Anticoagulation drug therapy: a review Harter, Katherine; Levine, Michael; Henderson, Sean O
The western journal of emergency medicine
16, Issue:
1
Journal Article
Peer reviewed
Open access
Historically, most patients who required parenteral anticoagulation received heparin, whereas those patients requiring oral anticoagulation received warfarin. Due to the narrow therapeutic index and ...need for frequent laboratory monitoring associated with warfarin, there has been a desire to develop newer, more effective anticoagulants. Consequently, in recent years many novel anticoagulants have been developed. The emergency physician may institute anticoagulation therapy in the short term (e.g. heparin) for a patient being admitted, or may start a novel anticoagulation for a patient being discharged. Similarly, a patient on a novel anticoagulant may present to the emergency department due to a hemorrhagic complication. Consequently, the emergency physician should be familiar with the newer and older anticoagulants. This review emphasizes the indication, mechanism of action, adverse effects, and potential reversal strategies for various anticoagulants that the emergency physician will likely encounter.
Study objective Older adults are frequently hospitalized from the emergency department (ED) after an episode of unexplained syncope. Current admission patterns are costly, with little evidence of ...benefit. We hypothesize that an ED observation syncope protocol will reduce resource use without adversely affecting patient-oriented outcomes. Methods This randomized trial at 5 EDs compared an ED observation syncope protocol to inpatient admission for intermediate-risk adults (≥50 years) presenting with syncope or near syncope. Primary outcomes included inpatient admission rate and length of stay. Secondary outcomes included 30-day and 6-month serious outcomes after hospital discharge, index and 30-day hospital costs, 30-day quality-of-life scores, and 30-day patient satisfaction. Results Study staff randomized 124 patients. Observation resulted in a lower inpatient admission rate (15% versus 92%; 95% confidence interval CI difference −88% to −66%) and shorter hospital length of stay (29 versus 47 hours; 95% CI difference −28 to −8). Serious outcome rates after hospital discharge were similar for observation versus admission at 30 days (3% versus 0%; 95% CI difference −1% to 8%) and 6 months (8% versus 10%; 95% CI difference −13% to 9%). Index hospital costs in the observation group were $629 (95% CI difference −$1,376 to −$56) lower than in the admission group. There were no differences in 30-day quality-of-life scores or in patient satisfaction. Conclusion An ED observation syncope protocol reduced the primary outcomes of admission rate and hospital length of stay. Analyses of secondary outcomes suggest reduction in index hospital costs, with no difference in safety events, quality of life, or patient satisfaction. Our findings suggest that an ED observation syncope protocol can be replicated and safely reduce resource use.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
When the COVID-19 pandemic hit the United States, the number of people confined in correctional facilities on a single day numbered 1.8 million. Incarcerated people are at an increased risk of ...contracting and spreading SARS-CoV-2. Recommendations from the Centers for Disease Control and Prevention on case recognition, management, isolation, and contact tracing are particularly challenging in jails because of the high turnover of incarcerated people. Beginning in late February 2020, the Department of Correctional Health Services in the Los Angeles County Jail system implemented a multipronged COVID-19 mitigation plan that was progressively amended in accordance with local and national recommendations. This plan entailed the creation of housing for people under investigation, SARS-CoV-2 screening upon entry, a mass-testing program, and identification and monitoring of medically vulnerable people. After the identification of the first laboratory-confirmed case on March 29, 2020, predictive models were generated to visualize potential disease spread and gain support for mitigation strategy planning, which forecasted approximately 3300-4600 cumulative cases during a 278-day period. From March 7 through December 31, 2020, the percentage positivity among unique people tested for SARS-CoV-2 was 11.6% (3933 of 33 921 tested). Among those screened at intake, the percentage positivity was 2.0% (502 of 25 702 tested). The ethnic distribution among people with a positive SARS-CoV-2 test result was largely representative of the overall jail population, and most people were asymptomatic. A sustainable, multifaceted mitigation plan that relies on collaboration among medical, custodial, and local public health personnel is essential for limiting the spread of SARS-CoV-2 infection in correctional facilities.
