- Email: [email protected]
Methotrexate Success Rates in Progressing Ectopic Pregnancies: A Reappraisal
648 Comment: This study identified severely decreased EF, BNP > 10,000 pg/mL, and LGE as risk factors for poor outcomes in myocarditis. Because this was a single-center retrospective study, there are limitations to the study, including the lack of standardized timing for obtaining the cardiac MRI. Further investigation is necessary to provide a more precise understanding of cardiac MRI findings at various stages of myocarditis and ways to create a useful risk-stratification system to improve care for pediatric myocarditis. , THE RIGHT TREATMENT AT THE RIGHT TIME IN THE RIGHT PLACE: A POPULATION-BASED, BEFORE-AND-AFTER STUDY OF OUTCOMES ASSOCIATED WITH IMPLEMENTATION OF AN ALL-INCLUSIVE TRAUMA SYSTEM IN A LARGE CANADIAN PROVINCE. Mckee JL, Roberts DJ, van Wijngaarden-Stephens MH, et al. Ann Surg 2015;261:558–64. Regionalized trauma care, centered around Level I trauma centers, is the standard of care in trauma due to demonstrated improved patient survival. However, this system faces significant limitations, as transport distances to Level I trauma centers increase, particularly in rural settings. An all-inclusive approach that seeks to involve trauma centers of all levels in secondary triage has been postulated to overcome this limitation and improve trauma outcomes. In this populationbased, before-and-after study, the authors designed, implemented, and evaluated an all-inclusive trauma care system throughout Alberta, Canada. In a survey of 21,772 major trauma patients, the authors analyzed patient admission/transfer practices and outcomes of mortality, length of stay (LOS), and the number of surgical interventions performed at definitive care. The epidemiologic characteristics of the beforeand-after patient cohorts were significantly different, including age, sex, most severe head injury, and hemodynamic instability. As expected, implementation of the all-inclusive model was associated with a decline in transfers directly to Level I trauma centers (risk ratio [RR] 0.91; 95% confidence interval [CI] 0.88–0.94; p < 0.001), an increase in transfers from Level III to Level I centers (RR 1.10; 95% CI 1.00–1.21), an increase in hospital transfers prior to arrival at a Level I center (RR 1.07; 95% CI 1.05– 1.10), and an increase in the percentage of major trauma patients admitted to Level III centers (3.4% in 2008 to 8.7% in 2011). In addition to the improved balance of trauma care distribution among all trauma centers, the all-inclusive model was also associated with improvements in patient outcomes. The hazard of mortality per patient decreased (hazard ratio [HR] 0.88; 95% CI 0.84–0.98). There was also a reduction in mean LOS by 1 day (95% CI 1.02–1.11, p = 0.02). However, there was an increase in adjusted hazard of mortality in the severe head injury subgroup admitted to Level III centers (HR 1.25; 95% CI 1.23–1.28). [Matthew Tjajadi, MD Denver Health Medical Center, Denver, CO]
Abstracts Comment: In this study, the authors sought to demonstrate that an all-inclusive approach to trauma care would lead to an increased number of patients cared for in local facilities without compromising on patient outcomes. The study demonstrated an improvement in patient mortality and length of stay. However, the epidemiological characteristics of the before-and-after groups were significantly different, which leads to questions regarding the validity of the comparisons. Other confounders include the fact that outcome improvement may be due to the general state of medical progress that is independent of system changes. The fact that implementing the all-inclusive approach involved improving infrastructure and a heightened level of staff training, communication, and awareness could also account for the improvements in outcome, rather than the specifics of the new system itself. , METHOTREXATE SUCCESS RATES IN PROGRESSING ECTOPIC PREGNANCIES: A REAPPRAISAL. Cohen A, Zakar L, Gil Y, et al. Am J Obstet Gynecol 2014;211:128.e1–5. Methotrexate