Utility of routine testing for patients with asymptomatic severe blood pressure elevation in the emergency department.

STUDY OBJECTIVE: Recommendations for the treatment of emergency department (ED) patients with asymptomatic severely elevated blood pressure advise assessment for occult, acute hypertensive target-organ damage. This study determines the prevalence of unanticipated, clinically meaningful test abnormalities in ED patients with asymptomatic severely elevated blood pressure. METHODS: This was a prospective observational study at 3 urban academic EDs. Consecutive patients with systolic blood pressure greater than or equal to 180 mm Hg or diastolic blood pressure greater than or equal to 110 mm Hg on 2 measurements were enrolled if they denied symptoms of hypertensive emergency. A basic metabolic panel, urinalysis, ECG, CBC count, and chest radiograph were obtained. Treating physicians were interviewed about the indication for each test and whether an abnormal result was anticipated according to clinical findings. When test results were available, physicians were asked whether abnormal findings were clinically meaningful, defined as leading to unanticipated hospitalization, medication modification, or further immediate evaluation. The primary outcome was the prevalence of unanticipated clinically meaningful test abnormalities. RESULTS: One hundred nine patients with asymptomatic severely elevated blood pressure were enrolled. Unanticipated abnormal test results were noted in 57 (52%) patients. Clinically meaningful unanticipated test abnormalities were found in 7 (6%) patients: basic metabolic panel in 2 (2%), CBC count in 3 (3%), urinalysis in 3 (4%), ECG in 2 (2%), and chest radiograph in 1 (1%). Five patients (5%) had abnormalities assessed as possible manifestations of acute hypertensive target-organ injury; none had abnormalities clearly related to severely elevated blood pressure. CONCLUSION: Screening tests of urban ED patients with asymptomatic severely elevated blood pressure infrequently detect unanticipated hypertension-related abnormalities that alter ED management.

The state of the clerkship: a survey of emergency medicine clerkship directors.

OBJECTIVES: An emergency medicine (EM) clerkship can provide a medical student with a unique educational experience. The authors sought to describe the current experiential curriculum of the EM clerkship, along with methods of evaluation, feedback, and grading. METHODS: A descriptive survey was utilized. Clerkship directors at EM residency programs accredited by the Accreditation Council for Graduate Medical Education completed an online questionnaire. Data were analyzed using descriptive statistics. RESULTS: Ninety-two (70%) of 132 EM clerkship directors completed the survey. Sixty institutions (65%) accepted only fourth-year medical students, and 35% accepted both third- and fourth-year students. The median number of didactic lecture hours provided during each rotation block for students was ten (interquartile range [IQR], 6-16). The average length of a student's clinical shift was eight hours, while the median number of clinical shifts reported per rotation was 15 (IQR, 14-16). The median number of hours worked weekly by a medical student was 40 (IQR, 35-43). Fifty-four EM clerkship directors (59%) incorporated the Accreditation Council for Graduate Medical Education six core competencies into their evaluation process. Seventy-one clerkship directors (77%) used a shift evaluation card to evaluate the clinical performance of medical students. Fifty-four (59%) incorporated an end-of-rotation written examination to determine the final rotation grade for a medical student. CONCLUSIONS: Medical students are exposed to a variety of didactic lectures and procedure labs but have similar experiences regarding shift length and work hours. Methods of evaluation of clinical performance vary across clinical sites.

Emergency medicine research directors and research programs: characteristics and factors associated with productivity.

BACKGROUND: Periodic surveys of research directors (RDs) in emergency medicine (EM) are useful to assess the specialty's development and evolution of the RD role. OBJECTIVES: To assess associations between characteristics and research productivity of RDs and EM programs. METHODS: A survey of EM RDs was developed using the nominal group technique and pilot tested. RDs or surrogate respondents at programs certified by the Accreditation Council for Graduate Medical Education were contacted by e-mail in early 2005. The survey assessed programs' research infrastructure and productivity, as well as RD characteristics, responsibilities, and career satisfaction. Three measures of research productivity were empirically defined: research publications, grant awards, and grant revenue. RESULTS: Responses were received from 86% of 123 EM programs. Productivity was associated with the presence of nonclinical faculty, dedicated research coordinators, and reduced clinical hours for research faculty. Programs with an RD did not have greater research productivity, using any measure, than those without an RD. The majority of RDs cited pursuing their own studies, obtaining funding, research mentoring, and research administration to be major responsibilities. The majority characterized internal research funding, grant development support, and support from other faculty as inadequate. Most RDs are satisfied with their careers and expect to remain in the position for three or more years. CONCLUSIONS: Research productivity of EM residency programs is associated with the presence of dedicated research faculty and staff and with reduced clinical demands for research faculty. Despite perceiving deficiencies in important resources, most RDs are professionally satisfied.

