James Quinn

All Publications

• Long COVID autonomic syndrome: Improved understanding through translational research. European journal of internal medicine Quinn, J. 2023

  View details for DOI 10.1016/j.ejim.2023.11.023

  View details for PubMedID 38057245

• An Underrecognized Cause of Recurrent Nocturnal Syncope with a Pacemaker: Sleep Rate Mode. The Journal of emergency medicine Woo, J. D., Quinn, J. V. 2023

  Abstract

  Nocturnal syncope is a common presentation in the emergency department, often related to orthostatic hypotension and subsequent loss of cerebral perfusion when patients get up from sleep to use the restroom faster than their cardiac output and vascular tone can accommodate. Poor hydration status and antihypertensive medications can increase this risk. Patients with syncope who present to the emergency department with a pacemaker are usually evaluated with a pacemaker interrogation to evaluate for runs of nonperfusing rhythms (e.g., ventricular tachycardia or fibrillation). Sleep rate mode (SRM) is a relatively new feature of modern pacemakers and is not currently recognized by emergency physicians. It was implemented to accommodate more physiologic fluctuations in heart rate during rapid eye movement sleep. There is a paucity of evidence supporting the clinical benefit of SRM and similarly no documentation of prior complications of SRM in the current literature.We report the case of a 92-year-old woman with a Medtronic Avisa pacemaker presenting with recurrent nocturnal syncope and bradycardia resulting in multiple emergency department visits. These episodes ultimately resolved by turning off SRM on her pacemaker. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: SRM is not currently flagged on interrogation report summaries provided to emergency physicians. This report highlights the importance of recognizing this mode as a potential etiology of nocturnal syncope related to chronotropic incompetence in patients with pacemakers.

  View details for DOI 10.1016/j.jemermed.2023.03.055

  View details for PubMedID 37301720

• Association of Vitamin C, Thiamine, and Hydrocortisone Infusion With Long-term Cognitive, Psychological, and Functional Outcomes in Sepsis Survivors: A Secondary Analysis of the Vitamin C, Thiamine, and Steroids in Sepsis Randomized Clinical Trial. JAMA network open Williams Roberson, S., Nwosu, S., Collar, E. M., Kiehl, A. L., Harrison, F. E., Bastarache, J., Wilson, J. E., Mart, M. F., Sevransky, J. E., Ely, E. W., Lindsell, C. J., Jackson, J. C. 2023; 6 (2): e230380

  Abstract

  Sepsis is associated with long-term cognitive impairment and worse psychological and functional outcomes. Potential mechanisms include intracerebral oxidative stress and inflammation, yet little is known about the effects of early antioxidant and anti-inflammatory therapy on cognitive, psychological, and functional outcomes in sepsis survivors.To describe observed differences in long-term cognitive, psychological, and functional outcomes of vitamin C, thiamine, and hydrocortisone between the intervention and control groups in the Vitamin C, Thiamine, and Steroids in Sepsis (VICTAS) randomized clinical trial.This prespecified secondary analysis reports the 6-month outcomes of the multicenter, double-blind, placebo-controlled VICTAS randomized clinical trial, which was conducted between August 2018 and July 2019. Adult patients with sepsis-induced respiratory and/or cardiovascular dysfunction who survived to discharge or day 30 were recruited from 43 intensive care units in the US. Participants were randomized 1:1 to either the intervention or control group. Cognitive, psychological, and functional outcomes at 6 months after randomization were assessed via telephone through January 2020. Data analyses were conducted between February 2021 and December 2022.The intervention group received intravenous vitamin C (1.5 g), thiamine hydrochloride (100 mg), and hydrocortisone sodium succinate (50 mg) every 6 hours for 96 hours or until death or intensive care unit discharge. The control group received matching placebo.Cognitive performance, risk of posttraumatic stress disorder and depression, and functional status were assessed using a battery of standardized instruments that were administered during a 1-hour telephone call 6 months after randomization.After exclusions, withdrawals, and deaths, the final sample included 213 participants (median [IQR] age, 57 [47-67] years; 112 males [52.6%]) who underwent long-term outcomes assessment and had been randomized to either the intervention group (n = 108) or control group (n = 105). The intervention group had lower immediate memory scores (adjusted OR [aOR], 0.49; 95% CI, 0.26-0.89), higher odds of posttraumatic stress disorder (aOR, 3.51; 95% CI, 1.18-10.40), and lower odds of receiving mental health care (aOR, 0.38; 95% CI, 0.16-0.89). No other statistically significant differences in cognitive, psychological, and functional outcomes were found between the 2 groups.In survivors of sepsis, treatment with vitamin C, thiamine, and hydrocortisone did not improve or had worse cognitive, psychological, and functional outcomes at 6 months compared with patients who received placebo. These findings challenge the hypothesis that antioxidant and anti-inflammatory therapy during critical illness mitigates the development of long-term cognitive, psychological, and functional impairment in sepsis survivors.ClinicalTrials.gov Identifier: NCT03509350.

  View details for DOI 10.1001/jamanetworkopen.2023.0380

  View details for PubMedID 36853612

  View details for PubMedCentralID PMC9975932

• Natural language processing to classify electrocardiograms in patients with syncope: A preliminary study. Health science reports Quinn, J., Kim, D., Rice, B. T., Hao, W. D. 2022; 5 (6): e904

  View details for DOI 10.1002/hsr2.904

  View details for PubMedID 36324425

  View details for PubMedCentralID PMC9621468

• Using a 29-mRNA Host Response Classifier To Detect Bacterial Coinfections and Predict Outcomes in COVID-19 Patients Presenting to the Emergency Department. Microbiology spectrum Ram-Mohan, N., Rogers, A. J., Blish, C. A., Nadeau, K. C., Zudock, E. J., Kim, D., Quinn, J. V., Sun, L., Liesenfeld, O., Yang, S. 2022: e0230522

  Abstract

  Clinicians in the emergency department (ED) face challenges in concurrently assessing patients with suspected COVID-19 infection, detecting bacterial coinfection, and determining illness severity since current practices require separate workflows. Here, we explore the accuracy of the IMX-BVN-3/IMX-SEV-3 29 mRNA host response classifiers in simultaneously detecting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and bacterial coinfections and predicting clinical severity of COVID-19. A total of 161 patients with PCR-confirmed COVID-19 (52.2% female; median age, 50.0 years; 51% hospitalized; 5.6% deaths) were enrolled at the Stanford Hospital ED. RNA was extracted (2.5 mL whole blood in PAXgene blood RNA), and 29 host mRNAs in response to the infection were quantified using Nanostring nCounter. The IMX-BVN-3 classifier identified SARS-CoV-2 infection in 151 patients with a sensitivity of 93.8%. Six of 10 patients undetected by the classifier had positive COVID tests more than 9 days prior to enrollment, and the remaining patients oscillated between positive and negative results in subsequent tests. The classifier also predicted that 6 (3.7%) patients had a bacterial coinfection. Clinical adjudication confirmed that 5/6 (83.3%) of the patients had bacterial infections, i.e., Clostridioides difficile colitis (n = 1), urinary tract infection (n = 1), and clinically diagnosed bacterial infections (n = 3), for a specificity of 99.4%. Two of 101 (2.8%) patients in the IMX-SEV-3 "Low" severity classification and 7/60 (11.7%) in the "Moderate" severity classification died within 30 days of enrollment. IMX-BVN-3/IMX-SEV-3 classifiers accurately identified patients with COVID-19 and bacterial coinfections and predicted patients' risk of death. A point-of-care version of these classifiers, under development, could improve ED patient management, including more accurate treatment decisions and optimized resource utilization. IMPORTANCE We assay the utility of the single-test IMX-BVN-3/IMX-SEV-3 classifiers that require just 2.5 mL of patient blood in concurrently detecting viral and bacterial infections as well as predicting the severity and 30-day outcome from the infection. A point-of-care device, in development, will circumvent the need for blood culturing and drastically reduce the time needed to detect an infection. This will negate the need for empirical use of broad-spectrum antibiotics and allow for antibiotic use stewardship. Additionally, accurate classification of the severity of infection and the prediction of 30-day severe outcomes will allow for appropriate allocation of hospital resources.

  View details for DOI 10.1128/spectrum.02305-22

  View details for PubMedID 36250865

• Detection of bacterial co-infections and prediction of fatal outcomes in COVID-19 patients presenting to the emergency department using a 29 mRNA host response classifier. medRxiv : the preprint server for health sciences Ram-Mohan, N., Rogers, A. J., Blish, C. A., Nadeau, K. C., Zudock, E. J., Kim, D., Quinn, J. V., Sun, L., Liesenfeld, O., Stanford COVID-19 Biobank Study Group, Yang, S. 2022

  Abstract

  Objective: Clinicians in the emergency department (ED) face challenges in concurrently assessing patients with suspected COVID-19 infection, detecting bacterial co-infection, and determining illness severity since current practices require separate workflows. Here we explore the accuracy of the IMX-BVN-3/IMX-SEV-3 29 mRNA host response classifiers in simultaneously detecting SARS-CoV-2 infection, bacterial co-infections, and predicting clinical severity of COVID-19.Methods: 161 patients with PCR-confirmed COVID-19 (52.2% female, median age 50.0 years, 51% hospitalized, 5.6% deaths) were enrolled at the Stanford Hospital ED. RNA was extracted (2.5 mL whole blood in PAXgene Blood RNA) and 29 host mRNAs in response to the infection were quantified using Nanostring nCounter.Results: The IMX-BVN-3 classifier identified SARS-CoV-2 infection in 151 patients with a sensitivity of 93.8%. Six of 10 patients undetected by the classifier had positive COVID tests more than 9 days prior to enrolment and the remaining oscillated between positive and negative results in subsequent tests. The classifier also predicted that 6 (3.7%) patients had a bacterial co-infection. Clinical adjudication confirmed that 5/6 (83.3%) of the patients had bacterial infections, i.e. Clostridioides difficile colitis (n=1), urinary tract infection (n=1), and clinically diagnosed bacterial infections (n=3) for a specificity of 99.4%. 2/101 (2.8%) patients in the IMX-SEV-3 Low and 7/60 (11.7%) in the Moderate severity classifications died within thirty days of enrollment.Conclusions: IMX-BVN-3/IMX-SEV-3 classifiers accurately identified patients with COVID-19, bacterial co-infections, and predicted patientsa risk of death. A point-of-care version of these classifiers, under development, could improve ED patient management including more accurate treatment decisions and optimized resource utilization.

  View details for DOI 10.1101/2022.03.14.22272394

  View details for PubMedID 35313598

• Transfer learning enables prediction of myocardial injury from continuous single-lead electrocardiography Journal of the American Medical Informatics Association Jin, B. T., Palleti, R., Shi, S., Ng, A., Quinn, J. V., Rajpurkar, P., Kim, D. 2022

  View details for DOI 10.1093/jamia/ocac135

• Syncope Time Frames for Adverse Events after Emergency Department Presentation: An Individual Patient Data Meta-Analysis. Medicina (Kaunas, Lithuania) Furlan, L., Trombetta, L., Casazza, G., Dipaola, F., Furlan, R., Marta, C., Numeroso, F., Pérez-Rodon, J., Quinn, J. V., Reed, M. J., Sheldon, R. S., Shen, W. K., Sun, B. C., Thiruganasambandamoorthy, V., Ungar, A., Costantino, G., Solbiati, M. 2021; 57 (11)

  Abstract

  Background and Objectives: Knowledge of the incidence and time frames of the adverse events of patients presenting syncope at the ED is essential for developing effective management strategies. The aim of the present study was to perform a meta-analysis of the incidence and time frames of adverse events of syncope patients. Materials and Methods: We combined individual patients' data from prospective observational studies including adult patients who presented syncope at the ED. We assessed the pooled rate of adverse events at 24 h, 72 h, 7-10 days, 1 month and 1 year after ED evaluation. Results: We included nine studies that enrolled 12,269 patients. The mean age varied between 53 and 73 years, with 42% to 57% females. The pooled rate of adverse events was 5.1% (95% CI 3.4% to 7.7%) at 24 h, 7.0% (95% CI 4.9% to 9.9%) at 72 h, 8.4% (95% CI 6.2% to 11.3%) at 7-10 days, 10.3% (95% CI 7.8% to 13.3%) at 1 month and 21.3% (95% CI 15.8% to 28.0%) at 1 year. The pooled death rate was 0.2% (95% CI 0.1% to 0.5%) at 24 h, 0.3% (95% CI 0.1% to 0.7%) at 72 h, 0.5% (95% CI 0.3% to 0.9%) at 7-10 days, 1% (95% CI 0.6% to 1.7%) at 1 month and 5.9% (95% CI 4.5% to 7.7%) at 1 year. The most common adverse event was arrhythmia, for which its rate was 3.1% (95% CI 2.0% to 4.9%) at 24 h, 4.8% (95% CI 3.5% to 6.7%) at 72 h, 5.8% (95% CI 4.2% to 7.9%) at 7-10 days, 6.9% (95% CI 5.3% to 9.1%) at 1 month and 9.9% (95% CI 5.5% to 17) at 1 year. Ventricular arrhythmia was rare. Conclusions: The risk of death or life-threatening adverse event is rare in patients presenting syncope at the ED. The most common adverse events are brady and supraventricular arrhythmias, which occur during the first 3 days. Prolonged ECG monitoring in the ED in a short stay unit with ECG monitoring facilities may, therefore, be beneficial.

  View details for DOI 10.3390/medicina57111235

  View details for PubMedID 34833453

  View details for PubMedCentralID PMC8623370

• Early Convalescent Plasma for High-Risk Outpatients with Covid-19. The New England journal of medicine Korley, F. K., Durkalski-Mauldin, V., Yeatts, S. D., Schulman, K., Davenport, R. D., Dumont, L. J., El Kassar, N., Foster, L. D., Hah, J. M., Jaiswal, S., Kaplan, A., Lowell, E., McDyer, J. F., Quinn, J., Triulzi, D. J., Van Huysen, C., Stevenson, V. L., Yadav, K., Jones, C. W., Kea, B., Burnett, A., Reynolds, J. C., Greineder, C. F., Haas, N. L., Beiser, D. G., Silbergleit, R., Barsan, W., Callaway, C. W., SIREN-C3PO Investigators 2021

  Abstract

  BACKGROUND: Early administration of convalescent plasma obtained from blood donors who have recovered from coronavirus disease 2019 (Covid-19) may prevent disease progression in acutely ill, high-risk patients with Covid-19.METHODS: In this randomized, multicenter, single-blind trial, we assigned patients who were being treated in an emergency department for Covid-19 symptoms to receive either one unit of convalescent plasma with a high titer of antibodies against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or placebo. All the patients were either 50 years of age or older or had one or more risk factors for disease progression. In addition, all the patients presented to the emergency department within 7 days after symptom onset and were in stable condition for outpatient management. The primary outcome was disease progression within 15 days after randomization, which was a composite of hospital admission for any reason, seeking emergency or urgent care, or death without hospitalization. Secondary outcomes included the worst severity of illness on an 8-category ordinal scale, hospital-free days within 30 days after randomization, and death from any cause.RESULTS: A total of 511 patients were enrolled in the trial (257 in the convalescent-plasma group and 254 in the placebo group). The median age of the patients was 54 years; the median symptom duration was 4 days. In the donor plasma samples, the median titer of SARS-CoV-2 neutralizing antibodies was 1:641. Disease progression occurred in 77 patients (30.0%) in the convalescent-plasma group and in 81 patients (31.9%) in the placebo group (risk difference, 1.9 percentage points; 95% credible interval, -6.0 to 9.8; posterior probability of superiority of convalescent plasma, 0.68). Five patients in the plasma group and 1 patient in the placebo group died. Outcomes regarding worst illness severity and hospital-free days were similar in the two groups.CONCLUSIONS: The administration of Covid-19 convalescent plasma to high-risk outpatients within 1 week after the onset of symptoms of Covid-19 did not prevent disease progression. (SIREN-C3PO ClinicalTrials.gov number, NCT04355767.).

  View details for DOI 10.1056/NEJMoa2103784

  View details for PubMedID 34407339

• Effect of Vitamin C, Thiamine, and Hydrocortisone on Ventilator- and Vasopressor-Free Days in Patients With Sepsis: The VICTAS Randomized Clinical Trial. JAMA Sevransky, J. E., Rothman, R. E., Hager, D. N., Bernard, G. R., Brown, S. M., Buchman, T. G., Busse, L. W., Coopersmith, C. M., DeWilde, C., Ely, E. W., Eyzaguirre, L. M., Fowler, A. A., Gaieski, D. F., Gong, M. N., Hall, A., Hinson, J. S., Hooper, M. H., Kelen, G. D., Khan, A., Levine, M. A., Lewis, R. J., Lindsell, C. J., Marlin, J. S., McGlothlin, A., Moore, B. L., Nugent, K. L., Nwosu, S., Polito, C. C., Rice, T. W., Ricketts, E. P., Rudolph, C. C., Sanfilippo, F., Viele, K., Martin, G. S., Wright, D. W. 2021; 325 (8): 742-750

  Abstract

  Sepsis is a common syndrome with substantial morbidity and mortality. A combination of vitamin C, thiamine, and corticosteroids has been proposed as a potential treatment for patients with sepsis.To determine whether a combination of vitamin C, thiamine, and hydrocortisone every 6 hours increases ventilator- and vasopressor-free days compared with placebo in patients with sepsis.Multicenter, randomized, double-blind, adaptive-sample-size, placebo-controlled trial conducted in adult patients with sepsis-induced respiratory and/or cardiovascular dysfunction. Participants were enrolled in the emergency departments or intensive care units at 43 hospitals in the United States between August 2018 and July 2019. After enrollment of 501 participants, funding was withheld, leading to an administrative termination of the trial. All study-related follow-up was completed by January 2020.Participants were randomized to receive intravenous vitamin C (1.5 g), thiamine (100 mg), and hydrocortisone (50 mg) every 6 hours (n = 252) or matching placebo (n = 249) for 96 hours or until discharge from the intensive care unit or death. Participants could be treated with open-label corticosteroids by the clinical team, with study hydrocortisone or matching placebo withheld if the total daily dose was greater or equal to the equivalent of 200 mg of hydrocortisone.The primary outcome was the number of consecutive ventilator- and vasopressor-free days in the first 30 days following the day of randomization. The key secondary outcome was 30-day mortality.Among 501 participants randomized (median age, 62 [interquartile range {IQR}, 50-70] years; 46% female; 30% Black; median Acute Physiology and Chronic Health Evaluation II score, 27 [IQR, 20.8-33.0]; median Sequential Organ Failure Assessment score, 9 [IQR, 7-12]), all completed the trial. Open-label corticosteroids were prescribed to 33% and 32% of the intervention and control groups, respectively. Ventilator- and vasopressor-free days were a median of 25 days (IQR, 0-29 days) in the intervention group and 26 days (IQR, 0-28 days) in the placebo group, with a median difference of -1 day (95% CI, -4 to 2 days; P = .85). Thirty-day mortality was 22% in the intervention group and 24% in the placebo group.Among critically ill patients with sepsis, treatment with vitamin C, thiamine, and hydrocortisone, compared with placebo, did not significantly increase ventilator- and vasopressor-free days within 30 days. However, the trial was terminated early for administrative reasons and may have been underpowered to detect a clinically important difference.ClinicalTrials.gov Identifier: NCT03509350.

  View details for DOI 10.1001/jama.2020.24505

  View details for PubMedID 33620405

  View details for PubMedCentralID PMC7903252

• Association Between US Physician Malpractice Claims Rates and Hospital Admission Rates Among Patients With Lower-Risk Syncope. JAMA network open Quinn, J., Chung, S., Murchland, A., Casazza, G., Costantino, G., Solbiati, M., Furlan, R. 2020; 3 (12): e2025860

  Abstract

  Importance: The US Government Accountability Office has changed its estimate of the annual costs of defensive medicine, largely because it has been difficult to objectively measure its impact. Evaluating the association of malpractice claims rates with hospital admission rates and the costs of admitting patients with low-risk conditions would help to document the impact of defensive medicine. Although syncope is a concerning symptom, most patients with syncope have a low risk of adverse outcomes. However, many low-risk patients are still admitted to the hospital, with associated costs of more than $2.5 billion per year in the US.Objective: To assess whether hospital admission rates after emergency department visits among patients with lower-risk syncope are associated with state-level variations in malpractice claims rates.Design, Setting, and Participants: This cross-sectional study of emergency department visits among patients with lower-risk syncope used deidentified data from the Clinformatics Data Mart database (Optum). Lower-risk syncope visits were defined as those with a primary diagnosis of syncope and collapse based on International Classification of Diseases, Ninth Revision, Clinical Modification code 780.2 or International Classification of Diseases, Tenth Revision, Clinical Modification code R55 that did not include another major diagnostic code for a condition requiring hospital admission (such as heart disease, cancer, or medical shock) or an inpatient hospital stay of more than 3 days. These data were linked to publicly available data from the National Practitioner Data Bank pertaining to physician malpractice claims between January 1, 2008, and December 31, 2017. The 2 data sets were linked at the state-year level. Data were analyzed from October 2, 2019, to September 12, 2020.Main Outcomes and Measures: The association between the rate of hospital admission after emergency department visits among patients with lower-risk syncope and the rate of physician malpractice claims was assessed at the state-year level using a state-level fixed-effects model. Standardized costs obtained from the Clinformatics Data Mart database were adjusted for inflation and expressed in 2017 US dollars using the Consumer Price Index.Results: Among 40 482 813 emergency department visits between 2008 and 2017, 519 724 visits (1.3%) were associated with syncope. Of those, 234 750 visits (45.2%) met the criteria for lower-risk syncope. The mean (SD) age of patients in the lower-risk cohort was 71.8 (13.5) years; 141 050 patients (60.1%) were female, and 44 115 patients (18.8%) were admitted to the hospital, representing an extra cost of $6542 per admission. The mean rate of physician malpractice claims varied from 0.27 claims per 100 000 people to 8.63 claims per 100 000 people across states and across years within states. A state-level fixed-effects regression model indicated that, for every 1 in 100 000-person increase in the physician malpractice claims rate, there was an absolute increase of 6.70% (95% CI, 4.65%-8.75%) or a relative increase of 35.6% in the hospital admission rate, which represented an additional $102 million in costs associated with this lower-risk cohort.Conclusions and Relevance: In this study, increases in physician malpractice claims rates were associated with increases in hospital admission rates and substantial health care costs for patients with lower-risk syncope, and these increases are likely associated with the practice of defensive medicine.

