001) using the 99th percentile cutoff. In 121 patients with a lower index of suspicion and without the requisite 6-hour interval between measurements, positivity increased from 5%with CK-MB by MONICA up to 12%to 16%with cTnI by AHA. Conclusions: A highly sensitive contemporary cTnI assay used with the AHA case definition results in a 62%to 84%increase in the frequency of AMI diagnosis compared with MONICA criteria.展开更多
文摘Objective: To retrospectively analyse the use of imaging studies in the Emergency Department of community hospitals using evidence based guidelines and clinical judgement. Methods: Medical records of 661 patients who visited the Emergency Department (ED) in 2015 and underwent imaging studies were reviewed. The Canadian Association of Radiologists, American College of Radiologists and Choosing Wisely Canada guidelines were used to determine the appropriateness of imaging studies. The use of prior patient imaging, the rate at which studies were repeated and the respective impacts on patient management of the imaging studies were also examined. Results: Of the 1056 imaging studies reviewed, 228 (22%) were found to be clinical situations where no imaging study was indicated while 168 (16%) were considered a suboptimal choice of imaging study or modality. When no study was recommended, a positive impact on the diagnosis was noted in 105 (46%) cases and on patient management 83 (36%) times. Notably, 219 (21%) patients had a relevant examination performed in the last 30 days, and 147 (14%) reports noted that the results of the prior study also concurred with the imaging study evaluated. Conclusion: In this study, 228 (22%) radiographs and CT studies, excluding MVC related imaging and extremity imaging, were not indicated based on appropriateness criteria and consequently had a limited impact on patient management. This supports the need for increased clinical decision support for ED physicians, regional health information exchanges and consideration of Computerized Physician Order Entry in the ED with embedded appropriateness criteria at the point of ordering.
文摘Purpose: Catheter drainage of intra-abdominal abscesses has shown to be effective in reducing sepsis and mortality. We sought to determine whether or not tissue plasminogen activator (tPA), a fibrinolytic, is safe and facilitates resolution when used as an adjunct during drainage of intra-abdo-minal abscesses. Methods: A single-blinded, prospective, multi-center, randomized control trial was performed on patients presenting with image confirmed abscesses;the first group (n = 24) received catheter-directed tPA of their abscess and the second group (n = 23) had their abscess drained without tPA instillation. Variables examined included patient age, gender, location of the abscess, pre-drainage volumes and size of catheters inserted. Baseline variables were compared between tPA and non-tPA groups using a chi-square test for discrete variables and a Wilcoxon rank sum test for continuous variables and for the outcome of drainage volume. Results: Technical success of the drainage procedures was 100% for both groups. The tPA group had higher volume of drainage over the first three days (median for total after 3 days: without tPA: 300 mL vs. with tPA: 322 mL, p = 0.42). At days 4 to 7 the tPA group had significant greater drainage volume than did the non-tPA patient group, 150 mL vs. 110 mL (p = 0.046). The number of days to resume diet was also assessed in the 20 patients where this datum was available, 11 tPA and 9 non-tPA with no difference between groups. No adverse events, such as localized or systemic bleeding were encountered. Conclusion: Instillation of tPA into catheter directed intra-abdominal abscesses was safe, easy to perform and was associated with significantly improved drainage of abscesses from days 4 -7.
文摘Background: The prevalence of acute myocardial infarction(AMI) has increased due to the recent definitions,but the magnitude of this effect using contemporary highly sensitive troponin assays is unclear. The objective of this study is to compare the diagnosis of AMI using a contemporary troponin I(cTnI) biomarker and the 2003 American Heart Association(AHA) case definition with diagnoses made using the 1994 World Health Organization MONICA definition. Methods: Contemporary troponin I measurements were performed with the Beckman Coulter AccuTnI assay(Chaska, MN) on plasma specimens originally assayed in 1996 for creatine kinase(CK)-MB mass from 486 emergency department patients presenting within 24 hours of onset of symptoms suggestive of cardiac ischemia. Results: In a subgroup of 258 patients with 2 specimens drawn at least 6 hours apart(the AHA “adequate set of biomarkers”), AMI prevalence using CK-MB was 19.4%(95%CI 15.0-24.7)based on MONICA and 19.8%(15.4-25.1) based on the AHA case definition using the criterion for change of ≥20%between specimens. Using cTnI as the biomarker of choice, under the AHA definition, the prevalence increased to as high as 35.7%(30.1-41.7, a relative increase of 84%, P< .001) using the 99th percentile cutoff. In 121 patients with a lower index of suspicion and without the requisite 6-hour interval between measurements, positivity increased from 5%with CK-MB by MONICA up to 12%to 16%with cTnI by AHA. Conclusions: A highly sensitive contemporary cTnI assay used with the AHA case definition results in a 62%to 84%increase in the frequency of AMI diagnosis compared with MONICA criteria.