has provided a noninvasive, medical therapeutic option for hemodynamically stable women who are diagnosed with extrauterine pregnancies. A recent study has shown that trending of sequential beta-human chorionic gonadotropin (b-hCG) levels can differentiate progressing ectopic pregnancies from those that spontaneously resolve. In this single-center retrospective cohort study, the authors sought to reevaluate the success rates of methotrexate in progressing ectopic pregnancies, correlate them with b-hCG levels, and compare the findings to previously published data. Of 1703 women with diagnosed ectopic pregnancy, a cohort of 1083 patients was identified as candidates for follow-up with daily b-hCG measurements. In 674 patients (39.5%), b-hCG levels declined with spontaneous resolution of the ectopic pregnancy. This was defined as a daily decline in b-hCG levels by > 15%. Patients with b-hCG levels increasing by > 15% were treated with methotrexate. The remaining patients had their b-hCG levels rechecked the following day for up to 5 days, at which point methotrexate was administered for increasing b-hCG levels. Methotrexate was given in the standard ‘‘single-dose’’ protocol (50 mg/m2 of body surface area). None of the 1083 patients decompensated during the ‘‘watchful waiting’’ period of serial b-hCG monitoring, and 409 (24%) received methotrexate treatment. Of those treated, 356 women (87.0%) were treated successfully; 53 (13.0%) required laparoscopic salpingectomy. Epidemiologic factors of maternal age, parity, gestational age, endometrial thickness, and size of the ectopic mass were not significantly different between the methotrexate and salpingectomy groups. Consistent with previous reports, women who were successfully treated had significantly lower b-hCG levels than those who failed treatment (1407 IU/mL vs. 2664 IU/mL; p < 0.0001). This ‘‘watchful waiting’’ protocol yielded lower methotrexate success rates than previously described (75% when b-hCG 2500–3500 IU/mL and 65% when b-hCG > 4500 IU/mL). In previous studies, success rates were based on prompt administration of methotrexate and were likely confounded by the percentage of patients who would have
The Journal of Emergency Medicine spontaneously resolved without intervention. Finally, the authors created a mathematical model demonstrating an exponential relationship between methotrexate failure rates and the b-hCG level. [Matthew Tjajadi, MD Denver Health Medical Center, Denver, CO] Comment: This study suggests that a ‘‘watchful waiting’’ protocol may be prudent in the management of hemodynamically stable extrauterine pregnancies, as a significant percentage of them spontaneously resolve. Mathematical modeling yielded an exponential relationship between methotrexate failure rates and the b-hCG level. The emergency physician may use this model to help educate patients and, in conjunction with Gynecology, counsel them as to whether expectant management, methotrexate therapy, or salpingectomy may be optimal. , IMPROVED MANAGEMENT OF ACUTE ASTHMA AMONG PREGNANT WOMEN PRESENTING TO THE ED. Hasegawa K, Cydulka RK, Sullivan AF, et al. Chest 2015;147:406–14. Asthma is a common medical condition affecting 4–8% of all pregnancies. More than a quarter of all pregnant patients with asthma have at least one emergency department (ED) encounter or hospital admission during pregnancy for acute exacerbation of asthma, and it is well known that poorly controlled asthma increases the risk of both fetal and maternal complications. This study identified pregnant patients presenting to 48 EDs with acute asthma exacerbations and evaluated treatment with systemic corticosteroids and whether or not patients were prescribed a course of steroids on ED discharge. Four multicenter observational studies were pooled over two time periods from 1996–2001 and 2011–2012 to compare trends in use of systemic corticosteroids. A total of 4895 patients were identified with a diagnosis of acute asthma exacerbation; among those aged 18–44 years with known pregnancy, 125 patients were selected for the