  View details for DOI 10.1001/jamanetworkopen.2020.25860

  View details for PubMedID 33320263

• Monitoring the Burden of Seizures and Highly Epileptiform Patterns in Critical Care with a Novel Machine Learning Method. Neurocritical care Kamousi, B., Karunakaran, S., Gururangan, K., Markert, M., Decker, B., Khankhanian, P., Mainardi, L., Quinn, J., Woo, R., Parvizi, J. 2020

  Abstract

  INTRODUCTION: Current electroencephalography (EEG) practice relies on interpretation by expert neurologists, which introduces diagnostic and therapeutic delays that can impact patients' clinical outcomes. As EEG practice expands, these experts are becoming increasingly limited resources. A highly sensitive and specific automated seizure detection system would streamline practice and expedite appropriate management for patients with possible nonconvulsive seizures. We aimed to test the performance of a recently FDA-cleared machine learning method (Claritgamma, Ceribell Inc.) that measures the burden of seizure activity in real time and generates bedside alerts for possible status epilepticus (SE).METHODS: We retrospectively identified adult patients (n=353) who underwent evaluation of possible seizures with Rapid Response EEG system (Rapid-EEG, Ceribell Inc.). Automated detection of seizure activity and seizure burden throughout a recording (calculated as the percentage of ten-second epochs with seizure activity in any 5-min EEG segment) was performed with Claritgamma, and various thresholds of seizure burden were tested (≥10% indicating≥30s of seizure activity in the last 5min,≥50% indicating≥2.5min of seizure activity, and≥90% indicating≥4.5min of seizure activity and triggering a SE alert). The sensitivity and specificity of Claritgamma's real-time seizure burden measurements and SE alerts were compared to the majority consensus of at least two expert neurologists.RESULTS: Majority consensus of neurologists labeled the 353 EEGs as normal or slow activity (n=249), highly epileptiform patterns (HEP, n=87), or seizures [n=17, nine longer than 5 min (e.g., SE), and eight shorter than 5 min]. The algorithm generated a SE alert (≥90% seizure burden) with 100% sensitivity and 93% specificity. The sensitivity and specificity of various thresholds for seizure burden during EEG recordings for detecting patients with seizures were 100% and 82% for≥50% seizure burden and 88% and 60% for≥10% seizure burden. Of the 179 EEG recordings in which the algorithm detected no seizures, seizures were identified by the expert reviewers in only two cases, indicating a negative predictive value of 99%.DISCUSSION: Claritgamma detected SE events with high sensitivity and specificity, and it demonstrated a high negative predictive value for distinguishing nonepileptiform activity from seizure and highly epileptiform activity.CONCLUSIONS: Ruling out seizures accurately in a large proportion of cases can help prevent unnecessary or aggressive over-treatment in critical care settings, where empiric treatment with antiseizure medications is currently prevalent. Claritgamma's high sensitivity for SE and high negative predictive value for cases without epileptiform activity make it a useful tool for triaging treatment and the need for urgent neurological consultation.

  View details for DOI 10.1007/s12028-020-01120-0

  View details for PubMedID 33025543

• Rapid Response Electroencephalograph With Artificial Intelligence for Diagnosing Seizures and Highly Epileptiform Patterns in Emergency Medicine Parvizi, J., Kamousi, B., Karunakaran, S., Quinn, J., Woo, R. MOSBY-ELSEVIER. 2020: S43

  View details for Web of Science ID 000582805600107

• Telemedicine to Decrease Personal Protective Equipment Use and Protect Healthcare Workers. The western journal of emergency medicine Ribeira, R., Shen, S., Callagy, P., Newberry, J., Strehlow, M., Quinn, J. 2020

  View details for DOI 10.5811/westjem.2020.8.47802

  View details for PubMedID 33052823

• Rates of Co-infection Between SARS-CoV-2 and Other Respiratory Pathogens. JAMA Kim, D., Quinn, J., Pinsky, B., Shah, N. H., Brown, I. 2020

  View details for DOI 10.1001/jama.2020.6266

  View details for PubMedID 32293646

• Efficacy of levetiracetam, fosphenytoin, and valproate for established status epilepticus by age group (ESETT): a double-blind, responsive-adaptive, randomised controlled trial. Lancet (London, England) Chamberlain, J. M., Kapur, J., Shinnar, S., Elm, J., Holsti, M., Babcock, L., Rogers, A., Barsan, W., Cloyd, J., Lowenstein, D., Bleck, T. P., Conwit, R., Meinzer, C., Cock, H., Fountain, N. B., Underwood, E., Connor, J. T., Silbergleit, R. 2020; 395 (10231): 1217-1224

  Abstract

  Benzodiazepine-refractory, or established, status epilepticus is thought to be of similar pathophysiology in children and adults, but differences in underlying aetiology and pharmacodynamics might differentially affect response to therapy. In the Established Status Epilepticus Treatment Trial (ESETT) we compared the efficacy and safety of levetiracetam, fosphenytoin, and valproate in established status epilepticus, and here we describe our results after extending enrolment in children to compare outcomes in three age groups.In this multicentre, double-blind, response-adaptive, randomised controlled trial, we recruited patients from 58 hospital emergency departments across the USA. Patients were eligible for inclusion if they were aged 2 years or older, had been treated for a generalised convulsive seizure of longer than 5 min duration with adequate doses of benzodiazepines, and continued to have persistent or recurrent convulsions in the emergency department for at least 5 min and no more than 30 min after the last dose of benzodiazepine. Patients were randomly assigned in a response-adaptive manner, using Bayesian methods and stratified by age group (<18 years, 18-65 years, and >65 years), to levetiracetam, fosphenytoin, or valproate. All patients, investigators, study staff, and pharmacists were masked to treatment allocation. The primary outcome was absence of clinically apparent seizures with improved consciousness and without additional antiseizure medication at 1 h from start of drug infusion. The primary safety outcome was life-threatening hypotension or cardiac arrhythmia. The efficacy and safety outcomes were analysed by intention to treat. This study is registered in ClinicalTrials.gov, NCT01960075.Between Nov 3, 2015, and Dec 29, 2018, we enrolled 478 patients and 462 unique patients were included: 225 children (aged <18 years), 186 adults (18-65 years), and 51 older adults (>65 years). 175 (38%) patients were randomly assigned to levetiracetam, 142 (31%) to fosphenyltoin, and 145 (31%) were to valproate. Baseline characteristics were balanced across treatments within age groups. The primary efficacy outcome was met in those treated with levetiracetam for 52% (95% credible interval 41-62) of children, 44% (33-55) of adults, and 37% (19-59) of older adults; with fosphenytoin in 49% (38-61) of children, 46% (34-59) of adults, and 35% (17-59) of older adults; and with valproate in 52% (41-63) of children, 46% (34-58) of adults, and 47% (25-70) of older adults. No differences were detected in efficacy or primary safety outcome by drug within each age group. With the exception of endotracheal intubation in children, secondary safety outcomes did not significantly differ by drug within each age group.Children, adults, and older adults with established status epilepticus respond similarly to levetiracetam, fosphenytoin, and valproate, with treatment success in approximately half of patients. Any of the three drugs can be considered as a potential first-choice, second-line drug for benzodiazepine-refractory status epilepticus.National Institute of Neurological Disorders and Stroke, National Institutes of Health.

  View details for DOI 10.1016/S0140-6736(20)30611-5

  View details for PubMedID 32203691

  View details for PubMedCentralID PMC7241415

• Personalized risk stratification through attribute matching for clinical decision making in clinical conditions with aspecific symptoms: The example of syncope. PloS one Solbiati, M., Quinn, J. V., Dipaola, F., Duca, P., Furlan, R., Montano, N., Reed, M. J., Sheldon, R. S., Sun, B. C., Ungar, A., Casazza, G., Costantino, G. 2020; 15 (3): e0228725

  Abstract

  Risk stratification is challenging in conditions, such as chest pain, shortness of breath and syncope, which can be the manifestation of many possible underlying diseases. In these cases, decision tools are unlikely to accurately identify all the different adverse events related to the possible etiologies. Attribute matching is a prediction method that matches an individual patient to a group of previously observed patients with identical characteristics and known outcome. We used syncope as a paradigm of clinical conditions presenting with aspecific symptoms to test the attribute matching method for the prediction of the personalized risk of adverse events.We selected the 8 predictor variables common to the individual-patient dataset of 5 prospective emergency department studies enrolling 3388 syncope patients. We calculated all possible combinations and the number of patients in each combination. We compared the predictive accuracy of attribute matching and logistic regression. We then classified ten random patients according to clinical judgment and attribute matching.Attribute matching provided 253 of the 384 possible combinations in the dataset. Twelve (4.7%), 35 (13.8%), 50 (19.8%) and 160 (63.2%) combinations had a match size ≥50, ≥30, ≥20 and <10 patients, respectively. The AUC for the attribute matching and the multivariate model were 0.59 and 0.74, respectively.Attribute matching is a promising tool for personalized and flexible risk prediction. Large databases will need to be used in future studies to test and apply the method in different conditions.

  View details for DOI 10.1371/journal.pone.0228725

  View details for PubMedID 32187195

  View details for PubMedCentralID PMC7080223

• Clinical diagnosis of benign paroxysmal positional vertigo and vestibular neuritis CANADIAN MEDICAL ASSOCIATION JOURNAL Johns, P., Quinn, J. 2020; 192 (8): E182–E186

  View details for DOI 10.1503/cmaj.190334

  View details for Web of Science ID 000519586200002

  View details for PubMedID 32094268

  View details for PubMedCentralID PMC7043823

• SARS-CoV-2 RNAaemia predicts clinical deterioration and extrapulmonary complications from COVID-19. medRxiv : the preprint server for health sciences Ram-Mohan, N. n., Kim, D. n., Zudock, E. J., Hashemi, M. M., Tjandra, K. C., Rogers, A. J., Blish, C. A., Nadeau, K. C., Newberry, J. A., Quinn, J. V., O'Hara, R. n., Ashley, E. n., Nguyen, H. n., Jiang, L. n., Hung, P. n., Blomkalns, A. L., Yang, S. n. 2020

  Abstract

  The determinants of COVID-19 disease severity and extrapulmonary complications (EPCs) are poorly understood. We characterise the relationships between SARS-CoV-2 RNAaemia and disease severity, clinical deterioration, and specific EPCs.We used quantitative (qPCR) and digital (dPCR) PCR to quantify SARS-CoV-2 RNA from nasopharyngeal swabs and plasma in 191 patients presenting to the Emergency Department (ED) with COVID-19. We recorded patient symptoms, laboratory markers, and clinical outcomes, with a focus on oxygen requirements over time. We collected longitudinal plasma samples from a subset of patients. We characterised the role of RNAaemia in predicting clinical severity and EPCs using elastic net regression.23·0% (44/191) of SARS-CoV-2 positive patients had viral RNA detected in plasma by dPCR, compared to 1·4% (2/147) by qPCR. Most patients with serial measurements had undetectable RNAaemia 10 days after onset of symptoms, but took 16 days to reach maximum severity, and 33 days for symptoms to resolve. Initially RNAaemic patients were more likely to manifest severe disease (OR 6·72 [95% CI, 2·45 - 19·79]), worsening of disease severity (OR 2·43 [95% CI, 1·07 - 5·38]), and EPCs (OR 2·81 [95% CI, 1·26 - 6·36]). RNA load correlated with maximum severity ( r = 0·47 [95% CI, 0·20 - 0·67]).dPCR is more sensitive than qPCR for the detection of SARS-CoV-2 RNAaemia, which is a robust predictor of eventual COVID-19 severity and oxygen requirements, as well as EPCs. Since many COVID-19 therapies are initiated on the basis of oxygen requirements, RNAaemia on presentation might serve to direct early initiation of appropriate therapies for the patients most likely to deteriorate.NIH/NIAID (Grants R01A153133, R01AI137272, and 3U19AI057229 - 17W1 COVID SUPP #2) and a donation from Eva Grove.Evidence before this study: The varied clinical manifestations of COVID-19 have directed attention to the distribution of SARS-CoV-2 in the body. Although most concentrated and tested for in the nasopharynx, SARS-CoV-2 RNA has been found in blood, stool, and numerous tissues, raising questions about dissemination of viral RNA throughout the body, and the role of this process in disease severity and extrapulmonary complications. Recent studies have detected low levels of SARS-CoV-2 RNA in blood using either quantitative reverse transcriptase real-time PCR (qPCR) or droplet digital PCR (dPCR), and have associated RNAaemia with disease severity and biomarkers of dysregulated immune response.Added value of this study: We quantified SARS-CoV-2 RNA in the nasopharynx and plasma of patients presenting to the Emergency Department with COVID-19, and found an array-based dPCR platform to be markedly more sensitive than qPCR for detection of SARS-CoV-2 RNA, with a simplified workflow well-suited to clinical adoption. We collected serial plasma samples during patients' course of illness, and showed that SARS-CoV-2 RNAaemia peaks early, while clinical condition often continues to worsen. Our findings confirm the association between RNAaemia and disease severity, and additionally demonstrate a role for RNAaemia in predicting future deterioration and specific extrapulmonary complications.Implications of all the available evidence: Variation in SARS-CoV-2 RNAaemia may help explain disparities in disease severity and extrapulmonary complications from COVID-19. Testing for RNAaemia with dPCR early in the course of illness may help guide patient triage and management.

  View details for DOI 10.1101/2020.12.19.20248561

  View details for PubMedID 33398290

  View details for PubMedCentralID PMC7781329

• Diagnostic yield of pulmonary embolism testing in patients presenting to the emergency department with syncope RESEARCH AND PRACTICE IN THROMBOSIS AND HAEMOSTASIS Kelly, C., Bledsoe, J. R., Woller, S. C., Stevens, S. M., Jacobs, J. R., Butler, A. M., Quinn, J. 2019

  View details for DOI 10.1002/rth2.12294

  View details for Web of Science ID 000504666900001

• Randomized Trial of Three Anticonvulsant Medications for Status Epilepticus. The New England journal of medicine Kapur, J., Elm, J., Chamberlain, J. M., Barsan, W., Cloyd, J., Lowenstein, D., Shinnar, S., Conwit, R., Meinzer, C., Cock, H., Fountain, N., Connor, J. T., Silbergleit, R. 2019; 381 (22): 2103-2113

  Abstract

  The choice of drugs for patients with status epilepticus that is refractory to treatment with benzodiazepines has not been thoroughly studied.In a randomized, blinded, adaptive trial, we compared the efficacy and safety of three intravenous anticonvulsive agents - levetiracetam, fosphenytoin, and valproate - in children and adults with convulsive status epilepticus that was unresponsive to treatment with benzodiazepines. The primary outcome was absence of clinically evident seizures and improvement in the level of consciousness by 60 minutes after the start of drug infusion, without additional anticonvulsant medication. The posterior probabilities that each drug was the most or least effective were calculated. Safety outcomes included life-threatening hypotension or cardiac arrhythmia, endotracheal intubation, seizure recurrence, and death.A total of 384 patients were enrolled and randomly assigned to receive levetiracetam (145 patients), fosphenytoin (118), or valproate (121). Reenrollment of patients with a second episode of status epilepticus accounted for 16 additional instances of randomization. In accordance with a prespecified stopping rule for futility of finding one drug to be superior or inferior, a planned interim analysis led to the trial being stopped. Of the enrolled patients, 10% were determined to have had psychogenic seizures. The primary outcome of cessation of status epilepticus and improvement in the level of consciousness at 60 minutes occurred in 68 patients assigned to levetiracetam (47%; 95% credible interval, 39 to 55), 53 patients assigned to fosphenytoin (45%; 95% credible interval, 36 to 54), and 56 patients assigned to valproate (46%; 95% credible interval, 38 to 55). The posterior probability that each drug was the most effective was 0.41, 0.24, and 0.35, respectively. Numerically more episodes of hypotension and intubation occurred in the fosphenytoin group and more deaths occurred in the levetiracetam group than in the other groups, but these differences were not significant.In the context of benzodiazepine-refractory convulsive status epilepticus, the anticonvulsant drugs levetiracetam, fosphenytoin, and valproate each led to seizure cessation and improved alertness by 60 minutes in approximately half the patients, and the three drugs were associated with similar incidences of adverse events. (Funded by the National Institute of Neurological Disorders and Stroke; ESETT ClinicalTrials.gov number, NCT01960075.).

  View details for DOI 10.1056/NEJMoa1905795

  View details for PubMedID 31774955

• Intensive vs Standard Treatment of Hyperglycemia and Functional Outcome in Patients With Acute Ischemic Stroke: The SHINE Randomized Clinical Trial. JAMA Johnston, K. C., Bruno, A., Pauls, Q., Hall, C. E., Barrett, K. M., Barsan, W., Fansler, A., Van de Bruinhorst, K., Janis, S., Durkalski-Mauldin, V. L. 2019; 322 (4): 326-335

  Abstract

  Hyperglycemia during acute ischemic stroke is common and is associated with worse outcomes. The efficacy of intensive treatment of hyperglycemia in this setting remains unknown.To determine the efficacy of intensive treatment of hyperglycemia during acute ischemic stroke.The Stroke Hyperglycemia Insulin Network Effort (SHINE) randomized clinical trial included adult patients with hyperglycemia (glucose concentration of >110 mg/dL if had diabetes or ≥150 mg/dL if did not have diabetes) and acute ischemic stroke who were enrolled within 12 hours from stroke onset at 63 US sites between April 2012 and August 2018; follow-up ended in November 2018. The trial included 1151 patients who met eligibility criteria.Patients were randomized to receive continuous intravenous insulin using a computerized decision support tool (target blood glucose concentration of 80-130 mg/dL [4.4-7.2 mmol/L]; intensive treatment group: n = 581) or insulin on a sliding scale that was administered subcutaneously (target blood glucose concentration of 80-179 mg/dL [4.4-9.9 mmol/L]; standard treatment group: n = 570) for up to 72 hours.The primary efficacy outcome was the proportion of patients with a favorable outcome based on the 90-day modified Rankin Scale score (a global stroke disability scale ranging from 0 [no symptoms or completely recovered] to 6 [death]) that was adjusted for baseline stroke severity.Among 1151 patients who were randomized (mean age, 66 years [SD, 13.1 years]; 529 [46%] women, 920 [80%] with diabetes), 1118 (97%) completed the trial. Enrollment was stopped for futility based on prespecified interim analysis criteria. During treatment, the mean blood glucose level was 118 mg/dL (6.6 mmol/L) in the intensive treatment group and 179 mg/dL (9.9 mmol/L) in the standard treatment group. A favorable outcome occurred in 119 of 581 patients (20.5%) in the intensive treatment group and in 123 of 570 patients (21.6%) in the standard treatment group (adjusted relative risk, 0.97 [95% CI, 0.87 to 1.08], P = .55; unadjusted risk difference, -0.83% [95% CI, -5.72% to 4.06%]). Treatment was stopped early for hypoglycemia or other adverse events in 65 of 581 patients (11.2%) in the intensive treatment group and in 18 of 570 patients (3.2%) in the standard treatment group. Severe hypoglycemia occurred only among patients in the intensive treatment group (15/581 [2.6%]; risk difference, 2.58% [95% CI, 1.29% to 3.87%]).Among patients with acute ischemic stroke and hyperglycemia, treatment with intensive vs standard glucose control for up to 72 hours did not result in a significant difference in favorable functional outcome at 90 days. These findings do not support using intensive glucose control in this setting.ClinicalTrials.gov Identifier: NCT01369069.

  View details for DOI 10.1001/jama.2019.9346

  View details for PubMedID 31334795

  View details for PubMedCentralID PMC6652154

• A Systematic Review of Noninvasive Electrocardiogram Monitoring Devices for the Evaluation of Suspected Cardiovascular Syncope JOURNAL OF MEDICAL DEVICES-TRANSACTIONS OF THE ASME Solbiati, M., Trombetta, L., Sacco, R. M., Erba, L., Bozzano, V., Costantino, G., Raj, S. R., Barbic, F., Casazza, G., Dipaola, F., Furlan, R., Kenny, R. A., Quinn, J. V., Sheldon, R. S., Shen, W., Sun, B. C., Thiruganasambandamoorthy, V., Reed, M. J. 2019; 13 (2)

  View details for DOI 10.1115/1.4042795

  View details for Web of Science ID 000467010600013

• FACTORS ASSOCIATED WITH INFLUENZA IN AN EMERGENCY DEPARTMENT SETTING JOURNAL OF EMERGENCY MEDICINE Pedersen, C. J., Quinn, J., Rogan, D. T., Yang, S. 2019; 56 (5): 478–83

  View details for DOI 10.1016/j.jemermed.2018.12.012

  View details for Web of Science ID 000466019400010

• Analytical and clinical validation of a microbial cell-free DNA sequencing test for infectious disease. Nature microbiology Blauwkamp, T. A., Thair, S., Rosen, M. J., Blair, L., Lindner, M. S., Vilfan, I. D., Kawli, T., Christians, F. C., Venkatasubrahmanyam, S., Wall, G. D., Cheung, A., Rogers, Z. N., Meshulam-Simon, G., Huijse, L., Balakrishnan, S., Quinn, J. V., Hollemon, D., Hong, D. K., Vaughn, M. L., Kertesz, M., Bercovici, S., Wilber, J. C., Yang, S. 2019

  Abstract

  Thousands of pathogens are known to infect humans, but only a fraction are readily identifiable using current diagnostic methods. Microbial cell-free DNA sequencing offers the potential to non-invasively identify a wide range of infections throughout the body, but the challenges of clinical-grade metagenomic testing must be addressed. Here we describe the analytical and clinical validation of a next-generation sequencing test that identifies and quantifies microbial cell-free DNA in plasma from 1,250 clinically relevant bacteria, DNA viruses, fungi and eukaryotic parasites. Test accuracy, precision, bias and robustness to a number of metagenomics-specific challenges were determined using a panel of 13 microorganisms that model key determinants of performance in 358 contrived plasma samples, as well as 2,625 infections simulated in silico and 580 clinical study samples. The test showed 93.7% agreement with blood culture in a cohort of 350 patients with a sepsis alert and identified an independently adjudicated cause of the sepsis alert more often than all of the microbiological testing combined (169 aetiological determinations versus 132). Among the 166 samples adjudicated to have no sepsis aetiology identified by any of the tested methods, sequencing identified microbial cell-free DNA in 62, likely derived from commensal organisms and incidental findings unrelated to the sepsis alert. Analysis of the first 2,000 patient samples tested in the CLIA laboratory showed that more than 85% of results were delivered the day after sample receipt, with 53.7% of reports identifying one or more microorganisms.

