Prediction of Early Recurrence After Acute Ischemic Stroke

The Journal of Emergency Medicine, Vol. 51, No. 1, pp. 91–97, 2016 0736-4679/$ - see front matter

Abstracts , EPIDEMIOLOGY OF EYE RELATED EMERGENCY DEPARTMENT VISITS. Channa R, Zafar SN, Canner JK, et al. JAMA Ophthalmology. 2016;134:312-319 Limited resources and increasing use of the Emergency Department (ED) for non-emergent complaints make it important to analyze patterns of use so cost effective, efficient care can be provided. Few studies have focused on eye related complaints in the ED where trained ophthalmologic professionals are rarely available. The goal of this study was to determine what ophthalmologic conditions are seen in the ED and to determine characteristics of visit types for all ages. This study evaluated patients using the Nationwide Emergency Department Sample (NEDS) database with diagnosis of primary eye related complaints. This study integrated data from January 1, 2006, through December 31, 2011, and included all patients presenting to the ED with eye related conditions across the United States (US). These visits were categorized based on age, eye related problems, ocular injuries, and emergent versus non-emergent visit status. Multivariate logistic regression analysis was used to determine the association between demographic and facility factors associated with presenting with emergent versus non-emergent visits. Over 90% of patients presenting to the ED with eye related chief complaints in the US were discharged home. Forty one percent of the total visits were determined to be emergent conditions. Emergent conditions were found to be more likely in the elderly (odds ratio [OR] 2.38, 95% confidence interval [CI] 2.38-2.44), male (OR 2.00, 95% CI 2.00-2.01), patients within the highest income quartile (OR 1.47, 95% CI 1.46-1.49), or patients with private insurance (OR 1.29, 1.28-1.30). There were 200,604 hospital admissions in the emergent group with primary admission diagnoses of orbital cellulitis, orbital floor blowout fractures, and eyelid abscess being most common. The authors found that throughout the six-year study period there has been a decline in eye related injuries such as ruptured globes, superficial injuries, and burns. However, there has been a slight increase in blowout fractures both secondary to striking injuries most commonly in younger males, but also related to falls in the elderly which is increasing given the ageing total population. Corneal abrasions and superficial lacerations make up 37.8% of injuries and are still the most common eye related injury seen in the ED. The authors concluded that in the United States approximately half of all ED visits for ophthalmologic complaints were non-emergent. The investigators suggest that if visits for benign conditions that do not affect vision can be diverted to

outpatient clinics or urgent care facilities the overall cost of healthcare can be decreased. [Sarah Krajicek, MD Denver Health Medical Center, Denver, CO] Comment: This study demonstrates that some ED visits for eye complaints are non-emergent. However, it may be difficult for patients to independently ascertain when an eye concern is emergent versus nonemergent. In addition, some patients may not have access to care outside of the ED for an ophthalmologic concern. Additional investigations into healthcare service delivery for eye complaints in the post-Affordable Care Act era are indicated to ascertain whether the legislation has resulted in improvements in access to care for emergent and nonemergent ophthalmologic concerns. , PREDICTION OF EARLY RECURRENCE AFTER ACUTE ISCHEMIC STROKE. Arsava EM, Kim GM, Oliveira-Filho J, et al. JAMA Neurology. 2016;73(4):396-401 Almost 50% of recurrent strokes take place within days to weeks of an acute ischemic stroke. Recurrent infarctions can lead to costly hospital admissions, increased morbidity, functional limitations, and increased mortality in patients with identifiable risk factors. It is unclear if the Recurrence Risk Estimator (RRE) is able to predict patients at higher risk for stroke recurrence on initial presentation. The objective of this study was to assess the validity of the RRE as a prognostic score and to analyze its ability to predict risk of early recurrence of stroke in a multicenter setting. This study evaluated patients ages $ 18 years presenting within 72 hours of symptom onset and with magnetic resonance imaging (MRI) confirmed diagnosis of acute ischemic stroke. This retrospective cohort study included 1,468 patients presenting to three academic hospitals in the United States (US), South Korea, and Brazil. Recruitment in the US group was completed between June 1, 2009, and April 30, 2011. Recruitment in the Korean and Brazilian cohorts occurred between January 1, 2007, and December 31, 2011. Investigators at each site who were blinded to the patient’s recurrence status assessed outcomes. The RRE uses a seven point score based on predictors such as history of stroke or transient ischemic attack, cause of ischemic event, location of infarct(s), and presence of multiple infracted areas. Neurologic outcomes were assessed with in person or telephone interviews as well as national registries to confirm survival status. Fifty-nine patients in the cohort had recurrent ischemic strokes within the study period resulting in a 4.2% 91