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NUK, OILJ, SAZU, UKNU, UL, UM, UPUK, VSZLJ
Necrotizing fasciitis (NF) is a life-threatening illness, particularly when surgical debridement is delayed. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score was developed to ...identify patients at higher risk for NF. Despite limited information in this regard, the LRINEC score is often used to "rule out" NF if negative. We describe the sensitivity of the LRINEC score in emergency department (ED) patients for the diagnosis of NF.
We conducted a chart review of ED patients in whom coding of hospital discharge diagnoses included NF. We employed standard methods to minimize bias. We used laboratory data to calculate the LRINEC score, and confirmed the diagnosis of NF via explicit chart review. We then calculated the sensitivity of a positive LRINEC score (standardly defined as six or greater) in our cohort. We examined the role of patient characteristics in the performance of the LRINEC score. Finally, we performed sensitivity analyses to estimate whether missing data for c-reactive protein (CRP) results were likely to impact our results.
Of 266 ED patients coded as having a discharge diagnosis of NF, we were able to confirm the diagnosis, by chart review, in 167. We were able to calculate a LRINEC score in only 80 patients (due to absence of an initial CRP value); an LRINEC score of 6 or greater had a sensitivity of 77%. Sensitivity analyses of missing data supported our finding of inadequate sensitivity to rule out NF. In sub-analysis, NF patients with concurrent diabetes were more likely to be accurately categorized by the LRINEC score.
Used in isolation, the LRINEC score is not sufficiently sensitive to rule out NF in a general ED population.
Correctional populations have been disproportionately affected by COVID-19, and many large outbreaks have occurred in jails and prisons. Vaccination is a key strategy to reduce the SARS-CoV-2 ...transmission in carceral settings. Although implementation can be challenging due to vaccine hesitancy and medical mistrust, correctional settings provide largely equitable healthcare access and present a unique opportunity to identify potential predictors of vaccine hesitancy independent of access issues.
We retrospectively analyzed electronic health record data for individuals offered COVID-19 vaccination at the Los Angeles County Jail between January 19, 2021, and January 31, 2023, and used multivariable logistic regression to determine predictors of COVID-19 vaccine refusal.
Of the 21,424 individuals offered COVID-19 vaccination, 2,060 (9.6 %) refused. Refusal was associated with male sex (aOR = 2.3, 95 % CI (1.9, 2.8)), age 18–34 (aOR = 1.2, 95 % CI (1.1, 1.4), referent group: age 45–54), Black race (aOR = 1.2, 95 % CI (1.1, 1.4)), reporting ever being houseless (aOR = 1.2, 95 % CI (1.1, 1.3)), and having a history of not receiving influenza vaccination while incarcerated (aOR = 2.4, 95 % CI (2.0, 2.8)). When analyzing male and female populations separately, male-specific trends reflected those seen in the overall population, whereas the only significant predictor of vaccine refusal in the female population was not receiving influenza vaccination while in custody (aOR = 6.5, 95 % CI (2.4, 17.6)).
Identifying predictors of vaccine refusal in correctional populations is an essential first step in the development and implementation of targeted interventions to mitigate vaccine hesitancy.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
OBJECTIVE: In the emergency department, hyperglycemic patients are screened for diabetic ketoacidosis (DKA) via a urine dipstick. In this prospective study, we compared the test characteristics of ...point-of-care β-hydroxybutyrate (β-OHB) analysis with the urine dipstick. RESEARCH DESIGN AND METHODS: Emergency-department patients with blood glucose ≥250 mg/dL had urine dipstick, chemistry panel, venous blood gas, and capillary β-OHB measurements. DKA was diagnosed according to American Diabetes Association criteria. RESULTS: Of 516 hyperglycemic subjects, 54 had DKA. The urine dipstick had a sensitivity of 98.1% (95% CI 90.1-100), a specificity of 35.1% (30.7-39.6), a positive predictive value of 15% (11.5-19.2), and a negative predictive value of 99.4% (96.6-100) for DKA. Using the manufacturer-suggested cutoff of >1.5 mmol/L, β-OHB had a sensitivity of 98.1% (90.1-100), a specificity of 78.6% (74.5-82.2), a positive predictive value of 34.9% (27.3-43), and a negative predictive value of 99.7% (98.5-100) for DKA. CONCLUSIONS: Point-of-care β-OHB and the urine dipstick are equally sensitive for detecting DKA (98.1%). However, β-OHB is more specific (78.6 vs. 35.1%), offering the potential to significantly reduce unnecessary DKA work-ups among hyperglycemic patients in the emergency department.