  View details for PubMedID 30742071

• Syncope in a Working-Age Population: Recurrence Risk and Related Risk Factors JOURNAL OF CLINICAL MEDICINE Barbic, F., Dipaola, F., Casazza, G., Borella, M., Minonzio, M., Solbiati, M., Raj, S. R., Sheldon, R., Quinn, J., Costantino, G., Furlan, R. 2019; 8 (2)

  View details for DOI 10.3390/jcm8020150

  View details for Web of Science ID 000460295400023

• Syncope in a Working-Age Population: Recurrence Risk and Related Risk Factors. Journal of clinical medicine Barbic, F., Dipaola, F., Casazza, G., Borella, M., Minonzio, M., Solbiati, M., Raj, S. R., Sheldon, R., Quinn, J., Costantino, G., Furlan, R. 2019; 8 (2)

  Abstract

  Syncope in a worker undertaking risky tasks may result in fatalities for the individual or for third parties. We aimed at assessing the rate of syncope recurrence and the risk factors underlying the likelihood of syncope relapse in a working-age population. A prospective cohort of all patients aged 18⁻65 years consecutively admitted to the Emergency Department for syncope was enrolled. Risk of syncope relapse was assessed at a six-month, 1-year, and 5-year follow-up. Predictors of syncope recurrence have been evaluated at six months and 1 year from the syncope index by a multivariable logistic regression analysis. 348 patients were enrolled. Risk of syncope relapse was 9.2% at 6 months, 11.8% at 1 year, and 23.4% at 5 years. At 6-month follow-up, predictor of syncope recurrence was ≥3 prior lifetime syncope episodes. At 1-year, ≥3 prior lifetime syncope episodes, diabetes mellitus, and anaemia were risk factors for syncope relapse. There was an exceeding risk of recurrence in the first 6 months and a reduced risk of 3.5% per year after the first year. Anaemia, diabetes mellitus, and prior lifetime syncope burden are of importance when giving advice about the resumption of "high risk" jobs following a syncope episode.

  View details for PubMedID 30699893

• Artificial neural networks and risk stratification in emergency departments. Internal and emergency medicine Falavigna, G., Costantino, G., Furlan, R., Quinn, J. V., Ungar, A., Ippoliti, R. 2018

  Abstract

  Emergency departments are characterized by the need for quick diagnosis under pressure. To select the most appropriate treatment, a series of rules to support decision-making has been offered by scientific societies. The effectiveness of these rules affects the appropriateness of treatment and the hospitalization of patients. Analyzing a sample of 1844 patients and focusing on the decision to hospitalize a patient after a syncope event to prevent severe short-term outcomes, this work proposes a new algorithm based on neural networks. Artificial neural networks are a non-parametric technique with the well-known ability to generalize behaviors, and they can thus predict severe short-term outcomes with pre-selected levels of sensitivity and specificity. This innovative technique can outperform the traditional models, since it does not require a specific functional form, i.e., the data are not supposed to be distributed following a specific design. Based on our results, the innovative model can predict hospitalization with a sensitivity of 100% and a specificity of 79%, significantly increasing the appropriateness of medical treatment and, as a result, hospital efficiency. According to Garson's Indexes, the most significant variables are exertion, the absence of symptoms, and the patient's gender. On the contrary, cardio-vascular history, hypertension, and age have the lowest impact on the determination of the subject's health status. The main application of this new technology is the adoption of smart solutions (e.g., a mobile app) to customize the stratification of patients admitted to emergency departments (ED)s after a syncope event. Indeed, the adoption of these smart solutions gives the opportunity to customize risk stratification according to the specific clinical case (i.e., the patient's health status) and the physician's decision-making process (i.e., the desired levels of sensitivity and specificity). Moreover, a decision-making process based on these smart solutions might ensure a more effective use of available resources, improving the management of syncope patients and reducing the cost of inappropriate treatment and hospitalization.

  View details for PubMedID 30353271

• Comparison of Electronic Clinical Decision Support for the Diagnosis of Suspected Pulmonary Embolism in Three Health Care Systems Bledsoe, J., Stevens, S. S., Woller, S. C., Brown, I. P., Madsen, T., Quinn, J., Johnson, S., Kelly, C., Elliott, C., Haug, P. MOSBY-ELSEVIER. 2018: S147–S148

  View details for DOI 10.1016/j.annemergmed.2018.08.380

  View details for Web of Science ID 000445690900369

• Using a novel rapid viral test to improve triage of emergency department patients with acute respiratory illness during flu season. Journal of clinical virology : the official publication of the Pan American Society for Clinical Virology Pedersen, C. J., Rogan, D. T., Yang, S., Quinn, J. V. 2018; 108: 72–76

  Abstract

  BACKGROUND: Acute respiratory illnesses (ARI) are mostly viral in etiology and cause significant morbidity and mortality. Point of care PCR (POC-PCR) is a promising new technology for rapid virus identification but utility in the Emergency Department (ED) is not yet defined.OBJECTIVES: Primarily, to investigate the value of POC-PCR in rapidly identifying RSV and influenza in the setting of ED triage. Additionally, to assess whether rapid knowledge of accurate test results would improve patient management by preventing nosocomial transmission and optimizing the prescription of antimicrobials for ARIs.STUDY DESIGN: A prospective cohort study of consecutive ED patients with ARI symptoms during peak flu season was conducted. Patient nasopharyngeal swabs were collected and tested using a POC-PCR device; physicians and patients were blinded to results. Virus positive and negative groups were compared by ED patient room placement and antimicrobial therapy ordered. Specificity and sensitivity were calculated using laboratory-PCR as the gold standard.RESULTS: Of 119 participants, 52.9% were POC-PCR positive - Influenza A (42.9%), RSV (41.3%), influenza B (15.9%). Nearly 70% of virus positive patients were placed rooms shared with non-ARI patients. Antibiotics were prescribed for 27.3% of virus positive patients, and 77.8% of oseltamivir-eligible patients did not receive therapy. POC-PCR was 100% sensitive (95% CI, 80.5-100.0%) and 95.2% specific (95% CI, 76.2-99.9%).CONCLUSIONS: Rapid POC-PCR for influenza and RSV in ED triage has excellent sensitivity and specificity and the potential to improve social distancing practices through better triage and increase appropriate prescription of antimicrobials.

  View details for PubMedID 30261422

• Pathology and laboratory medicine in low-income and middle-income countries 1: Access to pathology and laboratory medicine services: a crucial gap LANCET Wilson, M. L., Fleming, K. A., Kuti, M. A., Looi, L., Lago, N., Ru, K. 2018; 391 (10133): 1927–38

  Abstract

  As global efforts accelerate to implement the Sustainable Development Goals and, in particular, universal health coverage, access to high-quality and timely pathology and laboratory medicine (PALM) services will be needed to support health-care systems that are tasked with achieving these goals. This access will be most challenging to achieve in low-income and middle-income countries (LMICs), which have a disproportionately large share of the global burden of disease but a disproportionately low share of global health-care resources, particularly PALM services. In this first in a Series of three papers on PALM in LMICs, we describe the crucial and central roles of PALM services in the accurate diagnosis and detection of disease, informing prognosis and guiding treatment, contributing to disease screening, public health surveillance and disease registries, and supporting medical-legal systems. We also describe how, even though data are sparse, these services are of both insufficient scope and inadequate quality to play their key role in health-care systems in LMICs. Lastly, we identify four key barriers to the provision of optimal PALM services in resource-limited settings: insufficient human resources or workforce capacity, inadequate education and training, inadequate infrastructure, and insufficient quality, standards, and accreditation.

  View details for DOI 10.1016/S0140-6736(18)30458-6

  View details for Web of Science ID 000431861800028

  View details for PubMedID 29550029

• Prevalence of Pulmonary Embolism in Patients With Syncope. JAMA internal medicine Costantino, G. n., Ruwald, M. H., Quinn, J. n., Camargo, C. A., Dalgaard, F. n., Gislason, G. n., Goto, T. n., Hasegawa, K. n., Kaul, P. n., Montano, N. n., Numé, A. K., Russo, A. n., Sheldon, R. n., Solbiati, M. n., Sun, B. n., Casazza, G. n. 2018

  Abstract

  Sparse data and conflicting evidence exist on the prevalence of pulmonary embolism (PE) in patients with syncope.To estimate the prevalence of PE among patients presenting to the emergency department (ED) for evaluation of syncope.This retrospective, observational study analyzed longitudinal administrative data from 5 databases in 4 different countries (Canada, Denmark, Italy, and the United States). Data from all adult patients (aged ≥18 years) who presented to the ED were screened to identify those with syncope codes at discharge. Data were collected from January 1, 2000, through September 30, 2016.The prevalence of PE at ED and hospital discharge, identified using codes from the International Classification of Diseases, was considered the primary outcome. Two sensitivity analyses considering prevalence of PE at 90 days of follow-up and prevalence of venous thromboembolism were performed.A total of 1 671 944 unselected adults who presented to the ED for syncope were included. The prevalence of PE, according to administrative data, ranged from 0.06% (95% CI, 0.05%-0.06%) to 0.55% (95% CI, 0.50%-0.61%) for all patients and from 0.15% (95% CI, 0.14%-0.16%) to 2.10% (95% CI, 1.84%-2.39%) for hospitalized patients. The prevalence of PE at 90 days of follow-up ranged from 0.14% (95% CI, 0.13%-0.14%) to 0.83% (95% CI, 0.80%-0.86%) for all patients and from 0.35% (95% CI, 0.34%-0.37%) to 2.63% (95% CI, 2.34%-2.95%) for hospitalized patients. Finally, the prevalence of venous thromboembolism at 90 days ranged from 0.30% (95% CI, 0.29%-0.31%) to 1.37% (95% CI, 1.33%-1.41%) for all patients and from 0.75% (95% CI, 0.73%-0.78%) to 3.86% (95% CI, 3.51%-4.24%) for hospitalized patients.Pulmonary embolism was rarely identified in patients with syncope. Although PE should be considered in every patient, not all patients should undergo evaluation for PE.

  View details for PubMedID 29379959

• Clopidogrel and Aspirin in Acute Ischemic Stroke and High-Risk TIA. The New England journal of medicine Johnston, S. C., Easton, J. D., Farrant, M. n., Barsan, W. n., Conwit, R. A., Elm, J. J., Kim, A. S., Lindblad, A. S., Palesch, Y. Y. 2018

  Abstract

  Background Combination antiplatelet therapy with clopidogrel and aspirin may reduce the rate of recurrent stroke during the first 3 months after a minor ischemic stroke or transient ischemic attack (TIA). A trial of combination antiplatelet therapy in a Chinese population has shown a reduction in the risk of recurrent stroke. We tested this combination in an international population. Methods In a randomized trial, we assigned patients with minor ischemic stroke or high-risk TIA to receive either clopidogrel at a loading dose of 600 mg on day 1, followed by 75 mg per day, plus aspirin (at a dose of 50 to 325 mg per day) or the same range of doses of aspirin alone. The dose of aspirin in each group was selected by the site investigator. The primary efficacy outcome in a time-to-event analysis was the risk of a composite of major ischemic events, which was defined as ischemic stroke, myocardial infarction, or death from an ischemic vascular event, at 90 days. Results A total of 4881 patients were enrolled at 269 international sites. The trial was halted after 84% of the anticipated number of patients had been enrolled because the data and safety monitoring board had determined that the combination of clopidogrel and aspirin was associated with both a lower risk of major ischemic events and a higher risk of major hemorrhage than aspirin alone at 90 days. Major ischemic events occurred in 121 of 2432 patients (5.0%) receiving clopidogrel plus aspirin and in 160 of 2449 patients (6.5%) receiving aspirin plus placebo (hazard ratio, 0.75; 95% confidence interval [CI], 0.59 to 0.95; P=0.02), with most events occurring during the first week after the initial event. Major hemorrhage occurred in 23 patients (0.9%) receiving clopidogrel plus aspirin and in 10 patients (0.4%) receiving aspirin plus placebo (hazard ratio, 2.32; 95% CI, 1.10 to 4.87; P=0.02). Conclusions In patients with minor ischemic stroke or high-risk TIA, those who received a combination of clopidogrel and aspirin had a lower risk of major ischemic events but a higher risk of major hemorrhage at 90 days than those who received aspirin alone. (Funded by the National Institute of Neurological Disorders and Stroke; POINT ClinicalTrials.gov number, NCT00991029 .).

  View details for PubMedID 29766750

• The SEP-SEQ Trial - Clinical Validation of the Karius Plasma Next-Generation Sequencing Test for Pathogen Detection in Sepsis Thair, S., Aquino, R., Seng, H., Hollman, D., Hong, D., Blauwkamp, T. A., Kertesz, M., Ho, C., Mann, R., Quinn, J., Yang, S. AMER THORACIC SOC. 2018

  View details for Web of Science ID 000449978903017

• Outcomes in syncope research: a systematic review and critical appraisal. Internal and emergency medicine Solbiati, M. n., Bozzano, V. n., Barbic, F. n., Casazza, G. n., Dipaola, F. n., Quinn, J. V., Reed, M. J., Sheldon, R. S., Shen, W. K., Sun, B. C., Thiruganasambandamoorthy, V. n., Furlan, R. n., Costantino, G. n. 2018

  Abstract

  Syncope is the common clinical manifestation of different diseases, and this makes it difficult to define what outcomes should be considered in prognostic studies. The aim of this study is to critically analyze the outcomes considered in syncope studies through systematic review and expert consensus. We performed a systematic review of the literature to identify prospective studies enrolling consecutive patients presenting to the Emergency Department with syncope, with data on the characteristics and incidence of short-term outcomes. Then, the strengths and weaknesses of each outcome were discussed by international syncope experts to provide practical advice to improve future selection and assessment. 31 studies met our inclusion criteria. There is a high heterogeneity in both outcome choice and incidence between the included studies. The most commonly considered 7-day outcomes are mortality, dysrhythmias, myocardial infarction, stroke, and rehospitalisation. The most commonly considered 30-day outcomes are mortality, haemorrhage requiring blood transfusion, dysrhythmias, myocardial infarction, pacemaker or implantable defibrillator implantation, stroke, pulmonary embolism, and syncope relapse. We present a critical analysis of the pros and cons of the commonly considered outcomes, and provide possible solutions to improve their choice in ED syncope studies. We also support global initiatives to promote the standardization of patient management and data collection.

  View details for PubMedID 29349639

• Impact of Rapid Molecular Respiratory Virus Testing on Real-Time Decision Making in a Pediatric Emergency Department JOURNAL OF MOLECULAR DIAGNOSTICS Rogan, D. T., Kochar, M. S., Yang, S., Quinn, J. V. 2017; 19 (3): 460-467

  Abstract

  Acute respiratory illnesses (ARIs) are usually viral [influenza, respiratory syncytial virus (RSV)] and account for 25% of emergency department (ED) peak-season visits. Laboratory PCR testing is accurate albeit slow, whereas rapid antigen testing is inaccurate. We determined the impact of bedside PCR (molecular point-of-care test; mPOCT) on pediatric ARI management. This was a prospective cohort study of consecutive pediatric patients with ED-ordered respiratory PCR test, enrolled over 9 weeks during peak flu season. On ordering, ED physicians were interviewed to ascertain real-time plans if given immediate influenza/RSV PCR results for the current patient. Two groups were compared: actual management and management adjusted for mPOCT results. We compared ED length of stay (LOS), tests ordered, and antibiotic/antiviral ordering. One-hundred thirty-six respiratory PCR panels were ordered, 71 by admitting team, 61 for ED management. Of 61 ED-initiated tests, physicians indicated in 39 cases (64%) they would change patient management were bedside viral results available. Physicians would have decreased ED LOS by 33 minutes, ordered fewer tests (18%; P < 0.001) with average patient charge savings of $669, fewer antibiotics among discharged patients (17%; P = 0.043), and increased appropriate antiviral use (13%; P = 0.023). Rapid bedside ARI mPOCT PCR has the potential to decrease ED LOS, reduce diagnostic tests and patient charges, and increase appropriate use of antibiotics and antiviral agents.

  View details for DOI 10.1016/j.jmoldx.2017.01.009

  View details for Web of Science ID 000400314100011

  View details for PubMedID 28341587

  View details for PubMedCentralID PMC5417039

• PREDICTORS OF NONDIAGNOSTIC ULTRASOUND FOR APPENDICITIS JOURNAL OF EMERGENCY MEDICINE Keller, C., Wang, N. E., Imler, D. L., Vasanawala, S. S., Bruzoni, M., Quinn, J. V. 2017; 52 (3): 318-323

  Abstract

  Ionizing radiation and cost make ultrasound (US), when available, the first imaging study for the diagnosis of suspected pediatric appendicitis. US is less sensitive and specific than computed tomography (CT) or magnetic resonance imaging (MRI) scans, which are often performed after nondiagnostic US.We sought to determine predictors of nondiagnostic US in order to guide efficient ordering of imaging studies.A prospective cohort study of consecutive patients 4 to 30 years of age with suspected appendicitis took place at an emergency department with access to 24/7 US, MRI, and CT capabilities. Patients with US as their initial study were identified. Clinical (i.e., duration of illness, highest fever, and right lower quadrant pain) and demographic (i.e., age and sex) variables were collected. Body mass index (BMI) was calculated based on Centers for Disease Control and Prevention criteria; BMI >85th percentile was categorized as overweight. Patients were followed until day 7. Univariate and stepwise multivariate logistic regression analysis was performed.Over 3 months, 106 patients had US first for suspected appendicitis; 52 (49%) had nondiagnostic US results. Eighteen patients had appendicitis, and there were no missed cases after discharge. On univariate analysis, male sex, a yearly increase in age, and overweight BMI were associated with nondiagnostic US (p < 0.05). In the multivariate model, only BMI (odds ratio 4.9 [95% CI 2.0-12.2]) and age (odds ratio 1.1 [95% CI 1.02-1.20]) were predictors. Sixty-eight percent of nondiagnostic US results occurred in overweight patients.Overweight and older patients are more likely to have a nondiagnostic US or appendicitis, and it may be more efficient to consider alternatives to US first for these patients. Also, this information about the accuracy of US to diagnose suspected appendicitis may be useful to clinicians who wish to engage in shared decision-making with the parents or guardians of children regarding imaging options for children with acute abdominal pain.

  View details for DOI 10.1016/j.jemermed.2016.07.101

  View details for Web of Science ID 000397089400023

• MRI vs. Ultrasound as the initial imaging modality for pediatric and young adult patients with suspected appendicitis. Academic emergency medicine Imler, D., Keller, C., Sivasankar, S., Wang, N. E., Vasanawala, S., Bruzoni, M., Quinn, J. 2017

  Abstract

  While ultrasound (US), given its lack of ionizing radiation is currently the recommended initial imaging study of choice for the diagnosis of appendicitis in pediatric and young adult patients, it does have significant shortcomings. US is time intensive, operator dependent, and results in frequent inconclusive studies, thus necessitating further imaging, and admission for observation or repeat clinical visits. A rapid focused Magnetic Resonance Imaging (MRI) for appendicitis has been shown to have definitive sensitivity and specificity, similar to Computed tomography (CT) but without radiation and offers a potential alternative to US.In this single-center prospective cohort study, we sought to determine the difference in total length of stay and charges between rapid MRI and US as the initial imaging modality in pediatric and young adult patients presenting to the Emergency Department (ED) with suspected appendicitis. We hypothesized that rapid MRI would be more efficient and cost effective than US as the initial imaging modality in the ED diagnosis of appendicitis.A prospective randomized cohort study of consecutive patients was conducted in patients 2-30 years of age in an academic ED with access to both rapid MRI and US imaging modalities 24/7. Prior to the start of the study, the days of the week were randomized to either rapid MRI or US as the initial imaging modality. Physicians evaluated patients with suspected appendicitis per their usual manner. If the physician decided to obtain radiologic imaging, the pre-determined imaging modality for the day of the week was used. All decisions regarding other diagnostic testing and/or further imaging were left to the physician's discretion. Time intervals (min) between triage, order placement, start of imaging, end of imaging, image result and disposition (discharge vs. admission), as well as total charges (diagnostic testing, imaging and repeat ED visits) were recorded.Over a 100-day period, 82 patients were imaged to evaluate for appendicitis; 45/82 (55%) of patients were in the US first group; and 37/82 (45%) patients were in the rapid MRI first group. There were no differences in patient demographics or clinical characteristics between the groups and no cases of missed appendicitis in either group. 11/45 (24%) of US first patients had inconclusive studies, resulting in follow-up rapid MRI and 5 return ED visits contrasted with no inconclusive studies or return visits (p< 0.05) in the rapid MRI group. The rapid MRI compared to US group was associated with longer ED length of stay (mean difference 100 min; 95% CI 35-169) and increased ED charges (mean difference $4,887; 95% CI $1,821 - $8,513).In the diagnosis of appendicitis, US first imaging is more time efficient and less costly than rapid MRI despite inconclusive studies after US imaging. Unless the process of obtaining a rapid MRI becomes more efficient and less expensive, US should be the first line imaging modality for appendicitis in patients 2-30 years of age. This article is protected by copyright. All rights reserved.

  View details for DOI 10.1111/acem.13180

  View details for PubMedID 28207968

• Research in the Emergency Care Environment CLINICAL AND TRANSLATIONAL SCIENCE: PRINCIPLES OF HUMAN RESEARCH, 2ND EDITION Quinn, J., Pallin, D. J., Robertson, D., Williams, G. H. 2017: 501–13

  View details for DOI 10.1016/B978-0-12-802101-9.00027-2

  View details for Web of Science ID 000440395900027

• Neural networks as a tool to predict syncope risk in the Emergency Department. Europace Costantino, G., Falavigna, G., Solbiati, M., Casagranda, I., Sun, B. C., Grossman, S. A., Quinn, J. V., Reed, M. J., Ungar, A., Montano, N., Furlan, R., Ippoliti, R. 2016

  Abstract

  There is no universally accepted tool for the risk stratification of syncope patients in the Emergency Department. The aim of this study was to investigate the short-term predictive accuracy of an artificial neural network (ANN) in stratifying the risk in this patient group.We analysed individual level data from three prospective studies, with a cumulative sample size of 1844 subjects. Each dataset was reanalysed to reduce the heterogeneity among studies defining abnormal electrocardiogram (ECG) and serious outcomes according to a previous consensus. Ten variables from patient history, ECG, and the circumstances of syncope were used to train and test the neural network. Given the exploratory nature of this work, we adopted two approaches to train and validate the tool. One approach used 4/5 of the data for the training set and 1/5 for the validation set, and the other approach used 9/10 for the training set and 1/10 for the validation set. The sensitivity, specificity, and area under the receiver operating characteristic curve of ANNs in identifying short-term adverse events after syncope were 95% [95% confidence interval (CI) 80-98%], 67% (95% CI 62-72%), 0.69 with the 1/5 approach and 100% (95% CI 84-100%), 79% (95% CI 72-85%), 0.78 with the 1/10 approach.The results of our study suggest that ANNs are effective in predicting the short-term risk of patients with syncope. Prospective studies are needed in order to compare ANNs' predictive capability with existing rules and clinical judgment.

