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Community-acquired Pneumonia as Medical Emergency: Predictors of Early Deterioration
388 in patients with confirmed acute PE. Even in high-risk PE patients, undetectable cTnI was associated with low event rates, demonstrating that the assay can provide valuable prognostic data across all risk strata. Prognostic value of cTnI is incremental to ECG and right ventricular imaging, so it is best used as an adjunct to other clinical data. A limitation of the study is the fact that it was a retrospective study in a single academic medical center, but this investigation provides a foundation for prospective validation studies on the role of cTnI in prognostication in acute PE. , FIREARM VIOLENCE AMONG HIGH-RISK EMERGENCY DEPARTMENT YOUTH AFTER AN ASSAULT INJURY. Carter PM, Walton MA, Roehler DR, et al. Pediatrics 2015;135:805–15. Firearm homicide is the second leading cause of death in youth in the United States, and firearm-related injuries are associated with a substantial economic burden. The risk for firearm violence among high-risk youth has not been well studied, leading to a lack of data to guide prevention efforts. This study was a single-center prospective cohort study at an urban Level I trauma center emergency department (ED). Consecutive patients ages 14 to 24 years with drug use in the past 6 months seeking medical care for an assault (AIG) were compared with a proportionally sampled comparison group matched by age and gender with drug use in the past 6 months who were not assaulted (CG). The following populations were excluded from the study: sexual assault, child maltreatment, suicidal ideation or attempt, or a medical condition preventing informed consent. The primary outcome for the study was self-reported firearm aggression and firearm injury and mortality within 24 months of the baseline evaluation. The study included a selfadministered computerized screening survey and 90-min baseline survey initially, with follow-up at 6, 12, 18, and 24 months incentivized by increasing monetary reimbursement. Poisson regression was utilized to determine predictors of firearm violence. Over the study period, 349 AIG and 250 CG were enrolled. Among the AIG, 59% reported firearm violence within 24 months, compared with 42.5% of CG. Of those reporting firearm violence, 96.4% reported victimization, 94.4% reported being threatened or shot at, 7.5% sustained firearm injury requiring ED visit, 2 died from firearm injury, and 77% reported more than one incident of firearm violence. Patients reporting firearm violence were more likely than those without firearm violence to meet criteria for alcohol or drug use disorder, and half met diagnostic criteria for recent mental health illness. Male gender, African American race, ED presentation for assault, firearm possession, retaliatory attitudes, and criteria for drug use disorder were predictive of subsequent firearm violence. The authors concluded that high-risk youth in urban areas presenting to the ED for assault are likely to encounter future firearm violence. The investigators suggest that secondary violence prevention initiatives addressing firearms, retaliation, substance use, and mental health should be implemented during initial ED visits for assaulted youth. [Travis Allen Smith, MD Denver Health Medical Center, Denver, CO]
Abstracts Comment: This is one of the first studies addressing the complex problem of predicting firearm violence in American youth. Because this study was performed in a single, urban ED, additional studies are necessary to further explore the applicability of the risk factors identified for firearm violence in heterogeneous populations and health care settings. Identification of risk factors for firearm violence is a vital step in identifying strategies to prevent firearm violence in youth. Given the high proportion of patients in the study who experienced repeat violence, interventions to aid at-risk youth for firearm violence are especially important and should be implemented in health care settings, including the ED. Prevention strategies should also address mental illness and alcohol and drug use disorders, as these factors seem to correlate with firearm violence. , COMMUNITY-ACQUIRED PNEUMONIA AS MEDICAL EMERGENCY: PREDICTORS OF EARLY DETERIORATION. Kolditz M, Santiago E, Klapdor B, et al. Thorax 2015;70:551–8. Up to 70% of community-acquired pneumonia (CAP) patients suffer acute organ failure within 72 h of admission. Because organ failure is associated with significant morbidity and mortality, early recognition of CAP as a ‘‘medical emergency’’ is necessary to identify at-risk patients and provide early goal-directed resuscitation and interventions. The goal of the study was to characterize CAP as a medical emergency and evaluate predictors of early organ failure and in-hospital mortality. This prospective study enrolled