study’s cohort. Eighty-nine patients were pooled from the 1996–2001 period, vs. 36 from the later period. Patient characteristics were similar in the two time periods, including age, race, smoking status, and severity of asthma. Administration of corticosteroids in the ED increased significantly between the two time periods, from 51% to 78% (odds ratio [OR] 3.11; 95% confidence interval [CI] 1.27–7.60). Similarly, prescribed steroids at discharge increased from 42% to 63% (OR 2.49; 95% CI 0.97–6.37). The authors conclude that over the course of a decade, ED providers are increasing their administration of systemic corticosteroids for acute asthma exacerbation in pregnancy. The limitations of the study include it being observational, of relatively small size, and mostly consisting of academic EDs in urban areas. However, current treatment guidelines recommend the use of systemic corticosteroids in pregnancy, and this study suggests that ED providers are improving in their adherence to asthma treatment guidelines in pregnancy. [Graham Ingalsbe, MD Denver Health Medical Center, Denver, CO]
649 Comment: Treating pregnant patients is a difficult task for ED providers, particularly with the concern of pharmacotherapy and harm to the fetus. However, few data exist demonstrating fetal complications with systemic steroid therapy; conversely, it is well known that acute asthma does cause significant fetal and maternal harm. This study demonstrates that providers are slowly embracing the use of systemic steroid use in pregnant asthmatic patients, and adhering to current guidelines for clinical practice. , NEIGHBORHOOD SOCIOECONOMIC DISADVANTAGE AND 30-DAY REHOSPITALIZATION. King AJ, Jencks S, Brock J, et al. Ann Intern Med 2014;161:765–74. Rehospitalization is a common and costly complication in health care. It is estimated that Medicare spends more than $17 billion annually on 30-day readmissions, affecting 1 in 5 Medicare patients. Many factors are associated with 30-day rehospitalization. The authors of this study sought to correlate a patient’s socioeconomic disadvantage to risk of 30-day rehospitalization. Data were obtained from the Chronic Condition Data Warehouse of Medicare claims from 2004 to 2009. A random sample of 5% of Medicare beneficiaries was pooled, and an area deprivation index (ADI) was assigned to each patient. The ADI is an index that employs 17 data points including poverty, education, employment, and housing from U.S. census data arranged by ZIP code. Patients were arranged by ADI scores into the most disadvantaged 15% compared to the remaining 85%. After exclusions, more than 250,000 patients were pooled from more than 4800 hospitals. Rehospitalization rates were compared in each of these groups, with diagnoses of congestive heart failure, pneumonia, and acute myocardial infarction, the three diagnoses currently linked to Medicare reimbursement penalties for rehospitalization. Compared with the general population, 30-day rehospitalization rates were higher in the more disadvantaged 15% of neighborhoods. Thirty-day rehospitalization rates among the least disadvantaged 85% of neighborhoods did not vary significantly. Among the most disadvantaged neighborhoods, rehospitalization rates increased from 22% to 27% with worsening ADI. This trend continued with adjustment, with the most disadvantaged neighborhoods with an adjusted risk ratio of 1.09 (95% confidence interval 1.05–1.12) for 30-day rehospitalization. The authors conclude that the ADI is a useful predictor of 30-day rehospitalization among patients with diagnoses of congestive heart failure, pneumonia, and acute myocardial infarction. The study may be limited by the fact that patients listing a post office box or those not enrolled in census data were excluded from data sampling. However, this study demonstrates the importance of ADI as a factor in 30-day rehospitalization. [Graham Ingalsbe, MD Denver Health Medical Center, Denver, CO] Comment: Many factors lead to rehospitalization, which is a costly and potentially medically compromising complication.
