Quantitative sensory testing measures individual pain responses in emergency department patients.

BACKGROUND: Refining and individualizing treatment of acute pain in the emergency department (ED) is a high priority, given that painful complaints are the most common reasons for ED visits. Few tools exist to objectively measure pain perception in the ED setting. We speculated that variation in perception of fixed painful stimuli would explain individual variation in reported pain and response to treatment among ED patients. MATERIALS AND METHODS: In three studies, we 1) describe performance characteristics of brief quantitative sensory testing (QST) in 50 healthy volunteers, 2) test effects of 10 mg oxycodone versus placebo on QST measures in 18 healthy volunteers, and 3) measure interindividual differences in nociception and treatment responses in 198 ED patients with a painful complaint during ED treatment. QST measures adapted for use in the ED included pressure sensation threshold, pressure pain threshold (PPT), pressure pain response (PPR), and cold pain tolerance (CPT) tests. RESULTS: First, all QST measures had high inter-rater reliability and test-retest reproducibility. Second, 10 mg oxycodone reduced PPR, increased PPT, and prolonged CPT. Third, baseline PPT and PPR revealed hyperalgesia in 31 (16%) ED subjects relative to healthy volunteers. In 173 (88%) ED subjects who completed repeat testing 30 minutes after pain treatment, PPT increased and PPR decreased (Cohen's dz 0.10-0.19). Verbal pain scores (0-10) for the ED complaint decreased by 2.2 (95% confidence intervals [CI]: 1.9, 2.6) (Cohen's dz 0.97) but did not covary with the changes in PPT and PPR (r=0.05-0.13). Treatment effects were greatest in ED subjects with a history of treatment for anxiety or depression (Cohen's dz 0.26-0.43) or with baseline hyperalgesia (Cohen's dz 0.40-0.88). CONCLUSION: QST reveals individual differences in perception of fixed painful stimuli in ED patients, including hyperalgesia. Subgroups of ED patients with hyperalgesia and psychiatric history report larger treatment effects on ED pain and QST measures.

Comparison of three cognitive exams in cardiac arrest survivors.

BACKGROUND: Cognitive deficits may detract from quality of life after cardiac arrest. Their pattern and prevalence are not well documented. We used the Computer Assessment of Mild Cognitive Impairment (CAMCI), the Montreal Cognitive Assessment (MOCA) and the 41 Cent Test (41CT) to assess cognitive impairment in cardiac arrest survivors and examine the exams' diagnostic accuracy. We hypothesized that the scores of these exams would indicate the presence of cognitive impairment in arrest survivors, that the overall scores on the three study assessments would correlate with one another, and that the 41CT, MOCA, and executive function element of the CAMCI would vary independently from other non-executive CAMCI components, reflecting executive function impairment after cardiac arrest. METHODS: Four researchers administered the CAMCI, MOCA, and/or the 41CT to cardiac arrest survivors after discharge from the intensive care unit between 2010 and 2015. Physicians screened patients with the Mini-Mental State Exam to determine when this cognitive testing was feasible, generally when the patient was able to score 20-25 points on the MMSE. We performed pairwise correlations between the different subscales' and tests' scores. RESULTS: One hundred and fourteen participants completed the CAMCI, of which 38 (33.3%) participants additionally completed the MOCA and 41CT. The median (IQR) percentile score for CAMCI for all 114 participants was 33.5 (18.3, 49.8), which corresponds to moderately low risk of impairment. The median (IQR) for the MOCA was 22.0 (19, 24.8) out of a possible 30, which is considered indicative of abnormal cognitive function, and for the 41CT was 6 (5, 7) out of a possible 7 points when all 38 participants were included. MOCA correlated strongly with the overall CAMCI score (r=0.71); the CAMCI correlated moderately strongly with the 41CT (r=0.62) and the MOCA and 41CT were moderately strongly correlated with each other (r=0.56). When all 114 CAMCI scores were considered, the Executive Accuracy subscale was strongly correlated with the overall CAMCI score (r=0.81). CONCLUSION: The CAMCI detects cognitive impairment after cardiac arrest. The MOCA correlates strongly with the overall CAMCI and the executive function subscale of the CAMCI. The 41CT as appears less effective than the MOCA in detecting cognitive deficits.