patients from the multicenter German Competence network for the study of CAP (CAPNETZ). The inclusion criteria for the study were: age $ 18 years, pulmonary infiltrate on imaging, as well as at least one of four additional criteria: temperature $ 38.3 C, cough, purulent sputum, auscultatory evidence of pneumonia on examination. Patients with known immunodeficiency, tuberculosis, or nosocomial pneumonia acquisition were excluded. Follow-up regarding patient outcomes was conducted via telephone interview with patients or family. For the study, emergency CAP was defined as the need for mechanical ventilation (MV), vasopressors (VP), or death within 72 h or 7 days after hospitalization. Additionally, the authors evaluated the predictive ability of the American Thoracic Society/Infectious Disease Society of America 2007 (ATS/IDSA) minor criteria for emergency CAP. Of the 3427 enrolled patients, 140 (4%) met criteria for emergency CAP within 72 h of admission, and an additional 33 patients met the criteria between days 4 and 7 of admission. Mortality was highest in CAP patients presenting without an immediate need for MV/VP. Independent predictors of emergency CAP included focal chest examination findings, home oxygen, multi-lobar infiltrates, altered mentation, and abnormal vital signs. The ATS/IDSA minor criteria demonstrated a high negative predictive value. The authors concluded that, although rare, the presentation of emergency CAP is associated with a high mortality rate, especially in the group that did not require immediate MV/ VP and met emergency CAP criteria at 4–7 days after admission. The authors also concluded that independent predictors of emergency CAP include abnormal vital signs and evidence
The Journal of Emergency Medicine of end-organ dysfunction. The investigators concluded that the ATS/IDSA had a high sensitivity and high negative predictive value and low positive predictive value for prediction of emergency CAP without immediate need of MV/VP. [Kori S. Neessen, MD Denver Health Medical Center, Denver, CO] Comment: This study provides important information on prognostic factors that may facilitate early identification of CAP patients at risk for worse outcomes. Because the morbidity and mortality associated with organ failure in CAP is significant, early recognition and interventions in at-risk patients is especially important to improve health care quality and outcomes. , RATES AND CORRELATES OF RELAPSE FOLLOWING ED DISCHARGE FOR ACUTE ASTHMA. Rowe BH, Villa-Roel C, Majumdar SR, et al. Chest 2015;147:140–9. Asthma affects a significant portion of the adult population and accounts for 2 million emergency department (ED) visits in the United States annually. Up to 90% of these ED visits result in disposition home with subsequent relapse rates of 5– 25% in the first week and 21–35% in the first 3 weeks. Limited data are available to identify asthma patients at risk for relapse after an ED visit. This was a prospective, multicenter cohort study in Canada between November 2003 and March 2007. The inclusion criteria were ages 18 to 55 years, clinical diagnosis of asthma, and < 30 pack-years smoking history. The exclusion criteria were chronic obstructive pulmonary disease exacerbation, obstructive airway disease, chronic use of oral corticosteroids (OCSs), contraindications to OCSs, and serious or unstable comorbidities. All enrolled patients were discharged with a 5- to 7-day course of 50 mg prednisone, and ongoing or new-onset use of inhaled corticosteroid (ICS) or long-acting bagonist was strongly advised but not required. The primary outcome was relapse at 4 weeks, which was assessed by telephone interview at 3 days, 2 weeks, and 4 weeks. Secondary outcomes included adherence to the oral steroid and ICS as well as ICS side effects. Of the 807 asthma patients enrolled in the study, 144 (18%) relapsed within 4 weeks. One hundred thirty (90%) of those patients relapsed once, 13 (9%) relapsed twice, and 1 (< 1%) three times. Relapse to the ED accounted for 79% of all relapses among the study cohort, and 18 (16%) of these relapses resulted in hospitalization. Independent predictors of relapse included female sex (adjusted odds ratio [aOR] 1.9; 95% confidence interval [CI] 1.2–3.0), > 24 h of symptoms prior to the ED visit (aOR 1.7; 95% CI 1.3–2.2), past history OCS usage for asthma (aOR 1.5; 95% CI 1.1–2.0), current use of ICS/ long acting b-agonist combination agent (vs. monotherapy) (aOR 1.9; 95% CI 1.1–3.2), and owning a spacer device (aOR 1.6; 95% CI 1.3–1.9). The authors concluded that despite guideline-concordant discharge management of acute asthma exacerbations, a relapse rate of 18% was present, which was comparable to other studies not using guideline-concordant discharge management. The investigators propose that this suggests that treatment and nontreatment factors are related to relapse after an acute asthma exacerbation.