Evaluation and treatment of patients with severely elevated blood pressure in academic emergency departments: a multicenter study.

STUDY OBJECTIVE: Current guidelines advise that emergency department (ED) patients with severely elevated blood pressure be evaluated for acute target organ damage, have their medical regimen adjusted, and be instructed to follow up promptly for reassessment. We examine factors associated with performance of recommended treatment of patients with severely elevated blood pressure. METHODS: Observational study performed during 1 week at 4 urban, academic EDs. Severely elevated blood pressure was defined as systolic blood pressure greater than or equal to 180 mm Hg or diastolic blood pressure greater than or equal to 110 mm Hg on at least 1 measurement. ED staff were blinded to the study purpose. Demographics, presenting complaints, vital signs, tests ordered, medications administered, disposition, and discharge instructions were recorded, and associations were tested in bivariate analyses. RESULTS: Severely elevated blood pressure was noted in 423 patients. Serum chemistry was obtained in 73% of patients, ECG in 53% of patients, chest radiograph in 46% of patients, urinalysis in 43% of patients, and funduscopy documented in 36% of patients. All studies were performed in 6% of patients and were associated with complaints of dyspnea (odds ratio [OR] 3.1; 95% confidence interval [CI] 1.1 to 8.7) and chest pain (OR 3.0; 95% CI 1.2 to 7.6). Oral antihypertensives were administered to 36% of patients and were associated with blood pressure-related complaints (OR 2.0 [1.2 to 3.3]), patient-suspected severely elevated blood pressure (OR 5.6, 95% CI 2.0 to 15.3), and being uninsured (OR 2.0; 95% CI 1.2 to 3.3). Intravenous antihypertensives were given to 4% of patients, associated only with chest pain (OR 3.2; 95% CI 1.1 to 9.5). Modification of antihypertensive regimen was documented in 19% of discharged patients and associated with patient-suspected severely elevated blood pressure (OR 5.5; 95% CI 2.5 to 12.2) and being uninsured (OR 1.8; 95% CI 1.1 to 2.9). CONCLUSION: The majority of ED patients with severely elevated blood pressure do not receive the evaluation, medical regimen modification, and discharge instructions advised by current guidelines. Further study is necessary to determine whether these recommendations are appropriate in this setting.

Decreased mortality by normalizing blood glucose after acute ischemic stroke.

OBJECTIVES: Hyperglycemia after cerebral ischemia exacerbates brain injury and worsens the outcome of stroke patients. The authors sought to examine the effect of glycemic control on mortality after acute stroke. METHODS: This was a retrospective study of patients discharged with a diagnosis of ischemic stroke during a 40-month period from a large urban U.S. health system. Patients were compared by initial blood glucose (BG) levels and by glycemic control during the first 48 hours of hospitalization. RESULTS: Of 960 patients with thromboembolic stroke, 373 (38.9%) were hyperglycemic (BG > or = 130 mg/dL) on hospital admission. Admission hyperglycemia was associated with a higher mortality rate than was euglycemia (odds ratio [OR] = 3.15; 95% confidence interval [CI] = 1.45 to 6.85; p = 0.004). Persistent hyperglycemia (PerHyp) during 48 hours of hospitalization was associated with even higher mortality rate (unadjusted logistic regression, OR = 6.54; 95% CI = 2.41 to 17.87; p < 0.001). Glycemic control (normalization of BG to < 130 mg/dL) was associated with a 4.6-fold decrease in mortality risk as compared with the case of patients with PerHyp (p < 0.001). Multiple logistic regression showed glycemic control to be a strong independent determinant of survival (OR = 5.95; 95% CI = 1.24 to 28.6; p = 0.026) after acute stroke even after adjustment for age, gender, concomitant hypertension and diabetes, and stroke severity. CONCLUSIONS: Admission hyperglycemia is associated with a worse outcome after stroke than is euglycemia. Normalization of blood glucose during the first 48 hours of hospitalization appears to confer a potent survival benefit in patients with thromboembolic stroke.