92 recurrence rate at 90 days. The mean RRE score was 2.2 in the recurrence group compared to 1.0 in the group without additional ischemic events. Patients who presented with large artery atherosclerosis were more likely to have recurrence. The overall risk of stroke recurrence was found to be significantly higher in patients with higher RRE scores (p<0.001). The authors concluded that the RRE is a valid method of assessing the risk of stroke recurrence in a multicenter study with a diverse patient population. The investigators suggest that the RRE may become a useful clinical tool when deciding which patients are high-risk versus low-risk for targeted stroke prevention. [Sarah Krajicek, MD Denver Health Medical Center, Denver, CO] Comment: This study adds to the growing body of evidence in support of the RRE as a prediction tool to assess individuals at high risk for recurrent stroke. Additional studies are indicated to assess the role of the RRE in the setting of standardized treatment protocols for post-stroke care. , CANNABIS USE AND RISK OF PSYCHIATRIC DISORDERS. Blanco C, Hasin DS, Wall MM, et al. JAMA Psychiatry. 2016;73:388-395 Marijuana use is becoming more prevalent in the general population secondary to medicinal programs and legalization of marijuana in several states across the United States. There are known associations between cannabis use and psychiatric disorders. However, there have not been prospective studies looking at the incidence of mood disorders, anxiety, and substance abuse in association with cannabis use. The objective of this study was to prospectively evaluate the association between cannabis use and the risk of mental health disorders and substance abuse problems in the adult population. Patients ages $ 18 years were interviewed in two waves between 2001-2002 and 2004-2005 using the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). The investigators used multiple regression and propensity score matching to ascertain whether cannabis use in wave one was associated with psychiatric disorders at wave two. Psychiatric diagnoses were determined in wave two according to the Diagnostic and Statistical Manual of Mental Disorders IV criteria using the Alcohol Use Disorder and Associated Disabilities Interview Schedule (AUDADIS-IV). Thirty four thousand six hundred and fifty three respondents were enrolled in the study. Forty eight percent of the respondents were male. One thousand two hundred seventy nine individuals used cannabis in wave one. Cannabis use in wave one was associated with substance use disorders in wave two, including any substance use disorder (odds ratio [OR] 6.2 95% confidence interval [CI] 4.1-9.4), alcohol use disorder OR 2.7 (95% CI 1.9-3.8), any cannabis use disorder (OR 9.9.5 (95% CI 6.4-14.1). No association was found between first wave cannabis use and any mood disorder (OR 1.1, 95% CI 0.8-1.4) and anxiety disorder (OR 0.9, 95% CI 0.7-1.1). The authors concluded that in the general adult population, cannabis use in the first wave was associated with increased

Abstracts incidence of substance use disorders but not mood or anxiety disorders. [Sarah Krajicek Denver Health Medical Center, Denver, CO] Comment: As marijuana legalization is becoming more common in the United States, both policy makers and physicians will need to consider the associations cannabis use can have with other substance abuse disorders. This study provides insight into substance abuse patterns that may be associated with cannabis use. Additional investigations to identify individuals who use cannabis who are at risk for substance dependence may afford opportunities for early intervention. , ORAL PREDNISOLONE IN THE TREATMENT OF ACUTE GOUT: A PRAGMATIC, MULTICENTER, DOUBLE-BLIND, RANDOMIZED TRIAL. Rainer TH, Cheng CH, Janssens H, et al. Ann Intern Med. 2016;164:464-471 Gout is an inflammatory arthropathy which causes presentations to emergency departments due to acute pain. The standard of care for many years has been nonsteroidal anti-inflammatory drugs (NSAIDs), with the possible addition of colchicine. As gout is an inflammatory condition, it is logical to conclude that corticosteroids may be an effective treatment option for gout. This study seeks to expand on the existing evidence from several smaller trials that oral corticosteroids, rather than NSAIDs, are a safe and effective option for the treatment of gout. This was a multi-center, double blinded, randomized controlled trial in which 416 patients were enrolled and assigned to receive either indomethacin plus placebo or prednisolone plus placebo, each for 5 days. Each group also received acetaminophen for breakthrough pain. The primary outcomes were joint pain at rest and with activity; the secondary outcomes included adverse events, clinical appearance (erythema, tenderness, edema) of the involved joint, need for breakthrough medications, and need for further treatment, among others. Pain was assessed on the visual analogue scale, and +/- 13 mm was considered statistically significant. Patients’ pain was assessed by a research associate, at rest and during movement, prior to medication administration, and then at 30, 60, 90, and 120 minutes after administration while in the emergency department. After discharge, the patient performed self assessments daily on days 2-14. Pain assessments were analyzed using t tests, and adverse events were analyzed using chi square tests. They performed both per-protocol and intention-to-treat (ITT) analyses. Of the 416 patients enrolled (all analyzed by ITT), 40 did not complete the study (376 by per-protocol analysis). Both the indomethacin plus placebo and the prednisolone plus placebo groups shared similar baseline characteristics. Both groups had statistically significant reduction in pain scores during the 2 week study period. During their time in the emergency department, there was no statistically significant difference between groups for pain scores at rest (p=0.69) or with activity (p=0.56). During post ED follow up, there was also no statistically significant difference between groups for pain scores at