  View details for DOI 10.1093/europace/euw336

  View details for PubMedID 28017935

• One-two-triage: validation and reliability of a novel triage system for low-resource settings. Emergency medicine journal Khan, A., Mahadevan, S. V., Dreyfuss, A., Quinn, J., Woods, J., Somontha, K., Strehlow, M. 2016; 33 (10): 709-715

  Abstract

  To validate and assess reliability of a novel triage system, one-two-triage (OTT), that can be applied by inexperienced providers in low-resource settings.This study was a two-phase prospective, comparative study conducted at three hospitals. Phase I assessed criterion validity of OTT on all patients arriving at an American university hospital by comparing agreement among three methods of triage: OTT, Emergency Severity Index (ESI) and physician-defined acuity (the gold standard). Agreement was reported in normalised and raw-weighted Cohen κ using two different scales for weighting, Expert-weighted and triage-weighted κ. Phase II tested reliability, reported in Fleiss κ, of OTT using standardised cases among three groups of providers at an urban and rural Cambodian hospital and the American university hospital.Normalised for prevalence of patients in each category, OTT and ESI performed similarly well for expert-weighted κ (OTT κ=0.58, 95% CI 0.52 to 0.65; ESI κ=0.47, 95% CI 0.40 to 0.53) and triage-weighted κ (κ=0.54, 95% CI 0.48 to 0.61; ESI κ=0.57, 95% CI 0.51 to 0.64). Without normalising, agreement with gold standard was less for both systems but performance of OTT and ESI remained similar, expert-weighted (OTT κ=0.57, 95% CI 0.52 to 0.62; ESI κ=0.6, 95% CI 0.58 to 0.66) and triage-weighted (OTT κ=0.31, 95% CI 0.25 to 0.38; ESI κ=0.41, 95% CI 0.35 to 0.4). In the reliability phase, all triagers showed fair inter-rater agreement, Fleiss κ (κ=0.308).OTT can be reliably applied and performs as well as ESI compared with gold standard, but requires fewer resources and less experience.

  View details for DOI 10.1136/emermed-2015-205430

  View details for PubMedID 27466347

• Predictors of Nondiagnostic Ultrasound for Appendicitis. journal of emergency medicine Keller, C., Wang, N. E., Imler, D. L., Vasanawala, S. S., Bruzoni, M., Quinn, J. V. 2016

  Abstract

  Ionizing radiation and cost make ultrasound (US), when available, the first imaging study for the diagnosis of suspected pediatric appendicitis. US is less sensitive and specific than computed tomography (CT) or magnetic resonance imaging (MRI) scans, which are often performed after nondiagnostic US.We sought to determine predictors of nondiagnostic US in order to guide efficient ordering of imaging studies.A prospective cohort study of consecutive patients 4 to 30 years of age with suspected appendicitis took place at an emergency department with access to 24/7 US, MRI, and CT capabilities. Patients with US as their initial study were identified. Clinical (i.e., duration of illness, highest fever, and right lower quadrant pain) and demographic (i.e., age and sex) variables were collected. Body mass index (BMI) was calculated based on Centers for Disease Control and Prevention criteria; BMI >85th percentile was categorized as overweight. Patients were followed until day 7. Univariate and stepwise multivariate logistic regression analysis was performed.Over 3 months, 106 patients had US first for suspected appendicitis; 52 (49%) had nondiagnostic US results. Eighteen patients had appendicitis, and there were no missed cases after discharge. On univariate analysis, male sex, a yearly increase in age, and overweight BMI were associated with nondiagnostic US (p < 0.05). In the multivariate model, only BMI (odds ratio 4.9 [95% CI 2.0-12.2]) and age (odds ratio 1.1 [95% CI 1.02-1.20]) were predictors. Sixty-eight percent of nondiagnostic US results occurred in overweight patients.Overweight and older patients are more likely to have a nondiagnostic US or appendicitis, and it may be more efficient to consider alternatives to US first for these patients. Also, this information about the accuracy of US to diagnose suspected appendicitis may be useful to clinicians who wish to engage in shared decision-making with the parents or guardians of children regarding imaging options for children with acute abdominal pain.

  View details for DOI 10.1016/j.jemermed.2016.07.101

  View details for PubMedID 27692650

• Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. The New England journal of medicine Qureshi, A. I., Palesch, Y. Y., Barsan, W. G., Hanley, D. F., Hsu, C. Y., Martin, R. L., Moy, C. S., Silbergleit, R., Steiner, T., Suarez, J. I., Toyoda, K., Wang, Y., Yamamoto, H., Yoon, B. W. 2016

  Abstract

  Background Limited data are available to guide the choice of a target for the systolic blood-pressure level when treating acute hypertensive response in patients with intracerebral hemorrhage. Methods We randomly assigned eligible participants with intracerebral hemorrhage (volume, <60 cm(3)) and a Glasgow Coma Scale (GCS) score of 5 or more (on a scale from 3 to 15, with lower scores indicating worse condition) to a systolic blood-pressure target of 110 to 139 mm Hg (intensive treatment) or a target of 140 to 179 mm Hg (standard treatment) in order to test the superiority of intensive reduction of systolic blood pressure to standard reduction; intravenous nicardipine to lower blood pressure was administered within 4.5 hours after symptom onset. The primary outcome was death or disability (modified Rankin scale score of 4 to 6, on a scale ranging from 0 [no symptoms] to 6 [death]) at 3 months after randomization, as ascertained by an investigator who was unaware of the treatment assignments. Results Among 1000 participants with a mean (±SD) systolic blood pressure of 200.6±27.0 mm Hg at baseline, 500 were assigned to intensive treatment and 500 to standard treatment. The mean age of the patients was 61.9 years, and 56.2% were Asian. Enrollment was stopped because of futility after a prespecified interim analysis. The primary outcome of death or disability was observed in 38.7% of the participants (186 of 481) in the intensive-treatment group and in 37.7% (181 of 480) in the standard-treatment group (relative risk, 1.04; 95% confidence interval, 0.85 to 1.27; analysis was adjusted for age, initial GCS score, and presence or absence of intraventricular hemorrhage). Serious adverse events occurring within 72 hours after randomization that were considered by the site investigator to be related to treatment were reported in 1.6% of the patients in the intensive-treatment group and in 1.2% of those in the standard-treatment group. The rate of renal adverse events within 7 days after randomization was significantly higher in the intensive-treatment group than in the standard-treatment group (9.0% vs. 4.0%, P=0.002). Conclusions The treatment of participants with intracerebral hemorrhage to achieve a target systolic blood pressure of 110 to 139 mm Hg did not result in a lower rate of death or disability than standard reduction to a target of 140 to 179 mm Hg. (Funded by the National Institute of Neurological Disorders and Stroke and the National Cerebral and Cardiovascular Center; ATACH-2 ClinicalTrials.gov number, NCT01176565 .).

  View details for DOI 10.1056/NEJMoa1603460

  View details for PubMedID 27276234

• Syncope clinical management in the emergency department: a consensus from the first international workshop on syncope risk stratification in the emergency department EUROPEAN HEART JOURNAL Costantino, G., Sun, B. C., Barbic, F., Bossi, I., Casazza, G., Dipaola, F., McDermott, D., Quinn, J., Reed, M. J., Sheldon, R. S., Solbiati, M., Thiruganasambandamoorthy, V., Beach, D., Bodemer, N., Brignole, M., Casagranda, I., Del Rosso, A., Duca, P., Falavigna, G., Grossman, S. A., Ippoliti, R., Krahn, A. D., Montano, N., Morillo, C. A., Olshansky, B., Raj, S. R., Ruwald, M. H., Sarasin, F. P., Shen, W., Stiell, I., Ungar, A., van Dijk, J. G., Van Dijk, N., Wieling, W., Furlan, R. 2016; 37 (19): 1493-1498

  View details for DOI 10.1093/eurheartj/ehv378

  View details for PubMedID 26242712

• Emergency Medicine Resources within the Clinical Translational Science Institutes: A Cross-Sectional Study. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine Meurer, W. J., Quinn, J., Lindsell, C., Schneider, S., Newgard, C. D. 2016

  Abstract

  The Clinical and Translational Science Award (CTSA) program aims to strengthen and support translational research by accelerating the process of translating laboratory discoveries into treatments for patients, training a new generation of clinical and translational researchers, and engaging communities in clinical research efforts. Yet, little is known about how emergency care researchers have interacted with and utilized the resources of academic institutions with CTSAs.The purpose of this survey was to describe how emergency care researchers use local CTSA resources, to ascertain what proportion of CTSA consortium members have active emergency care research programs, and to solicit participation in a national CTSA-associated emergency care translational research network.Survey of all emergency departments affiliated with a CTSA.Of the 65 CTSA consortium members, three had no emergency care research program and we obtained responses from 46 of the remaining 62 (74% response rate). The interactions with and resources used by emergency care researchers varied widely. Methodology and biostatistics support was most frequently accessed (77%), followed closely by education and training programs (60%). Several emergency care research programs (76%) had submitted for funding through CTSAs, with 71% receiving awards. Most CTSA consortium members had an active emergency care research infrastructure: 21 (46%) had 24/7 availability to recruit and screen for research, 21 (46%) had less than 24/7 research recruitment. A number of emergency care research programs participated in NIH research networks with the Neurological Emergencies Treatment Trials network most highly represented with 23 (59%) sites. Most emergency care research programs (96%) were interested in participating in a CTSA-based emergency care translational research network.Despite little initial involvement in development of the CTSA program, there has been moderate interaction between CTSAs and emergency care. There is considerable interest in participating in a CTSA consortium based emergency care translational research network. This article is protected by copyright. All rights reserved.

  View details for DOI 10.1111/acem.12926

  View details for PubMedID 26826059

• Predictors of infection from dog bite wounds: which patients may benefit from prophylactic antibiotics? Emergency medicine journal Tabaka, M. E., Quinn, J. V., Kohn, M. A., Polevoi, S. K. 2015; 32 (11): 860-863

  Abstract

  To determine a current infection rate of dog bite wounds and predictors of wounds at risk for infection that may benefit from prophylactic antibiotics.A prospective multicentre observational study was conducted over 4.5 years. At the time of treatment Emergency Physicians completed a structured data form evaluating patient, wound and treatment characteristics of patients with dog bite wounds. Patients were followed up at 30 days to assess for infection. Predictor variables were analysed with univariate analysis, using either χ(2), parametric or nonparametric methods where appropriate. Significant variables and those with important interactions on univariate analysis were considered in a logistic regression (LR) analysis.495 patients with dog bites were enrolled and 345 had complete follow-up. Eighteen patients (5.2%, 95% CI 3.1% to 8.1%) had bites that became infected. On univariate analysis, only puncture wounds were found to be significantly associated with infection RR 2.8 (95% CI 1.2 to 6.9). However, location and wound closure met criteria for entry into the model having important interactions; facial wounds had a higher risk of infection than anticipated but were also more likely to be closed (p < 0.0001). A LR model considering puncture wounds, wound closure and wound location found that puncture wounds (OR 4.1 [95% CI 1.4 to 11.7]) and wound closure (OR 3.1 [95% CI 1.03 to 9.0]) were independent predictors of infection. The incidence of infection in wounds that were not punctured or closed during treatment was only 2.6% (95% CI 0.7% to 6.5%).Puncture wounds or wounds closed during treatment are dog bite wounds at a high risk of infection and should be considered for treatment with prophylactic antibiotics.

  View details for DOI 10.1136/emermed-2014-204378

  View details for PubMedID 25634096

• Syncope and presyncope: same mechanism, causes, and concern. Annals of emergency medicine Quinn, J. V. 2015; 65 (3): 277-278

  View details for DOI 10.1016/j.annemergmed.2014.09.001

  View details for PubMedID 25441246

• Syncope: a review of emergency department management and disposition. Clinical and experimental emergency medicine Patel, P. R., Quinn, J. V. 2015; 2 (2): 67–74

  Abstract

  Syncope is defined as a transient loss of consciousness due to cerebral hypoperfusion with spontaneous return to baseline function without intervention. It is a common chief complaint of patients presenting to the emergency department. The differential diagnosis for syncope is broad and the management varies significantly depending on the underlying etiology. In the emergency department, determining the cause of a syncopal episode can be difficult. However, a thorough history and certain physical exam findings can assist in evaluating for life-threatening diagnoses. Risk-stratifying patients into low, moderate and high-risk groups can assist in medical decision making and help determine the patient's disposition. Advancements in ambulatory monitoring have made it possible to obtain prolonged cardiac evaluations of patients in the outpatient setting. This review will focus on the diagnosis and management of the various types of syncope.

  View details for PubMedID 27752576

  View details for PubMedCentralID PMC5052859

• Very Early Administration of Progesterone for Acute Traumatic Brain Injury NEW ENGLAND JOURNAL OF MEDICINE Wright, D. W., Yeatts, S. D., Silbergleit, R., Palesch, Y. Y., Hertzberg, V. S., Frankel, M., Goldstein, F. C., Caveney, A. F., Howlett-Smith, H., Bengelink, E. M., Manley, G. T., Merck, L. H., Janis, L. S., Barsan, W. G. 2014; 371 (26): 2457-2466

  Abstract

  Traumatic brain injury (TBI) is a major cause of death and disability worldwide. Progesterone has been shown to improve neurologic outcome in multiple experimental models and two early-phase trials involving patients with TBI.We conducted a double-blind, multicenter clinical trial in which patients with severe, moderate-to-severe, or moderate acute TBI (Glasgow Coma Scale score of 4 to 12, on a scale from 3 to 15, with lower scores indicating a lower level of consciousness) were randomly assigned to intravenous progesterone or placebo, with the study treatment initiated within 4 hours after injury and administered for a total of 96 hours. Efficacy was defined as an increase of 10 percentage points in the proportion of patients with a favorable outcome, as determined with the use of the stratified dichotomy of the Extended Glasgow Outcome Scale score at 6 months after injury. Secondary outcomes included mortality and the Disability Rating Scale score.A total of 882 of the planned sample of 1140 patients underwent randomization before the trial was stopped for futility with respect to the primary outcome. The study groups were similar with regard to baseline characteristics; the median age of the patients was 35 years, 73.7% were men, 15.2% were black, and the mean Injury Severity Score was 24.4 (on a scale from 0 to 75, with higher scores indicating greater severity). The most frequent mechanism of injury was a motor vehicle accident. There was no significant difference between the progesterone group and the placebo group in the proportion of patients with a favorable outcome (relative benefit of progesterone, 0.95; 95% confidence interval [CI], 0.85 to 1.06; P=0.35). Phlebitis or thrombophlebitis was more frequent in the progesterone group than in the placebo group (relative risk, 3.03; CI, 1.96 to 4.66). There were no significant differences in the other prespecified safety outcomes.This clinical trial did not show a benefit of progesterone over placebo in the improvement of outcomes in patients with acute TBI. (Funded by the National Institute of Neurological Disorders and Stroke and others; PROTECT III ClinicalTrials.gov number, NCT00822900.).

  View details for DOI 10.1056/NEJMoa1404304

  View details for Web of Science ID 000346920300005

  View details for PubMedID 25493974

• Priorities for Emergency Department Syncope Research ANNALS OF EMERGENCY MEDICINE Sun, B. C., Costantino, G., Barbic, F., Bossi, I., Casazza, G., Dipaola, F., McDermott, D., Quinn, J., Reed, M., Sheldon, R. S., Solbiati, M., Thiruganasambandamoorthy, V., Krahn, A. D., Beach, D., Bodemer, N., Brignole, M., Casagranda, I., Duca, P., Falavigna, G., Ippoliti, R., Montano, N., Olshansky, B., Raj, S. R., Ruwald, M. H., Shen, W., Stiell, I., Ungar, A., van Dijk, J. G., Van Dijk, N., Wieling, W., Furlan, R. 2014; 64 (6): 649-655

  Abstract

  There is limited evidence to guide the emergency department (ED) evaluation and management of syncope. The First International Workshop on Syncope Risk Stratification in the Emergency Department identified key research questions and methodological standards essential to advancing the science of ED-based syncope research.We recruited a multinational panel of syncope experts. A preconference survey identified research priorities, which were refined during and after the conference through an iterative review process.There were 31 participants from 7 countries who represented 10 clinical and methodological specialties. High-priority research recommendations were organized around a conceptual model of ED decisionmaking for syncope, and they address definition, cohort selection, risk stratification, and management.We convened a multispecialty group of syncope experts to identify the most pressing knowledge gaps and defined a high-priority research agenda to improve the care of patients with syncope in the ED.

  View details for DOI 10.1016/j.annemergmed.2014.04.014

  View details for PubMedID 24882667

• Syncope Risk Stratification Tools vs Clinical Judgment: An Individual Patient Data Meta-analysis AMERICAN JOURNAL OF MEDICINE Costantino, G., Casazza, G., Reed, M., Bossi, I., Sun, B., Del Rosso, A., Ungar, A., Grossman, S., D'Ascenzo, F., Quinn, J., McDermott, D., Sheldon, R., Furlan, R. 2014; 127 (11)

  Abstract

  There have been several attempts to derive syncope prediction tools to guide clinician decision-making. However, they have not been largely adopted, possibly because of their lack of sensitivity and specificity. We sought to externally validate the existing tools and to compare them with clinical judgment, using an individual patient data meta-analysis approach.Electronic databases, bibliographies, and experts in the field were screened to find all prospective studies enrolling consecutive subjects presenting with syncope to the emergency department. Prediction tools and clinical judgment were applied to all patients in each dataset. Serious outcomes and death were considered separately during emergency department stay and at 10 and 30 days after presenting syncope. Pooled sensitivities, specificities, likelihood ratios, and diagnostic odds ratios, with 95% confidence intervals, were calculated.Thirteen potentially relevant papers were retrieved (11 authors). Six authors agreed to share individual patient data. In total, 3681 patients were included. Three prediction tools (Osservatorio Epidemiologico sulla Sincope del Lazio [OESIL], San Francisco Syncope Rule [SFSR], Evaluation of Guidelines in Syncope Study [EGSYS]) could be assessed by the available datasets. None of the evaluated prediction tools performed better than clinical judgment in identifying serious outcomes during emergency department stay, and at 10 and 30 days after syncope.Despite the use of an individual patient data approach to reduce heterogeneity among studies, a large variability was still present. Current prediction tools did not show better sensitivity, specificity, or prognostic yield compared with clinical judgment in predicting short-term serious outcome after syncope. Our systematic review strengthens the evidence that current prediction tools should not be strictly used in clinical practice.

  View details for DOI 10.1016/j.amjmed.2014.05.022

  View details for PubMedID 24862309

• DEGRADATION OF BENZODIAZEPINES AFTER 120 DAYS OF EMS DEPLOYMENT PREHOSPITAL EMERGENCY CARE McMullan, J. T., Jones, E., Barnhart, B., Denninghoff, K., Spaite, D., Zaleski, E., Silbergleit, R., Neurological Emergencies Treatment 2014; 18 (3): 368-374

  Abstract

  EMS treatment of status epilepticus improves outcomes, but the benzodiazepine best suited for EMS use is unclear, given potential high environmental temperature exposures.To describe the degradation of diazepam, lorazepam, and midazolam as a function of temperature exposure and time over 120 days of storage on active EMS units.Study boxes containing vials of diazepam, lorazepam, and midazolam were distributed to 4 active EMS units in each of 2 EMS systems in the southwestern United States during May-August 2011. The boxes logged temperature every minute and were stored in EMS units per local agency policy. Two vials of each drug were removed from each box at 30-day intervals and underwent high-performance liquid chromatography to determine drug concentration. Concentration was analyzed as mean (and 95%CI) percent of initial labeled concentration as a function of time and mean kinetic temperature (MKT).192 samples were collected (2 samples of each drug from each of 4 units per city at 4 time-points). After 120 days, the mean relative concentration (95%CI) of diazepam was 97.0% (95.7-98.2%) and of midazolam was 99.0% (97.7-100.2%). Lorazepam experienced modest degradation by 60 days (95.6% [91.6-99.5%]) and substantial degradation at 90 days (90.3% [85.2-95.4%]) and 120 days (86.5% [80.7-92.3%]). Mean MKT was 31.6°C (95%CI 27.1-36.1). Increasing MKT was associated with greater degradation of lorazepam, but not midazolam or diazepam.Midazolam and diazepam experienced minimal degradation throughout 120 days of EMS deployment in high-heat environments. Lorazepam experienced significant degradation over 120 days and appeared especially sensitive to higher MKT exposure.

  View details for DOI 10.3109/10903127.2013.869642

  View details for Web of Science ID 000337903300007

  View details for PubMedID 24548058

  View details for PubMedCentralID PMC4272820

• Traumatic lacerations: what are the risks for infection and has the 'golden period' of laceration care disappeared? Emergency medicine journal Quinn, J. V., Polevoi, S. K., Kohn, M. A. 2014; 31 (2): 96-100

  Abstract

  OBJECTIVE: To determine risk factors associated with infection and traumatic lacerations and to see if a relationship exists between infection and time to wound closure after injury. METHODS: Consecutive patients presenting with traumatic lacerations at three diverse emergency departments were prospectively enrolled and 27 variables were collected at the time of treatment. Patients were followed for 30 days to determine the development of a wound infection and desire for scar revision. RESULTS: 2663 patients completed follow-up and 69 (2.6%, 95% CI 2.0% to 3.3%) developed infection. Infected wounds were more likely to receive a worse cosmetic rating and more likely to be considered for scar revision (RR 2.6, 95% CI 1.7 to 3.9). People with diabetes (RR 2.70, 95% CI 1.1 to 6.5), lower extremity lacerations (RR 4.1, 95% CI 2.5 to 6.8), contaminated lacerations (RR 2.0, 95% CI 1.2  to 3.4) and lacerations greater than 5 cm (RR 2.9, 95% CI 1.6 to 5.2) were more likely to develop an infection. There were no differences in the infection rates for lacerations closed before 3% (95% CI 2.3% to 3.8%) or after 1.2% (95% CI 0.03% to 6.4%) 12 h. CONCLUSIONS: Diabetes, wound contamination, length greater than 5 cm and location on the lower extremity are important risk factors for wound infection. Time from injury to wound closure is not as important as previously thought. Improvements in irrigation and decontamination over the past 30 years may have led to this change in outcome.