Abstracts Comment: In this study, the authors sought to demonstrate that an all-inclusive approach to trauma care would lead to an increased number of patients cared for in local facilities without compromising on patient outcomes. The study demonstrated an improvement in patient mortality and length of stay. However, the epidemiological characteristics of the before-and-after groups were significantly different, which leads to questions regarding the validity of the comparisons. Other confounders include the fact that outcome improvement may be due to the general state of medical progress that is independent of system changes. The fact that implementing the all-inclusive approach involved improving infrastructure and a heightened level of staff training, communication, and awareness could also account for the improvements in outcome, rather than the specifics of the new system itself. , METHOTREXATE SUCCESS RATES IN PROGRESSING ECTOPIC PREGNANCIES: A REAPPRAISAL. Cohen A, Zakar L, Gil Y, et al. Am J Obstet Gynecol 2014;211:128.e1–5. Methotrexate has provided a noninvasive, medical therapeutic option for hemodynamically stable women who are diagnosed with extrauterine pregnancies. A recent study has shown that trending of sequential beta-human chorionic gonadotropin (b-hCG) levels can differentiate progressing ectopic pregnancies from those that spontaneously resolve. In this single-center retrospective cohort study, the authors sought to reevaluate the success rates of methotrexate in progressing ectopic pregnancies, correlate them with b-hCG levels, and compare the findings to previously published data. Of 1703 women with diagnosed ectopic pregnancy, a cohort of 1083 patients was identified as candidates for follow-up with daily b-hCG measurements. In 674 patients (39.5%), b-hCG levels declined with spontaneous resolution of the ectopic pregnancy. This was defined as a daily decline in b-hCG levels by > 15%. Patients with b-hCG levels increasing by > 15% were treated with methotrexate. The remaining patients had their b-hCG levels rechecked the following day for up to 5 days, at which point methotrexate was administered for increasing b-hCG levels. Methotrexate was given in the standard ‘‘single-dose’’ protocol (50 mg/m2 of body surface area). None of the 1083 patients decompensated during the ‘‘watchful waiting’’ period of serial b-hCG monitoring, and 409 (24%) received methotrexate treatment. Of those treated, 356 women (87.0%) were treated successfully; 53 (13.0%) required laparoscopic salpingectomy. Epidemiologic factors of maternal age, parity, gestational age, endometrial thickness, and size of the ectopic mass were not significantly different between the methotrexate and salpingectomy groups. Consistent with previous reports, women who were successfully treated had significantly lower b-hCG levels than those who failed treatment (1407 IU/mL vs. 2664 IU/mL; p < 0.0001). This ‘‘watchful waiting’’ protocol yielded lower methotrexate success rates than previously described (75% when b-hCG 2500–3500 IU/mL and 65% when b-hCG > 4500 IU/mL). In previous studies, success rates were based on prompt administration of methotrexate and were likely confounded by the percentage of patients who would have
The Journal of Emergency Medicine spontaneously resolved without intervention. Finally, the authors created a mathematical model demonstrating an exponential relationship between methotrexate failure rates and the b-hCG level. [Matthew Tjajadi, MD Denver Health Medical Center, Denver, CO] Comment: This study suggests that a ‘‘watchful waiting’’ protocol may be prudent in the management of hemodynamically stable extrauterine pregnancies, as a significant percentage of them spontaneously resolve. Mathematical modeling yielded an exponential relationship between methotrexate failure rates and the b-hCG level. The emergency physician may use this model to help educate patients and, in conjunction with Gynecology, counsel them as to whether expectant management, methotrexate therapy, or salpingectomy may be optimal. , IMPROVED MANAGEMENT OF ACUTE ASTHMA AMONG PREGNANT WOMEN PRESENTING TO THE ED. Hasegawa K, Cydulka RK, Sullivan AF, et al. Chest 2015;147:406–14. Asthma is a common medical condition affecting 4–8% of all pregnancies. More than a quarter of all pregnant patients with asthma have at least one emergency department (ED) encounter or hospital admission during pregnancy for acute exacerbation of asthma, and it is well known that poorly controlled asthma increases the risk of both fetal and maternal complications. This study identified pregnant