Safety and efficiency of emergency department assessment of chest discomfort.

BACKGROUND: Most Canadian emergency departments use an unstructured, individualized approach to patients with chest pain, without data to support the safety and efficiency of this practice. We sought to determine the proportions of patients with chest discomfort in emergency departments who either had acute coronary syndrome (ACS) and were inappropriately discharged from the emergency department or did not have ACS and were held for investigation. METHODS: Consecutive consenting patients aged 25 years or older presenting with chest discomfort to 2 urban tertiary care emergency departments between June 2000 and April 2001 were prospectively enrolled unless they had a terminal illness, an obvious traumatic cause, a radiographically identifiable cause, severe communication problems or no fixed address in British Columbia or they would not be available for follow-up by telephone. At 30 days we assigned predefined explicit outcome diagnoses: definite ACS (acute myocardial infarction [AMI] or definite unstable angina) or no ACS. RESULTS: Of 1819 patients, 241 (13.2%) were assigned a 30-day diagnosis of AMI and 157 (8.6%), definite unstable angina. Of these 398 patients, 21 (5.3%) were discharged from the emergency department without a diagnosis of ACS and without plans for further investigation. The clinical sensitivity for detecting ACS was 94.7% (95% confidence interval [CI] 92.5%- 96.9%) and the specificity 73.8% (95% CI 71.5%- 76.0%). Of the patients without ACS or an adverse event, 71.1% were admitted to hospital or held in the emergency department for more than 3 hours. INTERPRETATION: The current individualized approach to evaluation and disposition of patients with chest discomfort in 2 Canadian tertiary care emergency departments misses 5.3% of cases of ACS while consuming considerable health care resources for patients without coronary disease. Opportunities exist to improve both safety and efficiency.

Intensive care unit survivors have fewer hospital readmissions and readmission days than other hospitalized patients in British Columbia.

OBJECTIVE: Intensive care unit (ICU) patients who survive their hospital admission have a long-term survival that is similar to that of hospitalized patients who do not require ICU admission. The risk of future readmission to the hospital for these two patient groups is unknown. The objective of this study was to determine the association between ICU admission and number of readmissions to the hospital and number of readmission days. DESIGN: Cohort study for 3 yrs between 1994 and 1997. SETTING: All acute care hospitals in British Columbia, Canada. PATIENTS: A total of 23,859 patients admitted to the ICU and 40,052 patients admitted to the hospital but not the ICU (5% random sample of total). INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: We measured the number of readmissions to the hospital and the number of readmission days after discharge from the first admission to the hospital during the study period. For survivors to the end of the study period, patients who had been in the ICU had 0.66 readmissions per year and 5.29 readmission days per year compared with 0.73 readmissions per year and 5.48 readmission days per year for control subjects. After controlling for age, sex, socioeconomic status, number of previous ICU and hospital admissions, major clinical category during index admission, comorbidity score during index admission, length of hospital stay during index admission, size of index hospital, and period of follow-up, ICU admission was associated with fewer readmissions (survivors: rate ratio, 0.80; 95% confidence interval, 0.77-0.82; nonsurvivors: rate ratio, 0.85; 95%, confidence interval, 0.82-0.89) and readmission days (survivors: rate ratio, 0.91; 95% confidence interval, 0.87-0.95; nonsurvivors: rate ratio, 0.87; 95%, confidence interval, 0.81-0.92) than admission to the hospital but not the ICU. CONCLUSIONS: Survivors of a hospital stay that includes admission to an ICU have fewer hospital readmissions and readmission days after their discharge than do survivors of a hospital stay without intensive care.

Modest decreases in NNRTI susceptibility do not influence virological outcome in patients receiving initial NNRTI-containing triple therapy.

OBJECTIVE: To assess the prevalence of modest (< 10-fold) decreases in baseline non-nucleoside reverse transcriptase inhibitor (NNRTI) susceptibility and their impact on virological response to NNRTI-containing triple therapy in drug-naive individuals. METHODS: Baseline HIV resistance phenotype, genotype and response to therapy were examined retrospectively for all antiretroviral-naive individuals initiating therapy with two nucleoside analogues and an NNRTI in British Columbia, Canada, between 05/1997 and 08/1999 (n = 279), followed until July 31 2001. Time to viral suppression (first of at least two consecutive plasma viral loads < 400 copies HIV RNA copies/ml) and viral rebound (to > or = 400 copies/ml after first pVL < 400 copies HIV RNA copies/ml), were estimated by Kaplan-Meier methods. Multivariate analyses were performed using Cox proportional hazards regression. RESULTS: Nevirapine was the most commonly prescribed NNRTI (96%). Four- to 10-fold decreased susceptibility to NNRTIs was observed in > 30% of untreated individuals at baseline, an observation strongly driven by decreased susceptibility to delavirdine (22.4%). A > 10-fold decrease in susceptibility to any NNRTI was observed only rarely (< 2%). There was no association between four- and 10-fold decreased baseline susceptibility to NNRTIs and virological outcome (P > 0.05). In multivariate analyses, the strongest predictors of poor virological response to NNRTI-based therapy were baseline plasma viral load and the proportion of time on therapy in the first year of follow-up. There was no relationship between the presence of previously reported mutations associated with decreased NNRTI susceptibility (at codons 135 and 283 in HIV reverse transcriptase) and virological response. CONCLUSIONS: These data suggest that the clinically significant level of resistance to NNRTIs, particularly nevirapine, in drug-naive individuals is likely greater than four- to 10-fold.

Comparison of physician- and pharmacist-managed warfarin sodium treatment in open heart surgery patients.

