Influence of Patient and Clinician Gender on Emergency Department HEART Scores: A Secondary Analysis of a Prospective Observational Trial.

STUDY OBJECTIVE: Clinical decision aids can decrease health care disparities. However, many clinical decision aids contain subjective variables that may introduce clinician bias. The HEART score is a clinical decision aid that estimates emergency department (ED) patients' cardiac risk. We sought to explore patient and clinician gender's influence on HEART scores. METHODS: In this secondary analysis of a prospective observational trial, we examined a convenience sample of adult ED patients at one institution presenting with acute coronary syndrome symptoms. We compared ED clinician-generated HEART scores with researcher-generated HEART scores blinded to patient gender. The primary outcome was agreement between clinician and researcher HEART scores by patient gender overall and stratified by clinician gender. Analyses used difference-in-difference (DiD) for continuous score and prevalence-adjusted, bias-adjusted Kappa (PABAK) for binary (low versus moderate/high risk) score comparison. RESULTS: All 336 clinician-patient pairs from the original study were included. In total, 47% (158/336) of patients were women, and 52% (174/336) were treated by a woman clinician. The DiD between clinician and researcher HEART scores among men versus women patients was 0.24 (95% CI -0.01 to 0.48). Compared with researchers, men clinicians assigned a higher score to men versus women patients (DiD 0.51 [95% CI 0.16 to 0.87]), whereas women clinicians did not (DiD 0.00 [95% CI -0.33 to 0.33]). Agreement was the highest among women clinicians (PABAK 0.72; 95% CI 0.61 to 0.81) and lowest among men clinicians assessing men patients (PABAK 0.47; 95% CI 0.29 to 0.66). CONCLUSION: Patient and clinician gender may influence HEART scores. Researchers should strive to understand these influences in developing and implementing this and other clinical decision aids.

Use of high-sensitivity cardiac troponin in the emergency department: A policy resource and education paper (PREP) from the American College of Emergency Physicians.

This Policy Resource and Education Paper (PREP) from the American College of Emergency Physicians (ACEP) discusses the use of high-sensitivity cardiac troponin (hs-cTn) in the emergency department setting. This brief review discusses types of hs-cTn assays as well as the interpretation of hs-cTn in the setting of various clinical factors such as renal dysfunction, sex, and the important distinction between myocardial injury versus myocardial infarction. In addition, the PREP provides one possible example of an algorithm for the use of a hs-cTn assay in patients in whom the treating clinician is concerned about potential acute coronary syndrome.

A Prospective Evaluation of Clinical HEART Score Agreement, Accuracy, and Adherence in Emergency Department Chest Pain Patients.

STUDY OBJECTIVE: The HEART score is a risk stratification aid that may safely reduce chest pain admissions for emergency department patients. However, differences in interpretation of subjective components potentially alters the performance of the score. We compared agreement between HEART scores determined during clinical practice with research-generated scores and estimated their accuracy in predicting 30-day major adverse cardiac events. METHODS: We prospectively enrolled adult ED patients with symptoms concerning for acute coronary syndrome at a single tertiary center. ED clinicians submitted their clinical HEART scores during the patient encounter. Researchers then independently interviewed patients to generate a research HEART score. Patients were followed by phone and chart review for major adverse cardiac events. Weighted kappa; unweighted Cohen's kappa; prevalence-adjusted, bias-adjusted kappa (PABAK); and test probabilities were calculated. RESULTS: From November 2016 to June 2019, 336 patients were enrolled, 261 (77.7%) were admitted, and 30 (8.9%) had major adverse cardiac events. Dichotomized HEART score agreement was 78% (kappa 0.48, 95% confidence interval [CI] 0.37 to 0.58; PABAK 0.57, 95% CI 0.48 to 0.65) with the lowest agreement in the history (72%; WK 0.14, 95% CI 0.06 to 0.22) and electrocardiogram (85%; WK 0.4, 95% CI 0.3 to 0.49) components. Compared with researchers, clinicians had 100% sensitivity (95% CI 88.4% to 100%) (versus 86.7%, 95% CI 69.3% to 96.2%) and 27.8% specificity (95% CI 22.8% to 33.2%) (versus 34.6%, 95% CI 29.3% to 40.3%) for major adverse cardiac events. Four participants with low research HEART scores had major adverse cardiac events. CONCLUSION: ED clinicians had only moderate agreement with research HEART scores. Combined with uncertainties regarding accuracy in predicting major adverse cardiac events, we urge caution in the widespread use of the HEART score as the sole determinant of ED disposition.

Recommendations for the Emergency Department Prevention of Sport-Related Concussion.

Sport-related concussion refers to the subset of concussive injuries occurring during sport activities. Similar to concussion from nonsport mechanisms, sport-related concussion is associated with significant morbidity, including migrainous headaches, disruption in normal daily activities, and long-term depression and cognitive deficits. Unlike nonsport concussions, sport-related concussion may be uniquely amenable to prevention efforts to mitigate these problems. The emergency department (ED) visit for sport-related concussion represents an opportunity to reduce morbidity by timely diagnosis and management using best practices, and through education and counseling to prevent a subsequent sport-related concussion. This article provides recommendations to reduce sport-related concussion disability through primary, secondary, and tertiary preventive strategies enacted during the ED visit. Although many recommendations have a solid evidence base, several research gaps remain. The overarching goal of improving sport-related concussion outcome through enactment of ED-based prevention strategies needs to be explicitly studied.