Optimizing a Text Message Intervention to Reduce Heavy Drinking in Young Adults: Focus Group Findings.

BACKGROUND: Recent trial results show that an interactive short message service (SMS) text message intervention, Texting to Reduce Alcohol Consumption (TRAC), is effective in reducing heavy drinking in non-treatment-seeking young adults, but may not be optimized. OBJECTIVE: To assess the usability of the TRAC intervention among young adults in an effort to optimize future intervention design. METHODS: We conducted five focus groups with 18 young adults, aged 18-25 years, who had a history of heavy drinking and had been randomized to 12 weeks of the TRAC intervention as part of a clinical trial. A trained moderator followed a semistructured interview guide. Focus groups were audiotaped, transcribed, and analyzed to identify themes. RESULTS: We identified four themes regarding user experiences with the TRAC intervention: (1) ease of use, (2) comfort and confidentiality, (3) increased awareness of drinking behavior, and (4) accountability for drinking behavior. Participants' comments supported the existing features of the TRAC intervention, as well as the addition of other features to increase personalization and continuing engagement with the intervention. CONCLUSIONS: Young adults perceived the TRAC intervention as a useful way to help them reduce heavy drinking on weekends. Components that promote ease of use, ensure confidentiality, increase awareness of alcohol consumption, and increase accountability were seen as important.

A text message program as a booster to in-person brief interventions for mandated college students to prevent weekend binge drinking.

OBJECTIVE: To evaluate a text message (SMS) program as a booster to an in-person alcohol intervention with mandated college students. PARTICIPANTS: Undergraduates (N = 224; 46% female) who violated an on-campus alcohol policy over a 2-semester period in 2014. METHODS: The SMS program sent drinking-related queries each Thursday and Sunday and provided tailored feedback for 6 weeks. Response rates to SMS drinking-related queries and the associations between weekend drinking plans, drinking-limit goal commitment, and alcohol consumption were examined. Gender differences were explored. RESULTS: Ninety percent of SMS queries were completed. Weekend binge drinking decreased over 6 weeks, and drinking-limit goal commitment was associated with less alcohol consumption. Compared with women, men had greater reductions in alcohol consumption when they committed to a drinking-limit goal. CONCLUSIONS: Preliminary evidence suggests that an SMS program could be useful as a booster for helping mandated students reduce weekend binge drinking.

An Interactive Text Message Intervention to Reduce Binge Drinking in Young Adults: A Randomized Controlled Trial with 9-Month Outcomes.

BACKGROUND: Binge drinking is associated with numerous negative consequences. The prevalence and intensity of binge drinking is highest among young adults. This randomized trial tested the efficacy of a 12-week interactive text message intervention to reduce binge drinking up to 6 months after intervention completion among young adults. METHODS AND FINDINGS: Young adult participants (18-25 y; n = 765) drinking above the low-risk limits (AUDIT-C score >3/4 women/men), but not seeking alcohol treatment, were enrolled from 4 Emergency Departments (EDs) in Pittsburgh, PA. Participants were randomized to one of three conditions in a 2:1:1 allocation ratio: SMS Assessments + Feedback (SA+F), SMS Assessments (SA), or control. For 12 weeks, SA+F participants received texts each Thursday querying weekend drinking plans and prompting drinking limit goal commitment and each Sunday querying weekend drinking quantity. SA+F participants received tailored feedback based on their text responses. To contrast the effects of SA+F with self-monitoring, SA participants received texts on Sundays querying drinking quantity, but did not receive alcohol-specific feedback. The control arm received standard care. Follow-up outcome data collected through web-based surveys were provided by 78% of participants at 3- months, 63% at 6-months and 55% at 9-months. Multiple imputation-derived, intent-to-treat models were used for primary analysis. At 9-months, participants in the SA+F group reported greater reductions in the number of binge drinking days than participants in the control group (incident rate ratio [IRR] 0.69; 95% CI .59 to.79), lower binge drinking prevalence (odds ratio [OR] 0.52; 95% CI 0.26 to 0.98]), less drinks per drinking day (beta -.62; 95% CI -1.10 to -0.15) and lower alcohol-related injury prevalence (OR 0.42; 95% CI 0.21 to 0.88). Participants in the SA group did not reduce drinking or alcohol-related injury relative to controls. Findings were similar using complete case analyses. CONCLUSIONS: An interactive text-message intervention was more effective than self-monitoring or controls in reducing alcohol consumption and alcohol-related injury prevalence up to 6 months after intervention completion. These findings, if replicated, suggest a scalable approach to help achieve sustained reductions in binge drinking and accompanying injuries among young adults. TRIAL REGISTRATION: ClinicalTrials.gov NCT01688245.