389 [Kori S. Neessen, MD Denver Health Medical Center, Denver, CO] Comment: This study provides interesting insight into factors that may be associated with relapse after an acute asthma exacerbation, and suggests that there may be both nontreatmentand treatment-related factors related to relapse. Additional studies are needed to further evaluate the factors that impact outcomes after management of acute asthma exacerbations to optimize patient outcomes and identify interventions to prevent relapse in at-risk asthma patients. , ASSOCIATION OF EQUIPMENT WORN AND CONCUSSION INJURY RATES IN NATIONAL COLLEGIATE ATHLETIC ASSOCIATION FOOTBALL PRACTICES: 2004–2005 TO 2008–2009 ACADEMIC YEARS. Kerr ZY, Hayden R, Dompier TP, et al. Am J Sports Med 2015;43:1134–41. Despite extensive research surrounding football-related concussions, few data exist to examine the nature of concussions sustained during practice, where players have the majority of their at-risk exposure time and where a variety of protection and play type exists. This descriptive epidemiology study used the National Collegiate Athletic Association (NCAA) Injury Surveillance System database to evaluate concussion rates and concussion rate ratios during football practice sessions. Concussion rates were based on total concussions during practice and rate ratios based on the total number of athlete exposures (AEs; defined as a student athlete participating in one NCAA-sanctioned practice or competition with exposure to the possibility for athletic injury). The primary outcomes for the study were practice concussion rates by amount of equipment worn and equipment-specific practice concussion rates by football division, season, or practice type. Of the 1367 football-related concussions, 795 (58.2%) occurred during practice, with an injury rate of 0.39 per 1000 AEs (95% confidence interval 0.36–0.42). The highest concussion rate was in Division III (0.54/1000 AEs), followed by Division I (0.34/1000 AEs) and Division II (0.24/1000 AEs). The concussion rate was highest when players were wearing full padding (69.9%). The practice concussion rate of the preseason (0.76/1000 AEs) was higher than during the regular season (0.18/1000 AEs, p < 0.001) and the postseason (0.25/1000 AEs, p < 0.001). Among practice types, scrimmages had the highest concussion rates (1.55/ 1000 AEs). The authors concluded that football practice concussion rates are highest during fully padded, preseason and scrimmage practices, and the nature, intensity, and focus of the practice affects concussion rates. [Kori S. Neessen, MD Denver Health Medical Center, Denver, CO] Comment: A significant proportion of concussions occur during football practice sessions. Injury prevention efforts should be directed at educating students, trainers, and coaches on the risk of concussion during practice sessions and consideration of limiting contact during practices.