ACR Appropriateness Criteria® Cervical Neck Pain or Cervical Radiculopathy.

Nontraumatic neck pain is a leading cause of disability, with nearly 50% of individuals experiencing ongoing or recurrent symptoms. Radiographs are appropriate as initial imaging for cervical or neck pain in the absence of "red flag" symptoms or if there are unchanging chronic symptoms; however, spondylotic changes are commonly identified and may result in both false-positive and false-negative findings. Noncontrast CT can be complementary to radiographs for evaluation of new or changing symptoms in the setting of prior cervical spine surgery or in the assessment of extent of ossification in the posterior longitudinal ligament. Noncontrast MRI is usually appropriate for assessment of new or increasing radiculopathy due to improved nerve root definition. MRI without and with contrast is usually appropriate in patients with new or increasing cervical or neck pain or radiculopathy in the setting of suspected infection or known malignancy. Imaging may be appropriate; however, it is not always indicated for evaluation of cervicogenic headache without neurologic deficit. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Correction: Correction to 'Clinical Policy for Well-Appearing Infants and Children Younger Than 2 Years of Age Presenting to the Emergency Department With Fever' [Annals of Emergency Medicine 67 (2016) 625-639.e13].

Due to a miscommunication during the process of transferring this manuscript from our editorial team to Production, the Members of the American College of Emergency Physicians Clinical Policies Committee (Oversight Committee) were not properly indexed in PubMed. This has now been corrected online. The publisher would like to apologize for any inconvenience caused.

Computed tomography scanning in pediatric trauma: opportunities for performance improvement and radiation safety.

BACKGROUND: Recently, pediatric CT scanning protocols have reduced radiation exposure in children. Because evaluation with CT scan after trauma contributes to significant radiation exposure, we reviewed the CT scans in children at both initial presentation at a non-pediatric facility and subsequent transfer to a level I pediatric trauma center (PTC) to determine the number of scans, body area scanned, radiation dosage, and proportion of scans at each facility. METHODS: The trauma database was retrospectively reviewed for children aged 0 to 17 y initially evaluated for trauma at another facility and then transferred to our PTC for pediatric specialty care between January 2000 and December 2010. RESULTS: A total of 1562 patients with 1335 CT scans were reviewed over an 11-y period. The majority of CT scans occur at the referring facility compared to the PTC in a ratio of 7:3. CT of the head was the most frequent scan obtained (52%), and 17.9% of CT scans were repeated at the PTC. Less than 1% of CT scans performed at the non-pediatric centers contained radiation dosage information, precluding analysis of radiation exposure. CONCLUSIONS: The majority of CT scans for trauma occur at non-pediatric facilities, which demonstrates the need for referring facilities to perform optimal CT scans with the least amount of radiation exposure to the child. We believe this provides an opportunity for PTC performance improvement by facilitating the transfer of images and educating referring facilities about indications for CT scans, dosage amounts, and radiation reduction protocols.

Influence of obesity on mortality of drivers in severe motor vehicle crashes.

PURPOSE: The purpose of the study was to investigate the relationship between obesity and mortality of drivers in severe motor vehicle crashes involving at least one fatality. BASIC PROCEDURES: Fatalities were selected from 155,584 drivers included in the 2000-2005 Fatality Analysis Reporting System. Drivers were stratified by body mass index, confounders were adjusted for, and multiple logistic regression was used to determine the odds ratio (OR) of death in each body mass index class compared with normal weight. MAIN FINDINGS: The adjusted risk of death from lowest to highest, reported as the OR of death compared with normal weight with 95% confidence intervals, was as follows: (1) overweight (OR, 0.952; 0.911-0.995; P = .0293), (2) slightly obese (OR, 0.996; 0.966-1.026; P = .7758), (3) normal weight, (4) underweight (OR, 1.115; 1.035-1.201; P = .0043), (5) moderately obese (OR, 1.212; 1.128-1.302; P < .0001), and (6) morbidly obese (OR, 1.559; 1.402-1.734; P < .0001). PRINCIPAL CONCLUSIONS: There is an increased risk of death for moderately obese, morbidly obese, and underweight drivers and a decreased risk in overweight drivers.

Laparoscopic assessment of a migrated ventriculoperitoneal shunt into an inguinal hernia.

Placement of a ventriculoperitoneal (VP) shunt may increase intraabdominal pressure and lead to an abdominal or genitourinary complication. We report on a 2-month-old boy with complex congenital neurologic and cardiac anomalies who had a VP shunt migrate into the left inguinal hernia. This report demonstrates how a laparoscopic approach can be successfully used to reposition the VP shunt, identify a contralateral inguinal hernia, and repair both without any additional incisions.

Beneficial response to mild therapeutic hypothermia for comatose survivors of near-hanging.

Therapeutic hypothermia has been shown to clearly benefit comatose survivors of cardiac arrest. It is reasonable to postulate that if therapeutic hypothermia is beneficial for the neurological injury of cardiac arrest, then it may have a role in the treatment of near-hanging suffocation injuries. We report a retrospective series of 2 patients who received mild therapeutic hypothermia for their comatose state after a near-hanging injury. The exclusionary criteria and protocols that we use for comatose survivors of cardiac arrest were used. After at least 24 hours of mild therapeutic hypothermia, both patients had a complete return of neurological function, with Glasgow Coma Scale scores of 15 at the time of discharge from the hospital. These data, taken with other case series, suggest that therapeutic hypothermia may be beneficial for comatose survivors of near-hanging.