  View details for DOI 10.1136/emermed-2012-202143

  View details for PubMedID 23314208

• Usefulness of N-Terminal Pro-B-Type Natriuretic Peptide Increase as a Marker for Cardiac Arrhythmia in Patients With Syncope AMERICAN JOURNAL OF CARDIOLOGY Costantino, G., Solbiati, M., Casazza, G., Bonzi, M., Vago, T., Montano, N., McDermott, D., Quinn, J., Furlan, R. 2014; 113 (1): 98-102

  Abstract

  B-type natriuretic peptides (BNPs) have been investigated as biomarkers for risk stratification of patients with syncope. Their concentration can be influenced by age and co-morbidities. In the present study, we compared the change in N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels within 6 hours in patients with vasovagal and arrhythmic syncope to determine whether this change can predict arrhythmic syncope. Using a case-control design, 33 patients were enrolled. Of the 33 patients, 18 with arrhythmic syncope, as they underwent controlled ventricular tachycardia or ventricular fibrillation (VF) during device safety testing of an implantable cardioverter defibrillator implantation or battery replacement, were compared with 15 patients, who during a tilt-table test were diagnosed with vasovagal syncope (VS). For each patient, a blood sample for NT-proBNP evaluation was collected at baseline and 6 hours after the episode of ventricular tachycardia, VF, or VS. We calculated the percentage of increase in the 6-hour NT-proBNP concentration between the 2 groups using nonparametric techniques. We also calculated the area under a receiver operating characteristic curve with the 95% confidence intervals. The 6-hour change in the NT-proBNP concentrations between patients who had had an episode of ventricular tachycardia or VF and patients with VS was significantly different, with a median increase of 32% in the ventricular tachycardia or VF group versus 5% in the VS group (p <0.01). The area under a receiver operating characteristic curve to predict arrhythmic syncope was 0.8 (95% confidence interval 0.65 to 0.95). In conclusion, the results of the present study suggest that a 6-hour NT-proBNP increase might be able to predict arrhythmic syncope. Future work is needed to confirm these findings in undifferentiated emergency department patients who present with syncope.

  View details for DOI 10.1016/j.amjcard.2013.08.044

  View details for Web of Science ID 000329333800017

  View details for PubMedID 24169011

• Water is a safe and effective alternative to sterile normal saline for wound irrigation prior to suturing: a prospective, double-blind, randomised, controlled clinical trial. BMJ open Weiss, E. A., Oldham, G., Lin, M., Foster, T., Quinn, J. V. 2013; 3 (1)

  Abstract

  To determine if there is a significant difference in the infection rates of wounds irrigated with sterile normal saline (SS) versus tap water (TW), before primary wound closure.Single centre, prospective, randomised, double-blind controlled trial. Wound irrigation solution type was computer randomised and allocation was done on a sequential basis.Stanford University Medical Center Department of Emergency Medicine.Patients older than 1 year of age, who presented to the emergency department with a soft tissue laceration requiring repair, were entered into the study under informed consent. Exclusion criteria included any underlying immunocompromising illness, current use of antibiotics, puncture or bite wounds, underlying tendon or bone involvement, or wounds more than 9 h old.Non-caregivers used a computer generated randomisation code to prepare irrigation basins prior to treatment. Patients had their wounds irrigated either with TW or SS prior to closure, controlling for the volume and irrigation method used. The patient, the treating physician and the physician checking the wound for infection were all blind regarding solution type. Structured follow-up was completed at 48 h and 30 days to determine the presence of infection.The primary outcome measured was the difference in wound infection rates between the two randomised groups.During the 18-month study period, 663 consecutive patients were enrolled. After enrolment, 32 patients were later excluded; 29 patients because they were concurrently on antibiotics; two patients secondary to steroid use and one because of tendon involvement. Of the 631 remaining patients, 318 were randomised into the TW group and 313 into the SS group. Six patients were lost to follow-up (5 SS, 1 TW). A total of 625 patients were included in the statistical analysis. There were no differences in the demographic and clinical characteristics of the two groups. There were 20 infections 6.4% (95% CI 9.1% to 3.7%) in the SS group compared with 11 infections 3.5% (95% CI 5.5% to 1.5%) in the TW group, a difference of 2.9% (95% CI -0.4% to 5.7%).There is no difference in the infection rate of wounds irrigated with either TW or SS solution, with a clinical trend towards fewer wound infections in the TW group, making it a safe and cost-effective alternative to SS for wound irrigation.

  View details for DOI 10.1136/bmjopen-2012-001504

  View details for PubMedID 23325896

  View details for PubMedCentralID PMC3549228

• Water is a safe and effective alternative to sterile normal saline for wound irrigation prior to suturing: a prospective, double-blind, randomised, controlled clinical trial BMJ OPEN Weiss, E. A., Oldham, G., Lin, M., Foster, T., Quinn, J. V. 2013; 3 (1)

  Abstract

  To determine if there is a significant difference in the infection rates of wounds irrigated with sterile normal saline (SS) versus tap water (TW), before primary wound closure.Single centre, prospective, randomised, double-blind controlled trial. Wound irrigation solution type was computer randomised and allocation was done on a sequential basis.Stanford University Medical Center Department of Emergency Medicine.Patients older than 1 year of age, who presented to the emergency department with a soft tissue laceration requiring repair, were entered into the study under informed consent. Exclusion criteria included any underlying immunocompromising illness, current use of antibiotics, puncture or bite wounds, underlying tendon or bone involvement, or wounds more than 9 h old.Non-caregivers used a computer generated randomisation code to prepare irrigation basins prior to treatment. Patients had their wounds irrigated either with TW or SS prior to closure, controlling for the volume and irrigation method used. The patient, the treating physician and the physician checking the wound for infection were all blind regarding solution type. Structured follow-up was completed at 48 h and 30 days to determine the presence of infection.The primary outcome measured was the difference in wound infection rates between the two randomised groups.During the 18-month study period, 663 consecutive patients were enrolled. After enrolment, 32 patients were later excluded; 29 patients because they were concurrently on antibiotics; two patients secondary to steroid use and one because of tendon involvement. Of the 631 remaining patients, 318 were randomised into the TW group and 313 into the SS group. Six patients were lost to follow-up (5 SS, 1 TW). A total of 625 patients were included in the statistical analysis. There were no differences in the demographic and clinical characteristics of the two groups. There were 20 infections 6.4% (95% CI 9.1% to 3.7%) in the SS group compared with 11 infections 3.5% (95% CI 5.5% to 1.5%) in the TW group, a difference of 2.9% (95% CI -0.4% to 5.7%).There is no difference in the infection rate of wounds irrigated with either TW or SS solution, with a clinical trend towards fewer wound infections in the TW group, making it a safe and cost-effective alternative to SS for wound irrigation.

  View details for DOI 10.1136/bmjopen-2012-001504

  View details for Web of Science ID 000315082400012

  View details for PubMedID 23325896

  View details for PubMedCentralID PMC3549228

• The 60-day temperature-dependent degradation of midazolam and Lorazepam in the prehospital environment. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors McMullan, J. T., Pinnawin, A., Jones, E., Denninghoff, K., Siewart, N., Spaite, D. W., Zaleski, E., Silbergleit, R. 2012; 17 (1): 1-7

  Abstract

  The choice of the optimal benzodiazepine to treat prehospital status epilepticus is unclear. Lorazepam is preferred in the emergency department, but concerns about nonrefrigerated storage limits emergency medical services (EMS) use. Midazolam is increasingly popular, but its heat stability is undocumented.This study evaluated temperature-dependent degradation of lorazepam and midazolam after 60 days in the EMS environment.Lorazepam or midazolam samples were collected prior to (n = 139) or after (n = 229) 60 days of EMS deployment during spring-summer months in 14 metropolitan areas across the United States. Medications were stored in study boxes that logged temperature every minute and were stored in EMS units per local agency policy. Mean kinetic temperature (MKT) exposure was derived for each sample. Drug concentrations were determined in a central laboratory by high-performance liquid chromatography. Concentration as a function of MKT was analyzed by linear regression.Prior to deployment, measured concentrations of both benzodiazepines were 1.0 relative to labeled concentration. After 60 days, midazolam showed no degradation (mean relative concentration 1.00, 95% confidence interval [CI] 1.00-1.00) and was stable across temperature exposures (adjusted R(2) -0.008). Lorazepam experienced little degradation (mean relative concentration 0.99, 95% CI 0.98-0.99), but degradation was correlated to increasing MKT (adjusted R(2) 0.278). The difference between the temperature dependence of degradation of midazolam and lorazepam was statistically significant (T = -5.172, p < 0.001).Lorazepam experiences small but statistically significant temperature-dependent degradation after 60 days in the EMS environment. Additional study is needed to evaluate whether clinically significant deterioration occurs after 60 days. Midazolam shows no degradation over this duration, even in high-heat conditions.

  View details for DOI 10.3109/10903127.2012.722177

  View details for PubMedID 23148574

  View details for PubMedCentralID PMC4111795

• Standardized Reporting Guidelines for Emergency Department Syncope Risk-stratification Research ACADEMIC EMERGENCY MEDICINE Sun, B. C., Thiruganasambandamoorthy, V., Dela Cruz, J. 2012; 19 (6): 694-702

  Abstract

  There is increasing research interest in the risk stratification of emergency department (ED) syncope patients. A major barrier to comparing and synthesizing existing research is wide variation in the conduct and reporting of studies. The authors wanted to create standardized reporting guidelines for ED syncope risk-stratification research using an expert consensus process. In that pursuit, a panel of syncope researchers was convened and a literature review was performed to identify candidate reporting guideline elements. Candidate elements were grouped into four sections: eligibility criteria, outcomes, electrocardiogram (ECG) findings, and predictors. A two-round, modified Delphi consensus process was conducted using an Internet-based survey application. In the first round, candidate elements were rated on a five-point Likert scale. In the second round, panelists rerated items after receiving information about group ratings from the first round. Items that were rated by >80% of the panelists at the two highest levels of the Likert scale were included in the final guidelines. There were 24 panelists from eight countries who represented five clinical specialties. The panel identified an initial set of 183 candidate elements. After two survey rounds, the final reporting guidelines included 92 items that achieved >80% consensus. These included 10 items for study eligibility, 23 items for outcomes, nine items for ECG abnormalities, and 50 items for candidate predictors. Adherence to these guidelines should facilitate comparison of future research in this area.

  View details for DOI 10.1111/j.1553-2712.2012.01375.x

  View details for PubMedID 22687184

• Implementation of the Exception From Informed Consent Regulations in a Large Multicenter Emergency Clinical Trials Network: The RAMPART Experience ACADEMIC EMERGENCY MEDICINE Silbergleit, R., Biros, M. H., Harney, D., Dickert, N., Baren, J. 2012; 19 (4): 448-454

  Abstract

  Clinical trials investigating therapies for acutely and critically ill and injured patients in the earliest phases of treatment often can only be performed under regulations allowing for exception from informed consent (EFIC) for emergency research. Implementation of these regulations in multicenter clinical trials involves special challenges and opportunities. The Rapid Anticonvulsant Medication Prior to Arrival Trial (RAMPART), the first EFIC trial conducted by the Neurological Emergencies Treatment Trials (NETT) network, combined centralized resources and coordination with retention of local control and flexibility to facilitate compliance with the EFIC regulations. Specific methods used by the NETT included common tools for community consultation and public disclosure, sharing of experiences and knowledge, and reporting of aggregate results. Tracking of community consultation and public disclosure activities and feedback facilitates empirical research on EFIC methods in the network and supports quality improvements for future NETT trials. The NETT model used in RAMPART demonstrates how EFIC may be effectively performed in established clinical trial networks.

  View details for DOI 10.1111/j.1553-2712.2012.01328.x

  View details for Web of Science ID 000302858200011

  View details for PubMedID 22506949

  View details for PubMedCentralID PMC3335290

• Intramuscular versus Intravenous Therapy for Prehospital Status Epilepticus NEW ENGLAND JOURNAL OF MEDICINE Silbergleit, R., Durkalski, V., Lowenstein, D., Conwit, R., Pancioli, A., Palesch, Y., Barsan, W. 2012; 366 (7): 591-600

  Abstract

  Early termination of prolonged seizures with intravenous administration of benzodiazepines improves outcomes. For faster and more reliable administration, paramedics increasingly use an intramuscular route.This double-blind, randomized, noninferiority trial compared the efficacy of intramuscular midazolam with that of intravenous lorazepam for children and adults in status epilepticus treated by paramedics. Subjects whose convulsions had persisted for more than 5 minutes and who were still convulsing after paramedics arrived were given the study medication by either intramuscular autoinjector or intravenous infusion. The primary outcome was absence of seizures at the time of arrival in the emergency department without the need for rescue therapy. Secondary outcomes included endotracheal intubation, recurrent seizures, and timing of treatment relative to the cessation of convulsive seizures. This trial tested the hypothesis that intramuscular midazolam was noninferior to intravenous lorazepam by a margin of 10 percentage points.At the time of arrival in the emergency department, seizures were absent without rescue therapy in 329 of 448 subjects (73.4%) in the intramuscular-midazolam group and in 282 of 445 (63.4%) in the intravenous-lorazepam group (absolute difference, 10 percentage points; 95% confidence interval, 4.0 to 16.1; P<0.001 for both noninferiority and superiority). The two treatment groups were similar with respect to need for endotracheal intubation (14.1% of subjects with intramuscular midazolam and 14.4% with intravenous lorazepam) and recurrence of seizures (11.4% and 10.6%, respectively). Among subjects whose seizures ceased before arrival in the emergency department, the median times to active treatment were 1.2 minutes in the intramuscular-midazolam group and 4.8 minutes in the intravenous-lorazepam group, with corresponding median times from active treatment to cessation of convulsions of 3.3 minutes and 1.6 minutes. Adverse-event rates were similar in the two groups.For subjects in status epilepticus, intramuscular midazolam is at least as safe and effective as intravenous lorazepam for prehospital seizure cessation. (Funded by the National Institute of Neurological Disorders and Stroke and others; ClinicalTrials.gov number, ClinicalTrials.gov NCT00809146.).

  View details for DOI 10.1056/NEJMoa1107494

  View details for Web of Science ID 000300279800004

  View details for PubMedID 22335736

  View details for PubMedCentralID PMC3307101

• Electrocardiogram Findings in Emergency Department Patients with Syncope ACADEMIC EMERGENCY MEDICINE Quinn, J., McDermott, D. 2011; 18 (7): 714-718

  Abstract

  To determine the sensitivity and specificity of the San Francisco Syncope Rule (SFSR) electrocardiogram (ECG) criteria for determining cardiac outcomes and to define the specific ECG findings that are the most important in patients with syncope.A consecutive cohort of emergency department (ED) patients with syncope or near syncope was considered. The treating emergency physicians assessed 50 predictor variables, including an ECG and rhythm assessment. For the ECG assessment, the physicians were asked to categorize the ECG as normal or abnormal based on any changes that were old or new. They also did a separate rhythm assessment and could use any of the ECGs or available monitoring strips, including prehospital strips, when making this assessment. All patients were followed up to determine a broad composite study outcome. The final ECG criterion for the SFSR was any nonsinus rhythm or new ECG changes. In this specific study, the initial assessments in the database were used to determine only cardiac-related outcomes (arrhythmia, myocardial infarction, structural, sudden death) based on set criteria, and the authors determined the sensitivity and specificity of the ECG criteria for cardiac outcomes only. All ECGs classified as "abnormal" by the study criteria were compared to the official cardiology reading to determine specific findings on the ECG. Univariate and multivariate analysis were used to determine important specific ECG and rhythm findings.A total of 684 consecutive patients were considered, with 218 having positive ECG criteria and 42 (6%) having important cardiac outcomes. ECG criteria predicted 36 of 42 patients with cardiac outcomes, with a sensitivity of 86% (95% confidence interval [CI] = 71% to 94%), a specificity of 70% (95% CI = 66% to 74%), and a negative predictive value of 99% (95% CI = 97% to 99%). Regarding specific ECG findings, any nonsinus rhythm from any source and any left bundle conduction problem (i.e., any left bundle branch block, left anterior fascicular block, left posterior fascicular block, or QRS widening) were 2.5 and 3.5 times more likely associated with significant cardiac outcomes.The ECG criteria from the SFSR are relatively simple, and if used correctly can help predict which patients are at risk of cardiac outcomes. Furthermore, any left bundle branch block conduction problems or any nonsinus rhythms found during the ED stay should be especially concerning for physicians caring for patients presenting with syncope.

  View details for DOI 10.1111/j.1553-2712.2011.01120.x

  View details for Web of Science ID 000292779900007

  View details for PubMedID 21762234

• ECG Criteria of the San Francisco Syncope Rule ANNALS OF EMERGENCY MEDICINE Quinn, J., McDermott, D. 2011; 57 (1): 72-73

  View details for DOI 10.1016/j.annemergmed.2010.06.570

  View details for Web of Science ID 000285988500023

  View details for PubMedID 20828875

• Randomized controlled trial of prophylactic antibiotics for dog bites with refined cost model. The western journal of emergency medicine Quinn, J. V., McDermott, D., Rossi, J., Stein, J., Kramer, N. 2010; 11 (5): 435-441

  Abstract

  The aim of this study was to determine the rate of infection at which it is cost-effective to treat dog bite wounds with antibiotics.Our study was composed of two parts. First we performed a randomized, double-blind controlled trial (RCT) to compare the infection rates of dog bite wounds in patients given amoxicillin-clavulanic acid versus placebo. Subjects were immunocompetent patients presenting to the emergency department (ED) with dog bite wounds less than 12 hours old without suspected neurovascular, tendon, joint or bone injury, and who had structured follow-up after two weeks. Second, we developed a cost model with sensitivity analysis to determine thresholds for treatment.In the RCT, primary outcomes were obtained in 94 patients with dog bites. The overall wound infection rate at two weeks was 2% [95% CI 0 to 7%]. Two of 46 patients (4%) receiving no antibiotics developed infections, while none of the 48 patients (0%) receiving prophylactic antibiotics developed an infection (absolute reduction 4% [95% CI -1.0 to 4.5%]). Using a sensitivity analysis across a rate of infections from 0-10%, our cost model determined that prophylactic antibiotics were cost effective if the risk of wound infection was greater than 5% and antibiotics could decrease that risk by greater than 3%.Our wound infection rate was lower than older studies and more in line with current estimates. Assuming that prophylactic antibiotics could provide an absolute risk reduction (ARR) of 3%, it would not be cost effective to treat wounds with an infection rate of less than 3% and unlikely that the ARR would be achievable unless the baseline rate was greater than 5%, suggesting that only wounds with greater than 5% risk of infection should be treated. Future work should focus on identifying wounds at high-risk of infection that would benefit from antibiotic prophylaxis.

  View details for PubMedID 21293762

• NIH Roundtable on Opportunities to Advance Research on Neurologic and Psychiatric Emergencies ANNALS OF EMERGENCY MEDICINE D'Onofrio, G., Jauch, E., Jagoda, A., Allen, M. H., Anglin, D., Barsan, W. G., Berger, R. P., Bobrow, B. J., Boudreaux, E. D., Bushnell, C., Chan, Y., Currier, G., Eggly, S., Ichord, R., Larkin, G. L., Laskowitz, D., Neumar, R. W., Newman-Toker, D. E., Quinn, J., Shear, K., Todd, K. H., Zatzick, D. 2010; 56 (5): 551-564

  Abstract

  The Institute of Medicine Committee on the Future of Emergency Care in the United States Health System (2003) identified a need to enhance the research base for emergency care. As a result, a National Institutes of Health (NIH) Task Force on Research in Emergency Medicine was formed to enhance NIH support for emergency care research. Members of the NIH Task Force and academic leaders in emergency care participated in 3 Roundtable discussions to prioritize current opportunities for enhancing and conducting emergency care research. We identify key research questions essential to advancing the science of emergency care and discuss the barriers and strategies to advance research by exploring the collaboration between NIH and the emergency care community.Experts from emergency medicine, neurology, psychiatry, and public health assembled to review critical areas in need of investigation, current gaps in knowledge, barriers, and opportunities. Neurologic emergencies included cerebral resuscitation, pain, stroke, syncope, traumatic brain injury, and pregnancy. Mental health topics included suicide, agitation and delirium, substances, posttraumatic stress, violence, and bereavement.Presentations and group discussion firmly established the need for translational research to bring basic science concepts into the clinical arena. A coordinated continuum of the health care system that ensures rapid identification and stabilization and extends through discharge is necessary to maximize overall patient outcomes. There is a paucity of well-designed, focused research on diagnostic testing, clinical decisionmaking, and treatments in the emergency setting. Barriers include the limited number of experienced researchers in emergency medicine, limited dedicated research funding, and difficulties of conducting research in chaotic emergency environments stressed by crowding and limited resources. Several themes emerged during the course of the roundtable discussion, including the need for development of (1) a research infrastructure for the rapid identification, consent, and tracking of research subjects that incorporates innovative informatics technologies, essential for future research; (2) diagnostic strategies and tools necessary to understand key populations and the process of medical decisionmaking, including the investigation of the pathobiology of symptoms and symptom-oriented therapies; (3) collaborative research networks to provide unique opportunities to form partnerships, leverage patient cohorts and clinical and financial resources, and share data; (4) formal research training programs integral for creating new knowledge and advancing the science and practice of emergency medicine; and (5) recognition that emergency care is part of an integrated system from emergency medical services dispatch to discharge. The NIH Roundtable "Opportunities to Advance Research on Neurological and Psychiatric Emergencies" created a framework to guide future emergency medicine-based research initiatives.Emergency departments provide the portal of access to the health care system for most patients with acute neurologic and psychiatric illness. Emergency physicians and colleagues are primed to investigate neurologic and psychiatric emergencies that will directly improve the delivery of care and patient outcomes.

  View details for DOI 10.1016/j.annemergmed.2010.06.562

  View details for Web of Science ID 000284292800020

  View details for PubMedID 21036295

• Recruitment and Retention of Patients into Emergency Medicine Clinical Trials ACADEMIC EMERGENCY MEDICINE Cofield, S. S., Conwit, R., Barsan, W., Quinn, J. 2010; 17 (10): 1104-1112

  Abstract

  The emergency medicine (EM) and prehospital environments are unlike any other clinical environments and require special consideration to allow the successful implementation of clinical trials. This article reviews the specific issues involved in EM clinical trials and provides strategies from EM and non-EM trials to maximize recruitment and retention. While the evidence supporting some of these strategies is deficient, addressing recruitment and retention issues with specific strategies will help researchers deal with these issues in their funding applications and in turn develop the necessary infrastructure to participate in EM clinical trials.

  View details for DOI 10.1111/j.1553-2712.2010.00866.x

  View details for Web of Science ID 000282877400011

  View details for PubMedID 21040112

  View details for PubMedCentralID PMC3058592

• Diagnosis and Evaluation of Syncope in the Emergency Department EMERGENCY MEDICINE CLINICS OF NORTH AMERICA Ouyang, H., Quinn, J. 2010; 28 (3): 471-?

  Abstract

  With a careful history, physical examination, and directed investigation, physicians can determine the likely cause of syncope in more than 50% and perhaps up to 80% of patients. Understanding the cause of syncope allows clinicians to determine the disposition of high- and low-risk patients. Patients with a potential malignant cause, such as a cardiac or neurologic condition, should be treated and admitted. Those with benign causes can be safely discharged. This article reviews the diagnosis and ED work-up of syncope, the different classifications of syncope, and prognosis. The use of specific decision rules in risk stratification and syncope in the pediatric population are discussed in another article.