A major health concern among individuals with alcohol use disorder is alcohol withdrawal syndrome (AWS), where individuals with physical dependence on alcohol may experience withdrawal signs and ...symptoms upon stopping or reducing alcohol use. AWS has a range of severity, with the most severe cases referred to as complicated AWS, presenting as seizure or signs and symptoms indicative of delirium or new onset of hallucinations. In the general community, risk factors or predictors of complicated AWS among hospitalized patients have been described, but there is no literature that examines such risk factors in a correctional population. The Los Angeles County Jail (LACJ) is the nation's largest jail system and manages 10–15 new patients per day for AWS. Here we aim to identify the risk factors associated with alcohol withdrawal-related hospital transfers among incarcerated patients being managed for AWS in the LACJ.
From January 1, 2019, to December 31, 2020, data were gathered about LACJ patients who required transfer to an acute care facility for alcohol withdrawal-related concerns while on the Clinical Institute Withdrawal Assessment for Alcohol revised (CIWA-Ar) protocol. Log regression analysis was performed to generate an odds ratio for acute care facility transfer for the following variables: race, sex assigned at birth, age, CIWA-Ar scores, highest systolic blood pressure (SBP), and highest heart rate (HR).
Out of 15,658 patients on CIWA-Ar protocol during this 2-year time frame, a total of 269 (1.7%) were transferred to an acute care facility for alcohol withdrawal-related concerns. Of those 269 patients, significant risk factors associated with withdrawal-related hospital transfer included: Other race (OR 2.9, 95% CI 1.5–5.5), male sex assigned at birth (OR 1.6, 95% CI 1.0–2.5), age ≥55 years (OR 2.3, 95% 1.1–4.9), CIWA-Ar score 9–14 (OR 4.1, 95% CI 3.1–5.3), CIWA-Ar score ≥15 (OR 21.0, 95% CI 12.0–36.6), highest SBP ≥150 mmHg (OR 2.3, 95% CI 1.8–3.0), highest HR ≥ 110 bpm (OR 2.8, 95% CI 2.2–3.8).
Among patients studied, the higher CIWA-Ar score was the most significant risk factor associated with alcohol withdrawal-related hospital transfer. Other significant risk factors identified are race other than Hispanic, white, and African American; male sex assigned at birth; age ≥55 years; highest SBP ≥150 mmHg; and highest HR ≥ 110 bpm.
•Background: At the Twin Towers Correctional Facility in Los Angeles, approximately 20 newly incarcerated persons per day present with alcohol use disorder (AUD) that will require monitoring for alcohol withdrawal syndrome (AWS).•While risk factors associated with severe or complicated AWS have been identified in community settings, there are no studies examining such risk factors in the correctional setting, where AWS is encountered frequently.•Study Methodology: This is a retrospective observational study that reports on patients treated for AWS at the Los Angeles County jail during the period January 1, 2019 through December 31, 2020 with a study population of 15,658 individuals. Information was gathered in the electronic medical records to identify risk factors for alcohol withdrawal-related hospital transfer. Demographic data (biological sex, age in years, and ethnicity) was collected, as well as variables associated with AWS in the community (withdrawal symptoms via a CIWA-Ar score, systolic blood pressure, and heart rate).•Results: Out of 15,658 patients on CIWA-Ar protocol during this 2-year timeframe, a total of 269 (1.7%) were transferred to an acute care facility for alcohol withdrawal-related concerns. Of those 269 patients, significant risk factors associated with withdrawal-related hospital transfer included: Other race (OR 2.9, 95% CI 1.5-5.5), male gender (OR 1.6, 95% CI 1.0-2.5), age ≥ 55 years (OR 2.3, 95% CI 1.1-4.9), CIWA-Ar score 9-14 (OR 4.1, 95% CI 3.1-5.3), CIWA-Ar score ≥ 15 (OR 21.0, 95% CI 12.0-36.6), highest SBP ≥ 150 mmHg (OR 2.3, 95% CI 1.8-3.0), highest HR ≥ 110 bpm (OR 2.8, 95% CI 2.2-3.8).•Conclusion and Community Engagement: This analysis represents the largest study to examine the CIWA-Ar scale and the first description on the incidence of alcohol withdrawal-related hospital transfer and its risk factors in a jail system in the United States. We find that among incarcerated patients at the Los Angeles County Jail who require AWS monitoring, CIWA-Ar score is the strongest predictor for alcohol withdrawal-related hospital transfer. It is our hope that other correctional institutions will also be motivated to publish and share their observed risk factors and help expand our limited knowledge base.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
