The Association Between Use of Brain CT for Atraumatic Headache and 30-Day Emergency Department Revisitation.

OBJECTIVE: The purpose of this article is to describe the association between initial CT for atraumatic headache and repeat emergency department (ED) visitation within 30 days of ED discharge. MATERIALS AND METHODS: A retrospective observational study was performed at an academic urban ED with more than 85,000 annual visits. All adult patients with a chief complaint of headache from January through December 2010 who were discharged after ED evaluation were included in the analysis. Patients were excluded if they were transferred, died in the ED, or had a diagnosis indicating a traumatic mechanism. A propensity score-matched logistic regression model was used to determine whether the use of brain CT was associated with the primary outcome of ED revisitation within 30 days, controlling for potential confounding variables. RESULTS: Of 80,619 total patient visits to the ED during the study period, 922 ED discharges with a chief complaint of headache were included. A total of 139 (15.1%) patients revisited within 30 days. The return rate was 11.2% among patients who underwent CT at their initial visit and 21.1% among those who did not. In the adjusted analysis, controlling for age, race, sex, insurance status, triage vital signs, laboratory values, and triage pain level, the odds ratio for revisitation given CT performance was 0.49 (95% CI, 0.27-0.86). CONCLUSION: After adjustment for clinical factors, we found that patients who underwent a brain CT examination for atraumatic headache at an initial ED visit were less likely to return to the ED within 30 days. Future appropriate use quality metrics regarding ED imaging use may need to incorporate downstream health care use.

Hospitalized Heart Failure in the United States: Lessons Learned from Clinical Trial Populations.

Hospitalized heart failure (HHF) patients carry a prognosis comparable to many cancers and constitute more than 1 million hospital admissions annually in the United States. To date, North Americans have comprised a minority of those included in prior hospitalized HF trials and have been repeatedly shown to differ from patients in other areas of the world in terms of clinical characteristics, length of hospital stay, therapy utilization, and post-discharge outcomes. Recognizing the varying patient profiles and outcomes of North Americans enrolled in prior HHF trial programs is critical to optimizing design of future drug development programs and maximizing chances of bringing a novel therapeutic agent to the bedside.

Abdominal Computed Tomography Utilization and 30-day Revisitation in Emergency Department Patients Presenting With Abdominal Pain.

OBJECTIVES: The objective was to explore which patient characteristics are associated with repeat emergency department (ED) visitation within 30 days of ED discharge for patients presenting with abdominal pain. METHODS: A retrospective, observational study was conducted at a single, academic, urban ED with over 85,000 annual visits. A consecutive sample of adult patients with a chief complaint of abdominal pain from January 2010 through December 2010 who were discharged following ED evaluation were included in the analysis. A logistic regression model was used to determine which patient-level factors, including computed tomography (CT) utilization, were associated with the primary outcome of ED revisit within 30 days. RESULTS: Of 80,619 total ED patient visits during the study period, 3,928 ED discharges with a chief complaint of abdominal pain were included. A total of 487 (12.4%) patients revisited the ED within 30 days. No deaths were recorded. CT imaging was associated with a lower 30-day revisit rate (odds ratio [OR] = 0.69, 95% confidence interval [CI] = 0.55 to 0.87) after controlling for multiple other patient-level factors associated with revisits. Increasing age (OR = 1.01, 95% CI = 1.00 to 1.02), increasing triage pain scores (OR = 1.13, 95% CI = 1.08 to 1.18), elevated triage heart rate (OR = 1.42, 95% CI = 1.07 to 1.89), low sodium levels (OR = 1.56, 95% CI = 1.07 to 2.23), and anemia (OR = 1.42, 95% CI = 1.04 to 1.95) were all associated with increased rate of return. CONCLUSIONS: Performance of an abdominal CT was associated with fewer 30-day revisits, suggesting that future measures of "imaging appropriateness" and "ED overuse" consider downstream utilization of health care resources in addition to the index visit.

Lack of evidence for intravenous vasodilators in ED patients with acute heart failure: a systematic review.

There are nearly 700,000 annual US emergency department (ED) visits for acute heart failure (AHF). Although blood pressure is elevated on most of these visits, acute therapy remains focused on preload and not afterload reduction. Data from recent prospective studies suggest that patients with AHF with concomitant acute hypertension benefit from intravenous (IV) vasodilators. To better understand the use of vasodilators for such patients, we conducted a systematic review of (1) currently available intravenous vasodilators for ED patients with AHF, or (2) intravenous vasodilators that are not yet available, but have completed phase III clinical trials in AHF, and may be available for ED use in the future. We used multiterm search queries to retrieve research involving nitroglycerin, nitroprusside, enalaprilat, hydralazine, relaxin, and nesiritide. A total of 2001 unique citations were identified from 3 databases: PubMed, EMBASE, and CINAHL. Of these, 1966 were excluded on the basis of established review criteria, leaving 35 published articles for inclusion. Our primary finding was that intravenous nitrovasodilators, when used in the treatment of AHF in ED and ED-like settings, do improve short-term symptoms and appear safe to administer. There are no data suggesting that they impact mortality. Other commonly used vasodilators such as hydralazine and enalaprilat have very little published data about their safety and efficacy. Of note, few studies enrolled patients early in their course of treatment. Thus, to assess the specific impact of vasodilator therapy on both short- and long-term outcomes, future research efforts should focus on patient recruitment in the ED setting.

Dermabrasion and microdermabrasion.

Dermabrasion and microdermabrasion are facial resurfacing techniques that mechanically ablate aged or damaged skin to promote reepithelialization. Although the act of physically abrading the skin is common to both procedures, dermabrasion and microdermabrasion employ different instruments and are distinct in their technical executions. Dermabrasion completely removes the epidermis and penetrates to the level of the papillary or reticular dermis, inducing remodeling of the skin's structural proteins. Microdermabrasion only removes the uppermost layer of the epidermis, accelerating the natural process of exfoliation. Both techniques can result in clinically significant improvements in the appearance of skin and may become increasingly relevant among practitioners as new applications are developed.

Outcome predictors and spectrum of treatment eligibility with prospective protocolized management of intracerebral hemorrhage.

OBJECTIVE: Risk predictors, spectrum of treatment eligibility, and range of expected outcomes have not been validated in consecutive series including all cases of intracerebral hemorrhage (ICH) subjected to a prospective management protocol based on current guidelines. METHODS: Eighty-six cases of ICH were prospectively identified in conjunction with screening for a clinical trial during an 18-month period. All patients were subjected to protocolized management based on published "best practice" guidelines for ICH. Medical records were reviewed by trained researchers, and outcomes were assessed at various time points including latest follow-up (range, 0-24 months; mean, 3.97 months). Initial assessment parameters, treatment eligibility, and outcomes were based on standardized criteria. RESULTS: In accordance with past literature, mortality and functional outcomes were significantly worse in older patients, those with a larger ICH volume, and worse Glasgow Coma Scale scores, in univariate and multivariate models. The presence and severity of associated intraventricular hemorrhage also correlated with mortality and outcome. Significantly lower mortality (P = 0.024) and better functional outcomes (P = 0.018) were achieved at 30 days in patients with an ICH volume of less than 30 cm in this series than in previously published community-based historical controls without protocolized care. A tight correspondence between treatment eligibility and treatment administered was found. CONCLUSION: Previous estimates of poorer outcome in patients with ICH might not apply to contemporary management protocols, especially in patients with a smaller ICH volume. Outcome ranges in various risk categories and modeling of treatment eligibility will help project more realistic prognostication and assist with the design of future trials.