  View details for DOI 10.1016/j.emc.2010.03.007

  View details for Web of Science ID 000281737700005

  View details for PubMedID 20709239

• Drive-Through Medicine: A Novel Proposal for Rapid Evaluation of Patients During an Influenza Pandemic ANNALS OF EMERGENCY MEDICINE Weiss, E. A., Ngo, J., Gilbert, G. H., Quinn, J. V. 2010; 55 (3): 268-273

  Abstract

  During a pandemic, emergency departments (EDs) may be overwhelmed by an increase in patient visits and will foster an environment in which cross-infection can occur. We developed and tested a novel drive-through model to rapidly evaluate patients while they remain in or adjacent to their vehicles. The patient's automobile would provide a social distancing strategy to mitigate the person-to-person spread of infectious diseases.We conducted a full-scale exercise to test the feasibility of a drive-through influenza clinic and measure throughput times of simulated patients and carbon monoxide levels of staff. We also assessed the disposition decisions of the physicians who participated in the exercise. Charts of 38 patients with influenza-like illness who were treated in the Stanford Hospital ED during the initial H1N1 outbreak in April 2009 were used to create 38 patient scenarios for the drive-through influenza clinic.The total median length of stay was 26 minutes. During the exercise, physicians were able to identify those patients who were admitted and discharged during the real ED visit with 100% accuracy (95% confidence interval 91% to 100%). There were no significant increases of carboxyhemoglobin in participants tested.The drive-through model is a feasible alternative to a traditional walk-in ED or clinic and is associated with rapid throughput times. It provides a social distancing strategy, using the patient's vehicle as an isolation compartment to mitigate person-to-person spread of infectious diseases.

  View details for DOI 10.1016/j.annemergmed.2009.11.025

  View details for PubMedID 20079956

• Implementing a Real-time Complex Event Stream Processing System to Help Identify Potential Participants in Clinical and Translational Research Studies. AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium Weber, S., Lowe, H. J., Malunjkar, S., Quinn, J. 2010; 2010: 472-476

  Abstract

  Event Stream Processing is a computational approach to the problem of how to infer the occurrence of an event from a data stream in real time without reference to a database. This paper describes how we implemented this technology on the STRIDE platform to address the challenge of real time notification of patients presenting in the Emergency Department (ED) who potentially meet eligibility criteria for a clinical study. The system was evaluated against a standalone legacy alerting system and found to perform adequately. While our initial use of this technology was focused on relatively simple alerts, the system is extensible and has the potential to provide enterprise-level research alerting services supporting more complex scenarios.

  View details for PubMedID 21347023

  View details for PubMedCentralID PMC3041381

• A better way to estimate adult patients' weights AMERICAN JOURNAL OF EMERGENCY MEDICINE Lin, B. W., Yoshida, D., Quinn, J., Strehlow, M. 2009; 27 (9): 1060-1064

  Abstract

  In the emergency department (ED), adult patients' weights are often crudely estimated before lifesaving interventions. In this study, we evaluate the reliability and accuracy of a method to rapidly calculate patients' weight using readily obtainable anthropometric measurements. We compare this method to visual estimates, patient self-report, and measured weight.A convenience sample of adult ED patients in an academic medical center were prospectively enrolled. Midarm circumference and knee height were measured. These values were input in to equations to calculate patients' weights. A physician and nurse were then independently asked to estimate the patients' weights. Each patient was asked to report his/her own weight before being weighed. Calculated weights using the above equations, visual estimates, and patient reports were compared with actual weights by determining the percentage accurate within 10%. The intraclass correlation coefficient was used to determine the reliability of the estimates with respect to actual weights.Weight was determined within 10% accuracy of actual weight in 69% (95% confidence interval, 63-75) of calculated estimates, 54% (48-61) of physician estimates, 51% (44-57) of nurse estimates, and 86% (81-90) of patient estimates. The weight estimation tool calculated weights more accurately in males (74%, 65-82) than females (65%, 56-73). An analysis of errors revealed that when estimates were inaccurate, approximately half were overestimates and half were underestimates. The correlation coefficient between the calculated estimates and actual weights was 0.89. The correlation coefficient of actual weights with respect to physician estimates, nurse estimates, and doctor's estimates were 0.85, 0.78, and 0.95, respectively.This technique using readily obtainable measurements estimates weight more accurately than ED providers. The technique correlates well with actual patient weights. When available, patient estimates of their own weight are most accurate.

  View details for DOI 10.1016/j.ajem.2008.08.018

  View details for Web of Science ID 000272403400006

  View details for PubMedID 19931751

• Correlation of sonographic measurements of the internal jugular vein with central venous pressure AMERICAN JOURNAL OF EMERGENCY MEDICINE Donahue, S. P., Wood, J. P., Patel, B. M., Quinn, J. V. 2009; 27 (7): 851-855

  Abstract

  Determination of volume status is crucial in treating acutely ill patients. This study examined bedside ultrasonography of the internal jugular vein (IJV) to predict central venous pressure (CVP). Ultrasonography was performed on 34 nonventilated patients with monitored CVPs. The IJV was measured during the respiratory cycle and with the patient in different positions. Mean IJV diameter in patients with CVP less than 10 cm H2O was 7.0 mm (95% confidence interval [CI], 5.7-8.3) vs 12.5 mm (95% CI, 11.2-13.8) in patients with CVP of 10 cm H2O and greater. Measurement of end expiratory diameter with the patient supine had the highest correlation coefficient: 0.82 (95% CI). There was strong agreement among ultrasonographers: correlation coefficient, 0.92 (95% CI). This pilot study shows promise that ultrasonography of the IJV can be a noninvasive tool to predict CVP. Measurement of end expiratory diameter in supine patients exhibited a high correlation to CVP.

  View details for DOI 10.1016/j.ajem.2008.06.005

  View details for Web of Science ID 000269311400017

  View details for PubMedID 19683116

• Catheter-Related Bloodstream Infections The Challenge to Do Better ARCHIVES OF INTERNAL MEDICINE Quinn, J. 2009; 169 (15): 1353-1354

  View details for Web of Science ID 000268798100002

  View details for PubMedID 19667295

• Yield of Diagnostic Tests in Evaluating Syncopal Episodes in Older Patients INVITED COMMENTARY ARCHIVES OF INTERNAL MEDICINE Quinn, J. V. 2009; 169 (14): 1305-1306

  View details for Web of Science ID 000268373000008

  View details for PubMedID 19636032

• A prospective, randomized comparison of skin adhesive and subcuticular suture for closure of pediatric hernia incisions: cost and cosmetic considerations JOURNAL OF PEDIATRIC SURGERY Brown, J. K., Campbell, B. T., Drongowski, R. A., Alderman, A. K., Geiger, J. D., Teitelbaum, D. H., Quinn, J., Coran, A. G., Hirschl, R. B. 2009; 44 (7): 1418-1422

  Abstract

  In this study, we compared the skin adhesive 2-octylcyanoacrylate to subcuticular suture for closure of pediatric inguinal hernia incisions to determine if skin adhesive improves wound cosmesis, shortens skin closure time, and lowers operative costs.We prospectively randomized 134 children undergoing inguinal herniorrhaphy at our institution to have skin closure with either skin adhesive (n = 64) or subcuticular closure (n = 70). Data collected included age, sex, weight, type of operation, total operative time, and skin closure time. Digital photographs of healing incisions were taken at the 6-week postoperative visit. The operating surgeon assessed cosmetic outcome of incisions using a previously validated visual analog scale, as well as an ordinate scale. A blinded assessment of cosmetic outcome was then performed by an independent surgeon comparing these photographs to the visual analog scale. Operating room time and resource use (ie, costs) relative to the skin closure were assessed. Comparisons between groups were done using Student's t tests and chi(2) tests.Children enrolled in the study had a mean +/- SE age of 3.7 +/- 0.3 years and weighed 16 +/- 0.8 kg. Patients were predominantly male (82%). Patients underwent 1 of 3 types of open hernia repair as follows: unilateral herniorrhaphy without peritoneoscopy (n = 41; 31%), unilateral herniorrhaphy with peritoneoscopy (n = 55; 41%), and bilateral herniorrhaphy (n = 38; 28%). Skin closure time was significantly shorter in the skin adhesive group (adhesive = 1.4 +/- 0.8 minutes vs suture = 2.4 +/- 1.1 minutes; P = .001). Mean wound cosmesis scores based on the visual analog scale were similar between groups (adhesive = 78 +/- 21; suture=78 +/- 18; P = .50). Material costs related to herniorrhaphy were higher for skin adhesive (adhesive = $22.63 vs suture = $11.70; P < .001), whereas operating room time costs for adhesive skin closure were lower (adhesive = $9.33 +/- 5.33 vs suture = $16.00 +/- 7.33; P < .001). Except for a 7% incidence of erythema in both groups, there were no complications encountered.There is no difference in cosmetic outcome between skin adhesive and suture closure in pediatric inguinal herniorrhaphy. Material costs are increased because of the high cost of adhesive relative to suture. This is partially offset, however, by the cost savings from reduction in operating room time.

  View details for DOI 10.1016/j.jpedsurg.2009.02.051

  View details for Web of Science ID 000267939600022

  View details for PubMedID 19573672

• Acute myocardial infarction in patients with syncope CANADIAN JOURNAL OF EMERGENCY MEDICINE McDermott, D., Quinn, J. V., Murphy, C. E. 2009; 11 (2): 156-160

  Abstract

  We sought to determine the incidence of acute myocardial infarction (AMI) in emergency department (ED) patients with syncope, the characteristics of these AMIs and how helpful the initial electrocardiogram (ECG) was in identifying these cases.In a prospective cohort of consecutive patients with syncope, the initial ECG was found to be abnormal using a prespecified definition (any nonsinus rhythm or any new or age- indeterminate abnormalities). Patients were then followed up to identify an AMI diagnosed within 30 days of presentation.There were 1474 consecutive patient visits for syncope or near-syncope over a 45-month period spanning from Jul. 1, 2000, to Feb. 28, 2002, and Jul. 15, 2002, to Aug. 31, 2004, of which 46 (3.1%) were diagnosed with AMI. The majority of the AMI patients (42) had no ST segment elevation. The initial ECG was abnormal in 37 out of 46 cases. The diagnostic performance of the initial ECG was sensitivity 80% (95% confidence interval [CI] 67%-89%), specificity 64% (95% CI 61%-67%), negative predictive value 99% (95% CI 98%-100%), positive predictive value 7% (95% CI 6%-8%), positive likelihood ratio 2.2 (95% CI 1.6-2.5) and negative likelihood ratio 0.3 (95% CI 0.2-0.5).The incidence of AMI in patients presenting with syncope is low. A normal ECG has a high negative predictive value, although its sensitivity is limited.

  View details for Web of Science ID 000272257500010

  View details for PubMedID 19272217

• Death after emergency department visits for syncope: How common and can it be predicted? ANNALS OF EMERGENCY MEDICINE Quinn, J., McDermott, D., Kramer, N., Yeh, C., Kohn, M. A., Stiell, I., Wells, G. 2008; 51 (5): 585-590

  Abstract

  Syncope is a common condition that is usually benign but occasionally associated with death. This study evaluates the incidence of death after an emergency department (ED) visit for syncope and whether these deaths can be predicted.A prospective cohort study was conducted during a 45-month period. All patients were followed up 1-and-a-half years after their initial ED visit to determine whether they had died. Death certificates were independently reviewed by 2 physicians for the cause and date of death to determine whether the death was possibly related to the initial visit for syncope. Sensitivity and specificity of risk factors (defined by the San Francisco Syncope Rule) or age greater than 65 years was calculated for all-cause mortality and mortality thought possibly related to syncope.There were 1418 consecutive patients with syncope during the study period, representing 1.2% of all ED visits. The all-cause death rate was 1.4% at 30 days, 4.3% at 6 months, and 7.6% at 1 year. It was believed that the death rates from causes possibly related to syncope were 2.3% and 3.8% at 6 months and 1 year. Of the 112 deaths at 1 year, 37% were cardiac related. At 6 months, the risk factors had a sensitivity of 89% (95% confidence interval [CI] 79% to 95%) and specificity of 53% (95% CI 52% to 53%) for all-cause mortality and sensitivity of 100% (95% CI 90% to 100%) and specificity 52% (95% CI 52% to 53%) for predicting deaths likely or possibly related to syncope. Age greater than 65 years had similar sensitivity but much worse specificity compared with the set combined risk factors.Deaths related to syncope after an ED visit are low, especially in the first 6 months and can usually be predicted by risk factors.

  View details for DOI 10.1016/j.annemergmed.2007.08.005

  View details for Web of Science ID 000255487200006

  View details for PubMedID 17889403

• The cyanoacrylate topical skin adhesives AMERICAN JOURNAL OF EMERGENCY MEDICINE Singer, A. J., Quinn, J. V., Hollander, J. E. 2008; 26 (4): 490-496

  Abstract

  Each year there are over 7 million lacerations requiring wound closure in the emergency department. Traditionally, most lacerations have been closed with sutures. Topical cyanoacrylate skin adhesives offer many advantages over traditional wound closure devices. Recently, the Food and Drug Administration (FDA) has reclassified the topical skin adhesives. As a result, new topical skin adhesives are expected to enter the market in the near future. This article will review the structure and function of cyanoacrylates as well as their advantages, indications, and usage.

  View details for DOI 10.1016/j.ajem.2007.05.015

  View details for Web of Science ID 000255262000018

  View details for PubMedID 18410821

• Internationalizing the Broselow tape: How reliable is weight estimation in Indian children Conference of the Western-Society-for-Academic-Emergency-Medicine Ramarajan, N., Krishnamoorthi, R., Strehlow, M., Quinn, J., Mahadevan, S. V. WILEY-BLACKWELL PUBLISHING, INC. 2008: 431–36

  Abstract

  The Broselow pediatric emergency weight estimation tape is an accurate method of estimating children's weights based on height-weight correlations and determining standardized medication dosages and equipment sizes using color-coded zones. The study objective was to determine the accuracy of the Broselow tape in the Indian pediatric population.The authors conducted a 6-week prospective cross-sectional study of 548 children at a government pediatric hospital in Chennai, India, in three weight-based groups: < 10 kg (n = 175), 10-18 kg (n = 197), and > 18 kg (n = 176). Measured weight was compared to Broselow-predicted weight, and the percentage difference was calculated. Accuracy was defined as agreement on Broselow color-coded zones, as well as agreement within 10% between the measured and Broselow-predicted weights. A cross-validated correction factor was also derived.The mean percentage differences were -2.4, -11.3, and -12.9% for each weight-based group. The Broselow color-coded zone agreement was 70.8% in children weighing less than 10 kg, but only 56.3% in the 10- to 18-kg group and 37.5% in the > 18-kg group. Agreement within 10% was 52.6% for the < 10-kg group, but only 44.7% for the 10- to 18-kg group and 33.5% for the > 18-kg group. Application of a 10% weight-correction factor improved the percentages to 77.1% for the 10- to 18-kg group and 63.0% for the >18-kg group.The Broselow tape overestimates weight by more than 10% in Indian children > 10 kg. Weight overestimation increases the risk of medical errors due to incorrect dosing or equipment selection. Applying a 10% weight-correction factor may be advisable.

  View details for DOI 10.1111/j.1553-2712.2008.00081.x

  View details for PubMedID 18439198

• Internationalizing the broselow tape: How reliable is weight estimation in Indian children? 12th International Conference on Emergency Medicine Ramaralan, N., Krishnamoorthi, R., Strehlow, M., Quinn, J., Mahadevan, S. MOSBY-ELSEVIER. 2008: 512–13

  View details for Web of Science ID 000254648000160

• Validation of the Social Security Death Index (SSDI): An Important Readily-Available Outcomes Database for Researchers. The western journal of emergency medicine Quinn, J., Kramer, N., McDermott, D. 2008; 9 (1): 6-8

  Abstract

  To determine the accuracy of the online Social Security Death Index (SSDI) for determining death outcomes.We selected 30 patients who were determined to be dead and 90 patients thought to be alive after an ED visit as determined by a web-based searched of the SSDI. For those thought to be dead we requested death certificates. We then had a research coordinator blinded to the results of the SSDI search, complete direct follow-up by contacting the patients, family or primary care physicians to determine vital status. To determine the sensitivity and specificity of the SSDI for death at six months in this cohort, we used direct follow-up as the criterion reference and calculated 95% confidence intervals.Direct follow-up was completed for 90% (108 of 120) of the patients. For those patients 20 were determined to be dead and 88 alive. The dead were more likely to be male (57%) and older [(mean age 83.9 (95% CI 79.1 - 88.7) vs. 60.9 (95% CI 56.4 - 65.4) for those alive]. The sensitivity of the SSDI for those with completed direct follow-up was 100% (95% CI 91 -100%) with specificity of 100% (95% CI 98-100%). Of the 12 patients who were not able to be contacted through direct follow-up, the SSDI indicated that 10 were dead and two were alive.SSDI is an accurate measure of death outcomes and appears to have the advantage of finding deaths among patients lost to follow-up.

  View details for PubMedID 19561695

• Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with syncope. Journal of emergency nursing Huff, J. S., Decker, W. W., Quinn, J. V., Perron, A. D., Napoli, A. M., Peeters, S., Jagoda, A. S. 2007; 33 (6): e1-e17

  View details for PubMedID 18035161

• External validation of the San Francisco Syncope Rule ANNALS OF EMERGENCY MEDICINE Quinn, J., McDermott, D. 2007; 50 (6): 742-743

  View details for DOI 10.1016/j.annemergmed.2007.06.476

  View details for Web of Science ID 000251440500022

  View details for PubMedID 18023761

• Effects of implementing a rapid admission policy in the ED AMERICAN JOURNAL OF EMERGENCY MEDICINE Quinn, J. V., Mahadevan, S. V., Eggers, G., Ouyang, H., Norris, R. 2007; 25 (5): 559-563

  Abstract

  The purpose of this study is to determine the impact of a new rapid admission policy (RAP) on emergency department (ED) length of stay (EDLOS) and time spent on ambulance diversion (AD).The RAP, instituted in January 2005, allows attending emergency physicians to send stable patients, requiring admission to the general medicine service, directly to available inpatient beds. The RAP thereby eliminates 2 conventional preadmission practices: having admitting physicians evaluate the patient in the ED and requiring all diagnostic testing to be complete before admission. We compared patient characteristics, percentage of patients leaving without being seen, EDLOS for admitted patients, time on AD, and total adjusted facility charge for a 3-month period after the RAP implementation to the same period of the prior year.There was a 1.1% increase in census with no difference in patient demographics, acuity, or disposition categories for the 2 periods. The EDLOS decreased on average by 10.1 minutes (95% confidence interval [CI], 3.3-17.0 minutes), resulting in an average of 4.2 hours of extra bed availability per day. Weekly minutes of AD decreased 169 minutes (95% CI, 29-310 minutes). There was also a 3.2% increase (95% CI, 3.1%-3.3%) in adjusted facility charge between these periods in 2005 compared with 2004.The RAP resulted in a small decrease in the EDLOS, which likely decreased AD time. The resulting small increase in ED volume and higher acuity ambulance patients significantly improved ED revenue. Wider implementation of the policy and more uniform use among emergency physicians may further improve these measures.

  View details for DOI 10.1016/j.ajem.2006.11.034

  View details for PubMedID 17543661

• Risk stratification of patients with syncope. CJEM Quinn, J. 2007; 9 (3): 174-175

  View details for PubMedID 17488578

• Clinical policy: Dritical issues in the evaluation and management of adult patients presenting to the emergency department with syncope ANNALS OF EMERGENCY MEDICINE Huff, J. S., Decker, W. W., Quinn, J. V., Perron, A. D., Napoli, A. M., Peeters, S., Jagoda, A. S. 2007; 49 (4): 431-444

  View details for DOI 10.1016/j.annemergmed.2007.02.001

  View details for Web of Science ID 000245293700007

  View details for PubMedID 17371707

• Medical decisionmaking and the San Francisco syncope rule ANNALS OF EMERGENCY MEDICINE Quinn, J. V., McDermott, D. 2006; 48 (6): 762-763

  View details for DOI 10.1016/j.annemergmed.2006.06.050

  View details for Web of Science ID 000242310700029

  View details for PubMedID 17112946

• Prospective validation of the San Francisco syncope rule to predict patients with serious outcomes Annual Meeting of the Society-for-Academic-Emergency-Medicine Quinn, J., McDermott, D., Stiell, I., Kohn, M., Wells, G. MOSBY-ELSEVIER. 2006: 448–54

  Abstract

  We prospectively validate the San Francisco Syncope Rule (history of congestive heart failure, Hematocrit <30%, abnormal ECG result [new changes or non-sinus rhythm], complaint of shortness of breath, and systolic blood pressure <90 mm Hg during triage).In a prospective cohort study, consecutive patients with syncope or near syncope presenting to an emergency department (ED) of a teaching hospital were identified and enrolled from July 15, 2002, to August 31, 2004. Patients with trauma, alcohol, or drug-associated loss of consciousness and definite seizures were excluded. Physicians prospectively applied the San Francisco Syncope Rule after their evaluation, and patients were followed up to determine whether they had had a predefined serious outcome within 30 days of their ED visit.Seven hundred ninety-one consecutive visits were evaluated for syncope, representing 1.2% of all ED visits. The average age was 61 years, 54% of patients were women, and 59% of patients were admitted. Fifty-three visits (6.7%) resulted in patients having serious outcomes that were undeclared during their ED visit. The rule was 98% sensitive (95% confidence interval [CI] 89% to 100%) and 56% specific (95% CI 52% to 60%) to predict these events. In this cohort, the San Francisco Syncope Rule classified 52% of the patients as high risk, potentially decreasing overall admissions by 7%. If the rule had been applied only to the 453 patients admitted, it might have decreased admissions by 24%.The San Francisco Syncope Rule performed with high sensitivity and specificity in this validation cohort and is a valuable tool to help risk stratify patients. It may help with physician decisionmaking and improve the use of hospital admission for syncope.

  View details for DOI 10.1016/j.annemergmed.2005.11.019

  View details for Web of Science ID 000237162900013

  View details for PubMedID 16631985

• The San Francisco Syncope Rule vs physician judgment and decision making Annual Meeting of the Society-for-Academic-Emergency-Medicine Quinn, J. V., Stiell, I. G., McDermott, D. A., Kohn, M. A., Wells, G. A. W B SAUNDERS CO-ELSEVIER INC. 2005: 782–86

  Abstract

  To compare a clinical decision rule (San Francisco Syncope Rule [SFSR]) and physician decision making when predicting serious outcomes in patients with syncope.In a prospective cohort study, physicians evaluated patients presenting with syncope and predicted the chance (0%-100%) of the patient developing a predefined serious outcome. They were then observed to determine their decision to admit the patient. All patients were followed up to determine whether they had a serious outcome within 7 days of their emergency department visit. Analyses included sensitivity and specificity to predict serious outcomes for low-risk patients and comparison of areas under the receiver operating characteristic curve for the decision rule, physician judgment, and admission decisions.During the study period, there were 684 visits for syncope with 79 visits resulting in serious outcomes. The area under the receiver operating characteristic curve was 0.92 (95% confidence interval [CI], 0.88-0.95) for the SFSR compared with physician judgment 0.89 (95% CI, 0.85-0.93) and physician decision making 0.83 (95% CI, 0.81-0.87). Physicians admitted 28% of patients in a low-risk group, with a median length of stay of 1 day (interquartile range, 1-2.5 days). The SFSR had the potential to absolutely decrease admissions by 10% in this low-risk group and still predict all serious outcomes.Physician judgment is good when predicting which patients with syncope will develop serious outcomes, but contrary to their judgment, physicians still admit a large number of low-risk patients. The SFSR performs better than current physician performance and has great potential to aid physician decision making.