Using online crowdsourcing to understand young adult attitudes toward expert-authored messages aimed at reducing hazardous alcohol consumption and to collect peer-authored messages.

Text message delivered prevention interventions have the potential to improve health behaviors on a large scale, including reducing hazardous alcohol consumption in young adults. Online crowdsourcing can be used to efficiently develop relevant messages, but remains largely understudied. This study aims to use online crowdsourcing to evaluate young adult attitudes toward expert-authored messages and to collect peer-authored messages. We designed an online survey with four drinking scenarios and a demographic questionnaire. We made it available to people who reported age 18-25 years, residence in the US, and any lifetime alcohol consumption via the Amazon Mechanical Turk crowdsourcing platform. Participants rated 71 sample text messages on instrumental (helpful) and affective (interesting) attitude scales and generated their own messages. All messages were coded as informational, motivational, or strategy facilitating. We examined differences in attitudes by message type and by drinking status and sex. We surveyed 272 participants in 48 h, and 222 were included in analysis for a total participant payment cost of $178. Sample mean age was 23 years old, with 50 % being female, 65 % being of white race, and 78 % scored as hazardous drinkers. Informational messages were rated the most helpful, whereas motivational messages were rated the most interesting. Hazardous drinkers rated informational messages less helpful than non-hazardous drinkers. Men reported messages less helpful and interesting than women for most categories. Young adults authored 161 messages, with the highest proportion being motivational. Young adults had variable instrumental and affective attitudes toward expert-authored messages. They generated a substantial number of peer-authored messages that could enhance relevance of future alcohol prevention interventions.

Neurocognitive outcomes following successful resuscitation from cardiac arrest.

INTRODUCTION: Cardiac arrest commonly results in varying degrees of cognitive injury. Standard outcome measures used in the cardiac arrest cohort do not rigorously evaluate for these injury patterns. We examined the utility of the Computerized Assessment for Mild Cognitive Injury (CAMCI) in cardiac arrest (CA) survivors. We hypothesized that cognitive deficits would be more severe in patients who were comatose on hospital arrival. METHODS: Prospective cohort of CA survivors at a single tertiary care facility where participants received neurocognitive testing using CAMCI. CAMCI results were subdivided into memory, attention, and executive functions. Scores between subjects who were initially comatose and were not comatose following resuscitation were compared using the Mann-Whitney test. RESULTS: Of 72 subjects included, the majority (N=44) were initially comatose following resuscitation with mean age of 54 (±14) years. The majority experienced a good neurologic outcome based on Cerebral Performance Category (N=47; 66%) and Modified Rankin Scale (N=38; 53%). Time from resuscitation to CAMCI testing was not associated with total CAMCI score in this cohort (Pearson's r(2) value -0.1941, p=0.20). Initially comatose and not comatose subjects did not differ in their CAMCI overall scores (p=0.33), or in any subtest areas. The not comatose cohort had 1 subtest for which there was a Moderate Risk for mild cognitive impairment (Nonverbal Accuracy), and 2 for which there was a Moderately Low Risk (Verbal Accuracy and Executive Accuracy). The Comatose cohort had 4 subtests, which were deemed Moderately Low Risk for cognitive impairment (Verbal Accuracy, Attention Accuracy, Executive Accuracy and Nonverbal Accuracy). CONCLUSIONS: In-hospital CAMCI testing suggests memory, attention and executive impairment are commonly in patients following resuscitation from cardiac arrest. Outcome evaluations should test for deficits in memory, attention, and executive function.

Recreational drug overdose-related cardiac arrests: break on through to the other side.