A cross-sectional study was conducted in January 2020 to evaluate type 1 diabetes (T1D) management during and between incarcerations at the Los Angeles County Jail. Inclusion criteria were men with a ...T1D diagnosis who had been incarcerated twice within 5 years with at least two hemoglobin A1c values during each incarceration and a minimum of 3 months in the community between incarcerations. The primary outcome was the percentage change in A1c after release compared with the A1c during incarcerations. Five patients met inclusion criteria. During the first and second incarcerations, mean A1c was reduced by 13% and 9.6%, respectively. While in the community, mean A1c increased by 14%. These results highlight the importance of comprehensive reentry programs for patients with T1D, including linkage to community resources for diabetes management, so health gains made during incarceration are not lost.
Abstract Background Patients present to police, Emergency Medical Services, and the emergency department with aggressive behavior, altered sensorium, and a host of other signs that may include ...hyperthermia, “superhuman” strength, diaphoresis, and lack of willingness to yield to overwhelming force. A certain percentage of these individuals will go on to expire from a sudden cardiac arrest and death, despite optimal therapy. Traditionally, the forensic community would often classify these as “Excited Delirium” deaths. Objectives This article will review selected examples of the literature on this topic to determine if it is definable as a discrete medical entity, has a recognizable history, epidemiology, clinical presentation, pathophysiology, and treatment recommendations. Discussion Excited delirium syndrome is characterized by delirium, agitation, acidosis, and hyperadrenergic autonomic dysfunction, typically in the setting of acute-on-chronic drug abuse or serious mental illness or a combination of both. Conclusions Based upon available evidence, it is the consensus of an American College of Emergency Physicians Task Force that Excited Delirium Syndrome is a real syndrome with uncertain, likely multiple, etiologies.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Opioid overdose-related morbidity and mortality is a pressing public health crisis. Successful overdose reversal through bystander administration of naloxone is well documented, but there is an ...absence of literature on the implementation and impact of widespread naloxone access in a correctional setting during incarceration. The objective of this study was to describe our efforts to combat opioid overdose, prevent deaths, and examine and identify opioid use and predictors of opioid use through factors including age, sex assigned at birth, and ethnicity among the incarcerated population within the Los Angeles County jail system.
We retrospectively analyzed self-reported substance use information from all newly incarcerated persons from September 2018 to December 2020 to characterize opioid use in the Los Angeles County Jail system and used multivariable logistic regression analysis to determine predictors of substance use. We analyzed data on all cases of naloxone administration by custody personnel (i.e., all correctional officers) during the same period by examining patient demographic information, hospital discharge diagnosis, and patient outcome information. To describe naloxone training and access for incarcerated persons as an overdose prevention strategy, we reviewed electronic health record data on patient health outcomes for all cases of naloxone administration by an incarcerated person.
A total of 6.4 % (11,881 of 187,528) of incarcerated persons reported opioid use. In the multivariable analysis, reported substance use was most significantly associated with any ethnicity other than Black (aOR for White =11.2; 95 % CI 10.4, 12.0, aOR for Hispanic/Latinx 3.0; 95 % CI 2.8, 3.2, aOR for All Others; 5.2 95 % CI 4.6, 5.8) and being <65 years old. Naloxone was administered by custody personnel to a total of 129 patients, where 122 (94.6 %) survived and 7 (5.4 %) died. After the deployment of naloxone in jail housing units, there were two instances of bystander naloxone administration by incarcerated persons that led to successful opioid overdose reversal and survival.
The expansion of naloxone availability to both custody personnel and incarcerated persons is an effective and warranted method to ensure timely naloxone administration and successful overdose reversal in a correctional setting.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
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