OBJECTIVES: To compare the effectiveness of pharmacists and physicians in obtaining therapeutic anticoagulation on initiation of warfarin sodium therapy immediately following prosthetic cardiac valve insertion. Secondary objectives were the percentage of days with an international normalized ratio (INR) greater than four, the percentage of days with an INR less than two, the time to stabilize the INR within the therapeutic range, and the percentage of patients experiencing at least one major bleed. METHODS: This study was a before and after comparison using a retrospective chart review of patients who received warfarin sodium following cardiac valve surgery. Physicians dosed independently and pharmacists used a warfarin sodium nomogram to manage patients. RESULTS: A total of 227 patients (physician group, n=130; pharmacist group, n=97) satisfied the inclusion criteria. No differences were found between the two groups in the percentage of days in the therapeutic range (P=0.27), the percentage of days with INR less than two (P=0.06), the percentage of patients discharged before their INR stabilized (P=0.91) or the percentage of patients with a major bleed (P=0.72). The pharmacist group had 5.9% fewer days (P<0.001) with an INR greater than four than the physician group. CONCLUSIONS: Appropriately trained pharmacists appear equally safe and effective as physicians when managing warfarin sodium therapy in patients who have undergone cardiac valve replacement.

Do co-intoxicants increase adverse event rates in the first 24 hours in patients resuscitated from acute opioid overdose?

BACKGROUND: Patients frequently arrive in emergency departments (EDs) after being resuscitated from opioid overdose. Autopsy studies suggest that multidrug intoxication is a major risk factor for adverse outcomes after acute heroin overdose in patients. If this is true, there may be high-risk drug combinations that identify patients who require more intensive monitoring and prolonged observation. Our objective was to determine the impact of co-intoxication with alcohol, cocaine, or CNS depressant drugs on short-term adverse event rates in patients resuscitated from acute opioid overdose. METHODS: Data were extracted from the database of a prospective opioid overdose cohort study conducted between May 1997 and 1999. Patients were prospectively enrolled if they received naloxone for presumed opioid overdose. Investigators gathered clinical, demographic, and other predictor variables, including co-intoxicants used. Patients were followed to identify prespecified adverse outcome events occurring within 24 h, and multiple logistic regression was used to determine the association of concomitant drug use on short-term adverse event rates. RESULTS: Of 1155 patients studied, 58 (5%) had pure opioid overdose and 922 (80%) reported co-intoxicants, including alcohol, cocaine, and CNS depressants. Overall, out of 1056 patients with known outcome status there were 123 major adverse events (11.6%) and 194 minor adverse events (18.4%). After adjustment for age, gender, HIV status, cardiovascular disease, pulmonary disease and diabetes, we found that coadministration of alcohol, cocaine, or CNS depressants, alone or in combination, was not associated with increased risk of death or adverse events during the 24 h follow-up period. CONCLUSION: In patients resuscitated from acute opioid overdose, short-term outcomes are similar for patients with pure opioid overdose and multidrug intoxications. A history of cointoxication cannot be used to identify high-risk patients who require more intensive ED monitoring or prolonged observation.

Hypertriglyceridemic hyperapoB in type 2 diabetes.

OBJECTIVES: Much less attention has been paid to LDL in type 2 diabetes than to VLDL or HDL. In particular, there are few data on apoB levels in these patients. Moreover, most reports have focused on mean lipoprotein levels and consequently there is little information on the frequencies of the various dyslipidemic phenotypes. RESEARCH DESIGN AND METHODS: Plasma and lipoprotein lipids, apoB and apoA1 were measured by standardized methods. LDL particle size was determined by PAGE. The total cohort was divided into phenotypes by two different methods. The first was based on triglycerides (> or = or <1.5 mmol/l) and LDL cholesterol (> or = or <4 mmol/l), whereas the second was based on triglycerides (> or = or <1.5 mmol/l) and apoB (> or = or <120 mg/dl). RESULTS: For the overall cohort, plasma triglycerides were elevated (2.13 +/- 1.6 mmol/l), total and LDL cholesterol were normal (5.34 +/- 1.1 and 3.28 +/- 0.88 mmol/l, respectively), and peak LDL size was reduced (252.9 +/- 5.8 A). HDL cholesterol was between the 25th and 50th percentiles of the general population (1.12 +/- 0.36 mmol/l). The average level of apoB was 114 +/- 29 mg/dl, a value that is between the 50th and 75th percentiles of the general population and is higher than that for LDL cholesterol, which was between the 25th and the 50th percentiles of the population. The results of the phenotyping analysis were as follows. Using the conventional approach, only 23% has abnormal LDL, i.e., an elevated LDL cholesterol level. Using the new approach, almost 40% has an elevated apoB and therefore an elevated LDL particle number. Only 12.8% has combined hyperlipidemia based on the conventional approach, whereas almost one-third had the equivalent, hypertriglyceridemic hyperapoB-based on the new algorithm. The severity of the dyslipoproteinemia in this group was noteworthy. Although the average LDL cholesterol was 3.91 mmol/l, a value just below the 75th percentile of the general population, the average apoB was 145 mg/dl, a value that approximates the 95th percentile of the population. CONCLUSIONS: The dyslipidemic profile of patients with type 2 diabetes is not uniform. A substantial group have normal lipids and normal LDL particle number and size whereas others have markedly abnormal profiles. Diagnosis based on triglycerides and apoB rather than triglycerides and LDL cholesterol revealed that more than one in five had hypertriglyceridemic hyperapoB, which is characterized by hypertriglyceridemia, marked elevation of LDL particle number, small dense LDL, and low HDL, a constellation of abnormalities that is associated with markedly accelerated atherogenesis and therefore justifies intensive medical therapy.