INTRODUCTION: The annual rate of recreational overdose (OD)-related death is increasing exponentially, making unintentional overdose the leading cause of injury-related death in America. Unfortunately, little attention in the resuscitation community has focused on the post-arrest care of this rapidly growing population. METHODS: We included patients presenting between January 2009 and February 2014 after out-of-hospital cardiac arrest (OHCA) and abstracted baseline clinical characteristics and neurological outcomes. We considered an arrest to be an OD OHCA if toxicology screens were positive and not explained by therapeutic medication administration or home medications; or if there was a history strongly suggestive of OD. We compared the baseline clinical characteristics and outcomes between the OD and non-OD cohorts. RESULTS: In total, 591 OHCA patients were admitted, of which 85 (14%) arrests were OD-related. OD OHCA patients were significantly younger, had fewer medical comorbidities, were more likely to present with non-shockable rhythms and had worse baseline neurological function. However, overall survival, neurological outcomes and length of stay did not vary between groups. OD OHCA patients who survived to discharge had a significantly higher rate of favorable discharge dispositions (83% of OD OHCA survivors discharged to home or acute rehabilitation vs 62% of non-OD OHCA (P=0.03)). CONCLUSION: Patients who have suffered an OD OHCA make up a significant proportion of the overall OHCA population. Despite poor baseline prognostic factors, survival after OD OHCA was no worse than after non-OD OHCA, and among survivors a majority had a good neurological outcome.

A text message alcohol intervention for young adult emergency department patients: a randomized clinical trial.

STUDY OBJECTIVE: Opportunistic brief in-person emergency department (ED) interventions can be effective at reducing hazardous alcohol use in young adult drinkers, but require resources frequently unavailable. Mobile telephone text messaging (short message service [SMS]) could sustainably deliver behavioral support to young adult patients, but efficacy remains unknown. We report 3-month outcome data of a randomized controlled trial testing a novel SMS-delivered intervention in hazardous-drinking young adults. METHODS: We randomized 765 young adult ED patients who screened positive for past hazardous alcohol use to one of 3 groups: SMS assessments+feedback (SA+F) intervention who were asked to respond to drinking-related queries and received real-time feedback through SMS each Thursday and Sunday for 12 weeks (n=384), SMS assessments (SA) who were asked to respond to alcohol consumption queries each Sunday but did not receive any feedback (N=196), and a control group who did not participate in any SMS (n=185). Primary outcomes were self-reported number of binge drinking days and number of drinks per drinking day in the past 30 days, collected by Web-based timeline follow-back method and analyzed with regression models. Secondary outcomes were the proportion of participants with weekend binge episodes and most drinks consumed per drinking occasion during 12 weekends, collected by SMS. RESULTS: With Web-based data, there were decreases in the number of self-reported binge drinking days from baseline to 3 months in the SA+F group (-0.51 [95% confidence interval {CI} -0.10 to -0.95]), whereas there were increases in the SA group (0.90 [95% CI 0.23 to 1.6]) and the control group (0.41 [95% CI -0.20 to 1.0]). There were also decreases in the number of self-reported drinks per drinking day from baseline to 3 months in the SA+F group (-0.31 [95% CI -0.07 to -0.55]), whereas there were increases in the SA group (0.10 [95% CI -0.27 to 0.47]) and the control group (0.39 [95% CI 0.06 to 0.72]). With SMS data, there was a lower mean proportion of SA+F participants reporting a weekend binge during 12 weeks (30.5% [95% CI 25% to 36%) compared with the SA participants (47.7% [95% CI 40% to 56%]). There was also a lower mean drinks consumed per weekend during 12 weeks in the SA+F group (3.2 [95% CI 2.6 to 3.7]) compared to the SA group (4.8 [95% CI 4.0 to 5.6]). CONCLUSION: A text message intervention can produce small reductions in self-reported binge drinking and the number of drinks consumed per drinking day in hazardous-drinking young adults after ED discharge.

Pre-resuscitation lactate and hospital mortality in prehospital patients.