Elevated blood pressure in urban emergency department patients.

OBJECTIVES: There has been little systematic study of emergency department (ED) patients with elevated blood pressure (BP) values. The authors sought to characterize ED patients with elevated BP values, assess presenting symptoms, and determine the prevalence of elevated BP after discharge. METHODS: This was a cross-sectional study performed in four academic EDs. Adults presenting with systolic BP >or=140 mm Hg or diastolic BP >or=90 mm Hg were enrolled over a one-week equivalent period. Demographics, medical history, and symptoms were obtained by chart abstraction and structured interview. A random patient subset underwent a three-week follow-up interview. BP measurements were staged, using Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-VI) criteria, according to the greatest value noted in the ED. RESULTS: A total of 1,396 patients were enrolled. Stage 1 BP values were noted in 44.3%, stage 2 in 25.3%, and stage 3 in 30.3%. African American patients more frequently had stage 2 and 3 BP values than other ethnic groups. BP measurements were repeated in 61.1% of patients and were the same or greater in 51.3% of patients. Dyspnea was associated with greater BP values. Among the 63.9% of patients who were interviewed, 52.7% were not being treated for hypertension, and 42.1% of those with hypertension had recently missed a medication dose. Follow-up was obtained in 74.7% of those targeted. A visit to a medical practitioner since discharge was reported by 63.2%; of these, 26.1% reported that their BP remained elevated. CONCLUSIONS: Elevated BP is common among ED patients. African American patients are more likely than those of other ethnic groups to have greater BP values. The ED visit may be a good opportunity to identify patients with unrecognized or poorly controlled hypertension.

Interest in services among prostate cancer patients receiving androgen deprivation therapy.

Treatment side effects and decreased quality of life associated with androgen deprivation therapy (ADT) suggest the need for supportive services for prostate cancer (PC) patients receiving ADT. Nonetheless, uptake of services is low, suggesting that PC patients' preferences are not being addressed. We examined interest in supportive services and predictors of interest among 118 PC patients receiving ADT. Overall interest in services was associated with lower quality of life (p = 0.01). The majority of participants expressed interest in informational services (70%), with a minority (22%) expressing interest in psychosocial services. Interest in psychosocial services was associated with younger age (p = 0.02), and shorter duration of ADT (p < 0.04), but was unrelated to psychological distress or social support. Although most men (68%) reported that they would prefer not to take medication for depression, 75% would do so if advised by their physician. Overall, results suggest that PC patients on ADT prefer individualized informational support. Substantial interest (61%) in Oncolink, an internet-based informational resource, suggests the Internet may provide an acceptable mode of service delivery. Health care providers should consider integrating increased informational support into routine care and, more generally, consider patient preferences in prioritizing and designing support services.

What do ratings of cancer-specific distress mean among women at high risk of breast and ovarian cancer?

Women recruited from a hereditary cancer registry provided ratings of distress associated with different aspects of high-risk status and genetic testing and completed measures of general psychological distress, emotional and social health, and role functioning. Overall, high-risk status was rated as more distressing than undergoing genetic testing. Women without a personal history of cancer rated the level of distress associated with a positive test result to be greater than that associated with high-risk status. In contrast, level of distress associated with a positive test result was not significantly different from that associated with high-risk status for women with a personal history of cancer. Furthermore, women with a personal cancer history also anticipated that if they had an altered gene associated with increased risk of cancer, it would be less distressing than their diagnosis of cancer had been. Women with the highest ratings of cancer-related stress were less inclined to obtain testing, but were not more generally distressed or maladjusted. The need to interpret psychological distress and the stressfulness of genetic testing among high-risk women with respect to relevant comparison data is discussed.