Abstracts Comment: This is one of the first studies addressing the complex problem of predicting firearm violence in American youth. Because this study was performed in a single, urban ED, additional studies are necessary to further explore the applicability of the risk factors identified for firearm violence in heterogeneous populations and health care settings. Identification of risk factors for firearm violence is a vital step in identifying strategies to prevent firearm violence in youth. Given the high proportion of patients in the study who experienced repeat violence, interventions to aid at-risk youth for firearm violence are especially important and should be implemented in health care settings, including the ED. Prevention strategies should also address mental illness and alcohol and drug use disorders, as these factors seem to correlate with firearm violence. , COMMUNITY-ACQUIRED PNEUMONIA AS MEDICAL EMERGENCY: PREDICTORS OF EARLY DETERIORATION. Kolditz M, Santiago E, Klapdor B, et al. Thorax 2015;70:551–8. Up to 70% of community-acquired pneumonia (CAP) patients suffer acute organ failure within 72 h of admission. Because organ failure is associated with significant morbidity and mortality, early recognition of CAP as a ‘‘medical emergency’’ is necessary to identify at-risk patients and provide early goal-directed resuscitation and interventions. The goal of the study was to characterize CAP as a medical emergency and evaluate predictors of early organ failure and in-hospital mortality. This prospective study enrolled patients from the multicenter German Competence network for the study of CAP (CAPNETZ). The inclusion criteria for the study were: age $ 18 years, pulmonary infiltrate on imaging, as well as at least one of four additional criteria: temperature $ 38.3 C, cough, purulent sputum, auscultatory evidence of pneumonia on examination. Patients with known immunodeficiency, tuberculosis, or nosocomial pneumonia acquisition were excluded. Follow-up regarding patient outcomes was conducted via telephone interview with patients or family. For the study, emergency CAP was defined as the need for mechanical ventilation (MV), vasopressors (VP), or death within 72 h or 7 days after hospitalization. Additionally, the authors evaluated the predictive ability of the American Thoracic Society/Infectious Disease Society of America 2007 (ATS/IDSA) minor criteria for emergency CAP. Of the 3427 enrolled patients, 140 (4%) met criteria for emergency CAP within 72 h of admission, and an additional 33 patients met the criteria between days 4 and 7 of admission. Mortality was highest in CAP patients presenting without an immediate need for MV/VP. Independent predictors of emergency CAP included focal chest examination findings, home oxygen, multi-lobar infiltrates, altered mentation, and abnormal vital signs. The ATS/IDSA minor criteria demonstrated a high negative predictive value. The authors concluded that, although rare, the presentation of emergency CAP is associated with a high mortality rate, especially in the group that did not require immediate MV/ VP and met emergency CAP criteria at 4–7 days after admission. The authors also concluded that independent predictors of emergency CAP include abnormal vital signs and evidence
The Journal of Emergency Medicine of end-organ dysfunction. The investigators concluded that the ATS/IDSA had a high sensitivity and high negative predictive value and low positive predictive value for prediction of emergency CAP without immediate need of MV/VP. [Kori S. Neessen, MD Denver Health Medical Center, Denver, CO] Comment: This study provides important information on prognostic factors that may facilitate early identification of CAP patients at risk for worse outcomes. Because the morbidity and mortality associated with organ failure in CAP is significant, early recognition and interventions in at-risk patients is especially important to improve health care quality and outcomes. , RATES AND CORRELATES OF RELAPSE FOLLOWING ED DISCHARGE FOR ACUTE ASTHMA. Rowe BH, Villa-Roel C, Majumdar SR, et al. Chest 2015;147:140–9. Asthma affects a significant portion of the adult population and accounts for 2 million emergency department (ED) visits in the United States annually. Up to 90% of these ED visits result in disposition home with subsequent relapse rates of 5– 25% in the first week and 21–35% in the first 3 weeks. Limited data are available to identify asthma patients at risk for relapse after an ED visit. This was a prospective, multicenter cohort study in Canada between November 2003 and March 2007. The inclusion criteria were ages 18 to 55 years, clinical diagnosis of asthma, and < 30 