OBJECTIVE: Serum lactate elevations are associated with morbidity and mortality in trauma patients, but their value in prehospital medical patients prior to resuscitation is unknown. We sought to assess the distribution of blood lactate concentrations prior to intravenous (i.v.) resuscitation and examine the association of elevation on in-hospital death. METHODS: A convenience sample of adult patients over 14 months who received an i.v. line by eight EMS agencies in Western Pennsylvania had lactate measurement prior to any i.v. treatment. We assessed the lactate values and any relationship between these and hospital mortality (our primary outcome) and admission to the intensive care unit (ICU). We also compared the ability of lactate to discriminate outcomes with a prehospital critical illness score using age, Glasgow Coma Score, and initial vital signs. RESULTS: We included 673 patients, among whom 71 (11%) were admitted to the ICU and 21 (3.1%) died in-hospital. Elevated lactate (≥2 mmol/L) occurred in 307 (46%) patients and was strongly associated with hospital death after adjustment for known covariates (odds ratio = 3.57, 95% confidence interval [CI]: 1.10, 11.6). Lactate ≥2 mmol/L had a modest sensitivity (76%) and specificity (55%), and discrimination for hospital death (area under the curve [AUC] = 0.66, 95%CI: 0.56, 0.75). Compared to the prehospital critical illness score alone (AUC = 0.69, 95% CI: 0.59, 0.80), adding lactate to the score offered modest improvement (net reclassification improvement = 0.63, 95%CI: 0.23, 1.01, p < 0.05). CONCLUSIONS: Initial lactate concentration in our prehospital medical patient population was associated with hospital mortality. However, it is a modest predictor of outcome, offering similar discrimination to a prehospital critical illness score.

Mobile phone text message intervention to reduce binge drinking among young adults: study protocol for a randomized controlled trial.

BACKGROUND: Heavy episodic (binge) drinking is common among young adults and can lead to injury and illness. Young adults who seek care in the Emergency Department (ED) may be disproportionately affected with binge drinking behavior, therefore provide an opportunity to reduce future risk through screening, brief intervention and referral to treatment (SBIRT). Mobile phone text messaging (SMS) is a common form of communication among young adults and has been shown to be effective at providing behavioral support to young adult drinkers after ED discharge. Efficacy of SMS programs to reduce binge drinking remains unknown. METHODS/DESIGN: We will conduct a three parallel arm, randomized trial. A convenience sample of adults aged 18 to 25 years attending three EDs in Pittsburgh, PA and willing to participate in the study will be screened for hazardous alcohol consumption. Participants identified as hazardous drinkers will then be allocated to either 12 weeks of weekly SMS drinking assessments with feedback (SA+F), SMS drinking assessments without feedback (SA), or a control group. Randomization will be via an independent and remote computerized randomization and will be stratified by study site. The SA+F group will be asked to provide pre-weekend drinking intention as well as post-weekend consumption via SMS and will receive feedback messages focused on health consequences of alcohol consumption, personalized normative feedback, protective drinking strategies and goal setting. Follow-up data on alcohol use and injury related to alcohol will be collected through a password-protected website three, six and nine months later. The primary outcome for the study is binge drinking days (≥4 drinks for women; ≥5 drinks for men) during the previous month, and the main secondary outcome is the proportion of participants who report any injury related to alcohol in the prior three months. DISCUSSION: This study will test the hypothesis that a mobile phone text-messaging program will result in immediate and durable reductions in binge drinking among at-risk young adults. By testing an intervention group to an assessment-only and control group, we will be able to separate the effect of assessment reactivity. By collecting pre-weekend drinking intentions and post-weekend consumption data in the SA+F group, we will be able to better understand mechanism of change. TRIAL REGISTRATION: Clinicaltrials.gov NCT01688245.

Mobile phone text messaging to assess symptoms after mild traumatic brain injury and provide self-care support: a pilot study.

PURPOSE: To examine whether patients with mild traumatic brain injury (mTBI) receiving text messaging-based education and behavioral support had fewer and less severe postconcussive symptoms than those not receiving text-message support. Our secondary objective was to determine the feasibility of using text messaging to assess daily symptoms and provide support to patients with mTBI. DESIGN: Randomized controlled trial with 14-day follow-up. PARTICIPANTS: Convenience sample of 43 adult emergency department patients with mTBI. INTERVENTION: Fourteen days of timed SMS (short-message service) symptom assessments (9 AM: headaches; 1 PM: difficulty concentrating; 5 PM: irritability or anxiety) with self-care support messages. MAIN MEASURES: SMS symptom reports, Rivermead Postconcussion Symptoms Questionnaire. RESULTS: Compared with the control group, intervention participants trended to lower odds of reporting headaches (odds ratio [OR] = 0.38; 95% confidence interval [CI]: 0.07-1.99), concentration difficulty (OR = 0.32; 95% CI: 0.04-2.24), and irritability or anxiety (OR = 0.33; 95% CI: 0.05-2.35). There were also trends of lower mean scores for headaches (0.99 vs 1.19; P = .5), difficulty concentrating (0.88 vs 1.23; P = .2), and irritability/anxiety (1.00 vs 1.62; P = .06). There were high response rate to SMS symptom assessments and high satisfaction with the intervention. CONCLUSION: Those receiving the text messaging-based education and support had fewer and less severe postconcussive symptoms than the controls but none of the differences reached statistical significance. Further evaluation of more robust mobile interventions and larger sample of participants are still needed.