  View details for DOI 10.1016/j.ajem.2004.11.009

  View details for Web of Science ID 000232624900013

  View details for PubMedID 16182988

• Heat stress from enclosed vehicles: Moderate ambient temperatures cause significant temperature rise in enclosed vehicles PEDIATRICS McLaren, C., Null, J., Quinn, J. 2005; 116 (1): E109-E112

  Abstract

  Each year, children die from heat stroke after being left unattended in motor vehicles. In 2003, the total was 42, up from a national average of 29 for the past 5 years. Previous studies found that on days when ambient temperatures exceeded 86 degrees F, the internal temperatures of the vehicle quickly reached 134 to 154 degrees F. We were interested to know whether similarly high temperatures occurred on clear sunny days with more moderate temperatures. The objective of this study was to evaluate the degree of temperature rise and rate of rise in similar and lower ambient temperatures. In addition, we evaluated the effect of having windows "cracked" open.In this observational study, temperature rise was measured continuously over a 60-minute period in a dark sedan on 16 different clear sunny days with ambient temperatures ranging from 72 to 96 degrees F. On 2 of these days, additional measurements were made with the windows opened 1.5 inches. Analysis of variance was used to compare how quickly the internal vehicle temperature rose and to compare temperature rise when windows were cracked open 1.5 inches.Regardless of the outside ambient temperature, the rate of temperature rise inside the vehicle was not significantly different. The average mean increase was 3.2 degrees F per 5-minute interval, with 80% of the temperature rise occurring during the first 30 minutes. The final temperature of the vehicle depended on the starting ambient temperature, but even at the coolest ambient temperature, internal temperatures reached 117 degrees F. On average, there was an approximately 40 degrees F increase in internal temperature for ambient temperatures spanning 72 to 96 degrees F. Cracking windows open did not decrease the rate of temperature rise in the vehicle (closed: 3.4 degrees F per 5 minutes; opened: 3.1 degrees F per 5 minutes or the final maximum internal temperature.Even at relatively cool ambient temperatures, the temperature rise in vehicles is significant on clear, sunny days and puts infants at risk for hyperthermia. Vehicles heat up rapidly, with the majority of the temperature rise occurring within the first 15 to 30 minutes. Leaving the windows opened slightly does not significantly slow the heating process or decrease the maximum temperature attained. Increased public awareness and parental education of heat rise in motor vehicles may reduce the incidence of hyperthermia death and improve child passenger safety.

  View details for DOI 10.1542/peds.2004-2368

  View details for Web of Science ID 000230207500016

  View details for PubMedID 15995010

• Factors associated with patients who leave without being seen Annual Meeting of the Society-for-Academic-Emergency-Medicine Polevoi, S. K., Quinn, J. V., Kramer, N. R. WILEY-BLACKWELL PUBLISHING, INC. 2005: 232–36

  Abstract

  Patients who leave without being seen (LWBS) can be an indicator of patient satisfaction and quality for emergency departments (ED). The objective of this study was to develop a model to determine factors associated with patients who LWBS.A modified case-crossover design to determine the transient effects on the risk of acute events was used. Over a four-month period, time intervals when patients LWBS were matched (within two weeks), according to time of day and day of week, with time periods when patients did not LWBS. Factors considered were percentage of ED bed capacity, acuity of ED patients, length of stay of discharged patients in the ED, patients awaiting an admission bed in the ED, inpatient floor capacity, intensive care unit capacity, and the characteristics of the attending physician in charge. McNemar test, Wilcoxon signed-rank test, and conditional logistic regression analyses were used to determine significant variables.Over the study period, there were 11,652 visits, of which 213 (1.8%) resulted in patients who LWBS. Measures of inpatient capacity were not associated with patients who LWBS and ED capacity was only associated when >100%. This association increased with increasing capacity. Other significant factors were older age (p < 0.01) and completion of an emergency medicine residency (p < 0.01) of the physician in charge. When factors were considered in a multivariate model, ED capacity >140% (odds ratio, 1.96; 95% confidence interval = 1.22 to 3.17) and noncompletion of an emergency medicine residency (odds ratio, 1.85; 95% confidence interval = 1.17 to 2.93) were most important.ED capacity >100% is associated with patients who LWBS and is most significant at 140% capacity. ED capacity of 100% may not be a sensitive measure for overcrowding. Physician factors, especially emergency medicine training, also appear to be important when using LWBS as a quality indicator.

  View details for DOI 10.1197/j.aem.2004.10.029

  View details for Web of Science ID 000227266800008

  View details for PubMedID 15741586

• A real-time tracking, notification, and web-based enrollment system for emergency department research ACADEMIC EMERGENCY MEDICINE Quinn, J., Durski, K. 2004; 11 (11): 1245-1248

  Abstract

  The authors describe the development of a real-time tracking, notification, and Web-based enrollment system designed specifically to facilitate emergency department research. The system was developed in a cooperative arrangement between an emergency medicine researcher and a medical information software company. The system design and utilization are described as well as the security measures to ensure compliance with Health Insurance Portability and Accountability Act (HIPAA) regulations and database security.

  View details for DOI 10.1197/j.aem.2004.08.020

  View details for Web of Science ID 000225088900021

  View details for PubMedID 15528591

• Risk prediction for patients with syncope - In reply ANNALS OF EMERGENCY MEDICINE Quinn, J., McDermott, D. 2004; 44 (4): 423-424

  View details for DOI 10.1016/j.annemergmed.2004.03.046

  View details for Web of Science ID 000224211700020

• Patterns of complementary and alternative medicine use in ED patients and its association with health care utilization AMERICAN JOURNAL OF EMERGENCY MEDICINE Li, J. Z., Quinn, J. V., McCulloch, C. E., Jacobs, B. P., Chan, P. V. 2004; 22 (3): 187-191

  Abstract

  This study characterizes the use of complementary and alternative medicines (CAM) among ED patients and demonstrates patterns of healthcare utilization among users and nonusers of CAM therapies. A cross-sectional observational study was performed by administering questionnaires to ED patients at a university teaching hospital. Of the 356 patients surveyed, more than half (55%) had tried at least one complementary and alternative therapy within the past 12 months and 17% had tried CAM for their presenting medical problem. The use of CAM interventions varied significantly among different demographic groups. The number of ED visits over the past year did not differ between the users and nonusers of CAM, but those using alternative therapies did have more visits to outpatient physicians over the past 12 months (7.8 vs. 5.2; 95% confidence interval [CI], 7-4.6; P <.01). After controlling for age, ethnicity, education level, religion, income, and self-report of overall health status, users of CAM had more frequent visits to outpatient physicians (odds ratio [OR], 1.06; 95% CI, 1.02-1.1; P <.01), had no difference in their rates of hospitalization, but trended toward spending fewer days in the hospital when they were admitted (OR,.96; 95% CI,.92-1.0; P =.06). Complementary and alternative medicines are being used by a majority of ED patients with a significant number having used CAM for their presenting complaint before visiting the ED. CAM users do not differ in their utilization of the ED when compared with nonusers, but do have a significantly increased frequency of outpatient physician visits.

  View details for Web of Science ID 000221557700009

  View details for PubMedID 15138954

• Derivation of the San Francisco syncope rule to predict patients with short-term serious outcomes ANNALS OF EMERGENCY MEDICINE Quinn, J. V., Stiell, I. G., McDermott, D. A., Sellers, K. L., Kohn, M. A., Wells, G. A. 2004; 43 (2): 224-232

  Abstract

  The causes of syncope are usually benign but are occasionally associated with significant morbidity and mortality. We derive a decision rule that would predict patients at risk for short-term serious outcomes and help guide admission decisions.This prospective cohort study was conducted at a university teaching hospital and used emergency department (ED) patients presenting with syncope or near syncope. Physicians prospectively completed a structured data form when evaluating patients with syncope. Serious outcomes (death, myocardial infarction, arrhythmia, pulmonary embolism, stroke, subarachnoid hemorrhage, significant hemorrhage, or any condition causing a return ED visit and hospitalization for a related event) were defined at the start of the study. All patients were followed up to determine whether they had experienced a serious outcome within 7 days of their ED visit. Univariate analysis was performed with chi2 and nonparametric techniques on all predictor variables. kappa Analysis was performed on variables requiring interpretation. Variables with kappa more than 0.5 and a P value less than.1 were analyzed with recursive partitioning techniques to develop a rule that would maximize the determination of serious outcomes.There were 684 visits for syncope, and 79 of these visits resulted in patients' experiencing serious outcomes. Of the 50 predictor variables considered, 26 were associated with a serious outcome on univariate analysis. A rule that considers patients with an abnormal ECG, a complaint of shortness of breath, hematocrit less than 30%, systolic blood pressure less than 90 mm Hg, or a history of congestive heart failure has 96% (95% confidence interval [CI] 92% to 100%) sensitivity and 62% (95% CI 58% to 66%) specificity. If applied to this cohort, the rule has the potential to decrease the admission rate by 10%.The San Francisco Syncope Rule derived in this cohort of patients appears to be sensitive for identifying patients at risk for short-term serious outcomes. If prospectively validated, it may offer a tool to aid physician decision making.

  View details for DOI 10.1016/mem.2004.430

  View details for Web of Science ID 000188704300014

  View details for PubMedID 14747812

• Suturing versus conservative management of lacerations of the hand: randomised controlled trial BRITISH MEDICAL JOURNAL Quinn, J., Cummings, S., Callaham, M., Sellers, K. 2002; 325 (7359): 299-300A

  Abstract

  To assess the difference in clinical outcome between lacerations of the hand closed with sutures and those treated conservatively.Randomised controlled trial.Emergency department in a tertiary hospital.Consecutive patients presenting between 16 February and 30 November 2000 with uncomplicated lacerations of the hand (full thickness <2 cm; without tendon, joint, fracture, or nerve complications) who would normally require sutures. 154 patients were eligible, 58 refused, and 5 were missed; 91 patients with 95 lacerations were enrolled.Participants were randomised to suturing or conservative treatment.Primary outcome was cosmetic appearance after three months, rated on a previously validated visual analogue scale. Duration of treatment, pain during treatment, patients' assessment of their outcome, and the time for patients to resume normal activities were also measured.Participants treated with sutures and those treated conservatively did not differ significantly in the assessment of cosmetic appearance by independent blinded doctors after three months: 83 mm v 80 mm, (mean difference 3 (95% confidence interval -1 to 8) mm) on the visual analogue scale. The mean time to resume normal activities was the same in both groups (3.4 days). Patients treated conservatively had less pain (difference 18 (12 to 24) mm) and treatment time was 14 (10 to 18) min shorter.Similar cosmetic and functional outcomes result from either conservative treatment or suturing of small uncomplicated lacerations of the hand, but conservative treatment is faster and less painful.

  View details for Web of Science ID 000177482500014

  View details for PubMedID 12169503

  View details for PubMedCentralID PMC117762

• Determinants of poor outcome after laceration and surgical incision repair PLASTIC AND RECONSTRUCTIVE SURGERY Singer, A. J., Quinn, J. V., Thode, H. C., Hollander, J. E. 2002; 110 (2): 429-435

  Abstract

  The most important outcomes after repair of traumatic lacerations and surgical incisions are their long-term cosmetic appearance and development of infection. However, few studies have attempted to identify patient and wound characteristics associated with increased infection rates and suboptimal scar appearance. The authors determined patient and wound characteristics associated with wound infection or suboptimal appearance after laceration or incision repair. A secondary analysis of data collected from a multicenter randomized clinical trial comparing the outcome of lacerations and incisions closed with tissue adhesive or standard closure methods conducted at 10 clinical inpatient and outpatient sites was performed. The presence of infection and scar appearance were prospectively determined using validated outcomes. Univariate and multivariate analyses were performed to identify patient and wound characteristics associated with poor wound outcome (wound infection at 5 to 10 days or suboptimal appearance at 3 months). Eight hundred fourteen patients with 924 wounds (383 lacerations, 541 incisions) were enrolled. Mean age was 32 years and 47 percent were female. Characteristics associated with suboptimal cosmetic appearance on multivariate analysis were presence of associated tissue trauma [odds ratio (OR), 3.9; 95 percent confidence interval (CI), 1.4 to 10.7], use of electrocautery (OR, 3.4; 95 percent CI, 1.8 to 6.5), incomplete wound edge apposition (OR, 2.9; 95 percent CI, 1.7 to 5.0); extremity location (OR, 2.1; 95 percent CI, 1.2 to 3.7), and wound width (OR, 1.08; 95 percent CI, 1.01 to 1.14). Characteristics associated with wound infection on univariate analysis included associated tissue trauma (8.7 percent versus 1.2 percent, p = 0.04) and incomplete wound apposition (6.6 percent versus 0.5 percent). Suboptimal appearance was more common in infected wounds (relative risk, 3.2; 95 percent CI, 1.8 to 5.6). Suboptimal wound appearance is increased with extremity wounds, wide wounds, incompletely apposed wounds, associated tissue trauma, use of electrocautery, and infection. Type of closure device and use of deep sutures had no effect on infection rates or cosmetic appearance.

  View details for Web of Science ID 000177043900008

  View details for PubMedID 12142655

• Closure of lacerations and incisions with octylcyanoacrylate: A multicenter randomized controlled trial SURGERY Singer, A. J., Quinn, J. V., Clark, R. E., Hollander, J. E. 2002; 131 (3): 270-276

  Abstract

  Most lacerations and surgical incisions are closed with sutures or staples. Octylcyanoacrylate tissue adhesive (OCA) was recently approved for use in the United States. We compared the cosmetic appearance of lacerations and incisions repaired with OCA versus standard wound closure methods (SWC).A multicenter randomized clinical trial including patients with simple lacerations or surgical incisions was conducted at 10 clinical sites. Patients were randomly assigned to treatment with OCA or SWC. Follow-up was performed at 1 week and at 3 months to determine infection rates and cosmetic outcome.Eight hundred fourteen patients with 924 wounds (383 traumatic lacerations, 235 excisions of skin lesions or scar revisions, 208 minimally invasive surgeries, and 98 general surgical procedures) were enrolled. Groups were similar in baseline characteristics. Wound closure with OCA was faster than with SWC (2.9 vs 5.2 minutes, P <.001). At 1 week infection rates were similar (OCA, 2.1% vs SWC, 0.7%; P =.09) and fewer OCA wounds were erythematous (18% vs 36%, P <.001). There were no differences in wound dehiscence rates (OCA, 1.6% vs SWC, 0.9%; P =.35). At 3 months there was no difference in the percent of wounds with optimal appearance (OCA, 82% vs SWC, 83%; P =.67).Repair of traumatic lacerations and surgical incisions with OCA is faster than with SWC, and cosmetic outcome is similar at 3 months.

  View details for DOI 10.1067/msy.2002.121377

  View details for Web of Science ID 000174528400006

  View details for PubMedID 11894031

• The effect of a new tissue-adhesive wound dressing on the healing of traumatic abrasions Annual Meeting of the Society-of-Academic-Emergency-Medicine Quinn, J., Lowe, L., Mertz, M. KARGER. 2000: 343–46

  Abstract

  Octylcyanoacrylate is a new medical-grade adhesive with antimicrobial properties. It forms a thin, flexible, occlusive bandage.To determine the gross and histological effects of the spray bandage when treating abrasions.Abrasions were produced on the flanks of 18 albino guinea pigs and randomized to treatment with a control (Biobrane) or octylcyanoacrylate dressing. The wounds were assessed with digital photography using a previously validated method. Histopathological analysis was done on day 14.There were no differences in the mean wound-healing ratios on days 1 (1.25 vs. 1.23, p = 0.61), 7 (1.15 vs. 1.13, p = 0. 14) and 14 (1.03 vs. 1.02, p = 0.63) for tissue adhesive and Biobrane, respectively. There were no differences found on histopathological analysis either.This external spray bandage was well tolerated and did not show any signs of histotoxicity or adverse wound healing.

  View details for Web of Science ID 000166150500012

  View details for PubMedID 11146346

• A randomized, clinical trial comparing butylcyanoacrylate with octylcyanoacrylate in the management of selected pediatric facial lacerations ACADEMIC EMERGENCY MEDICINE Osmond, M. H., Quinn, J. V., Sutcliffe, T., Jarmuske, M., Klassen, T. P. 1999; 6 (3): 171-177

  Abstract

  To compare two tissue adhesives, butylcyanoacrylate and octylcyanoacrylate, in the treatment of small (<4 cm) superficial linear traumatic facial lacerations in children.This was a randomized, clinical trial with parallel design. 94 children <18 years of age seen in the ED of a tertiary care pediatric hospital with a facial laceration suitable for tissue adhesive closure underwent laceration closure using either butylcyanoacrylate or octylcyanoacrylate. The primary outcome was the cosmetic result at three months rated from photographs by a plastic surgeon on a visual analog scale (VAS). Secondary outcomes included the time to perform the procedure, the perceived difficulty of the procedure, the pain perceived by the patient, and a wound evaluation score at ten to 14 days and three months.Ninety-four patients were randomized with 47 in each group. The two groups were similar for baseline demographic and clinical characteristics. There was no difference in the three-month cosmesis VAS (median, 70.0 mm for n-butyl-2-cyanoacrylate vs 67.5 mm for octylcyanocrylate, p = 0.84). There was no difference between the groups for time to complete the procedure (p = 0.88), parent/patient-perceived pain of the procedure (p = 0.37), or physician-perceived difficulty of the procedure (p = 0.33). Similarly, there was no difference between the groups for the percentage of early (p = 0.58) or late (p = 0.71) optimal wound evaluation scores.In the closure of small linear pediatric facial lacerations, octylcyanoacrylate is similar to butylcyanoacrylate in ease of use and early and late cosmetic outcomes. The superior physical properties of octylcyanoacrylate appear to add little benefit to the management of these selected lacerations. Physician preference and differing costs may dictate use for these small selected lacerations.

  View details for Web of Science ID 000079862700004

  View details for PubMedID 10192666

• Tissue adhesive versus suture wound repair at 1 year: Randomized clinical trial correlating early, 3-month, and 1-year cosmetic outcome ANNALS OF EMERGENCY MEDICINE Quinn, J., Wells, G., Sutcliffe, T., Jarmuske, M., Maw, J., Stiell, I. 1998; 32 (6): 645-649

  Abstract

  To compare the 1-year cosmetic outcome of wounds treated with octylcyanoacrylate tissue adhesive and monofilament sutures and to correlate the early, 3-month, and 1-year cosmetic outcomes.We prospectively randomized 136 cases of traumatic laceration to repair with octylcyanoacrylate tissue adhesive or 5-0 or smaller monofilament suture. A wound score was assigned by a research nurse, and validated by a second nurse blinded to the treatment, at 5 to 10 days after injury (early), 3 months, and 1 year. Standardized photographs were taken at 3 months and 1 year and shown to a cosmetic surgeon blinded to the method of closure, who rated the wounds on a validated cosmesis scale.We were able to examine 77 lacerations at 1 year for follow-up. No differences were found in the demographic or clinical characteristics between groups. Likewise, at 1 year no difference was found in the optimal wound scores (73% versus 68%, P =.60) or in visual analog scale cosmesis scores (69 versus 69 mm, P =.95) for octylcyanoacrylate and sutures, respectively. Agreement was poor between early and 3-month wound scores (kappa=.34; 95% confidence interval [CI],.10 to.58) but a strong association existed between 3-month and 1-year wound scores (kappa=.71; 95% CI,.52 to.90). We noted a moderate correlation between 3-month and 1-year results on the visual analog cosmesis scale (intraclass correlation,.48; 95% CI, .30 to.63).One year after wound repair, no difference is noted in the cosmetic outcomes of traumatic lacerations treated with octylcyanoacrylate tissue adhesive and sutures. The assessment of wounds 3 months after injury and wound repair provides a good measure of long-term cosmetic outcome.

  View details for Web of Science ID 000077590700001

  View details for PubMedID 9832658

• Diagnosis of spontaneous splenic rupture with emergency ultrasonography ANNALS OF EMERGENCY MEDICINE Blaivas, M., Quinn, J. 1998; 32 (5): 627-630

  Abstract

  Rapid evaluation of the hypotensive patient in the emergency department is essential. The availability of ultrasonography in the ED, performed by emergency physicians and surgeons, has made it easier to evaluate the hypotensive trauma patient. We describe a 44-year-old man transferred to our institution from a community hospital for evaluation of syncope and hypotension with no obvious cause. On arrival the patient began to complain of slight lower abdominal pain. The patient's physical examination revealed minimal abdominal tenderness. A rapid ultrasound examination performed at bedside revealed the presence of intraperitoneal fluid. Examination of the spleen suggested likely rupture. The patient was promptly taken to surgery for splenectomy and discharged home in 4 days.

  View details for Web of Science ID 000076785300018

  View details for PubMedID 9795331

• Tissue adhesives ANNALS OF EMERGENCY MEDICINE Quinn, J. 1998; 32 (2): 274-274

  View details for Web of Science ID 000075126100031

  View details for PubMedID 9701322

• A new tissue adhesive for laceration repair in children 37th Annual Meeting of the Pediatric-Academic-Societies Bruns, T. B., Robinson, B. S., Smith, R. J., Kile, D. L., DAVIS, T. P., Sullivan, K. M., Quinn, J. V. MOSBY-ELSEVIER. 1998: 1067–70

  Abstract

  To determine the effectiveness of a new tissue adhesive, 2-Octylcyanoacrylate (2-OCA), for laceration repair, 83 children presenting to T.C. Thompson Children's Hospital Emergency Department with lacerations meeting eligibility requirements between February and June 1996 were randomized to receive 2-OCA or nonabsorbable sutures/staples. The length of time for repair was recorded. The length of time for laceration repair was decreased (2.9 minutes 2-OCA vs 5.8 minutes suture/staple; p < 0.001), the parents' assessment of the pain felt by their children in the 2-OCA group was less, and the wounds closed with tissue adhesive had slightly lower cosmesis scores. 2-OCA is an acceptable alternative to conventional methods of wound repair with comparable cosmetic outcome.