pack-years smoking history. The exclusion criteria were chronic obstructive pulmonary disease exacerbation, obstructive airway disease, chronic use of oral corticosteroids (OCSs), contraindications to OCSs, and serious or unstable comorbidities. All enrolled patients were discharged with a 5- to 7-day course of 50 mg prednisone, and ongoing or new-onset use of inhaled corticosteroid (ICS) or long-acting bagonist was strongly advised but not required. The primary outcome was relapse at 4 weeks, which was assessed by telephone interview at 3 days, 2 weeks, and 4 weeks. Secondary outcomes included adherence to the oral steroid and ICS as well as ICS side effects. Of the 807 asthma patients enrolled in the study, 144 (18%) relapsed within 4 weeks. One hundred thirty (90%) of those patients relapsed once, 13 (9%) relapsed twice, and 1 (< 1%) three times. Relapse to the ED accounted for 79% of all relapses among the study cohort, and 18 (16%) of these relapses resulted in hospitalization. Independent predictors of relapse included female sex (adjusted odds ratio [aOR] 1.9; 95% confidence interval [CI] 1.2–3.0), > 24 h of symptoms prior to the ED visit (aOR 1.7; 95% CI 1.3–2.2), past history OCS usage for asthma (aOR 1.5; 95% CI 1.1–2.0), current use of ICS/ long acting b-agonist combination agent (vs. monotherapy) (aOR 1.9; 95% CI 1.1–3.2), and owning a spacer device (aOR 1.6; 95% CI 1.3–1.9). The authors concluded that despite guideline-concordant discharge management of acute asthma exacerbations, a relapse rate of 18% was present, which was comparable to other studies not using guideline-concordant discharge management. The investigators propose that this suggests that treatment and nontreatment factors are related to relapse after an acute asthma exacerbation.
389 [Kori S. Neessen, MD Denver Health Medical Center, Denver, CO] Comment: This study provides interesting insight into factors that may be associated with relapse after an acute asthma exacerbation, and suggests that there may be both nontreatmentand treatment-related factors related to relapse. Additional studies are needed to further evaluate the factors that impact outcomes after management of acute asthma exacerbations to optimize patient outcomes and identify interventions to prevent relapse in at-risk asthma patients. , ASSOCIATION OF EQUIPMENT WORN AND CONCUSSION INJURY RATES IN NATIONAL COLLEGIATE ATHLETIC ASSOCIATION FOOTBALL PRACTICES: 2004–2005 TO 2008–2009 ACADEMIC YEARS. Kerr ZY, Hayden R, Dompier TP, et al. Am J Sports Med 2015;43:1134–41. Despite extensive research surrounding football-related concussions, few data exist to examine the nature of concussions sustained during practice, where players have the majority of their at-risk exposure time and where a variety of protection and play type exists. This descriptive epidemiology study used the National Collegiate Athletic Association (NCAA) Injury Surveillance System database to evaluate concussion rates and concussion rate ratios during football practice sessions. Concussion rates were based on total concussions during practice and rate ratios based on the total number of athlete exposures (AEs; defined as a student athlete participating in one NCAA-sanctioned practice or competition with exposure to the possibility for athletic injury). The primary outcomes for the study were practice concussion rates by amount of equipment worn and equipment-specific practice concussion rates by football division, season, or practice type. Of the 1367 football-related concussions, 795 (58.2%) occurred during practice, with an injury rate of 0.39 per 1000 AEs (95% confidence interval 0.36–0.42). The highest concussion rate was in Division III (0.54/1000 AEs), followed by Division I (0.34/1000 AEs) and Division II (0.24/1000 AEs). The concussion rate was highest when players were wearing full padding (69.9%). The practice concussion rate of the preseason (0.76/1000 AEs) was higher than during the regular season (0.18/1000 AEs, p < 0.001) and the postseason (0.25/1000 AEs, p < 0.001). Among practice types, scrimmages had the highest concussion rates (1.55/ 1000 AEs). The authors concluded that football practice concussion rates are highest during fully padded, preseason and scrimmage practices, and the nature, intensity, and focus of the practice affects concussion rates. [Kori S. Neessen, MD Denver Health Medical Center, Denver, CO] Comment: A significant proportion of concussions occur during football practice sessions. Injury prevention efforts should be directed at educating students, trainers, and coaches on the risk of concussion during practice sessions and consideration of limiting contact during practices.