Near-infrared spectroscopy in post-cardiac arrest patients undergoing therapeutic hypothermia.

AIMS: To investigate the relationship between tissue oxygen saturation during a vascular occlusion test with systemic hemodynamics, central and peripheral skin temperature in patients resuscitated from cardiac arrest. METHODS: This prospective, observational study included a convenience sample of 30 patients hospitalized in a multidisciplinary intensive care unit in a university hospital and treated with therapeutic hypothermia. Near infrared spectroscopy (NIRS) was used to measure thenar tissue oxygen saturation, desaturation rate and saturation recovery rate after the vascular occlusion test, conducted within 24h of hospital admission and within 12h of initiating re-warming. Measurements included heart rate (HR), mean arterial blood pressure (MAP), oxygen saturation, use of vasopressors and sedatives, core body (esophageal) and peripheral skin temperature and sequential organ failure assessment (SOFA) score. RESULTS: Peripheral skin temperature was found to have a significant effect on StO(2) deoxygenation and recovery slopes, resulting in lower rates at colder temperatures. This effect was independent of MAP, HR, and core temperature. NIRS-derived variables were not associated with SOFA score or use of vasopressors and did not predict mortality. DISCUSSION: Colder peripheral skin temperatures resulting in lower StO(2) desaturation rates may be explained by slower aerobic metabolism, thus lower extraction rate of oxygen, in the tissue beds. Lower recovery slopes at colder local temperatures may result from peripheral vasoconstriction during reactive hyperemia. CONCLUSION: We found that peripheral skin temperature in post-arrest critically ill patients undergoing TH strongly influences tissue oxygen desaturation and reoxygenation rates. In additional, changes in NIRS derived variables were independent of measures of shock, vasopressor use or illness severity.

Prediction of serious infection during prehospital emergency care.

BACKGROUND: Regionalization of emergency care for patients with serious infections has the potential to improve outcomes, but is not feasible without accurate identification of patients in the prehospital environment. OBJECTIVE: To determine the incremental predictive value of provider judgment in addition to prehospital physiologic variables for identifying patients who have serious infections. METHODS: We conducted a prospective study at a single teaching tertiary-care emergency department (ED) where a convenience sample of emergency medical services (EMS) providers and ED clinicians completed a questionnaire about the same patients. Prehospital providers provided limited demographics and work history about themselves. They also reported the presence of abnormal prehospital physiology for each patient (heart rate >90 beats/min, systolic blood pressure <100 mmHg, respiratory rate >20 breaths/min, pulse oximetry <95%, history of fever, altered mental status) and their judgment about whether the patient had an infection. At the end of formal evaluation in the ED, the physician was asked to complete a survey describing the same patient factors in addition to patient disposition. The primary outcome of serious infection was defined as the presence of both 1) ED report of acute infection and 2) patient admission. We included prehospital factors associated with serious infection in the prediction models. Operating characteristics for various cutoffs and the area under the curve (AUC) were calculated and reported with 95% confidence intervals (95% CIs). RESULTS: Serious infection occurred in 32 (16%) of 199 patients transported by EMS, 50% of whom were septic, and 16% of whom were admitted to the intensive care unit. Prehospital systolic blood pressure <100 mmHg, EMS-elicited history or suspicion of fever, and prehospital judgment of infection were associated with primary outcome. Presence of any one of these resulted in a sensitivity of 0.59 (95% CI 0.40-0.76) and a specificity of 0.81 (95% CI 0.74-0.86). The AUC for the model was 0.71. CONCLUSIONS: Including prehospital provider impression to objective physiologic factors identified three more patients with infection at the cost of overtriaging five. Future research should determine the effect of training or diagnostic aids for improving the sensitivity of prehospital identification of patients with serious infection.