  View details for Web of Science ID 000074065100035

  View details for PubMedID 9627610

• An assessment of clinical wound evaluation scales Annual Meeting of the Society-for-Academic-Emergency-Medicine Quinn, J. V., Wells, G. A. WILEY-BLACKWELL PUBLISHING, INC. 1998: 583–86

  Abstract

  To compare 2 clinical wound scales and to determine a minimal clinically important difference (MCID) on the visual analog cosmesis scale.Using data from 2 previously published clinical trials, 91 lacerations and 43 surgical incisions were assessed on the 2 scales; a 100-mm visual analog scale (VAS) (0 = worst possible scar, 100 = best possible scar) and a wound evaluation scale (WES) assessing 6 clinical variables (a score of 6 is considered optimal, while a score of < or =5 suboptimal). All wound assessments on the VAS were done by 2 cosmetic surgeons who rated photographs on 2 occasions. A cohort of wounds on the WES were assessed by a second observer. The difference of the mean optimal and suboptimal VAS scores for each study was used to determine a MCID on the VAS scale.The VAS scale yielded intraobserver agreements of 0.93 and 0.87 (95% CI: 0.89-0.96 and 0.78-0.93) and interobserver agreements of 0.50 and 0.71 (95% CI: 0.32-0.65 and 0.52-0.84) for lacerations and incisions, respectively. Kappa coefficient measuring agreement on the WES was 0.79 (95% CI: 0.57-1.0). The mean (+/-SD) VAS scores of optimal wounds were 72 +/- 12 mm and 65 +/- 20 mm, while the mean scores of suboptimal wounds were 57 +/- 17 mm and 50 +/- 23 mm for lacerations and incisions, respectively.An MCID on the VAS cosmesis scale is 15 mm. Studies should be designed to have a sample size and power to detect this difference.

  View details for Web of Science ID 000074112400009

  View details for PubMedID 9660284

• Prospective, randomized, controlled trial of tissue adhesive (2-octylcyanoacrylate) vs standard wound closure techniques for laceration repair Annual Meeting of the Society-for-Academic-Emergency-Medicine Singer, A. J., Hollander, J. E., Valentine, S. M., Turque, T. W., McCuskey, C. F., Quinn, J. V. WILEY-BLACKWELL PUBLISHING, INC. 1998: 94–99

  Abstract

  To compare a new tissue adhesive, 2-octylcyanoacrylate, with standard wound closure techniques for the repair of traumatic lacerations.A prospective, randomized, controlled clinical trial enrolled consecutive patients > 1 year of age with non-bite, non-crush-induced lacerations who presented < 6 hours after injury. Structured closed-question data sheets were completed at the time of laceration repair and suture removal. Patients were randomly assigned to treatment with either 2-octylcyanoacrylate or standard wound closure. Infection was determined at the time of suture removal. Long-term cosmetic appearance (> 3 months) was assessed by physicians using a previously validated categorical cosmetic scale and by patients using a 100-mm visual analog scale.There were 63 patients randomized to the octylcyanoacrylate group and 61 patients treated with standard wound closure techniques. The 2 treatment groups were similar with respect to age, gender, race, medical history, and wound characteristics. At the 5-to-10-day follow-up, only 1 wound was infected and only 2 wounds required reclosure due to dehiscence. These 3 patients received treatment with octylcyanoacrylate. At long-term follow-up, the cosmetic appearances were similar according to the patients (octylcyanoacrylate, 83.8 +/- 19.4 mm vs standard techniques, 82.5 +/- 17.6 mm; p = 0.72) and the physicians (optimal cosmetic appearance, 77% vs 80%; p = 0.67).Wounds treated with octylcyanoacrylate and standard wound closure techniques have similar cosmetic appearances 3 months later.

  View details for Web of Science ID 000071969400003

  View details for PubMedID 9492126

• Evaluation and management of traumatic lacerations NEW ENGLAND JOURNAL OF MEDICINE Singer, A. J., Hollander, J. E., Quinn, J. V. 1997; 337 (16): 1142-1148

  View details for Web of Science ID A1997YA91200007

  View details for PubMedID 9329936

• Octylcyanoacrylate tissue adhesive versus suture wound repair in a contaminated wound model SURGERY Quinn, J., Maw, J., Ramotar, K., Wenckebach, G., Wells, G. 1997; 122 (1): 69-72

  Abstract

  Octylcyanoacrylate tissue adhesive is a topical wound closure that precludes the need for foreign bodies (sutures) to close wounds. It also has an in vitro antimicrobial effect when standard disc sensitivity tests are used.To determine whether contaminated wounds closed with octylcyanoacrylate tissue adhesive will have a lower infection rate compared with wounds closed with 5-0 monofilament sutures, we designed a randomized, blinded, experimental animal study. Two incisions were made on 20 albino guinea pigs. The wounds were contaminated with 10(5) Staphylococcus aureus ATCC 12600 and randomly assigned to be closed with either topical octylcyanoacrylate tissue adhesive or percutaneous 5-0 polypropylene suture. Five days later the adhesive and sutures were removed, and a section of the wound was given to a histopathologist blinded to the type of wound closure. The wound was determined to be infected if inflammatory cells with intracellular cocci were seen. The rest of the wound was opened and examined for clinical evidence of infection. Quantitative bacteriologic analysis was performed.Five wounds in the tissue adhesive group were sterile on day 5, whereas all sutured wounds had positive cultures (25% versus 0%, p < 0.05). Fewer wounds in the tissue adhesive group were determined to be infected by histologic and clinical criteria (0% versus 55%, p < 0.001, and 20% versus 65%, p < 0.01, respectively). Agreement on the determination of infection by histologic and clinical criteria yielded a kappa coefficient of 0.46 (95% confidence interval [GI], 0.19 to 0.73). An infection criterion of 10(5) colony-forming units/gm of tissue correlated poorly with clinical and histologic infection rates (0.19 [95% CI, -0.06 to 0.44] and 0.13 [95% CI, -0.05 to 0.31], respectively).Contaminated wounds closed with sutures had higher infection rates compared with those reported with topical tissue adhesive. The amount of colonization may not be an accurate method to determine infection.

  View details for Web of Science ID A1997XK80800011

  View details for PubMedID 9225917

• A randomized trial comparing octylcyanoacrylate tissue adhesive and sutures in the management of lacerations JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Quinn, J., Wells, G., Sutcliffe, T., Jarmuske, M., Maw, J., Stiell, I., Johns, P. 1997; 277 (19): 1527-1530

  Abstract

  To assess the effectiveness of a new tissue adhesive for laceration closure.A prospective, randomized controlled trial.An adult teaching hospital.One hundred thirty patients with 136 lacerations who consented to enrollment during a 5-month period. The lacerations included all eligible nonmucosal facial lacerations, as well as selected extremity and torso lacerations (not on hands, feet, or joints). One hundred six lacerations were available for early follow-up, and 98 were available for 3-month evaluation.Lacerations were randomly allocated to have skin closure with octylcyanoacrylate adhesive or monofilament suture.A 3-month photograph of the wound was assigned a cosmesis score on a previously validated 100-mm visual analog cosmesis scale by a plastic surgeon who was unaware of the method of wound closure.There were no differences in the mean visual analog cosmesis scores (67 mm for octylcyanoacrylate vs 68 mm for sutures; P=.65). Similarly, there was no difference in the percentage of early (80% vs 82%; P=.80) or late (72% vs 75%; P=.74) optimal wound evaluation scores. The tissue adhesive was a faster method of wound repair (3.6 vs 12.4 minutes; P<.001) as well as being less painful (visual analog pain scores, 7.2 vs 18.0 mm; P<.001).Octylcyanoacrylate tissue adhesive effectively closes selected lacerations. This relatively painless and fast method of wound repair can replace the need for suturing several million lacerations each year.

  View details for Web of Science ID A1997WY96900030

  View details for PubMedID 9153366

• A prospective comparison of octylcyanoacrylate tissue adhesive and suture for the closure of head and neck incisions JOURNAL OF OTOLARYNGOLOGY Maw, J. L., Quinn, J. V., Wells, G. A., Ducic, Y., Odell, P. F., Lamothe, A., BROWNRIGG, P. J., Sutcliffe, T. 1997; 26 (1): 26-30

  Abstract

  To compare the tissue adhesive octylcyanoacrylate with subcuticular suture for the closure of head and neck incisions.A prospective comparison with a blinded assessment of cosmetic outcome.Fifty consecutive patients undergoing head and neck procedures at two University of Ottawa teaching hospitals.Twenty-six patients underwent skin closure with monofilament suture and 24 were closed with tissue adhesive. At 4 to 6 weeks the incisions were evaluated with a validated wound scale. Photographs of the incisions were rated using a visual analogue scale by two facial-plastic otolaryngologists who were blinded to the method of skin closure.The adhesive provided faster skin closure (29.7 seconds vs 289.0 seconds, p < .0001), and there were no differences in complications between the two groups. The primary outcome measure was the cosmetic appearance of the incision at 4 to 6 weeks. Although the adhesive group scored higher on both cosmesis scales, the visual analogue scale (octylcyanoacrylate 58.7 mm vs suture 53.2 mm) and the wound evaluation scale (57% vs 50% optimal wound scores), there were no statistical or clinically significant differences on either scale. The two facial-plastic otolaryngologists had good intraobserver and interobserver agreement when rating the cosmetic outcomes (0.87 and 0.71 respectively).Octylcyanoacrylate was found to be an effective method of skin closure in clean head and neck incisions. The practical advantages of tissue adhesives are reviewed.

  View details for Web of Science ID A1997WJ57100005

  View details for PubMedID 9055170

• Clinical wound evaluation ACADEMIC EMERGENCY MEDICINE Quinn, J. V. 1996; 3 (4): 298-299

  View details for Web of Science ID A1996UC22300004

  View details for PubMedID 8881536

• RANDOMIZED DOUBLE-BLIND CONTROLLED TRIAL COMPARING ROOM-TEMPERATURE AND HEATED LIDOCAINE FOR DIGITAL NERVE BLOCK ANNALS OF EMERGENCY MEDICINE Waldbillig, D. K., Quinn, J. V., Stiell, I. G., Wells, G. A. 1995; 26 (6): 677-681

  Abstract

  To determine whether warming of lidocaine decreases the pain of its injection during digital nerve block.Prospective, randomized, double-blind, controlled trial.Twenty healthy volunteers received bilateral digital nerve blocks of their middle finger. They were first randomly assigned to receive either room-temperature (21 degrees C) or heated (42 degrees C) 2% lidocaine in their first block. They were then randomly assigned to receive the first block in either the right or left hand. The blocks were performed in a standardized fashion by a single physician, who was blinded to which solution was being used. The volunteers rated the pain of each digital block on a 100-mm visual analog scale (VAS). Efficacy of each digital block was tested at 5 minutes.Heating of the lidocaine was associated with a significantly lower median VAS pain score (31.5 versus 25.0; P < .05). There was no difference in pain score between the two solutions in relation to which hand was used (P = .29) or whether the injection was the first or the second (P = .37). When all factors (temperature, order, and hand) were considered in the ANOVA with respect to VAS pain score, the only significant relation found was that between the temperature of the solution and the VAS pain score (P = .028).Heating of lidocaine decreases the pain of injection during digital nerve block.

  View details for Web of Science ID A1995TJ27800002

  View details for PubMedID 7492035

• USE OF RADIOGRAPHY IN ACUTE KNEE INJURIES - NEED FOR CLINICAL DECISION RULES ACADEMIC EMERGENCY MEDICINE Stiell, I. G., Wells, G. A., McDowell, I., Greenberg, G. H., McKnight, R. D., CWINN, A. A., Quinn, J. V., YEATS, A. 1995; 2 (11): 966-973

  Abstract

  To study: 1) the efficiency of the current use of radiography in acute knee injuries, 2) the judgments and attitudes of experienced clinicians in their use of knee radiography, and 3) the potential for decision rules to improve efficiency.This two-stage study of adults with acute knee injuries involved: 1) a retrospective review of all 1,967 patients seen over a 12-month period in the EDs of one community and two teaching hospital, and 2) a prospective survey of another 1,040 patients seen by attending emergency physicians. The prospective survey assessed each clinician's estimate of the probability of a knee or patella fracture; 120 patients were independently assessed by two physicians.Of the 1,967 patients seen in the first stage, 74.1% underwent radiography but only 5.2% were found to have fractures. Of the 1,727 knee and patella radiographic series ordered, 92.4% were negative for fracture. In the second stage, experienced physicians predicted the probability of fracture to be 0 or 0.1 for 75.6% of the patients. The kappa value for this response was 0.51 (95% CI 0.34 to 0.68). The physicians also indicated that they would have been comfortable or very comfortable in not ordering radiography for 55.5% of the patients. The area under the receiver operating characteristics curve for the physicians' prediction of fracture was 0.87 (95% CI 0.82 to 0.91), reflecting good discrimination between fracture and nonfracture cases. Likelihood ratios for the physicians' prediction ranged from 0.09 at the 0 level to 42.9 at the 0.9-1.0 level.Emergency physicians order radiography for most patients with acute knee injuries, even though they can accurately discriminate between fracture and nonfracture cases and expect most of the radiographs to be normal. These findings suggest great potential for more efficient use of knee radiography, possibly through the use of a clinical decision rule.

  View details for Web of Science ID A1995TB33800007

  View details for PubMedID 8536122

• VISUALIZATION OF C-7-T-1 ON PORTABLE LATERAL CERVICAL-SPINE RADIOGRAPHS USING A LEAD-LINED ACRYLIC FILTER Society-for-Academic-Emergency-Medicine Annual Meeting QUINN, D. V., Cwinn, A., Carr, B., Grahovac, S., Stiell, I., PELLAND, P. HANLEY & BELFUS INC. 1995: 610–14

  Abstract

  To determine whether lead-lined acrylic cervical filters can improve the quality of portable lateral cervical spine (c-spine) radiographs for trauma patients.Twenty trauma patients who required portable c-spine x-rays had these taken with a lead filter attached to the collimator of the portable x-ray machine to improve penetration and visualization of lower cervical structures without overpenetrating upper cervical structures. The radiographs of these patients were compared with the first portable c-spine radiographs without filters for 20 controls matched for gender and injury severity. The comparison of radiographs was done by an experienced emergency physician and a neuroradiologist blinded to whether the filter was used.The two groups were similar for demographic and clinical characteristics. There was a significant improvement in the ability to visualize the C7-T1 level for the filter group compared with the control group (65% vs 30%, p < 0.05). Agreement between the physicians was excellent (kappa = 0.79, 95% CI = 0.60-0.99).Lead-lined acrylic filters improve the ability to visualize the lower c-spine in trauma patients.

  View details for Web of Science ID A1995RF08500010

  View details for PubMedID 8521207

• N-2-butylcyanoacrylate: risk of bacterial contamination with an appraisal of its antimicrobial effects. journal of emergency medicine Quinn, J. V., Osmond, M. H., Yurack, J. A., MOIR, P. J. 1995; 13 (4): 581-585

  Abstract

  Numerous authors have recommended reusing vials of the tissue adhesive Histoacryl blue, despite the fact that it is manufactured for single use. The purpose of this study is to determine if Histoacryl vials become contaminated during reuse and to determine its inhibitory effects on various microbial pathogens. Ten consecutive vials used multiple times were collected from two hospitals, and the residual adhesive was cultured. The antibacterial effect of n-2-butylcyanoacrylate was then tested against various microbial pathogens. The vials were used an average of eight times and the time between opening and culturing the vials ranged from 2-30 days. There was no growth from any vials. Testing against microbial pathogens showed that the tissue adhesive is particularly effective at inhibiting gram-positive organisms. This study demonstrates that Histoacryl vials do not become contaminated after repeated use and that the tissue adhesive has an antibacterial effect that may be beneficial in the management of wounds.

  View details for PubMedID 7594385

• ECONOMIC COMPARISON OF A TISSUE ADHESIVE AND SUTURING IN THE REPAIR OF PEDIATRIC FACIAL LACERATIONS JOURNAL OF PEDIATRICS Osmond, M. H., Klassen, T. P., Quinn, J. V. 1995; 126 (6): 892-895

  Abstract

  To determine, from the societal perspective, the most cost efficient of the three methods commonly used to repair pediatric facial lacerations: nondissolving sutures, dissolving sutures, or a tissue adhesive (Histoacryl blue).Cost-minimization analysis and willingness-to-pay survey.Tertiary-care pediatric emergency department.All differential costs relevant to equipment utilization, pharmaceutical use, health care worker time, and parental loss of income for follow-up visits were calculated for each method. On the basis of previous research, our model assumes equal cosmetic outcome for the three methods. In addition, a convenience sample of 30 parents were surveyed in the emergency department to rank their preferences and willingness to pay for the three methods of wound closure.The reduction in cost (in Canadian dollars) per patient of switching from the standard nondissolving sutures was $49.60 for switching to tissue adhesive and $37.90 for dissolving sutures. Sensitivity analyses performed on key variables did not significantly alter our conclusions. Of those parents surveyed; 90% (95% confidence interval, 74% to 98%) chose tissue adhesive and 10% (95% confidence interval, 2% to 26%) chose dissolving sutures as their first choice for wound closure. Nondissolving sutures were ranked third by 29 of 30 parents. Parents were willing to pay a median (25th to 75th percentile) of $40 ($25 to $100) for tissue adhesive and $25 ($10 to $56) for dissolving sutures if only nondissolving sutures provided by the health care system (p = 0.1).Tissue adhesive is the preferred method of closure of pediatric facial lacerations because it results in the most efficient use of resources and is preferred by the majority of parents.

  View details for Web of Science ID A1995RC75400007

  View details for PubMedID 7776090

• APPEARANCE SCALES TO MEASURE COSMETIC OUTCOMES OF HEALED LACERATIONS AMERICAN JOURNAL OF EMERGENCY MEDICINE Quinn, J. V., DRZEWIECKI, A. E., Stiell, I. G., ELMSLIE, T. J. 1995; 13 (2): 229-231

  Abstract

  To develop an appearance scale that will allow the objective and scientific comparison of the cosmetic results of healed lacerations, 33 photographs of healed lacerations and incisions with variable cosmetic results were shown to four plastic surgeons. These plastic surgeons were asked to independently rate the photographs on two separate occasions using two scales, a Visual Analogue Scale and a Categorical Scale. Interobserver and intraobserver agreement were determined for each scale. Comparison of the scales with each other was done to assess consistency. The Visual Analogue Scale showed good interobserver agreement with an Intraclass Correlation Coefficient of 0.75. Intraobserver agreement was also high across the four observers with Pearson correlation coefficients ranging from 0.73 to 0.87. The agreement of the categorical scale was also good with a kappa coefficient for interobserver agreement of 0.53. The kappa coefficient for intraobserver agreement ranged from 0.48 to 0.72. Because the visual analogue scale and categorical scale showed good interobserver and intraobserver agreement, both may be considered good measurement tools in the comparison of alternate methods of laceration care.

  View details for Web of Science ID A1995QQ14700025

  View details for PubMedID 7893315

• DEBUNKING THE MYTHS ABOUT ANALGESIA CANADIAN MEDICAL ASSOCIATION JOURNAL Quinn, J. 1994; 151 (7): 914-915

  View details for Web of Science ID A1994PJ75900013

  View details for PubMedID 7922924

  View details for PubMedCentralID PMC1337270

• Need for sedation in a patient undergoing active compression--decompression cardiopulmonary resuscitation. Academic emergency medicine Quinn, J. V., Hebert, P. C., Stiell, I. G. 1994; 1 (5): 463-?

  Abstract

  The authors report the case of a 57-year-old man with a history of ischemic heart disease who presented to the emergency department with an acute myocardial infarction and hypotension. Despite aggressive pharmacotherapy, the patient's heart rate decreased, and he developed pulseless electrical activity within 15 minutes of his arrival. Cardiopulmonary resuscitation (CPR) was begun with an active compression-decompression (ACD) device, and the patient became agitated, making purposeful movements. When ACD-CPR was discontinued for a rhythm check, the patient had no pulse and became motionless. Agitation and purposeful movements occurred on two subsequent occasions with the initiation of ACD-CPR. The patient required physical restraints, sedation, and paralysis for personnel to perform endotracheal intubation and facilitate treatment. The implications of this case are discussed.

  View details for PubMedID 7614304

• Tissue adhesive wound repair revisited. journal of emergency medicine Noordzij, J. P., Foresman, P. A., Rodeheaver, G. T., Quinn, J. V., Edlich, R. F. 1994; 12 (5): 645-649

  Abstract

  The purpose of this experimental study was to compare the effect of a tissue adhesive, N-butyl-2-cyanoacrylate, on the wound's ability to resist infection and gain strength to the effect of percutaneous polypropylene suture. Percutaneous sutures damaged host defenses, inviting the growth of bacteria to a level that was significantly greater than that encountered with the tissue adhesive. Immediately after wound closure, percutaneous sutures provided a more secure closure, as measured by breaking strength, than did tissue adhesives. Seven days later, the breaking strengths of wounds closed by tissue adhesives did not differ significantly from those repaired with percutaneous sutures. Tissue adhesive closure requires less psychomotor skills than suture closure and is accomplished more rapidly than suture closure.

  View details for PubMedID 7989692

• A RANDOMIZED, CONTROLLED TRIAL COMPARING A TISSUE ADHESIVE WITH SUTURING IN THE REPAIR OF PEDIATRIC FACIAL LACERATIONS ANNALS OF EMERGENCY MEDICINE Quinn, J. V., Drzewiecki, A., Li, M. M., Stiell, I. G., Sutcliffe, T., ELMSLIE, T. J., Wood, W. E. 1993; 22 (7): 1130-1135

  Abstract

  To compare the tissue adhesive Histoacryl Blue with suturing in the repair of pediatric facial lacerations.Prospective, randomized controlled trial.Emergency department of a pediatric teaching hospital.Eighty-one children presenting with clean facial lacerations less than 4 cm in length and 0.5 cm in width.Patients were allocated randomly to have their lacerations repaired with sutures or Histoacryl Blue.The two groups were similar for demographic and clinical characteristics. Photographs taken at three months were rated by two plastic surgeons blinded to the method of closure. There was no difference between groups for appearance scores on a visual analog scale (60.5 mm for Histoacryl Blue versus 57.2 mm for suture, P = .45) or on a categorical scale (Histoacryl Blue versus sutures: unacceptable, 11% versus 13%; acceptable, 59% versus 71%; excellent, 30% versus 16%; P = .76). Measures of observer agreement produced Pearson correlations of .72 and .94 on the visual analog scale and kappa coefficients of .46 and .73 on the categorical scale. Histoacryl Blue was assessed as less painful on a visual analog scale (24.7 versus 43.7 mm, P < .01) and faster (7.9 versus 15.6 minutes, P < .001).Histoacryl Blue is a faster and less painful method of facial laceration repair that has cosmetic results similar to the use of sutures.

  View details for Web of Science ID A1993LK28100004

  View details for PubMedID 8517562