patients presenting to 48 EDs with acute asthma exacerbations and evaluated treatment with systemic corticosteroids and whether or not patients were prescribed a course of steroids on ED discharge. Four multicenter observational studies were pooled over two time periods from 1996–2001 and 2011–2012 to compare trends in use of systemic corticosteroids. A total of 4895 patients were identified with a diagnosis of acute asthma exacerbation; among those aged 18–44 years with known pregnancy, 125 patients were selected for the study’s cohort. Eighty-nine patients were pooled from the 1996–2001 period, vs. 36 from the later period. Patient characteristics were similar in the two time periods, including age, race, smoking status, and severity of asthma. Administration of corticosteroids in the ED increased significantly between the two time periods, from 51% to 78% (odds ratio [OR] 3.11; 95% confidence interval [CI] 1.27–7.60). Similarly, prescribed steroids at discharge increased from 42% to 63% (OR 2.49; 95% CI 0.97–6.37). The authors conclude that over the course of a decade, ED providers are increasing their administration of systemic corticosteroids for acute asthma exacerbation in pregnancy. The limitations of the study include it being observational, of relatively small size, and mostly consisting of academic EDs in urban areas. However, current treatment guidelines recommend the use of systemic corticosteroids in pregnancy, and this study suggests that ED providers are improving in their adherence to asthma treatment guidelines in pregnancy. [Graham Ingalsbe, MD Denver Health Medical Center, Denver, CO]
649 Comment: Treating pregnant patients is a difficult task for ED providers, particularly with the concern of pharmacotherapy and harm to the fetus. However, few data exist demonstrating fetal complications with systemic steroid therapy; conversely, it is well known that acute asthma does cause significant fetal and maternal harm. This study demonstrates that providers are slowly embracing the use of systemic steroid use in pregnant asthmatic patients, and adhering to current guidelines for clinical practice. , NEIGHBORHOOD SOCIOECONOMIC DISADVANTAGE AND 30-DAY REHOSPITALIZATION. King AJ, Jencks S, Brock J, et al. Ann Intern Med 2014;161:765–74. Rehospitalization is a common and costly complication in health care. It is estimated that Medicare spends more than $17 billion annually on 30-day readmissions, affecting 1 in 5 Medicare patients. Many factors are associated with 30-day rehospitalization. The authors of this study sought to correlate a patient’s socioeconomic disadvantage to risk of 30-day rehospitalization. Data were obtained from the Chronic Condition Data Warehouse of Medicare claims from 2004 to 2009. A random sample of 5% of Medicare beneficiaries was pooled, and an area deprivation index (ADI) was assigned to each patient. The ADI is an index that employs 17 data points including poverty, education, employment, and housing from U.S. census data arranged by ZIP code. Patients were arranged by ADI scores into the most disadvantaged 15% compared to the remaining 85%. After exclusions, more than 250,000 patients were pooled from more than 4800 hospitals. Rehospitalization rates were compared in each of these groups, with diagnoses of congestive heart failure, pneumonia, and acute myocardial infarction, the three diagnoses currently linked to Medicare reimbursement penalties for rehospitalization. Compared with the general population, 30-day rehospitalization rates were higher in the more disadvantaged 15% of neighborhoods. Thirty-day rehospitalization rates among the least disadvantaged 85% of neighborhoods did not vary significantly. Among the most disadvantaged neighborhoods, rehospitalization rates increased from 22% to 27% with worsening ADI. This trend continued with adjustment, with the most disadvantaged neighborhoods with an adjusted risk ratio of 1.09 (95% confidence interval 1.05–1.12) for 30-day rehospitalization. The authors conclude that the ADI is a useful predictor of 30-day rehospitalization among patients with diagnoses of congestive heart failure, pneumonia, and acute myocardial infarction. The study may be limited by the fact that patients listing a post office box or those not enrolled in census data were excluded from data sampling. However, this study demonstrates the importance of ADI as a factor in 30-day rehospitalization. [Graham Ingalsbe, MD Denver Health Medical Center, Denver, CO] Comment: Many factors lead to rehospitalization, which is a costly and potentially medically compromising complication.